COMPARISON OF CLINICAL OUTCOMES AND WOUND DYNAMICS OF SCLEROTOMY PORTS OF 20, 25, AND 23 GAUGE VITRECTOMY

Conjunctival Pigmentation Following Pars Plana Vitrectomy (PPV) for Rhegmatogenous Retinal Detachment: Risk Factors and Outcomes

Purpose: To investigate the incidence and the risk factors for conjunctival pigmentation at the sclerotomy sites following valved and non-valved cannula pars plana vitrectomy (PPV) performed by different surgical techniques.

Methods: This is a prospective observational study which included 70 eyes of 70 patients who underwent PPV for rhegmatogenous retinal detachment with follow-up visits at 1, 3, 6, 12, and 24 months. Twenty-eight eyes were operated using 25G non-valved cannulas (Group A), 22 eyes using 25G non-valved cannulas (Group B), and 20 eyes using 25G valved cannulas (Group C). The evaluated clinical parameters include the surgical technique, the patients' age, the number of retinal tears, the tamponade agent, the presence of residual sub-retinal fluid (SRF), and the duration of postoperative posturing.

Results: Group A was associated with significant conjunctival pigmentation at up to 6 months after PPV. Sulfur hexafluoride (SF6) gas tamponade was associated with less conjunctival pigmentation at 3 months follow-up visit [odds ratio, OR 0.09 (95% confidence interval, CI 0.01; 0.67)], whereas the presence of residual SRF was a significant risk factor for postoperative pigmentation at 1-year follow-up visit [OR 5.89 (95% CI 1.84; 23.12)]. The area of measured pigmentation was also positively correlated to the number of retinal tears at all follow-up visits over 2 years. Six patients presented with conjunctival pigmentation at 2 years follow-up visit.

Conclusion: New vitrectomy techniques with valved cannulas prevent the postoperative appearance of conjunctival pigmentation. The number of retinal tears, the presence of SRF, and the use of long-standing tamponade agents were the most significant predisposing factors. The post-vitrectomy conjunctival pigmentation gradually reduces over time.

[Ophthalmopathologic Aspects of Endophthalmitis]

Endophthalmitis is one of the most severe ophthalmic emergencies. Most patients experience a permanent decrease in visual acuity after the event, but the eye can be preserved in most cases. However, when the eye is enucleated after endophthalmitis, ophthalmopathologic investigation of the globe with respect to the clinical history can provide valuable information regarding the ultimately frustrating course of the disease that can be helpful for the treatment of future patients. Often, valuable aspects also emerge with regard to the therapeutic approach. For example, in therapy-resistant fungal endophthalmitis the necessity of penetrating keratoplasty with a large graft diameter and possibly even removal of the lens including the capsular bag should be stressed. In the following, five enucleated eyes with a different spectrum of endophthalmitis, as well as different potential pathways of exogenous and endogenous endophthalmitis, are illustrated clinically and ophthalmopathologically. In summary, endophthalmitis requires urgent intervention; however, various differential diagnoses must be excluded. Histopathologic examination of enucleated eyes is helpful for understanding the course of the disease and may also have forensic significance.

Pars Plana Vitrectomy Port Sizes: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

The uptake of small-gauge (SG; ie, 23-gauge [23-G], 25-gauge [25-G], and 27-gauge [27-G]) pars plana vitrectomy (PPV) has grown. We aim to investigate the advantages and disadvantages of various PPV port sizes in a meta-analysis of randomized controlled trials (RCTs).

MATERIALS AND METHODS

A systematic literature search was performed for RCTs comparing PPV port sizes for any indication. Weighted mean differences (WMDs) and risk ratios (RRs) were calculated, and meta-analysis was performed with random-effects models.

RESULTS

A total of 1,678 eyes from 22 RCTs were included. Risk-of-bias assessment found some concerns in 13 studies. Compared with 20-gauge PPV, there was no significant difference in the final or change in best-corrected visual acuity (BCVA; five studies analyzed each) relative to that of SG PPV. SG PPV was associated with a significantly greater incidence of hypotony (RR = 3.79; 95% confidence intervals [CI], 2.02 to 7.10; P < .0001; six studies) and choroidal detachment (RR = 5.65; 95% CI, 1.01 to 31.71; P = .05; three studies). Compared with 25-G PPV, there was no significant difference in BCVA at any time point with 23-G (two studies), and significantly more frequent port suturing was required with 23-G (RR = 0.46; 95% CI, 0.25 to 0.84; P = .01; two studies). Compared with 25-G PPV, 27-G was associated with a significantly better final BCVA (WMD = -0.06 logMAR; 95% CI, -0.11 to -0.01; P = .02; five studies) and a significantly lengthened surgery (WMD = 4.11 minutes; 95% CI, 0.18 to 8.05; P = .04; three studies).

CONCLUSIONS

There was no significant difference in visual or surgical outcomes following 20-gauge PPV relative to SG PPV (Grading of Recommendations, Assessment, Development, and Evaluation recommendation: low certainty), and there was an increased risk of postoperative complications with SG PPV (moderate certainty). Compared with 25-G PPV, 23-G required more frequent port suturing (moderate certainty), whereas 27-G may be associated with a better final BCVA but longer surgery (low and moderate certainty, respectively). [Ophthalmic Surg Lasers Imaging Retina. 2022;53:152-158.].

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.

Comparison of safety and effectiveness between 23-gauge and 25-gauge vitrectomy surgery in common vitreoretinal diseases

PURPOSE

To assess and compare safety and effectiveness between 23-gauge and 25-gauge vitrectomy systems for the treatment of common vitreoretinal diseases in non-vitrectomized eyes.

METHODS

Retrospective evaluation of patients who underwent pars plana vitrectomy from April 2018 to December 2019 at the Department of Ophthalmology and Optometry at the Medical University of Vienna (MUV) for the following indications: macular epiretinal membrane, macular hole, macular lamellar hole, vitreous hemorrhage, vitreous opacities, vitreomacular traction syndrome and macular edema.

RESULTS

201 eyes of 195 patients that underwent 23-gauge (n = 105 eyes) or 25-gauge (n = 96 eyes) vitrectomy were included in this study. The mean best-corrected visual acuity (BCVA) improved at 1-3 months postoperatively and beyond 3 months in both gauge groups. Risk of any complication within 1 month postoperatively was lower in the 25-gauge group, but the difference was statistically not significant (HR [95% CI]: 0.95 [0.53; 1.70], p = 0.85). Intraocular pressure less than 5 mmHg was observed in 2 eyes (2%) in the 23-gauge group at the first postoperative day. Intraocular pressure elevation over 25 mmHg occurred in 5 eyes (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group) at postoperative day 1, between 7 and 28 days in 5 cases (2 eyes, 2%, in 23-gauge and 3 eyes, 3%, in 25-gauge group), and in 2 eyes (2%) of the 23-gauge group at postoperative day 145 and 61, respectively. Retinal detachment occurred in 1 eye (1%) in the 23-gauge and in 3 eyes (3%) in the 25-gauge group. We did not observe any cases of endophthalmitis.

