Evaluation of Two Different Anterior Vitrectomies for Fluid Misdirection Syndrome Secondary to Cataract Surgery Combined with Goniosynechialysis

Abstract

Purpose: To evaluate two different approaches of anterior vitrectomy combined with hyaloidotomy, zonulectomy, and iridectomy (VHZI) for fluid misdirection syndrome (FMS) secondary to phacoemulsification with intraocular lens implantation combined with goniosynechialysis (phaco-IOL-GSL).

Methods: Nine patients with FMS who developed after a phaco-IOL-GSL procedure, were retrospectively studied from May 2015 to February 2018. They were treated with VHZI, in which 5 cases underwent local anterior vitrectomy via anterior chamber approach, and the others underwent comprehensive vitrectomy via pars plana approach. Main outcome measures were pre- and postoperative intraocular pressure (IOP), number of antiglaucoma medications, and relapse rate.

Results: Incidence of FMS secondary to phaco-IOL-GSL was 1.4% (9 in 652 eyes), which was promptly resolved in all affected cases. VHZI via anterior chamber approach resulted in a significant decrease in the mean IOP from 40.2 ± 9.7 mm Hg at presentation to 15.2 ± 4.8 mm Hg postoperatively (P=0.01). The median number of antiglaucoma medications reduced from 3 to 2 (P=0.066). Meanwhile, VHZI via pars plana approach also resulted in the reduction of the mean IOP values from 26.0 ± 5.7 mm Hg at presentation to 15.2 ± 3.3 mm Hg postoperatively (P=0.092). The median number of antiglaucoma medications also reduced from 3.5 to 1.5 (P=0.059). Relapse rate of the treatment through pars plana approach (0%, 0/4) was much lower than that through anterior chamber approach (40%, 2/5), although the difference was not statistically significant (P=0.444).

Conclusions: FMS is a rare but severe complication secondary to phaco-IOL-GSL. Compared to VHZI with local anterior vitrectomy via anterior chamber approach, VHZI with comprehensive anterior vitrectomy via pars plana approach might be a more effective procedure to treat FMS. The study has been registered in Contact ClinicalTrials.gov PRS Identifier: NCT04172857.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Copyright © 2020 Zhenbin Qian et al.

Figures

Figure 1

The preoperative and postoperative (a) IOP, (b) number of medications, and (c) BCVA of patients underwent VHZI via corneal incision or pars plana incision.

Figure 2

The schematic showing the anterior vitrectomy via (a) pars plana approach or (b–d) anterior chamber approach. (a) The vitrector inserted through the pars plana incision, approximately parallel to the plane of the iris. As a result, there is enough space for the movement of the vitrector, which is helpful to adequately create a wide disruption of the anterior hyaloid face and remove the anterior vitreous body around the tunnel. (b) The vitrector inserted through the peripheral iris defect into the vitreous cavity vertically. For the space of the vitrector, movement is limited to the vicinity of the incision, and the operative area cannot be observed during anterior vitrectomy, and the anterior vitreous around the passage is hard to be removed. (c) The residual vitreous around the passage after VHZI via anterior chamber approach may invade and block the passage. (d) The deposition of the fibrin exudates may form a membrane on the front surface of the residual vitreous around the channel.

Figure 3

The schematic showed (a) the hypothesis of the remnant vitreous moving forward and blocking the created passage after incomplete removal of the vitreous (comprehensive vitrectomy). (b) Residual posterior vitreous body does not easily block the upper tunnel directly for its more likely to accumulate at the lower part of vitreous cavity due to gravity.