Twenty-Gauge Transconjunctival Sutureless Vitrectomy Trocar System

Review of Small Gauge Vitrectomy: Progress and Innovations

Purpose. To summarise the surgical advances and evolution of small gauge vitrectomy and discuss its principles and application in modern vitreoretinal surgery. The advent of microincisional vitrectomy systems (MIVS) has created a paradigm shift away from twenty-gauge vitrectomy systems, which have been the gold standard in the surgical management of vitreoretinal diseases for over thirty years. Advances in biomedical engineering and surgical techniques have overcome the technical hurdles of shifting to smaller gauge instrumentation and sutureless surgery, improving surgical capabilities and expanding the indications for MIVS.

A NOVEL TECHNIQUE FOR SECURING SCLEROTOMIES IN 20-GAUGE TRANSCONJUNCTIVAL PARS PLANA VITRECTOMY: Surgical Outcomes and Complications in 529 Consecutive Cases

PURPOSE

To describe a novel technique for securing sclerotomies after 20-gauge transconjunctival pars plana vitrectomy and determine the efficacy, and short-term safety in various vitreoretinal diseases.

METHODS

Retrospective chart review of consecutive cases that underwent 20-gauge transconjunctival pars plana vitrectomy with sclerotomy hydration was conducted. The main outcome measures included intraocular pressure, intraocular gas bubble size in postoperative Day 1, and early postoperative complications. Secondary outcomes included postoperative visual acuity at 1-month postoperative visit.

RESULTS

Five hundred and twenty-nine eyes were evaluated. Mean gas/air fill and mean intraocular pressure were 75.1% and 14.8 mmHg on postoperative Day 1. Seven eyes (1.32%) had hypotony (intraocular pressure <6 mmHg) on Day 1, which normalized in all eyes by Day 7 (P = 0.0083). On postoperative Day 7, mean intraocular pressure was 17.1 mmHg. Hypotony was associated with a preoperative diagnosis of retinal detachment (P = 0.022), and silicone oil tamponade (P = 0.017). Mean best corrected visual acuity was 20/320 preoperatively and 20/125 postoperatively at 1-month follow-up visit (P < 0.0001). Twenty-seven cases had intraoperative or postoperative complications (5.1%). Rate of complications was not associated with the type of tamponade (P = 0.076).

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy with sclerotomy hydration appears to be safe with a low rate of hypotony and complications, and good final visual outcome.

A prospective study on postoperative discomfort after 20-gauge pars plana vitrectomy

Purpose

To evaluate postoperative pain and other irritation symptoms after 20-gauge (20G) pars plana vitrectomy.

Materials and methods

A total of 110 consecutive patients were enrolled in our studies, and 87 patients who underwent the conventional 20G pars plana vitrectomy were included in the final analysis. All vitrectomies were performed using the same surgical technique by the same surgeon. Patients were examined before surgery and 1 day, 3 days, 7 days, 1 month, and 2 months postoperatively. The main outcome measures include patient age and sex, intraocular pressure (IOP), ocular pain, pain score, pain medication use, and other irritation symptoms comprising itching, foreign body sensation, burning, photophobia, and dryness. The pain was evaluated using the Numerical Rating Scale scored from 0 to 10.

Results

Postoperative pain was relatively common during the first day after surgery, as it was reported by 43 (49.4%) patients. Then, the prevalence gradually decreased to eleven (12.6%) patients at 2 months. Most patients reported mild or moderate pain, with a pain score of 1–5, but only four patients were given analgesics for ocular pain. A postoperative rise of IOP was noted in 25 patients at day 1. Most of these patients with high IOP reported moderate pain. Other ocular irritation symptoms were varied after surgery. There was still one-quarter of patients that had foreign body sensation and dryness symptoms at month 2 after surgery.

Conclusion

Mild and moderate ocular pain were relatively common after 20G vitrectomy, which is more often associated with elevated IOP. Other irritation symptoms were also presented after surgery and could affect the life quality of patients. Therefore, the discomforts after 20G pars plana vitrectomy should be of concern, and timely management should be provided as part of routine postoperative care.

