Modified incision in 25-gauge vitrectomy in the creation of a tunneled airtight sclerotomy: an ultrabiomicroscopic study

Assessment of Zonular Integrity in Phakic Eyes Following Pars Plana Vitrectomy Using Ultrasound Biomicroscopy: A Prospective Paired Eye Comparative Study

PURPOSE

To assess zonular integrity in phakic patients post vitrectomy using ultrasound biomicroscopy (UBM).

DESIGN

Prospective, comparative, nonrandomized, double-masked, paired eye study.

METHODS

We used ultrasound biomicroscopy (UBM) to evaluate phakic patients with a history of unilateral pars-plana vitrectomy.

INCLUSION CRITERIA

(1) phakic patients with history of pars plana vitrectomy in one eye as the only procedure; (2) normal unoperated fellow eye; and (3) complete gas or air resolution from the vitreous cavity at the time of UBM assessment.

EXCLUSION CRITERIA

(1) monocular patients; (2) history of intraoperative lenticular trauma; (3) the use of silicone oil tamponade; (4) history of trauma or pseudoexfoliation in either eye; (5) history of other ocular conditions that can affect the integrity of zonules, such as uveitis or ectopia lentis; (6) eyes with extreme myopia or long axial length (> -8.00 D or >30.0 mm); (7) history of intravitreal injection in either eye; (8) age <18 years.

TECHNIQUE

A high-frequency (50 MHz) UBM device was used by a masked technician to obtain radial section images from zonular bundles at 8 different clock positions. Image quality was assessed in real time, captured, and saved. Two experienced masked observers (H.C. and C.B.) then assessed the quality of the images and graded the zonular findings. Only patients with adequate studies have been included. A unique grading system that was specifically devised for this study was used as the following: (0) clear, well-defined zonule(s); (1) uneven, disrupted zonules or stretched zonules; and (2) extensive loss of zonules. Each clock hour was graded according to this system and the total score was then calculated for each eye. In the primary outcome, 2 main groups were analyzed: vitrectomized eyes and healthy contralateral nonvitrectomized eyes. The mean total UBM score (TUS) from each group was compared and analyzed.

RESULTS

Thirty-five patients were recruited into this study. Eleven patients were male and 24 were female. The mean age was 66.3 years. Thirty patients had vitrectomy for vitreomacular interface disorders (either macular hole or epiretinal membrane), 1 patient had vitreous hemorrhage and the remaining 4 patients had rhegmatogenous retinal detachments. With regard to tamponade agents, SF6 was used in 21 (60%) patients, air in 9 (26%) patients, and C3F8 in 5 (14%) patients. The mean TUS in the vitrectomized eyes was 2.28 (SD 1.83) vs 2.24 (SD 1.77) in the nonvitrectomized eyes (P = .9531). Overall, in the comparative analysis of mean scores based on 2 graders' assessments for each clock position in vitrectomized and nonvitrectomized eyes, there were no significant differences noted between the groups.

CONCLUSION

This study found no evidence for a difference in the mean total UBM score in eyes following vitrectomy when compared to their contralateral healthy, nonvitrectomized eyes. This likely indicates that vitrectomy may not affect the integrity of zonules in phakic patients, at least for patients with vitreomacular interface disorders undergoing uncomplicated surgery.

Ciliochoroidal Detachment After Intrascleral Lens Fixation Using the Yamane Technique

PURPOSE

The purpose of this study was to compare the incidence of ciliochoroidal detachment (CCD) after intrascleral lens fixation using the Yamane technique and other vitrectomy procedures.

METHODS

This retrospective study evaluated patients who underwent intrascleral lens fixation using the Yamane technique at Hiroshima University Hospital between March 2023 and February 2024 and who could be followed up for at least one month. Patients who underwent vitrectomy for macular disease without air-fluid exchange comprised the control group. The frequency of CCD was compared using anterior segment optical coherence tomography imaging.

RESULTS

Forty-five eyes of 45 patients (26 men and 19 women, mean age 70.8 years) were included. There were no significant differences in the population means or proportions between the intrascleral fixation and control groups for age, sex ratio, right-to-left eye ratio, preoperative visual acuity, preoperative intraocular pressure (IOP), ocular axis, and corneal thickness. The population mean of IOP on the day after surgery was significantly lower in the Yamane intrascleral fixation group (8.4 mmHg) than in the control group (11.5 mmHg) (P < 0.05). There was no significant difference in the population proportions of CCD on the day after surgery between the Yamane intrascleral fixation group and the control group. However, the CCD incidence was 20 eyes (80%) for the Yamane intrascleral fixation group and 12 eyes (60%) for the control group, which was higher in the intrascleral fixation group. There was no significant difference in population means of IOP or population proportions of CCD at one week and one month.

CONCLUSIONS

There was no significant difference in population proportions of CCD on the day after surgery, although the CCD rate for the Yamane intrascleral fixation group was higher, and the population mean of the IOP was significantly lower. The Yamane technique assumedly lowered IOP because of the stress placed on the ciliary body. One week after the procedure, the IOP in the intrascleral fixation group normalized.

Optic inversion of scleral-fixated intraocular lens after vitrectomy with fluid-air exchange: case series and review of the literature

Lens dislocation is a significant complication after cataract surgery. Scleral fixation of 3-piece intraocular lens provides favorable visual outcome and can spare patients the need for lens exchange. Two patients presented with dislocated 3-piece lenses implanted over 10 years earlier. Both patients underwent pars plana vitrectomy and dropped lens rescue with scleral fixation. Postoperatively, the lens optic was found flipped nearly 90° at the optic-haptic junctions secondary to fluid-air exchange performed during vitrectomy. Both patients underwent intraocular lens exchange with a four point sclera fixated lens. Our study found that air tamponade is better avoided during rescue of old dislocated 3-piece lens implants. Intraocular lens exchange is preferred, when possible, to avoid complications associated with old dislocated lenses. Larger studies are needed to determine the effect of time on dislocated lens implants materials.

Scleral melt and uveal prolapse following 23-gauge pars plana vitrectomy

Purpose

To report a case of uncontrolled juvenile open angle glaucoma (JOAG), with secondary high axial myopia who presented with scleral melting and uveal prolapse post pars plana-vitrectomy.

Observations

A 17-year-old male juvenile glaucoma patient, not known to have any systemic disease underwent a right eye 23-gauge-pars plana vitrectomy for retinal detachment repair. Three weeks following his surgery he presented complaining of tearing and photophobia in the operated eye in the absence of any ocular pain. Clinical exam revealed enlarged sclerotomy sites with localized conjunctival and episcleral injection, scleral thinning and uveal prolapse. Infectious and serologic work up were obtained to rule out an infectious etiology or underlying autoimmune disease. Patient was successfully managed with topical steroids and a donor scleral patch graft.

