Combined surgery allows treating both a cataract and a retinal or vitreous condition (epiretinal membrane, macular hole, diabetic retinopathy, retinal detachment, etc.) in a single operation. It avoids two separate procedures and shortens recovery time, but requires precise preparation and choices tailored to each case. Julien Gozlan, M.D., ophthalmic surgeon in Paris 16, explains the indications, procedure, and prognosis of this combined surgery.
What is combined cataract + vitrectomy surgery?
Combined surgery brings together two surgical steps in a single operative session:
- the cataract step (removal of the opacified lens and placement of an intraocular lens implant);
- the vitrectomy step (partial or complete removal of the vitreous and treatment of the retina).
The procedure takes place in the operating room, most often under locoregional anesthesia (numbed eye, patient awake), sometimes under general anesthesia depending on the circumstances. The goal is to make the retina accessible, treat the retinal cause, and at the same time restore lens transparency to optimize vision.
When is combined cataract and vitrectomy surgery recommended?
Combined surgery is considered when the patient presents both:
- a clinically significant cataract (decreased vision, glare, daily discomfort);
- and a retinal or vitreous condition requiring vitrectomy.
The main situations include:
- macular epiretinal membrane with significant visual impairment;
- macular hole requiring vitrectomy with peeling;
- proliferative diabetic retinopathy complicated by intravitreal hemorrhage or macular traction;
- retinal detachment associated with an already advanced cataract;
- persistent intravitreal hemorrhage with cataract making visualization difficult;
- certain cases of high myopia with macular or vitreoretinal involvement.
In these situations, performing a single combined surgery avoids two anesthesia sessions and limits the development of rapid secondary cataract following vitrectomy alone.
Advantages of combined cataract + vitrectomy surgery
For the patient, the main benefits are:
- a single procedure instead of two, meaning less stress and simplified planning;
- a single anesthesia session (especially beneficial for frail or polymedicated patients);
- a shorter overall recovery period, with a single recovery timeline;
- better visualization of the retina during vitrectomy, thanks to the cataract already being removed;
- lower risk of rapid secondary cataract after vitrectomy alone, particularly in patients over 60 years of age.
In chronic conditions (diabetes, high myopia, membranes, macular holes), this approach often allows the patient to reach the best possible functional vision more quickly.
Limitations and points of caution
Combined surgery is not systematic. It also has limitations:
- the procedure is slightly longer than a simple cataract surgery;
- choosing the implant power is sometimes more challenging in highly myopic or very long eyes;
- visual recovery depends largely on the condition of the retina, sometimes more so than the cataract;
- as with any vitrectomy, there is a specific risk to the retina (detachment, recurrence of hemorrhage, macular edema, etc.).
This is why the decision to recommend combined cataract and vitrectomy surgery is made on a case-by-case basis, after a thorough assessment and detailed discussion during consultation.
Preoperative evaluation
Before combined surgery, several examinations are systematically reviewed:
- ocular biometry to calculate the implant power and set a visual target (distance vision, slight comfort myopia, etc.);
- corneal analysis (astigmatism, possible corneal topography) to select the appropriate type of implant;
- macular OCT to specify the nature of the vitreoretinal condition (membrane, hole, edema, traction) and its impact;
- evaluation of the retinal periphery through fundus examination, looking for at-risk lesions (holes, lattice degeneration, ischemic areas);
- if needed, retinal angiography (diabetes, venous occlusions, vascular conditions) to guide the surgical approach;
These elements help anticipate the type of vitrectomy, the possible use of gas or silicone oil tamponade, and to define the visual prognosis with the patient.
Procedure of combined cataract and vitrectomy surgery
1) Cataract step
The surgeon begins with the "cataract" portion of the procedure:
- creation of a small circular opening in the anterior capsule of the lens;
- fragmentation and aspiration of the opacified lens (phacoemulsification);
- placement of a transparent intraocular lens implant, calculated according to the visual plan.
This step is comparable to a "standard" cataract surgery, but it is adapted to the fact that a vitrectomy will follow in the same eye.
2) Vitrectomy step
Once the implant is in place, the surgeon performs the vitrectomy through very small incisions in the sclera. Depending on the condition, the surgeon may:
- remove the cloudy or hemorrhagic vitreous;
- peel an epiretinal membrane and/or the internal limiting membrane;
- treat a macular hole;
- reattach a detached retina and treat tears with laser;
- perform laser treatment of the retina in cases of diabetes or ischemia.
3) End of procedure: gas, oil, or clear fluid
At the end of surgery, the eye is filled with either clear fluid, a temporary gas, or, more rarely, silicone oil depending on the retinal condition. This step determines vision during the first weeks and certain instructions (positioning, flight restrictions, etc.).
Postoperative course and recovery
After combined surgery, it is normal to experience:
- very blurry vision during the first days or weeks, especially if gas was used;
- mild pain or a foreign body sensation, relieved by simple analgesics;
- a red eye, sometimes with small conjunctival hemorrhages;
- light sensitivity and temporary visual fatigue.
