Long-Term Visual Outcomes and Safety Profile of 27-Gauge Pars Plana Vitrectomy for Posterior Segment Disease

Twenty-seven-gauge vitrectomy: a consecutive, single-centre case series with exclusive use over a 4-year period

BACKGROUND

To assess the safety and effectiveness of the exclusive use of 27-gauge instruments for all vitreoretinal diseases requiring vitrectomy.

METHODS

In this retrospective study, 1020 consecutive surgeries were performed on 958 eyes of 848 patients using 27-gauge instruments from March 2017 to June 2021. Patients with a minimum follow-up of 3 months were included. Surgical case-mix, best-corrected visual acuity (BCVA), intraocular pressure (IOP), intra- and post-operative complications, and surgery times were recorded.

RESULTS

The study patients were followed up for averagely 11 months. Of the 1020 vitrectomies, 958 were primary procedures. Of the 148 retinal detachment (RD) cases, 138 (93%) required a single vitrectomy. Primary macular hole closure was achieved in 143 of 145 (99%) cases. The average surgical times were 55 and 38 min for RD surgeries and for all other indications, respectively. BCVA improved significantly at the final visit (20/49) compared with the pre-operative visit (20/78) (p < 0.01). IOP was similar at the pre-operative (14.8mmHg) and final (14.3mmHg) visits. Complications recorded include transient hypotony in 39 eyes, iatrogenic retinal breaks in 2 eyes, and a vitreous bleed in 1 other eye.

CONCLUSION

This study revealed that 27-gauge vitrectomy instruments can be used for a wide range of indications, with exclusive use in certain settings. The outcomes were similar to other gauges, including for rhegmatogenous retinal detachment, with minimal complications.

Refining vitrectomy for proliferative diabetic retinopathy

Pars plana vitrectomy (PPV) is the main treatment modality for patients with severe diabetic retinopathy. With the development of systems for microincision, wide-angle viewing, digitally assisted visualization, and intraoperative optical coherence tomography, contemporary PPV for diabetic retinopathy has been performed on a wider range of indications than previously considered. In this article, we reviewed, in conjunction with our collective experiences with Asian patients, the applications of new technologies for PPV in eyes with diabetic retinopathy and highlighted several important procedures and entities not generally reiterated in the literature, in order for vitreoretinal surgeons to optimize their approaches when facing the challenges imposed by the complications in diabetic eyes.

Pars plana vitrectomy in patients aged 85 years and older: a single-centre, retrospective cohort study

PURPOSE

To describe the epidemiology, indications and surgical results of pars plana vitrectomy (PPV) in patients over 85 years of age.

METHODS

A retrospective cohort study was performed including all consecutive patients aged 85 years or older who underwent PPV between September 2018 and March 2022 in a single hospital in Madrid, Spain. Data on diagnosis, comorbidities, surgical indication, surgical details, surgical complications and surgical outcomes were collected from medical records.

RESULTS

A total of 124 eyes of 119 patients (56 males, 47.1%) underwent PPV. Median age was 87 years (range 85-96). The most common surgical indications were complications of cataract surgery in 34 patients (28.6%), macular epiretinal membrane in 32 (26.9%), and rhegmatogenous retinal detachment (RRD) in 12 (10.1%). Mean preoperative best corrected visual acuity (BCVA) was 13.33 ± 42.34 ETDRS letters and improved to 40.05 ± 41.04 letters at 3 months (p < 0.001). BCVA had improved in 68.82% of patients at 3 months. Patients with chronic kidney disease (CKD; p < 0.001), RRD (p = 0.003), ocular trauma (p = 0.001) and age-related macular degeneration (AMD; p = 0.002) showed worse BCVA at 3 months from surgery. Patients with better preoperative BCVA (p < 0.001), and those who underwent 25G PPV (p = 0.041) showed better visual outcomes.

CONCLUSIONS

PPV is an effective technique for improving visual acuity in patients aged 85 years and older with vitreoretinal diseases. Visual outcomes were better when patients had a better preoperative visual acuity and underwent 25G PPV. Patients with a previous diagnosis of AMD or CKD, and those undergoing surgery for ocular trauma or RRD had worse visual outcomes.

The Anatomical and Functional Outcomes of 27-Gauge Pars Plana Vitrectomy in Diabetic Tractional Retinal Detachments in the South Asian Population

Objective The objective of this article was to report the clinical and surgical outcomes of diabetic tractional retinal detachment (TRD) with 27-gauge plus pars plana vitrectomy (27G+ PPV) Methods This is a retrospective, consecutive cohort study of 196 eyes of 176 patients that underwent 27G+ PPV for TRD from July 2015 to June 2019 at the ophthalmology department of Shifa International Hospital, Islamabad. The outcomes include primary and secondary anatomical attachment of the retina, best-corrected visual acuity, and post-operative complications. Results The mean age of the patients in this study was 55.3 ± 11.3 years. Out of 176 patients, there were 47.2% (n=83) females. The mean operating time calculated was 60 ± 36 min (range 22-130 min). Of 196 eyes, 64.3% (n=126) also combined phacoemulsification with lens implantation. Internal limiting membrane peeling was done in 11.7% (n=23) of the cases. Post-operatively, 98% (n=192) achieved primary retinal attachment, and 1.5% (n=3) underwent a second procedure to achieve retinal attachment. At three months follow-up, the mean best corrected visual acuity (BCVA) remarkably improved from 1.86 ± 0.59 to 0.54 ± 0.32 logarithm of the minimal angle of resolution (logMAR) (p-value<0.001). Among complications, one patient had intra-operative suprachoroidal oil migration, which was managed successfully, while post-operatively, 11 patients (5.6%) developed a transient rise in intraocular pressure, which was controlled with anti-glaucoma drugs, and one patient had vitreous cavity hemorrhage which resolved on its own with time. Conclusion This study strongly suggests that the 27G+ PPV offers successful repair of eyes with diabetic TRD with statistically significant improvement in visual acuity and minimal rate of complications.

