Original article
Femtophacovitrectomy. Case series and description of the technique
Femtofacovitrectomía. Serie de casos y descripción de la técnica
J.O. Moya Romeroa,b,
, G.A. Ochoa Máynezc, M.A. Cantero Vergarad, C.A. Gómez Cortesa,b
Corresponding author
a Alta Especialidad en Retina y Vítreo, Subsección de Retina, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico
b Alta Especialidad en Córnea y Segmento Anterior, Subsección de Córnea y Segmento Anterior, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico
c Subsección de Retina, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico
d Subsección de Córnea y Segmento Anterior, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico
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Serie de casos y descripción de la técnica" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "461" "paginaFinal" => "468" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Femtophacovitrectomy. Case series and description of the technique" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1847 "Ancho" => 2455 "Tamanyo" => 470862 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Procedimiento láser. A) Se realiza el acoplamiento del ojo con el objetivo láser mediante interfase Softfit™ (SoftFit-LenSxContac Lens, Alcon; Arlington, Texas, EE. UU.). B) Centrado de la capsulotomía y programación de fractura cristaliniana. C) Incisión corneal en 3 planos. D) Emisión del láser.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.O. Moya Romero, G.A. Ochoa Máynez, M.A. Cantero Vergara, C.A. Gómez Cortes" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.O." "apellidos" => "Moya Romero" ] 1 => array:2 [ "nombre" => "G.A." "apellidos" => "Ochoa Máynez" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Cantero Vergara" ] 3 => array:2 [ "nombre" => "C.A." 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(A) Pterygium head cleavage and surface keratectomy with Crescent 2.5<span class="elsevierStyleHsp" style=""></span>mm scalpel (Beaver-Visitec Labs, Waltham, MA, USA). Note the width of the scleral bed. (B) Conjunctival graft turned over the cornea after releasing the limbus, with the basal side facing upwards. (C) Placing the graft over the scleral bed with a hinge maneuver after applying Tissucol<span class="elsevierStyleSup">®</span>. Note the orientation of the limbal edge, identified with the asterisk. (D) Appearance after surgery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Gargallo-Benedicto, D. Hernández Pérez, Á. Olate-Pérez, E. Betancur-Delgado, M. Cerdà-Ibáñez, A. Duch-Samper" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Gargallo-Benedicto" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Hernández Pérez" ] 2 => array:2 [ "nombre" => "Á." "apellidos" => "Olate-Pérez" ] 3 => array:2 [ "nombre" => "E." 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"apellidos" => "Gómez Cortes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Alta Especialidad en Retina y Vítreo, Subsección de Retina, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Alta Especialidad en Córnea y Segmento Anterior, Subsección de Córnea y Segmento Anterior, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Subsección de Retina, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Subsección de Córnea y Segmento Anterior, Sección de Oftalmología, Hospital Central Militar, Mexico City, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Femtofacovitrectomía. Serie de casos y descripción de la técnica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1386 "Ancho" => 1843 "Tamanyo" => 357059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Laser procedure. (A) The eye is coupled with the laser lens by means of the Softfit™ interface (SoftFit-LenSxContac Lens, Alcon; Arlington, TX, USA). (B) Capsulotomy centering and programming lens fracture. (C) Corneal incision in 3 planes. (D) Laser emission.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients requiring surgery due to vitreoretinal diseases frequently exhibit lens opacity.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> In addition, vitrectomy produces pre-existing cataract progression and even when the cataract is not significant at the time it can progress, with percentages between 68% and 90% at 2 years follow-up.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2,3</span></a> Accordingly, eyes with some degree of lens opacity that require vitreoretinal surgery could be candidates for extraction for improving postoperative visual rehabilitation, reducing physical and cost risks by avoiding the need of a second procedure for cataract extraction. Cataract surgery techniques have evolved from intracapsular to extracapsular extraction, and toward phacoemulsification, leading to a progressive reduction in the size of the surgical incision, increasing safety and improved visual results, to the extent that phacoemulsification has been the surgery of choice for the past 2 decades.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Femtosecond laser is one of the main innovations of modern ophthalmic surgery. It is used mainly in corneal surgery and gained FDA approval for cataract surgery in 2010.