Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery

Outcomes of 23-Gauge Pars Plana Vitrectomy in Various Vitreoretinal Diseases

Background This study aimed to evaluate the safety, efficacy, and complications of 23-gauge (23-G) pars plana vitrectomy (PPV) in the treatment of various vitreoretinal diseases. Methodology A retrospective, cross-sectional study was conducted at Al-Shifa Trust Eye Hospital, Rawalpindi. All the eyes undergoing 23-G PPV between June 2020 and May 2023 meeting the inclusion criteria were included. Surgical outcomes and complications were assessed. Results A total of 350 eyes were included in our data. The most common indication was rhegmatogenous retinal detachment (RRD) (n = 144, 41.1%), followed by diabetic tractional retinal detachment (TRD) (n = 98, 21%). Satisfactory anatomical outcomes were achieved in all the indications. The primary success rate was 87.5% for RRD and 96.9% for TRD. The overall complication rate was 17.7%, with postoperative cataracts being the most frequent. Conclusions The 23-G PPV technique has proven to be a safe and effective approach for the surgical management of various vitreoretinal diseases, demonstrating favorable anatomical outcomes and a low rate of complications.

Secondary acute angle closure glaucoma after 25-gauge pars plana vitrectomy for a macular hole: a case report

BACKGROUND

Posterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole.

CASE PRESENTATION

A 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole.

CONCLUSIONS

This case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye.

Adverse Events Associated With 3 Vitrectomy Platforms Reported to the US FDA MAUDE Database

Purpose: To identify and describe adverse events (AEs) observed with real-world use of the following 3 vitrectomy platforms: Constellation (Alcon), Enhancing Visual Acuity (EVA, Dutch Ophthalmic Research Center), and Stellaris (Bausch + Lomb). Methods: All reports submitted to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database between January 2010 and November 2021 that were associated with the 3 vitrectomy platforms were analyzed. Each report was reviewed for AEs or consequences and the type of complication noted. Duplicates and reports with an inadequate narrative to categorize the event were excluded. A descriptive analysis was performed for the prevalence of device-specific issues within each platform. Results: The analysis included 2534 reports (1738 Constellation, 117 EVA, 679 Stellaris). Overall, the most commonly reported complications involved the vitrectomy probe (n = 957 [37.8%]) and the central processing unit (n = 368 [14.5%]). Differences in the distribution of AEs among the platforms were noted, with vitrectomy probe issues being the most reported events for the Constellation and Stellaris and infusion issues for the EVA. Infusion issues most frequently led to reports of patient harm with the Constellation (31/1738 [1.8%]) and EVA (7/116 [6.0%]), while issues with the vitrectomy probe were reported with the Stellaris (11/679 [1.6%]). Conclusions: An analysis of real-world data in the MAUDE database highlighted the spectrum of device-specific AEs of greatest relevance to surgical practice. Familiarity with potential device complications will help minimize harm to patients.

Vitreoretinal Surgery in Uveitis: From Old to New Concepts - A Review

PURPOSE

The aim of this article is to do a comprehensive literature review about the current role of pars plana vitrectomy in uveitis and in its different structural complications such as cystoid macular edema, epiretinal membrane, macular hole, and retinal detachment.

METHODS

This comprehensive literature review was performed based on a search on PubMed, BioMed Central, Science Open, and CORE databases, of relevant articles abording pars plana vitrectomy in uveitis.

DISCUSSION

Uveitis is a complex disease with multiple etiologies and pathogenic mechanisms. Therapeutic pars plana vitrectomy (PPV) may aid in uveitic structural complications such as cystoid macular edema, epiretinal membranes, macular hole, and retinal detachments even though some cases may present unpredictable visual outcomes. Diagnostic PPV with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

CONCLUSION

Over the years, pars plana vitrectomy has undergone significant transformations since its invention nearly 5 decades ago, however, the quality of evidence in the literature regarding its use for uveitis has not improved in the same way. Even though some structural uveitis complications (as previously mentioned) may respond well to surgery, there is still a certain unpredictability regarding its visual outcomes. On the other hand, diagnostic vitrectomy with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

T-shaped pars plana scleral incision to remove large intraocular foreign body

Aim

To investigate the efficacy and safety profile of T-shaped pars plana scleral incision technique in removing large intraocular foreign bodies, during 23-gauge pars plana vitrectomy.

Methods

Retrospective interventional case series that included patients diagnosed with a large intraocular foreign body (IOFB). Possible postoperative complications were recorded 24 h, 1 month, 3 and 6 months postoperatively.

Results

Thirty eyes of 30 patients (48 ± 5 years old) were enrolled. All IOFBs were successfully removed: mean diameters of 7.8 ± 2.0 mm and 2.6 ± 0.3 mm. Silicone oil and sulfur hexafluoride were used in 27 and 3 eyes, respectively. Lensectomy was performed in 27 eyes. Intraocular lens was implanted at first attempt in 12 eyes; during a second operation in 12 eyes and 6 eyes remained aphakic. At any follow-up, no signs of postoperative complications were observed. Secondary retinal detachment occurred in 12 eyes. Mean preoperative corrected distance visual acuity was 0.04, on the Snellen scale; it increased to 0.07, at last follow-up. Mean intraocular pressure was 17.97 mmHg. All eyes were preserved.

Conclusion

T-shaped scleral incision could be an effective, safe and easy-to-perform standard procedure to remove large IOFBs during pars plana vitrectomy, without increasing the risk of surgical complications and additional damage to the ocular tissues.

Comparison of complications of intrascleral fixation according to the extent of vitrectomy

BACKGROUND

Intraocular lens (IOL) fixation is performed after intraoperative anterior or total vitrectomy. This study aimed to compare the intraoperative and postoperative complications of these two techniques.

METHODS

This retrospective study included 235 eyes that underwent intrascleral fixation surgery at our hospital between July 2014 and January 2021. The eyes were classified into the anterior vitrectomy group (A-vit group; 134 eyes) and the pars plana vitrectomy group (PPV group; 101 eyes). The age, preoperative and postoperative best-corrected visual acuity, observation period, preoperative and postoperative intraocular pressure, and the incidence of intraoperative and postoperative complications were assessed.

RESULTS

Intrascleral fixation was performed more frequently in the PPV group, and a significant difference was observed between the eyes with a history of vitrectomy and eyes with scleral buckles (p = 0.00041). In terms of the incidence of postoperative complications following intrascleral fixation, the incidence of low intraocular pressure postoperative was higher in the PPV group than that in the A-vit group, and a significant difference was observed between the two groups (p = 0.01).

CONCLUSIONS

The visual outcome and complications following intrascleral fixation did not differ according to the extent of vitreous excision.

Twenty-seven-gauge vitrectomy: a consecutive, single-centre case series with exclusive use over a 4-year period

BACKGROUND

To assess the safety and effectiveness of the exclusive use of 27-gauge instruments for all vitreoretinal diseases requiring vitrectomy.

METHODS

In this retrospective study, 1020 consecutive surgeries were performed on 958 eyes of 848 patients using 27-gauge instruments from March 2017 to June 2021. Patients with a minimum follow-up of 3 months were included. Surgical case-mix, best-corrected visual acuity (BCVA), intraocular pressure (IOP), intra- and post-operative complications, and surgery times were recorded.

RESULTS

The study patients were followed up for averagely 11 months. Of the 1020 vitrectomies, 958 were primary procedures. Of the 148 retinal detachment (RD) cases, 138 (93%) required a single vitrectomy. Primary macular hole closure was achieved in 143 of 145 (99%) cases. The average surgical times were 55 and 38 min for RD surgeries and for all other indications, respectively. BCVA improved significantly at the final visit (20/49) compared with the pre-operative visit (20/78) (p < 0.01). IOP was similar at the pre-operative (14.8mmHg) and final (14.3mmHg) visits. Complications recorded include transient hypotony in 39 eyes, iatrogenic retinal breaks in 2 eyes, and a vitreous bleed in 1 other eye.

