Retinal breaks in small-gauge pars plana vitrectomy

Factors affecting anatomical and visual outcomes in Terson syndrome managed by surgery or observation

OBJECTIVES

To investigate visual outcomes and prognostic factors of patients with Terson syndrome (TS) managed with observation or pars plana vitrectomy (PPV).

METHODS

retrospective review of medical records of 117 eyes from 81 patients (43 females) with TS. Main outcome measures were final best corrected visual acuity (BCVA), intraoperative findings and long-term sequelae.

RESULTS

46 (39.3%) eyes were managed conservatively and 71 (60.7%) eyes underwent PPV. Median follow-up was 8.4 months. The PPV group had significantly worse (p < 0.001) baseline BCVA (median 2.3 versus 0.7 logMAR, Snellen equivalent 20/4000 versus 20/100). Final BCVA did not differ between the two groups (p = 0.38). Final BCVA ≥ 0.3 logMAR (20/40) in the surgery group was associated with post-operative retinal detachment (p = 0.013) and macular abnormalities (p = 0.014), and in the observation group with ocular comorbidity (p = 0.008). Retinal breaks were detected intraoperatively in 25 (35.2%) eyes and were associated with an interval longer than 3 months between ocular diagnosis and surgery (p = 0.04), but not with larger gauge instrumentation and posterior vitreous detachment. Incidence of ERM did not differ among patients managed conservatively and after PPV (p = 0.9) and between eyes undergoing early or delayed surgery (p = 0.09). The most common post-operative complications were cataract in 16 (22.5%) eyes and ERM in 8 (11.3%) eyes.

CONCLUSIONS

visual outcomes in TS are similar with both management strategies. Surgery allows faster and greater visual recovery but carries high risk of intraoperative retinal tears if delayed for longer than 3 months from initial presentation. ERM and retinal detachment are not correlated with timing of surgery or management strategy.

Inverse drainage Nd:YAG membranotomy for pre-macular hemorrhage

AIM

To report the outcomes of the "inverse drainage Nd:YAG laser membranotomy" technique for the management of pre-macular hemorrhage (PMH), which has its inferior margin near the fovea.

METHODS

This retrospective study included eyes with PMH, with its inferior margin located within 0.5 disc-diameter (DD) of the fovea. Laser membranotomy was performed near the superior margin of PMH followed by intravitreal injection of 0.3 mL undiluted sulphur hexafluoride (SF6) gas. The patients were advised to maintain a prone position for three days.

RESULTS

Twenty patients (20 eyes) with a mean age of 46.1 ± 18.6 years were included in the study. The mean duration of symptoms was 6.9 ± 7.0 days. The mean size of PMH was 4.1 ± 1.2DD. The causes of PMH were Valsalva retinopathy (n = 11) and retinal artery macroaneurysm (RAM, n = 9). The mean maximum height of the blood collection, measured by optical coherence tomography (OCT), within 1 disc-diameter from the inferior and superior borders of the PMH was 738.9 ± 232.9μm and 1240.6 ± 338.1μm respectively (p = 0.001). The mean best-corrected visual acuity (BCVA) improved from logMAR 1.32 ± 0.44 (Snellen equivalent, 20/418) to logMAR 0.11 ± 0.20 (Snellen equivalent, 20/26) (p = 0.001). Vitrectomy was not required in any case. Persistent pre-macular cavity, macular hole, epiretinal membrane (ERM), intra-ocular pressure spike, or rhegmatogenous retinal detachment (RRD) was not noted in any patient.

CONCLUSION

This technique can be safely used to treat eyes with PMH having its inferior margin near the fovea.

Intra- and post-operative risk of retinal breaks during vitrectomy for macular hole and vitreomacular traction

Background/Objective

To evaluate the development of intra- and post-operative retinal breaks after pars plana vitrectomy (PPV) for macular hole (MH) and/or vitreomacular traction (VMT).

Subjects/Methods

Medical records of patients who underwent PPV at Kellogg Eye Center between 1/1/2005–6/30/2018, were evaluated in three groups: group 1, MH/VMT (n = 136); group 2, epiretinal membrane (ERM) without VMT (n = 270); and group 3, diagnostic vitrectomy (DV) or vitreous opacities (n = 35). Statistical analyses were conducted using SAS.

