Transconjunctival sutureless vitrectomy: initial experience and surgical tips

Small-Gauge Vitrectomy for Macular Surgery Using a Systematic Approach to Wound Closure: 27-Gauge vs 25-Gauge

Purpose: To evaluate the effectiveness of and to compare vitrectomy performed with 25-gauge or 27-gauge instrumentation for macular surgery by assessing the surgical duration, wound closure, and complication rate using a systematic approach to wound closure. Methods: In this retrospective chart review, 125 25-gauge and 125 27-gauge consecutive small-gauge vitrectomy surgeries for epiretinal membrane, macular hole, vitreomacular adhesion, or a combination were analyzed during and immediately after surgery. Wound closure was performed using a systematic protocol. Results: Baseline characteristics were not statistically different between the 2 groups. The surgical duration was similar with 25-gauge vitrectomy and 27-gauge vitrectomy (P = .07). Although spontaneous wound closure was common in both groups, it was more common in the 27-gauge group (P = .22). Intraoperative and postoperative complications were uncommon in both groups. Conclusions: Findings show that 27-gauge vitrectomy is a safe, effective alternative to the more commonly used 25-gauge vitrectomy for macular surgery. Less manipulation was required to achieve wound closure with 27-gauge vitrectomy using a standardized wound-closure protocol. Smaller 27-gauge vitrectomy did not increase surgical time or complications over 25-gauge vitrectomy for macular surgery.

Intraocular biopsy in uveitis

An intraocular biopsy is performed for diagnostic, prognostic and investigational purposes. Biopsies help to confirm or exclude malignancies and differentiate inflammatory from infectious processes. Histopathological analysis is the final verdict in unresponsive uveitis, atypical inflammation, metastases and masquerade syndromes. Advances and refinement of techniques in cytopathology, immunohistochemistry, microbiological and molecular biologic study offer much more than just diagnosis. They provide prognosis based on cell characteristics and are helpful in planning treatment and intervention. Many biopsy procedures have evolved to provide more safety and minimise complications thus improving the quality of specimens or samples available for analysis. The type of biopsy and technique adopted varies based on the clinical suspicion, size and location of lesions. In uveitis, a working diagnosis of intraocular inflammation is made on clinical examination and laboratory investigations and ancillary tests. Malignancy and uveitis is interlinked and masquerade syndromes are among the commonest indications for biopsy and analysis of specimen. The various types of intraocular biopsies include aqueous tap, fine needle aspiration biopsy, vitreous biopsy, iris and ciliary body, and retinochoroidal biopsy. They will be reviewed in this article with respect to current perspective

Comparison of safety and effectiveness between 23-gauge and 25-gauge vitrectomy surgery in common vitreoretinal diseases

PURPOSE

To assess and compare safety and effectiveness between 23-gauge and 25-gauge vitrectomy systems for the treatment of common vitreoretinal diseases in non-vitrectomized eyes.

METHODS

Retrospective evaluation of patients who underwent pars plana vitrectomy from April 2018 to December 2019 at the Department of Ophthalmology and Optometry at the Medical University of Vienna (MUV) for the following indications: macular epiretinal membrane, macular hole, macular lamellar hole, vitreous hemorrhage, vitreous opacities, vitreomacular traction syndrome and macular edema.

RESULTS

201 eyes of 195 patients that underwent 23-gauge (n = 105 eyes) or 25-gauge (n = 96 eyes) vitrectomy were included in this study. The mean best-corrected visual acuity (BCVA) improved at 1-3 months postoperatively and beyond 3 months in both gauge groups. Risk of any complication within 1 month postoperatively was lower in the 25-gauge group, but the difference was statistically not significant (HR [95% CI]: 0.95 [0.53; 1.70], p = 0.85). Intraocular pressure less than 5 mmHg was observed in 2 eyes (2%) in the 23-gauge group at the first postoperative day. Intraocular pressure elevation over 25 mmHg occurred in 5 eyes (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group) at postoperative day 1, between 7 and 28 days in 5 cases (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group), and in 2 eyes (2%) of the 23-gauge group at postoperative day 145 and 61, respectively. Retinal detachment occurred in 1 eye (1%) in the 23-gauge and in 3 eyes (3%) in the 25-gauge group. We did not observe any cases of endophthalmitis.

CONCLUSION

Results in terms of safety, surgical success and visual outcomes for the treatment of common vitreoretinal surgery indications seem to be comparable between 23-gauge and 25-gauge vitrectomy systems, indicating that the two gauge systems can be used equally in the clinical routine.

Influence of Perfluorocarbon Liquids on Peripapillary Retinal Nerve Fiber-Layer Thickness Following Pars Plana Vitrectomy with Silicone Oil-Based Endotamponade

Background

Inner retina–layer modifications after pars plana vitrectomy (PPV) can be objectively assessed through spectral domain optical coherence tomography (SD-OCT).