25th RCOphth Congress, President's Session paper: 25 years of progress in vitreoretinal surgery

Over the past 25 years, vitreoretinal surgery has undergone considerable change in technology, techniques, and professional organisation. Many conditions that were considered untreatable in 1988 are now treated routinely by vitreoretinal surgeons. Over the same period, vitreoretinal surgery has become a separate subspecialty with its own scientific meetings and professional organisation. This article describes a noncomprehensive selection of some of the highlights of the past 25 years, including the establishment and growth of BEAVRS (British and Eire Association of Vitreoretinal Surgeons), the revolution in the management of macular holes, the development of submacular surgery, and the introduction of sutureless vitrectomy.

Different techniques of transconjunctival cannulated vitrectomy versus conventional non-cannulated vitrectomy in various vitreoretinal disorders

Purpose

To evaluate the safety and efficacy of different methods of transconjunctival cannulated vitrectomy versus conventional non-cannulated vitrectomy in various vitreoretinal disorders.

Methods

A prospective randomized study was done from August 2009 to February 2011. The study included 129 eyes of 122 patients, randomly divided into four groups. Group 1 comprised 34 eyes operated on using transconjunctival 20-gauge cannula Claes system. Group 2 comprised 32 eyes operated on using transconjunctival cannulated 23 gauge system. Group 3 comprised 27 eyes operated on using combined 20-gauge non-cannulated and 23-gauge transconjunctival cannulated system. Group 4 comprised 36 eyes operated on using conventional non-cannulated 20-gauge system.

Results

The four groups were demographically similar. Anatomical outcome was achieved in all cases. Vision was improved in 29 eyes (85.3%) in group 1, 23 eyes (71.9%) in group 2, 19 eyes (70.4%) in group 3, and 26 eyes (72.2%) in group 4. There was no statistical difference between the four groups 1-day postoperative (P=0.405) and 1-week postoperative intraocular pressure (P=0.254). The number of sutureless sclerotomies was 68 (66.6%) in group 1, 78 (81.3%) in group 2, 50 (61.8%) in group 3, and 0 in group 4. Hypotony occurred in one eye (2.9%) in group 1, three eyes (9.4%) in group 2, two eyes (7.4%) in group 3, and no eyes in group 4. Operative endophthalmitis did not occur in any one of the four groups.

Conclusion

Final anatomical and functional outcomes were not related to the type of sclerotomy used (cannulated or non-cannulated), the gauge used (20 or 23), the route (transconjunctival or transscleral), or type of suture used. The advantages of small-gauge transconjunctival vitrectomy were patient comfort, early ambulation, and preservation of the conjunctiva. This should be weighed against the cost of this cannula system.

Safety of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To study the safety of 20-gauge transconjunctival sutureless vitrectomy.

METHODS

Clinical data of patients who underwent 20-gauge transconjunctival sutureless vitrectomy for the first time, for various disorders, were reviewed retrospectively. The main outcome measures were the number of sclerotomies requiring suturing as well as the intra- and postoperative complications.

RESULTS

A total of 179 operations were performed. Indications for vitrectomy included 68 idiopathic epiretinal membranes, 26 macular holes, 23 phakic and 16 pseudophakic retinal detachments, and 46 various other, less common etiologies. Of these 179 operations, 166 (93%) were sutureless. Of the 537 sclerotomies created, 25 (5%) received a single transconjunctival-scleral suture. Intraoperative complications included premature dislodging of the cannulas in 2 sclerotomies and an iatrogenic horseshoe tear at 1 sclerotomy site. Postoperative complications comprised transient hypotony in 14 cases, subconjunctival gas in 2 cases, and choroidal effusion in 1 case. No serious complications (such as endophthalmitis) were observed.

