Pars plana vitrectomy with 25-gauge instruments in the treatment of idiopathic epiretinal membranes

Long-Term Visual Acuity and Optical Coherence Tomography Changes After Vitrectomy for Idiopathic Epiretinal Membranes

Objective

To evaluate the long-term visual acuity and retinal thickness changes after pars plana vitrectomy (PPV) for idiopathic epiretinal membranes (ERM).

Methods

We performed a retrospective analysis of 72 patients who underwent PPV for idiopathic ERM in a tertiary hospital over 5 consecutive years. The main outcome measurement was change in visual acuity and macular thickness as recorded with optical coherence tomography (OCT).

Results

Medical records of 239 patients with a diagnosis of ERM who underwent PPV with or without internal limiting membrane (ILM) peeling were reviewed; of these, 72 patients with idiopathic ERM were included in the final analysis. All patients completed at least one year of follow-up, and 23 patients (30%) had 5 or more years of follow-up. The mean preoperative best corrected visual acuity (BCVA) was 20/65, and mean preoperative central macular thickness (CMT) on OCT was 434 microns (µm). Mean postoperative BCVA and CMT at one year were 20/40 and 303 µm, respectively (p<0.0001). A total of 42 patients (58%) improved by 2 or more lines; BCVA and CMT continued to improve postoperatively for up to 5 years of the follow-up period. There was no significant difference in BCVA or CMT between phakic and pseudophakic patients, and ILM peeling was performed in 67% of patients. Improved BCVA at 1 year was associated with younger age (p<0.0001) and ILM peeling (p=0.020).

Conclusion

PPV is an effective treatment for idiopathic ERM, and ILM peel may be of benefit. BCVA continues to improve up to 2 years and beyond after surgery regardless of the duration of symptoms.

Iatrogenic retinal breaks and postoperative retinal detachments in microincision vitrectomy surgery compared with conventional 20-gauge vitrectomy: a meta-analysis

PURPOSE

To assess the incidence of iatrogenic retinal breaks (IRBs) and postoperative retinal detachments (RDs) in microincision vitrectomy surgery (MIVS) compared with 20-gauge (20 G) vitrectomy.

METHODS

A comprehensive literature search was performed to find relevant studies and a meta-analysis of the IRBs and postoperative RDs rates after 20 G vitrectomy versus MIVS was conducted.

RESULTS

Thirty-two studies were selected, including 14,373 eyes (6932 eyes in the 20 G group, 7441 eyes in the MIVS group). The meta-analysis demonstrated that the incidence of IRBs was significantly higher in 20 G vitrectomy vs. MIVS (OR = 2.22, 95% CI, 1.93-2.57, P < 0.00001) and in a subanalysis vs. 23 G MIVS (OR = 2.19, 95% CI, 1.87-2.56, P < 0.00001) and vs. 25 G MIVS (OR = 2.27, 95% CI, 1.62-3.18, P < 0.00001). Similar result was obtained in a subanalysis for macular surgery (OR = 2.44, 95% CI, 1.99-2.99, P < 0.00001), and also for sclerotomy-related IRBs (OR = 3.73, 95% CI, 2.55-5.44, P < 0.00001), but not for surgically induced posterior vitreous detachment-related IRBs (OR = 1.59, 95% CI, 0.89-2.84, P = 0.12). The incidence of postoperative RDs in 20 G vitrectomy was significantly higher compared to MIVS (OR = 1.72, 95% CI, 1.21-2.46, P = 0.003) and in a subanalysis vs. 23 G MIVS (OR = 2.45, 95% CI, 1.50-4.00, P = 0.0003), but not for 25 G MIVS (OR = 1.01, 95% CI, 0.63-1.64, P = 0.96). Similar result was obtained in a subanalysis for macular surgery (OR = 1.89, 95% CI, 1.26-2.85, P = 0.002).

CONCLUSION

This meta-analysis demonstrated that MIVS is associated with a lower risk of IRBs and postoperative RDs compared to 20 G vitrectomy.

