Modified sutureless sclerotomies in pars plana vitrectomy

SURGICAL OUTCOMES OF 27-GAUGE VITRECTOMY FOR A CONSECUTIVE SERIES OF 163 EYES WITH VARIOUS VITREOUS DISEASES

We examined 27-gauge vitrectomy in a consecutive series of cases to evaluate the outcome of a sutureless 27-gauge vitrectomy system. The findings of this study demonstrate that for the treatment of a variety of ocular diseases, the 27-gauge vitrectomy system is as safe and effective as larger-gauge vitrectomy systems.

Purpose:

To evaluate the safety and efficacy of 27-gauge vitrectomy for various vitreoretinal disorders.

Methods:

In this retrospective comparative study, 163 consecutive eyes with various diseases that underwent 27-gauge pars plana vitrectomy with or without ultraspeed transformer by a single surgeon from June 2012 through December 2014 were analyzed in regard to best-corrected visual acuity, intraocular pressure, intraoperative and postoperative complications, and surgery time.

Results:

In 2 eyes (1.2%), peripheral retina breaks were encountered intraoperatively, yet no other complications were found in those eyes. No cases required larger-gauge vitrectomy. Mean best-corrected visual acuity improved from 20/58 (logarithm of the minimum angle of resolution, 0.46 ± 0.64) preoperatively to 20/32 (logarithm of the minimum angle of resolution, 0.20 ± 0.40) postoperatively (P < 0.001). Mean follow-up was 16.7 months (range, 6–33 months). Intraocular pressure remained stable throughout the postoperative course. Hypotony was seen in 15 eyes (9.2%) at 1-day postoperative, yet that spontaneously improved within 1 week. No case of retinal detachment or endophthalmitis was recorded. In macular surgeries, such as idiopathic epiretinal membrane and macular hole combined with cataract surgery, the mean surgery time was 32.1 ± 6.9 minutes with ultraspeed transformer (n = 38) and 37.1 ± 7.7 minutes without ultraspeed transformer (n = 40) (P = 0.004).

Conclusion:

The 27-gauge pars plana vitrectomy was found to be safe and effective for treating various vitreoretinal disorders.

25-Gauge Transconjunctival Sutureless Pars Plana Vitrectomy

Purpose

To evaluate the effectiveness, feasibility, and safety of the transconjunctival sutureless vitrectomy (TSV) system for a variety of vitreoretinal diseases.

Methods

In this retrospective study, the authors evaluated 71 eyes of 63 patients who underwent pars plana vitrectomy (PPV) with the 25-gauge TSV system. The indications for surgical intervention were diabetic vitreous hemorrhage (29 eyes), diabetic macular edema (14 eyes), macular epiretinal membrane (13 eyes), endophthalmitis (5 eyes), vitreous opacities secondary to Behçet's disease (4 eyes), vitreous hemorrhage secondary to branch retinal vein occlusion (4 eyes), and vitreous hemorrhage secondary to age-related macular degeneration (2 eyes). Epiretinal membrane and internal limiting membrane removal, endolaser photocoagulation, and air-fluid exchange were performed when required.

Results

Mean follow-up was 3.6 months (range 1–8 months). Mean overall visual acuity (VA) was counting fingers (range light perception to 0.4) preoperatively and 0.2 (range 0.1 to 0.8) postoperatively (p=0.000). Statistically significant VA improvement was observed in eyes with vitreous hemorrhage, diabetic macular edema, and macular epiretinal membrane. VA improved postoperatively in all eyes with endophthalmitis and vitreous opacities secondary to Behçet's disease. The surgery was completed without conjunctival and scleral suturing in all eyes. Mean intraocular pressure (IOP) was 17.2 mmHg (range 10–26 mmHg) preoperatively, 12.4 mmHg (range 6–24 mmHg) on the first postoperative day, 16.6 mmHg (range 10–33 mmHg) at 1 week, and 15.4 mmHg (range 10–20 mmHg) at 1 month postoperatively. On the first postoperative day, IOP was below 10 mmHg (between 6 and 9 mmHg) in 12 eyes (16.9%). In these eyes, IOP was normalized within 1 week without affecting the visual outcome. Five eyes (7%) had transient increase of IOP controlled by topical antiglaucomatous medications. Vitreous washout using 25-gauge TSV system was performed in two eyes, in which vitreous hemorrhage recurred.

Conclusions

The TSV system was observed to be feasible, effective, and safe for a variety of vitreoretinal diseases. This minimally invasive and completely sutureless (transconjunctival) technique appears to decrease the convalescence period, operating time, and postoperative inflammatory response, and improve patient comfort.

Review of Small Gauge Vitrectomy: Progress and Innovations

Purpose. To summarise the surgical advances and evolution of small gauge vitrectomy and discuss its principles and application in modern vitreoretinal surgery. The advent of microincisional vitrectomy systems (MIVS) has created a paradigm shift away from twenty-gauge vitrectomy systems, which have been the gold standard in the surgical management of vitreoretinal diseases for over thirty years. Advances in biomedical engineering and surgical techniques have overcome the technical hurdles of shifting to smaller gauge instrumentation and sutureless surgery, improving surgical capabilities and expanding the indications for MIVS.