27-GAUGE PARS PLANA/PLICATA VITRECTOMY FOR PEDIATRIC VITREORETINAL SURGERY

PURPOSE

To report on the feasibility of 27-gauge (G) vitrectomy for pediatric patients.

METHODS

This study is an international, multicenter, retrospective, interventional case series. Participants were patients 17 years or younger who underwent 27-G vitrectomy for various indications.

RESULTS

The records of 56 eyes from 47 patients were reviewed. Mean age was 5.7 ± 5.2 years. Diagnoses included retinopathy of prematurity (Stages 3 with vitreous hemorrhage, 4A, 4B, and 5), Terson's syndrome, traumatic macular hole, posterior capsular opacification, endophthalmitis, and others. Instruments used were the 27-G infusion, 27-G vitreous cutter, 27-G light pipe, and 27-G internal limiting membrane forceps. Instrument bending was noted in one (1.8%) case. There were no cases with intraoperative complications, infusion issues, or postoperative endophthalmitis. There were 67/145 (46%) sclerotomies that required suturing, of which most (51/145) were sutured out of precaution. There were four cases (7.1%) that required conversion to a larger gauge and three cases (5.3%) that developed postoperative hypotony. Mean visual acuity improved from logarithm of the minimum angle of resolution 1.32 (20/420) to 0.72 (20/105), after a mean follow-up of 125.1 days (P = 0.01). Anatomic success was achieved in 96.4% of eyes after a single surgery.

CONCLUSION

Twenty-seven-gauge vitrectomy was safe and feasible in selected pediatric vitreoretinopathies. Further studies are warranted to examine indications and outcomes.

FLUIDIC PERFORMANCE OF A DUAL-ACTION VITRECTOMY PROBE COMPARED WITH A SINGLE-ACTION PROBE

PURPOSE

To assess flow rates, nearfield effects, and traction of a dual-cutting 20,000 cpm vitrectomy probe (HYPERVIT, Alcon) versus a single-cutting 10,000 cpm probe (Advanced ULTRAVIT, Alcon).

METHODS

Flow rates were evaluated for 25+ and 27+ gauge probes using balanced salt solution or porcine cadaver vitreous (biased open, 50/50, and biased closed duty cycles). Probes were suspended in an open beaker, and flow rates were calculated using a precision balance. Nearfield effects and flow pulsatility were assessed using a validated simulation model based on experimental microparticle image velocimetry. Traction was assessed by attaching vitreous to a cantilever beam and measuring the deflection of the beam.

RESULTS

For HYPERVIT probes, aqueous flow rates were similar across all cutting rates. Vitreous flow rates increased with increasing cutting rates. At maximum cutting rates, aqueous flow was 62%-67% greater (25+) and 63% greater (27+) with HYPERVIT versus Advanced ULTRAVIT ( P < 0.05); vitreous flow was 44%-47% greater (25+) and 26%-32% greater (27+) with HYPERVIT versus Advanced ULTRAVIT ( P < 0.05). Nearfield effects were reduced, and peak traction forces were significantly lower for HYPERVIT versus Advanced ULTRAVIT ( P < 0.05).

CONCLUSION

Significantly greater aspiration flow, reduced nearfield effects, and reduced traction were observed with dual-action versus single-action probes.

Intraoperative choroidal detachment during small-gauge vitrectomy: analysis of causes, anatomic, and visual outcomes

INTRODUCTION

To investigate the incidence and causes of intraoperative choroidal detachment (CD) during small-gauge vitrectomy, as well as the anatomic and visual outcomes.

METHODS

We retrospectively reviewed the medical records of 1026 consecutive patients who underwent small-gauge vitrectomy from June 2017 to December 2018 at Zhongshan Ophthalmic Centre, Guangzhou, China. Data on the presence, location, and extent of intraoperative CD and its relationship to the infusion cannula were collected. Patient demographic characteristics and postoperative anatomic and visual outcomes were also assessed.

RESULTS

A total of six cases were found to have intraoperative CD, including two with serous CD, three with limited haemorrhagic CD, and one with CD caused by inadvertent perfusion of gas during air/fluid exchange. Retraction of the infusion cannula and acute ocular hypotony were found to be the main causes of intraoperative CD in five out of the six cases. The best-corrected visual acuity of all cases significantly improved after the surgery.

CONCLUSION

The incidence of intraoperative CD during small-gauge vitrectomy is low; the predominant causes are retraction of the infusion cannula and acute ocular hypotony. Immediate awareness and timely closure of the incision may contribute to a better surgical prognosis.

Translational and clinical advancements in management of proliferative vitreoretinopathy

PURPOSE OF REVIEW

Despite advancement in the surgical instrumentation and techniques, proliferative vitreoretinopathy (PVR) remains the most common cause for failure of rhegmatogenous retinal detachment (RRD) repair. This review discusses ongoing translational and clinical advancements in PVR.

RECENT FINDINGS

PVR represents an exaggerated and protracted scarring process that can occur after RRD. The primary cell types involved are retinal pigment epithelium, glial, and inflammatory cells. They interact with growth factors and cytokines derived from the breakdown of the blood-retinal barrier that trigger a cascade of cellular processes, such as epithelial-mesenchymal transition, cell migration, chemotaxis, proliferation, elaboration of basement membrane and collagen and cellular contraction, leading to overt retinal pathology. Although there are currently no medical therapies proven to be effective against PVR in humans, increased understanding of the risks factors and pathophysiology have helped guide investigations for molecular targets of PVR. The leading therapeutic candidates are drugs that mitigate growth factors, inflammation, and proliferation are the leading therapeutic candidates.

