Sutureless vitrectomy surgery

Diathermy for 23-gauge sclerotomy: a functional and morphologic study to avoid ocular hypotony

Purpose

To evaluate diathermy to minimize sclerotomy leakage during small-gauge vitrectomy and prevent ocular hypotony.

Methods

This observational prospective study included 327 patients (327 eyes) who underwent diathermy to close the sclerotomy sites during 23-gauge pars plana vitrectomy (PPV). All patients were operated by a single surgeon (ED) and evaluated at 30 and 60 days postoperatively. Patients with glaucoma, topical/systemic steroids use exceeding 30 days, ocular inflammation, or trauma were excluded. Chi-square, Kruskal–Wallis, Fisher Exact test, and multivariate statistical analyses were performed to evaluate potential risk factors. The primary outcomes were open sclerotomies, leakage, and ocular hypotony.

Results

Sclerotomies remained open in 12 (3.6%) and 2 (0.6%) patients, respectively, at 30 and 60 days postoperatively, revealing no case of ocular hypotony. Leakage only occurred in four patients (1.2%) during week 1 postoperatively. Multivariate analysis indicated that additional vitreoretinal surgeries and longer surgeries were risk factors for persistent sclerotomy opening.

Conclusion

Diathermy was safe and feasible to close sclerotomies. Vitreoretinal surgery reoperations and longer surgeries were the most significant (P<0.05) risk factors for persistent sclerotomy opening, which may be functionally closed without evidence of leakage or ocular hypotony.

Passive removal of silicone oil through 23 gauge transconjunctival sutureless vitrectomy system

Objective:

To study the outcomes of passive removal of silicone oil by 23 Gauge Transconjunctival Sutureless Vitrectomy System.

Methods:

This prospective, consecutive case series study was conducted at Ophthalmology Department Unit I, Dow University of Health Sciences, Civil Hospital Karachi from January 2011 to December 2014. Only psuedophakic eyes with silicone oil temponade were selected. Main outcome measures were intra ocular pressure, time taken for removal of silicone oil, per operative and post operative complications. Pre and post operative IOP was compared by using two-tailed paired t-test and mean values with standard deviation were computed using difference of 95% confidence interval. Chi square test was applied for correlation of different variables. P-value of less than 0.05 was considered statistically significant.

Results:

Out of 79 patients who underwent passive ROSO, 38 (48.1%) were males. Mean age of patients was 47.5±7.1 (sd) years. Mean time taken for passive ROSO was 7.31±2.41 (sd) minutes. Pre and post operative intra ocular pressure shows statistically significant (p=0.000) decrease in IOP. Retinal redetachment found in 13 (16.5%) cases during follow up period.

Conclusion:

Passive removal of silicone oil with 23 G suture less vitrectomy system is safe and effective in terms of less per operative and post operative complications. In this simple technique, there is less tissue trauma and little time consumed so it provides more comfort to patients and surgeons as well.

Comparison of efficacy and safety between transconjunctival 23-gauge and conventional 20-gauge vitrectomy systems in macular surgery

Purpose

To compare the efficacy and safety of 23-gauge transconjunctival vitrectomy with the conventional 20-gauge method in idiopathic epiretinal membrane and macular hole surgery.

Methods

Sixty-one consecutive patients undergoing vitrectomy for idiopathic epiretinal membrane and macular hole were recruited to either 20- or 23-gauge vitrectomy groups and prospectively evaluated. Surgical success rates, operating time, surgery-related complications, long-term visual outcomes, and postoperative ocular surface problems are compared in the two groups.

Results

There were 31 eyes in the 20-gauge group and 33 eyes in the 23-gauge group. The macular hole closure rate after the first surgery was 83% and 90.9% in the 20-gauge and 23-gauge groups, respectively, with no significant difference between groups (p = 0.59). The success rate for idiopathic epiretinal membranes cases was 100% in both groups. There was no statistically significant difference between overall surgical times (p = 0.90). None of the patients in either group experienced postoperative complications of severe postoperative hypotony, vitreous hemorrhage or endophthalmitis, except one eye in the 20-gauge group, which was found to have retinal detachment. In both groups, statistically significant improvement in visual acuity was achieved 1-month postoperatively (p = 0.002) and thereafter at all postoperative visits (p < 0.05). The mean ocular surface scores were significantly lower in the 23-gauge group at all postoperative visits compared with the 20-gauge group scores (p = 0.001).

