Endoscopic vitreoretinal surgery: Review of current applications and future trends

Endoscopy provides unique optical properties to circumvent anterior segment opacities and visualize difficult-to-access anatomical regions, including retroirideal, retrolental, ciliary body, and anterior retinal structures. We summarize the basic principles and utilization of endoscopic vitreoretinal surgery, along with recent technological advances in the field base on a structured literature search in Pubmed, Embase, and Google Scholar database up to February, 2020. Endoscopy has been used in the management of retinal detachment, ischemic retinopathies with neovascular glaucoma, severe ocular trauma, endophthalmitis, lens-related disorders in the posterior segment, pediatric vitreoretinal diseases, and implantation of retinal prostheses. Ongoing development of endoscopic technology aims to provide higher resolution images with endoscopes of smaller diameter. New surgical techniques supported by the adoption of endoscopy are available to manage challenging surgical scenarios. Endoscopy can be a useful adjunct to microscope wide-angle viewing systems in the management of complex vitreoretinal diseases.

Endoscopy-assisted vitrectomy vs. vitrectomy alone: comparative study in complex retinal detachment with proliferative vitreoretinopathy

Background

Recurrent retinal detachment (RD) is still a widespread event despite the therapeutic options available. Proliferative vitreoretinopoathy (PVR) is one of the main causes of redetachment. Little is known about the use of endoscopy-assisted vitrectomy (E-PPV) in complex recurrent RD with PVR. The purpose of this study was to identify the potential advantages of E-PPV in complex RD with PVR compared with pars plana vitrectomy (PPV) alone.

Methods

Single-center, retrospective, observational, descriptive study. The medical records of 293 patients were reviewed. Patients who underwent PPV for complex rhegmatogenous RD and associated PVR between 2009 and 2017 were included. Patients with diabetic tractional RD, trauma, uveitis or detachment postendophthalmitis were excluded. After 2013, an endoscopic visualization system was used in a nonrandomized fashion at the surgeon’s discretion. Outcome measures (reattachment rate, number of surgeries, lens status, PVR stage, intraocular pressure, phthisis rate) were compared between the E-PPV and PPV-only groups with independent samples t-tests (continuous variables) and Fisher’s exact test (categorical variables), as well as time-adjusted analyses. Postoperative time to retinal redetachment was assessed with Kaplan–Meier survival analysis.

Results

One hundred one eyes from 100 patients met the inclusion criteria. The mean participant age was 63.3 years old (95% CI 60.4–66.1 years), without a significant difference between groups. E-PPV was performed in 36.6% (n = 37) of eyes, and 63.4% (n = 64) underwent PPV only. The mean follow-up was significantly longer in the PPV-only group (31.9 vs. 21.1 months; p = 0.021). Upon adjustment for follow-up duration, the mean number of surgeries was significantly lower in the PPV-only group (2.6 vs. 4.3 number of surgeries; p < 0.001) than in the E-PPV group. A significantly higher risk for redetachment was observed in the PPV-only group (HR [95% CI] 4.1 [1.4–11.8]) than in the E-PPV group (p = 0.037). The evolution to phthisis was 7% (n = 4) in the PPV-only group and 2.7% (n = 1) in the E-PPV group (p > 0.05).

Conclusions

Compared to PPV alone, endoscopy-assisted vitrectomy seems to be advantageous in achieving better reattachment rates in complex RD with advanced PVR. Endoscopic visualization allows a thorough examination and extensive anterior PVR and vitreous base dissection.

Endoscopy-assisted vitrectomy in the anterior vitreous

Endoscopy-assisted ocular surgery is a relatively old technique that is increasingly being recognized for its application in cases of vitreoretinal disease. This technique is especially useful when both the vitreous and retina are difficult to access because of media opacity, a small pupil, or a microcornea. In this context, the anterior vitreous is often difficult to dissect because of its complex pathological changes. This article reviews the common anatomical features and pathologies that are observed in the anterior vitreous, as well as the applications and indications of endoscopy-assisted vitrectomy in the anterior vitreous.