Conclusion and importance

This report addresses multiple risk factors for a devastating complication that may occur in predisposed patients, with primary or secondary axial myopia and a compromised sclera. This group of patients can be at risk of post-operative scleral melting and thinning and should be identified pre-operatively and monitored closely during their post-operative course.

Dexamethasone Intravitreal Implant Injection in Eyes with Comorbid Hypotony

PURPOSE

To evaluate outcomes in patients with hypotony treated with intravitreal dexamethasone implant (Ozurdex).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Thirteen patients (15 eyes) that received a total of 99 dexamethasone implant injections on occasions at which the intraocular pressure was low, meeting the definition of statistical hypotony.

METHODS

The medical records of 13 patients (15 consecutive eyes) receiving 1 or more intravitreal dexamethasone implants between December 2014 and April 2017 were reviewed retrospectively. Hypotony was defined as intraocular pressure less than 6.5 mmHg. The indications for intravitreal dexamethasone implant injection were intermediate or posterior uveitis (86.7%), diabetic macular edema (13.3%), and/or cystoid macular edema (6.7%).

MAIN OUTCOME MEASURES

The primary outcome measures were safety outcomes and best visual acuity within 6 months of the final intravitreal dexamethasone implant injection in a hypotonous eye.

RESULTS

In 15 eyes (13 patients), 99 injections were administered to eyes under circumstances of hypotony. Uveitic cystoid macular edema or diabetic macular edema was reduced after treatment in all cases. No complications were noted during the injection procedure. Three complications were noted in 2 patients after injection. Pseudophakodonesis and mild vitreous hemorrhage immediately after injection were noted in 1 patient, and a case of delayed-onset vitreous hemorrhage with pigment release was noted in another. All 3 complications resolved without intervention. The primary end point of this study-mean visual acuity-was stable over the follow-up period. In patients with hypotony whose intraocular pressure normalized during the follow-up period, this was attributable to management of glaucoma surgery-related complications rather than an effect of the intravitreal dexamethasone implant.

CONCLUSIONS

Intravitreal dexamethasone implant injection is a reasonable treatment option for patients with comorbid hypotony in whom clinical findings warrant treatment with a sustained-delivery intravitreal steroid implant. Further studies, including imaging of zonules before and after intravitreal dexamethasone implant injection in a hypotonous eye, could help define risks to intraocular lens stability with this procedure.

Influence of orientation of the external linear incision created by the 25-gauge trocar and related factors on sclerotomy closure: A clinical and optical coherence tomographic study

Purpose:

To assess the influence of orientation of the external linear incision created by the trocar and related factors on sclerotomy closure in 25-gauge (25G) transconjunctival vitreous surgery (TVS).

Methods:

A total of 46 eyes of 46 patients who underwent 25G TVS (23 circumferential incisions and 23 radial incisions) were studied. Clinical and anterior segment optical coherence tomography (AS-OCT)-based comparison of self-sealed and sutured sclerotomies was done. The influence of age, ocular surgeries and injections, axial length, cannula type, sclerotomy quadrant, surgery duration, vitreous base excision, and tamponade on suture rates was analyzed.

Results:

Of the 46 eyes, 23 eyes required suturing [circumferential: 17 (74%) and radial: 6 (26%); P = 0.003]. A significantly lesser proportion of superonasal quadrant and inferotemporal quadrant sclerotomies needed suturing [9 (24%) and 12 (27%)] when compared with superotemporal quadrant [17 (37%)]. Sclerotomies to the left of the surgeon and the infusion port required significantly lesser suturing [10 (25%) and 13 (28%), respectively] when compared with that of surgeon's right [15 (35%)]. Suturing was significantly lesser when gas or oil tamponade was used [5 (36%) and 2 (20%), respectively] when compared with no tamponade [16 (73%)]. In eyes without tamponade, suturing was lesser with radial sclerotomies (P = 0.003). The odds of having an open sclerotomy tract on AS-OCT were ≥5 when circumferential sclerotomies were used.

Conclusion:

Self-sealing was more common with radial external incisions. Tamponade was associated with less suturing. Superotemporal sclerotomies and sclerotomies toward the surgeon's dominant hand were often sutured. In this cohort, other factors did not influence sclerotomy closure.

Comparison of postoperative ciliary body changes associated with the use of 23-gauge and 20-gauge system for pars plana vitrectomy

Background

To compare the ciliary body changes associated with the use of 23-gauge (23G) and 20-gauge (20G) systems for pars plana vitrectomy.

Methods

A total of 60 patients (60 eyes) with idiopathic epiretinal membrane who were scheduled for surgical treatment were selected and randomly assigned to 20G group or 23G group. Time required for incision making, vitrectomy, and incision closure was compared between the two groups. Changes in ciliary body were evaluated by ultrasound microscopy (UBM). Anterior chamber inflammation was assessed with laser flare meter instrument.

Results

Incision-making time (4.5 ± 0.9 min) and incision-closure time (2.8 ± 0.7 min) in the 23G group were significantly shorter than those in the 20G group (10.1 ± 1.5 min and 11.3 ± 2.2 min, respectively). No significant intergroup difference was observed with respect to time required for vitrectomy (21.6 ± 3.3 min and 20.7 ± 3.2 min, respectively). Ciliary body thickness in the 23G group recovered back to preoperative levels after 4 weeks, as against 8 weeks in the 20G group. Postoperative ciliary body thickness in the 20G group was significantly higher than that in the 23G group (p < 0.05). The aqueous protein concentration in 23G group recovered back to preoperative levels after 2 weeks, as against 4 weeks in the 20G group. Postoperative aqueous protein concentration in the 20G group was significantly higher than that in the 23G group (p < 0.05).

Conclusions

The use of 23G system was associated with significantly milder injury to the ciliary body as compared to that associated with the use of 20G system.

Trial registration

The study was retrospectively registered on Chinese Clinical Trial Registry. The clinical study registration number was ChiCTR-INR-17011082. Date of registration: 2017-04-07.

Conjunctival Displacement to the Corneal Side for Oblique-Parallel Insertion in 25-Gauge Vitrectomy

Purpose

To assess the usefulness of the method of oblique-parallel trocar insertion with conjunctival displacement to the corneal side in 25-gauge (G) transconjunctival vitrectomy.

