Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy

Endothelial loss following postoperative intracameral triamcinolone acetonide and subconjunctival dexamethasone injections

OBJECTIVES

To compare endothelial toxicity and efficacy of two local steroid injections (intracameral triamcinolone acetonide and subconjunctival dexamethasone) in controlling postoperative inflammation following pars plana vitrectomy (PPV) combined with phacoemulsification cataract surgery.

METHODS

This cohort included 54 patients that underwent combined surgery and received either intracameral triamcinolone acetonide injections (n = 27, IC-TA group) or subconjunctival dexamethasone (n = 27, Sc-Dex group) injections at the end of the surgery. All participants had at least 4 months or longer follow-up. A detailed ophthalmologic examination including intraocular pressure (IOP) measurement and specular microscopy was performed at every visit.

RESULTS

Endothelial cell density (ECD) reduced significantly in IC-TA group postoperatively (2418 vs. 2249, p = 0.019), while it did not change significantly in Sc-Dex group (2541 vs. 2492, p = 0.247). Postoperative ECD was also significantly lower in IC-TA group compared to Sc-Dex group (p = 0.011). Preoperative and postoperative IOP values remained unchanged both in IC-TA and Sc-Dex groups (p = 0.424 and p = 0.523, respectively). However, 4 patients in IC-TA group and 5 patients in the Sc-Dex group needed glaucoma medications. The postoperative need for glaucoma medications was similar between the groups (p = 0.347). Postoperative inflammation was well controlled in both groups and none of the patients developed fibrin membrane or synechiae postoperatively.

CONCLUSION

Both treatments were effective in controlling postoperative inflammation, but patients in IC-TA group experienced significantly higher endothelial loss. Sc-Dex injections are safer in terms of endothelial loss and preferable to control postoperative inflammation following complex intraocular surgeries.

OUTCOMES OF COMBINED PHACOEMULSIFICATION AND PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Comparative Study

PURPOSE

To evaluate and to compare the anatomical and functional results of phacovitrectomy and pars plana vitrectomy (PPV) alone for phakic rhegmatogenous retinal detachment.

METHODS

Retrospective, comparative case series of 266 phakic eyes that underwent either combined phacovitrectomy or PPV alone for primary retinal detachment. The primary anatomical success rate, the final best-corrected visual acuity, and the refractive outcomes were analyzed.

RESULTS

One hundred and twenty-seven eyes were included in the combined group and 139 in the PPV group. The primary anatomical success rate was 84.3% in the combined group and 89.2% in the PPV group (P = 0.311). One hundred and nine (78.4%) eyes of the PPV group required cataract removal for visual rehabilitation during the follow-up period. There was no significant difference between the two groups in terms of the mean final best-corrected visual acuity (P = 0.185) and mean visual changes (P = 0.470). Overall, combined cataract extraction resulted in a significant myopic shift compared with delayed cataract surgery (P = 0.047).

CONCLUSION

Combined phacoemulsification and PPV is a safe and effective procedure to treat retinal detachment. The anatomical and functional results were comparable with those obtained with PPV and delayed cataract surgery. However, the refractive outcomes were less favorable and shifted toward myopia, especially in macula-off cases.

Combined Femtosecond Laser-Assisted Cataract Surgery and 27-Gauge Transconjunctival Sutureless Vitrectomy

Purpose

To report the outcomes of combined surgery using femtosecond laser-assisted cataract surgery (FLACS) and sutureless 27-gauge pars plana vitrectomy with intravitreal tamponade.

Methods

This retrospective clinical study involved 23 eyes of 23 patients on whom combined vitreoretinal surgery was performed. Patients were initially given the femtosecond laser treatment that was performed after selection of capsulotomy and lens fragmentation patterns. The capsulotomy diameter was chosen as 4.9 mm in all patients. After the femtosecond laser, the sutureless phacovitrectomy procedure was performed. At the end of surgery, perfluoropropane or sterile air tamponade was applied.

Results

The mean age of patients was 66.43 ± 7.61 (range, 54–83) years. Fifteen patients were females (65.2%). The mean follow-up was 16.09 ± 4.71 (range, 9–25) months. The most common surgical indication was epiretinal membrane (65.3%). The mean preoperative best-corrected visual acuity (BCVA) was 0.71 ± 0.44 (range, 1.7–0.3) logMAR, and the mean postoperative BCVA at 6 months was 0.16 ± 0.14 (range, 0.4–0) logMAR (p < 0.001). The mean target sphere refractive error was −0.24 ± 0.16 (range, −0.50–0.11) D, and the mean postoperative spherical equivalent refractive error was −0.14 ± 0.39 (range, −1.00–0.50) D at 6 months (p=0.196). All intraocular lenses (IOLs) remained well centered in the capsular bag during surgery and follow-up. There was no iris capture, posterior synechiae, capsular opacification, or pseudophakic cystoid macular edema. The only complication related to femtosecond laser was two cases of subconjunctival haemorrhage related with suction.