CONCLUSION

This study revealed that 27-gauge vitrectomy instruments can be used for a wide range of indications, with exclusive use in certain settings. The outcomes were similar to other gauges, including for rhegmatogenous retinal detachment, with minimal complications.

27‑Gauge vitrectomy vs. 25‑gauge vitrectomy in the management of proliferative diabetic retinopathy with preoperative intravitreal injection of conbercept

Small-gauge vitrectomy has become popular due to its notable advantages, including less trauma, shortened convalescence and improved manoeuvrability. The aim of the present study was to compare the surgical outcomes of 27-gauge (27-G) vitrectomy with those of 25-gauge (25-G) vitrectomy in the management of proliferative diabetic retinopathy (PDR) with preoperative intravitreal injection of conbercept. The data of 48 consecutive patients with PDR (48 eyes) were retrospectively collected. The patients underwent conbercept intravitreal injection and pars plana vitrectomy with a 27-G group (23 eyes) or 25-G group (25 eyes) vitrectomy system. The operating time, suturing rate, endodiathermy rate, postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complications were recorded. The mean postoperative BCVA at final follow-up was significantly improved compared with that at the baseline in both groups (P<0.001 for both). The differences in the mean BCVA changes between the two groups were not significant (P>0.99), and no differences were observed in the final central foveal thickness (P=0.51) between the two groups. The final IOP remained stable compared with that at the baseline in the 27-G group (P=0.36) and the 25-G group (P=0.05). The suturing rate was significantly decreased in the 27-G group compared with the 25-G group (P=0.04). There were no significant differences between the two groups in terms of the operating time (P=0.18), rate of endodiathermy use (P>0.99), iatrogenic retinal breaks (P=0.42) or postoperative recurrent vitreous haemorrhage (P>0.99). In addition, no case of ocular hypotony was observed in either group. In conclusion, 27-G vitrectomy was as efficient and safe as 25-G vitrectomy in the management of PDR in terms of operating time and complications. With reference to the literature, preoperative conbercept injection appears to assist in decreasing the incidence of intraoperative and postoperative complications.

Analysis of Risk Factors for Revitrectomy in Eyes with Diabetic Vitreous Hemorrhage

Purpose

We aimed to investigate the risk factors associated with revitrectomy in eyes with diabetic vitreous hemorrhage and to determine the prognosis of these patients at least one year postoperatively.

Patients and Methods

This retrospective case-control study had a minimum follow-up period of one year. Patients were divided into single vitrectomy group (control group, n=202) and revitrectomy group (case group, n=36) for analysis. The indications, number, and timing of revitrectomies were documented. And the revitrectomy group was further divided into two vitrectomies group (n=30) and three or more vitrectomies group (n=6). The best-corrected visual acuity (BCVA) at the last follow-up and the occurrence of neovascular glaucoma (NVG) were compared among the single vitrectomy, two vitrectomies and three or more vitrectomies groups. We conducted a thorough collection of patient data and used univariate and binary logistic regression analyses to identify the risk factors associated with revitrectomy.

Results

A total of 197 patients (238 eyes) were included. Thirty-six eyes (15.1%) required revitrectomy with six eyes (2.5%) undergoing three or more vitrectomies during the follow-up period. The median duration of the second vitrectomy was 3 (2-6) months. The indications for a second vitrectomy included 28 eyes (77.8%) of postoperative vitreous hemorrhage and 7 eyes (22.2%) combined with tractional retinal detachment. Patients undergoing three or more vitrectomies had significantly worse postoperative BCVA and a higher incidence of NVG (P<0.01). Fibrinogen> 4 g/L (P<0.001) and preoperative anti-vascular endothelial growth factor intravitreal injection (P=0.015) were independent risk factors for revitrectomy, and glycated hemoglobin A1c (HbA1c)>10% (P=0.049) showed significant difference only in univariate analysis.

Conclusion

Patients requiring revitrectomy tended to have higher fibrinogen levels, tightly adhered fibrovascular membranes, higher HbA1c levels, and worse prognoses.

COVID-19 reduced scleral buckling training in fellows and shifted young ophthalmologists' preference toward vitrectomy: An Asia-Pacific survey

BACKGROUND

To assess rhegmatogenous retinal detachment (RRD) surgery trends and training among young ophthalmologists (YOs, vitreoretinal fellows or attendings/consultants with ≤10 years of independent practice) and the impact of the COVID-19 pandemic.

METHODS

An anonymous online survey was completed by 117 YOs in the Asia-Pacific regarding their RRD surgery experiences in 2021-2022.

RESULTS

To achieve a 90% probability of surgical competency, 91 vitrectomy and 34 scleral buckling (SB) completions during fellowship were needed. In total, 49 (41.9%) YOs had fellowship affected by COVID-19. In the COVID versus pre-COVID era, however, the volume of SB completions per fellowship year decreased significantly (median [IQR] 3.3 [1.5, 9] vs. 13 [6.5, 23]; p < 0.001) and was lower than the required volume to achieve competency. YOs were less confident in conducting SB versus vitrectomy (3.5 ± 1.1 vs. 4.2 ± 0.8, p < 0.001), and they reported a decrease in the proportion of SB (-3.1%, p = 0.047) and an increase in the proportion of vitrectomy (+4.8%, p < 0.001) after the pandemic outbreak. Apart from RRD clinical characteristics, surgical confidence is among the main factors that affect surgical method decisions. During the pandemic, more YOs may have avoided SB due to the need for general anaesthesia, leading to longer surgical time and risk of viral transmission during intubation/extubation.

CONCLUSIONS

SB surgical exposure is suboptimal in most fellowship programs in the 11 Asia-Pacific countries/regions we surveyed and further declined during the COVID-19 pandemic. YOs are less confident in performing SB, leading to a trend toward primary vitrectomy since the COVID-19 outbreak.

Evaluation of the Efficiency and Safety of a 27-Gauge 20,000 Cuts per Minute Vitreous Cutter

Purpose

The aim of this study was to evaluate the efficiency and safety of a 27-gauge (G) 20,000 cuts per minute (cpm) vitreous cutter in clinical settings.

Patients and Methods

This was a retrospective and observational study of 40 eyes of 40 patients with idiopathic epiretinal membrane (ERM). Twenty patients (20 eyes) were treated using a 27G 10,000-cpm vitreous cutter (Advanced ULTRAVIT^® Probe, Alcon), whereas the remaining 20 patients (20 eyes) were treated using a 27G 20,000-cpm cutter (Hypervit^® dual-blade probe, Alcon). All the surgeries were performed by the same surgeon (YM). The time from the start of vitrectomy to the start of ERM peeling was independently measured by two separate examiners using digital videos of each surgery. The average duration of vitrectomy was calculated for each patient. Additionally, the data of the patients in the two groups were extracted from their medical and surgical records and compared.

Results

The time from the initiation of vitrectomy until the start of ERM peeling was 184 ± 56.9 and 152 ± 39.5 s for the 10,000-cpm and 20,000-cpm groups, respectively. The duration of vitrectomy was significantly shorter in the 20,000-cpm group than in the 10,000-cpm group (p = 0.041). Postoperative vitreous hemorrhage was observed in one patient in the 10,000-cpm group, whereas no complications were observed in the 20,000-cpm group.

Conclusion

In a clinical setting, the 27G 20,000-cpm vitreous cutter may have a higher safety profile and higher efficacy for vitreous removal than that of the 27G 10,000-cpm vitreous cutter.

Incidence of early complications requiring treatment plan changes after vitreoretinal surgery: a single-center study in South Korea

BACKGROUND

Information regarding incidence of treatment plan changes may be useful when discussing postoperative treatment plans for patients. Moreover, it may help establish a standardized postoperative treatment plan. This study aimed to evaluate the incidence of early complications requiring treatment plan changes in patients following vitreoretinal surgery and investigate its risk factors.

METHODS

This single-center retrospective study included 465 patients who had undergone vitreoretinal surgery. The reasons, incidence, and timing of treatment plan changes within 14 days of surgery were identified. Potential factors associated with the changes, such as patient demographics, surgeon's experience, diagnoses, and type of surgery were also analyzed.