Methods

25-G vitrectomy was performed in 77 consecutive eyes. Before making oblique-parallel trocar insertions, the conjunctiva was conventionally displaced superiorly in 35 eyes, but was displaced toward the corneal side in 42 eyes. After surgery, the distance between the scleral and conjunctival wounds was measured with calipers. The frequency of scleral wound exposure was assessed.

Results

After cannula removal at the end of surgery, inferior repositioning of the superiorly displaced conjunctiva was observed, while marked posterior repositioning of the corneal side caused displacement of the conjunctiva due to gravity. The superior displacement distances between the sclera and conjunctival wounds were 2.4±0.3 mm at the infusion port, 2.0±0.4 mm at the superior temporal port, and 1.9±0.4 mm at the superior nasal port, while the corresponding distances for corneal side displacement were 3.6±0.5, 3.5±0.5, and 2.5±0.5 mm, and were all significantly (p<0.0001) greater with corneal side displacement. The frequency of scleral wound exposure due to conjunctival damage around the cannula (infusion port) was significantly (p=0.0164) lower for corneal side displacement (0/42; 16.7%) than superior displacement (5/35; 14.3%). There was no postoperative endophthalmitis in all 77 patients studied.

Conclusions

In 25-G transconjunctival vitrectomy, using oblique-parallel trocar insertions with the conjunctiva displaced toward the corneal side results in marked posterior repositioning of the conjunctiva after cannula extraction. Corneal side conjunctival displacement is technically easy and completely covers the scleral wound. This method is expected to be effective in preventing endophthalmitis.

27-gauge and 25-gauge vitrectomy day surgery for idiopathic epiretinal membrane

BACKGROUND

This study compared the postoperative outcomes of 27-gauge (G) and 25-G vitrectomy performed for the treatment of idiopathic epiretinal membrane (ERM).

METHODS

The study design was single center, retrospective, interventional case series. Two hundred consecutive eyes that underwent primary vitrectomy for ERM (27-G vitrectomy in 100 eyes and 25-G vitrectomy in 100 eyes) were studied for 6 months. In all eyes, scleral tunnels were made using angle incisions, and air or gas exchange was performed.

RESULTS

There were no significant differences in age, spherical diopter power, as well as preoperative Early Treatment Diabetic Retinopathy Study (ETDRS) score, central retinal thickness (CRT), and intraocular pressure between the 27-G and 25-G groups. The proportions of simultaneous cataract surgery (27-G vs. 25-G: 82% vs. 90%), air-filled eyes (99% vs. 98%), and scleral wound suture at the end of surgery (0% vs. 0%) were not significantly different between two groups. The mean operation time for vitrectomy was significantly (P = 0.0322) longer by 4 min for 27-G (37 min) compared to 25-G (33 min) vitrectomy. Gain in ETDRS score was significantly (P = 0.0421) better in 27-G group (4.7 ± 8.1 letters) compared to 25-G group (1.1 ± 13.6 letters) at 1 month post-vitrectomy, but not significantly different at 3 and 6 months (P = 0.0835 and 0.0569, respectively). Decrease in CRT was significantly (P = 0.0354) greater in 27-G group (-24.2 ± 50.0 μm) compared to 25-G group (-8.0 ± 48.6 μm) at 1 month post-vitrectomy, but not significantly different at 3 and 6 months (P = 0.6059 and 0.1725, respectively). On postoperative day 1, hypotony (≤ 6 mmHg) was observed in 2 eyes in 27-G group and 6 eyes in 25-G group, while ocular hypertension (≥ 25 mmHg) was found in 4 eyes in 27-G group and 11 eyes in 25-G group, with no significant differences between two groups. Postoperative complications requiring treatment occurred in one eye (vitreous hemorrhage) in 27-G group, and in two eyes (vitreous hemorrhage and retinal detachment in one eye each) in 25-G group.

CONCLUSIONS

Although 27-G vitrectomy requires operation time of 4 min longer compared to 25-G vitrectomy for ERM surgery, using the 27-G system results in earlier recovery of visual acuity, CRT improvement and stabilized ocular pressure.

Vitrectomy in high myopia: a narrative review

Pathologic myopia is associated with degenerative changes of the globe, especially at the posterior pole. Eyes affected by pathologic myopia have higher odds to undergo posterior segment surgery and, in those eyes, vitreoretinal surgery is challenging. Many practical tips and tricks can make the surgical procedures simpler, significantly preventing sight-threatening intra- and post-operative complications. Moreover, novel surgical techniques and technological advancements (i.e. ad-hoc instrumentation, minimally invasive vitreoretinal surgery, filters, dye staining, intraoperative optical coherence tomography and 3-dimensional surgery) may play role in highly myopic eyes. The aim of the present work is to review practical tips and tricks, novel surgical techniques and technological advancements.

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.

Evaluation of mechanical closure resistance of sutureless vitrectomy sclerotomies after conjunctival cauterization with bipolar diathermy forceps

BACKGROUND

Suturing is the most widely used technique to close leaking sclerotomies after transconjunctival sutureless vitrectomy (TSV). However, with the aim of avoiding the disadvantages caused by conjunctival stitches, there have been described other closure techniques, such as the cauterization of the conjunctiva placed over the incisions. To continue advancing knowledge of the incisional occlusion effect achieved by conjunctival diathermy, it would be also interesting to study the wound closure resistance obtained under intraocular pressure (IOP) changes, given that in the early postoperative period eyes are subjected to pressure stress. In our study, we compare the mechanical resistance observed in sclerotomies treated with bipolar diathermy after TSV compared to that found in incisions in which cauterization was not performed.

METHODS

This was an experimental, randomized, and observer-masked study in which 23-gauge TSV was performed in 80 cadaveric pig eyes. Once each vitrectomy was finished, cauterization was performed with bipolar diathermy forceps on the conjunctiva placed over one of the superior sclerotomy sites; no maneuver was performed over the other superior incision. IOP was gradually increased by means of the vitrectomy system (Accurus; Alcon Laboratories, TX) until one of the superior sclerotomies opened, allowing internal ocular solution to escape.

RESULTS

In 35 % of cases (28 of 80 eyes), sclerotomies subjected to diathermy allowed intraocular fluid escape first (p = 0.01). When comparing opening pressure values, cauterized incisions leaked at significantly higher pressure levels than those in which diathermy was not applied (p < 0.001).

CONCLUSIONS

Bipolar diathermy on sutureless sclerotomies has demonstrated to be, in our experimental model, an effective method for increasing the sclerotomy closure resistance. Although its use in vitrectomized eyes has previously been described, our study is the first to analyze the response of cauterized sclerotomies to IOP increases.