SUMMARY

Although multiple molecular targets have been investigated to prevent and treat PVR, none have yet demonstrated substantial evidence of clinical benefit in humans though some show promise. Advancements in our understanding of the pathophysiology of PVR may help develop a multipronged approach for this condition.

Case Report: Exacerbation and Spontaneous Separation of the Epiretinal Membrane Following Laser Photocoagulation of a Vasoproliferative Tumor of the Retina

The present report concerns a rare vasoproliferative tumor of the retina (VPTR) combined with a severe case of secondary epiretinal membrane (ERM). A 56-year-old male patient was diagnosed with VPTR and secondary ERM of the left eye. The patient underwent two rounds of laser photocoagulation (LP) of the tumor. The exacerbation of the ERM was observed after the first round of LP, while spontaneous separation over the five-month follow-up period was noted after the second round of LP. Thus, LP may represent a viable alternative treatment approach for VPTR combined with severe ERM.

Outcomes of Primary 27-Gauge Vitrectomy for 73 Consecutive Cases With Uveitis-Associated Vitreoretinal Disorders

Background: Since the advent of 27-gauge microincision vitrectomy system a decade ago, evidence regarding the feasibility, safety, and effectiveness of 27-gauge pars plana vitrectomy (PPV) has increased. Aim: To assess the effectiveness and safety profile of 27-gauge PPV for various vitreoretinal conditions associated with uveitis. Methods: We retrospectively investigated 73 consecutive cases that underwent primary 27-gauge PPV for uveitis-related ocular disorders between October 2014 and April 2021. The primary outcome measures were mean change in logMAR best-corrected decimal visual acuity (BCVA) pre-operatively to 3 months post-operatively, the proportion of BCVA improvement category defined as the degree of logMAR BCVA difference ("improved" [≤-0.3], "unchanged" [-0.3 to 0.3], and "worsened" [≥0.3]) pre-operatively to 3 months post-operatively, the mean change in intraocular inflammation scores pre-operatively to 3 months post-operatively; and intraoperative and post-operative complications. Results: The mean logMAR BCVA significantly improved from 0.69 pre-operatively to 0.42 at 3 months post-operatively (P = 0.017). The percentages of eyes with "improved," "unchanged," and "worsened" BCVA at 3 months post-operatively were 37, 50, and 13%, respectively. The mean anterior chamber cell score was 0.6 pre-operatively and 0.2 at 3 months post-operatively (P = 0.001), the mean anterior chamber flare score was 0.4 pre-operatively and 0.1 at 3 months post-operatively (P = 0.004), and the mean vitreous haze score was 1.9 pre-operatively and 0.1 at 3 months post-operatively (P < 0.001). Surgery-related complications occurred in 35 (48%) eyes, 68% of which were related to intraocular pressure and transient. Conclusions: Given its risk-benefit profile, 27-gauge PPV is a promising option for the treatment of vitreoretinal disorders in uveitis.

Massive Delayed Hemorrhagic Choroidal Detachment and Giant Retinal Tear Detachment Following Scleral-Fixated Akreos IOL

A 78-year-old woman underwent 25-gauge pars plana vitrectomy and scleral fixation for a dislocated intraocular lens in the left eye under general anesthesia. She developed massive hemorrhagic choroidal detachment 1 day later. A giant retinal tear detachment and proliferative vitreoretinopathy was noted at postoperative Week 7 and repaired with choroidal drainage, 240° peripheral retinectomy, perfluorocarbon liquid, endolaser, and silicone oil. Hypotony associated with the 25-gauge sclerotomies used for suture fixation was the suspected etiology for this complication. Use of 27-gauge instrumentation or application of fibrin glue to superior sclerotomies may help reduce the incidence of postoperative hypotony. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:288-292.].

INCIDENCE AND RISK FACTORS FOR HYPOTONY AFTER 25-GAUGE PARS PLANA VITRECTOMY WITH NONEXPANSILE ENDOTAMPONADE

PURPOSE

The purpose of this study was to assess the incidence and risk factors for early postoperative hypotony after 25-gauge pars plana vitrectomy with nonexpansile endotamponade.

METHODS

A retrospective study of consecutive patients who underwent 25-G pars plana vitrectomy. Hypotony was defined as an intraocular pressure of 5 mmHg or less after surgery and ocular hypertension as an intraocular pressure greater than 21 mmHg.

RESULTS

Overall, 307 eyes of 307 patients with a mean age of 61.7 ± 14.3 of which 56.7% were males were included. Hypotony was identified in 5.2% of cases (n = 16) at Day 1 and 0.7% (n = 2) at Week 1 with no hypotony-related complications. The hypotony group had a higher number of previous vitreoretinal surgeries (1.5 ± 1.1 vs. 0.4 ± 0.7, P < 0.001) and a higher prevalence of preoperative ocular hypertension (22.2% vs. 4.8%, P = 0.02), pseudophakia (77.8% vs. 48.4%, P = 0.01), silicone oil removal (61.1% vs. 8.3%, P < 0.001), and external diathermy performed (55.6% vs. 20.1%, P = 0.001). In stepwise multivariate analysis, significant parameters were silicone oil removal (R = 16.34%, odds ratio 13.45, P < 0.001), pseudophakia (R = 5.69%, odds ratio 3.65, P = 0.03), and younger age (R = 2.68%, odds ratio 0.96, P = 0.04).

CONCLUSION

Silicone oil removal is a significant risk factor for early postoperative hypotony after 25-G pars plana vitrectomy.

Comparison of Visual and Anatomic Outcomes Following RRD Surgery Using 23-Gauge Versus 25-Gauge Vitrectomy: PRO Study Report No. 12

BACKGROUND AND OBJECTIVE

Most surgeons now utilize small-gauge (23- or 25-gauge) pars plana vitrectomy (PPV) with or without scleral buckling for repair of rhegmatogenous retinal detachments (RRD), in addition to primary scleral buckle (SB), but comparative data between the two gauges are limited.

