How do you decide between a combined phacovitrectomy approach versus a staged procedure for patients with a retinal detachment and dense cataract?

A primary buckle might be a consideration here to avoid the issue of the cataract altogether. But if planning to add a buckle (with vitrectomy) during these cases, it is impossible to preoperatively perform lens measurements (i.e., axial length), which would be a relative contraindication to performing concurrent CE/IOL. Even in the event that a buckle is not indicated, I never perform phacovitrectomy for RD repair. When vitrectomy is indicated, the overwhelming majority of cataracts are not prohibitive for RD repair with modern-day wide-angle viewing systems and endoillumination with Xenon bulbs. If the cataract is sufficiently dense to prohibit my ability to successfully repair a retinal detachment with vitrectomy (these types of cases ar...

In a patient with a dense cataract and non-PVD-related RD (an uncommon scenario since a dense cataract is typically seen in older patients, and RDs are usually PVD-related in that age group), staging the RD repair—buckle first, followed by phaco once the retina is attached—is an option. In a patient with a dense cataract and a PVD-related RD (more common scenario), I favor a combined phaco-vitrectomy approach. Cataracts tend to progress after vitrectomy, making the postoperative exam more challenging. Removing the cataract allows for a more thorough vitreous base shave, better peripheral retinal examination, and a more complete gas fill. Patient positioning does not need to be strict once the cataract is removed. I also recommend phaco-vitr...