Idiopathic macular holes have an approximate incidence of 1 case per 1,000 people leading to decreased central visual acuity.¹ When a visually significant cataract is present concurrently with a macular hole, there are several important preoperative and postoperative surgical considerations for both the cataract surgeon and retina specialist. These patients pose several challenges for surgeons, including timing of the surgeries, whether to consider concurrent phacovitrectomy, and intraocular lens (IOL) implant options. This article discusses the factors that determine the optimal order and timing of surgery and special considerations to keep in mind.

PREOPERATIVE CATARACT SURGERY CONSIDERATIONS

A detailed fundoscopic examination to identify macular pathology is paramount during patient evaluation for cataract surgery. Setting expectations for patients after surgery and determining the optimal intraocular lens for the patient relies on the ability of the cataract surgeon to identify subtle vitreomacular traction (VMT) and full-thickness macular holes (FTMH). Preoperative optical coherence tomography (OCT) may help to discern the presence of vitreomacular interface pathology. Also, patients undergoing cataract surgery may develop a posterior vitreous detachment (PVD) postoperatively. In the presence of preoperative VMT, counseling patients that development of a PVD following cataract surgery may cause the VMT to progress is also important so that they are aware in the case of potential new symptoms. Additionally, if a FTMH is missed prior to cataract surgery, postoperative visual acuity may not meet the patient’s expectations. The routine use of preoperative OCT imaging has vastly improved diagnosis of these vitreomacular pathologies and can help avoid diagnostic misses.

ORDER OF SURGERY: CATARACT SURGERY FIRST OR MACULAR HOLE REPAIR FIRST

The patient’s age and level of lens opacification are important to consider in the case of a phakic patient with a FTMH. If the lens is clear or allows for sufficient visualization to perform membrane peeling, macular hole surgery should not be delayed, because chronic macular holes have worse visual outcomes and lower rates of successful closure. In patients under the age of 50 with FTMH without significant lens opacification, vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade alone without lens extraction could be considered. There is always concern that the patient will develop a visually significant cataract after vitrectomy. A retrospective review investigating the progression of cataract after vitrectomy in different age groups found the rate of cataract progression in patients under the age of 50 was minimal after vitrectomy for macular hole repair. However, there was a statistically significant increase in cataract progression in patients over the age of 50 who underwent vitrectomy.² The patient’s age, grade of lens opacification, and ability to visualize the retina and macula for safe and effective surgery affect the timing and potential need for more urgent cataract surgery.

CATARACT SURGERY BEFORE MACULAR HOLE REPAIR

Visually Significant Cataracts

In patients older than 50 with visually significant lens opacification precluding a sufficient view to allow for membrane peeling, it is important to perform cataract surgery prior to vitrectomy to ensure adequate visualization for vitrectomy and safe and complete ILM peeling.

Non-visually Significant Cataracts

In cases where the cataract is not visually significant, the chance of developing a cataract soon after vitrectomy should be considered. A complete vitrectomy with posterior vitreous detachment and anterior vitreous removal increases the risk of cataract development.³ There are many theories as to why cataracts progress after vitrectomy. These include the difference in ionic composition or temperature of the vitrectomy infusion solution compared to the native vitreous, light toxicity from the operating microscopy during surgery, and increased posterior lens capsule permeability leading to crystalline lens protein oxidation.

Another factor to consider is the use of intraocular gas tamponade for macular hole repair. The use of intravitreal gas causes nuclear sclerosis to increase by 60%, compared to eyes without use of a gas bubble.² These cataracts most often manifest as vacuoles, posterior capsular opacities, and lens feathering. The longevity of intraocular gas tamponade and in turn the duration of lens exposure to gas correlates with cataract progression.⁴ To minimize this problem and promote macular hole closure, retina specialists recommend avoiding supine positioning after surgery.⁵ Given that cataract progression is in large part inevitable after macular hole repair in older patients, lens extraction prior to or concurrent with vitrectomy has its advantages in some patients.