CONCLUSION

20-gauge transconjunctival sutureless vitrectomy can be considered safe, as the intra- and postoperative complications observed are neither numerous nor significant. Sclerotomies appear to be safe and relatively easy to perform, without compromising the advantages of sutureless surgery.

[Sutureless transconjunctival 20-gauge vitrectomy]

PURPOSE

To evaluate the safety and efficacy of 20-gauge transconjunctival sutureless vitrectomy for a variety of vitreoretinal conditions.

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 29 eyes of 29 patients treated with 20-gauge transconjunctival sutureless vitrectomy. The main outcome measures included intraocular pressure, visual acuity, surgical time, and intraoperative and postoperative complications.

RESULTS

The mean follow-up duration was 5.7 months. There were only two cases of postoperative ocular hypotony (6.9%) and one suspect case of endophthalmitis. Mean overall acuity improved from 0.495 logMar at baseline to 0.29 logMar (p=0.002) and mean total operative time was 19 min. We observed no cases of retinal detachment.

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy is an effective surgical technique, but other studies are needed to confirm its safety and its value in other indications.

Outcomes of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To assess the effectiveness and safety of the 20-gauge transconjunctival sutureless vitrectomy system in vitreoretinal surgeries.

METHODS

The charts of 102 consecutive patients who underwent 20-gauge transconjunctival sutureless vitrectomy by 1 surgeon were retrospectively reviewed. The main outcome measures were intraoperative and postoperative complications and postoperative intraocular pressure and Snellen visual acuity relative to preoperative values. Patients were evaluated before surgery and 1 day, 1 week, 1 month, and 3 months postoperatively.

RESULTS

No trocar-related intraoperative complications were recorded. Two patients (2%) each required suturing of 1 sclerotomy because of leakage at completion of surgery. Mean preoperative visual acuity (in logarithm of the minimum angle of resolution units) was 1.1 ± 0.6. By 3 months after surgery, the mean visual acuity had improved to 0.8 ± 0.5 (P < 0.001). Mean preoperative intraocular pressure was 14.7 ± 5.1 mmHg. Mean postoperative intraocular pressure was 14.2 ± 5.5 mmHg (P = 0.48) at Day 1 and 14.6 ± 4.3 mmHg (P = 0.82) at Day 7 after surgery. Hypotony was present in 3 patients (3%) on the first postoperative day, but their intraocular pressure normalized spontaneously within 1 week. None of the patients developed postoperative endophthalmitis or retinal detachment.

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy is a safe and effective technique for the surgical treatment of a variety of vitreoretinal pathologies.

Adjunctive use of a novel releasable suture technique in transconjunctival vitrectomy

PURPOSE

The purpose of this study was to determine the merits of a transconjunctival vitrectomy with the releasable suture technique in a large series of 20-gauge, 23-gauge, and hybrid trocar vitrectomy and to assess its effectiveness in minimizing the occurrence of incompetent wound closures.

METHODS

One hundred and one patients, with a variety of vitreoretinal disorders, and totaling 125 eyes, were enrolled. Each entry site wound was closed, with the releasable suture technique using 8-0 nylon. Postoperatively, sutures were released under a slit lamp at the office a mean 22.9 hours after surgery. In addition to the usual intraoperative and postoperative identification of complications, preoperative and postoperative intraocular pressures were monitored.

RESULTS

The full results from all 337 sclerotomies (206, 20 gauge; and 131, 23 gauge) were assessed. It was observed that there were no significant differences between preoperative and postoperative intraocular pressure measurements (P > 0.05); no eyes required fluid or gas supplements, there was no significant wound leakage or hypotony; and no significant complications occurred, such as endophthalmitis or choroidal detachment.

CONCLUSION

These results indicate that transconjunctival vitrectomy with releasable sutures, including those conducted with larger instrument trocar systems, offer patients excellent chances for a favorable outcome without incidences of postoperative wound leakage or hypotony.