Conclusions

Transconjunctival 23-gauge vitrectomy appears to be as effective and safe as conventional 20-gauge vitrectomy in idiopathic epiretinal membrane and macular hole surgeries.

Fifty consecutive cases of transconjunctival sutureless 23-gauge vitrectomy combined with phacoemulsification and IOL implantation

BACKGROUND AND OBJECTIVE

To evaluate safety and effectiveness of combined 23-gauge vitrectomy and phacoemulsification with intraocular lens (IOL) implantation for eyes with vitreoretinal conditions and progressed cataract.

PATIENTS AND METHODS

The authors retrospectively reviewed 50 previously nonvitrectomized eyes of 50 patients with various vitreoretinal conditions and cataract affecting visual acuity. They underwent combined surgery with sutureless transconjunctival 23-gauge vitrectomy and phacoemulsification with IOL implantation. Surgical indications were a progressed cataract with various retinal conditions.

RESULTS

Best-corrected visual acuity (BCVA) improved from 0.23 (range: 0.125 to 0.32; standard deviation [SD]: 0.08) to 0.48 (range: 0.32 to 0.8; SD: 0.16). Spherical equivalent changed from 0.50 to 0.08 diopters. Cataract surgery mean time was 10.46 minutes, vitrectomy mean opening time was 1.1 minutes, and mean vitrectomy procedure time varied widely depending on the type of retinal surgery (20.06 minutes; range: 5 to 55; SD: 11.10). At 1 week, relative hypotony was found in 12% and hypotony was found in 4%. There was no hypotony 3 months after surgery.

CONCLUSION

Transconjunctival 23-gauge vitrectomy with phacoemulsification with IOL implantation appears effective with an acceptable safety profile for patients with cataract with simultaneous retinal diseases.

Transconjunctival Sutureless 23-gauge Vitrectomy for Vitreoretinal Diseases: Outcome of 30 Consecutive Cases

Background:

To describe the initial experience, effectiveness, and safety profile of 23-gauge instrumentation for a variety of vitreoretinal conditions.

Methods:

A retrospective review of 30 consecutive 23-gauge vitrectomy cases done by a single vitreoretinal surgeon for various posterior segment conditions was done. All surgeries were performed using the two-step 23-gauge system developed by Dutch Ophthalmic Research Center (DORC). All patients had at least 3-month follow-up. Main outcome measures included surgical success, visual acuity, intraocular pressure, and operative complications.

Results:

Mean follow-up was 7.7 months (range 3–12 months). Indications for surgery included rhegmatogenous retinal detachment (n=8), nonclearing vitreous hemorrhage (n=6), tractional retinal detachment (n=5), macular hole (n=5), epiretinal membrane (n=3), retained lens fragments (n=2) and endophthalmitis (n=1). Gas tamponade was used in 18 eyes (60%) and silicone oil in six eyes (20%). Mean overall preoperative visual acuity was 20/1053 and final acuity was 20/78 (P = 0.001). Mean intraocular pressure after 6 hours was 15.1mmHg (range 4-25 mmHg) and on postoperative day one was 14.5 mmHg (range 2-21 mmHg). Four eyes (13.3%) required suturing of sclerotomy intraoperatively. Conversion to 20-gauge was done in one eye (3.3%). Hypotony was reported in one eye (3.3%) postoperatively. Subconjunctival silicone oil reported in one eye (3.3%). There were no postoperative complications of endophthalmitis, retinal or choroidal detachment.

Conclusion:

23-gauge transconjunctival sutureless vitrectomy was effective in the management of wide variety of vitreoretinal surgical indications. The safety profile compared favorably with published rates for 25-gauge systems.