Conclusions

FLACS is a safe and effective technique providing the advantage of repeatable, precise capsulorhexis shape and size to achieve a well-centered and stable IOL postoperatively. These advantages can certainly improve the results of vitrectomy, especially in gas-filled eyes. FLACS and 27-gauge sutureless combined surgery may be a future trend in appropriate cases.

Chandelier-assisted retroillumination for phacoemulsification in phacovitrectomy

Purpose:

To describe chandelier-assisted retroillumination for phacoemulsification in patients with poor fundal glow due to posterior segment pathology during combined phacovitrectomy procedure.

Methods:

This was a prospective observational study. Thirty eyes underwent combined phacoemulsification and 25G sutureless pars plana vitrectomy. Sclerotomy port for chandelier tip was made in the inferotemporal or superonasal quadrant based on the incision site for phacoemulsification. Later, it was replaced with infusion cannula or endoilluminator. Cases included had posterior segment pathologies such as vitreous hemorrhage and vitritis.

Results:

Red reflex was markedly enhanced during phacoemulsification for all cases. In all eyes, a continuous curvilinear capsulorhexis was achieved without the use of dye. The posterior capsule remained intact in all cases. The visual acuity in all patients improved, and the median best-corrected visual acuity was 20/60 (range: 4/60–20/30) at 6 months. There were no intraoperative or postoperative complications.

Conclusion:

Cases with poor red reflex pose a challenge for anterior segment surgeons, and chandelier-assisted retroillumination proves to be a safe and effective tool in combined phacovitrectomy surgeries. Moreover, no additional cannula port is required for this chandelier insertion.

Surgical peripheral iridectomy via a clear-cornea phacoemulsification incision for pupillary block following cataract surgery in acute angle closure

Background

To describe a technique of surgical peripheral iridectomy via a clear-cornea tunnel incision to prevent or treat pupillary block following phacoemulsification.

Methods

Description of technique and retrospective description results in 20 eyes of 20 patients with acute angle closure with coexisting visually significant cataract undergoing phacoemulsification considered at risk of postoperative papillary block as well as two pseudo-phakic eyes with acute postoperative pupillary-block. Following phacoemulsification and insertion of an intraocular lens, a needle with a bent tip was inserted behind the iris through the corneal tunnel incision. A blunt iris repositor was introduced through the paracentesis and placed above the iris to exert posterior pressure and create a puncture. The size of the puncture was enlarged using scissors. For postoperative pupillary block the same technique was carried out through the existing incisions created for phacoemulsification.

Results

Peripheral iridectomy was successfully created in all 22 eyes. At a mean follow-up of 18.77 ± 9.72 months, none of the iridectomies closed or required enlargement. Two eyes had mild intraoperative bleeding and one eye a small Descemet’s detachment that did not require intervention. No clinically significant complications were observed. Visual acuity and IOP improved or was maintained in all patients. The incidence of pupillary block in our hospital was 0.09% overall, 0.6% in diabetics and 3.5% in those with diabetic retinopathy.

Conclusions

This technique of peripheral iridectomy via the cornea tunnel incision can be safely used during phacoemulsification in eyes at high risk of pupillary block or in the treatment of acute postoperative pupillary-block after cataract surgery. The technique is likely to be especially useful in brown iris, or if a laser is not available.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye

BACKGROUND:

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies.

METHODS:

Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature.

RESULTS:

We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery.

DISCUSSION AND CONCLUSION:

Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

To assess surgical outcomes of combined femtosecond laser-assisted cataract surgery with 25-gauge vitrectomy surgery at a tertiary eye care center

Background:

The aim of this study was to assess the surgical outcomes of combined femtosecond laser-assisted cataract surgery (FLACS) with 25-gauge vitrectomy surgery.

Materials and Methods:

A retrospective analysis of 45 patients who underwent combined FLACS with 25-gauge vitrectomy surgery.