Results

20.6% of patients with MH/VMT, 8.5% of patients with ERM, and 5.7% of patients with DV or vitreous opacities had either intra-operative or post-operative breaks. Indication of MH/VMT versus ERM was a significant predictor for this outcome (p = .0112). The incidence of retinal breaks was higher in operations using 23-gauge versus 25-gauge PPV (25.0% vs. 7.4%, p < .0001).

Conclusions

The presence of MH and/or VMT is a significant risk factor for retinal breaks from PPV, as is use of 23-gauge vitrectomy.

To Treat or Not to Treat: Management Options for Symptomatic Vitreous Floaters

Vitreous floaters are a common cause for presentation to ophthalmologists, and may significantly affect visual function. In the absence of some more serious underlying pathology such as uveitis, many patients may not experience significant persistent visual impairment from floaters. For some patients, the symptomatic effects of floaters may persist. For these patients, treatment options are available, of which the most commonly reported is vitrectomy. Other treatment modalities have also become more common, notably YAG vitreolysis. Selection of appropriate patients for surgery is often difficult, in part due to the relative lack of objective outcomes with which to measure both visual impairment and improvement post-procedure. Although well-tolerated, vitrectomy does carry with it risks, including iatrogenic retinal breaks, retinal detachment, and in phakic patients, subsequent cataract formation. Techniques such as small gauge vitrectomy, intraoperative examination and treatment of breaks or other worrying lesions, and careful consideration of the need for posterior vitreous detachment induction may help limit the incidence of these adverse events. For other treatment options such as YAG vitreolysis, research and clinical experience remain more limited, and as such the long-term efficacy and risks of these therapies are still unclear. Here, we review the evidence surrounding the role of vitrectomy and YAG vitreolysis in the treatment of vitreous floaters and potential means to minimize therapeutic complications.

International multi-center study of iatrogenic retinal tears in pars plana vitrectomy

AIM

To study and compare the effect of different surgical settings on the development of iatrogenic retinal tears (IRT) in conventional (20-gauge) and microincisional vitrectomy.

METHODS

An international retrospective comparative study of 394 patients who had simple vitrectomy at three tertiary centers. Surgeries were performed by four retina surgeons using different viewing systems. Two groups of eyes were compared: microincisional vitrectomy (327 eyes) and conventional (67 eyes) vitrectomy. An iatrogenic tear was defined as the occurrence of one or more peripheral retinal tears during surgery or at any visit in the first 6wk postoperatively.

RESULTS

Mean age was 67±12y and 55% were female. Iatrogenic tears occurred in 11/394 (2.8%) of eyes. The rate of tears was similar among different surgeons and viewing systems (P=0.93 and P=0.76, respectively). Surgical indication, preexisting pseudophakia/aphakia, induction of posterior vitreous detachment (PVD) during surgery, and the use triamcinolone acetonide didn't significantly affect the rate of tears (P>0.1 for all factors). A higher rate of tears was found in the conventional group compared to the microincisional group (respectively, 7.5%, 1.8%, P=0.02).

CONCLUSION

The rate of IRT in vitrectomy is not significantly affected by surgical indication, preexisting PVD or pseudophakia, or use of triamcinolone or different viewing systems but is significantly higher in conventional vitrectomy. Microincisional platforms improve the safety of vitrectomy regardless of the viewing system used.

Vitreous Biopsy Under Air: Technique, Complications, and Volume Outcomes

BACKGROUND AND OBJECTIVE

Classic vitreous biopsy, which targets the vitreous with an undiluted sample of 1 mL to 2 mL, has been used as a diagnostic analysis. Vitrectomy under air infusions have been reported to be able to extract more vitreous sample. In this study, the authors introduce a way of obtaining vitreous sample under air irrigation using 23-gauge vitrectomy and discuss the benefits and potential risks of this procedure.

PATIENTS AND METHODS

In this retrospective case series study, a total of 65 eyes of 65 patients with macular epiretinal membrane (ERM) or macular hole (MH) were enrolled. A vitreous biopsy was carried out with air infusion. Vitrectomy with fluid infusion was then carried out to remove the residual vitreous. Medical records of patients with macular ERM or MH were reviewed and analyzed. Clinical data, including age, sex, best-corrected visual acuity (BCVA), optical coherence tomography (OCT), axial length, presence of posterior vitreous detachment (PVD), presence of liquefication of vitreous, and refraction, were recorded and investigated. The volume of vitreous sample, visual outcome, and complications related to vitreous biopsy at 1-month follow-up were recorded and analyzed.

