It is estimated that up to 52% of patients will require cataract surgery within 1 year of undergoing vitrectomy, and approximately 80% will develop a visually significant cataract within 2 years.1
Balancing and timing cataract and retina surgeries can be a logistical challenge, with patients and surgeons alike facing the task of coordinating timing and managing delays between procedures. Phacovitrectomy offers a potential solution.
Phacovitrectomy: An overview
Phacovitrectomy refers to performing cataract surgery (phacoemulsification) at the time of pars plana vitrectomy (PPV) for retinal pathology. The main advantage of this technique is that it is a single surgical event, reducing patient exposure to anesthesia and associated costs. It features a single recovery period compared to a staged procedure.2-5
Phacovitrectomy is also advantageous to the retina surgeon as it allows for an improved view of the retina during PPV.4 Phacovitrectomy is more commonly performed in Europe than in the US,6 despite similar visual and refractive outcomes compared to vitrectomy followed by cataract surgery.3-5,7,8
Significant studies on phacovitrectomy
A prospective comparative study between 60 eyes that underwent phacovitrectomy and 60 eyes that underwent phacoemulsification alone found no differences in myopic shift or intraocular lens (IOL) displacement.3 Additionally, one extensive retrospective review of 648 eyes undergoing phacovitrectomy found that best-corrected visual acuity (BCVA) improved from 20/192 to 20/46 at 12-month follow-up, with few complications and no cases of endophthalmitis.4
Many other studies have demonstrated the safety and efficacy of phacovitrectomy. Some retinal surgeons will additionally perform a posterior capsulotomy during phacovitrectomy to obviate the potential need for a YAG capsulotomy at a later date.9
Since virtually all patients who undergo a vitrectomy develop cataract progression within 2 years,10 addressing both pathologies in a single surgical encounter is often practical.
Patient selection for phacovitrectomy
Careful pre-operative evaluation is essential; important considerations and documentation of comorbidities that may affect surgical outcomes include:
- General ocular comorbidities: Corneal disease (e.g., Fuchs’ dystrophy) can impact outcomes, as decompensation during longer surgical procedures can obscure the view to the fundus and cause scleral thinning, zonular instability, or advanced cataract
- Posterior segment pathology: Macular disease (e.g., epiretinal membrane, macular hole), possibly contraindicating the use of premium IOLs
- Anatomic variables possibly compromising IOL power accuracy:
- Staphyloma
- Scleral buckle
- History of macula-off retinal detachment
- Patient factors: Counsel patients about the increased procedural time and complexity associated with a single event versus spreading out the time and complexity over multiple surgeries spanning multiple months
Advantages of combined surgery
Phacovitrectomy offers advantages both to the patient and the retina specialist. The primary advantage is the ability to combine cataract extraction and vitrectomy into a single, streamlined surgical procedure. This reduces the patient’s number of trips to the operating room, post-operative visits, and anesthesia exposure, while facilitating a faster visual recovery.
The approach is particularly beneficial for patients with multiple systemic comorbidities or intellectual disability, for whom repeated anesthesia exposures may increase the risk of anesthesia-related morbidity. It also reduces the total surgical cost and provides environmental benefits by decreasing the number of surgical events, associated material costs, and waste.
From the surgeon’s standpoint, performing cataract extraction before PPV improves visualization of the posterior segment, especially in the presence of significant lens opacity. It facilitates a more complete shave of the vitreous base without concern for lens touch.
Additionally, if complications such as posterior capsular rupture or lens drop occur, the retina surgeon is already present and equipped to address them immediately. Lastly, cataract surgery is technically easier when performed before vitrectomy, as the vitreous provides posterior support to the lens.
Disadvantages of phacovitrectomy
There are potential downsides to phacovitrectomy. The combined procedure is inherently more complex than either procedure alone. Combined surgery increases operative time, which may lead to corneal decompensation, especially in patients with underlying corneal pathology (e.g., Fuchs’ dystrophy).
Moreover, some insurance providers offer reduced reimbursement for the second procedure when both are performed during a single surgical event. As previously mentioned, given the multiple wounds in the eye from the cataract surgery and the vitrectomy ports, there is a higher risk of hypotony and IOL decentration or prolapse, so care must be taken to avoid these complications. Iridocapsular adhesion is more common in phacovitrectomy.
Additionally, IOL optic prolapse anteriorly from a gas bubble is more prevalent in phacovitrectomy. IOL power calculations may also be less accurate in patients with retinal pathology (e.g., macular edema, retinal detachment). Silicone IOLs should not be used if silicone oil tamponade is planned. It is possible to have prolonged post-operative inflammation in long, complicated cases.
For retina surgeons who may not feel comfortable performing cataract surgery, it is recommended to either be experienced with phacoemulsification or work simultaneously with an anterior segment surgeon.
To learn more about IOL power calculations, check out How to Calculate IOL Power: A Guide for Ophthalmology Residents!
In conclusion
Phacovitrectomy is a valuable technique in modern vitreoretinal surgery that enables the treatment of cataracts and retinal pathology simultaneously.
It offers significant advantages for both the patient and surgeon by reducing surgical burden, anesthesia exposure, and clinic visits, while providing better visualization for the retina surgeon without sacrificing visual outcomes.
Newer machines, such as the Alcon Unity, Bausch + Lomb Stellaris Elite, and DORC EVA Nexus, provide an even easier way to facilitate phacovitrectomy in a setting that doesn’t require two machines.