CONCLUSION

Results in terms of safety, surgical success and visual outcomes for the treatment of common vitreoretinal surgery indications seem to be comparable between 23-gauge and 25-gauge vitrectomy systems, indicating that the two gauge systems can be used equally in the clinical routine.

INCIDENCE AND RISK FACTORS FOR HYPOTONY AFTER 25-GAUGE PARS PLANA VITRECTOMY WITH NONEXPANSILE ENDOTAMPONADE

PURPOSE

The purpose of this study was to assess the incidence and risk factors for early postoperative hypotony after 25-gauge pars plana vitrectomy with nonexpansile endotamponade.

METHODS

A retrospective study of consecutive patients who underwent 25-G pars plana vitrectomy. Hypotony was defined as an intraocular pressure of 5 mmHg or less after surgery and ocular hypertension as an intraocular pressure greater than 21 mmHg.

RESULTS

Overall, 307 eyes of 307 patients with a mean age of 61.7 ± 14.3 of which 56.7% were males were included. Hypotony was identified in 5.2% of cases (n = 16) at Day 1 and 0.7% (n = 2) at Week 1 with no hypotony-related complications. The hypotony group had a higher number of previous vitreoretinal surgeries (1.5 ± 1.1 vs. 0.4 ± 0.7, P < 0.001) and a higher prevalence of preoperative ocular hypertension (22.2% vs. 4.8%, P = 0.02), pseudophakia (77.8% vs. 48.4%, P = 0.01), silicone oil removal (61.1% vs. 8.3%, P < 0.001), and external diathermy performed (55.6% vs. 20.1%, P = 0.001). In stepwise multivariate analysis, significant parameters were silicone oil removal (R = 16.34%, odds ratio 13.45, P < 0.001), pseudophakia (R = 5.69%, odds ratio 3.65, P = 0.03), and younger age (R = 2.68%, odds ratio 0.96, P = 0.04).

CONCLUSION

Silicone oil removal is a significant risk factor for early postoperative hypotony after 25-G pars plana vitrectomy.

Comparison of Visual and Anatomic Outcomes Following RRD Surgery Using 23-Gauge Versus 25-Gauge Vitrectomy: PRO Study Report No. 12

BACKGROUND AND OBJECTIVE

Most surgeons now utilize small-gauge (23- or 25-gauge) pars plana vitrectomy (PPV) with or without scleral buckling for repair of rhegmatogenous retinal detachments (RRD), in addition to primary scleral buckle (SB), but comparative data between the two gauges are limited.

PATIENTS AND METHODS

This study is an analysis of primary RRD repairs comparing 23- versus 25-gauge vitrectomy for PPV or combination PPV/SB from January 1, 2015, through December 31, 2015, across multiple institutions. The primary outcome was single-surgery success and secondary outcomes included postoperative complications.

RESULTS

There were 1,932 eyes that met inclusion criteria. There was no statistically significant difference in single-surgery success (82.9% vs. 83.8%; P = 0.6329). There were similar rates of postoperative hypotony, endophthalmitis, vitreous hemorrhage, and choroidal detachment. The findings were similar when analyzing only eyes that underwent primary PPV without SB.

CONCLUSION

Both 23- and 25-gauge vitrectomy systems have similar anatomic and visual outcomes in the primary repair of RRD. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:70-76.].

Vitreous incarceration in sutured vs non-sutured sclerotomies after 25-gauge macular surgery

OBJECTIVES

To study the patterns of vitreous incarceration in sutured vs non-sutured sclerotomies in patients subjected to 25-gauge macular surgery.

METHODS

A prospective study of 135 eyes affected by epiretinal membrane or macular hole. Vitreal disposition was evaluated via ultrasound biomicroscopy (UBM) at the sclerotomy sites between 30 and 40 days after surgery, once the tamponade had completely disappeared.

RESULTS

In total, 349 sclerotomies (86.2%) of 99 patients were non-sutured while 56 sclerotomies (13.8%) of 36 patients were sutured at the end of the surgical procedure. Among the 36 patients with sutured sclerotomies, 15 out of 36 (41.6%) had at least two sclerotomies sutured. All the sclerotomy sites were evaluated (405 sclerotomies). Sclerotomy suture was significantly associated with a less aggressive pattern of vitreal incarceration (OR: 0.16, 95% CI: 0.07-0.35, p < 0.001). Compared to preoperative values, day 1 post operative IOP was not significantly different in patients with sutured sclerotomies, while patients with non-sutured sclerotomies had a significantly lower day 1 post operative IOP.

CONCLUSIONS

In 25-gauge macular surgery, UBM evaluation documented a higher rate of postoperative vitreous incarceration in the non-sutured sclerotomies, confirming the previously postulated role of the residual vitreous, left at the end of the surgery, in closing the sclerotomy site.

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.

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.

Intravitreal Aflibercept injection with Panretinal photocoagulation versus early Vitrectomy for diabetic vitreous hemorrhage: randomized clinical trial

Background

To compare efficacy and safety of intravitreal aflibercept (IVA) injection with panretinal photocoagulation (PRP) versus early vitrectomy for diabetic vitreous hemorrhage (VH).

Methods

Prospective, randomized study that included 34 eyes with diabetic VH. They were divided into two groups, Group Ι (17 eyes) received three successive IVA injections followed by PRP and group ΙΙ (17 eyes) for whom early vitrectomy was done. Follow up was carried out after one, two, three, six and nine months. The primary outcome measure was change in the mean best corrected visual acuity (BCVA) after nine months, secondary outcome measures were mean duration of clearance of VH and rate of recurrent hemorrhage with any additional treatment in both groups. Complications were reported.

Results

There was no statistically significant difference regarding initial demographic criteria between both groups. The mean final log MAR BCVA was statistically better than the initial BCVA in both groups (0.51 ± 0.20, 1.17 ± 0.48 for group I and 0.48 ± 0.18, 1.44 ± 0.44 for group II, P < 0.001). There was no statistically significant difference between both groups regarding the mean final Log Mar BCVA (0.51 ± 0.20 for group I, 0.48 ± 0.18 for group II, p ≥ 0.05), the mean duration of clearance of VH was 7.8 ± 1.8 weeks, 5 days for group I and II respectively. PRP was completely done for all eyes in group I after three months. The difference in the recurrence rate between group I (29.4%) and group II (11.8%) was statistically significant (p < 0.05). Vitrectomy was done for three eyes (17.6%) due to recurrent non-resolving VH in group I. late recurrent VH occurred in two eyes (11.8%) in group II, IVA was given with complete clearance of the hemorrhage. No vision threatening complications were reported in both groups.

Conclusion

Both intravitreal injection of aflibercept followed by PRP and early vitrectomy are effective and safe modalities for treatment of diabetic vitreous hemorrhage. Early vitrectomy leads to faster vision gain with less incidence of recurrence than intravitreal injection.