RESULTS

The mean of undiluted vitreous sample volume was 2.1 mL ± 0.2 mL. There were seven patients whose vitreous samples were less than 2 mL during the vitreous biopsy. The mean age of patients was 62.9 years ± 8.4 years (range: 35 years to 85 years) at diagnosis. There were 18 male and 47 female patients. At 1-month follow-up, no patient had decreased visual acuity. There was one patient who had a peripheral retinal break and was treated with photocoagulation during the operation (1.5%). The insufficient vitreous sample that may occur during the vitreous biopsy under air infusion was related to liquefication of vitreous (28.8%).

CONCLUSION

In summary, vitreous biopsy with air infusion is a safe and effective maneuver to harvest undiluted vitreous in patients without significant vitreous inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:365-370.].

Modified Vitrectomy Technique for Phakic Rhegmatogenous Retinal Detachment with Intermediate Break

Purpose

To evaluate the effects of a modification of the traditional 25-gauge pars plana vitrectomy technique in the treatment of uncomplicated macula-on rhegmatogenous retinal detachment (RRD) with intermediate retinal break(s) and marked vitreous traction in the phakic eye.

Methods

Prospective, noncomparative, and interventional case series. All consecutive phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, with at least 1 year of postoperative follow-up, were enrolled. In all eyes, "localized 25-gauge vitrectomy" under air infusion with localized removal of the vitreous surrounding the retinal break(s), in association with laser photocoagulation and air tamponade, was performed. The primary end point was the rate of primary retinal attachment. Secondary end points were cataract progression and assessed by digital Scheimpflug lens photography (mean change of nuclear density units) and the rate of complications.

Results

Thirty-two phakic eyes were included in the final analysis. At 12 months, the primary outcome of anatomical success was achieved in 94% of eyes. The mean nuclear density units did not change significantly at any time point during the follow-up. After localized vitrectomy, one eye developed an epiretinal membrane, and one eye developed cystoid macular edema; no other significant complications were reported.

Conclusions

"Localized vitrectomy" has a high anatomical success rate in phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, without causing progression of cataract.

Postoperative Complications of Pars Plana Vitrectomy for Diabetic Retinal Disease

Despite recent advances in the medical management of diabetic retinal disease, there remain established indications for vitreoretinal surgery in the treatment of severe proliferative diabetic retinopathy. These include non-clearing vitreous hemorrhage and tractional retinal detachment. Advances in surgical instrumentation, technique, and experience have led to improved visual outcomes, as well as a corresponding decrease in the incidence of postoperative complications. However, the presence of systemic and ocular factors in diabetic patients increases the risk of adverse events compared to non-diabetic individuals. This review will focus on the most important postoperative complications following pars plana vitrectomy, with specific considerations for the diabetic patient.

Pars plana vitrectomy with partial tamponade of filtered air in Rhegmatogenous retinal detachment caused by superior retinal breaks

BACKGROUND

To investigate the anatomic and functional outcomes of pars plana vitrectomy (PPV) with partial tamponade of filtered air for rhegmatogenous retinal detachment (RRD) caused by superior retinal breaks.

METHODS

Retrospective, comparative, consecutive case series study. Patients with RRD caused by superior retinal breaks undergone PPV with partial tamponade (Group A) and whole tamponade (Group B) of filtered air were included. The main outcomes were primary and final success rates, best corrected visual acuity (BCVA), and rate of postoperative cataract surgery.

RESULTS

Forty-one patients (41 eyes) were included in Group A and 36 patients (36 eyes) were included in Group B. There were no significant differences in primary or final success rates between Groups A and B (P = 0.618 and P = 1.000, respectively). The patients in Group A experienced quicker postoperative vision improvement (from the Week 1 follow-up) than the patients in Group B (from the Month 3 follow-up). The postoperative cataract surgery rate of Group A (7/31) was lower than that of Group B (13/26) (P = 0.031).

CONCLUSIONS

PPV with partial tamponade of air is effective in achieving a high anatomic success rate, quicker postoperative vision improvement, and lower rate of postoperative cataract surgery in RRD caused by superior retinal breaks.

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.

