Gowri Pachigolla, M.D., Steven Verity, M.D., Good afternoon. My name is Gowri Pachigolla and I am a second year resident. My study evaluated the outcomes of planned phacoemulsification complicated by vitreous loss performed by third-year residents. Outcomes of resident-performed phacoemulsification cataract extraction complicated by vitreous loss Gowri Pachigolla, M.D., Steven Verity, M.D., Preston H. Blomquist, M.D. April 2008 The University of Texas Southwestern Medical Center at Dallas, TX

Introduction 67-97.7% of patients with postop BCVA of 20/40 or better Over 2.5 million cataract extractions are performed per year in the US 97% of cataract extraction are performed using phacoemulsification techniques Accidental vitreous loss has been associated with CME, glaucoma, retinal detachment, endophthalmitis, vitreous hemorrhage, IOL dislocation, corneal endothelial decompensation and retinal vascular occlusions Nevertheless most patients (67-97%), even in training centers, achieve at least BCVA 20/40 Leaming DV. Practice styles and preferences of ASCRS members--2003 survey. J Cataract Refract Surg 2004; 30:892-900

Introduction Nishi: no significant difference in several outcome measures, including VA, incidence of postop complications and endothelial cell loss All of the previous comparative studies have included ECCE; however, more recent studies (including one done at Parkland in 2002) have suggested that in cases of vitreous loss, ECCE resulted in worse outcomes than phaco. Additionally, a study of 87 cases of vitreous loss performed by senior surgeons in the UK during the time period of conversion from ECCE to phacoemulsification, found that 20/40 vision was achieved in 83% of phacoemulsification cases, but in only 68% of ECCE. Most comparative studies in the past have found that outcomes after posterior capsular rupture or vitreous loss are significantly worse than after uncomplicated cases However, one study by Nishi demonstrated equivalent outcomes in several measures including VA, incidence of post-operative complications and endothelial cell loss More recently with phacoemulsification becoming the predominant technique for CE, a few studies have shown that in cases of vitreous loss, ECCE fare worse Nishi O. Vitreous loss in posterior chamber lens implantation. J Cataract Refract Surg 1987; 13:424-7. Chan FM, et al. Short-term outcomes in eyes with posterior capsule rupture during cataract surgery. J Cataract Refract Surg 2003; 29:537-41. Blomquist PH, et al. Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002; 28:847-52. Ah-Fat FG, et al. Vitreous loss during conversion from conventional extracapsular cataract extraction to phacoemulsification. J Cataract Refract Surg 1998; 24: 801–805.

Purpose & Methods To compare clinical outcomes after resident-performed phacoemulsification complicated by vitreous loss and uncomplicated control cases Retrospective comparative study of all consecutive patients undergoing planned phacoemulsification from April 2005 to March 2006 at Parkland Memorial Hospital Exclusions: <4 weeks of followup, combined procedures, planned ECCE, h/o ruptured globe, dislocated native lens

Results 525 consecutive patients were identified 127 excluded Initial search of billing data revealed 525 consecutive patients during the time frame. 127 patients were excluded for the aforementioned reasons. Of note, there were 4 aborted cases, one of which was rescheduled within the time frame of the study and therefore included in the data analysis. 4 aborted cases: resp distress, malfunctioning equipment, retrobulbar hemorrhage, retrobulbar anesthesia of the incorrect eye 525 consecutive patients were identified 127 excluded inadequate follow-up (67) combined surgical procedure (29) unavailable operative report (13) primary ECCE (5) cases performed by fellows (4) unavailable medical charts (3) history of ruptured globe (2) dislocated native lens (1) 4 aborted cases. 1 rescheduled within study time and included in the data analysis. A total of 398 patients were included in the study

Results 3 groups: Controls (366 eyes) 2. Vitreous loss group (23 eyes) According to the operative record, patients were categorized into three groups based on unplanned intraoperative events: those without vitreous loss (control group), those with vitreous loss and completion of cataract extraction using phacoemulsification technique (vitreous loss group), and those undergoing conversion to ECCE or ICCE regardless of vitreous prolapse into the anterior chamber (conversion group). 3 groups: Controls (366 eyes) No vitreous loss 2. Vitreous loss group (23 eyes) Completion of CE with phacoemulsification 3. Conversion group (9 eyes) Conversion to ECCE/ICCE regardless of vitreous loss

Unplanned operative incidents Demographics Overall, 57% of cases were female, with a mean age of 61.8 years. Mean follow-up time was 36.8 weeks. Mean followup time was less for the vitreous loss group. Of note, although roughly equal percentage of right and left eyes were operated on, within the vitreous loss group, almost 70% of cases involved the left eye. Mean follow up time was less for the Vitreous loss group. Unplanned operative incidents Numbers in parenthesis are percentages

Operative procedures and IOL Types 27 patients had automated anterior vitrectomy and 2 had manual anterior vitrectomy. Anterior capsular staining was utilized in over 27% of cases and iris hooks in almost 4% of cases. Most eyes in the Control group had IOLs placed within the bag, while Sulcus and AC lenses were most commonly placed in the Vitreous loss and Conversion groups respectively. Most eyes in the Control group had IOLs placed within the bag, while Sulcus and ACIOLs were more commonly placed in the Vitreous Loss and Conversion groups respectively.

