Should a patient over 55 years old with proliferative diabetic retinopathy (PDR) undergoing vitrectomy for vitreous hemorrhage also have cataract surgery at the time of vitrectomy?

From the Guidelines

For patients over 55 with proliferative diabetic retinopathy (PDR) undergoing vitrectomy for vitreous hemorrhage, combined cataract surgery at the same time is generally recommended. This combined approach (phacovitrectomy) is beneficial because patients in this age group often have existing cataracts or will likely develop them soon after vitrectomy, as vitrectomy itself accelerates cataract formation, with most patients developing visually significant cataracts within 1-2 years after the procedure 1. By performing both surgeries simultaneously, patients avoid the need for a second operation, experience faster visual rehabilitation, and reduce overall healthcare costs. The combined procedure also provides better visualization for the surgeon during vitrectomy and allows better postoperative monitoring of the retina.

Some key points to consider in this decision include:

• The patient's specific cataract status: those with significant cataracts may benefit more from combined surgery 1.
• Overall health: patients with multiple comorbidities may be at higher risk for complications from combined surgery 1.
• Complexity of the retinal pathology: very complex PDR requiring extensive manipulation may be better suited to a staged approach to reduce surgical time and potential complications 1.

However, the benefits of combined cataract and vitrectomy surgery for patients with PDR and vitreous hemorrhage generally outweigh the risks, and this approach is supported by recent clinical guidelines and studies 1. Ultimately, the decision to perform combined surgery should be individualized based on the patient's unique circumstances and medical history.

From the Research

Patient Considerations

• Patients over 55 years old with proliferative diabetic retinopathy (PDR) undergoing vitrectomy for vitreous hemorrhage may also require cataract surgery, as the risk of cataract formation is a significant post-operative complication 2.
• The decision to perform cataract surgery at the time of vitrectomy should be based on the individual patient's needs and the presence of significant cataract formation 3.

Surgical Outcomes

• Combining vitrectomy with phacoemulsification as a single surgical intervention may be a suitable therapeutic choice for diabetic patients with severe cataracts and vitreoretinal disease requiring vitrectomy, as it does not significantly increase the risk of visual impairment or retinopathy development 3.
• Vitrectomy surgery may have intraoperative and postoperative complications, including cataract, anterior hyaloidal fibrovascular proliferation, fibrovascular ingrowth, retinal detachment, and recurrent vitreous hemorrhage 4.

Age-Related Considerations

• Young patients who underwent vitrectomy for PDR had more severe clinical characteristics before vitrectomy, but achieved better final visual outcomes than older patients with type 2 diabetes 5.
• Older patients may have a higher risk of postoperative complications, such as cataract formation, and may require careful consideration of the benefits and risks of combined cataract and vitrectomy surgery 2, 5.

Clinical Characteristics and Surgical Outcomes

• The clinical features of PDR and the surgical outcomes of its complications can vary depending on the patient's age, with younger patients tend to have more severe disease and better visual outcomes after surgery 5.
• The final best-corrected visual acuity (BCVA) was significantly improved relative to the preoperative BCVA in both young and old patient groups, but the incidence of postoperative recurrent retinal detachment was higher in the young patient group 5.