Trial registration

Randomized clinical trial under the number of NCT04153253 on November 6, 2019 “Retrospectively registered”.

Iatrogenic retinal breaks and postoperative retinal detachments in microincision vitrectomy surgery compared with conventional 20-gauge vitrectomy: a meta-analysis

PURPOSE

To assess the incidence of iatrogenic retinal breaks (IRBs) and postoperative retinal detachments (RDs) in microincision vitrectomy surgery (MIVS) compared with 20-gauge (20 G) vitrectomy.

METHODS

A comprehensive literature search was performed to find relevant studies and a meta-analysis of the IRBs and postoperative RDs rates after 20 G vitrectomy versus MIVS was conducted.

RESULTS

Thirty-two studies were selected, including 14,373 eyes (6932 eyes in the 20 G group, 7441 eyes in the MIVS group). The meta-analysis demonstrated that the incidence of IRBs was significantly higher in 20 G vitrectomy vs. MIVS (OR = 2.22, 95% CI, 1.93-2.57, P < 0.00001) and in a subanalysis vs. 23 G MIVS (OR = 2.19, 95% CI, 1.87-2.56, P < 0.00001) and vs. 25 G MIVS (OR = 2.27, 95% CI, 1.62-3.18, P < 0.00001). Similar result was obtained in a subanalysis for macular surgery (OR = 2.44, 95% CI, 1.99-2.99, P < 0.00001), and also for sclerotomy-related IRBs (OR = 3.73, 95% CI, 2.55-5.44, P < 0.00001), but not for surgically induced posterior vitreous detachment-related IRBs (OR = 1.59, 95% CI, 0.89-2.84, P = 0.12). The incidence of postoperative RDs in 20 G vitrectomy was significantly higher compared to MIVS (OR = 1.72, 95% CI, 1.21-2.46, P = 0.003) and in a subanalysis vs. 23 G MIVS (OR = 2.45, 95% CI, 1.50-4.00, P = 0.0003), but not for 25 G MIVS (OR = 1.01, 95% CI, 0.63-1.64, P = 0.96). Similar result was obtained in a subanalysis for macular surgery (OR = 1.89, 95% CI, 1.26-2.85, P = 0.002).

CONCLUSION

This meta-analysis demonstrated that MIVS is associated with a lower risk of IRBs and postoperative RDs compared to 20 G vitrectomy.

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.

Comparison of 23 Gauge Transconjunctival releasable Suture Vitrectomy with standard 20 gauge Vitrectomy

Objective:

To compare effectiveness of releasable transconjunctival sutures in 23 gauge vitrectomy and standard 20 gauge vitrectomy.

Methods:

This prospective comparative study was conducted in Department of Vitreoretinal Surgery, Al Ehsan Eye Hospital, Lahore from June 2016 to March 2017. It included 84 patients in total (Group-A: 42 patients underwent 23 gauge releasable suture vitrectomy; Group-B: 42 patients who underwent standard 20 gauge vitrectomy). Pre operative and post operative best corrected visual acuity, surgical duration, pre and post operative intraocular pressure and complication profile was compared between two groups.

Results:

The leading cause for vitrectomy was vitreous haemorrhage. (Group-A; n=15 ;35.71%; Group-B; n=17; 40.47%). There was statistically significant improvement in preoperative and postoperative BCVA in both groups (Group A: P-value < 0.05; Group B P-value < 0.05) but there was no significant difference in post operative BCVA between two groups at 3 months (P-value > 0.05). Surgical time for 23G vitrectomy Group was statistically less than 20 G vitrectomy Group (51 +/-18 minutes for Group-A versus 78 +/- 13 minutes for Group-B; p-value < 0.05). Visual analog score for pain / discomfort was also significantly less for Group-A than Group-B. There was no significant difference in intraocular pressures between the two groups.

Conclusions:

Releasable suture technique for small gauge vitrectomy is a safe and easily adaptable technique that has certain significant advantages over 20G absorbable suture vitrectomy.

VITREOUS INCARCERATION IN SCLEROTOMIES AFTER VALVED 23-, 25-, OR 27-GAUGE AND NONVALVED 23- OR 25-GAUGE MACULAR SURGERY

PURPOSE

To study the patterns of vitreous incarceration at sclerotomy sites by ultrasound biomicroscopy in patients subjected to valved or nonvalved small-gauge pars plana vitrectomy.

METHODS

A prospective comparative study of 88 eyes affected by epiretinal membrane and macular hole. Patients were divided into four groups: valved or nonvalved 23-gauge (16 eyes each) and valved or nonvalved 25-gauge (20 eyes each); their vitreal disposition was compared by ultrasound biomicroscopy. Vitreal disposition was also assessed in 16 eyes of 16 patients subjected to valved 27-gauge pars plana vitrectomy.

RESULTS

Three vitreal patterns were identified: P0 (vitreous not visible or vitreous strand distant from the sclerotomy site), P1 (vitreous strand parallel to and in contact with the sclerotomy site), and P2 (vitreous strand entrapped in the sclerotomy site). The effect of valved trocar use on vitreous incarceration seemed to be somewhat beneficial, but no statistically significant effect could be shown (odds ratio: 0.85, 95% confidence interval: 0.42-1.74, P = 0.657). Similarly, no differences in vitreous incarceration were shown among vitrectomy gauges (23, 25, or 27) both in a model including valved trocars only (P = 0.858) and in a model with all available data (P = 0.935).

CONCLUSION

In 23- and 25-gauge macular surgeries, postoperative vitreous incarceration does not seem to be reduced using valved cannulas and was similar to that observed in 27-gauge surgery.

SCLEROTOMY LEAKAGE IN TRANSCONJUNCTIVAL SMALL-GAUGE PARS PLANA VITRECTOMY: Effect of Removing the Cannula Over the Light Pipe

PURPOSE

To determine the effect of cannula removal over the light pipe on the incidence of sclerotomy leakage and to evaluate other factors that may influence the incidence of sclerotomy leaks and hypotony on conclusion of small-gauge transconjunctival pars plana vitrectomy.

METHODS

Retrospective, interventional clinical study of consecutive patients who underwent small-gauge transconjunctival pars plana vitrectomy at a single academic center. Eyes were divided into a group in which cannulae were removed over the light pipe (Group L) and a group in which cannulae were simply pulled out (Group N). The primary comparison was the comparison in requirement for suturing of sclerotomies between Groups L and N.

RESULTS

Forty-eight eyes of 48 patients were included in the study (Group L: 21 eyes; Group N: 27 eyes). In Group L, 14/42 (33%) superior sclerotomies required suturing compared with 7/54 (13%) sclerotomies in Group N (P = 0.024). Superior sclerotomy leaks were also more common in Group L (28/42, 67%) compared with Group N (23/54, 43%, P = 0.024). Similarly, more eyes had hypotony after cannula removal in Group L (11/21; 52%) compared with Group N (5/27; 19%, P = 0.03). There were no differences in any of these measures when comparing fluid-filled to air- or gas-filled eyes.