A NOVEL TECHNIQUE FOR SECURING SCLEROTOMIES IN 20-GAUGE TRANSCONJUNCTIVAL PARS PLANA VITRECTOMY: Surgical Outcomes and Complications in 529 Consecutive Cases

PURPOSE

To describe a novel technique for securing sclerotomies after 20-gauge transconjunctival pars plana vitrectomy and determine the efficacy, and short-term safety in various vitreoretinal diseases.

METHODS

Retrospective chart review of consecutive cases that underwent 20-gauge transconjunctival pars plana vitrectomy with sclerotomy hydration was conducted. The main outcome measures included intraocular pressure, intraocular gas bubble size in postoperative Day 1, and early postoperative complications. Secondary outcomes included postoperative visual acuity at 1-month postoperative visit.

RESULTS

Five hundred and twenty-nine eyes were evaluated. Mean gas/air fill and mean intraocular pressure were 75.1% and 14.8 mmHg on postoperative Day 1. Seven eyes (1.32%) had hypotony (intraocular pressure <6 mmHg) on Day 1, which normalized in all eyes by Day 7 (P = 0.0083). On postoperative Day 7, mean intraocular pressure was 17.1 mmHg. Hypotony was associated with a preoperative diagnosis of retinal detachment (P = 0.022), and silicone oil tamponade (P = 0.017). Mean best corrected visual acuity was 20/320 preoperatively and 20/125 postoperatively at 1-month follow-up visit (P < 0.0001). Twenty-seven cases had intraoperative or postoperative complications (5.1%). Rate of complications was not associated with the type of tamponade (P = 0.076).

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy with sclerotomy hydration appears to be safe with a low rate of hypotony and complications, and good final visual outcome.

EFFECTS OF A MODIFIED VITRECTOMY PROBE IN SMALL-GAUGE VITRECTOMY: An Experimental Study on the Flow and on the Traction Exerted on the Retina

PURPOSE

Thorough this experimental study, the physic features of a modified 23-gauge vitrectomy probe were evaluated in vitro.

METHODS

A modified vitrectomy probe to increase vitreous outflow rate with a small-diameter probe, that also minimized tractional forces on the retina, was created and tested. The "new" probe was created by drilling an opening into the inner duct of a traditional 23-gauge probe with electrochemical or electrodischarge micromachining. Both vitreous outflow and tractional forces on the retina were examined using experimental models of vitreous surgery.

RESULTS

The additional opening allowed the modified probe to have a cutting rate of 5,000 cuts per minute, while sustaining an outflow approximately 45% higher than in conventional 23-gauge probes. The modified probe performed two cutting actions per cycle, not one, as in standard probes. Because tractional force is influenced by cutting rate, retinal forces were 2.2 times lower than those observed with traditional cutters.

CONCLUSION

The modified probe could be useful in vitreoretinal surgery. It allows for faster vitreous removal while minimizing tractional forces on the retina. Moreover, any available probe can be modified by creating a hole in the inner duct.

Active Silicone Oil Removal with a Transconjunctival Sutureless System: Is the 23-Gauge System Safe and Effective?

OBJECTIVES

To evaluate the safety and efficacy of active silicone oil removal with a 23-gauge (G) transconjunctival sutureless system.

MATERIALS AND METHODS

One hundred sixteen eyes of 113 patients who had previous retinal detachment surgery with pars plana vitrectomy and silicone oil injection surgery, and underwent silicone oil removal surgery with 23-G transconjonctival sutureless technique in our clinic between January 2009 and April 2014 were reviewed retrospectively. The patients were evaluated with regard to postoperative changes in best corrected visual acuity and intraocular pressure (IOP), and complications that occurred during and after surgery.

RESULTS

Of the 113 patients with mean age of 61.1±9.7 years (29-88 years), 62 (54.8%) were males and 51 (45.2%) were females. Silicone oil removal was performed 8.43±5.24 months after the initial surgery. Mean follow-up was 13.38±4.35 months. Visual acuity improved in 69 eyes (59.48%). Anatomic success was achieved in 113 eyes (97.41%). Mean IOP was 16.2±7.2 mmHg at baseline and 14.4±2.6 mmHg at postoperative day 1 (p=0.643). Eight eyes needed suturation of at least one sclerotomy. Retinal redetachment occurred in 3 eyes (2.5%) resulting in a decrease in vision. There were no cases of choroidal detachment, endophthalmitis, clinically significant corneal endothelial decompensation, or macular edema.

CONCLUSION

Active removal of 1,300-centistoke silicone oil with a 23-G transconjunctival sutureless system is a simple, sutureless technique causing minor surgical trauma. Active removal of silicone oil with the 23-G transconjunctival sutureless technique was found to be effective and safe in both phakic and pseudophakic eyes.

Comparison of Conjunctival Cytological Alterations following Conventional and Sutureless Sclerotomies

PURPOSE

To assess the alterations in conjunctival impression cytology following 23-gauge transconjunctival sutureless versus conventional pars plana vitrectomy.

PATIENTS AND METHODS

Sixty consecutive patients were enrolled in the study. Conjunctival impression cytology was performed on 30 eyes (of 30 subjects) with 23-gauge transconjunctival sutureless vitrectomy and on 30 eyes (of 30 subjects) with conventional vitrectomy. Conjunctival impression cytology was performed preoperatively on the 1st day and in the 3rd month after the surgery. Impression cytology specimens of each group were graded and scored using a range of 0-3 according to Nelson's method.