PATIENTS AND METHODS

This study is an analysis of primary RRD repairs comparing 23- versus 25-gauge vitrectomy for PPV or combination PPV/SB from January 1, 2015, through December 31, 2015, across multiple institutions. The primary outcome was single-surgery success and secondary outcomes included postoperative complications.

RESULTS

There were 1,932 eyes that met inclusion criteria. There was no statistically significant difference in single-surgery success (82.9% vs. 83.8%; P = 0.6329). There were similar rates of postoperative hypotony, endophthalmitis, vitreous hemorrhage, and choroidal detachment. The findings were similar when analyzing only eyes that underwent primary PPV without SB.

CONCLUSION

Both 23- and 25-gauge vitrectomy systems have similar anatomic and visual outcomes in the primary repair of RRD. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:70-76.].

Short-Term Results of Ocriplasmin Versus Prompt Vitrectomy for Macular Hole. Which Performs Better?

In this retrospective study, we compared the anatomical and functional changes in patients with vitreomacular traction associated with macular holes between the following groups: (1) Patients who were treated with a single intravitreal injection of ocriplasmin (the OCRIALONE group); (2) those who failed the ocriplasmin treatment and underwent vitrectomy one month later (the OCRIVIT group); and (3) patients who directly underwent par plana vitrectomy (VITREALONE group). A total of 38 patients, 19 in the OCRIALONE group + OCRIVIT group (seven and 12 patients, respectively) and 19 in the VITREALONE group with focal vitreomacular adhesion associated with macular holes were evaluated with spectral domain optical coherence tomography. Functional examinations included best-corrected visual acuity (BCVA) and microperimetry analysis. Visual function changes were compared between the OCRIALONE group + OCRIVIT group and VITREALONE group up to three months. Furthermore, a subgroup analysis compared the OCRIVIT group and the VITREALONE group. BCVA values and the mean retinal sensitivity showed statistically significant improvement in all groups (p < 0.001). Specifically, the retinal sensitivity values at the end of the follow-up were significantly higher in the OCRIALONE group + OCRIVIT group than in the VITREALONE group. These functional findings were also confirmed when the statistical analysis was conducted between the OCRIVIT group and the VITREALONE group. Although the OCRIALONE group + OCRIVIT group exhibited faster retinal thinning than the VITREALONE group (p = 0.006), the analysis of the OCRIVIT group versus the VITREALONE group did not show any statistically significant difference. The better functional results and similar anatomical findings suggest that ocriplasmin can be used as a first-line treatment, and that prompt pars plana vitrectomy as primary surgery does not provide better outcomes in comparison with pars plana vitrectomy after ocriplasmin injection.

Vitreous incarceration in sutured vs non-sutured sclerotomies after 25-gauge macular surgery

OBJECTIVES

To study the patterns of vitreous incarceration in sutured vs non-sutured sclerotomies in patients subjected to 25-gauge macular surgery.

METHODS

A prospective study of 135 eyes affected by epiretinal membrane or macular hole. Vitreal disposition was evaluated via ultrasound biomicroscopy (UBM) at the sclerotomy sites between 30 and 40 days after surgery, once the tamponade had completely disappeared.

RESULTS

In total, 349 sclerotomies (86.2%) of 99 patients were non-sutured while 56 sclerotomies (13.8%) of 36 patients were sutured at the end of the surgical procedure. Among the 36 patients with sutured sclerotomies, 15 out of 36 (41.6%) had at least two sclerotomies sutured. All the sclerotomy sites were evaluated (405 sclerotomies). Sclerotomy suture was significantly associated with a less aggressive pattern of vitreal incarceration (OR: 0.16, 95% CI: 0.07-0.35, p < 0.001). Compared to preoperative values, day 1 post operative IOP was not significantly different in patients with sutured sclerotomies, while patients with non-sutured sclerotomies had a significantly lower day 1 post operative IOP.

CONCLUSIONS

In 25-gauge macular surgery, UBM evaluation documented a higher rate of postoperative vitreous incarceration in the non-sutured sclerotomies, confirming the previously postulated role of the residual vitreous, left at the end of the surgery, in closing the sclerotomy site.

Standardized scleral buckling approach in the management of noncomplex primary rhegmatogenous retinal detachment

PURPOSE

To analyze the anatomical and functional outcomes of a standardized scleral buckling approach in patients with noncomplex primary rhegmatogenous retinal detachment (RRD).

METHODS

Retrospective institutional case series of 135 eyes of 131 patients diagnosed with noncomplex primary RRD. All patients underwent scleral buckling surgery with the placement of an encircling 5 mm oval sponge at 15 ± 2 mm posteriorly from the limbus, cryopexy, subretinal fluid drainage, and air tamponade.

RESULTS

Final anatomical success at 12 months was achieved in all 135 eyes (100%). Primary anatomical surgical success was obtained in 127 out of 135 eyes (94%), while re-detachment occurred in eight out of 135 cases (6%). Primary anatomical success was significantly lower in pseudophakic eyes (p < 0.001). At the end of the follow-up period, no vision loss was observed in any patient and both sphere and cylinder refraction shift was mild. There was a low rate of postoperative complications. Nine out of 135 eyes (6.6%) developed full thickness macular hole, whether in 24 out of 135 eyes (17.8%) epiretinal membrane development was noticed.

CONCLUSION

A standardized scleral buckling approach for primary noncomplex RRD may be effective. The technique is reproducible, easier, and quicker to perform if compared to classic scleral buckling procedures, suggesting that it may represent a valuable surgical option. Special care is needed in the management of pseudophakic RRD due to higher risk of RRD recurrence.