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> Femtosecond laser is utilized for creating corneal incisions, capsulotomy, nucleus fragmentation and correcting astigmatism through arcuate incisions,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> improving results in procedure reproducibility, resistance, uniformity and precision.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At present, retina procedures yield improved visual results due to recent technological breakthroughs, better instruments and refining of surgical techniques that enable ambulatory surgery and shorter surgery and postop recovery times.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> Jindal Bali et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> presented the first study to combine 25<span class="elsevierStyleHsp" style=""></span>G pars plana vitrectomy and femtosecond laser-assisted phacoemulsification in 8 patients under retrobulbar blocking, concluding that this alternative provides potential benefits for the success of the combined procedure such as centered and reproducible capsulorhexis, which enables excellent intraocular lens stability, less need for ultrasound and therefore lower corneal edema possibilities in vitreoretinal surgery. The second study was published by Gomez-Resa et al.,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> comprising 21 cases with combined 23<span class="elsevierStyleHsp" style=""></span>G factor vitrectomy and femtosecond laser, reporting only one complication associated to laser, the loss of suction in one case. Said authors conclude that it is a safe and effective technique providing greater advantages than conventional phacovitrectomy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study is to assess the safety and surgical results in the execution of femtosecond laser-assisted cataract phacoemulsification combined with pars plana vitrectomy, herein termed as “femtophacovitrectomy”.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects, material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective, longitudinal, noncomparative, interventional study on a series of cases with the objective of assessing safety and surgical results of femtosecond laser-assisted cataract phacoemulsification combined with pars plana vitrectomy (femtophacovitrectomy) in selected cases. The study was carried out in the Ophthalmology Dept. within the Retina Section of the Central Military Hospital in the period comprised between June 2013 and February 2014. The study selected patients with the clinical diagnostic of vitreoretinal disease and cataracts (graded according to the LOCS III system<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">,</span> including patients with nuclear sclerosis between NO2 and NO4) who, according to the judgment of the assessing ophthalmologists, were candidates to pars plana vitrectomy combined with cataract extraction by means of femtosecond laser-assisted phacoemulsification (non-probabilistic sampling due to recruitment of consecutive cases). In addition, patients should exhibit sufficient cooperation, acceptance and adequate understanding of the requirements for the planned procedure. Informed consents were obtained from all the patients who accepted their participation in the protocol after explaining the risks and benefits thereof. The study complied with the ethical standards of the institution and the regulations of the General Health Act, as well as with the Helsinki Declaration (1964) including the 1975 Tokyo amendment. It also fulfills the international guidelines for biomedical research, in the framework of the Transparency Act concerning personal data protection in force in our country.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion criteria comprised pupil dilatation on the 5.5<span class="elsevierStyleHsp" style=""></span>mm, phacodonesis, lens subluxation, pseudoexfoliation syndrome, traumatic cataracts, posterior synechiae<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>h, intraocular pressure<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>mmHg on the surgery date (taken during presurgery examination), any corneal opacity that prevented adequate anterior segment visualization, regmatogenous retina detachment (discarded with A/B mode ultrasound in the case of dense vitreous hemorrhage), indication for placing scleral cerclage, active inflammation or with quiescence period under 3 months, patient inability to follow verbal instructions (mental or hearing alterations), claustrophobia, physical tremor or limitation for remaining in supine position during the laser procedure, presence of ocular or systemic disease preventing surgery, not accepting participation in the study, follow-up under 3 months and incomplete files.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All the procedures were carried out by a surgeon with ample experience in femtosecond laser-assisted phacoemulsification cataract extraction, in vitreoretinal surgery training (JOMR, second-year <span class="elsevierStyleItalic">fellowship</span> of the high retina and vitreous specialty, with broad experience in conventional and femtosecond laser-assisted phacoemulsification).