Methods

This study explored prospectively changes in retinal nerve-fiber layer (RNFL) thickness with SD-OCT in eyes undergoing PPV with silicone oil–based tamponade with and without use of perfluorocarbon liquids (PFCLs) during the early postoperative phase (up to 3 months) at the Research Institute of Ophthalmology, Egypt.

Results

Thirty patients were recruited who underwent PPV and silicone oil–based tamponade for either retinal detachment or diabetic retinopathy between April 2019 and September 2019. Mean RNFL thickness showed no significant change during follow-up at the first week (102.90±30.68 mm), 1 month (107.30±32.27), or three months (105.90±36.68; p=0.46, 0.68). There were significant correlations noticed between RNFL thinning and axial length of eyes, intraocular pressure, and use of PFCLs during the follow-up period.

Conclusion

The RNFL tends to change postvitrectomy, but not significantly. Careful examination and consistent follow-up is required for postvitrectomy patients with larger axial length and intraoperative PFCL use.

Reconsidering the Postoperative Day 0 Visit for Retina Surgery

BACKGROUND AND OBJECTIVE

This study compares outcomes of patients who were examined on postoperative (PO) day 0 and PO day 1 following retina surgery.

PATIENTS AND METHODS

A nonrandomized, comparative, retrospective series of one vitreoretinal surgeon was conducted on 166 patients with a PO day 0 visit (approximately 5 hours following surgery) and 428 patients with a PO day 1 visit.

RESULTS

Among patients examined at PO day 0, 4.6% had hypotony (intraocular pressure [IOP] ≤ 5 mm Hg) and 1.8% needed intervention for elevated IOP (IOP ≥ 30 mm Hg) compared with 1.6% and 4.0% of patients, respectively, examined on PO day 1.

CONCLUSION

Following retina surgery, there is a similar percentage of patients with abnormal IOP when patients are examined on PO day 0 when compared with PO day 1. However, the rate of hypotony was statistically higher on PO day 0, and there was a trend toward more elevated IOP on PO day 1. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e52-e56.].

Short- and Long-Term Outcomes of Vitreoretinal Surgeries With Deferred First Postoperative Visits at Day 3 or Later

Background and Objective:

Postoperative (PO) day 1 visits can be challenging for certain patients (eg, satellite office patients). This study analyzes the proportion of eyes requiring changes in management on the first PO visit day ≥3 following vitreoretinal surgery.

Study Design/Materials and Methods:

A retrospective, consecutive case series of 1 vitreoretinal surgeon was conducted on 246 surgeries of 231 patients with the first PO examination day ≥3 from January 1, 2008 to December 31, 2013. Clinical parameters were statistically analyzed to identify eyes with pressure issues or early interventions. Short- and long-term outcomes were assessed at PO weeks 1 to 4 and months 3 to 8.

Results:

At the first PO visit ≥3 (mean 4.5) days, 3.3% eyes had intraocular pressure (IOP) ≤5, 3.3% IOP ≥30, 0.8% choroidal detachments, 0.4% vitreous hemorrhage, and 0% endophthalmitis. About 2.0% of eyes required intervention (IOP medications). Surgical indications, procedure, and tamponade were not predictive of pressure issues or early intervention ( P > .05). At weeks 1 to 4 and month 3 to 8, 4% to 6% of eyes required additional intervention or surgery.

Conclusion:

The first PO visit day ≥3 after vitreoretinal surgeries had low intervention rates. Few complications or additional surgeries occurred throughout the study period.

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.

Passive removal of silicone oil through 23 gauge transconjunctival sutureless vitrectomy system

Objective:

To study the outcomes of passive removal of silicone oil by 23 Gauge Transconjunctival Sutureless Vitrectomy System.

Methods:

This prospective, consecutive case series study was conducted at Ophthalmology Department Unit I, Dow University of Health Sciences, Civil Hospital Karachi from January 2011 to December 2014. Only psuedophakic eyes with silicone oil temponade were selected. Main outcome measures were intra ocular pressure, time taken for removal of silicone oil, per operative and post operative complications. Pre and post operative IOP was compared by using two-tailed paired t-test and mean values with standard deviation were computed using difference of 95% confidence interval. Chi square test was applied for correlation of different variables. P-value of less than 0.05 was considered statistically significant.

Results:

Out of 79 patients who underwent passive ROSO, 38 (48.1%) were males. Mean age of patients was 47.5±7.1 (sd) years. Mean time taken for passive ROSO was 7.31±2.41 (sd) minutes. Pre and post operative intra ocular pressure shows statistically significant (p=0.000) decrease in IOP. Retinal redetachment found in 13 (16.5%) cases during follow up period.

Conclusion:

Passive removal of silicone oil with 23 G suture less vitrectomy system is safe and effective in terms of less per operative and post operative complications. In this simple technique, there is less tissue trauma and little time consumed so it provides more comfort to patients and surgeons as well.