Valved versus nonvalved cannula small-gauge pars plana vitrectomy for repair of retinal detachments with Grade C proliferative vitreoretinopathy

Purpose

Valved cannulas are a recent addition to small-gauge pars plana vitrectomy (PPV) and provide stable intraocular fluidics. The goal of this study was to compare outcomes and postoperative complication rates of valved vs nonvalved cannula small-gauge PPV for repair of retinal detachments (RDs) complicated by Grade C proliferative vitreoretinopathy (PVR).

Methods

A retrospective chart review of 364 consecutive eyes with either valved or nonvalved cannula PPV for RD repair was performed. The primary outcomes were single surgery and final anatomic success and change in best-corrected visual acuity for repair of RDs complicated by Grade C PVR.

Results

We identified 36 eyes in the valved group and 31 eyes in the nonvalved group with Grade C PVR RD. The single surgery success was 83% vs 77% (P=0.555) and the final anatomic success was 94% vs 87% (P=0.404) in the valved vs nonvalved eyes, respectively. The mean final visual acuity gain was −0.36 logarithm of the minimum angle of resolution (logMAR; approximate Early Treatment Diabetes Retinopathy Study [ETDRS] score =17 letters) in valved eyes vs −0.33 logMAR (approximate ETDRS score =16 letters) in nonvalved eyes (P=0.81). Postoperative complication rates including postoperative day 1 hypotony, hypertony, and anterior chamber fibrin formation; postoperative retention of intraocular or subretinal perfluorocarbon liquid; and subsequent epiretinal membrane peel were not statistically different between groups.

Conclusion

Valved cannula PPV yields equivalent visual acuity and anatomic outcomes without increased postoperative complication rates compared to traditional nonvalved cannula PPV for Grade C PVR-associated RD repair.

The Incidence of Rhegmatogenous Retinal Complications in Macular Surgery After Prophylactic Preoperative Laser Retinopexy: A Retrospective Study

The aim of the study is to evaluate the clinical characteristics of intraoperative retinal breaks (RBs) and postoperative retinal detachment (RRD) in patients undergoing pars plana vitrectomy (PPV) for macular disorders, who were treated preoperatively with prophylactic peripheral laser retinopexy.This observational cohort study comprised of 254 patients who underwent macular surgery and were preoperatively subjected to prophylactic laser retinopexy anterior to the equator. The main outcome measures were the incidence and characteristics of intraoperative RBs and postoperative RRD.Intraoperative RBs occurred in 14 patients (5.5%). Ten patients presented a sclerotomy-related RB (3.9%) and 4 patients a nonsclerotomy-related RB (1.6%). Two patients showed postoperative RRD (0.7%). Neither of the 2 patients with postoperative RRD was macula-off at presentation: one of them was successfully operated on with scleral buckling and the other was managed by observation alone. A significantly increased risk for the intraoperative development of sclerotomy-related RB was found in 20-gauge PPV compared with 23/25-gauge PPV.Preoperative prophylactic peripheral laser retinopexy does not guarantee the prevention of intraopertaive RBs or postoperative RRD. However, it might prevent the involvement of the macula when RRD occurs postoperatively.

Surgical and Functional Results of Hybrid 25-27-Gauge Vitrectomy Combined with Coaxial 2.2 mm Small Incision Cataract Surgery

Purpose. To investigate outcomes after coaxial 2.2 mm small incision cataract surgery combined with hybrid 25-27-gauge vitrectomy in eyes with vitreoretinal disease and age-related cataract. Methods. A single-center, retrospective case series study of 55 subjects (55 eyes) with a mean age of 70 years who underwent combined small incision phacoemulsification, intraocular lens (IOL) implantation, and hybrid 25-27-gauge vitrectomy during the 12-month period to December 2014. Intraoperative and postoperative complications and visual results were the main outcome measures. Results. The mean follow-up period was 6 months (range: 2–18 months). Intraoperative findings were 3 retinal breaks (5.5%). No cases required corneal or scleral suture or conversion to larger-gauge vitrectomy. Postoperative complications consisted of posterior capsule opacification (12.7%), elevated intraocular pressure >30 mmHg (1.8%), and fibrin reaction (5.5%). There were no cases of hypotony (<7 mmHg), IOL decentration, or postoperative endophthalmitis. Visual acuity (mean ± SD) improved from 0.52 ± 0.6 logMAR preoperatively to 0.22 ± 0.46 logMAR at final postoperative visit (P < 0.0001). Conclusion. Surgical and visual outcomes suggest hybrid 25-27-gauge vitrectomy combined with small incision phacoemulsification and IOL implantation is feasible, safe, and effective as a one-step surgical procedure for the management of vitreoretinal pathologies and concurrent cataract.