Non-contact wide-angled visualization with chandelier-assisted scleral buckling for primary uncomplicated rhegmatogenous retinal detachment

PURPOSE

To report our experience in non-contact wide-angled visualization with chandelier-assisted scleral buckling (SB) in uncomplicated primary rhegmatogenous retinal detachments (RRD).

METHODS

Retrospective case series of 282 eyes that underwent non-contact wide-angled visualization with chandelier-assisted SB and were followed for a mean of 13.5 months.

RESULTS

There were 160 male patients. The average age was 42.6 years old. There were 262 eyes that were phakic, 18 pseudophakic, and 2 aphakic. Two-thirds of eyes presented with the macula detached. Eyes had an average of 1.6 breaks. The single operation anatomic success rate was 85.1% (240/282). The pre-op visual acuity improved from 1.21 to 0.76 logMAR at 6 months (p < 0.0001). Complications included a case of scleral laceration, choroidal hemorrhage, 3 epiretinal membranes, 1 macular fold, and 4 eyes with buckle exposure.

CONCLUSION

Non-contact wide-angled visualization with chandelier-assisted SB compares favorably with conventional SB for primary uncomplicated primary RRD.

Complications of vitreoretinal surgery

PURPOSE OF REVIEW

The present article reviews the most common and most serious vision-threatening and life-threatening complications of vitreoretinal surgery.

RECENT FINDINGS

Serious complications after vitreroretinal surgery are rare. Endophthalmitis for example has recently been estimated to occur in 0.08% of small gague vitrectomy. Other complications such as cataract are almost unavoidable, becoming visually significant in up to 80% of patients. The introduction of smaller gauge vitrectomy systems has reduced surgical times, conjunctival scarring and inflammation, and the rate of some complications such as retinal tears. Ocular venous air embolism is an exceedingly rare complication that is potentially life threating and therefore important for all vitreoretinal surgeons to be aware of.

SUMMARY

Though vitreoretinal surgery is well tolerated and effective, it is inevitable that all surgeons will experience complications and are therefore best served by understanding the potential complications, strategies to reduce the likelihood of them occurring, and ways to address them when they do happen.

Vitreous and Vision Degrading Myodesopsia

Macromolecules comprise only 2% of vitreous, yet are responsible for its gel state, transparency, and physiologic function(s) within the eye. Myopia and aging alter collagen and hyaluronan association causing concurrent gel liquefaction and fibrous degeneration. The resulting vitreous opacities and collapse of the vitreous body during posterior vitreous detachment are the most common causes for the visual phenomenon of vitreous floaters. Previously considered innocuous, the vitreous opacities that cause floaters sometimes impact vision by profoundly degrading contrast sensitivity function and impairing quality-of-life. While many people adapt to vitreous floaters, clinically significant cases can be diagnosed with Vision Degrading Myodesopsia based upon echographic assessment of vitreous structure and by measuring contrast sensitivity function. Perhaps due to the ubiquity of floaters, the medical profession has to date largely ignored the plight of those with Vision Degrading Myodesopsia. Improved diagnostics will enable better disease staging and more accurate identification of severe cases that merit therapy. YAG laser treatments may occasionally be slightly effective, but vitrectomy is currently the definitive cure. Future developments will usher in more informative diagnostic approaches as well as safer and more effective therapeutic strategies. Improved laser treatments, new pharmacotherapies, and possibly non-invasive optical corrections are exciting new approaches to pursue. Ultimately, enhanced understanding of the underlying pathogenesis of Vision Degrading Myodesopsia should result in prevention, the ultimate goal of modern Medicine.

Hybrid 23/27 Gauge Vitrectomy - Combining the Charm of 27G with the Efficacy of 23G

Background

Minimally invasive transconjunctival sutureless vitrectomy (MIVS) has evolved into the standard of care, smaller incisions thought to result in lower ocular surface trauma and shorter times to recovery. The currently most relevant limitations in macular surgery may be light intensity and 27G instrument stability. Therefore, we thought to compare standard 23 and 27G vitrectomy with a hybrid technique using one 23G and two 27G ports regarding surgical times and short-term outcomes.

Methods

This retrospective comparison included 90 single-center consecutive cases of eyes undergoing elective micro-invasive vitrectomy for epiretinal membranes or idiopathic macular holes between October 2017 and June 2018. The main criteria for the comparison were total surgical time as primary outcome parameter and treatment-demanding intra- and postoperative complications along with recovery of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from prior to surgery to 1 month thereafter as secondary parameters as independent parameters for the recovery from the pre-existing pathology and the surgical trauma.

Results

Surgical times were shorter with 23G and 23/27G compared to 27G (23G: 38.4±13.1; 27G: 48.1±15.3; 23/27G: 34.9±9 mins; p=0.0005) with no differences in BCVA and CRT outcomes. Switching from 27G to a larger port size was not necessary in any instance. Cryotherapy was applied in 15%, 30%, and 22.5% to suspected retinal pathologies, beyond these, in 5%, 0%, and 7.5% for retinal tears. Four postoperative retinal detachments occurred (4.4%), one in the 23G and three in the 23/27G group requiring re-vitrectomy.

Conclusion

In this exploratory case series, 23/27G hybrid vitrectomy, combining the advantages of 23G and 27G techniques, resulted in shorter surgical times without evident disadvantages. The combination with cataract surgery was unproblematic.

Efficacy of 27-Gauge Vitrectomy with Internal Limiting Membrane Peeling for Epiretinal Membrane in Glaucoma Patients

Purpose

To evaluate the efficacy of epiretinal membrane (ERM) surgery for patients with ERM and glaucoma.

Methods

We reviewed the medical records of 20 consecutive ERM patients with glaucoma, who underwent 27-gauge microincision vitrectomy surgery (27GMIVS) with internal limiting membrane (ILM) peeling. The preoperative and 6-month postoperative visual field was tested with the Humphrey Field Analyzer (HFA) 24-2 program. Changes in threshold sensitivity in the HFA test points were analyzed point-by-point, with points classified into groups based on sensitivity as abnormal (less than 5th percentile in pattern deviation) or normal (all other points) and based on location as central (12 central points) or peripheral (all other points) with a linear mixed-effects model.