Influence of silicone oil tamponade on self-sealing sclerotomy using 25-gauge transconjunctival sutureless vitrectomy: a retrospective comparative study

Background

Characteristic complications have been reported for transconjunctival sutureless vitrectomy, such as postoperative sclerotomy leakage and postoperative hypotony. Particular attention to sclerotomy closure is required in cases of silicone oil tamponade, because postoperative supplementation of silicone oil implies reoperation, whereas postoperative supplement of gas is comparatively easy. This study investigated sclerotomy closure in cases of silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy.

Methods

We enrolled 19 consecutive eyes with silicone oil injection (Group A, self-sealing sclerotomies, n = 10) (Group B, sutured sclerotomies, n = 9) and 10 eyes with silicone oil removal (Group C, self-sealing sclerotomies) using 25-gauge TSV. Postoperative intraocular pressure was compared between Groups A and B, and between Groups A and C using repeated-measures analysis of variance (ANOVA), one-way factorial ANOVA, and the Tukey-Kramer test.

Results

No significant differences in age or axial length were seen among groups, but surgical time differed significantly between Group C and the other groups. Mean duration of silicone oil tamponade was 3.2 ± 1.4 months in Group C, and no sclerotomies in Group A or C required suture placement. Postoperative silicone oil leakage to the subconjunctival space was not encountered in Group A. No cases showed postoperative hypotony (defined as intraocular pressure <5 mmHg). Significant differences in intraocular pressure within the same postoperative period were not identified between Groups A and B. Conversely, significant differences in intraocular pressure within the same postoperative period were identified at postoperative days 1 and 2, although not at postoperative week 1 or postoperative month 1 between Groups A and C.

Conclusions

The procedure for sclerotomy closure seems to have little influence on postoperative intraocular pressure in eyes with silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy, because silicone oil tamponade may avoid postoperative hypotony by decreasing sclerotomy leakage in the early postoperative period.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-015-0159-z) contains supplementary material, which is available to authorized users.

Vitreous incarceration after ranibizumab injection: an ultrasound biomicroscopy study

BACKGROUND AND OBJECTIVE

The aim of the study was to evaluate vitreous incarceration at the injection site using ultrasound biomicroscopy (UBM) after intravitreal injection of ranibizumab.

PATIENTS AND METHODS

The study included 39 eyes of 34 patients who underwent intravitreal injection of 0.05 mL of ranibizumab. UBM (HiScan; Optikon, Rome, Italy) with a 50 MHz probe was performed 1 day after surgery to determine the existence of vitreous incarceration at the injection site.

RESULTS

The mean patient age was 59.7 (± 10.1) years, and 58.9% were female. Vitreous incarceration into the pars plana site was detected in six eyes (15.3%) the day after intravitreal injection.

CONCLUSION

Vitreous incarceration at the injection site after intravitreal injection is thought to lead to a higher risk for complications such as infection, retinal breaks, retinal detachment, vitreous hemorrhage, and fibrovascular proliferation at the injection site. To understand the clinical importance of vitreous incarceration, further long-term prospective studies are necessary.

Evaluation of Wound Morphology of Sclerotomy Sites of Sutureless Vitrectomy Using Spectralis Anterior Segment Optical Coherence Tomography

PURPOSE

The aim of the study was to evaluate wound morphology in vivo in eyes undergoing sutureless vitrectomy.

DESIGN

This was a prospective consecutive case series.

METHODS

Twenty eyes undergoing sutureless vitrectomy were evaluated using anterior segment optical coherence tomography on days 1, 15, and 30. Ten eyes each belonged to 23-gauge (group A) and 25-gauge (group B). Scans were taken on the incision sites. Group A cases were further divided into group A1 and A2 on the basis of the surgical time of less than 15 minutes' and more than 15 minutes' duration, respectively.

RESULTS

On day 1, the mean outer and inner incision diameters in group A were 236.6 and 146 µm, and those for group B were 118.6 and 90 µm. A significant decrease (P < 0.0001) in both the port sizes was observed in both groups' follow-up. Group B showed significant decrease (P < 0.0001) in the port sizes on l follow-up as compared with group A. Group A1 had smaller incision size as compared with group A2 on the first postoperative day, although not statistically significant(P > 0.05).

CONCLUSIONS

In both groups, the sclerotomy incisions showed good healing at 1-month duration. The 25-gauge sclerotomies showed better healing characteristics of wound morphology as compared with the 23-gauge sclerotomies.

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.

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.

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.

Evaluation of conjunctival bleb detection after vitrectomy by ultrasound biomicroscopy, optical coherence tomography and direct visualization

PURPOSE

To compare ultrasound biomicroscopy (UBM), anterior-segment optical coherence tomography (AS-OCT), and direct visualization for detecting conjunctival blebs in sutureless sclerotomies after vitrectomy. Conjunctival blebs are formed by sclerotomy leakage due to incompetent closure.

METHODS

Experimental, randomized, and observer-masked study in which 23-gauge vitrectomies were performed in cadaveric pig eyes. Postoperative conjunctival blebs were assessed by UBM, AS-OCT, and direct visualization. No conjunctival blebs were classified as Grade 0 (G0), thin blebs (less than or equal to one-half of scleral thickness) as Grade 1 (G1) and thick blebs (greater than one-half of scleral thickness) as Grade 2 (G2).

RESULTS

Fifty pig eyes were included. Conjunctival blebs were found in 13.3% (8% G1, 5.3% G2) of the incisions analyzed by UBM, in 20% (14.7% G1, 5.3% G2) of the sclerotomies studied by AS-OCT, and in 7.3% (2% G1, 5.3% G2) of the wounds evaluated by direct visualization. AS-OCT was the most sensitive method for identifying conjunctival blebs when compared with UBM and direct visualization (p<0.001). In turn, UBM was better than direct visualization for observing sclerotomy blebs (p=0.004).

CONCLUSIONS

AS-OCT is the most sensitive technique for detecting subclinical blebs (G1) and thus, it may be useful in research for studying the influence that surgical factors and maneuvers may exert on sclerotomy closure capacity after vitrectomy. Direct visualization, that is used in routine clinical practice to determine which sclerotomies should be sutured, is useful only to identify thick blebs (G2) after vitrectomy.

Reduction of vitreous contamination rate after 25-gauge vitrectomy by surface irrigation with 0.25% povidone-iodine

PURPOSE

To examine whether repeated ocular surface irrigation with 0.25% povidone-iodine, which is highly bactericidal and nonoculotoxic, reduces bacterial contamination of the vitreous during 25-gauge vitrectomy.