RESULTS

In the conventional pars plana vitrectomy group, statistically significant alterations in the conjunctival impression cytology were detected on the 1st postoperative day (p = 0.001) and in the 3rd postoperative month (p = 0.001), whereas in the 23-gauge transconjunctival sutureless pars plana vitrectomy group, statistically significant changes were observed on the 1st postoperative day. However, no significant changes were observed in the following 3 postoperative months (p = 0.08).

CONCLUSION

The properties of impression cytology were altered in the early postoperative period after sutureless and conventional vitrectomy. These changes were improved in the sutureless vitrectomy group only. Sutureless vitrectomy also had an advantageous effect on the conjunctival cytological changes and conjunctival structure.

Scleral Buckling for Rhegmatogenous Retinal Detachment Using Vitrectomy-Based Visualization Systems and Chandelier Illumination

PURPOSE

The objective of this study was to evaluate an alternative approach to scleral buckling surgery using vitrectomy-based chandelier visualization systems instead of the indirect ophthalmoscope.

DESIGN

This was a prospective case series.

METHODS

Ten eyes underwent scleral buckling under microscope using contact wide-angle lens with 25-gauge chandelier illumination and were followed up for 6 months.

RESULTS

An encirclage was done in 8 eyes, and segmental buckle used in 2 eyes. Excellent intraoperative visualization was achieved, and all routine buckling steps were easily replicated with this approach.

CONCLUSIONS

Using contact wide-angle lens along with chandelier illumination under microscope allows good visualization for scleral buckling procedure. This approach may allow excellent visibility with zooming capabilities for each step of the procedure as well as allows transmission to a monitor in the theater for teaching purposes apart from allowing better ergonomics for the surgeon.

In vivo comparison of 23- and 25-gauge sutureless vitrectomy incision architecture using spectral domain optical coherence tomography

Purpose. To investigate the in vivo incision architecture using spectral domain optical coherence tomography (SD-OCT) in 23-gauge and 25-gauge transconjunctival sutureless pars plana vitrectomy (TSPPV). Methods. A prospective observational study of 22 eyes of 22 patients that underwent three-port 25-gauge (10 eyes) or 23-gauge (12 eyes) TSPPV was performed. The three sclerotomies sites in each eye were analyzed by Corneal Adapter Model (CAM) RTVue SD-OCT (Optovue Inc., Fremont, CA, USA) with wound cross-section images (longitudinal and transversal) on days 1, 7, and 30 postoperatively. Transversal and longitudinal length, location, angle between the conjunctival surface tangent and the incision plane, and architecture deformations were evaluated. Results. All patients (22 eyes) completed the study and surgeries lasted less than 60 minutes. All wounds were obliquely performed, 23-gauge mean angle was 23 ± 5°, and 25-gauge angule was 21 ± 4°. Twenty-three-gauge sclerotomy transversal mean length was 1122 ± 242 μm and 25-gauge transversal sclerotomy mean length was 977 ± 174 μm; 23-gauge longitudinal mean length was 363 ± 42 μm and 25-gauge longitudinal sclerotomy mean length was 234 ±19 μm; 23-gauge open wound thickness mean was 61 ± 28 μm and 25-gauge open wound thickness mean was 22 ± 6 μm. All results were statistically significant (P < 0.05). No vitreous incarceration or silicone oil residue was observed in incision sites with both gauges. Conclusions. The 23-gauge and 25-gauge architectural wound constructions were well visualized using CAM SD-OCT. Statistical differences between the two gauges were observed throughout the study period.

Comparison of the 20-gauge conventional vitrectomy technique with the 23-gauge releasable suture vitrectomy technique

PURPOSE

To compare the efficacy of the transconjunctival releasable suture technique for pars plana vitrectomy using 23-gauge (23G) instruments versus the conventional 20-gauge (20G) technique.

METHODS

A retrospective and interventional case series was consecutively performed for 199 eyes of the 192 patients that were a part of this study. Clinical data were reviewed retrospectively regarding the operation time, preoperative and postoperative intraocular pressure, visual acuity and astigmatism for 54 consecutive patients who received a 23G releasable suture vitrectomy and for 98 consecutive patients who received a 20G conventional vitrectomy during the period between April 2007 and September 2010.

RESULTS

Mean operation time based on the operation record was 88.5 ± 20.1 minutes in the 23G releasable suture vitrectomy group and 102.1 ± 23.1 minutes in the 20G conventional vitrectomy group, respectively (p = 0.01). The last best-corrected visual acuity (BCVA) was significantly better than the preoperative BCVA in both patient groups (p = 0.01, p = 0.01). The 23G releasable suture group showed less surgically induced astigmatism than the 20G conventional vitrectomy group. Vitreous bleeding was observed to be in 6 eyes (5.9%) in the 23G group, and in 8 eyes (8.2%) in the 20G group. In addition, ocular hypertension was noted to be in 3 eyes (3.0%) in the 23G group, and 6 eyes (6.1%) in the 20G group. No serious complications such as postoperative hypotony or endophthalmitis were observed in either group.