RESULTS

The treatment plan was changed in 76 patients (16.3%) at a mean of 4.0 ± 3.2 days after vitreoretinal surgery. The reasons for the plan changes were increased intraocular pressure (IIOP) in 66(86.8%), intraocular inflammation in 2(2.6%), corneal edema in 3(3.9%), leakage from the sclerotomy wound in 3(3.9%) patients, and combined IIOP and intraocular inflammation in 2(2.6%). The date of discharge was postponed because of treatment plan changes in 17 patients (22.4%). The incidence of plan changes was higher in patients who underwent gas or oil tamponade (P < 0.001) and those who underwent surgery performed by less experienced surgeons (P = 0.034).

CONCLUSIONS

Treatment plan was changed in 16.3% of patients after vitreoretinal surgery. The risk of treatment plan changes was associated with the surgeon's experience in vitreoretinal surgery and the type of surgery. These results should be considered when establishing standardized care plans for patients who require vitreoretinal surgery.

IMMEDIATE VITRECTOMY vs TAP AND INJECT IN EYES WITH ACUTE POSTCATARACT ENDOPHTHALMITIS AND VISUAL ACUITY ≥HM: A Randomized Clinical Trial

PURPOSE

To compare the outcomes of immediate pars plana vitrectomy (PPV) and tap and inject in eyes with postcataract surgery endophthalmitis.

METHODS

Patients presenting with acute postcataract surgery endophthalmitis and visual acuity between ≥ hand movement and <6/18 were randomized to receive either PPV (Group A) or tap and inject (Group B).

RESULTS

There were 26 and 31 eyes in Group A and Group B, respectively. The final mean visual acuity at 6 weeks [0.14 (Snellen equivalent 6/7.5) versus 0.22 (Snellen equivalent 6/9.5) LogMAR in Groups A and B, respectively; P = 0.2] was similar. However, eyes in Group A had significantly greater mean letter gain in vision compared with Group B (66.36 vs. 43.36, P = 0.02), and more eyes in Group A (88%) than in Group B (65%) attained a visual acuity of ≥ 6/18 ( P = 0.06). Eyes in Group B needed more reinterventions including delayed vitrectomy after tap and inject than those in Group A (39% vs. 8%; P = 0.09). On subgroup analysis, the mean visual acuity at the final follow-up was significantly better in the immediate PPV group compared with the delayed PPV group ( P = 0.04).

CONCLUSION

PPV resulted in earlier recovery, lesser interventions, and greater change in visual acuity than tap and inject in eyes with postcataract surgery endophthalmitis presenting with visual acuity of ≥HM.

Two-Port “Dry Vitrectomy” as a New Surgical Technique for Rhegmatogenous Retinal Detachment: Focus on Macula-on Results

We evaluated a new surgical technique for treating primary rhegmatogenous retinal detachment (RRD), consisting of localized vitrectomy near the retinal break associated with drainage of subretinal fluid without infusion. Twelve eyes of twelve patients with primary RRDs with macula-on superior, temporal, and/or nasal quadrants’ RRD with retinal breaks between 8 and 4 o’clock, pseudophakic or phakic eyes, were enrolled. All eyes underwent a two-port 25-gauge vitrectomy with localized removal of the vitreous surrounding the retinal break(s), followed by a 20% SF6 injection and cryopexy. The difference between pre-operative (T0) and post-operative mean BCVA at 6 months follow-up (T6) was not statistically significant (0.16 logMAR vs. 0.21 logMAR; p = 0.055). Primary anatomic success at 6 months was achieved by 86% of patients. No other complications, except for two retinal re-detachments linked to an incorrect head position of the patients, were recorded. Although further studies are necessary to evaluate the treatment’s efficacy, we believe our technique could be considered a valid alternative for managing primary RRD.

NONPERFORATING INTRASCLERAL STABBING FOR SUTURELESS 23G SCLEROTOMY CLOSURE

PURPOSE

The need for suturing leaking sclerotomies have not been eliminated completely in transconjunctival sutureless vitrectomy (TSV). This study aims to describe a novel technique for 23-gauge (G) sclerotomy closure in TSV surgery and discuss its effectiveness.

MATERIALS AND METHODS

Two hundred and thirty cases of 180 patients who underwent 23G TSV with various diagnoses were included to the study. Cases with connective tissue diseases, thin sclera, and significant conjunctival and scleral scarring were excluded. Nonperforating intrascleral stabbing (NIS) was performed to leaking 23G sclerotomies (n = 650) and 27G chandeliers (n = 84). Demographics, rate of sclerotomy closure with NIS procedure, the need for suturing, and complications of the procedure were recorded.

RESULTS

The overall success of NIS was found to be 91.0% in sclerotomies. Although 9.1% of sclerotomies required sutures, 592 of the 650 sclerotomies could be closed with NIS procedure ( P < 0.001). Nonperforating intrascleral stabbing procedure helped close 98.8% of leaking 27G chandeliers. An average of 1.28 ± 0.52 NIS attempts were needed for successful sclerotomy closure. Closure of sclerotomies with the NIS technique were somewhat related to the location of the sclerotomy, history of TSV and NIS, duration of TSV, and type of endotamponade. Hypotonia and choroidal detachment were seen in one case. No additional interventions were needed to normalize intraocular pressure in any case. Subconjunctival hemorrhage happened to be the leading complication of the procedure.

CONCLUSION

NIS procedure seems as a practical, reproducible, cost-effective, and uncomplicated approach, which significantly reduces the need to suture 23G sclerotomies. Further studies are required.

Intravitreal dexamethasone: variation of surgical technique and prevention of ocular complications with ASOCT follow-up

PURPOSE

To verify the correct decision-making procedure on performing an intravitreal injection by investigating the in vivo wound morphology and evolution of 22-gauge wounds after dexamethasone oblique injection with anterior segment optical coherence tomography (OCT).

DESIGN

Prospective, observational consecutive case series.

METHODS

Subjects underwent a dexamethasone injection at University Eye Clinic of Turin. All the injections have been performed in an oblique (aka beveled or angled) fashion. Patients were divided according to the number of injections already performed with dexamethasone. Group 1 consisted of patients at the first injection, group 2 of patients at a second or more injection always in the same quadrant, and group 3 of patients at the second or more injection in a different quadrant. The incisions were imaged with the Heidelberg SPECTRALIS OCT device on postoperative days 1, 8, and 15. The main outcome measure was wound structure/characteristics (e.g., presence of gaping) as evaluated with OCT. Surgical and ocular parameters were also recorded.

RESULTS

Thirty-three consecutive patients were investigated. OCT demonstrated closed wounds in all eyes on postoperative days 1, 8, and 15. In all patients, the external (entry) side of the incision was seen as a gape; however, the rest of the wound was closed. No complications were recorded in the different patients during the follow-up. In patients of group 1, we identified the scleral pathway in 10 eyes at day 1. At 8 days in 9 of 10 eyes, the sclera had returned to its restitutio ad integrum. In patients of group 2, the scleral pathway was recognizable on the first day of control; in 7 patients, this was accompanied by the presence of intrascleral edema with peri-wound fluid. At the 8-day checkup, 3 eyes still showed signs attributable to the intrascleral pathway accompanied by peri-wound edema. In group 3, it was possible to identify the intrascleral pathway in 8 patients. There were no signs of intrascleral peri-wound edema or other anatomical changes in 9 patients as early as the first day. In the 8-day follow-up, the signs of scleral edema were absent in the single patient who presented them. At 15 days, there were no signs of scleral pathway in all eyes analyzed.

CONCLUSIONS

Speaking of intravitreal injections of slow-release dexamethasone, the technique that involves moving the conjunctiva and a beveled or angled sclerotomy after a careful choice of the injection site, paying attention to vary the quadrant involved with each puncture, reduces the number of days of closure of the sclera via and the scleral damage, thus protecting the patient from complications. For the future, it is hoped that the operating microscope and intraoperative OCT will be used on every occasion.