CONCLUSION

Removing the cannula over the light pipe results in a greater frequency of leaking, including leaking that results in hypotony or that requires suturing. The technique of cannula removal affects the risk of leakage and the risk of requiring suturing of a sclerotomy.

Comparison of subconjunctival scarring after microincision vitrectomy surgery using 20-, 23-, 25- and 27-gauge systems in rabbits

PURPOSE

To compare subconjunctival scarring after vitrectomy in rabbit eyes using different gauge systems by analysing anterior segment optical coherence tomography (AS-OCT) images and histological sections.

METHODS

Vitrectomy using 20-, 23-, 25- and 27-gauge systems was performed for rabbits. Anterior segment optical coherence tomography (AS-OCT) images of the incision sites were obtained before and at day 1, 7 and 1 month after surgery. We measured the thickness of conjunctival epithelium, stroma, Tenon's capsule and total conjunctiva of these three layers, then determined the preservation rates of the borderlines between each layer. Surgical invasion was estimated by histological observation.

RESULTS

The thickness of total conjunctiva, or the thickness of both conjunctival stroma and Tenon's capsule in the 20-gauge group was significantly thicker than that in the 27-gauge group at day 1 and day 7 after surgery. Preservation rates of the conjunctival stroma/Tenon's capsule borderline were significantly lower in the 20-gauge group than in the 25- and 27-gauge groups at day 1, day 7 and 1 month. Preservation rates of the Tenon's capsule/sclera borderline were significantly lower in the 20-gauge group than in the 25- and 27-gauge groups at 1 month. In the 27-gauge group, the number of α-smooth muscle actin-positive fibroblasts was significantly smaller than in the 20-gauge group at day 7.

CONCLUSION

Based on the finding of AS-OCT and histology, micro incision vitreous surgery, especially using 27-gauge, contributed to less subconjunctival scarring postoperatively. Therefore, the 27-gauge pars plana vitrectomy (PPV) may be a more effective technique for preserving the structure of conjunctiva.

25G compared with 20G vitrectomy under Resight non-contact wide-angle lenses for Terson syndrome

The aim of the present study was to compare the effectiveness of 25G vitrectomy to standard 20G vitrectomy for treatment of Terson syndrome under Resight non-contact wide-angle lenses. This was a case-control study of 20 patients with Terson syndrome (study group) that underwent 25G vitrectomy under Resight non-contact wide-angle lenses, with those of 20 matched patients that underwent 20G vitrectomy (control group). Medical records were reviewed from between July 2011 and October 2013. Data included results of the Early Treatment Diabetic Retinopathy Study examination, ophthalmology B-scan ultrasonography and fundus photography. The mean age, follow-up time, the preoperative visual acuity of LogMAR and the preoperative intraocular pressure (IOP) were all comparable in the two groups (all P>0.05). There were statistically significant differences in postoperative visual acuity of LogMAR compared with preoperative visual acuity (P<0.001) in both groups, but no difference between the groups (P=0.845). However, the operative times (13.5 min in study group vs. 42 min in control group) and post-operative IOP at day 1 (13.5 vs. 20 mmHg) were significantly reduced in the study group compared to the control group (P<0.001). Therefore, the present findings suggest that 25G Vitrectomy for Terson syndrome under Resight non-contact wide-angle lenses can achieve a significantly shorter operative time and lower post-operative IOP compared with 20G Vitrectomy.

Short- and Long-Term Outcomes of Vitreoretinal Surgeries With Deferred First Postoperative Visits at Day 3 or Later

Background and Objective:

Postoperative (PO) day 1 visits can be challenging for certain patients (eg, satellite office patients). This study analyzes the proportion of eyes requiring changes in management on the first PO visit day ≥3 following vitreoretinal surgery.

Study Design/Materials and Methods:

A retrospective, consecutive case series of 1 vitreoretinal surgeon was conducted on 246 surgeries of 231 patients with the first PO examination day ≥3 from January 1, 2008 to December 31, 2013. Clinical parameters were statistically analyzed to identify eyes with pressure issues or early interventions. Short- and long-term outcomes were assessed at PO weeks 1 to 4 and months 3 to 8.

Results:

At the first PO visit ≥3 (mean 4.5) days, 3.3% eyes had intraocular pressure (IOP) ≤5, 3.3% IOP ≥30, 0.8% choroidal detachments, 0.4% vitreous hemorrhage, and 0% endophthalmitis. About 2.0% of eyes required intervention (IOP medications). Surgical indications, procedure, and tamponade were not predictive of pressure issues or early intervention ( P > .05). At weeks 1 to 4 and month 3 to 8, 4% to 6% of eyes required additional intervention or surgery.

Conclusion:

The first PO visit day ≥3 after vitreoretinal surgeries had low intervention rates. Few complications or additional surgeries occurred throughout the study period.

Surgical outcomes of 23-gauge transconjunctival pars plana vitrectomy combined with lensectomy for glaucomatous eyes with extremely shallow anterior chamber and cataract

Background

Glaucoma combined with an extremely shallow anterior chamber and cataracts remains as a complex condition to deal with. And the emergence of microincision vitrectomy surgery (MIVS) system may provide an ideal option for the treatment of that. We report a clinical study of surgical outcomes of 23-gauge transconjunctival pars plana vitrectomy (PPV) combined with lensectomy in the treatment of glaucomatous eyes with extremely shallow anterior chamber and cataract.

Methods

Prospective, nonrandomized and noncomparative case series study. Consecutive patients with secondary glaucoma, extremely shallow anterior chamber and cataract were recruited to have combined surgeries of 23-gauge transconjunctival pars plana vitrectomy and lensectomy. The main outcomes were best corrected visual acuity (BCVA), intraocular pressure (IOP), anterior chamber depth (ACD), number of anti-glaucoma medications and surgery-associated complications.

Results

Seventeen consecutive patients with secondary glaucoma, extremely shallow anterior chamber and cataract were recruited. The mean follow-up was 21.2 ± 8.8 months. Postoperatively, there was no significant improvement of BCVA (P = 0.25). The mean intraocular (IOP) decreased significantly from 43.14 ± 6.53 mmHg to 17.29 ± 1.80 mmHg (P < 0.001), and the mean depth of anterior chamber increased significantly from 0.507 ± 0.212 mm to 3.080 ± 0.313 mm (P < 0.001). The mean number of anti-glaucoma medications decreased from 4.1 ± 0.8 to 0.6 ± 0.8 (P < 0.001). No severe vision-threatening intra- or post-operative complications occurred.

Conclusions

Glaucoma with an extremely shallow anterior chamber and cataract can be managed well with the combined surgeries of 23-gauge pars plana vitrectomy and lensectomy. The surgical procedure is an effective and safe method to resolve the pupillary block and deepen the anterior chamber.