Preoperative lenticular characteristics Pre-existing lenticular characteristics including if the lens was described as “Mature” or if a history of trauma was elicited were recorded. Having at least one preoperative lenticular pathology was statistically more common in the Conversion group versus the Control group. Over 50% for Conversions versus 15% for Controls. Having at lease one preoperative lenticular pathology was more common in the Conversion group than in the Control group. Numbers in parenthesis are percentages * P = 0.006, versus Control group (z-test)

Late complications Both the Vitreous loss and Conversion groups were significantly more often complicated by at least one late adverse event, including cystoid macular edema (CME), vitreous in the anterior chamber and persistent corneal edema, when compared to the Control group. Over 50% for the Conversions, almost 40% for the Vitreous loss compared to only about 13% for Controls. However, taking CME alone, this occurred significantly more often in the Conversion group only. The 8.7% rate of retinal tear/detachment in the Vitreous loss group is higher than in previous studies, but this represented only 2 cases. One of these patients had a history of a RD in the fellow eye. The other had a dropped nuclear fragment and a retinal tear was diagnosed and treated during PPL. Although there were 3 cases of endophthalmitis recorded, only 1 was culture-positive. The other 2 cases had delayed-onset vitritis that was presumed to be secondary to P. acnes endophthalmitis by the Uveitis service. Both the Vitreous Loss and Conversion groups were more often complicated by at least one late adverse event, while CME occurred more frequently in the Conversion group only. Only one of the endophthalmitis cases was culture-positive. Numbers in parenthesis are percentages * P < 0.001, versus Control group (z-test) + P = 0.002 for Vitreous loss and Conversion groups versus Controls (z-test)

Visual outcomes Mean logMAR BCVA (Snellen equivalent) Mean pre and post-operative BCVA are shown here. BCVA significantly improved after CE in all three groups. The Conversion group had significantly worse preop VA than Controls suggesting that the density of their cataracts was more profound. Excluding patients with preexisting ocular disease contributing to vision worse than 20/40, postop BCVA was not significantly worse in the Vitreous loss group compared to Controls. Alternately, postop BCVA in the Conversion group was significantly worse than Controls. Of the 9 patients in the Vitreous loss and Conversions groups with <20/40 BCVA, 8 had persistent CME and 6 had ACIOLs. Additionally, the percentage of patients achieving 20/40 or better vision was greater in the control group than in the vitreous loss or conversion groups; however, this difference was only significant for the conversion group. 94% in Controls versus 81% and 44% for the other groups. Mean logMAR BCVA (Snellen equivalent) Postop BCVA was not significantly worse in the Vitreous Loss group compared to Controls, with both groups having approximately 20/30 vision. Alternately, postop BCVA in the Conversion group was significantly worse than in Controls with a VA of about 20/70 in the Conversion group. * P < 0.05, versus Control group (ANOVA on ranks) + P >= 0.05, versus Control group (ANOVA on ranks) ~ P < 0.05, versus Control group (ANOVA on ranks) Percentage of eyes with postoperative BCVA 20/40 or better * P = < 0.001, versus Control group (z-test) Postoperative BCVA excludes 57 patients in the Control group and 2 in the Vitreous loss group with preexisting ocular disease accounting for BCVA < 20/40

Conclusion In the past, comparative studies evaluating visual outcome after CE complicated by v-loss have included ECCE. Given the more complicated postop course and poorer visual outcomes after complicated and uncomplicated ECCE, the current study chose to separate these patients. Although this study is limited by its small sample size and f/u time, it does conclude that although v-loss p planned resident-phaco CE more often results in late complications, visual outcome is not signif worse as long as complications don’t result in conv to E/ICCE In the past, comparative studies evaluating clinical outcomes after CE complicated by vitreous loss have included ECCE. Given the more complicated postop course and variable VA outcomes after complicated and uncomplicated ECCE, the current study chose to separate these patients. The study is limited by its small sample size and limited follow up time; however, it does conclude that although, vitreous loss after resident-performed phacoemulsification more often results in late complications, visual outcome is not significantly worse as long as complications do not result in conversion to EC/ICCE. Careful surgical planning and anticipation of conversion to ECCE may improve outcomes.