Pars plana vitrectomy in uveitis in the era of microincision vitreous surgery

Pars plana vitrectomy (PPV) in uveitis is indicated for various diagnostic and therapeutic indications. With the advent of microincision vitreous surgery (MIVS), the use of PPV in uveitis has increased with a wider spectrum of indications due to shorter surgical time, less patient discomfort, less conjunctival scarring, and a decreased rate of complications as compared to standard 20G vitrectomy. Because of faster post-operative recovery in terms of visual improvement and reduction of inflammation, and reduced duration of systemic corticosteroids, MIVS has gained popularity in uveitis as an adjunctive therapy to the standard of care medical therapy. The safety and efficacy of MIVS is related to the emerging vitrectomy techniques with better and newer cutters, illuminating probes, and accessory instruments. Because of the instrumentation and fluidics of MIVS, PPV is emerging as a safe and useful alternative for diagnostic challenges in uveitis, aiding in earlier diagnosis and better outcome of inflammatory disease, even in the presence of severe and active inflammation, which was once considered a relative contraindication for performing vitreous surgery. However, for surgical interventions for therapeutic indications and complications of uveitis, it is advisable to achieve an optimum control of inflammation for best results. The increasing reports of the use of MIVS in uveitis have led to its wider acceptance among clinicians practicing uveitis.

SUTURELESS CLOSURE OF 23- AND 25-GAUGE LEAKING SCLEROTOMIES WITH THE SCLERAL NEEDLING TECHNIQUE

PURPOSE

To describe and evaluate the efficacy of a novel technique, scleral needling (SN), for securing 23- and 25-gauge leaking sclerotomies in microincision vitrectomy surgery.

METHODS

A retrospective comparative review of consecutive cases of 23- and 25-gauge pars plana vitrectomy performed by a single vitreoretinal surgeon before the introduction of the SN technique (pre-SN; November 2016 to January 2017) and after the introduction of the SN technique (post-SN; November 2017 to January 2018) was conducted. The SN technique was implemented as an alternative to suturing, using a 30-gauge needle inserted perpendicularly through the full thickness of the sclera adjacent to the scleral opening, with the needle then immediately removed and sclerotomy closure confirmed.

RESULTS

A total of 203 eyes, 105 from pre-SN and 98 from post-SN, were included in the study. The number of eyes requiring suture closure was significantly reduced from 39% in the pre-SN group to 2% in the post-SN group (P < 0.001). The mean postoperative intraocular pressure and incidence of hypotony on Days 1 to 2, Days 3 to 20, and Days 21 to 50 was not significantly different between the pre-SN and post-SN groups. No major complications associated with the SN technique were noted during the study period.

CONCLUSION

The SN technique is a safe and simple method for effectively securing leaking sclerotomies in microincision vitrectomy surgery.

[Removal of higher viscosity oil through a hybrid 2-port 23/25 gauge pars plana vitrectomy]

This article presents a new hybrid method of a combined 2‑port 23/25G pars plana vitrectomy for removal of silicone oil (5700 centistokes) compared to a 25G vitrectomy. In this hybrid technique the infusion is performed through a 25G cannula and the oil removal through a 23G cannula. The duration of the surgery and the intraocular pressure (IOP) in both groups were compared. The oil removal using the hybrid technique was performed significantly faster with a reduction of the time by 32.2% but there was no difference in the IOP. In conclusion, silicone oil removal through a 25G cannula is generally possible but oil removal with the new hybrid technique is much faster.

Comparison of 27-gauge and 25-gauge vitrectomy in the management of tractional retinal detachment secondary to proliferative diabetic retinopathy

OBJECTIVE

To compare surgical outcomes between 27 and 25-gauge vitrectomy in proliferative diabetic retinopathy (PDR) with tractional retinal detachment (TRD).

METHODS

This retrospective study was conducted to compare the intraoperative status, operation time, use of instruments, endotamponade substance, wound suture number, and iatrogenic break, between 27 and 25-gauge vitrectomy in 43 eyes afflicted by PDR with TRD. The post-surgical results, best-corrected visual acuity, intraocular pressure, recurrent vitreous haemorrhage, and re-operation rate were regularly followed up for 6 months.

RESULTS

Patients in the 25 and the 27-gauge groups did not differ significantly in terms of pre-surgical conditions, such as age, gender, pre-existing glaucoma, best-corrected visual acuity (BCVA) and the severity of their TRD. The mean operation time was 56.7 minutes in the 27-gauge group and 63.7 minutes in the 25-gauge group (p = 0.94). There is significantly less use of micro forceps in the 27-gauge group (p = 0.004). No difference between micro scissors and chandelier usage were noted; neither was their difference in iatrogenic retinal breaks. Significantly fewer wound sutures were noted in the 27-gauge group (p < 0.001). The post-operative results revealed no significant difference in ocular hypertension, hypotony, BCVA improvement, recurrent vitreous haemorrhage and re-operation rate.

CONCLUSIONS

The 27-gauge vitrectomy system offers comparable surgical outcomes in PDR with TRD. The 27-gauge vitrectomy system is suitable for complicated retinal surgery.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

FLOW DYNAMICS OF BEVELED-TIP AND FLAT-TIP VITREOUS CUTTERS

PURPOSE

To compare the flow dynamics of beveled-tip to that of flat-tip vitreous cutters.

METHOD

The aspiration rates of balanced salt solution and swine vitreous were measured for 25-gauge and 27-gauge beveled-tip and flat-tip vitreous cutters. Fluorescent polymer microspheres were mixed with balanced salt solution to make the flow visible. The flow dynamics at maximal cutting rates and reflux of balanced salt solution were measured with video images of a high-speed camera.

RESULTS

The aspiration rates of balanced salt solution of the 25-gauge and 27-gauge beveled-tip cutters were significantly higher than that of the flat-tip cutters at 7,500 cut/min (P = 0.0001, P = 0.038, respectively). The aspiration rate of swine vitreous by the 25-gauge beveled-tip cutter was significantly higher than that of the flat-tip cutters (P = 0.006). The mean aspiration flow in front of the cutter was significantly faster for both beveled-tip than flat-tip cutters (P = 0.003, P = 0.023). The angle of the mean aspiration flow of both beveled-tip cutters was turned to the proximal side (P = 0.004, P = 0.003). The mean reflux flow of both beveled-tip cutters was significantly faster than that of the flat-tip cutters (P = 0.006, P = 0.006).

CONCLUSION

The beveled-tip cutters have a greater velocity of aspirating frontal and proximal flow resulting in higher aspiration rates and greater reflux flow velocity.

Research Trends and Hotspot Analysis of Conjunctival Bacteria Based on CiteSpace Software

OBJECTIVE

To sort out the literature related to conjunctival bacteria and summarize research hotspots and trends of this field.

MATERIALS AND METHODS

The relevant literature data from 1900 to 2019 was retrieved from the Web of Science Core Collection database. After manual selection, each document record includes title, author, keywords, abstract, year, organization, and citation. We imported the downloaded data into CiteSpace V (version 5.5R2) to draw the knowledge map and conduct cooperative network analysis, discipline and journal analysis, cluster analysis, and burst keyword analysis.

RESULTS

After manual screening, there were 285 relevant papers published in the last 28 years (from 1991 to 2019), and the number is increasing year by year. The publications of conjunctival bacteria were dedicated by 1381 authors of 451 institutions in 56 countries/regions. The United States dominates this field (82 literatures), followed by Germany (23 literatures) and Japan (23 literatures). Overall, most cited papers were published with a focus on molecular biology, genetics, nursing, and toxicology. Most papers fall into the category of ophthalmology, veterinary sciences, and pharmacology and pharmacy. The only organized cluster is the "postantibiotic effect," and the top 5 keywords with the strongest citation bursts include "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity".

CONCLUSION

The global field of conjunctival bacteria has expanded in the last 28 years. The United States contributes most. However, there are little cooperation among authors and institutions. Overall, this bibliometric study organized one cluster, "postantibiotic effect", and identified the top 5 hotspots in conjunctival bacteria research: "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity". Thus, further research focuses on these topics that may be more helpful to prevent ocular infection and improve prophylaxis strategies to bring a benefit to patients in the near future.

