Medical versus surgical management of retained lens fragments

Schaal and Barr1 should be applauded for exploring the role of medical versus surgical therapy for retained lens material as this is underreported in the literature. However, the conclusion that select patients had reasonable outcomes from a delayed surgical or conservative approach can be made only in hindsight given the huge impact of selection bias. Previous large series have shown that delayed vitrectomy increases the risk for both retinal detachment and ocular hypertension, and these in turn are associated with poorer visual outcomes.2,3 This is supported by a pathological correlate.4 The present study was a small retrospective series that found no statistically significant difference in visual acuity outcomes between the 3 groups. The mean final visual acuity was 20/38 in the medical group compared with 20/25 in the early surgery group. Had the sample sizes been larger, this clinically significant difference may have been statistically significant. In 2 recent large series, the proportion of patients with final visual acuity of 20/40 or better, after excluding patients with preexisting pathology, was 76.4%2 and 82.6%.3 In the present study, only 65% achieved 20/40 or better. The overall results may have been further compromised had patients with retinal detachment at presentation been included. It is important to note that a significant number of patients in large series had retinal detachment on initial assessment or at the time of vitrectomy for retained lens fragments.2,3 Finally, the present study may have included a number of patients with retained cortical material only, which may be less likely to require surgery. Although many patients with retained lens material after cataract surgery do not require urgent vitrectomy, we believe that early referral for a vitreoretinal opinion is critical. Delayed vitrectomy does not equal delayed referral.