</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient preparation:</span> it begins 45<span class="elsevierStyleHsp" style=""></span>min before surgery instilling tropicamide and phenylephrine (TP Ofteno, 50<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>mg/ml, Sophia, Zapopan, Jalisco, Mexico) in the sac fundus of the eye to be operated, 3 times at 15<span class="elsevierStyleHsp" style=""></span>min intervals to achieve adequate pupil dilatation. Vital signs are monitored under the supervision of the anesthetist, without sedation, to facilitate adequate patient cooperation during the procedure. Subsequently, 0.5% tetracaine topical anesthetic (Ponti Ofteno, 5<span class="elsevierStyleHsp" style=""></span>mg/ml, Sophia, Zapopan, Jalisco, Mexico) is administered over the ocular surface 5<span class="elsevierStyleHsp" style=""></span>minutes prior to surgery and another drop immediately prior to coupling the eye with the laser lens.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Surgical technique description</span>: LenSx V2.20 femtosecond laser platform was utilized (wavelength, 1.030<span class="elsevierStyleHsp" style=""></span>nm at 50<span class="elsevierStyleHsp" style=""></span>kHz, 600–800<span class="elsevierStyleHsp" style=""></span>fs pulses, with a maximum energy pulse of 15<span class="elsevierStyleHsp" style=""></span>μJ; Alcon Laboratorios, Fort Worth, TX, USA) for programming the corneal incisions, anterior capsulotomy and lens fracture. The primary corneal incision had 2.8<span class="elsevierStyleHsp" style=""></span>mm, at 135°, 5<span class="elsevierStyleHsp" style=""></span>μm spot separation, 4<span class="elsevierStyleHsp" style=""></span>μm separation between layers, 6<span class="elsevierStyleHsp" style=""></span>μJ energy; 5<span class="elsevierStyleHsp" style=""></span>mm capsulotomy with 5<span class="elsevierStyleHsp" style=""></span>μm spot separation, 5<span class="elsevierStyleHsp" style=""></span>μm separation between layers, 8<span class="elsevierStyleHsp" style=""></span>μJ energy. Two cuts were made for the fracture in all cases, with 5.4<span class="elsevierStyleHsp" style=""></span>mm diameter, 10<span class="elsevierStyleHsp" style=""></span>μm spot separation, 10<span class="elsevierStyleHsp" style=""></span>μm separation between layers, 10<span class="elsevierStyleHsp" style=""></span>μJ energy. After selecting all the parameters, corneal docking was performed by means of a sterile SoftFit™ interface (SoftFit-LenSxContac Lens [Alcon; Arlington, TX, USA]) (comprising a curved interface and the contact lens assembled on the laser lens tip that served as a sterile barrier between laser and patient). The system descended to make contact with the patient eye, with sensors detecting the lens position and the docking force. The surgeon observed the contact of the interface with the cornea utilizing video microscope device and applied suction when adequate corneal docking was achieved, observing on the screen the anterior segment optic coherence tomography images (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), carrying out the limbal centering, adjusting capsulotomy characteristics, corneal incisions and lens fragmentation. Laser treatment was initiated in capsulotomy, lens fragmentation and corneal incisions sequence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">After performing the laser procedure, according to each case and the internal availability of operating rooms, the patient was moved on the stretcher within the same surgery under the surgical microscope. In other cases, the patient was moved to another surgery adjacent to the laser platform. Retrobulbar anesthesia was administered and subsequently aseptic and antiseptic measures were applied on the periocular region with 10% isodine solution (DermoDine, Iodopovidona 11%, DEGASA S.A. de C.V. CD. Mexico, Mexico), including 5% sac fundus with 3<span class="elsevierStyleHsp" style=""></span>min exposure. Sterile fields were placed, Slade-Murdoch blepharostat was utilized (AE-1033 Asico, Westmont, LI, USA) and conjunctival sac fundus were irrigated (balanced saline solution, SSB, Laboratorio PISA, S.A de C.V. Guadalajara, Jal, Mexico). Trans-conjunctival trocar (23 or 25<span class="elsevierStyleHsp" style=""></span>Ga) was placed in the angle at 30–45°, temporal inferior for infusion, and in X and II hours for vitrectome and endoillumunation at 4<span class="elsevierStyleHsp" style=""></span>mm of the limbus (phakics)<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">,</span> and a closed infusion cannula was placed. A blunt dissection was made of the corneal incisions created with the laser utilizing a Slade spatula (AE-2326. Asico, Westmont, LI, USA), injecting trypan blue (Vision Blue, 0.06% D.O.R.C, Zuidland, Holland) (in order to document the study, full capsulotomy was performed) and viscoelastic (Discovisc, 4% condroitin sulfate, 1.65% sodium hyaluronate, Alcon; Arlington, TX, USA) in the anterior chamber.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The anterior capsule was withdrawn with utrata by means of the napkin technique.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> Lens segmentation was completed with <span class="elsevierStyleItalic">pre-chopper</span> (Akahoshi Nucleus Splitter AE-4289 femtosecond chopper, Asico, Westmont, LI, USA).