In Europe, many ophthalmic surgeons are trained to perform both anterior and posterior segment procedures. Patients who require cataract surgery often have concomitant retinal conditions, some as simple as vitreous degeneration, to more complex cases of epiretinal membranes, macular holes, and retinal detachment, that could be addressed in the same surgery. Vice versa, many of our patients in whom we perform vitrectomy develop cataracts, requiring a second procedure.
In fact, the incidence of cataract formation and progression after vitrectomy has been shown to be as high as 80% over 2 years, particularly for older patients, and even higher when intraocular gas tamponade is employed.1,2 In patients younger than 50 years of age, although the risk of cataract formation is lower (7% vs 79%),2 the risk increases in longer term follow-up.3 Further, these post-vitrectomy cataracts tend to be accompanied by zonular weakness, deep and unstable anterior chamber, and posterior capsule plaques and defects, and the overall complication rates in cataract surgery post-vitrectomy are higher— approximately 12.5% intraoperatively and 20.8% postoperatively. The risk of retinal re-detachment is approximately 5.6% and the rates of subluxed IOLs are higher than in nonvitrectomized eyes.4,5 The obvious solution would be to combine these procedures into one surgery, so why are we not doing this for many of our patients? Some concerns that surgeons may have regarding performing a combined cataract and vitrectomy procedure may include a more unstable anterior chamber during vitrectomy, difficulties with visualization, more postoperative inflammation, inaccuracies in biometric measurements, and IOL subluxation.6
In cataract surgery, the benefits of microincisions have long been recognized to include a less invasive procedure and a more stable self-sealing microincision. In the past several years, transconjunctival sutureless vitrectomy has become widespread, offering benefits similar to what is seen with microincision cataract surgery. But what about the concerns with chamber stability, visualization, and fluidics?
Cataract surgeons have had the Stellaris (Bausch + Lomb, Aliso Viejo, CA) advanced phaco platform available to them for several years. Recently, however, Bausch + Lomb launched the Stellaris PC, a fully combined phaco and vitrectomy system which addresses many of the issues that have made surgeons hesitant to adopt combined surgery into practice.
STELLARIS PC FEATURES
The vitrector on the Stellaris PC operates at up to 5000 cuts per minute (cpm) and has a visual and tactile port location indicator. The over-molded rubber grip on the cutter is ergonomic and designed so that the gauge that is being used is easily identified. Further, an extension handle is available for surgeons who prefer a longer handpiece.
The high speed of the vitrectomy cutter translates to less traction on the retina, and the new design of the port brings the cutter opening closer to the distal end, which allows the surgeon to move closer to the retina while maintaining a safe procedure. The 23- and 25-gauge cutters are as efficient as the 20-gauge cutter at their highest speeds.
The new, redesigned Venturi pump responds promptly to surgeon commands via a wireless multifunction footpedal, improving the transition to posterior segment surgery. Additionally, the disposable packs for the Stellaris PC are specifically designed for combined procedures.
The disappointment of discovering lens clouding during posterior segment surgery is no longer present, and we do not have to change or reorganize our machine. The line of instrumentation for 23- and 25-gauge surgery includes disposable forceps that grasp membranes with strength and precision, and excellent small-gauge scissors. These disposables also allow easier entry with trocars and provide an overall smoother surgery.
The Stellaris PC has both xenon- and mercury-lamp types that are independent and designed to eliminate phototoxic wavelengths. The surgeon can choose between four color filters allow depending on his or her needs.
MY COMBINED PROCEDURE
In the first combined case that I performed with the Stellaris PC (Figure 1), the patient had a dense cataract (Figure 2) and an epiretinal membrane (ERM). The Venturi pump was particularly helpful for this scenario because the fluidics kept the chamber stable. The phaco procedure was smooth and I only had to raise the bottle to 60 cm and use 10% maximum ultrasound power. After implanting the IOL through the 1.8-mm incision, I made an easy transition to the posterior segment. I stained the membrane with triamcinolone acetonide and used an amber color filter to minimize the white color of the drug and to see the central vitreous on removal (Figure 3).
I removed the ERM with the new Bausch + Lomb 23-gauge disposable forceps (Figure 4), and for the internal limiting membrane (ILM), I used Brilliant Peel (Fluoron, Ulm, Germany); with this dye and the light source on the Stellaris PC, the ILM can be safely and easily removed using Tano forceps. After ILM removal, I removed the remaining central membrane material.
To perform every type of sutureless vitreoretinal surgery we use the 23-gauge set of instruments, which make posterior vitreous detachment easy. With 23-gauge, I find it easy to remove the ERM and ILM. Using 5000 cpm and the excellent fluidics control on the Stellaris PC, I can approach the retina for careful vitreous removal. The viscous fluid pump allows us to use silicone oil internal tamponade for macular hole (Figure 5). The same 23-gauge approach is preferred for retinal detachments, when it is very important to match fluidics and cutting for close retinal work.
SUMMARY
In my opinion, the Stellaris PC is the first truly complete combined surgical platform and has become my most effective partner in surgery. The machine has features that make the transition from the anterior segment to the posterior segment extraordinarily smooth in terms of safety and efficacy, so surgeons no longer need two systems to perform both surgeries at the highest level. The posterior segment surgeon will find in the Stellaris PC the best partner for advanced vitreoretinal surgery, without the need for a second machine for advanced cataract surgery.
Roberto Bellucci, MD, is the Head of the Ophthalmic Unit at the University Hospital, in Verona, Italy. He reports that he is a consultant to Bausch + Lomb. Dr. Bellucci may be reached at roberto.bellucci@ospedaleuniverona.it.
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