Evaluation of wound closure using different incision techniques with 23-gauge and 25-gauge microincision vitrectomy systems. Retina. 2008;28:242-248. [PMID: 18301029 DOI: 10.1097/iae.0b013e318156dea3]

Ultrasound biomicroscopic findings of conventional and sutureless sclerotomy sites after 20-, 23-, and 25-G pars plana vitrectomy

PURPOSE

We examined sclerotomies that were performed using 20-G systems and non-stitch 23-G systems, one-step (23/1) and two-step procedures (23/2), as well as one-step 25-G systems for pars plana vitrectomy (PPV) with ultrasound biomicroscopy (UBM) to assess subconjunctival bleb formation, vitreous incarceration, and wound closure.

METHODS

This study is a prospective, non-randomized, monocentre study comprising 40 patients; we examined sclerotomies using UBM after 20-G, 23/1-G, 23/2-G, and 25-G PPV in 10 patients each on days 1 and 30 postoperatively.

RESULTS

Subconjunctival bleb formation was not detected in any of the eyes on the first day after surgery in the 20-G and 23/2-G groups and was observed in 5 (50%, 25 G) and 2 eyes (20%, 23/1 G). By day 30 postoperatively, all blebs had spontaneously resolved. The sclerotomy tunnel could be detected by UBM at day 1 postoperatively in 10 (100%, 20 G), 9 (90%, 25 G), 7 (70%, 23/1 G), and 7 eyes (70%, 23/2 G). Thirty days postoperatively, it was present in 10 (100%, 20 G), 1 (10%, 25 G), 3 (30%, 23/1 G), and 1 (10%, 23/2 G) eye. Vitreous incarceration occurred in 2 (20%, 20 G), 7 (70%, 25 G), 4 (40%, 23/1 G), and 2 (20%, 23/2 G) eyes.

CONCLUSIONS

Anatomical closure of sclerotomies without subconjunctival bleb formation as seen on UBM was achieved at day 1 after 23/2-G and 20-G PPV and after 30 days postoperatively in all other non-stitch PPV techniques. Vitreous incarceration is common after 25-G PPV. Non-stitch sclerotomies can frequently no longer be detected by UBM 30 days postoperatively.

Sutureless vitrectomy

Sutureless vitrectomy has rapidly been accepted as an essential part of a vitreoretinal surgical setup. The size and structure of the wound along with near intact conjunctival covering makes the incision self-sealing and safe. This allows the vitrectomy instruments to be used without creating an initial limited peritomy to expose bare sclera, and obviates the need for sutures at the end of the procedure. Wound construction is the essential step in ensuring postoperative wound stability. Both one-step and two-step wound constructions have been described. Key points include an oblique, tunneled approach to ensure a valve-like effect as well as misalignment of conjunctival and scleral wounds by displacing conjunctiva during construction. Advantages include decreased operative times in certain cases and decreased postoperative inflammation, early postoperative rehabilitation, improved patient comfort, and minimal conjunctival damage. Complications are based around wound competence, hypotony, and its relationship to endophthalmitis rates. Early reports highlighted an increase in endophthalmitis though further studies are required to accurately assess the incidence. Endophthalmitis has not been reported in cases that underwent fluid/air exchange. This review focuses on techniques, benefits, complications, personal experiences, and the safety profiles of sutureless vitrectomy systems. A literature review was undertaken using ′Medline′ and ′Pubmed′. Search terms included sutureless vitrectomy, 20 gauge, 23 gauge, 25 gauge, and transconjunctival and small gauge vitrectomy.

Evaluation of wound closure in oblique 23-gauge sutureless sclerotomies with visante optical coherence tomography

PURPOSE

To investigate the in vivo real-time wound morphology of fresh 23-gauge sutureless oblique sclerotomy wounds with anterior segment optical coherence tomography (OCT).

DESIGN

Prospective, observational case series.

METHODS

Subjects underwent three-port pars plana vitrectomy with a 23-gauge trocar/cannula microincision surgical system at the Cole Eye Institute. All incisions were created in an oblique (aka beveled or angled) fashion. The incisions were imaged with the Visante OCT (Carl Zeiss Meditec, Dublin, California, USA) device on postoperative days 1 and 8. The main outcome measure was wound structure (eg, presence of gaping) as evaluated with OCT. Surgical and ocular parameters were also recorded.

RESULTS

Fourteen patients were investigated. Gross clinical examination revealed no evidence of leakage. OCT demonstrated closed wounds in all eyes on postoperative days 1 and 8. The external (entry) site of the incision was occasionally seen as a gape; however the rest of the wound was closed. One patient with closed wounds had transient hypotony along with shallow peripheral choroidals noted on postoperative day 1, which resolved on their own.

CONCLUSIONS

Oblique incisions have been proposed for microincision sutureless vitrectomy to prevent wound leakage, hypotony, and the secondary risk of endophthalmitis. This study demonstrates that oblique incisions provide adequate wound apposition as shown by OCT even on postoperative day 1.