Suprachoroidal fluid as a complication of 23-gauge vitreous surgery

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative severe suprachoroidal air as a complication of 23-gauge vitrectomy combined with air-fluid exchange

We reported a rare case of sudden onset of severe but reversible suprachoroidal air that occurred at the moment of air–fluid exchange in 23-gauge vitrectomy. A 31-year-old male patient presented with a large break at 10–11 o’clock and high bullous, nearly total retinal detachment. He underwent first surgery with silicon oil injection at the end of the surgery. He was arranged to have a second surgery for silicon oil removal through pars plana vitrectomy which was performed smoothly at first. While switching to another mode of air–fluid exchange to clean the residual emulsified oil droplets, surgical view disappeared completely and was suddenly replaced with severe and total suprachoroidal air, which fortunately resolved within 3 days without any other severe complications.

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.

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification for rhegmatogenous retinal detachment repair

AIM

To assess the outcomes of combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification with intraocular lens implantation for rhegmatogenous retinal detachment (RRD) repair.

METHODS

This was a retrospective, consecutive, non-comparative, interventional case series of 30 eyes of 30 patients who underwent combined sutureless vitrectomy and clear corneal cataract surgery for the repair of RRD. The principal outcome measures were primary anatomical success rate, reasons for redetachment, final visual acuity, and surgical complications.

RESULTS

Primary reattachment was achieved in 27 eyes (90.0%). The reasons for redetachment (3 eyes, 10%) were incomplete laser retinopexy, persistent chronic subretinal fluid, and proliferative vitreoretinopathy, respectively. The logarithm of the minimum angle of resolution visual acuity (mean±SD) improved from 0.76±0.74 preoperatively to 0.21±0.37 6 months' postoperatively (P<0.0001). Postoperative hypotony was not detected, but 1 eye (3.3%) had increased intraocular pressure (30mmHg) with spontaneous resolution. No endophthalmitis developed during follow-up. Macular pucker was detected in 3 eyes (10.0%).

CONCLUSION

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification with intraocular lens implantation for RRD repair was proven safe and effective. It may provide not only the known advantages of conventional combined surgery, but also additional advantages such as less conjunctival fibrosis and the maintenance of stable intraocular pressure with low risks of postoperative hypotony and intraocular pressure elevation.

A simple method for detecting vitrectomy infusion line position in hazy media, in case of poor visualization

PURPOSE

To introduce a simple and practical method for detecting vitrectomy infusion line position in a hazy media.

METHODS

The position of the infusion cannula was evaluated before and during vitrectomy in 17 eyes of 17 patients with hazy media. This procedure was performed by using the light pipe inserted partially into the cannula and determining the color of transmitted light into the vitreous cavity. Dark red or brownish color was considered as suprachoroidal placement and bright whitish color as the correct position of the cannula tip.

RESULTS

In 13 patients, the position of the cannula was considered as a precise position by using the aforementioned method at the beginning of the operation, and vitrectomy was performed without any infusion line-related complications. In two cases, the incorrect placement of the infusion cannula was confirmed with this technique, and the cannula was reinserted and repositioned. In two cases, secondary slippage of the cannula in suprachoroidal space was detected by using this method during vitrectomy, and another cannula was tried in another position.

CONCLUSION

Using the color of light pipe inserted partially into the cannula is a safe and simple method for evaluating the position of the infusion line in the eye.

Suprachoroidal hemorrhage in pars plana vitrectomy: risk factors and outcomes over 10 years

PURPOSE

To investigate the rate and risk factors of developing suprachoroidal hemorrhage (SCH) after pars plana vitrectomy (PPV) and the outcomes as a result.

DESIGN

Retrospective, comparative consecutive series.

PARTICIPANTS

A total of 5459 patients who underwent pars plana vitrectomies over 10 years in 3 surgical centers.

METHODS

All patient demographic, medical, and ophthalmic data and operative information from 3 vitreoretinal centers were entered prospectively into an electronic medical record. Univariate analysis was undertaken, comparing risk factors between cases (SCH) and controls. Multivariable logistic regression was performed to test for independence between the risk factors (P < 0.2 in univariate analysis) and SCH.

MAIN OUTCOME MEASURES

Risk factors for developing SCH. Visual outcome and development of complications.