25-Gauge Pars Plana Vitrectomy for Retained Lens Fragments in Complicated Cataract Surgery

PURPOSE

To verify the efficacy of 25-gauge pars plana vitrectomy (PPV) for the management of posteriorly dislocated lens material after complicated cataract extraction and to determine in what patients this approach offers the optimal benefit in terms of efficacy and safety, considering the amount of retained nuclear material and the duration of surgery.

METHODS

Forty eyes of 40 patients with retained lens fragments undergoing early (within 1 week) or late (within >1 week) 25-gauge PPV were retrospectively reviewed. The amount of dislocated nuclear material was graded by the surgeon intraoperatively, and the patients were divided into two groups according to the nuclear grading: group A (≤50% dropped nucleus) and group B (>50% dropped nucleus). The presence of brunescent nuclear pieces was considered. The outcomes measured included best-corrected visual acuity (BCVA) and postoperative complications such as retinal detachment, cystoid macular edema (CME) and postoperative ocular hypertension or hypotonia.

RESULTS

The patients had a mean age of 78 years. The mean preoperative logarithm of the minimum angle of resolution (logMAR) BCVA was 0.57 ± 0.24 (20/80). A significant positive correlation was found between nuclear material grade and PPV duration (R2 = 0.81, p < 0.0001). None of the patients had dislocation of brunescent nuclear pieces. On postoperative day 1, the mean postoperative intraocular pressure was 16.75 ± 2.7 mm Hg, with no case of ocular hypotonia. At 6 months of follow-up, the mean logMAR BCVA improved to 0.23 ± 0.3 (20/32). Retinal detachment developed in 4 patients (10%), occurring only in patients of group B (p < 0.002). Four patients with late PPV developed postoperative CME, with no case of CME among patients with early vitrectomy (p = 0.014).

CONCLUSION

Removal of dislocated lens fragments after complicated cataract surgery can be effectively managed with 25-gauge PPV, although it appears to be most efficient for cases with a limited amount of dislocated lens material. In consideration of the higher rate of retinal detachment observed in cases of prolonged PPV time, the expected duration of surgery should be taken into account when choosing the best surgical approach. Visual outcomes are not affected by the timing of PPV, whereas early vitrectomy seems to prevent the onset of inflammatory macular edema.

Performance Comparison of High-Speed Dual-Pneumatic Vitrectomy Cutters during Simulated Vitrectomy with Balanced Salt Solution

PURPOSE

To measure flow rate of balanced salt solution and IOP during simulated vitrectomy using two sets of high-speed dual-pneumatic probes.

METHODS

A closed-model eye system measured IOP and flow rate of a balanced salt solution through infusion cannula. The Constellation Vision System was tested with two sets of high-speed dual-pneumatic probes (UltraVit 23-gauge and enhanced 25+-gauge 5000-cpm probes; UltraVit 23-gauge and enhanced 25+-gauge 7500-cpm probes; n = 6 each) under different vacuum levels and cut rates in three duty cycle modes.

RESULTS

In both probe sets, flow rates were dependent on cut rate with the biased open and biased closed duty cycles. Flow rates were highest with the biased open duty cycle, lower with the 50/50 duty cycle, and lowest with the biased closed duty cycle. IOP, as expected, was inversely associated with flow rate using both probe sets.

CONCLUSIONS

The 7500-cpm probes offer greater control and customization compared with 5000-cpm probes under certain experimental conditions. At maximum cut rates, performance of 7500-cpm probes was similar to that of 5000-cpm probes, suggesting that 7500-cpm probes may be used without sacrifice of flow rate and IOP stability.

TRANSLATIONAL RELEVANCE

Customization of vitrectomy parameters allows greater surgeon control during vitrectomy and may expand the usefulness of vitrectomy probes.

Clinical Analysis of 23-Gauge Vitrectomy for the Treatment of Acute Endophthalmitis after Cataract Surgery

Purpose

We performed a retrospective study to evaluate the surgical efficacy and timing of 23-G vitrectomy for acute endophthalmitis following cataract surgery, and to determine when silicone oil tamponade and intraocular lens (IOL) removal are indicated during vitrectomy for endophthalmitis.

Methods

We enrolled 21 patients (21 eyes) diagnosed with acute endophthalmitis following cataract surgery who underwent endoscope-assisted 23-G vitrectomy using a wide-angle noncontact lens. Silicone oil tamponade was performed when retinal tear or detachment occurred. The IOL was not removed during primary vitrectomy. Postoperative systemic broad-spectrum antibiotics were used.

Results

All infections were controlled by treatment. Best-corrected visual acuity was >0.05 in 14 patients (66.7%) after treatment, which was significantly higher than that before treatment (2/21, 9.5%). Two patients experienced retinal detachment at 10 and 14 days after primary vitrectomy; the IOL was removed during secondary surgery, and silicone oil tamponade was performed. One patient experienced endophthalmitis recurrence 2 months after vitrectomy; secondary surgery was performed to remove the peripheral vitreous body, the pars plana of the ciliary body, and the IOL and capsule.

Conclusions

Vitrectomy should be performed when acute endophthalmitis is diagnosed following cataract surgery. Silicone oil tamponade should be performed only when retinal break or detachment occurs. The IOL does not necessarily require removal.

23-gauge versus 25-gauge vitrectomy for proliferative diabetic retinopathy: a comparison of surgical outcomes

PURPOSE

This study compared clinical outcomes and complications between 23-gauge (23g) and 25-gauge (25g) transconjunctival sutureless vitrectomy in patients with proliferative diabetic retinopathy.

STUDY DESIGN

It was a retrospective study using data prospectively defined and collected. 80 eyes underwent 23g transconjunctival sutureless vitrectomy, and 80 eyes underwent 25g surgery using the same vitrectomy system by one surgeon. Primary outcome measures were best-corrected visual acuity, intraocular pressure (IOP), and incidence of intraoperative and postoperative complications.

RESULTS

Vision was significantly improved after intervention in both groups (p ≥ 0.0001). There was no significant difference in visual outcomes between the groups (p = 0.43) or in the type and frequency of retinal breaks occurring during surgery (p = 0.63). The 23g group had significantly more patients with a day 1 IOP of <6 mm Hg (p = 0.034) and significantly more patients requiring a sclerostomy suture postoperatively (p = 0.014).

CONCLUSION AND MESSAGE

Both gauges are equally effective for the treatment of proliferative diabetic retinopathy.

Comparison of the effects of 23-gauge and 25-gauge microincision vitrectomy blade designs on incision architecture

Purpose

To compare the effects of different 23- and 25-gauge microincision vitrectomy trocar cannula entry systems on incision architecture.