Results:

A total number of 45 eyes of 45 patients were treated with a mean age of 63.27 years (range 45–75). The mean follow-up was 3 months (range 3–12 months). The mean preoperative best-corrected visual acuity was 1.47 ± 0.86. The mean postoperative vision was 0.36 ± 0.36 and 0.275 ± 0.184 at a paired t-test revealed a statistically significant improvement in visual acuity at 1 month (P < 0.001) and 3 months (P < 0.001). The most common indication for surgery was full-thickness macular hole (51.1%), vitreous hemorrhage (24.4%), followed by epiretinal membrane (17.7%) and rhegmatogenous retinal detachment (4.4%).

Conclusion:

Combining FLACS with vitrectomy may be a step toward achieving better outcomes when combined CS and vitrectomy is performed.

Changes in Axial Length and Refractive Error After Noninvasive Normalization of Intraocular Pressure From Elevated Levels

PURPOSE

To explore the changes in axial length and refractive error after noninvasive normalization of intraocular pressure (IOP) from elevated levels.

DESIGN

A prospective observational study.

METHODS

We enrolled 51 consecutive patients with abnormally elevated unilateral IOP (≥10 mm Hg compared with that of the fellow eye, in which the IOP was ≤21 mm Hg). In all patients, the keratometric value and axial length were obtained with the aid of an IOLMaster before and after IOP normalization (defined as attainment of an IOP difference of ≤3 mm Hg compared with the fellow eye, with or without topical application of ocular hypotensive therapy). We focused principally on IOP, axial length, the keratometric value, and the predicted refractive difference (the predicted refractive error after IOP normalization upon placement of an IOL with a power for emmetropia correction determined prior to IOP normalization).

RESULTS

The axial length was significantly reduced from 23.5 to 23.3 mm after IOP normalization, from 45.9 mm Hg to 14.3 mm Hg (P < .001). The change in IOP correlated with that of the axial length (r = 0.826, P < .001), but not with the change in the keratometric value (P = .618). The change in axial length per 10 mm Hg IOP decrease was -0.06 mm (P < .001). The IOP change was correlated with the predicted refractive difference (r = 0.693, P < .001); the predicted refractive difference per 10 mm Hg IOP decrease was +0.15 diopter (P < .001).

CONCLUSIONS

The axial length decreased and the predicted refractive difference increased (hyperopia) as IOP decreased. Therefore, a possible risk of postoperative hyperopic shift should be considered when biometric examination for IOL power calculation is performed in a patient with an abnormally elevated IOP.

Intraocular lens power estimation in combined phacoemulsification and pars plana vitrectomy in eyes with epiretinal membranes: a case-control study

PURPOSE

To evaluate the accuracy of postoperative refractive outcomes of combined phacovitrectomy for epiretinal membrane (ERM) in comparison to cataract surgery alone.

MATERIALS AND METHODS

Thirty-nine eyes that underwent combined phacovitrectomy with intraocular lens (IOL) implantation for cataract and ERM (combined surgery group) and 39 eyes that received phacoemulsification for cataract (control group) were analyzed, retrospectively. The predicted preoperative refractive aim was compared with the results of postoperative refraction.

RESULTS

In the combined surgery group, refractive prediction error by A-scan and IOLMaster were -0.305±0.717 diopters (D) and -0.356±0.639 D, respectively, compared to 0.215±0.541 and 0.077±0.529 in the control group, showing significantly more myopic change compared to the control group (p=0.001 and p=0.002, respectively). Within each group, there was no statistically significant difference in refractive prediction error between A-scan and IOLMaster (all p>0.05). IOL power calculation using adjusted A-scan measurement of axial length based on the macular thickness of the normal contralateral eye still resulted in significant postoperative refractive error (all p<0.05). Postoperative refraction calculated with adjusted axial length based on actual postoperative central foveal thickness change showed the closest value to the actual postoperative achieved refraction (p=0.599).

CONCLUSION

Combined phacovitrectomy for ERM resulted in significantly more myopic shift of postoperative refraction, compared to the cataract surgery alone, for both A-scan and IOLMaster. To improve the accuracy of IOL power estimation in eyes with cataract and ERM, sequential surgery for ERM and cataract may need to be considered.

Combined 23-gauge vitrectomy and femtosecond laser-assisted cataract surgery

BACKGROUND

The aim of this study was to assess the safety and surgical results of femtosecond laser-assisted phacovitrectomy.