Outcomes of 27 Gauge Microincision Vitrectomy Surgery for Posterior Segment Disease

PURPOSE

To report the initial experience, clinical outcomes, and safety profile of 27 gauge pars plana vitrectomy (PPV) in eyes with posterior segment disease.

DESIGN

Multicenter, retrospective, interventional case series.

METHODS

setting: Private practice and tertiary care settings.

STUDY POPULATION

Eyes undergoing 27 gauge PPV for a vitreoretinal surgery indication.

INTERVENTION

Three-port, transconjunctival 27 gauge PPV.

MAIN OUTCOME MEASURES

Change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 90 days.

RESULTS

Ninety-five eyes met the inclusion criteria. Surgical indications included epiretinal membrane (n = 26), diabetic tractional retinal detachment (n = 14), full-thickness macular hole (n = 11), rhegmatogenous retinal detachment with (n = 7) or without (n = 9) proliferative vitreoretinopathy (PVR), vitreous hemorrhage (n = 10), vitreous opacities (n = 8), endophthalmitis (n = 4), sub-silicone oil retinal detachment (n = 3), retained lens material (n = 1), submacular hemorrhage (n = 1), and aqueous misdirection (n = 1). Mean logMAR visual acuity improved from 1.08 ± 0.71 (20/240 Snellen equivalent) preoperatively to 0.53 ± 0.65 (20/67 Snellen equivalent) postoperatively (P < .001). Mean follow-up was 144 days (median 127 days, range 90-254 days). There were no intraoperative complications and no case required conversion to 20, 23, or 25 gauge instrumentation. A total of 3 sclerotomy sites (1.1%) were sutured at the conclusion of surgery. Postoperative complications included transient ocular hypertension in 8 eyes (8.4%), transient hypotony in 5 eyes (5.3%), and vitreous hemorrhage in 5 eyes (5.3%). No cases of postoperative endophthalmitis, sclerotomy-related retinal tears, or choroidal detachments were encountered in the follow-up period.

CONCLUSION

The 27 gauge PPV was well tolerated with low rates of intraoperative and postoperative complications across varied surgical indications.

Rates of Vitrectomy among Enrollees in a United States Managed Care Network, 2001-2012

PURPOSE

To determine whether vitrectomy surgery rates have changed over the past decade and factors affecting the odds of undergoing this procedure.

DESIGN

Retrospective, longitudinal cohort study.

PARTICIPANTS

All enrollees 21 years of age or older between 2001 and 2012 in a United States managed care network.

METHODS

Claims data from a managed care network were analyzed to identify all enrollees who underwent 1 vitrectomy or more each year from 2001 through 2012. Rates of vitrectomy per 1000 enrollees were computed each year from 2001 through 2012 for the entire group and separately for patients with and without diabetes mellitus. Multivariate logistic regression assessed factors affecting the odds of undergoing vitrectomy surgery.

MAIN OUTCOME MEASURES

Annual rates of vitrectomy surgery from 2001 through 2012 and odds ratios (ORs) of undergoing a vitrectomy with 95% confidence intervals (CIs).

RESULTS

Among the 11 161 907 eligible enrollees, 40 892 (0.4%) underwent vitrectomy over the 12-year period. The average age of those undergoing vitrectomy was 57±13 years. Overall vitrectomy rates increased 31% from 2001 to 2012 (from 1.47 to 1.92 per 1000 patients). During this same period, the vitrectomy rate among persons with diabetes mellitus decreased by 43% (from 5.84 to 3.31 per 1000 patients with diabetes). Women had 24% decreased odds of undergoing vitrectomy (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.72-0.79). The odds of undergoing a vitrectomy were 17% greater for black persons (adjusted OR, 1.17; 95% CI, 1.07-1.27) and 7% higher for persons with diabetes (adjusted OR, 1.07; 95% CI, 1.01-1.14).

CONCLUSIONS

Overall, we observed an increase in the vitrectomy rates per 1000 enrollees in this large managed care network over the course of the past decade. However, among persons with diabetes mellitus, vitrectomy rates declined substantially over this period. These changes may be explained, in part, by advances in surgical instrumentation and imaging methods to detect retinal diseases changing indications for surgery, improvements in diabetes care, and alternative treatment options for managing retinal conditions. These results may be useful for future planning of manpower needs and highlight the need for aggressive prevention of complications in black persons with diabetes.

A prospective study on postoperative discomfort after 20-gauge pars plana vitrectomy

Purpose

To evaluate postoperative pain and other irritation symptoms after 20-gauge (20G) pars plana vitrectomy.

