Performing vitrectomy in phakic patients—without simultaneous lens removal—presents unique challenges that demand precision, planning, and a solid understanding of ocular anatomy. This approach is particularly useful in young patients or those undergoing procedures that are not expected to trigger rapid cataract formation. While secondary cataracts remain a possibility, careful surgical technique can significantly reduce the need for future intervention.

 

Trocar Placement and Entry Technique
A foundational step is the correct placement of the trocars. These should always be inserted 4 mm from the limbus, angled toward the posterior pole—preferably in the direction of the optic nerve—to avoid inadvertent contact with the crystalline lens. Before activating the infusion, it is critical to verify that the cannula is within the vitreous cavity.

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Anterior Vitrectomy and Hyaloidectomy
In phakic eyes, anterior vitrectomy and hyaloid removal must be approached with additional caution. The proximity to the posterior capsule increases the risk of damage, making it essential to work slowly and avoid deep anterior maneuvers. Small, controlled movements are key.

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Crossing the Midline—Myth or Risk?
Traditionally, surgeons are taught to avoid crossing the midline in phakic vitrectomies. While this rule serves as a safe baseline, in practice, it is sometimes necessary to reach across the visual axis. To do so safely, the globe can be gently tilted toward the intended working side. This creates more space and minimizes the chance of instrument-lens contact.

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Laser Application and Indentation
Endolaser can be particularly challenging in these cases. Success depends on maintaining control and directing the instruments consistently toward the posterior pole. Slight ocular tilting toward the treatment area facilitates safer access and better visualization. Peripheral laser application can be completed under air at the end of the procedure, when the surgical field is typically clearer.

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Postoperative Considerations
When using air or gas tamponade, patients must be instructed to avoid the supine position postoperatively, as this may promote cataract formation or the appearance of feathery opacities.

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Conclusion
Phakic vitrectomy is both feasible and safe when executed with proper technique and awareness. With attention to detail and gentle maneuvers, complications can be minimized, allowing excellent outcomes for a carefully selected group of patients.
 

Eye Q Points – Vitrectomy in Phakic Patients

1. Trocars: 4 mm from limbus, aim for the optic nerve:
   Always place the trocars 4 mm from the limbus and direct them toward the posterior pole to avoid lens contact.

2. Avoid broad movements near the lens:
   During anterior vitrectomy and hyaloid removal, use controlled, delicate maneuvers to protect the posterior capsule.

3. Crossing the midline is possible—with technique:
   Slightly tilt the eye toward the working side to increase space and reduce the risk of lens touch when crossing with instruments.

4. Laser under control with proper globe positioning:
   Direct both the laser and endoillumination toward the posterior pole, tilting the globe toward the area being treated for safer access.

5. No supine position post-op with gas/air:
   If gas or air is used, advise the patient to avoid lying on their back to prevent cataract formation and feathery opacities.

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