METHODS

A retrospective analysis of the medical records of patients over 50 years of age with vitreoretinal pathology, who had undergone pars plana vitrectomy using 23-gauge instruments and femtosecond laser-assisted cataract surgery and implantation of an intraocular lens, was performed at the Instituto de Microcirugía Ocular between June 2012 and September 2013. The diameter of the anterior capsulorhexis was set at 4.8 mm in cases where a gas tamponade was used and at 5 mm in all other cases. During the pars plana vitrectomy, posterior capsulotomy was performed on all eyes. An assessment was carried out of preoperative characteristics, surgical indications, postoperative results and complications. Only patients with a minimum of 3 months of follow-up were included.

RESULTS

A total of 21 eyes in 21 patients (71.4% women) were treated. Mean age (± SD) was 65.8 ± 6.4 years (range 53-76). The most common indication for surgery was epiretinal membrane (61.9%), followed by vitreous haemorrhage (23.8%) and macular hole (14.3%). The mean preoperative best corrected visual acuity (BCVA) was 0.81 ± 1.01 logMAR and the mean postoperative BCVA was 0.12 ± 0.19 logMAR (p = 0.003). 85.7% of patients improved their visual acuity. The remaining patients maintained their visual acuity. The only intraoperative complication related to femtosecond laser was 1 case of suction loss (4.8%). A patient with rhegmatogenous retinal detachment discovered during surgery required an additional circular scleral procedure and developed synechiaes in the early postoperative period (<1 month). There were no cases of subluxation of the intraocular lens. Mean follow-up was 6 months (range 3-14).

CONCLUSIONS

The application of femtosecond laser in phacovitrectomy is a safe and effective technique that presents advantages compared to conventional techniques in cases of macular pathology and/or vitreous haemorrhage.

Changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment

PURPOSE

To evaluate changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment (RRD) compared with other retinal diseases.

DESIGN

Retrospective observational case-control study.

METHODS

A total of 55 patients who had combined surgery between January 2007 and December 2012 were enrolled. The 25 patients who underwent combined surgery for RRD were included in the RRD group, and 30 patients who underwent combined surgery for other vitreoretinal pathology were included in the control group. Refractive axial length and intraocular pressure (IOP) measurements were performed, and the factors influencing the postoperative refractive outcomes were analyzed.

RESULTS

The mean differences between the postoperative and predicted refractive outcomes in the RRD group and the control group were -0.43D±0.67 (P=.046) and -0.08D±0.53 (P=.767), respectively. The mean preoperative IOPs of the affected eye and the fellow eye in the RRD group were 11.44 mm Hg±3.15 and 13.16 mm Hg±2.73 (P=.045), but no differences were found in the affected eyes and fellow eyes of the control group. The differences were 14.20 mm Hg±2.95 and 14.17 mm Hg±3.50, respectively (P=.974). The mean postoperative IOPs in the affected eyes and the fellow eyes of the 2 groups were not significantly different. For all eyes, the refractive differences correlated with IOP changes in the RRD group. (r=.659, r2=.435, P<.001).

CONCLUSIONS

The postoperative refractive outcomes in the RRD group shifted toward myopia by a mean of 0.35 diopters compared with the control group. Normalizing preoperative lowered IOP after combined surgery in RRD may be the key factor in understanding this myopic shift.

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.

The safety and efficacy of passive removal of silicone oil with 23-gauge transconjunctival sutureless system

PURPOSE

To evaluate the safety and efficacy of passive removal of silicone oil with 23-gauge (G) transconjunctival sutureless system.

METHODS

This is a single-center, prospective, interventional, randomized control study. Forty eyes of 40 patients were enrolled in this study and randomized into 2 groups. Group 1 (n = 20) patients underwent passive removal of silicone oil with 23-G transconjunctival sutureless system. Group 2 (n = 20) underwent 20-G active silicone oil removal using all three 20-G ports. In both groups, air-fluid exchange was performed and the globe was left air filled at the end of surgery. All eyes in both groups received 360 degrees endolaser. We recorded surgical time, time for silicone oil removal, number of sutured 23-G sclerotomy sites, presence of preoperative scarring at sclerotomy site, postoperative hypotony, endophthalmitis, and inflammation at sclerotomy site.

RESULTS

Opening and closing times were significantly shorter in Group 1 than in Group 2. Only 3 cases (15%) in Group 1 required 1 additional suture each in the superior sclerotomy site. Both groups were similar in safety in terms of chance of endophthalmitis, redetachment rate, and postoperative hypotony. Only 1 patient of Group 1 (5%) and 5 patients of Group 2 (25%) showed significant conjunctival inflammation at the end of 2 weeks.