Materials and methods

A total of 110 consecutive patients were enrolled in our studies, and 87 patients who underwent the conventional 20G pars plana vitrectomy were included in the final analysis. All vitrectomies were performed using the same surgical technique by the same surgeon. Patients were examined before surgery and 1 day, 3 days, 7 days, 1 month, and 2 months postoperatively. The main outcome measures include patient age and sex, intraocular pressure (IOP), ocular pain, pain score, pain medication use, and other irritation symptoms comprising itching, foreign body sensation, burning, photophobia, and dryness. The pain was evaluated using the Numerical Rating Scale scored from 0 to 10.

Results

Postoperative pain was relatively common during the first day after surgery, as it was reported by 43 (49.4%) patients. Then, the prevalence gradually decreased to eleven (12.6%) patients at 2 months. Most patients reported mild or moderate pain, with a pain score of 1–5, but only four patients were given analgesics for ocular pain. A postoperative rise of IOP was noted in 25 patients at day 1. Most of these patients with high IOP reported moderate pain. Other ocular irritation symptoms were varied after surgery. There was still one-quarter of patients that had foreign body sensation and dryness symptoms at month 2 after surgery.

Conclusion

Mild and moderate ocular pain were relatively common after 20G vitrectomy, which is more often associated with elevated IOP. Other irritation symptoms were also presented after surgery and could affect the life quality of patients. Therefore, the discomforts after 20G pars plana vitrectomy should be of concern, and timely management should be provided as part of routine postoperative care.

Efficacy and safety of active silicone oil removal through a 23-gauge transconjunctival cannula using an external vacuum pump

AIM

To evaluate the efficacy and safety of active removal of silicone oil with low and high viscosity through a 23-gauge transconjunctival cannula using an external vacuum pump.

METHODS

This study was conducted as a prospective, interventional case series. A total of 22 eyes of 21 patients [1000 centistokes (cSt): 17 eyes, 5700 cSt: 5 eyes] were included in this study. All patients underwent active silicone oil removal via the entire lumen of a 23-gauge microcannula with suction pressure of a 650-700 mm Hg vacuum using an external vacuum pump. A tubing adaptor from the Total Plus Pak(®) (Alcon, Fort Worth, USA) was used to join the microcannula and silicone vacuum tube connected to an external vacuum pump. Main outcome measures were mean removal time, changes of intraocular pressure (IOP) and visual acuity, and intraoperative and postoperative complications.

RESULTS

Mean removal time (min) was 1.49±0.43 for 1000 cSt and 7.12±1.27 for 5700 cSt. The IOP was 18.57±7.48 mm Hg at baseline, 11.68±4.55 mm Hg at day 1 postoperatively (P<0.001), and 15.95±4.92, 16.82±3.81, 17.41±3.50, and 17.09±3.01 mm Hg after one week, one month, three months, and six months, respectively. All patients showed improved or stabilized visual acuity. There was no occurrence of intraoperative or postoperative complications during the follow up period.

CONCLUSION

This technique for active removal of silicone oil through a 23-gauge cannula using an external vacuum pump is fast, effective, and safe as well as economical for silicone oil with both low and high viscosity in all eyes with pseudophakia, aphakia, or phakia.

25th RCOphth Congress, President's Session paper: 25 years of progress in vitreoretinal surgery

Over the past 25 years, vitreoretinal surgery has undergone considerable change in technology, techniques, and professional organisation. Many conditions that were considered untreatable in 1988 are now treated routinely by vitreoretinal surgeons. Over the same period, vitreoretinal surgery has become a separate subspecialty with its own scientific meetings and professional organisation. This article describes a noncomprehensive selection of some of the highlights of the past 25 years, including the establishment and growth of BEAVRS (British and Eire Association of Vitreoretinal Surgeons), the revolution in the management of macular holes, the development of submacular surgery, and the introduction of sutureless vitrectomy.

Comparison of two scleral incision techniques in 23-gauge transconjunctival vitrectomy

BACKGROUND AND OBJECTIVE

To compare two 23-gauge transconjunctival vitrectomy incision techniques, parallel and perpendicular to the alignment of scleral fibers, in terms of hypotony and postoperative intraocular pressure (IOP).

PATIENTS AND METHODS

Fifty-three eyes of 53 patients who underwent 23-gauge one-step trocar pars plana vitrectomy were randomly assigned to undergo scleral incision parallel (group 1, 26 eyes) or perpendicular (group 2, 27 eyes) to the limbus. Patients were observed postoperatively for wound healing, leakage, endophthalmitis, IOP, and hypotony at 1 day, 1 week, and 1, 3, 6, and 9 months.

RESULTS

No difference in preoperative IOP was observed (P = .229). Postoperative IOP was significantly lower in group 2 (P = .009). Hypotony rates did not differ between the groups. Intraocular gas or silicone tamponade was used intraoperatively in 26 cases. In cases in which no gas or silicone was given (n = 27), IOP measurements were significantly lower in group 2 (P = .021). There was no difference in hypotony ratios for gas/silicone injection versus no injection (P = 1.00) or in postoperative visual acuity (P = .350). Visual acuity improved significantly in both groups at follow-up examinations.