Results

Visual acuity and mean deviation improved postoperatively (P < 0.001 for both) in all patients. Threshold sensitivity in central or peripheral points that were abnormal preoperatively improved postoperatively (P=0.006 or P < 0.001, respectively). Threshold sensitivity also improved in the central normal test points (P=0.03), but not in the peripheral normal points (P=0.12).

Conclusion

Visual acuity improved, and there was no visual field progression, after ERM surgery in glaucomatous eyes during a 6-month postoperative follow-up, suggesting that ERM and ILM removal using 27GMIVS may be effective even in glaucomatous eyes.

Surgical Innovations in the Treatment of Diabetic Macular Edema and Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetic macular edema (DME) and complications of proliferative diabetic retinopathy (PDR) are the primary causes of vision loss in patients with diabetic retinopathy. As the incidence of diabetes increases worldwide, new, cost-effective treatments for DME and PDR will become paramount. Currently, anti-vascular endothelial growth factor (anti-VEGF) medications are considered first-line treatment. However, multiple visits for injections and the economic and time burden they entail make this treatment modality less than ideal. Early vitrectomy as well as depot delivery systems for medications could potentially reduce the treatment burden of patients with diabetes, prevent visual loss, and provide long-term stabilization of retinopathy in patients with diabetes. Newer port delivery systems for anti-VEGF medications could one day make this treatment modality better suited for patients across the globe.

RECENT FINDINGS

Real-world data shows poor compliance with treatment among patients with diabetes. Recent publications show catastrophic results when anti-VEGF treatments are stopped abruptly. The port delivery system for ranibizumab shows maintenance of adequate anti-VEGF levels in the vitreous cavity for many months. Early vitrectomy can provide cost-effective long-term stabilization in eyes with diabetic retinopathy. Microincisional vitrectomy as a treatment for DME and PDR remains controversial and larger trials are needed to definitively prove its superiority over other modalities; however, small-scale data point towards its usefulness in specific populations. Newer port delivery systems of anti-VEGF show promise in decreasing the number of office visits in patients with diabetic retinopathy.

Multicenter survey of sutureless 27-gauge vitrectomy for primary rhegmatogenous retinal detachment: a consecutive series of 410 cases

PURPOSE

To evaluate the surgical outcomes of the 27-gauge (G) vitrectomy system for the treatment of primary rhegmatogenous retinal detachment (RRD).

METHODS

This retrospective consecutive series multicenter study involved a total of 410 eyes of 406 patients who underwent 3-port transconjunctival 27G pars plana vitrectomy (PPV) for RRD between November 2014 and December 2016 and who were followed for a minimum of 3 months postoperative. The main outcome measure was primary reattachment, with the secondary outcome measures being final reattachment, improvement of visual acuity (VA), intraocular pressure (IOP), intraoperative and postoperative complications, and surgery time.

RESULTS

Of the 410 treated eyes, primary reattachment was achieved in 392 (95.6%) and final reattachment was achieved in 410 (100%). In 226 eyes (55.1%) with macula-on RRD, the mean logarithm of the minimum angle of resolution (logMAR) VA improved from 0.16 ± 0.51 pre-surgery to 0.02 ± 0.14 post-surgery (P = 0.11). In 184 eyes (44.9%) with macula-off RRD, logMAR VA improved from 1.06 ± 0.77 pre-surgery to 0.26 ± 0.35 post-surgery (P < 0.001). Following surgery, the mean IOP was highest at 1 day (15.7 ± 7.0 mmHg) postoperative. In all eyes, surgery was concluded without the use of sutures or the need of conversion to a larger-gauge instrument. Although hypotony was observed in 14 (3.4%) of the 410 treated eyes at 1 day postoperative, it spontaneously resolved within 1 week without additional surgical intervention. No postoperative complications such as infectious endophthalmitis were observed throughout the follow-up period.

CONCLUSION

Our findings show that 27G PPV is both safe and effective for the treatment of primary RRD.

Outcomes of vitrectomy for diabetic tractional retinal detachment in Chicago's county health system

PURPOSE

To examine outcomes of 23-gauge (23G) pars plana vitrectomy (PPV) for complex diabetic tractional retinal detachment (TRD) in Chicago's Cook County Health and Hospitals System (CCHHS).

MATERIALS AND METHODS

This is a retrospective noncomparative study of diabetic TRD cases that underwent PPV at CCHHS. Primary retinal reattachment rate, visual function, and postoperative complications were analyzed.

RESULTS

Sixty nine consecutive cases were included. Primary reattachment and final attachment were achieved in 68/69 eyes (98.6%). Secondary retinal detachment was noted in 1 eye (1.4%). Vitreous hemorrhage requiring repeat PPV developed in 5 eyes (7.2%) and reoperation due to other complications was required in 4/69 eyes (5.8%). Perfluoropropane (C3F8) gas tamponade was used in 91.3% of eyes and silicone oil in 8.7% of eyes. Mean LogMAR visual acuity significantly improved from 1.84 ± 0.61 to 0.93 ± 0.66, (P<0.0001). Vision was stabilized or improved in 66 eyes (95.7%). Visual acuity of 20/200 or better was achieved in 49/69 eyes (71.0%) and 20/50 or better in 16/69 eyes (23.2%).

CONCLUSIONS

Even in patients with severe and advanced diabetic TRD pathology and unique demographics as seen in CCHHS, modern vitrectomy techniques can provide excellent anatomical and visual outcomes.