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.

Cataract formation following vitreoretinal procedures

Purpose

To evaluate the incidence and prevalence of cataract formation, progression, and extraction in patients that underwent vitreoretinal procedures and to evaluate factors that can potentially predispose patients to postoperative cataracts.

Materials and methods

The medical records of consecutive patients who underwent vitreoretinal surgery at the Yale Eye Center with at least 6 months of follow-up and no prior intraocular surgery were obtained. Preoperative, intraoperative, and postoperative data were recorded and analyzed in this retrospective observational study. The main outcome measures were defined as cataract extraction, formation, and progression after vitreoretinal procedures. The lens status of the surgical eye was recorded preoperatively and at 1 month, 3 months, 6 months, 12 months, 24 months, and 36 months postoperatively.

Results

A total of 193 eyes of 180 patients fulfilled the inclusion criteria. The percentages of eyes with mild lens change were 96% after 20-gauge pars plana vitrectomy (PPV), 72% after small gauge (23- and 25-gauge) PPV, 38% after scleral buckle (SB), 38% after pneumatic retinopexy (PR), and 91% after PPV plus SB (PPV+SB). Posterior subcapsular and nuclear sclerotic cataracts were the most common with almost all developing within 24 months. There was no statistically significant difference (P=1.00) between the rate of cataract extraction after 20-gauge (41%) and small gauge PPV (42%), but there was a statistically significant difference between PPV and non-PPV (SB, 6%; PR, 7%; P<0.001) and PPV and PPV+SB groups (69%; P=0.0063).

Conclusion

Cataracts were common following PPV regardless of the gauge. SB and PR led to the lowest while PPV+SB led to the highest risk of postoperative cataracts.

Visual acuity outcomes following surgery for idiopathic epiretinal membrane: an analysis of data from 2001 to 2011

PURPOSE

Pars plana vitrectomy (PPV) is commonly used to remove the epiretinal membrane (ERM), but the timing of surgical intervention guided by visual acuity (VA) performance at presentation is uncertain.

PATIENTS AND METHODS

Prospectively entered clinical data of 237 patients on an electronic patient record from 2001 to 2011 were analysed to determine visual outcomes, in particular in relation to pre-operative VA.

RESULTS

The mean age of the patients was 68.8 years and 54.4% were female. Median follow-up was 0.55 years. The median pre-operative logMAR VA was 0.60 (SD 0.48-0.78, Snellen equivalent 6/36) and post-operative VA was 0.30 (SD 0.18-0.60, 6/12, P<0.005). Pre-operative VA correlated with post-operative VA (linear R(2)=0.22, P<0.0001). In all, 69.6% of patients showed an improvement in VA, 15.2% showed no change, and the condition of 15.2% worsened. The number of patients with an improvement in logMAR VA of more than 0.3 was greatest in those who had a pre-operative VA of 1.0 (6/60) or worse, followed by those in the range of 0.6-0.9 and then those with pre-operative VA of 0.5 or better (P<0.001). The proportion of patients with visual improvement of logMAR VA of more than 0.3 increased statistically with progressing years (P=0.019).

CONCLUSION

In conclusion, this study shows improvement in VA after PPV and ERM removal. Patients with better initial VA achieve higher levels of visual outcome but those with poorer pre-operative VA show a greater change in VA following ERM surgery. Results of surgery improved over the time period of the study.

A systematic review of endophthalmitis after microincisional versus 20-gauge vitrectomy

BACKGROUND

Endophthalmitis is a rare but severe complication of vitrectomy.

CLINICAL RELEVANCE

Post-surgical endophthalmitis is suspected to be more frequent after microincisional (23- and 25-gauge) compared with standard (20-gauge) vitrectomy.

METHODS

We conducted a systematic review of studies that compared microincisional and standard vitrectomy by searching MEDLINE and EMBASE up to November 2012. We used the Bayesian meta-analysis method to compute the odds ratio (OR) of endophthalmitis. We conducted subgroup analyses to compare the effect of different incision types and use of perioperative antibiotics.