CONCLUSION

Parallel and perpendicular incisions resulted in similar postoperative hypotony rates, but perpendicular incisions were associated with lower IOP.

Safety of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To study the safety of 20-gauge transconjunctival sutureless vitrectomy.

METHODS

Clinical data of patients who underwent 20-gauge transconjunctival sutureless vitrectomy for the first time, for various disorders, were reviewed retrospectively. The main outcome measures were the number of sclerotomies requiring suturing as well as the intra- and postoperative complications.

RESULTS

A total of 179 operations were performed. Indications for vitrectomy included 68 idiopathic epiretinal membranes, 26 macular holes, 23 phakic and 16 pseudophakic retinal detachments, and 46 various other, less common etiologies. Of these 179 operations, 166 (93%) were sutureless. Of the 537 sclerotomies created, 25 (5%) received a single transconjunctival-scleral suture. Intraoperative complications included premature dislodging of the cannulas in 2 sclerotomies and an iatrogenic horseshoe tear at 1 sclerotomy site. Postoperative complications comprised transient hypotony in 14 cases, subconjunctival gas in 2 cases, and choroidal effusion in 1 case. No serious complications (such as endophthalmitis) were observed.

CONCLUSION

20-gauge transconjunctival sutureless vitrectomy can be considered safe, as the intra- and postoperative complications observed are neither numerous nor significant. Sclerotomies appear to be safe and relatively easy to perform, without compromising the advantages of sutureless surgery.

Changes in day 1 post-operative intraocular pressure following sutureless 23-gauge and conventional 20-gauge pars plana vitrectomy

Background/Aims:

The benefits associated with transconjunctival sutureless vitrectomy techniques are continuing to be defined. The purpose of this study was to compare the incidence of extreme changes in day 1 intraocular pressure (IOP) following 23-gauge sutureless vitrectomy compared with conventional 20-gauge vitrectomy.

Methods:

Fifty consecutive 23-gauge and 50 consecutive 20-gauge cases were included; eyes with a history of previous vitreoretinal surgery were excluded. 23-gauge surgery was completed with passive fluid air exchange where no long acting tamponade was indicated. The surgery remained sutureless unless a leak was visible at the end of the procedure. Data were collected by retrospective case note review. Statistical analysis was carried out using Fisher’s exact and chi-square tests.

Results:

Twenty-two percent (11/50) of 23-gauge vitrectomies required suturing of one or more ports. On the first post-operative day hypotony (IOP<5mmHg) occurred in 1/50 eyes in the 20- and 23-gauge groups. Raised pressure (IOP>21mmHg) occurred in 30% (15/50) of eyes in the 20-gauge group and 8% (4/50) of eyes in the 23-gauge group; IOP>30mmHg only occurred in the 20-gauge group (3/50).

Conclusion:

Fluid air exchange following 23-gauge vitrectomy is associated with very low risk of day 1 hypotony. This predominantly sutureless technique appears to reduce the incidence and magnitude of early post-operative IOP elevation compared with conventional 20-gauge vitrectomy.

Reactivation of ocular toxoplasmosis after pars plana vitrectomy

PURPOSE

To report a case with reactivation of toxoplasma choroiretinitis after pars plana vitrectomy.

PATIENTS AND METHODS

A 58-year-old female patient was diagnosed with secondary epiretinal membrane in her right eye. Bimanual 23-gauge pars plana vitrectomy and membrane peeling was performed. At first week postoperatively, visual acuity decreased; in slit-lamp examination, there were 3+ cells in the anterior chamber with keratic precipitate. Fundoscopic examination revealed reactivation of chorioretinitis adjacent to the previous scar.

RESULTS

The patient was diagnosed with reactivation of toxoplasma chorioretinitis and treated with oral trimethoprim-sulfamethoxazole, clindamycin and topical prednisolon acetate, and cyclopentolate drops for 5 weeks. Forty-eight hours after initiation of antibiotics, oral prednisone was added to the regimen and the dose was tapered to zero over the following 5 weeks. After 3 weeks of treatment, lesion was inactivated.

CONCLUSION

Ocular toxoplasmosis reactivation may develop after pars plana vitrectomy. After intraocular surgery, reactivation of ocular toxoplasmosis should be considered in the follow-up.

[Clinical outcomes of cataract surgery combined with 23-gauge vitrectomy]

PURPOSE

To report the clinical outcomes of cataract surgery (phacoemulsification and intraocular lens implantation) combined with 23-gauge vitrectomy, and to evaluate the effectiveness and safety of this technique.

