Combined phacoemulsification and removal of gas following macular hole surgery Henry B. Smith, MA, MBBS, MRCOphth, Nelson A. Sabrosa, MD, PhD, Niall Patton, MD, FRCOphth, Robert E. MacLaren, DPhil, FRCOphth We describe a technique for combined fluid–gas exchange and phacoemulsification 2 weeks after macular hole surgery to achieve rapid visual rehabilitation. The procedure uses a standard cataract set and requires minimal vitreoretinal expertise. We encountered no significant complications and obtained long-term outcomes comparable to those with conventional management. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:229–234 Q 2011 ASCRS and ESCRS Online Video There is currently a debate about whether to posture patients face-down after vitrectomy and gas for macu- lar hole treatment. 1 A requirement for posturing may deter some patients, particularly those with musculo- skeletal problems, from having surgery. Other sequelae such as deep vein thrombosis and ulnar nerve palsies are also reported. 2 Advocates of non- prone posturing cite pilot studies showing macular hole closure rates of 88% to 92% without face-down posturing. 3–5 Those in favor of posturing find support in a recent prospective randomized clinical trial of 150 eyes 6 that showed a higher closure rate in patients randomized to prone posturing than in those randomized to nonprone posturing (97% versus 88%, PZ.027). However, in that study the overall results were skewed by a marked difference in one subgroup of patients who had larger holes (500 mm to 800 mm) treated with hexafluoroethane gas. This makes it diffi- cult to extrapolate the conclusions of that study to macular hole surgery using perfluoropropane (C 3 F 8 ) gas, which is more widely used in other studies and is longer-acting, providing a larger bubble in the im- mediate postoperative period. Although the posturing debate is unresolved, it seems reasonable to assume that the greater surface area in the immediate postop- erative period will ensure that long-acting gases such as C 3 F 8 will cover macular holes more effectively, despite varying orientations of the eye. Such gases would, therefore, be preferable for nonprone postur- ing, particularly for larger holes. As most patients develop or already have cataract, another topic of debate is whether to perform phaco- emulsification at the same time as macular hole surgery or as a separate procedure. 3 In addition to patient convenience, advantages of a combined proce- dure include the opportunity for a more complete anterior vitrectomy and the introduction of a slightly larger bubble. Having gas in the eye may, however, cause problems with lens displacement and optic cap- ture in up to 9% of cases. 7 Small biometry errors have also been reported due to a myopic shift following combined phacovitrectomy cases (possibly due to anterior lens displacement). 8 In many centers, service issues and specialist expertise determine the way the surgery is performed; frequently as 2 sequential proce- dures, with vitrectomy and gas followed by cataract extraction at a later date. In the latter case, cataract extraction is usually performed once the gas has reab- sorbed and the hole is confirmed to be closed several months after the vitrectomy. Another issue of debate relates to the type of gas used. Long-acting gases such as C 3 F 8 have the advan- tage of providing a larger bubble in the immediate Submitted: March 18, 2010. Final revision submitted: September 30, 2010. Accepted: October 1, 2010. From Moorfields Eye Hospital (Smith, Sabrosa, Patton, MacLaren) and University College London Moorfields NIHR Ophthalmology Biomedical Research Centre (MacLaren), London, and Nuffield Laboratory of Ophthalmology (MacLaren), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom. Corresponding author: Henry B. Smith, MA, MBBS, MRCOphth, VR Research Department, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, United Kingdom. E-mail: hbs@doctors.net.uk. Q 2011 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/$ - see front matter 229 doi:10.1016/j.jcrs.2010.11.014 TECHNIQUE