RESULTS

We identified 3 small randomized and 18 nonrandomized studies that reported 68 cases of endophthalmitis in 148 643 participants. The overall OR of endophthalmitis for microincisional versus standard vitrectomy was 2.3 (95% credible interval [CrI], 0.8-5.8). We found an increased risk of endophthalmitis using a microincisional straight approach compared with standard vitrectomy (OR, 15.1; 95% CrI, 2.01-179), but not for a beveled approach (OR, 0.82; 95% CrI, 0.23-2.28). The OR of studies that reported on mixed microincision was between these 2 values (OR, 4.4; 95% CrI, 1.32-14.3). We estimated that the overall rate of endophthalmitis with 20-gauge vitrectomy was 3 cases in 10 000 procedures, and the probability that a beveled microincision increases the rate of endophthalmitis to more than 6 or 9 events was small (no more than 5% or 1%, respectively).

CONCLUSIONS

We did not find an increased risk of endophthalmitis for microincisional vitrectomy compared with standard vitrectomy. The beveled approach seems to be safer than a straight approach, supporting the current recommendation of its adoption in microincisional vitrectomy. However, these findings must be interpreted cautiously because of the small number of endophthalmitis events reported from included studies.

Combined 25-gauge microincision vitrectomy and toric intraocular lens implantation with posterior capsulotomy

PURPOSE

To evaluate the efficacy of combined 25-gauge microincision vitrectomy surgery (MIVS) and toric intraocular lens (IOL) implantation with posterior capsulotomy.

METHODS

Noncomparative, interventional case series performed at a single center. Twelve patients with vitreoretinal disease and cataracts, with preexisting regular corneal astigmatism greater than 1 diopter, underwent 25-gauge MIVS and toric IOL implantation with posterior capsulotomy.

RESULTS

The toric IOL was successfully implanted in each case. At 6 months postoperatively, mean axis rotation was 5.7° ± 3.1°. At 1 month postoperatively, mean uncorrected and best corrected visual acuity improved; the improvement was maintained after 6 months. The absolute residual refractive cylinder was significantly lower postoperatively than the pre-existing regular corneal cylinder (P = .003). There were no surgical complications except temporary posterior iris synechiae in one case.

CONCLUSIONS

Combined 25-gauge MIVS and toric IOL implantation with posterior capsulotomy is a practical and safe method to treat vitreoretinal disease and cataracts with pre-existing corneal astigmatism.

Influence of sutureless 23-gauge sclerotomy architecture on postoperative intraocular pressure decrease: results of a multivariate analysis

PURPOSE

To evaluate the factors affecting the postoperative intraocular pressure (IOP) decrease in 23-gauge (23-G) sutureless vitrectomy, including incision architecture evaluated by anterior segment spectral-domain optical coherence tomography (SD-OCT).

METHODS

A prospective cohort study of 43 patients who underwent primary transconjunctival 23-G pars plana vitrectomy. All sclerotomy wounds were imaged 1 day after surgery using the anterior segment module of SD-OCT (OCT Spectralis, Heidelberg Engineering, Heidelberg, Germany). 23-G sclerotomy architecture, preoperative and postoperative medical data were also prospectively collected.

RESULTS

Multivariate logistic regression analysis, with backward elimination, found that surgery duration (adjusted OR = 9.17, p = 0.020) and loss of wound apposition (adjusted OR = 15.12, p = 0.022) were risk factors for significant postoperative IOP decrease (≥3 mmHg) 1 day after surgery; while age, gender, myopia, and gas tamponade were not risk or protective factors for postoperative IOP decrease.

CONCLUSIONS

In 23-G pars plana vitrectomy, the early postoperative decrease in IOP is mainly influenced by surgery duration and the self-sealing nature of the sclerotomy. The IOP decrease was not influenced by the presence or the absence of gas tamponade.

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.

