We thank Dr Fikret Ucar for his interest on our study “Dropped Lens Fragments Retrieval Using Endoscopy-Assisted Pars Plana Vitrectomy in Patients With Corneal Opacity.” We appreciate the opportunity of discussing his helpful comments.
Dr Ucar noted that in our supplemental brief video on endoscopy-assisted pars plana vitrectomy (E-PPV) “fundus imaging does not appear to be significantly impaired,” suggesting “a more detailed classification of the extent to which corneal opacity limited fundus visualization” would clarify “why simpler techniques such as epithelial debridement were not considered sufficient in these cases.”
The 74 patients who met the inclusion criteria in our 2013-2023 study presented differing surgical challenges. Patients underwent standard operating microscope PPV (S-PPV) lens fragment removal if they had no corneal edema or their edema did not interfere with effective fundus visualization. If corneal edema precluded effective S-PPV, patients were given the choice of E-PPV once the necessary equipment was available in 2018 or waiting for corneal edema to diminish.
S-PPV was converted intraoperatively to E-PPV (1) if corneal haze or edema that was not significant preoperatively or that became apparent intraoperatively prevented effective operating microscopic ophthalmoscopy or (2) if fragments were positioned in locations better visualized endoscopically for removal. S-PPV was planned initially for our patient in the supplemental video because corneal edema was deceptively modest, as Dr Ucar noted. The case was classified as E-PPV, however, because supplemental endoscopy was needed because of stromal edema that precluded effective operating microscope visualization of lens fragment removal.
In brief, “a more detailed classification of the extent to which corneal opacity limited fundus visualization” was inappropriate for our study because decision making was based, case-by-case, on (1) the vitreoretinal surgeon’s preoperative and intraoperative judgment of the media clarity needed for effective surgical fundus visualization and (2) the intraoperatively evolving needs of minimally traumatic lens fragment removal. Subjective slitlamp grading of corneal haze was not needed, and objective measurements of corneal edema and light scattering using Scheimpflug photography or anterior segment optical coherence tomography were also unnecessary.
Disappointed and occasionally distraught patients with dropped lens fragments after cataract surgery complications confront the distress, lost time, reduced vision, logistics, uncertainty, and cost of an unanticipated second intraocular operation. These problems are prolonged when corneal edema delays S-PPV. The emotional benefit to these patients of having their ocular problems addressed promptly by E-PPV should not be ignored.
E-PPV can reduce delays in lens fragment removal and facilitate S-PPV if visualization problems occur intraoperatively. These benefits are accomplished without the recovery delay, transient visual reduction, discomfort, and potential recurrent corneal erosion of patients undergoing epithelial debridement for edematous corneas damaged at least temporarily by cataract surgery.
CRediT authorship contribution statement
RADWAN S. AJLAN: Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. MARTIN A. MAINSTER: Conceptualization, Supervision, Visualization, Writing – original draft, Writing – review & editing. AMANDA K. HERTEL: Writing – review & editing. MARY CHAMPION: Writing – review & editing.
Declaration of interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
See the original article for any disclosures of the authors.
References
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