Hypotony after 25-gauge vitrectomy

PURPOSE

To describe the incidence of hypotony after 25-gauge vitrectomy and to identify preoperative and intraoperative factors that influence the occurrence of hypotony.

DESIGN

Retrospective, nonrandomized, interventional case series.

METHODS

We reviewed 122 consecutive cases of 25-gauge vitrectomy for all surgical indications. The primary outcome measure was intraocular pressure (IOP) at postoperative day 1, measured with Goldmann tonometry. Secondary outcome measures were clinical signs of hypotony and other complications.

RESULTS

Hypotony, defined as an IOP of 5 mm Hg or less, was found in 13.1% of cases on postoperative day 1. Clinical signs of hypotony were encountered in 7 eyes (5.7%). The risk of hypotony was significantly lower in cases with air or gas tamponade (3.3%) than in cases without tamponade (22.4%). Hypotony was encountered more often in reoperations (29.9%) than in primary operations (9.2%; statistically significant difference). In cases in which intravitreal triamcinolone was used, the risk of hypotony was significantly higher (35.3%) than in cases without triamcinolone (10.3%). Phakic eyes had significantly less chance of hypotony (6.7%) than pseudophakic eyes (15.6%) and eyes undergoing combined phacoemulsification and vitrectomy (25.0%). At postoperative day 7, all cases of hypotony recovered spontaneously. None of our cases developed endophthalmitis.

CONCLUSION

Our results show that a transient hypotony occurs commonly after 25-gauge vitrectomy. Hypotony was significantly influenced by tamponade, reoperation, intraoperative lens status, and use of intravitreal triamcinolone. Although all cases of hypotony recovered spontaneously without permanent damage, the high frequency of hypotony does impose potential risks. Increased vigilance with focus on perioperative antisepsis and low tolerance of sclerotomy leakage are important for the prevention of endophthalmitis. Strategies aimed at lowering the risk of hypotony are needed to improve the safety of this promising technique.

[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.

25-GAUGE MACULAR SURGERY

PURPOSE

To report the safety and surgical outcome of 25-gauge transconjunctival sutureless vitrectomy for macular conditions.

METHODS

In a single-center, retrospective, noncomparative case series, 160 eyes of 150 patients underwent 25-gauge vitrectomy for different macular conditions: 108 eyes for idiopathic macular pucker, 24 for idiopathic macular hole, and 28 for tractional diabetic macular edema. Main outcome measures were surgical time, preoperative and 1-day intraocular pressure (IOP), preoperative and 1-month, 3-month, and 6-month visual acuity, intraoperative and postoperative complications, anatomical results, and cataract progression. All patients were observed up for at least 6 months.

RESULTS

Mean follow-up was 10 months (range, 6-20 months). Mean operative time +/- SD was 21 +/- 11 minutes. Mean 1-day IOP was 14 +/- 4 mmHg. No IOP was <8 mmHg on postoperative day 1. Mean overall preoperative visual acuity was 20/70, and mean overall postoperative visual acuity was 20/40 (P <or= 0.001). Sixty percent of patients gained >or=2 Snellen lines of visual acuity at 1 month; 74%, at 3 months; and 67%, at 6 months (P <or= 0.001, all times). There were no intraoperative complications. Three percent of eyes had complications during follow-up. Twenty-five percent of phakic eyes presented with a significant cataract at the 6-month follow-up.

CONCLUSIONS

25-Gauge vitrectomy is a safe and effective procedure for macular surgery. The absence of intraoperative complications and relatively low rate of postoperative complications suggest that this technique is safe and effective for treating macular conditions.

Outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease

PURPOSE

To describe the initial experience, effectiveness, and safety profile of 23-gauge instrumentation for a variety of vitreoretinal conditions.

DESIGN

Single-center, retrospective, noncomparative, consecutive interventional case series.

PARTICIPANTS

Seventy-seven eyes of consecutive patients who underwent 23-gauge transconjunctival vitrectomy surgery by a single surgeon at the Manhattan Eye, Ear, and Throat Hospital from October 2004 through October 2005.