CONCLUSIONS

The 23G releasable suture technique is as effective as the 20G conventional technique and offers several advantages.

Comparative study between a standard 25-gauge vitrectomy system and a new ultrahigh-speed 25-gauge system with duty cycle control in the treatment of various vitreoretinal diseases

AIM

To compare a standard 25-gauge vitrectomy system with a new ultrahigh-speed (UHS) 25-gauge system with duty cycle control for pars plana vitrectomy.

METHODS

In this prospective, controlled clinical trial, 120 patients (divided into 2 groups of 60 patients) underwent a 3-port pars plana vitrectomy for the treatment of epiretinal membranes, macular holes, retinal detachment, and complications of diabetic retinopathy. Evaluations were performed preoperatively, intraoperatively, on the first 3 postoperative days, and at 1 week, 1 month, and 3 months. Main outcome measures were vitrectomy time, induction of posterior vitreous detachment, and intra- and postoperative complications. Vitrectomy time included retinal manipulation, but did not include wound opening and closure.

RESULTS

The duration of surgery was significantly different between the groups. Patients in the new UHS 25-gauge group had a significantly shorter duration of vitrectomy time (P < 0.0001). Mean overall vitrectomy time was 1,583.7 ± 875.4 seconds (26 minutes) in the standard 25-gauge group and 1,106.3 ± 575.9 seconds (18 minutes) in the UHS 25-gauge group. Twenty-nine patients (48.3%) in the standard group and 27 patients (45.0%) in the UHS group experienced induction of posterior vitreous detachment. Thirteen patients (21.7%) in the standard 25-gauge group and 1 patient (1.7%) in the new UHS group had intraoperative iatrogenic retinal breaks.

CONCLUSION

The new-generation UHS 25-gauge system may provide a new paradigm of high-flow, smaller-diameter instrumentation, thus increasing the efficiency of the small-gauge technique and the safety of the surgery.

Multi-purpose extraocular forceps for small-gauge pars plana vitrectomy

A multi-purpose titanium forceps has been developed for small-gauge pars plana vitrectomy surgery. These forceps were designed to provide the vitreoretinal surgeon with a single tool for the extraocular manipulations that are necessary for the placement and removal of 23- and 25-gauge trochars for small-incision, sutureless pars plana vitrectomy surgery. The forceps has been designed to allow for the atraumatic manipulation of the conjunctiva, measurement of distance from the limbus, and a strong purchase of the trochar for both its fixation and removal.

Small-gauge vitrectomy in traumatic retinal detachment

PURPOSE

To report the outcome of retinal detachment surgery following trauma treated with small-gauge vitrectomy.

DESIGN

Retrospective chart review.

PARTICIPANTS

Adult patients presenting with a retinal detachment following severe trauma between 2007 and 2009 that underwent vitreoretinal surgery with either 25- or 23-gauge vitrectomy.

METHODS

  Data collected included; age, sex, eye, time interval between injury and diagnosis of retinal detachment, anatomical and functional success, complications, and length of follow up.

MAIN OUTCOME MEASURES

Anatomical and functional outcome.

RESULTS

Nineteen consecutive adult patients with traumatic retinal detachment were included. The mean age was 51.4 ± 19.3 years; 68.5% were male. Thirteen patients (68.4%) presented with visual acuity of hand movement or worse including six patients with light perception only. Five eyes achieved 6/60 vision or better, and three eyes had visual acuity of 6/12 or better. During the period of follow up six eyes experienced a recurrent retinal detachment.

CONCLUSION

Traumatic retinal detachment can be successful managed with small-gauge vitrectomy.

Fifty consecutive cases of transconjunctival sutureless 23-gauge vitrectomy combined with phacoemulsification and IOL implantation

BACKGROUND AND OBJECTIVE

To evaluate safety and effectiveness of combined 23-gauge vitrectomy and phacoemulsification with intraocular lens (IOL) implantation for eyes with vitreoretinal conditions and progressed cataract.

PATIENTS AND METHODS

The authors retrospectively reviewed 50 previously nonvitrectomized eyes of 50 patients with various vitreoretinal conditions and cataract affecting visual acuity. They underwent combined surgery with sutureless transconjunctival 23-gauge vitrectomy and phacoemulsification with IOL implantation. Surgical indications were a progressed cataract with various retinal conditions.

RESULTS

Best-corrected visual acuity (BCVA) improved from 0.23 (range: 0.125 to 0.32; standard deviation [SD]: 0.08) to 0.48 (range: 0.32 to 0.8; SD: 0.16). Spherical equivalent changed from 0.50 to 0.08 diopters. Cataract surgery mean time was 10.46 minutes, vitrectomy mean opening time was 1.1 minutes, and mean vitrectomy procedure time varied widely depending on the type of retinal surgery (20.06 minutes; range: 5 to 55; SD: 11.10). At 1 week, relative hypotony was found in 12% and hypotony was found in 4%. There was no hypotony 3 months after surgery.

CONCLUSION

Transconjunctival 23-gauge vitrectomy with phacoemulsification with IOL implantation appears effective with an acceptable safety profile for patients with cataract with simultaneous retinal diseases.