METHODS

Overall, 4,407 eyes undergoing 25-gauge vitrectomy were studied; of these, 2,801 were irrigated with infusion fluid (group A) and 1,606 with 0.25% povidone-iodine (group B). In each group (A and B), 103 eyes were studied bacteriologically, using ocular surface fluid samples after placing lid speculum (S1), after operative field irrigation (S2), and in vitreous samples at the beginning (V1) and at the completion of vitrectomy (V2).

RESULTS

Bacterial contamination rate in S1 did not differ significantly between the groups A (5.5%) and B (6.8%). However, the contamination rates in S2, V1, and V2 were apparently lower in group B (0%, 0%, and 0%, respectively) than in group A (2.0%, 1.0%, and 2.0%, respectively). Incidence of endophthalmitis was 0 of 2,801 eyes in group A and 0 of 1,606 eyes in group B.

CONCLUSION

In 25-gauge vitrectomy, repeated operative field irrigation with 0.25% povidone-iodine reduced bacterial contamination in vitreous to extremely low level.

Healing of conjunctival wounds after 23-gauge sutureless vitrectomy

PURPOSE

To evaluate the healing course of conjunctival wounds in eyes undergoing 23-gauge sutureless vitrectomy and to determine when the potential for ocular surface fluid contamination is no longer a serious concern.

METHODS

Prospective observational case series. Thirty-four eyes from 34 patients that underwent transconjunctival 23-gauge sutureless vitrectomies were included. A total of 102 conjunctival wounds overlaying the sutureless sclerotomies from 34 eyes were evaluated prospectively by slit-lamp biomicroscopic examination using cobalt blue light with fluorescein dye staining. The configuration and size of the conjunctival wounds were measured with fluorescein dye staining postoperatively on Days 1, 4, 8, and 15.

RESULTS

Seventy-five conjunctival wounds (73.5%) had not healed completely 4 days after the operation. Eight days after surgery, the proportion of eyes with fluorescein staining at the conjunctival wound decreased to 13.7%. Fifteen days after surgery, there was no fluorescein staining at the conjunctival wound in any case. Combined cataract extraction was a factor that delayed the healing of the conjunctival wound (P = 0.036).

CONCLUSION

The results suggest that, regarding conjunctival integrity, patients should be safe from intraocular contamination 15 days after 23-gauge sutureless vitrectomy. Concomitant cataract extraction might lengthen the conjunctival wound healing process in these eyes.

Comparing the effects of three different intravitreal injection techniques on vitreous reflux and intraocular pressure

PURPOSE

To compare the effects of straight, oblique, and double-plane tunnel scleral intravitreal injection techniques, on short-term intraocular pressure (IOP) changes, occurrence of vitreous reflux (VR), and/or other complications.

METHODS

A total of 105 patients were included in this prospective study. Patients were assigned randomly to one of the straight injection group (SI; n=35), oblique injection group (OI; n=35), or double-plane tunnel injection group (DPTI; n=35). The occurrence of VR and preinjection and postinjection IOP at 2 and 6 h were compared between groups, and complications were assessed.

RESULTS

The mean patient age was 71.1±6.6 years (range 58 to 86 years; 50 women and 55 men). In the SI, OI, and DPTI groups, VR occurred in 18 (51.4%), 12 (34.3%), and 6 patients (17.1%), respectively. Mean preinjection IOPs were 15.4, 14.8, and 15.6 mmHg, and changed to 17.3, 18.0, and 20.0 mmHg at the second hour, and 15.7, 16.2, and 16.1 mmHg at the sixth hour, respectively. No significant differences among the groups were found in terms of complications such as transient mild uveitis or subconjunctival hemorrhage.

CONCLUSION

Double-plane tunnel injection prevents VR from the injection site and has no additional complications than other techniques.

Transconjunctival sutureless vitrectomy versus 20-gauge vitrectomy for vitreoretinal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Transconjunctival sutureless vitrectomy is appealing to vitreoretinal surgeons around the world. However, its use versus 20-gauge vitreoretinal surgery is still controversial. The aim of this meta-analysis was to compare the safety and functional outcomes of transconjunctival sutureless vitrectomy versus 20-gauge vitrectomy for vitreoretinal surgery.

METHODS

Data sources, including PubMed, Medline, EMBASE, and Cochrane Controlled Trials Register, were searched to identify potentially relevant randomized controlled trials. A meta-analysis was performed using RevMan 5.0 software. The primary factors included patients' discomfort, operating time and early postoperative complications. Visual acuity and surgically induced astigmatism were chosen as secondary outcomes.

RESULTS

A total of 471 participants with 479 eyes in eight trials between 2005 and 2011 were analyzed. Transconjunctival sutureless vitrectomy was associated with significantly fewer patients suffering from postoperative discomfort at 1 day (odds ratio [OR] 0.07; 95 % confidence interval [CI] 0.01 to 0.49; p = 0.007) and 7 days (OR 0.14; 95 % CI 0.03 to 0.73; p = 0.02) follow-up, and was more effective in reducing surgically induced astigmatism (mean difference -0.23D; 95 % CI -0.31 to -0.15; p < 0.00001) compared to 20-gauge vitrectomy. The sutureless group achieved shorter wound opening (mean difference -1.97 minutes; 95 % CI -2.69 to -1.25; p < 0.00001) as well as wound closure time (mean difference -4.55 minutes; 95 % CI -5.43 to -3.66; p < 0.00001), but the overall surgery time was comparable (mean difference -0.14 minutes; 95 % CI -3.52 to 3.24; p = 0.93). There were no significant differences in the complication rates between the two groups with the exception of postoperative hypotony, which was more likely with the sutureless group (OR 3.73; 95 % CI 1.43 to 9.76; p = 0.007).

CONCLUSIONS

According to the present data, transconjunctival sutureless vitrectomy offered significantly less postoperative discomfort and decreased surgically induced astigmatism without increasing the risk of vision-threatening complications. Further trials with contemporary equipment and larger sample size are suggested to confirm this conclusion.

Early postoperative hypotony and ciliochoroidal detachment after microincision vitrectomy surgery

PURPOSE

To determine the relationship between a ciliochoroidal detachment and intraocular pressure (IOP) after microincision vitrectomy surgery (MIVS).

DESIGN

Prospective, consecutive, observational case series.