TRANSCONJUNCTIVAL NONVITRECTOMIZING VITREOUS SURGERY VERSUS 25-GAUGE VITRECTOMY IN PATIENTS WITH EPIRETINAL MEMBRANE: A Prospective Randomized Study

PURPOSE

To compare the clinical outcomes and the rate of complications of 27-gauge transconjunctival nonvitrectomizing vitreous surgery (NVS) and of 25-gauge transconjunctival sutureless vitrectomy surgery for idiopathic epiretinal membrane removal.

METHODS

In this prospective randomized study, 83 phakic eyes of 83 consecutive patients with an idiopathic epiretinal membrane were randomized to receive 27-gauge NVS (NVS-group) or 25-gauge vitrectomy (Standard-group). Main outcome measures were best-corrected visual acuity, central retinal thickness, nuclear density units' changes, and rate of complications.

RESULTS

Thirty-nine eyes of the Standard-group and 40 of the NVS-group were considered in final analysis. Mean best-corrected visual acuity improved significantly in both groups, with a significant better result at 12 months in NVS-group (P = 0.039; t-test). Central retinal thickness decreased significantly in both groups (P < 0.001, Tukey test), without significant difference between the two groups at any time point. At 12 months, nuclear density increased significantly in the Standard-group (analysis of variance, P < 0.001), and it did not change in the NVS-group (analysis of variance, P = 0.537). Epiretinal membrane recurred in 5.1% of eyes in the Standard-group and in 7.5% of eyes in the NVS-group (Fisher's exact test, P = 1.000).

CONCLUSION

The 27-gauge NVS is an effective surgical procedure in eyes with epiretinal membrane and it induces less progression of nuclear sclerosis than 25-gauge vitrectomy.

Advantages of diabetic tractional retinal detachment repair

Purpose

To evaluate the outcomes and complications of patients with diabetic tractional retinal detachment (TRD) treated with pars plana vitrectomy (PPV).

Patients and methods

We retrospectively studied a case series of 24 eyes of 21 patients at a single tertiary, university-affiliated medical center. A review was carried out on patients who underwent PPV for the management of TRD due to proliferative diabetic retinopathy from October 2011 to November 2013. Preoperative and final visual outcomes, intraoperative and postoperative complications, and medical background were evaluated.

Results

A 23 G instrumentation was used in 23 eyes (95.8%), and a 25 G instrumentation in one (4.2%). Mean postoperative follow-up time was 13.3 months (4–30 months). Visual acuity significantly improved from logarithm of the minimum angle of resolution (LogMAR) 1.48 to LogMAR 1.05 (P<0.05). Visual acuity improved by ≥3 lines in 75% of patients. Intraoperative complications included iatrogenic retinal breaks in seven eyes (22.9%) and vitreal hemorrhage in nine eyes (37.5%). In two eyes, one sclerotomy was enlarged to 20 G (8.3%). Postoperative complications included reoperation in five eyes (20.8%) due to persistent subretinal fluid (n=3), vitreous hemorrhage (n=1), and dislocated intraocular lens (n=1). Thirteen patients (54.2%) had postoperative vitreous hemorrhage that cleared spontaneously, five patients (20.8%) required antiglaucoma medications for increased intraocular pressure, seven patients (29.2%) developed an epiretinal membrane, and two patients (8.3%) developed a macular hole.

Conclusion

Patients with diabetic TRD can benefit from PPV surgery. Intraoperative and postoperative complications can be attributed to the complexity of this disease.

Iatrogenic retinal breaks caused by infusion fluid during pars plana vitrectomy

OBJECTIVE

To describe a series of cases of iatrogenic retinal breaks (IRBs) caused by the infusion fluid flow of a 25-gauge pars plana vitrectomy (PPV) system.

DESIGN

Retrospective case series.

METHODS

During 25-gauge PPV, 4 cases had IRBs caused by infusion fluid flow. The IRBs rapidly progressed to localized retinal detachment.