CONCLUSION

Passive removal of silicone oil with 23-G transconjunctival sutureless system may hasten postoperative recovery by decreasing overall surgical time and postoperative inflammation. It is a safe and effective procedure when compared with 20-G active silicone oil removal for 1000 centistoke oil.

Differences between the combination of the 25-gauge vitrectomy with phacoemulsification versus 20-gauge vitrectomy and phacofragmentation

Introduction:

In the present study we determine the differences observed between 25-gauge-vitrectomy combined with phacoemulsification, and the 20-gauge-vitrectomy combined with pars plana phacofragmentation.

Methods:

A prospective study of a sample of 987 eyes of 661 patients randomly divided into two groups. 25-gauge-vitrectomy plus phacoemulsification included 486 eyes, and 20-gauge-vitrectomy plus phacofragmentation 501 eyes. We evaluated the differences at the time of the surgery, the intra-and postoperative complications, and the variations in intraocular pressure.

Results:

The final visual outcome was similar in both groups. The most important differences between groups were: surgical time was faster in group 1 than in group 2, (mean time: 35.16 ± 3.49, 44.74 ± 5.30 minutes). Intraoperative complications were more numerous in group 1. In group 1, postoperative low levels of intraocular pressure are present in all patients with 2.77% of patients with hypotension (<8 mmHg), and three choroidal effusion. In group 2, intraocular lens decentration and retinal detachment are more frequent (2.38% and 1.39%, respectively).

Conclusions:

In the present study, both techniques have a similar number of complications and have a similar postoperative outcome, and are valid for the management of the pathologies selected.

[Outcomes of 110 consecutive 25-gauge transconjunctival sutureless pars plana vitrectomies]

PURPOSE

To evaluate the safety and efficacy of the 25-gauge transconjunctival vitrectomy system for a variety of vitreoretinal surgery indications at short-term follow-up.

METHODS

Retrospective study of consecutive interventional cases that underwent surgery performed by one surgeon using the Alcon 25-Gauge vitrectomy system, in Bordeaux University Hospital, from September 2004 to May 2006. Indications were epiretinal macular membrane (72 eyes), macular hole (24 eyes), and other diseases (14 eyes).

RESULTS

One hundred and ten eyes of 105 consecutive patients underwent surgery. None required conversion to 20-gauge vitrectomy or wound suture. One iatrogenic retinal break occurred intraoperatively. Two transient wound leaks, seven cases of hypotonia, one of chronic endophthalmitis, one of rhegmatogenous retinal detachment, one of retinal break, two recurrent intravitreal hemorrhages, and six cases of hypertonia were noted postoperatively. Three eyes required additional surgery. Mean overall visual acuity improved from 0.691 +/- 0.465 logMAR preoperatively to 0.476 +/- 0.492 logMAR at 1 month (p<0.0001). Visual acuity improvement was statistically significant for eyes with macular epiretinal membrane (p<0.0001) and macular hole (p=0.0158). The macular hole closure rate was 87.5%. Mean operative time was 25.91+/-10.94 min. Mean follow-up was 13.32+/-18.1 weeks. Thirteen eyes developed cataracts during the follow-up period.

CONCLUSION

Vitrectomy with the 25-Gauge system appears to be relatively safe and particularly appropriate for macular surgery.

[Long-term results after pars plana vitrectomy with 25 gauge technique]

BACKGROUND

The 25-gauge technique of pars plana vitrectomy appears to be a very suitable method, especially for patients with pathological epiretinal alterations of the macula. However, the procedure has been criticized for insufficient impermeability with an increased risk of endophthalmitis and that the flexibility of instruments is too high.

METHOD

Between 2002 and 2006, 625 eyes from 620 patients were operated on using the 25-gauge technique. Epiretinal membranes in different stages had been diagnosed in all patients. The operations were performed by only one surgeon.

RESULTS

The epiretinal membranes were successfully removed in all patients and 329 eyes were analyzed with long-term follow up over 3.1 years. The mean improvement in visual acuity before and after surgery was -0.41 in LogMAR. One week postoperatively normal IOP was observed in all cases. The mean preoperative IOP was 17 mmHg and 8 mmHg 1 day after surgery. In nine patients with postoperative hypotony and choroidal detachment an additional suture was required and seven patients developed a retinal detachment. Endophthalmitis was not observed in any of the patients during the follow-up period.

CONCLUSIONS

The 25-gauge PPV technique appears to be effective and safe for the treatment of epiretinal membranes. The operation has low complication rates with respect to endophthalmitis or retinal detachment. The procedure has recently been further improved by using more stable instruments and better lighting.