METHODS

Thirty eyes of 30 patients with an epiretinal membrane that underwent MIVS were prospectively studied. The intraocular pressure (IOP) was measured before 3-port MIVS, and at 1 minute, 1 and 3 hours, and at 1 day postoperatively. All of the 90 sclerotomies were examined by swept source optical coherence tomography to assess the wound and presence of a ciliochoroidal detachment at 3 hours and at 1 day postoperatively. The mean IOP and closure rate of the sclerotomies were compared between eyes with and without a ciliochoroidal detachment. The correlation between the presence of ciliochoroidal detachment and postoperative IOP was determined.

RESULTS

The incidence of ciliochoroidal detachment was 63.3% (19 eyes) during the 1-day observation period. The mean postoperative IOPs were significantly lower than the preoperative IOPs in eyes with a ciliochoroidal detachment (P < .05). The mean postoperative IOPs were significantly higher in eyes without a ciliochoroidal detachment than in eyes with a ciliochoroidal detachment (P < .05). The incidence of open sclerotomies was significantly higher in eyes with a ciliochoroidal detachment than in eyes without a ciliochoroidal detachment at 3 hours postoperatively (P = .03).

CONCLUSIONS

A shallow ciliochoroidal detachment develops in 63.3% of eyes after MIVS. Hypotony at the early postoperative period may be a risk factor for a ciliochoroidal detachment.

Ultrasound biomicroscopy study of vitreous incarceration subsequent to intravitreal injections

OBJECTIVE

To study the existence of vitreous incarceration by ultrasound biomicroscopy (UBM) at the pars plana after direct intravitreal injection of triamcinolone acetonide ± bevacizumab without anterior chamber paracentesis.

DESIGN

Interventional case series.

PARTICIPANTS

Patients undergoing intravitreal injection of triamcinolone acetonide with or without intravitreal bevacizumab.

METHODS

In 21 eyes, the existence of vitreous incarceration at the pars plana site of intravitreal injection of 0.05 mL of drug was studied by UBM (50 MHz probe of the VUmax, Sonomed, NY), the day after surgery, by 1 technician. The reason for injection was diabetic retinopathy in 12 (57.1%) eyes; age-related macular degeneration in 6 (28.6%) eyes; branch retinal vein occlusion in 2 (9.5%) eyes; and choroiditis in 1 eye (4.8%). In 1 eye, only triamcinolone acetonide was injected, and in the other eyes, bevacizumab mixed with triamcinolone acetonide was injected.

RESULTS

We studied 21 eyes in 13 patients. Of the subjects, 61.5% were male. The mean age of the patients was 62.2 years. On the day after intravitreal injection of the drug, vitreous incarceration into the pars plana site was detected by UBM in 42.9% of the eyes.

CONCLUSION

Vitreous incarceration exists after intravitreal injection of drug, but its clinical importance is still unknown. Further long-term prospective studies are recommended.

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.

Optic Disc Pit Maculopathy: The Value of Small-Gauge Vitrectomy, Peeling, Laser Treatment, and Gas Tamponade

Purpose

To report the outcome of 10 patients with optic pit maculopathy (OPM) and evaluate the role of small-gauge vitrectomy, gas endotamponade, and additional laser photocoagulation treatment.

Methods

We retrospectively investigated 10 patients who underwent small-gauge, sutureless vitrectomy for OPM, detachment of the posterior hyaloid, internal limiting membrane (ILM) peeling, endolaser photocoagulation on the temporal margin of the optic disc, and gas tamponade. Preoperative and postoperative best-corrected visual acuity (BCVA) was recorded and optical coherence tomography (OCT) imaging was performed.

Results

Seven out of 10 patients gained at least 2 lines of vision; 2 patients gained 1 line of vision. Visual improvement occurred more than 3 months after surgery. One myopic patient developed a macular hole postoperatively, resulting in a poor functional result even though complete retinal attachment was achieved. The functional outcome did not always correlate well with the OCT imaging, in which complete retinal reattachment was observed in 5 out of 10 eyes.

Conclusions

The therapeutic approach should include both small-gauge vitrectomy and ILM peeling to relieve vitreoretinal traction, as well as laser photocoagulation of the temporal margin of the optic disc in order to prevent vitreous fluid from entering the subretinal/intraretinal space. In addition, the patients should be told that visual recovery can take a long time.

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.

Multicenter survey with a systematic overview of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery

PURPOSE

To explore the incidence and visual outcomes of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery (MIVS).

DESIGN

Retrospective, interventional, multicenter survey with a systematic review.

METHODS

A clinical database search was performed at 27 institutions involving 43 868 consecutive patients who underwent vitrectomy between November 2003 and October 2008 to identify all patients with endophthalmitis after vitrectomy. A systematic review of studies reporting the endophthalmitis rates after MIVS versus 20-gauge vitrectomy was conducted to assess the pooled incidence rates of postvitrectomy endophthalmitis.

RESULTS

The endophthalmitis rates from the multicenter survey were 0.034% (10 cases per 29 030 eyes) after 20-gauge vitrectomy and 0.054% (8 cases per 14 838 eyes) after MIVS, with no significant (P = .603) differences between groups. Although the incidence in 25-gauge cases (6 per 8238 eyes; 0.073%) was greater than in 23-gauge cases (2 per 6600 eyes; 0.030%), the difference was not significant (P = 0.451). Of 8 eyes in which endophthalmitis developed after MIVS, 6 eyes (75%) had a final visual acuity of 0.5 or better, and none lost light perception. By combining the results of 7 studies, including the current multicenter survey, meta-analyses from a total of 77 956 cases at the baseline showed that the pooled endophthalmitis rates after MIVS (0.08%; 95% confidence interval, 0.030% to 0.164%) and after 20-gauge vitrectomy (0.030%; 95% confidence interval, 0.012% to 0.048%) did not differ significantly (P = .207, pooled risk difference; 0.0005 [95% confidence interval, -0.0002 to 0.0012]).

CONCLUSIONS

The incidence of postvitrectomy endophthalmitis was low with no significant differences between MIVS and 20-gauge vitrectomy.

Effect of operative field irrigation on intraoperative bacterial contamination and postoperative endophthalmitis rates in 25-gauge vitrectomy

PURPOSE

The purpose of this study was to compare bacterial contamination and endophthalmitis rates with different irrigation methods in 25-gauge vitrectomy.

METHODS

A total of 4,347 eyes undergoing 25-gauge vitrectomy were studied prospectively. Of these, 2,801 eyes were irrigated with infusion fluid (group A) and 1,546 with 1.25% povidone-iodine (group B) after lid speculum placement. Bacteriologic culture was performed for 103 eyes in group A and 155 eyes in group B using the following samples: ocular surface fluid after placement of the lid speculum (left eye 1), ocular surface fluid after operative field irrigation (left eye 2), vitreous collected after angled incision made while some irrigation fluid remains in the conjunctival sac (V1), and vitreous at the completion of vitrectomy (V2).