RESULTS

The first 3 cases had IRBs on the nasal quadrant midperiphery of the retina. The IRBs were treated with laser retinopexy and tamponade during surgery. Case 4 had a macular hole and macular detachment during scleral indentation. The IRBs seemed to be caused by intraocular pressure (IOP) control mechanisms of the vitrectomy device.

CONCLUSIONS

To prevent IRBs caused by infusion fluid flow, we recommend using an IOP control limit of 4 mL/min for 25-gauge vitrectomy, with valved cannulas. In addition, the surgeon must be cautious during scleral indentation and air-fluid exchange not to cause a rebound hypotonia.

Iatrogenic retinal breaks in 25-gauge vitrectomy under air compared with the standard 25-gauge system for macular diseases

PURPOSE

To evaluate the incidence rates of iatrogenic retinal breaks in eyes that underwent 25-gauge vitrectomy under air compared with 25-gauge standard vitrectomy for idiopathic macular holes or idiopathic epiretinal membranes.

METHODS

In this retrospective, comparative interventional study, 435 eyes were enrolled. In all patients after core vitrectomy and epiretinal/inner limiting membrane peeling, complete vitrectomy of the base was performed, respectively under air (air group) or under fluid infusion (standard group).

RESULTS

The number of eyes with iatrogenic retinal breaks was significantly lower in the air group than in standard group (4/197 and 16/238, 2% and 7%, respectively; P = 0.035). A postoperative retinal detachment developed in 2 eyes (1%) in the standard group, and in no eyes of the air group (0%). Factors related to the occurrence of retinal breaks were surgically induced posterior vitreous detachment (P = 0.006), standard vitrectomy (P = 0.023), and surgery for macular hole (P = 0.030).

CONCLUSION

The 25-gauge vitrectomy under air is associated with a lower incidence rate of retinal breaks compared with the standard 25-gauge vitrectomy.

Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. However, this may be complicated by persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction; VMT). VMT itself may be associated with epiretinal membrane formation and the development of idiopathic macular holes (IMH). Such pathologies may cause visual disturbances, including metamorphopsia, photopsia, blurred vision, and decreased visual acuity, which impact an individual's quality of life. Technologies such as optical coherence tomography allow an increasingly more accurate visualisation of the macular anatomy, including quantification of macular hole characteristics, and this facilitates treatment decision-making. Pars plana vitrectomy remains the primary treatment option for many patients with VMT or IMH; for the latter, peeling of the inner limiting membrane (ILM) of the retina has shown improved outcomes when compared with no ILM peeling. The development of narrow-gauge transconjunctival vitrectomy systems has improved the rate of visual recovery following surgery. Ocriplasmin, by degrading laminin and fibronectin at the vitreoretinal interface, may allow induction of PVD in a non-invasive manner. Indeed, clinical studies have supported its use as an alternative to surgery in certain patient populations. However, further research is still needed with respect to greater understanding of the pathophysiology underlying the development of VMT and IMH.

[The periphery of the vitrectomised eye]

The periphery of the vitrectomised eye is the site of retinal breaks in 1 to 15% of cases. These breaks must be looked for and treated to avoid retinal detachment. They are more frequent in the presence of fragile lesions in high myopia, or vitreoretinal traction. They can be related to vitreous incarceration in a sclerotomy site or with the movements of the vitrectomy probe. Traction is proportional to aspiration rate, and inversely proportional to the distance between the cutter and the vitreous base. Twenty-three- or 25-gauge transconjunctival vitrectomy seems to decrease the risk of vitreous incarceration and peripheral retinal tear.

United Kingdom National Ophthalmology Database study of vitreoretinal surgery: report 3, retinal detachment

PURPOSE

To describe rhegmatogenous retinal detachment (RD) surgery.

DESIGN

National Ophthalmology Database study.

PARTICIPANTS

A total of 3403 eyes from 3321 patients undergoing primary RD surgery.

METHODS

Participating centers prospectively collected clinical data using a single electronic medical record system, with automatic extraction of anonymized data to a national database, from 2002 to 2010.

MAIN OUTCOME MEASURES

Description of the primary procedures performed, intraoperative complication rate, and proportion of eyes undergoing subsequent RD or cataract surgery. We undertook an exploratory analysis of change in visual acuity (VA) using the data available.