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> Subsequently, the bubbles generated by the laser procedure were aspired in order to avoid pupil blockage and posterior capsule rupture. The procedure continued with conventional hydrodissection and nucleus rotation, lens fragments phacoemulsification and aspiration of cortical remains, implanting through injection a foldable lens (hydrophobic acrylic, Acrysof SN60WF IQ, Alcon; Arlington, TX, USA), maintaining viscoelastic during the retina surgery up to the moment prior to performing the liquid/air exchange, at which time it is washed with BSS.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Central and peripheral vitrectomy was performed utilizing the Constellation<span class="elsevierStyleSup">®</span> Vision System (ALCON; Arlington, TX, USA) and a noncontact broad field visualization system BIOM II (Oculus, Wetzlar, Germany).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The following steps were performed in accordance with the condition of each case: induction of posterior vitreous detachment through active suction with vitrectome, segmentation and delamination of fibrovascular membranes, epiretinal membrane staining under air with trypan blue (Vision Blue, 0.06% D.O.R.C, Zuidland, Holland), internal limiting membrane staining with brilliant blue (Brillant Blue G-250. Sigma–Aldrich, San Luis, MO, USA), membrane peeling with tweezers for internal limiting membrane (Ref: 706.44. ALCON; Arlington, TX, USA); endophotocoagulation and hemostasia through diathermia, placing tamponade in the vitreous cavity as per surgeon criteria (18% sulfur hexafluoride gas [SF6]) performing partial fluid/air exchange for preventing hypotony when long duration tamponade was not necessary,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> withdrawing the trocar and verifying that esclerotomies were sealed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Antibiotic/steroid eyedrops were instilled (Sophixin Dx Ofteno, dexamethasone phosphate/ciprofloxacin chlorhydrate, Laboratorios Sophia S.A. de C.V., Zapopan, Jalisco, Mexico), and using an occluding patch at the end of the procedure. Standard postoperative management comprised the application of Sophixin Dx Ofteno every 4<span class="elsevierStyleHsp" style=""></span>h the first week, reducing the dose in subsequent days.</p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients underwent a pre- and postoperative examination comprising best corrected visual acuity (BCVA) with Snellen board (converted to LogMAR for statistical analysis), slitlamp biomicroscopy, intraocular pressure measurement with Goldmann applanation tonometer (Slitlamp BQ900<span class="elsevierStyleSup">®</span>, HaagStreit, Ohio, USA/Indirect Ophthalmoscope All Pupil, Keeler, Broomall, PA, USA) and posterior segment visualization through indirect ophthalmoscopy. Complications were documented. Follow-up was provided on day one, week one, month one and 3 (thereafter in accordance with the criterion of the examining ophthalmologist).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nonparametric statistical analysis was performed with percentage ranges and averages, as well as parametric analysis for visual acuity with LogMar, utilizing the <span class="elsevierStyleItalic">T</span> for student for the scalar variable related to a confidence interval of 95% and a statistical significance of 0.05 by means of SPSS application version 20.0 (IBM/SPSS, Inc., Chicago, LI, USA).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">The study included 35 patients, 20 males (57.1%) and 15 females (42.9%), who fulfilled the inclusion criteria and accepted participation in the study. The mean age was 60.76 years<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 (between 51 and 70 years). The total amount of eyes was 35 (21 right and 14 left eyes), with a mean follow-up of 13.3 months (10–16 months). Preoperative diagnostics were: vitreous hemorrhage (12 grade III and 5 grade IV) secondary to diabetic retinopathy (DR) in 11 cases and in 6 secondary to central retina vein occlusion; epiretinal membrane, 7; macular hole, 6 (4 cases in grade III and 2 cases in grade IV, according to the Gass classification)<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> and 5 vitreous hemorrhage cases with tractional retina detachment (TRD) secondary to DR. Gauge 23<span class="elsevierStyleHsp" style=""></span>G was utilized in 24 cases (68.5%) and gauge 25<span class="elsevierStyleHsp" style=""></span>G in 11 cases (31.5%). Overall, 95% of vitreous hemorrhage cases with and without TRD were performed with gauge 23<span class="elsevierStyleHsp" style=""></span>G, mainly in dense hemorrhages to optimize surgery time (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Mean preoperative LogMAR BCVA was 1.3 (0.6–1.9), being ≤20/200 in 80% (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The presence of intraoperative miosis (pupil under 4<span class="elsevierStyleHsp" style=""></span>mm) was observed after performing the laser procedure surgery and before performing lens phacoemulsification in 6 cases (14.28%). This occurred when patients exhibited <span class="elsevierStyleItalic">rubeosis iridis</span> or pupil ≤6.5<span class="elsevierStyleHsp" style=""></span>mm. this was managed in 2 cases with the use of Malyugin ring (MicroSurgical Technology, Redmond, WA, USA), in