RESULTS

A total of 5459 PPVs were undertaken for a wide range of indications. Fifty-six cases of PPV were complicated by SCH (1.03%). Multivariable logistic regression showed that significant risk factors for developing this included advancing age, (mean age, 69 years in cases and 60 years in controls; odds ratio [OR], 1.04; P = 0.001), male sex (76.8% of cases and 58.7% of controls; OR, 2.38; P = 0.008), presence of rhegmatogenous retinal detachment (RRD) (80.3% of cases and 52.5% of controls; OR, 5.92; P < 0.0001), presence of a dropped lens fragment (10.7% of cases and 4.5% of controls; OR, 6.94; P = 0.002), and the use of antiplatelet or anticoagulant drugs (33.9% of cases and 17.7% of controls; OR, 2.29; P = 0.007). Suprachoroidal hemorrhage was more common with increasing quadrants of RRD. The significant operative risk factor was application of an explant (25% of cases and 4.07% of controls; OR, 5.63; P < 0.0001). Phthisis (7.1% of cases and 0.9% of controls; P = 0.002, Fisher exact test) and glaucoma (14.3% of cases and 7.2% of controls; P = 0.044, chi-square test) were more common in cases than in controls.

CONCLUSIONS

The risk factors for developing intraoperative SCH during PPV are male sex, advancing age, RRD, a scleral explant, a dropped lens fragment, and the use of aspirin or warfarin. Patients with this complication have a greater risk of developing ocular hypertension requiring treatment and phthisis.

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.

Suprachoroidal gas injection as a complication of pars plana vitrectomy confirmed by computed tomography

Background

Suprachoroidal gas injection has been reported as a complication of pneumatic retinopexy, and the usefulness of B-scan ultrasonography has been reported. A case of suprachoroidal gas injection as a complication of pars plana vitrectomy confirmed by computed tomography (CT) is presented here.

Methods

A 64-year-old woman developed a vitreous hemorrhage due to a retinal tear secondary to an old branch retinal vein occlusion. A 23-gauge pars plana vitrectomy was performed. Sclerotomies were performed at a 30° angle. After air–fluid exchange, sulfur hexafluoride gas was injected through a temporo-superior sutured sclerotomy with direct visualization of the entire needle tip. Postoperatively, a large choroidal elevation was identified temporo-superiorly with intravitreal gas, and the patient complained of a mild headache.

Results

On postoperative Day 7, a CT scan showed two low-density areas, confirming the presence of suprachoroidal gas; intravitreal gas blocked visualization of the suprachoroidal gas on B-scan ultrasonography. On postoperative Day 14, the intravitreal gas resolved and a CT scan showed a small amount of residual suprachoroidal gas. By this time, the headache had completely resolved.

Conclusion

Suprachoroidal gas injection is a rare complication of pars plana vitrectomy that resolves spontaneously. In this case, CT scans confirmed the presence of suprachoroidal gas despite the presence of intravitreal gas.

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy

PURPOSE

To evaluate the results and complications of combined 23-gauge sutureless vitrectomy, clear corneal phacoemulsification, and intraocular lens implantation in patients with proliferative diabetic retinopathy.

METHODS

This was a retrospective, consecutive, noncomparative, interventional case series of 136 eyes of 108 patients who underwent combined sutureless vitrectomy and clear corneal cataract surgery for the complications of proliferative diabetic retinopathy. The main outcome measures were visual outcomes and surgical complications.

RESULTS

Main indications for the combined surgery were vitreous hemorrhage (78 eyes, 57.4%) and tractional retinal detachment (36 eyes, 28.7%). The logarithm of the minimum angle of resolution visual acuity (mean ± SD) improved from 0.86 ± 0.59 preoperatively to 0.39 ± 0.52 six months postoperatively (P < 0.0001). Intraoperative retinal tear occurred in 7 eyes (5.1%) and postoperative vitreous hemorrhage in 10 eyes (7.5%). Even in the absence of suturing of sclerotomy sites, only 1 eye (0.7%) had postoperative hypotony (<6 mmHg). During the 6 months after surgery, only 1 eye (0.7%) developed neovascular glaucoma and 6 eyes (4.4%) required a repeat vitrectomy (3 for retinal detachment and 3 for vitreous hemorrhage).

CONCLUSION

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy was safe and effective. It may have not only the known advantages of conventional combined surgery but also additionally those such as faster visual rehabilitation and less conjunctival fibrosis.

Difficulty in inserting 25- and 23-gauge trocar cannula during vitrectomy

PURPOSE

To determine the incidence of difficulty in inserting a 25- and 23-gauge trocar cannula (DITC) during 25- or 23-gauge micro-incision vitrectomy surgery (MIVS).

METHODS

Retrospective, consecutive, interventional case series performed by a single surgeon at a single centre. We defined a DITC as the condition where at least 1 trocar cannula could not be inserted into the vitreous at the beginning of MIVS. The incidence of DITC was calculated from 1,525 eyes, and the pre-operative demographics of the DITC cases were compared to those of the non-DITC cases.