RESULTS

Of 3403 operations, 2693 (79.1%) were pars plana vitrectomy (PPV), 413 (12.1%) were retinopexy with a scleral buckle (SB), and 297 (8.7%) were PPV with an SB (PPV-SB). For PPV and PPV-SB, 18.8% were with hexafluoroethane, 12.1% were with perfluoropropane, 43.1% were with sulfahexafluoride, 1.8% were with air, 17.9% were with silicone oil, and 10.7% were with cataract surgery. Within 1 year of vitrectomy, 52.1% of phakic eyes had undergone cataract surgery. For all RD operations combined (and excluding cataract surgery complications), 5.1% had 1 or more intraoperative complication, 13.0% underwent further RD surgery, and 8.3% had silicone oil in situ at last review. The RD reoperation rate was 13.3%, 12.3%, and 14.5% for PPV, SB, and PPV-SB, respectively. For 961 eyes with a baseline and final VA measurement, the median presenting logarithm of the minimum angle of resolution VA improved from 1.0 to 0.5 (20/200-20/63) after a median follow-up of 0.6 years.

CONCLUSIONS

These results may help vitreoretinal surgeons to benchmark their intraoperative complication rate and reoperation rate and to compare their surgical techniques with their peers'. They suggest that the benefits of RD surgery greatly outweigh the risks.

Iatrogenic retinal breaks in 20-G versus 23-G pars plana vitrectomy

BACKGROUND

The purpose of this study was to compare the incidence of iatrogenic anterior retinal breaks in 20-G vitrectomy (PPV) with transconjunctival 23-G PPV.

METHODS

Retrospective, observational review study involving consecutive patients undergoing PPV in a single center in the UK during a 2-year period.

RESULTS

Sclerotomy-related entry-site breaks (ESB) were found in 50/628 (7.9 %) 20-G PPV cases and 5/296 (1.7 %) 23-G PPV eyes (p<0.0001*). Anterior non-sclerotomy iatrogenic breaks (ANSB) were present in 55/628 (8.7 %) 20-G PPV cases and 18/296 (6.1 %) 23-G PPV eyes (p=0.19). The incidence of total anterior iatrogenic breaks (ANSB + ESB) was 105/628 (16.7 %) for 20-G PPV and 23/296 (7.8 %) for 23-G PPV (p=0.002*). Univariate analysis showed that posterior vitreous detachment induction was the only risk factor significantly associated with the development of anterior retinal breaks for both 20-G and 23-G PPV. Multivariate logistic model of risk factors for development of iatrogenic retinal breaks demonstrated that 23-G PPV was the most important factor reducing the risk of anterior breaks (p<0.0001*).

CONCLUSIONS

We report the largest series of patients undergoing 20-G and 23-G vitrectomy, where 23-G vitrectomy was associated with a significantly lower incidence of anterior iatrogenic retinal breaks.

United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery: report 1; case mix, complications, and cataract

AIM

To report the vitreoretinal (VR) surgical case mix in the United Kingdom, the intraoperative complication rate of pars plana vitrectomy (PPV), and the incidence of post-vitrectomy cataract extraction.

METHODS

Participating hospitals prospectively collected ophthalmic data using a single electronic medical record system, with automatic extraction of anonymised data to a national database. This study included the subset of 11618 VR operations undertaken on 9619 eyes, of 8741 patients, over 8 years, from 27 sites. Surgical data included the indication for surgery, all procedure elements, and whether or not an intraoperative complication occurred. Post-vitrectomy cataract data were also analysed. The main outcome measures were a description of the indications for surgery, intraoperative PPV complication rate, and percentage of eyes undergoing post-vitrectomy cataract surgery (PVCS).

RESULTS

The most common indications for VR intervention were retinal breaks and rhegmatogenous retinal detachment (48.5%), macular hole (9.8%), epiretinal membrane (9.6%), and diabetic eye disease (7.3%). Overall, 7.8% of PPVs had at least one intraoperative complication-the most common were iatrogenic retinal breaks (3.2%), and lens touch (1.2-1.6% of phakic eyes). PVCS occurred in 50.2, 68.7, and 74.0% of eyes at 1, 2, and 3 years, respectively.

CONCLUSION

VR surgery is undertaken for a wide range of conditions, but a small number of diagnoses encompass the majority of cases. Intraoperative PPV complications are not uncommon, and post-vitrectomy cataract is to be expected in most phakic eyes.