Intraoperative switch to a temporal surgical approach in 23- and 25-gauge microcannula-based sutureless transconjunctival vitrectomy

Purpose:

To illustrate a surgical method in which the infusion port during a three-port pars plana vitrectomy is moved intraoperatively from the traditional infra-temporal location and placed supra-nasally, thus permitting a temporal surgical approach to better tackle superior and inferior vitreoretinal pathology.

Methods:

Description of surgical technique.

Results:

When the location of the vitreoretinal pathology and/or the patient's anatomy prevents adequate visualization or surgical access and/or the instrument flexibility precludes sufficient maneuvering of the eyeball, a temporal approach to the vitrectomy may be employed by utilizing the interchangeable microcannulas of 23- and 25-gauge vitrectomy systems. The infusion port is dis-inserted from the traditional infra-temporal microcannula and reaffixed in the supra-nasal microcannula. The surgeon, the operating microscope, and the foot pedals are then adjusted to a temporal orientation, and the instruments inserted through the temporally placed microcannulas.

Conclusions:

The flexibility of interchangeable microcannulas in 23- and 25-gauge PPV systems permits intraoperative switching between superior and temporal surgical sites to better manage posterior segment pathology.

Transconjunctival 20-gauge pars plana vitrectomy using a single entry cannulated sutureless system

PURPOSE

Pars plana vitrectomy with a 20-gauge transconjunctival cannulated sutureless (TCS) system has the potential of combining the advantages of smaller-gauge vitrectomy systems with the economical advantage of not needing to purchase any additional handheld instruments. However, the sclerotomy size is much larger, and self-sealing sclerotomies may be more difficult to construct. Therefore, we evaluated the need for sclerotomy suturing after performing 20-gauge TCS vitrectomy.

METHODS

A retrospective chart review was performed on the first consecutive 55 eyes of 54 patients who underwent 20-gauge TCS vitrectomy. The main outcome measure was the number of sclerotomies requiring suturing and complications.

RESULTS

Of the 164 sclerotomies made, 101 sclerotomies (62%) were not sutured, whereas the remaining 63 sclerotomies (38%) were closed with a single transconjunctival- scleral suture. The reasons for suturing included leakage and gaping at the sclerotomy, conjunctiva not covering the sclerotomy site, and prevention of gas leak. Complications noted include premature dislodging of cannulas, retinal tear, hypotony, hemorrhagic choroidals, subconjunctival gas, and less than full gas fill.

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy is associated with risks similar to other cannulated systems while retaining most of the functionality and handheld instrumentation of the 20-gauge approach. A possibly higher sclerotomy suturing rate relative to smaller-gauge approaches is a disadvantage of this technique.

Sutureless vitrectomy

Sutureless vitrectomy has rapidly been accepted as an essential part of a vitreoretinal surgical setup. The size and structure of the wound along with near intact conjunctival covering makes the incision self-sealing and safe. This allows the vitrectomy instruments to be used without creating an initial limited peritomy to expose bare sclera, and obviates the need for sutures at the end of the procedure. Wound construction is the essential step in ensuring postoperative wound stability. Both one-step and two-step wound constructions have been described. Key points include an oblique, tunneled approach to ensure a valve-like effect as well as misalignment of conjunctival and scleral wounds by displacing conjunctiva during construction. Advantages include decreased operative times in certain cases and decreased postoperative inflammation, early postoperative rehabilitation, improved patient comfort, and minimal conjunctival damage. Complications are based around wound competence, hypotony, and its relationship to endophthalmitis rates. Early reports highlighted an increase in endophthalmitis though further studies are required to accurately assess the incidence. Endophthalmitis has not been reported in cases that underwent fluid/air exchange. This review focuses on techniques, benefits, complications, personal experiences, and the safety profiles of sutureless vitrectomy systems. A literature review was undertaken using ′Medline′ and ′Pubmed′. Search terms included sutureless vitrectomy, 20 gauge, 23 gauge, 25 gauge, and transconjunctival and small gauge vitrectomy.