Methods

We tested one ridged microvitreoretinal (MVR), one non-ridged MVR, one pointed beveled, and one round-tipped beveled blade (n=10 per blade design per incision type). Each blade’s straight and oblique incision architecture was assessed in a silicone disc simulating the sclera. Wound leakage under pressure and endoscopic observations were conducted on sclerotomy sites of isolated porcine eyes (n=4 per blade design) after simulated vitrectomy.

Results

Differences in blade design created distinct incision architecture. Incisions were linear with the ridged MVR blade, flattened “M-shaped” with the non-ridged MVR blade, asymmetrical chevron-shaped with the pointed beveled blade, and curved with the round-tipped beveled blade. With the exception of oblique entry incision thickness, both MVR blade designs created thinner incisions than the beveled blades at entry and exit sites. Only the ridged MVR blade created incisions with no leakage. Vitreous incarceration was observed with all trocar cannula systems.

Conclusion

Wound closure in porcine eyes was similar with all blades despite differences in incision architecture. Wound leakage occurred at low to moderate infusion pressures with most blades; no wound leakage was observed with ridged MVR blades.

In-office use of the intrector for the removal of retained lens cortex

PURPOSE

To report a case and technique for the removal of retained lens cortex material in an office-based procedure using a portable battery-powered vitrectomy system.

METHODS

Case report.

RESULTS

An 88-year-old man underwent uncomplicated office-based vitrectomy for the removal of retained lens material with good anatomical and visual outcomes.

CONCLUSION

The authors report a case of the removal of retained cortex material using an office-based vitrector. Clinicians should be aware of this technique for selected patients.

Endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes

Endophthalmitis following pars plana vitrectomy is a very uncommon cause of endophthalmitis. Cases reported over the last decade show a decrease in incidence over time. To optimize visual outcome, early diagnosis and treatment are essential. In this review we report a summary of the incidence of endophthalmitis following vitrectomy, various risk factors for their occurrence, the microbiological profile and the visual outcomes post treatment.

25-Gauge pars plana vitrectomy for ciliary block (malignant) glaucoma

To evaluate the efficacy of 25-ga pars plana vitrectomy (PPV) and 25-ga PPV combined with phacoemulsification surgery for managing ciliary block (malignant) glaucoma. The medical records of 11 eyes, in nine consecutive patients with malignant glaucoma were retrospectively reviewed to determine the efficacy of 25-ga PPV for alleviating this disease. All phakic eyes underwent phacoemulsification surgery during vitrectomy. Control of intraocular pressure (IOP), pre- and postoperative best-corrected visual acuity (BCVA), and development of intra- and postoperative complications were evaluated during follow-up. Malignant glaucoma was promptly resolved, and recurrence was not observed during a mean follow-up period of 12.7 ± 3.2 (range 6-18) months. The mean IOP decreased from 35.9 ± 2.9 mmHg, preoperatively, to 16.0 ± 1.4 mmHg, measured at last visit (P = 0.013). Although IOP control was achieved in all eyes after surgery, two eyes required long-term topical antiglaucoma medication. The mean logarithm of the minimum angle of resolution BCVA improved from +0.69 ± 0.11, preoperatively, to +0.29 ± 0.07, postoperatively (P = 0.027). No severe intraoperative complications were observed. Postoperative complications mostly occurred during the first week after surgery, including transient corneal edema and Descemet's membrane folds in three eyes, fibrotic exudation in 2, local iris posterior synechia in 1, and transient hypotony in 1, which were resolved spontaneously or with medication. The 25-ga PPV procedure seems to be safe and effective for treating malignant glaucoma. Combined vitrectomy with phacoemulsification surgery and a staged surgical approach may improve the success rate.

Influence of the source of incisional vitreous incarceration on sclerotomy closure competency after transconjunctival sutureless vitrectomy

PURPOSE

To evaluate the influence that the origin of incisional vitreous incarceration may have on the presence of postoperative conjunctival blebs over sclerotomies after transconjunctival sutureless vitrectomy (TSV). Blebs are formed by incisional leakage due to incompetent closure.

METHODS

Twenty-three-gauge TSV was performed in 83 cadaveric pig eyes. Once each vitrectomy was finished, ultrasound biomicroscopy (UBM) was used to assess the presence of postoperative conjunctival blebs over the sclerotomy sites, as well as the existence of vitreous incarcerated in incisions. Vitreous strands may come from the perisclerotomy area, running parallel to the sclera toward the inner hole of the sclerotomies, or may radiate from the core of the vitreous cavity.

RESULTS

Vitreous entrapment was found in 73.9% of the sclerotomies; 43.4% of the incisions showed vitreous strands coming parallel to the sclera (12.9% of them showed conjunctival bleb), 19.7% of the wounds presented vitreous aiming toward the core of the vitreous cavity (2% of them had conjunctival bleb) and 10.8% of the entrances presented both vitreous incarceration sources (none of them showed bleb). Incisions with vitreous entrapment parallel to the sclera were associated with a significantly greater sclerotomy leakage rate.

CONCLUSIONS

Sclerotomies with vitreous incarceration coming from the core of the vitreous cavity showed a greater incisional closure competency than that observed in incisions with vitreous entrapment coming from the pericannular area; if these results were confirmed in humans, different postoperative suture rates may be expected on sclerotomies according to the vitrectomy degree performed in different areas of the vitreous cavity.

Evaluation of Wound Morphology of Sclerotomy Sites of Sutureless Vitrectomy Using Spectralis Anterior Segment Optical Coherence Tomography

PURPOSE

The aim of the study was to evaluate wound morphology in vivo in eyes undergoing sutureless vitrectomy.

DESIGN

This was a prospective consecutive case series.

METHODS

Twenty eyes undergoing sutureless vitrectomy were evaluated using anterior segment optical coherence tomography on days 1, 15, and 30. Ten eyes each belonged to 23-gauge (group A) and 25-gauge (group B). Scans were taken on the incision sites. Group A cases were further divided into group A1 and A2 on the basis of the surgical time of less than 15 minutes' and more than 15 minutes' duration, respectively.

RESULTS

On day 1, the mean outer and inner incision diameters in group A were 236.6 and 146 µm, and those for group B were 118.6 and 90 µm. A significant decrease (P < 0.0001) in both the port sizes was observed in both groups' follow-up. Group B showed significant decrease (P < 0.0001) in the port sizes on l follow-up as compared with group A. Group A1 had smaller incision size as compared with group A2 on the first postoperative day, although not statistically significant(P > 0.05).

CONCLUSIONS

In both groups, the sclerotomy incisions showed good healing at 1-month duration. The 25-gauge sclerotomies showed better healing characteristics of wound morphology as compared with the 23-gauge sclerotomies.

Intraoperative endoscopic observation of sclerotomy site after cannula removal for 23-gauge vitrectomy

BACKGROUND

The purpose of this study was to determine the incidence of vitreous incarceration in sclerotomy after cannula removal during 23-gauge vitrectomy.