one case with iris retractors and in one case with pupil stretching due to the absence of pupil dilatation with viscoelastic and intrachamber adrenaline. In all diagnosed macular hole cases, brilliant blue staining and internal limiting membrane peeling was performed. In 5 epiretinal membrane cases (71%) trypan blue staining was performed and subsequently brilliant blue staining and internal limiting membrane peeling. In all TRD cases membrane segmentation and delamination was performed in accordance with each case. In 66% of cases endophotocoagulation was performed (Nd:YAG dual frequency 532<span class="elsevierStyleHsp" style=""></span>nm, Purepoint, Alcon; Arlington, TX, USA), that was supplementary to the presurgery action on the patient in 36.36% (cases with DR and central retinal vein occlusion). In the 6 macular hole cases, 18% SF6 gas was left as tamponade at the end of the surgery, as well as in one vitreous hemorrhage case and TRD that presented peripheral iatrogenic retinotomy (2.85%). In the rest of procedures (80%) partial exchange with air was performed. Only one patient (2.85%) exhibited leak through the sclerotomy when withdrawing the 2 main trocars, and for this reason a single stitch with poliglactin 910 8-0 (Vicryl, [Poliglactil 910] 8-0, Johnson & Johnson, New Jersey, USA) was applied. In the early post-surgery (first 4 weeks), all patients exhibited variable grades of subconjunctival hemorrhages that were correlated to the coupling area of the femtosecond laser suction interface. Only one patient (2.85%) exhibited post-surgery vitreous hemorrhage (first 24<span class="elsevierStyleHsp" style=""></span>h) grade I, which was resolved in 3 weeks. Overall, 20% of patients exhibited stromal corneal edema. In 100% of these cases ≤a 2+ to 4+ (subjective scale) was located in the upper third (associated to the corneal incision) which was resolved without difficulties with conventional medical management. None of the patients exhibited hypotony (IOP<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg), only one patient (2.85%) exhibited postoperative ocular hypertension (≥21<span class="elsevierStyleHsp" style=""></span>mmHg), associated to the expansion of intraocular gas utilized as tamponade for the macular hole, which was resolved with topical hypotensors during the first week post-surgery. None of the patients exhibited endophthalmitis or required a second surgical intervention. In the late postoperative period (>4 weeks), none of the patients required a new surgery, while 3 cases with DR history and one secondary to OVCR exhibited macular edema documented with optic coherence tomography the second month after surgery, with the indication of applying intravitreal antiangiogenic (Lucentis, Ranibizumab 0.5<span class="elsevierStyleHsp" style=""></span>mg/0.05<span class="elsevierStyleHsp" style=""></span>ml; Genentech, South San Francisco, CA, USA). BCVA was taken at months 3 post-surgery, finding postoperative improvement in 91.4% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05), with 3 cases remaining without changes and without any patient suffering visual loss. A mean LogMAR of 0.5 (20/63) (1.3–0.3) was registered, which was of ≥1.0 (20/200) in 91% of cases. None of the patients suffered visual loss (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Cataract surgery techniques have evolved toward a progressive reduction in surgical incision sizes, increasing safety and improving visual results. Since the femtosecond laser was approved in 2010, its effectiveness and safety has been demonstrated in numerous articles reporting better results in reproducibility, resistance, uniformity and precision<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">17,18</span></a>; with centered capsulotomies that provide adequate intraocular lens stability that diminish the need for ultrasound and therefore lower corneal edema<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> probabilities, thus facilitating better visualization of the retina while performing vitreoretinal surgery.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The combination of femtosecond laser-assisted cataract phacoemulsification and pars plana vitrectomy was published in 2010 as an alternative in selected cases.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> The benefits of femtosecond laser for retinal surgery include the possibility of performing programmed capsulotomy at the desired diameter.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In their series, Jindal Bali et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> did not describe the capsulotomy diameter or mention the use of tamponade (gas or air). Gomez-Resa et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> modified the diameter on the basis of presurgical planning which included the use of intraocular gas: 5.0<span class="elsevierStyleHsp" style=""></span>mm if not required and 4.8<span class="elsevierStyleHsp" style=""></span>mm when necessary. The present study utilized a standard diameter of 5.0<span class="elsevierStyleHsp" style=""></span>mm, independently of the need for tamponade or not as well as of the postoperative position. In addition, as in other series, no problems were observed in the centering of the ocular lens.