RESULTS

The bacterial contamination rate in left eye 1 did not differ significantly between groups A (5.5%) and B (5.8%). However, the rates in left eye 2, V1, and V2 were lower in group B (0%, 0%, and 0.6%, respectively) than in group A (2.0%, 1.0%, and 2.0%). Incidences of endophthalmitis were 0 of 2,801 eyes and 0 of 1,546 eyes in groups A and B, respectively.

CONCLUSION

After lid speculum placement, ocular surface contamination occurred in approximately 6% of eyes. Irrigating the operative field again with 1.25% povidone-iodine and performing sclerotomy with some povidone-iodine remaining in the conjunctival sac prevented bacterial contamination of the vitreous.

Three-step incision for 23-gauge vitrectomy reduces postoperative hypotony compared with an oblique incision

BACKGROUND AND OBJECTIVE

to assess the efficacy and safety of the newly developed three-step incision method of performing 23-gauge vitrectomy.

PATIENTS AND METHODS

a retrospective comparative study in which a consecutive series of 45 eyes that underwent the three-step incision type of 23-gauge vitrectomy was compared with a series of 27 consecutive eyes that had previously undergone the oblique incision type of 23-gauge vitrectomy.

RESULTS

no cases of postoperative hypotony (< 6 mm Hg) were noted in the three-step group compared with 3 cases (11%) in the oblique group (P = .05). The three-step incision resulted in a significantly higher mean intraocular pressure than the conventional incision on postoperative day 1 (14.1 ± 6.7 mm Hg vs 10.9 ± 3.7 mm Hg; P = .05), but there was no significant difference after 1 week.

CONCLUSION

the three-step incision for performing 23-gauge vitrectomy effectively prevented postoperative hypotony and demonstrated a safety profile comparable to that of the oblique incision.

Incidence of retinal detachment after small-incision, sutureless pars plana vitrectomy compared with conventional 20-gauge vitrectomy in macular hole and epiretinal membrane surgery

PURPOSE

The purpose of this study was to evaluate the incidence of retinal detachment (RD) after a small-incision, sutureless vitrectomy compared with conventional 20-gauge vitrectomy in macular hole and epiretinal membrane surgery and to investigate the clinical features and possible causative agents.

METHODS

The authors performed a computerized database analysis to retrospectively identify all patients who underwent vitrectomy at our institution between March 2001 and March 2009 for epiretinal membrane and macular hole. The authors further investigated the clinical features of patients who showed RD within 6 months postoperatively in the study eye. The incidence rate and clinical features of the affected eyes were analyzed.

RESULTS

During the study period, 2,432 vitrectomies were performed for epiretinal membrane and macular hole. The incidence of RD was 1.7% (31 of 1,862) after sutureless 25- or 23-gauge vitrectomy and 1.2% (7 of 570) after conventional 20-gauge vitrectomy. The difference was not statistically significant. Moreover, the difference between 25-gauge surgery (28 of 1,580) and 23-gauge surgery (3 of 282) was not statistically significant. In 9 of 38 cases (24%), the RD was probably attributable to the underlying pathology (e.g., an unclosed macular hole and reopening of preexisting retinal tears). Twenty-one eyes (76%) presented new retinal tears that were not related to the sclerotomies in both groups.

CONCLUSION

The incidence of RD after macular surgery is not increased in small-gauge, sutureless vitrectomy compared with the standard 20-gauge procedure. In most cases, the RD is not caused by the surgical technique itself but caused by new retinal breaks.

Retinal detachment after small-incision, sutureless pars plana vitrectomy: possible causative agents

BACKGROUND AND PURPOSE

To identify possible agents causing retinal detachment following small-incision, sutureless vitrectomy.

METHODS

Computer-based, retrospective analysis to identify all patients who had undergone small-incision sutureless vitrectomy and presented retinal detachment (RD) in the study eye within 6 months postoperatively. The clinical charts of these patients were reviewed.

RESULTS

The investigation involved 2,598 small-incision, sutureless vitrectomies. Thirty-seven eyes presented subsequent RD. Indications for sutureless vitrectomy were idiopathic epiretinal membrane (n = 15), idiopathic macular hole (n = 15), recurrent macular hole (n = 1), rhegmatogenous retinal detachment (n = 5) and vitreous haemorrhage due to proliferative diabetic retinopathy (PDR) (n = 1). The median time between sutureless vitrectomy and RD presentation was 51 days (range 11-173 days); mean 59 days (SD 46.5). In 14 eyes (38%), the RD was most likely due to the underlying pathology (e.g., unclosed macular hole, reopening of pre-existing retinal tears, worsening of PDR). Twenty-three eyes (62%) presented with new retinal tears that were not in the proximity of the sclerotomies.

CONCLUSION

In most cases, the RD was not caused by the sutureless technique itself, but was most likely due to the underlying pathology, or due to new retinal tears that were not in the proximity of the sclerotomies.

Outcomes and complications of rhegmatogenous retinal detachment repair with selective sutureless 25-gauge pars plana vitrectomy

PURPOSE

To evaluate the outcomes and complications associated with the repair of rhegmatogenous retinal detachment (RRD) using 25-gauge pars plana vitrectomy (PPV) with selective sclerotomy suturing.

DESIGN

Retrospective case series.

METHODS

Analysis of consecutive 25-gauge pars plana vitrectomy cases performed for treating RRD was conducted. Reviewed parameters included demographics, ophthalmic history, results of ocular examinations, and intraoperative as well as postoperative complications. Analysis of the surgery digital video disc recordings revealed complications such as iatrogenic retinal breaks and retinal or subretinal tugging by the soft-tip cannula.

RESULTS

Forty-two eyes with RRD were evaluated with a follow-up of at least 3 months. The preoperative best-corrected visual acuity (BCVA) of 20 eyes with macula-on RRD ranged between 20/20 and 20/40 (mean, 20/30). Twenty-two eyes with macula-off RRD had preoperative BCVA ranging between 20/70 and hand movements (mean, 20/400). The single-surgery success rate was 97.4%. The final BCVA of the macula-on eyes ranged between 20/20 and 20/40 (mean, 20/30). In the eyes with macula-off RRD, the postoperative BCVA ranged between 20/30 and 20/400 (mean, 20/73). Sutures were placed on at least 1 scleral wound because of intraoperative gas leakage in 36.4% of the eyes. On the first postoperative day, all the eyes receiving gas tamponade had a 100% fill. None of the eyes in the study had postoperative hypotony, ciliochoroidal effusion, or choroidal hemorrhage. No cases of postoperative subconjunctival gas or oil leakage were noted.