INTERVENTION

All patients underwent 3-port 23-gauge vitrectomy using Dutch Ophthalmic Research Corporation instrumentation and an Alcon Accuris Vitrector.

MAIN OUTCOME MEASURES

Postoperative visual acuity at months 1 and 3, intraoperative and postoperative complications, and operative time.

RESULTS

Mean acuity improved from 20/190 at baseline to 20/108 (P<0.0001) and 20/74 (P<0.0001) at months 1 and 3, respectively. By diagnosis, patients with epiretinal membrane (n = 20) improved from 20/124 to 20/93 (P = 0.0046), macular hole (n = 18) from 20/174 to 20/57 (P = 0.0007), rhegmatogenous retinal detachment (RD) (n = 14) from 20/248 to 20/51 (P = 0.0004), tractional RD (n = 12) from 20/175 to 20/62 (P = 0.0159), nonclearing vitreous hemorrhage (n = 12) from 20/1345 to 20/189 (P = 0.0004), vitreomacular traction (n = 4) from 20/145 to 20/124 (P = 0.7525), and retained lens fragments (n = 4) from 20/308 to 20/140 (P = 0.0972). One patient who underwent diagnostic vitrectomy had stable 20/50 acuity. Two patients had hypotony on postoperative day 1, 1 patient required a sutured sclerotomy intraoperatively, and no patients developed choroidal effusions. No intraoperative tears were noted. Surgical times collected on 17 patients during the final month of the study demonstrated a mean opening time (range) of 103 seconds (70-162), mean closing time of 75 seconds (17-470), and net operating time of 24.1 minutes (7.1-74.6).

CONCLUSIONS

Twenty-three-gauge instrumentation is effective for a variety of vitreoretinal surgical indications. The safety profile compared favorably with published rates for 25-gauge systems.

Pars-plana-Vitrektomie mit Infusionszugang über eine korneale Parazentese bei pseudophaken Augen

BACKGROUND

More than 50% of vitrectomies are performed in pseudophakic eyes. There is free communication between the anterior segment of the eye and the vitreous cavity through the zonular fibres of the lens. This means it is possible to use a primary anterior chamber infusion for pars-plana vitrectomy.

METHODS

For some years, therefore, we have used an anterior chamber approach for the infusion cannula when carrying out such simple vitreo-retinal procedures as silicone oil removal or macular pucker peeling in pseudophakic eyes.

RESULTS

In all eyes the anterior chamber access was placed via a corneal paracenthesis and during all vitrectomies it was held in place by corneal tissue tone with no need for suturing. Secure wound closure was also achieved without suturing by simply swelling the paracentesis. Conventional sclerotomies were closed with absorbable sutures. During vitrectomy the infusional flow was sufficient to ensure adequate intraocular pressure regardless of intraocular lens type and diameter.

CONCLUSIONS

In pseudophakic eyes the anterior chamber infusion approach by way of a paracentesis is a safe way of reducing surgical trauma during vitrectomy. It must, however, be borne in mind that when an endotamponade is applied it is necessary to switch the infusion to one of the sclerotomies.

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

BACKGROUND

The standard straight incision for 25-gauge vitrectomy may not close well at the end of surgery with post-operative hypotony. To overcome incompetent wound closure, oblique insertion of the trocars has been suggested. More recently we have developed an oblique incision. which is parallel to the scleral fibres instead of perpendicular and therefore avoids cutting. The aim of this study was to compare the effectiveness of the different incisions and to investigate their behaviour with the UBM.

METHODS

45 patients affected by macular holes were operated; in 15 eyes using oblique-parallel insertion (OPAI), in 15 oblique-perpendicular (OPEI) and in 15 straight incision (SI). Patients underwent UBM examinations 1 day, 1 week, 1 month p.o.