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Masket et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> found that corneal incisions created with femtosecond laser eye were stable, reproducible, precise and located exactly at the preselected site. Gómez-Resa et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> described the use of sutures in all their cases to avoid corneal stromal edema during vitrectomy as well as to stabilize the anterior chamber during trocar insertion via pars plana. The present study did not utilize corneal sutures because all incisions were watertight during the procedure (even during the scleral peripheral indentation and while raising IOP to 60<span class="elsevierStyleHsp" style=""></span>mmHg for performing hemostasia in some cases), and placing the trocars prior to phacoemulsification preempted the risk of anterior chamber collapse due to loss of viscoelastic.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Burkhard Dick et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> published a histological study of corneal incisions with femtosecond laser, revealing a complete cut of nearly all corneal layers with minimum tissue adherences. Accordingly, after performing the incision the eye is regarded as open, and the controversy arises about whether or not carrying out the laser procedure and the surgery in a different operating rooms would increase the risk of infection. The Central Military Hospital is equipped with only one platform for performing laser procedures and cataracts, and for this reason in some cases the surgery is carried out in the same operating room and in other cases in a different room in accordance with the hospital requirements, without finding complications associated to this practice.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Gómez-Resa et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> carried out the procedure in the same operating room, in contrast with Jindal Bali et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> who performed in different rooms, without reporting difficulties due to this difference in any of the series.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Capsular blockage has been described due to not aspiring the bubbles located between the posterior capsule at the surface. The laser-assisted cataract surgery performed in the Military Hospital always separates the fragments pre-cut by the laser and the aspiration of said bubbles, which has avoided related complications. Gómez-Resa et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> described trans-surgical posterior capsulotomy in all cases immediately after performing phacoemulsification with the objective of obtaining a better trans-surgical visualization and avoiding postoperative posterior capsule or opacity. The limitation of this procedure is that it does not aspire viscoelastic from the anterior surface at the end of the procedure on the basis that it can be eliminated from the eye through the trabecular mesh, thus avoiding intraocular lens manipulation at the end of the surgery. However, intraocular hypertension is exhibited by up to 23.8% of cases during the first 24<span class="elsevierStyleHsp" style=""></span>h post-surgery.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The authors do not routinely perform trans-surgical posterior capsulotomy and recommend this procedure only if silicon oil will be inserted as tamponade or if the posterior capsule exhibits metaplasia that cannot be withdrawn with capsular polishing, as this would impair trans-surgical visualization or interfere with postoperative assessment. It is recommended to aspire the viscoelastic from the anterior chamber in all cases before fluid/air exchange and subsequently performing assisted capsulotomy with the vitreotome in order to avoid the mobilization thereof, without presenting trans-or post-surgery intraocular lens instability (data not published). For this reason, it is considered that not withdrawing the viscoelastic only increases postoperative comorbidity.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In contrast with previous series, the present study includes patients with TRD secondary to DR without finding increases in the number of complications or technical difficulties for executing the procedure. As other authors, this study did not include regmatogenous retina detachment patients due to the possible risk of increasing its extension and the difficulties with suction during the laser procedure in case of ocular hypotony. The present study included patients operated with gauge 23 and 25<span class="elsevierStyleHsp" style=""></span>G, without finding differences associated to this, as similarly reported in the 2 previous series which utilized only one gauge in each.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The incidence of intraoperative complications in combined procedures comprising pars plana vitrectomy and femtosecond laser-assisted cataract extraction is below 10%. This low incidence could be related to the selection of cases, generally with low complexity. The present series of cases found a similar incidence, regardless of whether the procedure was carried out by a single surgeon or by an anterior segment surgeon and a retina surgeon, as reported by Gómez-Resa et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The presence of miosis was described after femtosecond laser-assisted cataract surgery, attributed to sudden temperature increases in the aqueous humor<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> and to the release of inflammatory mediators (prostaglandin E2).