ADVANTAGES OF CATARACT EXTRACTION PRIOR TO VITRECTOMY

Many retina surgeons prefer patients to be pseudophakic prior to macular hole repair for a more thorough vitrectomy and improved visualization. From the perspective of the cataract surgeon, cataract surgery following vitrectomy can be more complex due to loss of anterior vitreous counterpressure, which leads to increased fluctuations in anterior chamber depth, zonular instability, and flaccid posterior capsule.⁶ Patients who develop postoperative cystoid macular edema following cataract surgery may be at increased risk of reopening or recurrence of the macular hole.⁷ The final advantage of cataract surgery prior to macular hole repair involves the ability to completely remove the peripheral vitreous in pseudophakic patients. Peripheral vitreous shaving is not possible in patients who are phakic, because the lens prohibits complete removal. Particularly in large or chronic macular holes, a large gas bubble with >95% gas fill is important for hole closure.⁸ A more thorough vitrectomy allows for more complete or larger gas fill, which is important in more complex macular hole cases.

COMBINED PHACOVITRECTOMY CONSIDERATIONS

Combined phacovitrectomy is commonly performed outside the United States, but it has not become routine practice domestically. Many retina surgeons who do not routinely perform cataract surgery may not feel comfortable with phacoemulsification and prefer to have that portion of the surgery undertaken by an experienced cataract surgeon. Having both surgeons present requires coordination that can be hard to achieve in modern-day practice. Despite the issues coordinating combined surgery, there are several advantages. When phacoemulsification and vitrectomy are combined, patients have quicker visual rehabilitation and visual recovery.⁹ Having the cataract removed prior to vitrectomy allows for optimal visualization when performing ILM peeling, which can be challenging if media opacities are present. Additionally, there have been studies showing significant cost savings when surgeries are combined.¹⁰ Lastly, patient satisfaction scores in a single study showed a preference for combined surgery over sequential surgery.¹¹

Disadvantages of a combined surgery include less predictable postoperative refractive error. A notable myopic shift in the postoperative refraction after combined phacovitrectomy surgeries for macular hole repair has been seen in multiple studies.¹² No definitive conclusion has been drawn as to the etiology of the myopic shift, but theories include gas tamponade causing anterior displacement of the IOL and possibly thicker macula and absence of the foveal depression leading to errors in the preoperative lens calculation.

CONSIDERATIONS FOR CATARACT SURGERY AFTER MACULAR HOLE REPAIR

If sequential cataract surgery is to be performed after vitrectomy for macular hole repair, choosing the appropriate timing of cataract surgery is critical. We recommend waiting at least 3 months after vitrectomy to ensure adequate time for the eye to heal and to assure successful closure without recurrence of the hole. Monitoring closely for postoperative cystoid macular edema and treating promptly helps prevent macular hole reopening after cataract surgery.⁷

INTRAOCULAR LENS CHOICES

Choosing the right intraocular lens for patients undergoing cataract extraction and vitrectomy surgery for macular hole repair takes careful consideration of the properties of each lens. Below is an overview of considerations for IOL selection in patients who are undergoing macular hole repair. These recommendations are summarized in Table 1. In routine cases with no macular pathology or retinal disease such as tears, lattice, or high myopia, the cataract surgeon should choose the lens that best meets the patient’s needs.

Silicone Hydrophobic Lenses

This type of lens should be avoided in patients needing retinal surgery. The lens makes retinal surgery more difficult, because the lens is prone to fogging, particularly during fluid-air exchange. If the patient were to need silicone oil placement in the future, there is a risk of silicone oil attachment that can require lens explanation if visually significant.

Hydrophilic Acrylic Lenses

These lenses have a risk of opacities from lens calcification. The presence of anterior or posterior air or gas tamponade can induce a calcification process, resulting in opacification of these lenses (Figure 1).

Multifocal Intraocular Lenses

These lenses should be avoided in any patient with underlying macular pathology, including macular holes. Patients may be unhappy due to difficulty with these lenses when there is concurrent macular pathology. Additionally, visualization for ILM peeling or any retinal surgery can be difficult in patients with multifocal IOLs as the view of the retina can be distorted.^13,14

CONCLUSION

Determining the appropriate timing of cataract surgery when a patient has a concomitant macular hole can be challenging. Considering the various scenarios outlined in this article and consulting with retina and cataract colleagues to comanage these patients helps to determine the best timing for repair and other surgical considerations to optimize visual outcomes for patients. RP

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