A treatment with antibiotic and anti-inflammatory eye drops is prescribed for several weeks. Follow-up visits allow monitoring of intraocular pressure, the condition of the retina and cornea, and proper positioning of the implant.
Visual recovery is gradual: it often takes several weeks to several months to assess the final result, especially if the retinal condition was severe initially.
Visual prognosis: what determines the outcome?
The outcome of combined cataract and vitrectomy surgery depends primarily on:
- the nature of the retinal condition (membrane, macular hole, diabetic retinopathy, retinal detachment, etc.);
- the duration of the lesions and the extent of macular involvement before surgery;
- the condition of the outer retinal layers on OCT (ellipsoid zone, external limiting membrane);
- the general health status (diabetes control, high myopia, vascular history);
- the absence of significant postoperative complications.
In many cases, the surgery achieves a clear and lasting visual improvement, but it is important to maintain realistic expectations: even when perfectly performed, the procedure cannot make a severely damaged retina completely "new."
FAQ
Is combined surgery riskier than cataract surgery alone?
It is generally more complex than cataract surgery alone, as it combines two procedures (cataract + vitrectomy) during the same operation. Current techniques are minimally invasive and well standardized, but potential risks include those of cataract surgery and those of vitreoretinal surgery (inflammation, fluctuations in eye pressure, retinal complications depending on the condition being treated). The level of risk depends primarily on the initial retinal condition and is explained on a case-by-case basis before the procedure.
Will I experience more pain than after cataract surgery alone?
Generally, no. Postoperative pain is often minimal and well controlled with eye drops and simple analgesics if needed. The main discomfort comes more from prolonged blurry vision, especially if a gas tamponade was used, or if the retina was severely affected before surgery.
How long should I plan for recovery?
You should generally expect several weeks to regain more stable vision, sometimes longer if the retinal condition was advanced (retinal detachment, macular hole, hemorrhage, diabetic retinopathy, etc.). Recovery also depends on the presence of gas (very blurry vision as long as the bubble is significant), positioning instructions, and the speed of healing. Resumption of activities is generally gradual and is discussed during follow-up consultations.
Can I fly after the operation?
In the presence of intraocular gas, air travel and altitude are strictly contraindicated until the gas has completely disappeared, as the bubble can expand and dangerously increase the pressure inside the eye. With air (shorter duration), clear fluid, or silicone oil, the instructions differ: they are specified according to the tamponade used and your situation.
Will I still need glasses?
Combined surgery corrects the cataract, but does not guarantee complete freedom from glasses. The need for glasses depends on the chosen refractive target, astigmatism, healing, and especially the condition of the macula (which determines the final visual quality). Distance and/or reading glasses may therefore still be necessary. The goal is to achieve the best possible compromise between clarity, comfort, and safety.
Is combined cataract and vitrectomy surgery always possible?
No, it is not always performed. In some cases, it is preferable to perform a vitrectomy alone (for example, if the cataract is mild in a young patient), or conversely, to treat the cataract first if the retinal condition is not urgent and the ocular media are too opaque for optimal retinal surgery. The choice depends on the clarity of the ocular media, the urgency of the retinal condition, age, and your visual goals.
What if I am diabetic or highly myopic?
In diabetic patients or those with high myopia, combined surgery can be particularly appropriate (improved retinal access, cataract potentially progressing faster after vitrectomy alone). On the other hand, the risk of retinal complications or limited visual recovery may be higher, depending on the condition of the macula and the retinal periphery. Follow-up is therefore often more closely monitored, and the prognosis is discussed in detail before the procedure.
What are the warning signs after the operation?
You should seek emergency medical attention in case of severe pain, marked redness, sudden decrease in vision, appearance of a dark curtain, a shower of floaters, unusual flashes of light, or nausea associated with a sensation of a very tense eye (which may suggest increased pressure). It is better to get checked quickly than to let a concerning symptom progress.
When to consult Dr. Julien Gozlan?
You may request a specialist opinion if:
- you have a cataract and a retinal condition that has already been diagnosed;
- combined cataract + vitrectomy surgery has been mentioned and you would like a second opinion;
- you are diabetic or have high myopia with progressive vision loss;
- you have already had surgery on one eye and are weighing the best strategy for the second.
Dr. Julien Gozlan, ophthalmologist in Paris 16, reviews your examinations, assesses the benefit of combined surgery, and offers you a personalised surgical plan.
📍 Consultation at the Ophthalmic Practice Paris – Auteuil
Dr. Julien Gozlan welcomes you at the Ophthalmic Practice Paris – Auteuil to review your cataract, your retinal condition, and the potential benefit of combined cataract + vitrectomy surgery.
Book an AppointmentFurther reading
- Cataract: understanding the condition as a whole, beyond visual symptoms alone.
- Cataract surgery: how the procedure works, implants, and recovery.
- Vitrectomy: procedure, indications, and recovery.
- Macular epiretinal membrane: symptoms, OCT, and surgical treatment.