<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> This, together with the characteristics of patients with iris ischemia and mean presurgery pupil dilatation, gives rise to a variable that must be considered while planning these cases, which can be managed with various alternatives such as medicaments, viscoelastic, mechanical dilatation and the use of dilating devices.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Comparing visual results with other series is difficult as they depend on the severity of each case and associated complications. Even so, 80% reported visual improvements, similar to the percentages obtained in the present study.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9,10,25</span></a> With the present data, it can be stated that this case series presents the highest number of surgeries combining the subjects technology, with similar results to those reported elsewhere, including TRD cases without increased complications. The results of femtophacovitrectomy depend on an adequate selection of the procedure and the patient for the chosen technique, and is feasible and safe to carry out associated procedures such as endophotocoagulation, internal limiting membrane peeling and use of different tamponade.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">With adequate selection of patients and pathologies, femtosecond laser-assisted phacoemulsification in combination with pars plana vitrectomy is a safe and efficient option, with complication risk rates and technical surgical difficulties similar to those of conventional phacovitrectomy. The presence of intra-surgery miosis must be taken into account in cases with mean pupil dilatation or presurgery rubeosis iridis.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The limitations of the present study include the small number of patients and the absence of a control group, although it enables registering the experience with this technique in our continent with results similar to published reviews as well as to initiate new research lines that could provide additional data enabling the generalization of the reported results.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors state that they do not have any conflict of interests with any of the products described in this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres733542" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec737371" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres733543" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec737370" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-02-03" "fechaAceptado" => "2016-03-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec737371" "palabras" => array:5 [ 0 => "Phacovitrectomy" 1 => "Pars plana vitrectomy" 2 => "Cataract surgery" 3 => "Femtosecond laser" 4 => "Femtophacovitrectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec737370" "palabras" => array:5 [ 0 => "Facovitrectomía" 1 => "Vitrectomía pars plana" 2 => "Cirugía de catarata" 3 => "Láser de femtosegundo" 4 => "Femtofacovitrectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to assess the safety and surgical results of combined pars plana vitrectomy and femtosecond laser-assisted cataract surgery (femtophacovitrectomy).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective, non-comparative case series was conducted by selecting patients with cataract and vitreoretinal pathology who underwent femtophacovitrectomy by a single surgeon at the <span class="elsevierStyleItalic">Hospital Central Militar</span> between June 2013 and February 2014. An evaluation was made of the preoperative characteristics, surgical indications, results, and postoperative complications, with a minimum follow-up of 3 months.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 35 eyes of 35 patients, of whom 20 (57.1%) were male. The mean age was 60.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 years. Diagnoses included vitreous hemorrhage (19 cases), macular hole (6 cases), epiretinal membrane (7), and tractional detachment (5 cases). The mean best corrected visual acuity was 1.3 LogMAR before surgery, and 0.5 LogMAR at 3-months follow-up (<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span></span><<span class="elsevierStyleHsp" style=""></span>0.05). No patient had visual loss. The intra-operative complication was miosis in 14.28%. In the early postoperative period (<1 month), all had subconjunctival hemorrhage, with moderate corneal edema in 20% of cases, and only 2.85% (one case) ocular hypertension associated with use of intraocular gas. There were no cases of endophthalmitis. The mean follow-up was 13.3 months (10–16 months).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of femtosecond laser in phacovitrectomy is a safe and effective alternative, with similar risk of complications in cases of macular pathology, tractional retinal detachment, and/or vitreous hemorrhage.