RESULTS

OPAI was airtight after the removal of 25 g cannulas. UBM examination 1 day post-operatively (p.o) showed the 45 sclerotomies were well healed with perfect apposition of the internal wound lips. 39 sclerotomies were undetectable, 6 slightly evident. With OPEI the incisions were airtight at the end of surgery. At the 1 day p.o. UBM examination the 45 sclerotomies were well-healed but a minimal gape was clearly visible in all of them, 3 eyes showed peripheral cilio-choroidal (CCD) detachment, which was resolved after 7 days although the gape was still evident. At 1 month p.o. examination the gape was not detectable in 20 sites, evident in 25. With SI at the end of the surgery conjunctival bleb formation was detected in 10 cases, air-gas refilling was performed in 7 eyes and 3 sclerotomies were sutured. At 1 day p.o. hypotony was recorded in 5 patients, recovering at the 7 day follow-up. At the 1 day p.o. UBM examination showed a significant gape in all sites, weak vitreous entrapment was shown in 36, subconjunctival fluid in 4, CCD in 7. At the 7 day UBM the CCD had disappeared in 4 and was reduced in 3. At the 1 month p.o. the sclerotomy defect was still detectable but other complications were no longer evident.

CONCLUSIONS

OPAI achieved the quickest and most complete sealing since the 1st day p.o without complications, therefore it could be safer when performing 25-g vitrectomy with extensive manipulation.

Problems associated with the 25-gauge transconjunctival sutureless vitrectomy system during and after surgery

OBJECTIVE

To report the initial experiences with the 25-gauge transconjunctival sutureless vitrectomy (TSV) system, including intraoperative and postoperative problems.

METHODS

We retrospectively reviewed the medical records and surgical videotapes of 50 consecutive patients who underwent vitrectomy performed by one surgeon using the TSV system.

RESULTS

Intraoperatively, we encountered such problems as difficulty in inserting the microcannula, which led to deformity, instability of the microcannula, self-disconnection of the infusion tip and resultant lens damage, and conversion to 20-gauge conventional vitrectomy. Postoperatively, there were 8 cases with hypotony (IOP < 6 mm Hg) on day 1, 6 cases with elevated IOP, and 3 cases with retinal detachment during follow-up.

CONCLUSION

Though certain problems exist during and after surgeries using TSV, this system is both convenient and safe for various vitreoretinal procedures.

Longer-term outcomes of transconjunctival sutureless 25-gauge vitrectomy

PURPOSE

To report longer-term outcomes in eyes undergoing 25-gauge transconjunctival sutureless vitrectomy.

DESIGN

Retrospective, noncomparative, case series.

METHODS

Chart review of the initial 45 consecutive patients (45 eyes) that underwent TSV by one surgeon (T.S.H.) for idiopathic epiretinal membrane (n = 15), refractory diabetic macular edema (n = 11), idiopathic macular hole (n = 10), and nonclearing vitreous hemorrhage (n = 9). All patients had at least 6-month follow-up. Main outcome measures included visual acuity (VA), intraocular pressure, intraoperative complications, and postoperative complications.

RESULTS

Mean follow-up was 13 months (range 6 to 25 months). Mean overall preoperative VA vs last postoperative VA was 20/229 and 20/65, respectively (P < .0001). Statistically significant VA improvement was seen for each patient subgroup. Mean preoperative intraocular pressure was 16.9 mm Hg (range 10-26 mm Hg). On postoperative day 1, week 1, and week 4, median intraocular pressure was 14.6 mm Hg (range 8-17 mm Hg), 17.6 mm Hg (range 8-38 mm Hg), and 17.7 mm Hg (range 9-33 mm Hg), respectively. No intraoperative complications occurred. Postoperative complications were 1 inferior retinal detachment (2.2%) 4 weeks after macular hole repair, 1 macular hole (2.2%) 6 months after epiretinal membrane peel, and 23 worsening cataracts in 29 phakic eyes (79.3%).

CONCLUSIONS

Less surgically complex vitreoretinal pathology may be successfully repaired with TSV. After a mean follow-up of more than 1 year, minimal complications were seen, and none was specifically related to the sutureless nature of the procedure.