Transconjunctival Sutureless 23-gauge Vitrectomy for Vitreoretinal Diseases: Outcome of 30 Consecutive Cases

Background:

To describe the initial experience, effectiveness, and safety profile of 23-gauge instrumentation for a variety of vitreoretinal conditions.

Methods:

A retrospective review of 30 consecutive 23-gauge vitrectomy cases done by a single vitreoretinal surgeon for various posterior segment conditions was done. All surgeries were performed using the two-step 23-gauge system developed by Dutch Ophthalmic Research Center (DORC). All patients had at least 3-month follow-up. Main outcome measures included surgical success, visual acuity, intraocular pressure, and operative complications.

Results:

Mean follow-up was 7.7 months (range 3–12 months). Indications for surgery included rhegmatogenous retinal detachment (n=8), nonclearing vitreous hemorrhage (n=6), tractional retinal detachment (n=5), macular hole (n=5), epiretinal membrane (n=3), retained lens fragments (n=2) and endophthalmitis (n=1). Gas tamponade was used in 18 eyes (60%) and silicone oil in six eyes (20%). Mean overall preoperative visual acuity was 20/1053 and final acuity was 20/78 (P = 0.001). Mean intraocular pressure after 6 hours was 15.1mmHg (range 4-25 mmHg) and on postoperative day one was 14.5 mmHg (range 2-21 mmHg). Four eyes (13.3%) required suturing of sclerotomy intraoperatively. Conversion to 20-gauge was done in one eye (3.3%). Hypotony was reported in one eye (3.3%) postoperatively. Subconjunctival silicone oil reported in one eye (3.3%). There were no postoperative complications of endophthalmitis, retinal or choroidal detachment.

Conclusion:

23-gauge transconjunctival sutureless vitrectomy was effective in the management of wide variety of vitreoretinal surgical indications. The safety profile compared favorably with published rates for 25-gauge systems.

Outcomes of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To assess the effectiveness and safety of the 20-gauge transconjunctival sutureless vitrectomy system in vitreoretinal surgeries.

METHODS

The charts of 102 consecutive patients who underwent 20-gauge transconjunctival sutureless vitrectomy by 1 surgeon were retrospectively reviewed. The main outcome measures were intraoperative and postoperative complications and postoperative intraocular pressure and Snellen visual acuity relative to preoperative values. Patients were evaluated before surgery and 1 day, 1 week, 1 month, and 3 months postoperatively.

RESULTS

No trocar-related intraoperative complications were recorded. Two patients (2%) each required suturing of 1 sclerotomy because of leakage at completion of surgery. Mean preoperative visual acuity (in logarithm of the minimum angle of resolution units) was 1.1 ± 0.6. By 3 months after surgery, the mean visual acuity had improved to 0.8 ± 0.5 (P < 0.001). Mean preoperative intraocular pressure was 14.7 ± 5.1 mmHg. Mean postoperative intraocular pressure was 14.2 ± 5.5 mmHg (P = 0.48) at Day 1 and 14.6 ± 4.3 mmHg (P = 0.82) at Day 7 after surgery. Hypotony was present in 3 patients (3%) on the first postoperative day, but their intraocular pressure normalized spontaneously within 1 week. None of the patients developed postoperative endophthalmitis or retinal detachment.

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy is a safe and effective technique for the surgical treatment of a variety of vitreoretinal pathologies.

23-gauge transconjunctival sutureless vitrectomy: visual outcomes and complications

PURPOSE

To report results and complications of 23-gauge transconjunctival sutureless pars plana vitrectomy for a variety of vitreoretinal diseases.

METHODS

A prospective consecutive case series study was performed in 66 eyes of 66 patients. Indications for surgery were epiretinal membrane (n = 20), rhegmatogenous retinal detachment (n = 19: 14 pseudophakic, 5 phakic), macular hole (n = 16), vitreous hemorrhage (n = 5), cyclodialysis (n = 1), intraocular lens luxation (n = 1), asteroid hyalosis (n = 1), congenital retinoschisis (n = 1), and endophtalmitis (n = 2). Main outcome measures included visual acuity, intraocular pressure, and intra- and post-operative complications.

RESULTS

Mean patient age at time of operation was 68 ± 12 years. Overall, visual acuity improved from 1.03 ± 1.00 logMAR preoperatively to 0.32 ± 0.33 logMAR postoperatively (p < 0.01) after a mean follow-up time of 9.3 ± 4.7 months. Mean preoperative intraocular pressure was 13.9 ± 3.5 mmHg, and mean postoperative intraocular pressure was 17.9 ± 9.6 mmHg on day 1 (p < 0.01) and 14.7 ± 2.8 mmHg (p = 0.05) at final visit. Concerning complications, 2 cases of hypotony and 7 of hypertony occurred on day 1, a macular hole reopened some weeks later, and a retinal detachment recurred in one case.

CONCLUSION

23-gauge transconjunctival sutureless vitrectomy is an effective and safe technique for a variety of vitreoretinal diseases.

Comparison of retinal breaks observed during 23 gauge transconjunctival vitrectomy versus conventional 20 gauge surgery for proliferative diabetic retinopathy

BACKGROUND

To assess the rate and type of retinal break formation in patients undergoing 23 gauge transconjunctival vitrectomy surgery for complications of proliferative diabetic retinopathy compared with 20 gauge vitrectomy surgery.