Comparison of 27-Gauge and 25-Gauge Microincision Vitrectomy Surgery for the Treatment of Vitreoretinal Disease: A Systematic Review and Meta-Analysis

BACKGROUND

We performed a systematic review and meta-analysis to evaluate the safety and effectiveness of 27-gauge (27-G) microincision vitrectomy surgery (MIVS) compared with 25-guage (25-G) MIVS for the treatment of vitreoretinal disease.

METHODS

A systematic electronic search was conducted in March 2020 in PubMed, Embase, and the Cochrane library. Eligible criteria for including studies were controlled trials comparing 27-G vitrectomy with 25-G vitrectomy in patients with vitreoretinal disease. The main outcomes included operation time; best corrected visual acuity (BCVA) in logMAR; postoperative intraocular pressure (IOP); primary anatomical success rate for rhegmatogenous retinal detachment (RRD) cases and postoperative central macular thickness (CMT) for idiopathic epiretinal membrane (ERM) cases; intraoperative/postoperative complications. Odds ratio (OR) and mean difference (MD) were synthesized under fixed or random effects models.

RESULTS

Eleven studies enrolling 940 eyes were identified. Among those 11 studies, six studies were on the treatment of RRD and five studies were on the treatment of ERM, so subgroup analyses were conducted. The total pooled results indicated that 27-G surgery system had obvious advantages in improving BCVA at six months after the vitrectomy (P = 0.004) and reducing intraoperative/postoperative complications (P = 0.03). However, the mean operation time was significantly longer by three minutes for 27-G compared with 25-G vitrectomy (P = 0.002). In subgroup analyses, for the treatment of ERM cases, 27-G group was associated with less complications and longer operation time. However, for the treatment of RRD cases, 27-G groups and 25-G groups were comparable in operation time, postoperative BCVA, postoperative IOP, and primary anatomical success rate.

CONCLUSIONS

This meta-analysis confirmed that 27-G MIVS was an effective and safe surgical system compared with 25-G MIVS for the treatment of RRD and ERM cases, even though 27-G system needs a longer surgical time.

Successful surgical outcomes after 23-, 25- and 27-gauge vitrectomy without scleral encircling for giant retinal tear

PURPOSE

Retinal detachment due to giant retinal tears (GRTs), tears larger than 90°, is rare and difficult to treat. Here, we show and compare surgical results of 23-, 25- and 27-gauge (G) micro-incision vitrectomy surgery (MIVS) for GRT.

STUDY DESIGN

Retrospective and interventional case series.

METHODS

Retrospective review of 41 eyes of 38 patients with GRT who underwent MIVS. Surgical outcomes after MIVS, including reattachment rates and postoperative complications, were compared between instrument gauges. All patients were followed for at least 6 months postoperatively.

RESULTS

MIVS with 23G, 25G and 27G instruments was performed in 7, 19 and 15 eyes, respectively. Silicone oil (SO) was used in 34 of 41 eyes (83%) with a mean removal time of 43.8 days after first surgery. Best-corrected visual acuity (BCVA) was recovered or maintained in 39 eyes (95%). Reattachment was attained after initial surgery in 38 of 41 eyes (93%) (23G: 6/7 [86%]; 25G: 17/19 [89%]; 27G: 15/15 [100%]). Final reattachment was eventually achieved in all eyes (two eyes needed support from scleral encircling). Postoperative complications occurred in 16 eyes (39%) (23G: 3/7 [43%]; 25G: 8/19 [42%]; 27G: 5/15 [33%]), including macular pucker, cystoid macular edema, macular hole, subretinal perfluorocarbon liquid, retinal folds, vitreous hemorrhage and redetachment. There were no significant differences between the three groups in rate of high myopia, GRT size, operation time, phacovitrectomy rate, SO usage rate, initial reattachment rate, final reattachment rate, preoperative BCVA, final BCVA or rate of postoperative complications.

CONCLUSION

Despite occasional postoperative complications, primary MIVS, regardless of gauge size, appears to be a safe and feasible option for GRT surgery.

Multiple factors in the prediction of risk of recurrent vitreous haemorrhage after sutureless vitrectomy for non-clearing vitreous haemorrhage in patients with diabetic retinopathy

Background

We aimed to analyse multiple factors in the prediction of risk of postoperative recurrent vitreous haemorrhage (RVH) for non-clearing vitreous haemorrhage in patients with diabetic retinopathy (DR) who underwent sutureless vitrectomy with 23- (23G) or 25-gauge (25G) narrow-gauge systems.

Methods

A retrospective consecutive case series design was used. DR patients who underwent sutureless vitrectomy for non-clearing vitreous haemorrhage between June 2017 and October 2019 were enrolled. All operations were performed at a tertiary hospital. Patient demographics and risk factors, including age, gender, duration of diabetes, preoperative fasting blood sugar levels (FBSL), systolic blood pressure (SBP), serum creatinine (Cr), urea, triamcinolone acetonide (TA), electrical coagulation, air-fluid exchange, pan-retinal photocoagulation status (PRP), anti-vascular endothelial growth factor drug (anti-VEGF), and other factors, were recorded. Patients were divided into two groups based on the timing of their postoperative RVH: immediate postoperative RVH (within 2 weeks after operation) and delayed postoperative RVH (beyond 2 weeks after operation).

Results

Overall, 167 eyes (167patients) were enrolled. Seventy eyes were underwent 23G and 25G sutureless vitrectomy performed in 97 eyes, respectively. Postoperative RVH developed in 18 eyes (25.7%) in Group 23G and in 20 eyes (21.6%) in Group 25G (P = 0.540). Of these, 3 eyes (4.3%) had severed RVH in Group 23G compared with 5 eyes (5.2%) in Group 25G (P = 0.584). Delayed postoperative RVH occurred in 6 eyes (8.6%) in Group 23G and 8 eyes (8.2%) in Group 25G (P = 0.789). A binomial logistic regression analysis revealed that age, duration of diabetes, and Cr level were significantly associated with RVH in both Group 23G (P < 0.05) and Group 25G (P < 0.05).

Conclusions

The incidence and severity of RVH were 25.7 and 4.3%, respectively, in Group 23G and 21.6 and 5.2%, respectively, in Group 25G. Thus, the 23G sutureless vitrectomy approach was as safe as the 25G sutureless vitrectomy approach for treating vitreous haemorrhage in patients with DR. A younger age, shorter duration of diabetes, and higher Cr levels were risk factors for postoperative RVH in sutureless vitrectomy.

Minimally interface vitrectomy for rhegmatogenous retinal detachment with a single break in young patients

Purpose

This study evaluates a new surgical technique consisting of minimal vitreous removal under air (minimal interface vitrectomy; MIV) to reduce postoperative complications while preserving the ability to address surgical factors at the retinal break.

Methods

This retrospective analysis examined the outcomes of minimal interface vitrectomies in consecutive cases, with a minimum 12-month follow-up period, of primary rhegmatogenous retinal detachment (RRD), recurrent RRD after pars plana vitrectomy (PPV), or failed surgery after primary scleral buckling surgery (SBS).

Results

Twelve eyes of 12 patients with RRD underwent MIV. The total surgical duration was 190–300 s (mean, 245.25 s). Eight (66.7%) eyes were treated with cryotherapy, and 4 (33.3%) with endolaser to seal the retinal break. Successful, complete retinal reattachment was achieved in all eyes and maintained during follow-up. No intra- or postoperative complications occurred and no patients developed inflammation or cataract during follow-up.

Conclusion and Importance

We effectively removed traction and subretinal fluid and treated breaks with endolaser or cryotherapy by using a novel minimal interface vitrectomy technique in this selected population.

Comparative analysis of 23-, 25-, and 27-gauge forceps stiffness and related displacement

PURPOSE

To test the stiffness and displacement of different vitreous forceps. Physical features and deformation after multiple procedures were also measured.