CONCLUSIONS

Modification of the standard 25-gauge sutureless technique with selective scleral wound suturing may contribute to preventing wound leakage and possible postoperative complications of hypotony or partial tamponade.

Ultrasound biomicroscopic findings of conventional and sutureless sclerotomy sites after 20-, 23-, and 25-G pars plana vitrectomy

PURPOSE

We examined sclerotomies that were performed using 20-G systems and non-stitch 23-G systems, one-step (23/1) and two-step procedures (23/2), as well as one-step 25-G systems for pars plana vitrectomy (PPV) with ultrasound biomicroscopy (UBM) to assess subconjunctival bleb formation, vitreous incarceration, and wound closure.

METHODS

This study is a prospective, non-randomized, monocentre study comprising 40 patients; we examined sclerotomies using UBM after 20-G, 23/1-G, 23/2-G, and 25-G PPV in 10 patients each on days 1 and 30 postoperatively.

RESULTS

Subconjunctival bleb formation was not detected in any of the eyes on the first day after surgery in the 20-G and 23/2-G groups and was observed in 5 (50%, 25 G) and 2 eyes (20%, 23/1 G). By day 30 postoperatively, all blebs had spontaneously resolved. The sclerotomy tunnel could be detected by UBM at day 1 postoperatively in 10 (100%, 20 G), 9 (90%, 25 G), 7 (70%, 23/1 G), and 7 eyes (70%, 23/2 G). Thirty days postoperatively, it was present in 10 (100%, 20 G), 1 (10%, 25 G), 3 (30%, 23/1 G), and 1 (10%, 23/2 G) eye. Vitreous incarceration occurred in 2 (20%, 20 G), 7 (70%, 25 G), 4 (40%, 23/1 G), and 2 (20%, 23/2 G) eyes.

CONCLUSIONS

Anatomical closure of sclerotomies without subconjunctival bleb formation as seen on UBM was achieved at day 1 after 23/2-G and 20-G PPV and after 30 days postoperatively in all other non-stitch PPV techniques. Vitreous incarceration is common after 25-G PPV. Non-stitch sclerotomies can frequently no longer be detected by UBM 30 days postoperatively.

Comparison of internal anterior chamber diameter measured with ultrabiomicroscopy with white-to-white distance measured using digital photography in aphakic eyes

PURPOSE

Measuring the anterior chamber diameter (AC) is important both for diagnostics and before ocular surgery. In clinical practice, horizontal AC diameter is usually estimated on the basis of measurements of corneal diameter (so-called white-to-white [WTW] distance). The usual method for selecting an appropriate size for an AC lens is to add 1 mm to WTW measurement. The purpose of this study was to compare AC diameter measured using ultrasound biomicroscopy (UBM) with WTW distance measured using digital photography in aphakic eyes.

METHODS

The data were gathered prospectively from a nonrandomized consecutive series of aphakic patients. The examined group consisted of 23 eyes of 23 adult patients, mean age 71.17 years. WTW diameter was measured in the 3 o'clock and 9 o'clock meridian on a digital photograph. Internal horizontal AC diameter measurements were performed in the 3 o'clock and 9 o'clock meridian with the Sonomed Ultrabiomicroscopy device with a 50-MHz probe.

RESULTS

Mean horizontal WTW diameter measured using digital photographs was 11.65+/-0.38 mm and mean horizontal internal AC diameter measured using UBM was 13.53+/-0.83 mm. A significant difference in mean WTW diameter measured using digital photography and UBM was found (Mann-Whitney U test, p<0.05). There was a significant correlation between these values (Spearman=0.70, p<0.001).

CONCLUSIONS

In order to obtain good and precise measurements of internal AC diameter, a method of direct visualization of the intraocular structures should be used. Despite the limits of a small case series, our results support the use of UBM technique for preoperative evaluation of the internal AC diameter and AC intraocular lens sizing in aphakic eyes.

A 27-gauge instrument system for transconjunctival sutureless microincision vitrectomy surgery

OBJECTIVES

To evaluate the efficiency, preliminary safety, and feasibility of a 27-gauge instrument system for transconjunctival microincision vitrectomy surgery (MIVS) in a variety of vitreoretinal diseases.

DESIGN

Experimental, interventional case series.

PARTICIPANTS

Thirty-one eyes (31 patients) underwent a variety of vitreoretinal procedures using the 27-gauge transconjunctival MIVS system to treat epiretinal membrane (n = 10), idiopathic macular holes (n = 7), diabetic vitreous hemorrhage (n = 5), vitreous opacity with suspicion of intraocular lymphoma (n = 4), focal diabetic traction retinal detachment (n = 3), macular traction syndrome (n = 1), and macular edema secondary to central retinal vein occlusion (n = 1).

METHODS

We developed a 27-gauge instrument system that includes an infusion line, a high-speed vitreous cutter, an illumination system, and a variety of vitreoretinal instruments, such as membrane forceps and sharp-tipped endophotocoagulation probes. The duty cycle of the 27- and 25-gauge cutters was measured for several cut rates using a high-speed imaging camera. Infusion and aspiration rates were measured using balanced saline solution (BSS) and porcine vitreous with different aspiration levels. Surgical outcomes, including anatomic success, visual outcomes, operating times, and intraoperative and postoperative complications, were evaluated.

MAIN OUTCOME MEASURES

Duty cycle of cutters, infusion and aspiration rates, and surgical results of 27-gauge vitrectomy.

RESULTS

Although the infusion and aspiration rates of the 27-gauge system measured in BSS were reduced to an average of 62% and 80%, respectively, compared with those of the 25-gauge system, the duty cycle of the 27-gauge cutter, 61% at 1000 cpm and 38% at 1500 cpm, was equal to or better than those of the 25-gauge cutter (62% and 28%, respectively). Analysis of the fluid dynamics showed that vented gas-forced infusion can be set to range from 20 to 30 mmHg to control intraocular pressure (IOP) during 27-gauge vitrectomy. Anatomic success was achieved in all study eyes (100%); 20 eyes (65%) had visual improvement of 3 lines or more. No eyes required conversion to larger gauge instrument. All sclerotomies self-sealed without hypotony (IOP < or = 7 mmHg) from 1 day postoperatively.

CONCLUSIONS

Although the fluid dynamics and cutting efficiency of 27-gauge instruments are lower compared with 25-gauge MIVS, the 27-gauge system is feasible and may reduce concerns about wound sealing-related complications in selected cases.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.