METHODS

Retrospective case notes review of two consecutive series of patients who had primary pars plana vitrectomy for complications of proliferative diabetic retinopathy by a single surgeon. The control group had standard 20 gauge vitrectomy surgery whilst the second group had 23 gauge transconjunctival vitrectomy surgery.

RESULTS

Eighty-five eyes were included in the 20 gauge group and 85 eyes in the 23 gauge group. The groups were well matched for surgical complexity and indications for surgery, as well as a variety of other preoperative variables. There was a significant reduction in the incidence of peripheral sclerotomy-related retinal breaks and lesions suspicious for breaks (4/85 [5%] 23 gauge versus 14/85 [16%] 20 gauge, P = 0.02) and posterior retinal breaks (3/85 [4%] 23 gauge versus 12/85 [14%] 20 gauge, P = 0.03). Six eyes (7%) in total had definite new retinal breaks of any type detected in the 23 gauge group compared with 16 (18.8%) in the 20 gauge group (P = 0.04). One patient in each group experienced a retinal detachment postoperatively related in both cases to a posterior retinal break associated with recurrent traction.

CONCLUSION

In this series of patients, 23 gauge transconjunctival vitrectomy surgery was associated with a lower rate of retinal break formation than 20 gauge vitrectomy for proliferative diabetic retinopathy.

A new dual port cutter system for vitrectomy surgery

PURPOSE

To evaluate and compare the performance of several designs of 20-gauge dual port (DP) vitreous cutter tips with a standard 20-gauge single port tip.

METHODS

Custom 20-gauge pneumatic vitreous DP cutter tips with different sizes and port positions were evaluated through porcine vitreous and water flow rates. Five designed and fabricated DP cutter tips were compared with a normal single port control tip and evaluated by the measurement of water and porcine vitreous flow rates, and surgical examination in enucleated porcine eyes.

RESULTS

Some DP tips approached a maximum vitreous and water flow rates, removing water and vitreous faster than the normal control tip. With reference to surgical evaluation, some DP tips performed better than the single port tip for bulk vitrectomy, but none shaved the vitreous base more effectively.

CONCLUSION

The DP cutter system has the potential to increase the flow rates depending on the size and position of the extra port. In the future, the DP cutter may allow the surgeon to perform bulk vitrectomy more efficiently.

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 using different incision techniques with 23-gauge and 25-gauge microincision vitrectomy systems

PURPOSE

To describe the anatomic and histopathologic outcomes using different incision techniques with transconjunctival 23-G and 25-G vitrectomy systems.

METHODS

New Zealand rabbits were randomized to either 23-G or 25-G vitrectomy surgeries using angled incisions and straight incisions. After pars plana vitrectomy, the cannulas were removed and 0.1% trypan blue was injected to evaluate for leakage. The animals were killed on day 7 and the eyes enucleated for gross analysis and histopathologic analysis by frozen section.

RESULTS

Leakage of trypan blue was noted from 10.8% and 5.7% of straight and angled incisions, respectively. There was no difference between 23-G and 25-G incisions (8.3%). On gross examination, the 25-G system resulted in 58% and 24% open external wounds for straight and angled incisions, respectively (P = 0.04). The 23-G system resulted in 83% and 39% open external wounds with straight and angled incisions, respectively (P = 0.017). The average wound area after the 23-G surgery was 223.1 microm(2) and 115.7 microm(2) for straight versus angled incisions, respectively (P = 0.02). The average wound area formed after the 25-G surgery was 160.3 microm(2) and 85.2 microm(2) for straight versus angled incisions, respectively (P = 0.001).

CONCLUSIONS

Outcomes were similar for 23-G angled incisions, 25-G straight incisions, and 25-G angled incisions.

Vitreous dynamics: vitreous flow analysis in 20-, 23-, and 25-gauge cutters

PURPOSE

To evaluate porcine vitreous flow and balanced saline solution (BSS) flow rates in different vitrectomy systems.

METHODS

Porcine vitreous was obtained within 24 hours of slaughter. A high-speed (2 samples/s) balance, precise to 0.01 g, was used. Variable cut rates and vacuum pressures were analyzed in vitreous and BSS. The vitreous was labeled with glass microspheres and triamcinolone acetonide. A high-speed (400 frames/s) camera was used to record cutting for each condition.

RESULTS

For all cutters, there was no vitreous flow at zero cut rates (off). In 25-gauge cutters, at 500 mmHg of vacuum, the electric cutter produced higher average flow rates at high cut rates (600 cpm, 0.004 mL/s, and 1500 cpm, 0.013 mL/s) than pneumatic, which demonstrated a decreased flow at speeds higher than 1000 cpm (1000 cpm, 0.015 mL/s, and 1500 cpm, 0.006 mL/s). The percentage of vitreous flow rate/BSS flow rate in different aspiration and cut rates showed an ascending curve. This demonstrates evidence of flow obstruction in 25- (all cut rates), 23- (all cut rates), and 20-gauge (all cut rates). Flow obstruction and surge movements were seen in the high-speed videos.

CONCLUSIONS

The vitrectomy systems each illustrate different performances of vitreous removal. The physical characteristics of vitreous resulted in nonuniform flow in all vitreous cutters.