METHODS

Eleven different 23-, 25-, and 27-gauge vitreous forceps were studied. The measurements were repeated loading the probe at different distances from the tip: at the top of the tip and 10 and 20 mm from the tip, respectively. For each probe, 10 successive identical bending tests were performed. The total length and the internal and external diameters of each forceps were also measured.

RESULTS

A total of 330 successive identical bending tests were performed. No progression in deformation after the repeated measurements was recorded (p > 0.05). In each gauge group, displacement differences were detected according to the manufacturing metal properties, the total length, and the thickness of the shaft wall. A minimal adequate model to describes forceps displacements in terms of their significant predictors, such as gauge, model, and load distance from the tip, was created.

CONCLUSION

We provided a precise assessment of the stiffness and displacement of different vitreous forceps to enable surgeons to select the optimal instrument according to the benefits and limitations of each forceps.

ANATOMICAL AND VISUAL OUTCOMES IN STAGE 5 RETINOPATHY OF PREMATURITY WITH MICROINCISION VITRECTOMY SURGERY

PURPOSE

To report anatomical and visual outcomes and potential prognostic factors with microincision vitrectomy surgery in Stage 5 retinopathy of prematurity.

METHODS

The medical records of premature babies who underwent microincision vitrectomy surgery for Stage 5 retinopathy of prematurity using 23G, 25G, or 27G instrumentation and had a minimum follow-up of 6 weeks were, retrospectively, analyzed. Primary outcome measures were anatomical success at last follow-up defined as retinal attachment at the posterior pole and visual outcomes. Potential risk factors and complications influencing anatomical outcomes were also analyzed.

RESULTS

One hundred seventy eyes of 115 infants underwent lensectomy and vitrectomy with microincision vitrectomy surgery. After a mean follow-up of 30.59 ± 33.24 weeks, anatomical success was achieved in 56 eyes (33.7%) of 166 eyes that had a minimum follow-up of 6 weeks. Occurrence of vitreous hemorrhage was more with 23 gauge (62.27%) as compared to 25 gauge (37.73%) (P = 0.024). With increase in age with each week, the probability of achieving anatomical success was found to be significantly more (odds ratio 1.030; confidence interval = 1.010-1.060; P = 0.008). Presence of anterior segment pathology was associated with poor anatomical outcomes (odds ratio 2.480; confidence interval = 1.190-5.160; P = 0.010). Seventeen children with attached retina had a follow-up of 14 months-5 years, of which ambulatory vision was recorded in five eyes and the ability to identify objects close to face in 12 eyes.

CONCLUSION

Although surgery for Stage 5 retinopathy of prematurity is challenging, anatomical success can be seen in one-third of cases with microincision vitrectomy surgery. Visual prognosis may be limited but still beneficial.

Clinical comparison of 27-gauge and 23-gauge instruments on the outcomes of pars plana vitrectomy surgery for the treatment of vitreoretinal diseases

PURPOSE OF REVIEW

To compare outcomes of 27-gauge and 23-gauge pars plana vitrectomy (PPV) for treatment of vitreoretinal diseases.

RECENT FINDINGS

Sixty-eight patients undergoing microincisional PPV for treatment of vitreoretinal diseases were randomized 1 : 1 to 27-gauge or 23-gauge surgery with a 7500 cuts-per-minute vitrectomy probe. The most common reasons for vitrectomy were epiretinal membrane (49%) and vitreous hemorrhage (24%). Mean ± standard deviation (SD) changes from immediate preoperative to immediate postoperative intraocular pressure were -0.40 ± 6.60 mmHg in the 27-gauge and -3.05 ± 7.64 mmHg in the 23-gauge group (adjusted mean difference 2.42 mmHg, 95% lower confidence limit 0.64, P = 0.013), but these changes were not associated with primary reason for vitrectomy (P = 0.065). Mean ± SD conjunctival edema grades in the 27-gauge and 23-gauge groups 1 week after surgery were 0.02 ± 0.124 and 0.10 ± 0.246, respectively (least squares mean difference -0.09, 95% upper confidence limit -0.03, P = 0.004), and were 0.01 ± 0.122 and 0.12 ± 0.338, respectively, at the probe incision site. Conjunctival edema grades were similar in both groups at 1 and 3 months. Mean ± SD pain ratings on postoperative day 1 - an indicator of patient comfort - were similar in the two groups.

SUMMARY

Smaller diameter vitrectomy instruments are associated with smaller reductions in immediate postoperative intraocular pressure.

Evaluation of pre- and post-surgery reading ability in patients with epiretinal membrane: a prospective observational study

Background

This study aimed to investigate the pre- and post-surgery reading ability in patients with idiopathic epiretinal membrane (ERM) to evaluate whether measurement of reading performance is a helpful test in addition to visual acuity (VA) as an assessment measure.

Methods

This prospective observational study involved 42 eyes of 40 patients with idiopathic ERM. Best-corrected visual acuity (BCVA), reading ability, and metamorphopsia score were evaluated at baseline and at 3, 6, and 12 months post-surgery. As the outcome measure, the reading ability of each patient (i.e., overall performance) was examined with MNREAD-J, the Japanese version of the MNREAD reading acuity (RA) charts, to determine RA, critical print size (CPS), and maximum reading speed (MRS). Generally, a difference of 0.2 logMAR or more is considered a significant change in BCVA. Thus, as a subgroup analysis, we additionally evaluated the BCVA and reading ability of the patients with a BCVA difference of 0.1 logMAR or less between at baseline and at 12 months post-surgery.

Results

Relative to their values at baseline, the subjects exhibited significantly improved BCVA, RA, and CPS throughout the post-surgery examination period (P < 0.001) and significantly improved MRS at 12 months post-surgery (P = 0.04). No significant change in the vertical metamorphopsia score was observed throughout the post-surgery follow-up period. However, and compared to the value at baseline, significant improvements in the horizontal metamorphopsia score were observed at 3, 6 (P < 0.05), and 12 months (P < 0.001) post-surgery. In the subgroup analysis of the 23 eyes that exhibited a BCVA improvement of 0.1 logMAR or less, the median BCVA did not change, but the median RA and CPS improved by 0.2 logMAR.

Conclusions

Our findings showed that the surgical removal of ERM improves reading ability, even when the BCVA score does not improve. The measurement of reading performance appears to be a helpful test in addition to VA as a measure for assessing the surgical removal of ERM.

Incidence and Risk Factors of Iatrogenic Retinal Breaks: 20-Gauge versus 25-Gauge Vitrectomy for Idiopathic Macular Hole Repair

Purpose

We compared the incidences of iatrogenic retinal breaks and postoperative retinal detachment between eyes that underwent 20-gauge vitrectomy and those that underwent 25-gauge vitrectomy for idiopathic macular hole repair.

Methods

This retrospective nonrandomized consecutive observational case series included 185 eyes of 183 patients (130 eyes of 129 patients and 55 eyes of 54 patients in the 20- and 25-gauge groups, respectively). We assessed the relationship between the incidence of retinal breaks and postoperative retinal detachment and related this to posterior vitreous detachment and lattice degeneration.

Results

The incidences of iatrogenic retinal breaks were 36.9% and 12.7% in the 20-gauge and 25-gauge groups, respectively. These groups did not differ in their respective frequencies of posterior vitreous detachment (the 20-gauge group: 31.5% and the 25-gauge group: 27.3%) and lattice degeneration (the 20-gauge group: 14.6% and the 25-gauge group: 7.3%). Among eyes without lattice degeneration, the 20-gauge group showed a higher incidence of iatrogenic retinal breaks than the 25-gauge group. However, among the eyes with lattice degeneration, the frequency of retinal breaks did not differ between the two surgery types, and four cases of postoperative retinal detachment were reported in both groups.

Conclusions

The incidence of retinal breaks related to idiopathic macular hole surgery is higher among patients undergoing 20-gauge vitrectomy than among those undergoing 25-gauge vitrectomy. Posterior vitreous detachment and lattice degeneration are associated with considerably increased incidences of retinal break.

The 100 Most Cited Articles on Vitrectomy: A Bibliographic Perspective

PURPOSE

To analyze the 100 most-cited articles on pars plana vitrectomy (PPV).