RESULTS

The incidence of DITC for all cases was 0.6% (9 of 1,525 eyes). Overall, there were 242 eyes with a retinal detachment (RD), and 8 of the 9 eyes with DITC had an RD with an incidence of 3.3% (8 of 242 RD eyes). Seven of these 8 eyes had a total RD, 4 also had a choroidal detachment, 4 eyes were also myopic (>-8.0 dpt, high myopia), and 6 of the 8 eyes were hypotonic (<8 mm Hg). The DITC cases had larger RDs (p<0.0001), a higher incidence of choroidal detachment (p<0.0001), higher myopia (p=0.0204) and hypotony (p=0.0003) than the non-DITC eyes with an RD.

CONCLUSIONS

A large RD, a choroidal detachment, high myopia and hypotony are significant risk factors for DITC. We recommend that MIVS should be performed cautiously for eyes with these risk factors.

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

PURPOSE

To examine the inner surface of the sclerotomy during microincision vitrectomy surgery by Miyake-Apple view.

METHODS

The anterior half of porcine eyes was attached to a transparent acrylic plate with cyanoacrylate glue. Then, either a 23-gauge or a 25-gauge trocar-cannula was inserted through the sclera obliquely. The inner surface of the entrance site was observed posteriorly by Miyake-Apple view. These images were compared with the endoscopic view of two patients who underwent vitreous surgery for an epiretinal membrane.

RESULTS

When the trocar-cannula was inserted obliquely, the Miyake-Apple view showed that the ciliary epithelium at the sclerotomy site was stretched. When the trocar-cannula was inserted vertically, the ciliary epithelium was folded, and the folds remained even after the trocar was removed. Vitreous strands were seen incarcerated into the sclerotomy site. In human eyes, a folding of the ciliary epithelium was not clearly seen with the endoscopic view but the incarcerated vitreous was seen.

CONCLUSION

The Miyake-Apple view provided a precise, in vivo, observation of the inner surface of the entry site. It disclosed the morphological stress on the ciliary epithelium by the sclerotomy.

Comparative study of 23-gauge vitrectomy versus 20-gauge vitrectomy for the treatment of rhegmatogenous retinal detachment

PURPOSE

To compare the safety and efficacy of 20- and 23-gauge pars plana vitrectomy (PPV) for the management of primary rhegmatogenous retinal detachment (RD) with proliferative vitreoretinopathy (PVR) grade B or less.

METHODS

This comparative nested case-control study included 35 consecutive 23-gauge transconjunctival PPV cases matched (1:1) with 35 cases of 20-gauge PPV (from a prospective cohort of 1,150 patients) for the baseline visual acuity (VA), axial length, lens and macular status, the location and number of breaks, and PVR grade. All patients had complete PPV, cryotherapy, fluid-gas exchange, and a minimum follow-up of 6 months. The exclusion criteria were eyes with previous vitreoretinal surgery, combined vitrectomy and cataract surgery, RD secondary to trauma or macular hole, diabetic retinopathy, aphakic eyes, giant tears, or posteriorly located breaks precluding treatment using transconjunctival cryotherapy.

RESULTS

Baseline examination disclosed pseudophakia in 77.1%, high myopia in 11.4%, 2.7 ± 2.2 retinal breaks/eye, attached macula in 37.1%, and PVR grade B in 24.3% of the cases. The mean operative time and intraoperative complication rate (11.4%) were similar in both groups. In the 23-G group, we noted three cases of iatrogenic retinal tears and one case of choroidal detachment secondary to a dislodgment of the infusion line. Suturing the sclerotomy sites or the conjunctiva was required in 5.7 and 51% of the eyes, respectively. The single reattachment rate was similar in both groups, 74.3% in the 20-G group, and 80% in the 23-G group. The final anatomical success rate was 97% in the two groups. Mean preoperative VA of 1.2 ± 0.9 logMAR improved similarly in both groups to 0.4 ± 0.4 at the 6-month visit. A final vision of 20/40 or better was achieved similarly in 62.9% of the eyes in the 20-G group and 60% in the 23-G group.

CONCLUSIONS

Twenty-three-gauge PPV provides anatomical and visual results similar to the 20-G technique for the management of uncomplicated rhegmatogenous RD.

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.

Presumed sclerotomy site bleeding inflowing into the anterior chamber after the removal of a 23-gauge microcannula in 23-gauge sutureless vitrectomy

We experienced two cases of the influx of the sclerotomy site bleeding into the anterior chamber during 23-gauge sutureless vitrectomy for pseudophakic rhegmatogenous retinal detachment. Soon after the removal of a 23-gauge microcannula at the end of the surgery, presumed sclerotomy site hemorrhage was rapidly fluxed into the anterior chamber. The anterior chamber bleeding might come from the sclerotomies rather than from episcleral vessels. The posterior pressure in the gas-filled pseudophakic eye might have pushed the sclerotomy site bleeding into the anterior chamber. We could not find any vitreous hemorrhages. The hemorrhage within the anterior chamber spontaneously absorbed within 14 days.