METHODS

A retrospective, consecutive, non-comparative study which included 105 eyes. Phacoemulsification and intraocular lens implantation (in the capsular sac) combined with 23-gauge vitrectomy were performed. Indications for undergoing surgery were varied. Best corrected logMAR visual acuity (VA) and intraocular pressure (IOP) were measured pre- and postoperatively, and postoperative complications were recorded.

RESULTS

Patients were followed-up for a mean of 16.6±9.9 months. The mean preoperative VA was 0.83±0.40 logMAR, and mean postoperative VA one month after surgery was 0.44±0.38 logMAR. The postoperative visual acuity improved in 83.8% of cases. The mean preoperative IOP was 16.6±3.7mmHg, while the mean postoperative IOP was 22.5±12.8mmHg (1 day after surgery), 17.5±6.8mmHg (after 1 week), and 15.3±3.8mmHg (after 1 month). Postoperative complications included posterior capsular opacification (n=5), macular edema (n=4), corneal de-epithelization (n=3), retinal detachment (n=2), proliferative vitreoretinopathy (n=2), choroidal detachment (n=1), macular hole (n=1), vitreous hemorrhage (n=1), epiretinal membrane (n=1), and transient elevated intraocular pressure (n=36).

CONCLUSIONS

The surgery reported in this study involving phacoemulsification combined with 23-gauge vitrectomy was found to be safe and effective, and was associated with improved clinical features, including rapid rehabilitation, a low incidence of complications, and avoids repeat surgery.

Primary 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment

AIM

To report the effectiveness and safety of primary 23-Gauge (G) vitreoretinal surgery for rhegmatogenous retinal detachment (RRD).

METHODS

In this retrospective study, 49 eyes of 49 consecutive patients who underwent primary 23-G transconjunctival sutureless vitrectomy (TSV) for RRD between January 2007 and July 2009 at our institution were evaluated.

RESULTS

Mean follow-up time was 8.9±7.7 months (1-28 months). Retinal reattachment was achieved with a single operation in 47(95.9%) of 49 eyes. In two eyes (4.1%), retinal redetachment due to new breaks was successfully treated with reoperation using the 23-G TSV system. Mean logMAR visual acuity was 2.01±0.47 preoperatively and 1.3±0.5 postoperatively (P<0.001, Paired t-test). Mean preoperative intraocular pressure (IOP) was 14.1±2.8mmHg. Mean postoperative IOP was 12.3±3.6mmHg at 1 day, 13.1±2.1mmHg at 1 week, 14.3±2.2mmHg at 1 month. Iatrogenic peripheral retinal break was observed in 1 eye (2.0%) intraoperatively. No sutures were required to close the scleral or conjunctival openings, and no eyes required convertion of surgery to 20-G vitrectomy.

CONCLUSION

Primary 23-G TSV system was observed to be effective and safe in the treatment of RRD.

Primary 23-gauge sutureless vitrectomy for rhegmatogenous retinal detachment

Aims:

To report a prospective non-comparative consecutive interventional study on the safety and efficacy of 23-Gauge transconjunctival sutureless pars plana vitrectomy for primary rhegmatogenous retinal detachment (RRD).

Materials and Methods:

Fifty eyes of 50 consecutive patients were recruited between June 2007 and January 2008. All surgeries were performed using the one-step 23-Gauge system with angled incisions. The surgical protocol consisted of a minimum of eight clinical visits: baseline, 1 day, 1 week, 1-, 3- and 6- months after the initial surgery. The endpoints were anatomical, functional results and complications arising from the surgery.

Results:

Anatomical success was achieved in 82% of cases (41 out of 50) with single surgery and rose to 98% (49 out of 50) with additional surgery. Mean visual acuity improved from logMAR 0.48(SD 0.36) to 0.26(SD 0.31), P < 0.001. Two cases with ocular hypotony, defined as an intraocular pressure ≤ 6mmHg, that were associated with a choroidal detachment were seen.

Conclusions:

Acceptable anatomical and functional success rates can be achieved with primary 23-Gauge transconjunctival sutureless vitrectomy for RRD. We found that the approach technique is different from conventional vitrectomy and the complications arising from post surgical hypotony and leakage from sclerotomies are potentially higher compared to 20-Gauge vitrectomy.

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.

[Surgery of the idiopathic epimacular membrane on transconjunctival 25-gauge vitrectomy (TSV): a series of 50 cases]

BACKGROUND

The surgery of the idiopathic epimacular membrane has gained from the advent of 25-gauge transconjunctival vitrectomy (TSV) initiated by Fujii in 2002.

PATIENTS AND METHODS

In this retrospective study, we tested 50 patients operated on for epimacular membrane with 25-gauge TSV at the Quinze-Vingts National Ophthalmology Hospital in Paris from December 2004 to June 2006.

RESULTS

No postoperative endophthalmitis, major hypotonia, or sclerotomy leakage were observed. However, two cases (4%) of retinal detachment and 47% postoperative cataract were noted at 3 months. After evolving 3 months later, distant and close visual acuity were significantly improved.