Fluid dynamics in three 25-gauge vitrectomy systems: principles for use in vitreoretinal surgery

PURPOSE

To compare infusion and extrusion fluid volumes with three 25-gauge vitrectomy systems.

METHODS

The infusion and aspiration rates of 25-gauge systems from Alcon (Fort Worth, TX, USA), Bausch & Lomb (St Louis, MO, USA), and the Dutch Ophthalmic Research Centre (DORC, Zuidland, the Netherlands) were measured in vitro using balanced saline solution with different heights (40, 60, 80, 100, 120 cm) of infusion bottle, cutter velocities (800, 1100, 1500 cuts/ min) and aspiration powers (100, 200, 300, 400, 500 mmHg).

RESULTS

The infusion flow velocities differed among the systems (p < 0.001 for all comparisons [p-values 0.0009-0.0001]). The aspiration rates of the Alcon and Bausch & Lomb systems were lower than that of the DORC system (p < 0.02 for all comparisons [p-values 0.018-0.002]).

CONCLUSIONS

Infusion and extrusion fluid rates differ among 25-gauge vitrectomy systems. These results may help to optimize ideal aspiration and infusion parameters among 25-gauge vitrectomy systems used to treat vitreoretinal diseases.

Outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease

PURPOSE

To describe the initial experience, effectiveness, and safety profile of 23-gauge instrumentation for a variety of vitreoretinal conditions.

DESIGN

Single-center, retrospective, noncomparative, consecutive interventional case series.

PARTICIPANTS

Seventy-seven eyes of consecutive patients who underwent 23-gauge transconjunctival vitrectomy surgery by a single surgeon at the Manhattan Eye, Ear, and Throat Hospital from October 2004 through October 2005.

INTERVENTION

All patients underwent 3-port 23-gauge vitrectomy using Dutch Ophthalmic Research Corporation instrumentation and an Alcon Accuris Vitrector.

MAIN OUTCOME MEASURES

Postoperative visual acuity at months 1 and 3, intraoperative and postoperative complications, and operative time.

RESULTS

Mean acuity improved from 20/190 at baseline to 20/108 (P<0.0001) and 20/74 (P<0.0001) at months 1 and 3, respectively. By diagnosis, patients with epiretinal membrane (n = 20) improved from 20/124 to 20/93 (P = 0.0046), macular hole (n = 18) from 20/174 to 20/57 (P = 0.0007), rhegmatogenous retinal detachment (RD) (n = 14) from 20/248 to 20/51 (P = 0.0004), tractional RD (n = 12) from 20/175 to 20/62 (P = 0.0159), nonclearing vitreous hemorrhage (n = 12) from 20/1345 to 20/189 (P = 0.0004), vitreomacular traction (n = 4) from 20/145 to 20/124 (P = 0.7525), and retained lens fragments (n = 4) from 20/308 to 20/140 (P = 0.0972). One patient who underwent diagnostic vitrectomy had stable 20/50 acuity. Two patients had hypotony on postoperative day 1, 1 patient required a sutured sclerotomy intraoperatively, and no patients developed choroidal effusions. No intraoperative tears were noted. Surgical times collected on 17 patients during the final month of the study demonstrated a mean opening time (range) of 103 seconds (70-162), mean closing time of 75 seconds (17-470), and net operating time of 24.1 minutes (7.1-74.6).

CONCLUSIONS

Twenty-three-gauge instrumentation is effective for a variety of vitreoretinal surgical indications. The safety profile compared favorably with published rates for 25-gauge systems.

Modified incision in 25-gauge vitrectomy in the creation of a tunneled airtight sclerotomy: an ultrabiomicroscopic study

BACKGROUND

The standard straight incision for 25-gauge vitrectomy may not close well at the end of surgery with post-operative hypotony. To overcome incompetent wound closure, oblique insertion of the trocars has been suggested. More recently we have developed an oblique incision. which is parallel to the scleral fibres instead of perpendicular and therefore avoids cutting. The aim of this study was to compare the effectiveness of the different incisions and to investigate their behaviour with the UBM.

METHODS

45 patients affected by macular holes were operated; in 15 eyes using oblique-parallel insertion (OPAI), in 15 oblique-perpendicular (OPEI) and in 15 straight incision (SI). Patients underwent UBM examinations 1 day, 1 week, 1 month p.o.

RESULTS

OPAI was airtight after the removal of 25 g cannulas. UBM examination 1 day post-operatively (p.o) showed the 45 sclerotomies were well healed with perfect apposition of the internal wound lips. 39 sclerotomies were undetectable, 6 slightly evident. With OPEI the incisions were airtight at the end of surgery. At the 1 day p.o. UBM examination the 45 sclerotomies were well-healed but a minimal gape was clearly visible in all of them, 3 eyes showed peripheral cilio-choroidal (CCD) detachment, which was resolved after 7 days although the gape was still evident. At 1 month p.o. examination the gape was not detectable in 20 sites, evident in 25. With SI at the end of the surgery conjunctival bleb formation was detected in 10 cases, air-gas refilling was performed in 7 eyes and 3 sclerotomies were sutured. At 1 day p.o. hypotony was recorded in 5 patients, recovering at the 7 day follow-up. At the 1 day p.o. UBM examination showed a significant gape in all sites, weak vitreous entrapment was shown in 36, subconjunctival fluid in 4, CCD in 7. At the 7 day UBM the CCD had disappeared in 4 and was reduced in 3. At the 1 month p.o. the sclerotomy defect was still detectable but other complications were no longer evident.