DESIGN

Bibliographic study.

METHODS

Literature search using the bibliographic databases of the ISI Web of Knowledge, limited to research articles published between 1971 and 2018 in peer-reviewed journals of ophthalmology.

MAIN OUTCOME MEASURE

Number of citations since publication.

RESULTS

The 100 most-cited articles on PPV were published in 11 different ophthalmology journals, with 73 of them published in Ophthalmology (n = 31), American Journal of Ophthalmology (n = 26), and Archives of Ophthalmology (n = 16). They originated from 14 different countries, predominantly from the United States (n = 64), and 99 of them were written in English. Their topics cover a wide spectrum of retinal conditions that vary from decade to decade as the technique of PPV evolved and became applicable to more indications.

CONCLUSIONS

This bibliographic study provides a unique historic perspective of the development of PPV and its applications from its introduction to its current status.

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.

Multicenter survey of sutureless 27-gauge vitrectomy for primary rhegmatogenous retinal detachment: a consecutive series of 410 cases

PURPOSE

To evaluate the surgical outcomes of the 27-gauge (G) vitrectomy system for the treatment of primary rhegmatogenous retinal detachment (RRD).

METHODS

This retrospective consecutive series multicenter study involved a total of 410 eyes of 406 patients who underwent 3-port transconjunctival 27G pars plana vitrectomy (PPV) for RRD between November 2014 and December 2016 and who were followed for a minimum of 3 months postoperative. The main outcome measure was primary reattachment, with the secondary outcome measures being final reattachment, improvement of visual acuity (VA), intraocular pressure (IOP), intraoperative and postoperative complications, and surgery time.

RESULTS

Of the 410 treated eyes, primary reattachment was achieved in 392 (95.6%) and final reattachment was achieved in 410 (100%). In 226 eyes (55.1%) with macula-on RRD, the mean logarithm of the minimum angle of resolution (logMAR) VA improved from 0.16 ± 0.51 pre-surgery to 0.02 ± 0.14 post-surgery (P = 0.11). In 184 eyes (44.9%) with macula-off RRD, logMAR VA improved from 1.06 ± 0.77 pre-surgery to 0.26 ± 0.35 post-surgery (P < 0.001). Following surgery, the mean IOP was highest at 1 day (15.7 ± 7.0 mmHg) postoperative. In all eyes, surgery was concluded without the use of sutures or the need of conversion to a larger-gauge instrument. Although hypotony was observed in 14 (3.4%) of the 410 treated eyes at 1 day postoperative, it spontaneously resolved within 1 week without additional surgical intervention. No postoperative complications such as infectious endophthalmitis were observed throughout the follow-up period.

CONCLUSION

Our findings show that 27G PPV is both safe and effective for the treatment of primary RRD.

Outcomes of 23G vitrectomy and internal limiting membrane peeling with brilliant blue in patients with myopic foveoschisis from a retrospective cohort study

The aim of the present study was to investigate whether internal limiting membrane (ILM) peeling in patients with myopic foveoschisis (MF) treated with 23-gauge (23G) vitrectomy improved the anatomical and visual outcomes. In this retrospective cohort study, from March 2014 to August 2017 at the Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University (Nanchang, China), 60 patients (60 eyes) with MF underwent 23G vitrectomy. The patients were grouped according to whether they underwent brilliant blue-assisted ILM peeling (peeling group) or not (non-peeling group). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography were measured. There were 30 eyes in each group and the baseline characteristics were similar (all P>0.05). BCVA improved in 24 eyes (80%) in the peeling group and 25 eyes (83.3%) in the non-peeling group (P=0.922). Preoperative CMT was not significantly different between the peeling and non-peeling group (458±62.2 vs. 460±61.1 µm, respectively, P=0.229). However, postoperative CMT was significantly different between the peeling and non-peeling group (269.3±67.7 vs. 294.4±60.5 µm, respectively; P=0.015). In the peeling group, MF was completely resolved in all 30 eyes, but only in 26 eyes in the non-peeling group (P=0.038). Postoperative Amsler testing was positive in five eyes in the peeling group and 13 eyes in the non-peeling group (P=0.024). Complications were similar in both groups; postoperatively, there were one and two cases of iatrogenic peripheral retinal break, three and two cases of macular hole, and one and one case of retinal detachment in the peeling and non-peeling groups, respectively.23G vitrectomy combined with brilliant blue-assisted ILM peeling resulted in better visual and anatomical effects compared with 23G vitrectomy alone in patients with MF.

Indications and outcomes of vitrectomy surgery in a series of 1000 black African eyes

Objective

To determine the common indications for, and outcomes of pars plana vitrectomy surgery among black Africans in a low-resource setting.

Methods and Analysis

A retrospective, non-comparative case review was undertaken. Data from 1000 consecutive eyes of 1000 patients in a single centre who underwent pars plana vitrectomy surgery between May 2005 and July 2013 were used for the study. Demographic data, primary indication for surgery, ocular status and outcomes were assessed.

Results

Rhegmatogenous retinal detachment was the most common primary indication occurring in 61.8% of eyes. Diabetic vitrectomy, trauma and proliferative sickle cell retinopathy were also common indications occurring in 10.1%, 6.1% and 4.5% of eyes, respectively. At presentation, 33% of patients with retinal detachment had some form of proliferative vitreoretinopathy, and half of those had the more advanced grades C and D. Patients presented on an average of 13.5 months after onset of symptoms. As a result, visual outcomes were less than other reported studies.

Conclusion

Retinal detachment was the most common indication for vitrectomy, but even these cases presented late with an advanced presentation. This study highlights the need for affordable and accessible vitreoretinal services in Sub-Saharan Africa and increased awareness of general eye health, along with strategies to reduce trauma and identify early those at risk of chronic eye diseases, such as diabetic retinopathy and sickle cell retinopathy.

One-year outcomes of 27-gauge versus 25-gauge pars plana vitrectomy for uncomplicated rhegmatogenous retinal detachment repair

Background

27-gauge (27G) and 25-gauge (25G) transconjunctival sutureless vitrectomy (TSV) were considered equal about safety, effectiveness and vitrectomy time for the treatment of rhegmatogenous retinal detachment (RRD), although larger and long-term comparative studies are needed to confirm previous knowledge. Furthermore, a combined comparison of time duration of surgery and vitreous removal was never performed. Our purpose was to compare the safety and efficacy of 27G versus 25G TSV for the treatment of uncomplicated RRD over a 1-year follow-up.

Methods

A 12-months single-center prospective, randomized, interventional study of 92 consecutive patients was performed. 46 patients underwent 27G TSV (Group 1) and 46 underwent 25G TSV (Group 2). Primary outcomes were primary and final reattachment rate, and final functional success (visual acuity ≥ 20/200, 1 LogMar). Secondary outcomes were the surgical and vitrectomy time. Complications were recorded.

Results

All functional and morphologic data at baseline and at all follow-up time points up to 12 months after surgery were available for only 88 patients. Four patients in Group 1 dropped out of the study after surgery. There was no significant difference in baseline characteristics between the two groups. Primary and final reattachment rates were 90.5% and 100% in Group 1, and 95.6% and 100% in Group 2, respectively (p > .05, p > .05, respectively). Visual acuity improved from 1.5 ± 1.09 LogMar to 0.38 ± 0.55 LogMar in Group 1 (p < .001) and 1.2 ± 0.9 LogMar to 0.49 ± 0.53 LogMar in Group 2 (p < .001), without significant difference between the groups (p > .05). The surgical time was 73.2 ± 11.3 min with 27G TSV and 64.4 ± 9.5 min with 25G TSV (p = .0001). The vitrectomy time was 19.9 ± 3.8 min with 27G TSV and 20.8 ± 3.8 min with 25G TSV (p > .05). One single case of choroidal detachment occurred.

Conclusions

Reattachment rates, functional success and vitrectomy time were comparable between 27G and 25G TSV for RRD. Surgical time was significantly longer using 27G vitrectomy.