CONCLUSION

TSV appears to be a useful method for epimacular membrane ablation.

The safety and efficacy of passive removal of silicone oil with 23-gauge transconjunctival sutureless system

PURPOSE

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

METHODS

This is a single-center, prospective, interventional, randomized control study. Forty eyes of 40 patients were enrolled in this study and randomized into 2 groups. Group 1 (n = 20) patients underwent passive removal of silicone oil with 23-G transconjunctival sutureless system. Group 2 (n = 20) underwent 20-G active silicone oil removal using all three 20-G ports. In both groups, air-fluid exchange was performed and the globe was left air filled at the end of surgery. All eyes in both groups received 360 degrees endolaser. We recorded surgical time, time for silicone oil removal, number of sutured 23-G sclerotomy sites, presence of preoperative scarring at sclerotomy site, postoperative hypotony, endophthalmitis, and inflammation at sclerotomy site.

RESULTS

Opening and closing times were significantly shorter in Group 1 than in Group 2. Only 3 cases (15%) in Group 1 required 1 additional suture each in the superior sclerotomy site. Both groups were similar in safety in terms of chance of endophthalmitis, redetachment rate, and postoperative hypotony. Only 1 patient of Group 1 (5%) and 5 patients of Group 2 (25%) showed significant conjunctival inflammation at the end of 2 weeks.

CONCLUSION

Passive removal of silicone oil with 23-G transconjunctival sutureless system may hasten postoperative recovery by decreasing overall surgical time and postoperative inflammation. It is a safe and effective procedure when compared with 20-G active silicone oil removal for 1000 centistoke oil.

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.

The competency of pars plana vitrectomy incisions: a comparative histologic and spectrophotometric analysis

PURPOSE

To compare the relative competency of pars plana vitrectomy (PPV) sclerotomies.

DESIGN

Laboratory investigation.

METHODS

PPV was performed in human cadaveric eyes using 20-gauge (20 G), 23-gauge (23 G), and 25-gauge (25 G) instrumentation. India ink was applied over a sclerotomy site while the intraocular pressure was varied. The presence of India ink particles (IIPs) along incisions was evaluated by histologic analysis. Spectrophotometric absorbance levels of vitreous aspirates were measured.

RESULTS

PPV was performed in a control eye and two eyes, each using standard 20 G, standard 23 G, perpendicular 25 G, and beveled 25 G instrumentation incisions. IIPs were not detected in the 20 G incisions either on histology or by spectrophotometry. IIPs were detected along the entire incision length in one of two eyes with 23 G sclerotomies and confirmed by spectrophotometry. IIPs were detected along the entire incision length in one of two eyes with 25 G perpendicular sclerotomies and confirmed by spectrophotometry in both eyes. IIPs were noted partially along the length in one of the two beveled 25 G eyes, but not detected in either eye by spectrophotometry.

CONCLUSIONS

During the early postoperative period, sutureless vitrectomy incisions may allow entry of ocular surface fluid. These findings may provide a pathophysiologic mechanism for the reported increased risk of endophthalmitis in small-gauge vitrectomy surgery.

A comparative study of tissue glue and vicryl suture for conjunctival and scleral closure in conventional 20-gauge vitrectomy

AIM

To describe the use of tissue glue to close scleral and conjunctival wounds, and to compare the clinical outcomes using tissue glue and vicryl suture for closing these areas in conventional 20-gauge (G) vitrectomy.

METHODS

Thirty eyes of 30 patients were included in this study. The indications for vitreoretinal surgery were diabetic vitreous haemorrhage with severe vitreoretinal traction in 10 eyes, retinal detachment and proliferative vitreoretinopathy in 14 eyes, and vitreous opacity in 6 eyes. Tissue glue (Tisseel, Baxter AG Industries, Vienna, Austria) was used to attach scleral and conjunctival wounds in 15 eyes and vicryl sutures in 15 eyes. The patients were allotted into two subgroups as tissue glue group (TG) and vicryl suture group (VG). The sclerotomy sites were evaluated with ultrasound biomicroscopy (UBM) postoperatively in TG. Follow-up period was 2 months. The groups were statistically compared for ocular signs and symptoms by Mann-Whitney U-test.

RESULTS

No scleral wound leakage and conjunctival reattachment were observed at the end of the surgical procedure and during the follow-up period. No adverse effects were seen in TG. Abnormal fibrous ingrowth was not detected at the sclerotomy sites by means of UBM in TG. Patient comfort was significantly higher in TG than VG (P<0.05).

CONCLUSIONS

Tissue glue has no adverse effects on ocular tissue and can be used as a substitute for suture materials, and the use of tissue glue decreases patient symptoms during the postoperative period after 20-G vitrectomy. Tissue glue can enable to perform sutureless surgery in the conventional 20-G vitrectomy.