METHODS

Thirty-seven eyes underwent 23-gauge sutureless vitrectomy. Oblique sclerotomies were made parallel to the limbus and tangentially to the sclera. Once past the trocar sleeve, the angle was changed to 90 degrees perpendicular to the surface and the trocar and cannula inserted. Vitreous gel was removed until the intraocular edge of the infusion cannula was free from the gel. The cannula was extracted with insertion of a light probe. The sclerotomy site was evaluated endoscopically through another cannula in 32 eyes; in five eyes, another infusion tube was inserted into the cannula to maintain intraocular pressure, the original infusion was removed, and the sclerotomy site observed.

RESULTS

No vitreous incarceration occurred in 30 (94%) eyes when one cannula was removed with insertion of a light probe, and minimal incarceration occurred in two (6%) eyes. No incarceration occurred in five eyes with observation of the infusion site.

CONCLUSION

The incidence of vitreous incarceration is low when a light probe or vitreous cutter is inserted. Inserting the light probe through the cannula during its removal and creating an oblique sclerotomy may reduce vitreous incarceration.

Surgical outcomes of 23-gauge vitrectomy for the management of lens fragments dropped into the vitreous cavity during cataract surgery

PURPOSE

To assess the clinical features and surgical outcomes of 23-Gauge (G) vitrectomy for lens fragments dropped into the vitreous during cataract surgery.

METHODS

A retrospective, non-comparative, interventional case series at a single medical center. The medical records of 45 eyes from 45 consecutive patients who were referred to our hospital for surgical retrieval of phacoemulsification dropped lens fragments and who underwent 23-G vitrectomy were retrospectively reviewed. Data pertaining to patient demographics, pre- and post-operative Snellen visual acuity, and postoperative complications were recorded. Factors associated with dropped lens fragments were also examined.

RESULTS

Mean patient age was 68.18 ± 11.47 years. The preoperative and postoperative mean logarithm of minimum angle of resolution (logMAR) visual acuity was 1.91 ± 0.59 (Snellen equivalent 0.06 ± 0.15) and 0.42 ± 0.51 (Snellen equivalent 0.54 ± 0.31), respectively. Forty-two eyes (93.3%) had dislocated lens fragments <50% of the total lens size. Two eyes (4.4%) had a large and hard lens nucleus, which necessitated the use of a 20-G fragmatome to efficiently and completely remove the lens material. At the final examination, 30 eyes (66.6%) had a visual acuity better than 20/40. Post-vitrectomy complications included elevated IOP for at least 3 months (n = 5 eyes, 11.1%), intraocular lens dislocation (n = 2 eyes, 4.4%), and cystoid macular edema (n = 1 eye, 2.2%). No cases of postoperative endophthalmitis or retinal detachment were observed.

CONCLUSIONS

A 23-G vitrectomy is safe and efficient for the surgical management of dropped lens fragments following cataract surgery.

Changes in day 1 post-operative intraocular pressure following sutureless 23-gauge and conventional 20-gauge pars plana vitrectomy

Background/Aims:

The benefits associated with transconjunctival sutureless vitrectomy techniques are continuing to be defined. The purpose of this study was to compare the incidence of extreme changes in day 1 intraocular pressure (IOP) following 23-gauge sutureless vitrectomy compared with conventional 20-gauge vitrectomy.

Methods:

Fifty consecutive 23-gauge and 50 consecutive 20-gauge cases were included; eyes with a history of previous vitreoretinal surgery were excluded. 23-gauge surgery was completed with passive fluid air exchange where no long acting tamponade was indicated. The surgery remained sutureless unless a leak was visible at the end of the procedure. Data were collected by retrospective case note review. Statistical analysis was carried out using Fisher’s exact and chi-square tests.

Results:

Twenty-two percent (11/50) of 23-gauge vitrectomies required suturing of one or more ports. On the first post-operative day hypotony (IOP<5mmHg) occurred in 1/50 eyes in the 20- and 23-gauge groups. Raised pressure (IOP>21mmHg) occurred in 30% (15/50) of eyes in the 20-gauge group and 8% (4/50) of eyes in the 23-gauge group; IOP>30mmHg only occurred in the 20-gauge group (3/50).

Conclusion:

Fluid air exchange following 23-gauge vitrectomy is associated with very low risk of day 1 hypotony. This predominantly sutureless technique appears to reduce the incidence and magnitude of early post-operative IOP elevation compared with conventional 20-gauge vitrectomy.

Influence of sclerotomy use on vitreous incarceration in an experimental model of vitrectomized eye

PURPOSE

To evaluate the influence of sclerotomy use during vitrectomy (vitreous cutter, illumination probe, or infusion-line entrance) on postoperative vitreous incarceration using an experimental model of vitrectomized eye.

MATERIALS AND METHODS

Experimental, randomized, and observer-masked study in which 23-gauge transconjunctival sutureless vitrectomy was performed in cadaveric pig eyes. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2).

RESULTS

A total of 46 eyes were included. Vitreous incarceration was detected in 91.3% (43.5% G1, 47.8% G2) of the sclerotomies used by the vitreous cutter probe, 95.7% (45.7% G1, 50% G2) of the illumination-pipe entrances, and 93.5% (45.7% G1, 47.8% G2) of the infusion-line incisions. No statistical differences were found when comparing incisional vitreous incarceration after vitrectomy according to sclerotomy use.

CONCLUSION

Different manipulation of the sclerotomies, depending on their use, does not seem to influence postvitrectomy vitreous entrapment in our experimental model.

A systematic review of endophthalmitis after microincisional versus 20-gauge vitrectomy

BACKGROUND

Endophthalmitis is a rare but severe complication of vitrectomy.

CLINICAL RELEVANCE

Post-surgical endophthalmitis is suspected to be more frequent after microincisional (23- and 25-gauge) compared with standard (20-gauge) vitrectomy.

METHODS

We conducted a systematic review of studies that compared microincisional and standard vitrectomy by searching MEDLINE and EMBASE up to November 2012. We used the Bayesian meta-analysis method to compute the odds ratio (OR) of endophthalmitis. We conducted subgroup analyses to compare the effect of different incision types and use of perioperative antibiotics.

RESULTS

We identified 3 small randomized and 18 nonrandomized studies that reported 68 cases of endophthalmitis in 148 643 participants. The overall OR of endophthalmitis for microincisional versus standard vitrectomy was 2.3 (95% credible interval [CrI], 0.8-5.8). We found an increased risk of endophthalmitis using a microincisional straight approach compared with standard vitrectomy (OR, 15.1; 95% CrI, 2.01-179), but not for a beveled approach (OR, 0.82; 95% CrI, 0.23-2.28). The OR of studies that reported on mixed microincision was between these 2 values (OR, 4.4; 95% CrI, 1.32-14.3). We estimated that the overall rate of endophthalmitis with 20-gauge vitrectomy was 3 cases in 10 000 procedures, and the probability that a beveled microincision increases the rate of endophthalmitis to more than 6 or 9 events was small (no more than 5% or 1%, respectively).

