Miyake-Apple view of inner side of sclerotomy during microincision vitrectomy surgery

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intraoperative management of posterior capsular rupture

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture.

RECENT FINDINGS

Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures.

SUMMARY

With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

An endoscopic overview of the anterior vitreous base in retinal detachment and anterior proliferative vitreoretinopathy

PURPOSE

Anterior proliferative vitreoretinopathy (PVR) is an important cause of persistent or recurrent retinal detachment (RD). Endoscopy provides 360° panoramic viewing of the vitreous cavity and high-magnification viewing of the anterior vitreous base (AVB). This study describes the 'in vivo' anatomy and pathoanatomy of the AVB using an ocular endoscope in RD and anterior PVR.

METHODS

An intraoperative analysis of over 2000 consecutive eyes undergoing vitrectomy for RD operated with endoscopy-assisted vitrectomy was performed. It was recorded in notes dictated during surgery and in standardized operative reports. Around 1500 surgical videotapes, with the exclusion of diabetic retinopathy and trauma, selected by reviewing the OR reports and notes were retrospectively reviewed.

RESULTS

Seven endoscopic criteria associated with anterior PVR complicating RD are described: 'en bloc' stiff anterior vitreous retraction, ciliary detachment, seeding of the AVB by abundant pigmented and/or white granulations, anterior tissue displacement, stiff 'wrinkling' at the vitreoretinal juncture, persistent shallow ciliary/RD under perfluorocarbon liquids and traction-related retinal surface haemorrhages. Causes responsible for failure of conventional vitrectomy for RD are highlighted. Findings in case of hypotony and cyclitic membranes are described.

CONCLUSIONS

Endoscopy is a significant adjunct to our understanding of the development of anterior loop traction by obviating the two constitutive parts of the AVB, anterior and posterior, their interconnections and their respective connections to the anterior segment and to the retina. It provides a unique evaluation and thorough eradication of the anterior vitreous cortex as a scaffold for anterior PVR. It might be an adjunct to the prevention of anterior PVR.

Intraoperative endoscopic observation of sclerotomy site after cannula removal for 23-gauge vitrectomy

BACKGROUND

The purpose of this study was to determine the incidence of vitreous incarceration in sclerotomy after cannula removal during 23-gauge vitrectomy.

METHODS

Thirty-seven eyes underwent 23-gauge sutureless vitrectomy. Oblique sclerotomies were made parallel to the limbus and tangentially to the sclera. Once past the trocar sleeve, the angle was changed to 90 degrees perpendicular to the surface and the trocar and cannula inserted. Vitreous gel was removed until the intraocular edge of the infusion cannula was free from the gel. The cannula was extracted with insertion of a light probe. The sclerotomy site was evaluated endoscopically through another cannula in 32 eyes; in five eyes, another infusion tube was inserted into the cannula to maintain intraocular pressure, the original infusion was removed, and the sclerotomy site observed.

RESULTS

No vitreous incarceration occurred in 30 (94%) eyes when one cannula was removed with insertion of a light probe, and minimal incarceration occurred in two (6%) eyes. No incarceration occurred in five eyes with observation of the infusion site.

CONCLUSION

The incidence of vitreous incarceration is low when a light probe or vitreous cutter is inserted. Inserting the light probe through the cannula during its removal and creating an oblique sclerotomy may reduce vitreous incarceration.

Influence of sclerotomy use on vitreous incarceration in an experimental model of vitrectomized eye

PURPOSE

To evaluate the influence of sclerotomy use during vitrectomy (vitreous cutter, illumination probe, or infusion-line entrance) on postoperative vitreous incarceration using an experimental model of vitrectomized eye.

MATERIALS AND METHODS

Experimental, randomized, and observer-masked study in which 23-gauge transconjunctival sutureless vitrectomy was performed in cadaveric pig eyes. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2).

RESULTS

A total of 46 eyes were included. Vitreous incarceration was detected in 91.3% (43.5% G1, 47.8% G2) of the sclerotomies used by the vitreous cutter probe, 95.7% (45.7% G1, 50% G2) of the illumination-pipe entrances, and 93.5% (45.7% G1, 47.8% G2) of the infusion-line incisions. No statistical differences were found when comparing incisional vitreous incarceration after vitrectomy according to sclerotomy use.

CONCLUSION

Different manipulation of the sclerotomies, depending on their use, does not seem to influence postvitrectomy vitreous entrapment in our experimental model.

Comparison of 23-gauge sutureless sclerotomy architecture and clinical outcomes in macular and non-macular surgery using spectral-domain optical coherence tomography

PURPOSE

To compare the 23-gauge (23-G) sutureless vitrectomy incision architecture in macular and non-macular surgery, using anterior segment spectral-domain optical coherence tomography (SD-OCT), and to evaluated its influence on clinical outcomes.

METHODS

A prospective, observational case series of 43 patients who underwent primary transconjunctival 23-G pars plana vitrectomy (PPV) for macular and non-macular diseases. All sclerotomy wounds were imaged 1 day after surgery using the anterior segment module of SD-OCT (OCT Spectralis; Heidelberg Engineering, Heidelberg, Germany). Sclerotomy architecture, including good wound apposition, presence of gaping and misalignment of the roof and floor of the incisions were evaluated. Preoperative, intraoperative and postoperative medical record data were also prospectively collected.

RESULTS

  Incision gaping and misalignment of the roof and floor occurred more frequently in the superotemporal and superonasal quadrants than in the inferotemporal quadrant (p < 0.05) and was more frequent in the non-macular group than in the macular group (p < 0.05). The incidence of incision gaping increased significantly as the incision angle increased. In the macular group, the mean postoperative intraocular pressure (IOP) did not change from the preoperative value, whereas in the non-macular group, the mean IOP decreased significantly from 15.09 ± 2.58 mmHg preoperatively to 12.18 ± 3.25 mmHg on the first postoperative day (p < 0.005). The mean IOP did not differ significantly between the two groups of surgery at 1 week, and at 1 month postoperatively.

CONCLUSIONS

  In 23-G PPV, non-macular surgery is associated with a significant postoperative IOP decrease in comparison with macular surgery, which could be explained by the most remodelled wound architecture.