Effect of Ocriplasmin on objectively assessed retinal function after treatment of vitreomacular diseases

BACKGROUND

The scope of the study was the functional assessment of possible effects of intravitreally injected ocriplasmin using electroretinographical (ERG) examinations.

METHODS

Seven subjects suffered from pathologies within the label of ocriplasmin (Jetrea^® ) were examined in the study. An extended international society for clinical electrophysiology of vision ERG protocol was used for baseline recordings (before treatment) and was repeated for comparison 3 months after treatment with intravitreally injected ocriplasmin. All subjects were examined using 6 steps and a 9 Hz flicker protocol as scotopic flicker response under dark-adapted conditions. Under light-adapted conditions, two single-flash responses (standard flash and On/Off protocol) and a 31 Hz flicker response was used for functional assessment.

RESULTS

A significant reduction of amplitudes was found for the lowest stimulation intensity (0.0001 cd.s/m²) under dark-adapted conditions after treatment (p = 0.027). All other parameters were not significantly different after treatment including the scotopic flicker response. Under light-adapted state, the a- and b-wave amplitudes were not significantly altered after treatment for single-flash and flicker responses. The On- and Off-responses were not significantly different between baseline and after the treatment.

CONCLUSIONS

One single significant difference of all examined parameters mirrors a difference due to chance, even if a negative effect of proteolytic enzymes on laminin and fibronectin of retinal cells cannot be entirely excluded. Nevertheless, this result should be respected in order to ensure a safe use of ocriplasmin for patients with vitreoretinal disorders.

Primary Choroidal Lymphoma Diagnosed with 27-Gauge Pars Plana Vitrectomy Choroidal Biopsy

Background

Currently, transvitreal fine-needle aspiration biopsy is the most widely used tissue biopsy technique in cases of suspected intraocular lymphoma due to its relative simplicity and low trauma. The small sample produced, however, may be inadequate for diagnostic and prognostic analyses due to mechanical artefacts, insufficient material, or sampling errors. Small case series have demonstrated choroidal biopsy via vitrectomy to be safe and effective. With smaller-gauge vitrectomy instruments, visual recovery is rapid, and post-operative inflammation and conjunctival scarring is minimised. Furthermore, smaller-gauge instrumentation does not appear to affect the diagnostic yield of biopsies for intraocular lymphoma in vitro. We report a case of primary choroidal lymphoma successfully diagnosed with 27-gauge pars plana vitrectomy choroidal biopsy.

Case Presentation

A 72-year-old female presented with a 6-month history of painless blurred vision in her right eye. Fundus examination revealed a large pale choroidal mass centred on the posterior pole with overlying exudative retinal detachment. Enhanced depth imaging optical coherence tomography revealed a markedly thickened choroid with an undulating appearance. B-scan ultrasonography demonstrated diffuse, smooth thickening of the choroid, and retrobulbar extrascleral hypoechoic nodules. A 27-gauge pars plana vitrectomy was performed and choroidal biopsy taken. Histopathologic, immunohistochemical, and flow cytometry studies confirmed a diagnosis of extranodal marginal zone B-cell lymphoma. Systemic workup found no evidence of systemic lymphoma. As such, the patient was diagnosed with primary choroidal lymphoma. She underwent intensity-modulated external beam radiotherapy with subsequent resolution of disease.

Conclusions

Primary choroidal lymphoma can be safely and effectively diagnosed via 27-gauge vitrectomy choroidal biopsy.

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

A Propensity-Score Matching Comparison between 27-Gauge and 25-Gauge Vitrectomy Systems for the Repair of Primary Rhegmatogenous Retinal Detachment

Purpose

To compare the anatomical and visual results and complications of 27-gauge versus 25-gauge transconjunctival sutureless vitrectomy for the management of primary rhegmatogenous retinal detachment.

Methods

A prospective, propensity score-matched 6-month study was performed. All patients underwent either 27-gauge or 25-gauge vitrectomy as the first surgical intervention and were followed up over a 6-month period, in order to evaluate anatomical success, change in best-corrected visual acuity (BCVA), and intraoperative and postoperative complications including intraocular pressure dysregulation.

Results

Propensity score matching resulted in two groups of 37 eyes each. All eyes completed a six-month follow-up. Baseline demographic and preoperative ocular characteristics showed no statistically significant difference between the two cohorts. The single operation success rate was 33/37 (89%) for 27-gauge cases and 34/37 (92%) for 25-gauge cases (p=0.7). The final anatomical success rate was 100% for each of the two cohorts. Mean BCVA change at the 6-month postoperative follow-up visit was −0.67 logMAR in the 27-gauge group and −0.71 logMAR in the 25-gauge group (p=0.9). Two patients in the 25-gauge group experienced transient hypotony after surgery.

Conclusion

No significant difference between 27-gauge and 25-gauge transconjunctival sutureless vitrectomy for the repair of primary rhegmatogenous retinal detachment was recorded in terms of reattachment rate, BCVA, intraoperative and postoperative complications.

Proliferative Vitreoretinopathy: A Review

Proliferative vitreoretinopathy (PVR) is the most common cause for failure of rhegmatogenous retinal detachment repair and is characterized by the growth and contraction of cellular membranes within the vitreous cavity and on both sides of the retinal surface as well as intraretinal fibrosis. Currently, PVR is thought to be an abnormal wound healing response that is primarily driven by inflammatory, retinal, and RPE cells. At this time, surgery is the only management option for PVR as there is no proven pharmacologic agent for the treatment or prevention of PVR. Laboratory research to better understand PVR pathophysiology and clinical trials of various agents to prevent PVR formation are ongoing.

Comparison of a Three-Dimensional Heads-Up Display Surgical Platform with a Standard Operating Microscope for Macular Surgery

PURPOSE

To assess safety, efficacy, and outcomes of vitreoretinal surgery for macular pathology using a 3-dimensional heads-up display (3D HUD) surgical platform compared with a standard operating microscope (SOM).