Hybrid clear corneal micro-incision surgical technique for stage 5 retinopathy of prematurity

A safe technique for entry incisions and closure in stage 5 retinopathy of prematurity (ROP) surgery is being described. Three 23G clear corneal incisions are made which allow for safe and snug entry of 25G calibrated infusion and 25G instruments for performing lensectomy, membrane removal and vitrectomy. At the end of surgery, air is injected and corneal entries are hydrated for sutureless closure. The technique was performed in 50 eyes of 36 children with stage 5 ROP. The hybrid technique ensured safe entry and exit with stable anterior chamber during surgery. None of the cases developed retinal breaks during surgical entry nor had any complications such as hypotony, flat anterior chamber, hyphaema or corneal edema in post operative period. Clear corneal entry using 23G incisions for 25G instrument access is a safe and effective technique for performing lensectomy and vitrectomy with sutureless closure in cases with stage 5 ROP.

Ocular Venous Air Embolism (OVAE): A Review

Purpose:

The purpose of this article is to review and analyze reported cases of ocular venous air embolism (OVAE) to develop a reliable clinical definition of OVAE and effective prevention strategies.

Methods:

We reviewed all reports of suspected air embolism during vitrectomy published in PubMed since the introduction of pars plana vitrectomy, and 5 cases found elsewhere and separately reported concurrent with this review.

Results:

OVAE is a precipitous drop in end-tidal CO2, a choroidal detachment, or a choroidal wound, followed by signs of impending or actual cardiovascular collapse, during vitrectomy air infusion. In each case meeting the above clinical definition, entrained air was found whenever it was sought (8/8, 100%), either by antemortem imaging or postmortem forensic investigations. Most OVAE cases were fatal (9/13, 69%), with 8 of 9 deaths (89%) occurring the day of surgery.

Conclusions:

OVEA is a rare but usually fatal complication of air infusion into the eye during vitrectomy. Although received with skepticism when first reported (2005), OVAE may be the most lethal type of surgical air embolization because of its high entrainment pressure and proximity to the heart. Because the effective response time to avoid a fatal OVAE outcome can be less than 1 minute, use of preventive measures is critical—most notably a “time out” before air infusion to confirm infusion cannula positioning, and immediate cessation of air infusion if choroidal detachment is detected.

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.

Application of Laser Flare Photometry in the Quantification of Blood-Aqueous Barrier Breakdown after Micro-incision Vitrectomy

Purpose: The purpose of the study is to quantify aqueous flare using laser flare photometry (LFM) in patients undergoing 25-G pars plana vitrectomy (PPV) and assess the need for postoperative topical corticosteroid administration . Methods: Prospective evaluation of 50 eyes (50 patients) was performed using LFM until day 30 postoperative. Duration of surgery, indication of PPV, and use of laser and/or cryotherapy were noted. Topical corticosteroids were used if mean LFM values were >50, or if there was anterior chamber fibrin. Results: Mean age of the subjects was 48.62 ± 10.07 years. The preoperative LFM value for 50 subjects was 17.42 ± 25.20. Topical corticosteroids were initiated in only 22 patients. The LFM values of subjects were not different from baseline at 1 month whether or not the subjects received corticosteroids (p > 0.106). Conclusions: With 25-G PPV, there is minimal breakdown of blood-aqueous barrier. LFM helps in monitoring postoperative inflammation, obviating the need for topical corticosteroids in significant number of patients.

Optical Biometry-Based Intraocular Lens Calculation and Refractive Outcomes after Phacovitrectomy for Rhegmatogenous Retinal Detachment and Epiretinal Membrane

We investigate the refractive error after phacovitrectomy for rhegmatogenous retinal detachment (RRD; 100 eyes) and epiretinal membrane (ERM; 102 eyes). Axial lengths were measured by optical biometry in most patients. The main outcome measures were the refractive and absolute prediction errors. The overall mean refractive prediction error (ME) and mean absolute prediction error (MAE) were −0.40 ± 0.72 D and 0.62 ± 0.55 D, respectively, at 3 months postoperatively. The ME and MAE were significantly higher in the RRD group than in the ERM group (−0.63 ± 0.74 D vs −0.16 ± 0.63 D, P < 0.001 and 0.75 ± 0.62 D vs 0.49 ± 0.43 D, P = 0.002, respectively), indicating greater myopic shift in the RRD group. In the RRD group, adding +0.5 D to the preoperative predicted refractive power decreased the postoperative ME and MAE to −0.13 ± 0.74 D and 0.58 ± 0.47 D, respectively. Based on our results, we conclude that postoperative myopic shift was significantly higher in the RRD group than in the ERM group, possibly because of forward displacement of the intraocular lens by gas tamponade. The myopic shift can be minimized by adding +0.5 D to the predicted refractive power in patients undergoing phacovitrectomy for RRD.

Soloist performance of vitrectomy probe in proliferative diabetic retinopathy

Purpose:

To evaluate the feasibility and outcomes of the sole use of 23g pars plana vitrectomy in cases with diabetic vitreous hemorrhage with vitreoretinal traction.

Methods:

Prospective interventional case series involving patients between January 2013 and January 2018. All eyes underwent 23g pars plana vitrectomy with internal tamponade. Intraoperative parameters including ancillary instruments, the methods used for hemostasis and complications were all recorded. Postoperative parameters including anatomic success rate, functional success, and postoperative complications were recorded and analyzed. Patients were followed up for at least 12 months.

Results:

A total of 68 eyes of 66 patients were included. Intraoperative ancillary instruments were required in 5 (7.4%) eyes. None of the cases required the use of chandelier illumination, endodiathermy, or scissors. Mean best-corrected visual acuity improved significantly from LogMAR 1.67 ± 0.63 preoperative to 1.22 ± 0.38 at 1-year follow-up (P = 0.005). Functional success was achieved in 37 (54.4%) eyes at 1-year follow-up. Iatrogenic breaks occurred in 3 (4.4%) eyes, vitreous hemorrhage in 4 (5.9%) eyes, and epiretinal membranes in 3 (4.4%) eyes. Repeated vitrectomy was done in 3 (4.4%) eyes.

Conclusion:

The 23g vitrectomy probe proved to be a safe, effective, and beneficial single tool that could accomplish the diabetic vitrectomy mission exclusively with minimal aid from other instruments in cases with vitreous hemorrhage associated with vitreoretinal traction.

TWENTY-FIVE-GAUGE PARS PLANA VITRECTOMY IN COMPLEX RETINAL DETACHMENTS ASSOCIATED WITH GIANT RETINAL TEAR

PURPOSE

To study the structural and functional outcomes of 25-gauge pars plana vitrectomy in giant retinal tear-associated retinal detachments.

METHODS

Seventeen eyes of 17 patients with giant retinal tear, who underwent 25-gauge pars plana vitrectomy over a period of 15 months at a tertiary eye care center by a single surgeon, were recruited in this retrospective interventional study.

RESULTS

Giant retinal tears were mostly traumatic (35.3%) or associated with myopia (35.3%) and occurred in young (mean age 25.7 years) males (94.1%). Most eyes had best-corrected visual acuity ≤20/1,200 (in 82.3%), foveal detachment (in 88.2%), and proliferative vitreoretinopathy ≤Grade B (in 82.3%). The giant retinal tear extent was more than 180° in 29.4% and the fellow eye was involved in 35.2% of eyes. All eyes underwent 25-gauge pars plana vitrectomy with encircling band in 41.1%, perfluorocarbon liquid use in 82.3%, and endotamponade with sulphur hexafluoride (23.6%) or silicone oil (76.4%). At mean follow-up of 10.2 months, reattachment rate was 88.2%. Only 35.2% of eyes achieved final visual acuity ≥20/80 with a cause of poor vision being cataract, secondary glaucoma, macular pucker, and corneal edema.

CONCLUSION

Twenty-five-gauge pars plana vitrectomy can achieve excellent attachment rates in eyes with giant retinal tear-associated retinal detachment. It can be as efficient as larger-gauge vitrectomy, at the same time retaining all advantages of smaller-gauge surgery.