Study of intraocular pressure after 23-gauge and 25-gauge pars plana vitrectomy randomized to fluid versus air fill

PURPOSE

To determine if a difference in intraocular pressure (IOP) exists after small-gauge pars plana vitrectomy randomized to fluid versus 80% sterile air fill.

METHODS

Ninety-two eyes undergoing 23-gauge and 25-gauge transconjunctival pars plana vitrectomy were randomized to fluid versus air fill, and IOP was measured at 5 different time points.

RESULTS

There is no difference in the mean IOP for eyes undergoing small-gauge pars plana vitrectomy randomized to fluid versus air fill after vitrectomy. Using 23-gauge instrumentation, the mean immediate and 2-hour postoperative IOPs were statistically lower than the mean preoperative IOP. The mean Postoperative Day 1 and Week 1 IOPs were statistically higher than the mean immediate postoperative IOP. Using 25-gauge instrumentation, the mean IOP was not statistically different at any time points in the 2 groups. When comparing 23-gauge with 25-gauge instrumentation, the immediate postoperative IOP was statistically lower and the rate of suture closure for sclerotomies was higher for 23-gauge vitrectomy.

CONCLUSION

When performing 23-gauge or 25-gauge pars plana vitrectomy, there was no difference in mean IOP for fluid- versus air-filled eyes. However, the mean IOP in the immediate postoperative period was statistically lower, and there was a higher rate of suture closure for 23-gauge compared with 25-gauge instrumentation.

Endophthalmitis in the era of small gauge transconjunctival sutureless vitrectomy--meta analysis and review of literature

PURPOSE

The goal of this study was to review, evaluate, and perform a meta-analysis on the current literature that reports rates of postoperative endophthalmitis after small gauge transconjunctival sutureless vitrectomy (TSV) and compare it to 20-gauge pars plana vitrectomy (20G PPV).

METHODS

We performed an extensive review of the current literature. We included only large comparative institutional reviews. Meta-analysis of these reviews was performed.

RESULTS

We found six large retrospective comparative cases series on the 25-gauge (25G) TSV as compared to 20G PPV. The test for homogeneity for the meta-analysis indicates that the studies are not homogeneous and therefore the evidence is tentative.

CONCLUSION

We cannot conclude that 25G TSV has a higher rate of postoperative endophthalmitis compared to the 20G PPV. Future retrospective or prospective trials need to take into consideration multiple factors.

Advantages and limitations of small gauge vitrectomy

Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages, but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusion and aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. The advantages include decreased surgical times, less tissue manipulation, reduced inflammation and pain postoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than 20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreous opacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also some increased complications related to small gauge vitrectomy, including dislocation of cannulas intraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.

[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.

25-Gauge pars plana vitrectomy for retained lens fragments

PURPOSE

The purpose of this study was to report the outcomes and complications of 25-gauge pars plana vitrectomy for the management of retained lens fragments after complicated cataract surgery.

METHODS

This is a retrospective consecutive case series of 17 patients who presented with retained lens fragments, ranging from mostly cortex to the entire lens, which were managed using only 25-gauge instrumentation.

RESULTS

Eight men and 9 women (mean age, 73.1 years) were followed for a mean of 4.5 months after 25-gauge vitrectomy for removal of retained lens fragments. Mean preoperative visual acuity was 20/427 and mean final postoperative visual acuity was 20/62. Mean surgical operating time was 48.5 minutes. Mean preoperative intraocular pressure was 24.5 mmHg and mean 1-day postoperative intraocular pressure was 17.9 mmHg. No cases required the use of a phacofragmatome, no sutures were required to close the sclerotomies, and there were no cases of postoperative hypotony. Cystoid macular edema and glaucoma developed postoperatively in 29.4% and 5.9% of eyes, respectively. There were no cases of postoperative retinal detachment or endophthalmitis.

CONCLUSION

A 25-gauge vitrectomy technique, without the use of a phacofragmatome, may be a suitable alternative to 20-gauge vitreous surgery using a phacofragmatome in the management of retained lens fragments after complicated cataract surgery. Clinical outcomes and complication rates are comparable to those found in the literature for 20-gauge surgery.