DESIGN

Prospective, single-center, unmasked, randomized study.

PARTICIPANTS

Patients undergoing pars plana vitrectomy (PPV) for epiretinal membrane (ERM) or full-thickness macular hole (MH) at Wills Eye Hospital.

METHODS

Patients were randomized 1:1 to undergo surgery with a 3D HUD surgical platform or SOM. Patients who had previous PPV were excluded. Surgical choices, including PPV gauge, were based on surgeon preference. Standard surgical safety parameters, Early Treatment Diabetic Retinopathy Study visual acuity (VA), minimum required endoillumination levels, operative times, and surgeon "ease of use" of the viewing platform were recorded. Patients were followed up to postoperative month 3 (POM3).

MAIN OUTCOME MEASURES

The main outcome measures were total operative time, macular peel time, surgeon rating of viewing system ease of use, minimum required endoillumination, intraoperative complication rate, and postoperative VA.

RESULTS

Thirty-nine eyes of 39 patients with a mean age of 67.60±8.21 SD years were enrolled. Indications included ERM (n = 26 [3D HUD = 14, SOM = 12]) and MH (n = 13 [3D HUD = 9, SOM = 4]). Minimum required endoillumination was significantly lower with 3D HUD (mean 22.70%±15.10% SD) compared with SOM (mean 39.06%±2.72%; P < 0.001). There was no significant difference in overall operative time, but macular peel time was significantly longer using 3D HUD (mean 14.76±4.79 minutes) than SOM (11.87±8.07 minutes; P = 0.004). Surgeon-reported ease of use was significantly higher (easier) using SOM compared with 3D HUD (P = 0.004). There was no statistically significant difference between the groups in POM3 logarithm of the minimum angle of resolution (logMAR) VA or change in logMAR VA from baseline (all P > 0.681). There were no clinically significant intraoperative complications in either group.

CONCLUSIONS

Three-dimensional heads-up display surgical visualization is an evolving technology demonstrating comparable efficacy to the SOM for macular surgery. Although overall surgical times were similar, 3D HUD macular peel times were longer and associated with less ease of use in this study, which may partly be due to a learning curve with new technology.

Surgical outcomes of 27-gauge and 25-gauge vitrectomy day surgery for proliferative diabetic retinopathy

PURPOSE

To compare postoperative outcomes of 27-gauge (G) and 25-G vitrectomy conducted as day surgery for proliferative diabetic retinopathy (PDR).

METHODS

One hundred eighty-five consecutive PDR patients (185 eyes) who underwent primary vitrectomy (27-G in 64 eyes, 25-G in 121 eyes) were analyzed.

RESULTS

The 27-G and 25-G groups did not differ significantly in preoperative Early Treatment Diabetic Retinopathy Study (ETDRS) score, age, or preoperative intraocular pressure. The proportions of simultaneous cataract surgery (27-G vs. 25-G: 59.4% vs. 62.4%) and air-filled eyes (76.6% vs. 85.1%) were not significantly different between two groups. Both groups showed significant improvement in ETDRS score at postoperative 1, 3, and 6 months (all, P < 0.0001). Mean gain in ETDRS score from baseline was apparently better in 27-G group than in 25-G group at 1, 3, and 6 months, but there were no significant differences (1 month: 20.3 vs. 13.1 letters, P = 0.0703; 3 months: 22.9 vs. 17.5 letters, P = 0.1561; 6 months: 24.3 vs. 19.3 letters, P = 0.3313). Operation time was apparently longer for 27-G vitrectomy, but there was no significant difference (54.0 vs. 51.1 min, P = 0.3676). The same was observed for postoperative intraocular pressure at postoperative day 1 (19.7 vs. 18.1 mmHg, P = 0.1353). Incidence of postoperative retinal detachment (1.6% vs. 0.8%) and reoperation due to vitreous hemorrhage (6.3% vs. 6.6%) was not different between two groups.

CONCLUSIONS

The 27G system is as safe and as useful as the 25G system when used for PDR and can be expected to achieve earlier recovery of postoperative visual acuity.

Outcomes of transconjunctival sutureless 27-gauge vitrectomy for vitreoretinal diseases

AIM

To evaluate the safety and efficacy profile of 27-gauge (27G) pars plana vitrectomy (PPV) for the treatment of various vitreoretinal diseases.

METHODS

The clinical outcomes of 61 eyes (58 patients) with various vitreoretinal diseases following 27G PPV were retrospectively reviewed.

RESULTS

Surgical indications included rhegmatogenous retinal detachment (n=24), full-thickness macular hole (n=12), diabetic retinopathy (n=11), vitreous hemorrhage (n=6), Eales disease (n=4), pathological myopia-related vitreous floater (n=2), and macular epiretinal membrane (n=2). The mean follow-up was 166.4±61.3d (range 98-339d). The mean logMAR best-corrected visual acuity (BCVA) improved from 1.7±1.1 [0.02 decimal visual acuity (VA) equivalent] preoperatively to 1.2±1.0 (0.06 decimal VA equivalent) at the last postoperative visit (P<0.001). The mean operative time was 49.9min. With the exception of complicated cataract in one eye, no intraoperative complications were encountered. No case required conversion to conventional 20-, 23- or 25G instrumentation in all surgical maneuvers except for silicone oil infusion, which required a 25G oil injection syringe. Postoperative complications included transient ocular hypertension, vitreous hemorrhage, persistent intraocular pressure elevation, subconjunctival oil leakage, and recurrent retinal detachment. No cases of hypotony, endophthalmitis, and sclerotomy-related tears were observed.

CONCLUSION

The current results suggest that 27G PPV system is a safe and effective treatment for various vitreoretinal diseases. When learning to perform 27G PPV, surgeons may encounter a learning curve and should gradually expand surgical indications from easy to pathologically complicated cases.