Short-term outcomes of 23-gauge pars plana vitrectomy

PURPOSE

To report the initial experience and safety profile of 23-gauge pars plana vitrectomy (PPV) in eyes undergoing vitreoretinal surgery.

DESIGN

Retrospective, multicenter, consecutive, interventional case series.

METHODS

The inclusion criteria for this study included eyes that underwent primary, 23-gauge PPV for various indications including, but not limited to, epiretinal membrane, nonclearing vitreous hemorrhage, idiopathic macular hole, and rhegmatogenous retinal detachment (RD), and postoperative follow-up of at least 12 weeks. Exclusion criteria included history of prior vitrectomy, glaucoma filtration surgery, or administration of gas at expansile concentrations. Main outcome measures included best-corrected Snellen visual acuity (VA), intraocular pressure (IOP), intraoperative complications, and postoperative complications.

RESULTS

Ninety-two patients met the inclusion criteria. The overall VA improved from 20/238 (range, 20/25 to hand motions [HM]) preoperatively to 20/82 (range, 20/20 to HM) postoperatively (P < .001). Each surgical indication experienced a statistically significant VA improvement. Intraoperative complications included retinal tears observed in two eyes (2.2%). Sclerotomy sutures were required intraoperatively in two eyes (2.2%). Postoperative complications included postoperative day 1 hypotony in six eyes (6.5%), a retinal tear in one eye (1.1%), and a recurrent RD in one eye (1.1%). No cases of endophthalmitis were observed.

CONCLUSIONS

Intraoperative and postoperative complications were rare in this series of 23-gauge vitrectomy. Postoperative day 1 hypotony was the most common complication observed. All cases of postoperative hypotony resolved at postoperative week 1 without intervention. Retinal tear or detachment was an uncommon complication in the intraoperative and postoperative settings. Postoperative endophthalmitis was not noted in this case series.

Wound leakage and hypotony after 25-gauge sutureless vitrectomy: factors affecting postoperative intraocular pressure

BACKGROUND AND OBJECTIVE

To investigate the factors related to postoperative hypotony after 25-gauge sutureless vitrectomy.

PATIENTS AND METHODS

Of 109 consecutive eyes undergoing sutureless vitrectomy, 95 fluid-filled eyes were randomly assigned to three groups according to the order of infusion cannula removal. In group 1 (30 eyes), the infusion was removed first. In group 2 (32 eyes), the infusion was removed after another cannula. In group 3 (33 eyes), the infusion was removed last. Intraocular pressure (IOP) was measured on preoperative day 1 and postoperative days 1, 7, and 30.

RESULTS

Mean age was 58.9 +/- 11.6 years (range: 18 to 80 years). Among each factor (including order of infusion removal, age, sex, axial length, preoperative IOP, previous vitrectomy, indications for vitrectomy and lens status), only age was significantly correlated with IOP on postoperative day 1 (P = .019). In 13 eyes in which hypotony persisted through postoperative day 2 (IOP < or = 5 mm Hg), the age of the patients was significantly younger than those who did not experience persisting hypotony (P = .006).

CONCLUSION

Younger patients were more likely to experience early postoperative hypotony.

The safety and efficacy of transconjunctival sutureless 23-gauge vitrectomy

Purpose

To evaluate the efficacy and safety of vitreoretinal surgery using a 23-gauge transconjunctival sutureless vitrectomy (TSV) system for various vitreoretinal diseases.

Methods

A retrospective, consecutive, interventional case series was performed for 40 eyes of 40 patients. The patients underwent vitreoretinal procedures using the 23-gauge TSV system, including idiopathic epiretinal membrane (n=7), vitreous hemorrhage (n=11), diabetic macular edema (n=10), macular hole (n=5), vitreomacular traction syndrome (n=5), diabetic tractional retinal detachment (n=1), and rhegmatogenous retinal detachment (n=1). Best corrected visual acuity (BCVA), intraocular pressure (IOP), and intra- and post-operative complications were evaluated.

Results

Intraoperative suture placement was necessary in 3 eyes (7.5%). The median BCVA improved from 20/400 (LogMAR, 1.21±0.63) to 20/140 (LogMAR, 0.83±0.48) at 1 week (p=0.003), 20/100 (LogMAR, 0.85±0.65) at 1 month (p=0.002), 20/100 (LogMAR, 0.73±0.6) at 3 months (p=0.001). In 1 eye, IOP was 5 mmHg at 2 hours and 4 mmHg at 5 hours, but none of the eyes showed hypotony after 1 postoperative day. No serous postoperative complications were observed during a mean follow-up of 8.4±3.4 months (range 3-13 months)

Conclusions

The 23-gauge TSV system shows promise as an effective and safe technique for a variety of vitreoretinal procedures. It appears to be a less traumatic, more convenient alternative to 20-gauge vitrectomy in some indications.