CONCLUSIONS

OPAI achieved the quickest and most complete sealing since the 1st day p.o without complications, therefore it could be safer when performing 25-g vitrectomy with extensive manipulation.

Étude comparative de la vitrectomie transconjonctivale sans suture à 25-gauges avec celle à 20-gauges

PURPOSE

The transconjunctival sutureless vitrectomy (TSV 25) is a new technique showing substantial progress.

METHODS

A prospective study of 66 eyes of 66 patients who underwent surgical procedures using the transconjunctival standard vitrectomy system (TSV 25), between June 2004 and June 2005. The results were compared with the results in an equivalent population (66 patients) that underwent vitrectomy with a standard 20-gauge system.

RESULTS

The most important differences between groups were 1) shorter surgical time in the 25-gauge vitrectomy group than in the 20-gauge group, with a mean time of 28.15+/-5.50 min for group 1 and 44.15+/-5.64 min for group 2 (p<0.001) and 2) lower mean postoperative intraocular tension in the first group of patients: in this group, the intraocular tension before surgery was a mean of 16.27+/-1.76 mmHg, decreasing to 12.17+/-1.36 mmHg, with a posterior increase to normal values of 15.06+/-1.66 mmHg at 7 days after surgery and a mean of 16.10+/-1.51 mmHg at 15 days. This decrease was not observed in the group of patients who underwent 20-gauge vitrectomy surgery. The other postoperative complications were similar in both groups except for four cases of anterior proliferation and two cases of fibrinous uveitis in group 2.

CONCLUSION

The transconjunctival sutureless system (TSV 25) decreases surgical time and postoperative inflammation, with optimal postoperative patient comfort, but currently the accurate selection of patients remains important.

Problems associated with the 25-gauge transconjunctival sutureless vitrectomy system during and after surgery

OBJECTIVE

To report the initial experiences with the 25-gauge transconjunctival sutureless vitrectomy (TSV) system, including intraoperative and postoperative problems.

METHODS

We retrospectively reviewed the medical records and surgical videotapes of 50 consecutive patients who underwent vitrectomy performed by one surgeon using the TSV system.

RESULTS

Intraoperatively, we encountered such problems as difficulty in inserting the microcannula, which led to deformity, instability of the microcannula, self-disconnection of the infusion tip and resultant lens damage, and conversion to 20-gauge conventional vitrectomy. Postoperatively, there were 8 cases with hypotony (IOP < 6 mm Hg) on day 1, 6 cases with elevated IOP, and 3 cases with retinal detachment during follow-up.

CONCLUSION

Though certain problems exist during and after surgeries using TSV, this system is both convenient and safe for various vitreoretinal procedures.

Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy

We describe a technique for combined cataract and vitreoretinal surgery using a 25-gauge transconjunctival sutureless vitrectomy system. This technique was successfully performed in 20 consecutive cases. Outcomes were assessed in terms of visual acuity, intraocular pressure, postoperative refractive error, and incidence of complications. The technical feasibility, rationale, and advantages and disadvantages of this technique are discussed.

Surgical Outcomes of 25-Gauge Transconjunctival Vitrectomy Combined With Cataract Surgery for Vitreoretinal Diseases

Introduction: To report surgical outcomes of 25-gauge transconjunctival vitrectomy combined with cataract surgery for the management of a variety of vitreoretinal diseases. Materials and Methods: A retrospective, interventional case study was conducted. Chart review of a consecutive series of 150 eyes of 144 patients who underwent 25-gauge vitrectomy combined with phacoemulsification and intraocular lens implantation for epiretinal membrane (n = 62), refractory macular oedema associated with retinal vascular disorders (n = 29), idiopathic macular hole (n = 21), non-clearing vitreous haemorrhage (n = 18), rhegmatogenous retinal detachment (n = 11), tractional retinal detachment associated with proliferative diabetic retinopathy (n = 7), and subretinal haemorrhage (n = 2). Main outcome measures included pre- and postoperative visual acuity, operating time, intraocular pressure, intra- and postoperative complications. Results: The mean follow-up period was 9.7 months (range, 6 to 26). The mean overall visual acuity improved from 20/100 preoperatively to 20/38 at final visit (P <0.001). Statistically significant improvement of visual acuity was also observed in each subgroup. Operative time was shortened in macular surgery. No intraoperative complications were noted attributable to small-gauge instruments and no cases required conversion to 20-gauge standard instrumentation. However, 12 eyes (8%) required suture placement to at least one sclerotomy site. Postoperative intraocular pressure remained stable in most cases except 18 eyes (13%) with transient hypotony during the first week after surgery. One case of retinal detachment but no case of endophthalmitis was observed throughout the follow-up period. Conclusions: 25-gauge vitrectomy combined with cataract surgery is a safe and effective system for the management of a variety of vitreoretinal diseases, especially cases requiring minimal intraocular manipulation. Further study is recommended to evaluate potential postoperative complications. Key words: Minimally invasive surgery, Vitreous surgery