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la seguridad y los resultados quirúrgicos al realizar una facoemulsificación de catarata asistida con láser de femtosegundo combinado con vitrectomía pars plana (femtofacovitrectomía).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo, no comparativo de una serie de casos. Se seleccionó a pacientes con enfermedad vítreo-retiniana y catarata, tratados mediante femtofacovitrectomía en el Hospital Central Militar entre junio de 2013 y febrero de 2014, por un solo cirujano. Se realizó una evaluación de las características preoperatorias, indicaciones quirúrgicas, resultados y complicaciones postoperatorias; con un seguimiento mínimo de 3 meses.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 35 ojos de 35 pacientes, 20 (57,1%) eran masculinos; la edad promedio fue de 6076<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4,2 años. Diagnósticos incluidos: hemorragia vítrea (19 casos), agujero macular (6 casos), membrana epirretiniana (7) y desprendimiento traccional (5 casos). La mejor agudeza visual corregida preoperatoria promedio fue de 1,3 LogMAR y la posoperatoria a los 3 meses, en promedio, fue de 0,5 LogMAR (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05). Ningún paciente presentó pérdida visual. La complicación intraoperatoria fue miosis en un 14,28%. En el postoperatorio temprano (<1 mes), todos presentaron hemorragia subconjuntival; edema corneal moderado en el 20% de los casos; solo el 2,85% (un caso) presentó hipertensión intraocular asociada a uso de gas intraocular. No hubo ningún caso de endoftalmitis. El seguimiento promedio fue de 13,3 meses (10-16 meses).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso del láser de femtosegundo en facovitrectomía es una alternativa segura y efectiva, con riesgo de complicaciones similar en casos de enfermedad macular, desprendimiento traccional de retina o hemorragia vítrea.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moya Romero JO, Ochoa Máynez GA, Cantero Vergara MA, Gómez Cortes CA. Femtofacovitrectomía. Serie de casos y descripción de la técnica. Arch Soc Esp Oftalmol. 2016;91:461–468.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1386 "Ancho" => 1843 "Tamanyo" => 357059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Laser procedure. (A) The eye is coupled with the laser lens by means of the Softfit™ interface (SoftFit-LenSxContac Lens, Alcon; Arlington, TX, USA). (B) Capsulotomy centering and programming lens fracture. (C) Corneal incision in 3 planes. (D) Laser emission.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1336 "Ancho" => 1842 "Tamanyo" => 271374 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Femtophacovitrectomy. (A) Placing 23<span class="elsevierStyleHsp" style=""></span>G trocar prior to phacoemulsification. (B) Capsulotomy extraction. (C) Separation of pre-cut fragments assisted with <span class="elsevierStyleItalic">pre-chopper</span>. (D) Lens fragments emulsification. (E) Vitrectomy pars plana. (F) End of the surgery after withdrawing the trocar.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1079 "Ancho" => 1480 "Tamanyo" => 74423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Best corrected visual acuity (LogMAR) of patients treated with femtophacovitrectomy. BCVA: best corrected visual acuity; PostQx: post-surgery; PreQx: pre-surgery.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Femtophacovitrectomy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gauge 23<span class="elsevierStyleHsp" style=""></span>G \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gauge 25<span class="elsevierStyleHsp" style=""></span>G \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">No. of eyes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Sex of patient</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean age in years</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Preoperative diagnostic</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitreous hemorrhage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Epiretinal membrane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Macular hole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitreous hemorrhage and tractional retina detachment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1210479.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics and pre-surgery diagnostic of patients treated with femtophacovitrectomy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined phacoemulsification, intraocular lens implantation, and vitrectomy for eyes with coexisting cataract and vitreoretinal pathology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.M. 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| Year/Month | Html | Total | |
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| 2018 March | 3 | 0 | 3 |
| 2018 February | 7 | 6 | 13 |
| 2018 January | 15 | 2 | 17 |
| 2017 December | 14 | 3 | 17 |
| 2017 November | 7 | 2 | 9 |
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| 2017 September | 6 | 4 | 10 |
| 2017 August | 7 | 2 | 9 |
| 2017 July | 11 | 4 | 15 |
| 2017 June | 10 | 6 | 16 |
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| 2017 April | 19 | 7 | 26 |
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