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  • Retina/Vitreous

    Review of: Combined versus sequential pars plana vitrectomy and phacoemulsification for macular hole and epiretinal membrane

    Daud F, Daud K, Popovic M, et al. Ophthalmology Retina, August 2023

    For patients with macular holes and epiretinal membranes, a large-scale meta-analysis found no significant differences in efficacy or safety when comparing combined pars plana vitrectomy (PPV) and phacoemulsification vs separately performing the two procedures.

    Study design

    This systemic review and meta-analysis reviewed Ovid MEDLINE, EMBASE, and Cochrane CENTRAL databases for articles comparing combined PPV plus phacoemulsification (phacovitrectomy) vs sequential surgery (PPV followed by phacoemulsification) for the treatment of macular holes (MHs) and epiretinal membranes (ERMs). Of the 6470 studies reviewed, 8 retrospective studies and 2 randomized controlled trials were included in this analysis. The combined and sequential groups included 435 eyes and 420 eyes, respectively, and the primary outcome was mean BCVA at 12-month follow-up. Secondary outcomes included refractive error, MH nonclosure rate, changes in macular thickness, and complications.


    No significant differences were found between combined phacovitrectomy versus sequential surgery in terms of 12-month BCVA, absolute refractive error, MH nonclosure rate, and associated retinal or vitreous complications. Of note, BCVA was better in the combined group at 6 months, likely reflecting the longer recovery required in the sequential group as well as the potential for cataract progression to counteract visual gains when the two procedures are performed separately.


    This meta-analysis included low-quality studies and a small sample size overall. In addition, the analysis only included two randomized controlled trials. The relatively short follow-up duration is also a limitation.

    Clinical significance

    This study demonstrates that visual outcomes and complication rates appear similar between combined phacovitrectomy versus sequential surgery for MHs and ERMs. Phacovitrectomy is certainly more convenient for the patient and less costly to the medical system. That said, it can be quite difficult to coordinate care between anterior and posterior segment surgeons. It would be helpful to understand the visual acuity results and complication rates in sequential surgery when phacoemulsification is performed prior to vitrectomy. This sequence allows the posterior segment surgeon to have the clearest view and affords the cataract surgeon a less complicated surgery by avoiding phacoemulsification in a vitrectomized eye. Including this comparison in future analyses would aid in deciding on the best approach for patients with MH and ERM. In addition, the safety and efficacy of combined surgery in short, uncomplicated cases may be quite different than the results in longer cases such as complex diabetic traction detachments. Therefore, we must be careful when attempting to extrapolate from these results.

    Financial Disclosures: Dr. Lisa Schocket discloses no financial relationships.