The safety and efficacy of transconjunctival sutureless 23-gauge vitrectomy

Purpose

To evaluate the efficacy and safety of vitreoretinal surgery using a 23-gauge transconjunctival sutureless vitrectomy (TSV) system for various vitreoretinal diseases.

Methods

A retrospective, consecutive, interventional case series was performed for 40 eyes of 40 patients. The patients underwent vitreoretinal procedures using the 23-gauge TSV system, including idiopathic epiretinal membrane (n=7), vitreous hemorrhage (n=11), diabetic macular edema (n=10), macular hole (n=5), vitreomacular traction syndrome (n=5), diabetic tractional retinal detachment (n=1), and rhegmatogenous retinal detachment (n=1). Best corrected visual acuity (BCVA), intraocular pressure (IOP), and intra- and post-operative complications were evaluated.

Results

Intraoperative suture placement was necessary in 3 eyes (7.5%). The median BCVA improved from 20/400 (LogMAR, 1.21±0.63) to 20/140 (LogMAR, 0.83±0.48) at 1 week (p=0.003), 20/100 (LogMAR, 0.85±0.65) at 1 month (p=0.002), 20/100 (LogMAR, 0.73±0.6) at 3 months (p=0.001). In 1 eye, IOP was 5 mmHg at 2 hours and 4 mmHg at 5 hours, but none of the eyes showed hypotony after 1 postoperative day. No serous postoperative complications were observed during a mean follow-up of 8.4±3.4 months (range 3-13 months)

Conclusions

The 23-gauge TSV system shows promise as an effective and safe technique for a variety of vitreoretinal procedures. It appears to be a less traumatic, more convenient alternative to 20-gauge vitrectomy in some indications.

25-Gauge transconjunctival sutureless vitrectomy

PURPOSE OF REVIEW

The history and development of 25-gauge transconjunctival sutureless vitrectomy are reviewed in this paper. The expanded spectrum of appropriate cases and recent innovations in vitrectomy surgery are discussed, as are longer-term outcomes and possible complications.

RECENT FINDINGS

25-Gauge pars plana vitrectomy has evolved significantly since its introduction in 2002, with newer instruments and novel techniques expanding the scope and improving outcomes in vitreoretinal surgery. Proper case selection is imperative, as the smaller scale of the instruments and decreased fluidics work most efficiently when extensive manipulation of intraocular tissue or significant membrane dissection is not required. Unique complications of 25-gauge surgery such as hypotony and a possible increased rate of endophthalmitis may be related to unsutured sclerotomies, and revisions in surgical approach may help to decrease these potentially devastating complications.

SUMMARY

Clinical experience over the last several years has proven that this sutureless system is both safe and efficacious. Decreased surgical times, reduced postoperative inflammation, and more rapid patient recovery have all contributed to an increased acceptance of 25-gauge vitrectomy by retinal physicians.

Factors influencing refractive outcomes after combined phacoemulsification and pars plana vitrectomy

PURPOSE

To evaluate the factors influencing the refractive outcomes of combined phacoemulsification, foldable intraocular lens (IOL) implantation, and pars plana vitrectomy (PPV).

SETTING

Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea.

METHODS

One hundred fifty-four consecutive patients who had combined phacoemulsification, IOL implantation, and PPV between September 2001 and August 2004 were enrolled in a prospective study. Refractive, keratometric, and axial length measurements were performed preoperatively and 4 months postoperatively. The factors influencing the postoperative refractive outcomes were analyzed.

RESULTS

The mean refractive prediction error (ie, actual minus predicted spherical equivalent [SE]) was -0.06 diopters (D) +/- 0.75 (SD). In long eyes (preoperative axial length more than 24.5 mm), the mean predicted SE and actual SE were -0.81 +/- 0.76 D and -1.24 +/- 0.79 D, respectively; the difference was significantly different (P = .001, paired t test). Patients with a preoperative visual acuity worse than 5/200 and those with preoperative foveal detachment had a significant postoperative myopic shift (P = 0.024 and P = 0.002, respectively; paired t test). Postoperative refractive error was not influenced by the intraocular air or gas tamponade during surgery (P = 0.336, paired t test).

CONCLUSIONS

The combined surgery included a small biometric error that was within the tolerable range in most cases. However, myopic shifts developed in patients with long axial lengths, poor preoperative visual acuity, and the preoperative presence of foveal detachment.