The options to minimize the surgical trauma to treat ocular diabetic complications and to improve postoperative recovery and quality of life require an individualized approach

Within the past ten years, small incision pars-plana vitrectomy, and refined microsurgical techniques, together with the introduction of various intravitreally applied drugs, significantly improved the anatomical and functional outcome. Unfortunately many diabetic patients with vitreoretinal complications also have cataract. In diabetic retinopathy, the benefit of simultaneous cataract surgery was long under debate due to possible side effects such as fibrinous reaction or secondary glaucoma. We review recent reports about the results of PPV for complication of diabetic retinopathy and the influence of a simultaneous cataract surgery, that compare different surgical approaches. Pars plana vitrectomy carried out with conventional 0,9 mm incisions (20G PPV) were related to higher incidences of postoperative inflammatory reactions and to a higher frequency of postoperative hypertensive events as compared to small incision vitrectomy (23G PPV). Postoperative recovery was faster in eyes with 23G surgery than after 20G surgery, with no delay by a simultaneous cataract surgery. A 23G-PPV improves the postoperative recovery and the quality of life for the diabetic patient. Cataract is no longer an obstacle for a vitreoretinal surgery. Postoperative recovery is faster and the new technique has less side effects than the conventional technique. In the future, a drug assisted vitrectomy will further reduce the surgical trauma. However, the new options are not equally benefitial for all patients. A further improvement in the quality of life will require a more individualized approach of microsurgical treatment for ocular complications of diabetes.

Adverse events after pars plana vitrectomy among medicare beneficiaries

OBJECTIVES

To assess the complication rates of pars plana vitrectomy (PPV) among older Americans and to determine whether rates of adverse events and additional operations have changed during the past decade.

METHODS

Claims data were reviewed to identify all adults aged 68 years or older in the 5% Medicare sample who underwent their first PPV during 1994-1995, 1999-2000, and 2004-2005. One-year rates of severe complications (endophthalmitis, suprachoroidal hemorrhage, or retinal detachment), less severe complications, receipt of an additional operation, and blindness were calculated and compared among the 3 groups using Cox regression. Analyses were adjusted for prior adverse events (during the previous 3 years), demographic characteristics, and comorbid conditions.

RESULTS

The 1994-1995, 1999-2000, and 2004-2005 cohorts had 3263, 5064, and 5263 patients, respectively. The 1-year severe complication rates did not differ among the 3 groups (range, 4.8%-5.5%). The hazard of a less severe complication or an additional operation was higher in the 2004-2005 cohort than in the earlier cohorts (P < .05 for all comparisons). The hazard of endophthalmitis was higher in black individuals (P = .07) and those of other races (P = .02) than in white patients.

CONCLUSIONS

During the past decade, rates of severe complications after PPV remained stable, but rates of less severe complications and subsequent operations increased. Future studies should explore the potential factors that explain these changes and the alarming elevated incidence of post-PPV endophthalmitis among nonwhite individuals.

Bacterial endophthalmitis following 25-gauge transconjunctival sutureless vitrectomy

PURPOSE

To report a case of endophthalmitis following 25-gauge transconjunctival sutureless vitrectomy.

DESIGN

Observational case report.

METHODS

An 87-year-old male who underwent sutureless 25-gauge vitrectomy developed unilateral endophthalmitis. Vitreous culture revealed Staphylococcus coagulase-negative bacteria. He was subsequently treated with intravitreal antibiotics and oral prednisone.

RESULTS

The endophthalmitis resolved with a best corrected visual acuity of 6/200 with the presence of an epiretinal membrane.

CONCLUSIONS

Possible contributing factors to endophthalmitis following sutureless vitrectomy include decreased vitreous irrigation/lavage, lack of a watertight wound, and/or vitreous wicking, all of which may promote intraocular bacterial entrance. A sutureless vitrectomy system may increase the risk of vitrectomy-associated endophthalmitis.