CONCLUSIONS

We did not find an increased risk of endophthalmitis for microincisional vitrectomy compared with standard vitrectomy. The beveled approach seems to be safer than a straight approach, supporting the current recommendation of its adoption in microincisional vitrectomy. However, these findings must be interpreted cautiously because of the small number of endophthalmitis events reported from included studies.

Fibrovascular ingrowth after 25-gauge transconjunctival vitrectomy in proliferative diabetic retinopathy

The authors describe two patients with proliferative diabetic retinopathy bilaterally who were treated with transconjunctival 25-gauge pars plana vitrectomy (PPV) for dense vitreous hemorrhage (VH). After 4 and 10 months, respectively, both developed recurrent VH. They were initially managed with in-office gas-fluid exchange and anti-VEGF intravitreal injection. Soon after gas bubble resorption, the VH recurred. Color external photos revealed engorged episcleral vessels superotemporally, and ultrasound biomicroscopy confirmed the presence of fibrovascular ingrowth (FVI) at the sclerotomy site in both patients. They were successfully treated with a slightly modified 25-gauge PPV technique. Although FVI is well-recognized following conventional 20-gauge vitrectomy, this report is the first to detail FVI arising after small-gauge transconjunctival vitrectomy.

Comparative evaluation of 23- and 25-gauge microincision vitrectomy surgery in management of diabetic macular traction retinal detachment

PURPOSE

To compare the efficacy, outcomes, and complications of 23-G and 25-G microincision vitrectomy surgery (MIVS) in cases of diabetic tractional retinal detachment (TRD).

METHODS

This is a prospective, single-blinded, randomized, comparative study. Fifty eyes of 50 patients with diabetic TRD involving or threatening macula were randomized into 2 groups of 25 each. Group 1 underwent 23-G MIVS and group 2 underwent 25-G MIVS. Patients were followed up at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. The primary outcome measure was anatomic and visual success after surgery. We also compared the 2 alternative MIVS systems and assessed various intraoperative and postoperative parameters.

RESULTS

Anatomic achievement was achieved in all eyes and both groups showed a significant improvement in vision after surgery (p = 0.033 and p = 0.004, respectively) and were comparable (p = 0.584). Mean surgical time in 25-G surgery was significantly longer than in 23-G surgery by 4.60 minutes (p<0.001). Postoperative mean astigmatism was comparable in the 2 groups and postoperative hypotony was not encountered in either group. No port-related breaks were seen in either group; however, iatrogenic breaks occurred in 4 eyes in the 23-G group and 5 eyes in the 25-G group (p = 1.000). There was significantly less immediate postoperative pain and foreign body sensation in the 25-G group compared with the 23-G group.

CONCLUSIONS

Both 23-G and 25-G MIVS have comparable visual and anatomic results for diabetic TRD; however, 25-G surgery may be associated with less postoperative pain and discomfort than 23-G surgery.

Scleral Buckling for Rhegmatogenous Retinal Detachment Using Vitrectomy-Based Visualization Systems and Chandelier Illumination

PURPOSE

The objective of this study was to evaluate an alternative approach to scleral buckling surgery using vitrectomy-based chandelier visualization systems instead of the indirect ophthalmoscope.

DESIGN

This was a prospective case series.

METHODS

Ten eyes underwent scleral buckling under microscope using contact wide-angle lens with 25-gauge chandelier illumination and were followed up for 6 months.

RESULTS

An encirclage was done in 8 eyes, and segmental buckle used in 2 eyes. Excellent intraoperative visualization was achieved, and all routine buckling steps were easily replicated with this approach.

CONCLUSIONS

Using contact wide-angle lens along with chandelier illumination under microscope allows good visualization for scleral buckling procedure. This approach may allow excellent visibility with zooming capabilities for each step of the procedure as well as allows transmission to a monitor in the theater for teaching purposes apart from allowing better ergonomics for the surgeon.

In vivo comparison of 23- and 25-gauge sutureless vitrectomy incision architecture using spectral domain optical coherence tomography

Purpose. To investigate the in vivo incision architecture using spectral domain optical coherence tomography (SD-OCT) in 23-gauge and 25-gauge transconjunctival sutureless pars plana vitrectomy (TSPPV). Methods. A prospective observational study of 22 eyes of 22 patients that underwent three-port 25-gauge (10 eyes) or 23-gauge (12 eyes) TSPPV was performed. The three sclerotomies sites in each eye were analyzed by Corneal Adapter Model (CAM) RTVue SD-OCT (Optovue Inc., Fremont, CA, USA) with wound cross-section images (longitudinal and transversal) on days 1, 7, and 30 postoperatively. Transversal and longitudinal length, location, angle between the conjunctival surface tangent and the incision plane, and architecture deformations were evaluated. Results. All patients (22 eyes) completed the study and surgeries lasted less than 60 minutes. All wounds were obliquely performed, 23-gauge mean angle was 23 ± 5°, and 25-gauge angule was 21 ± 4°. Twenty-three-gauge sclerotomy transversal mean length was 1122 ± 242 μm and 25-gauge transversal sclerotomy mean length was 977 ± 174 μm; 23-gauge longitudinal mean length was 363 ± 42 μm and 25-gauge longitudinal sclerotomy mean length was 234 ±19 μm; 23-gauge open wound thickness mean was 61 ± 28 μm and 25-gauge open wound thickness mean was 22 ± 6 μm. All results were statistically significant (P < 0.05). No vitreous incarceration or silicone oil residue was observed in incision sites with both gauges. Conclusions. The 23-gauge and 25-gauge architectural wound constructions were well visualized using CAM SD-OCT. Statistical differences between the two gauges were observed throughout the study period.

23-gauge vitrectomy for retained lens material

A technique for removal of retained lens material is described with a three-port 23-gauge vitrectomy system. Removal of the core vitreous is first performed, followed by removal of the cortical vitreous. All vitreous adhesions to the lens are cleared. The cut rate is then decreased to 1,500 cuts per minute, and vacuum increased to 600 mm Hg. The cortical lens material is cleared first, and then the nuclear material is taken with the same vitrectomy probe using the light pipe to assist in crushing the nuclear fragments. With this technique, even large dense nuclear and cortical retained lens material can be removed from the vitreous chamber without the need for a fragmatome.

Transconjunctival sutureless vitrectomy versus 20-gauge vitrectomy for vitreoretinal surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Transconjunctival sutureless vitrectomy is appealing to vitreoretinal surgeons around the world. However, its use versus 20-gauge vitreoretinal surgery is still controversial. The aim of this meta-analysis was to compare the safety and functional outcomes of transconjunctival sutureless vitrectomy versus 20-gauge vitrectomy for vitreoretinal surgery.

METHODS

Data sources, including PubMed, Medline, EMBASE, and Cochrane Controlled Trials Register, were searched to identify potentially relevant randomized controlled trials. A meta-analysis was performed using RevMan 5.0 software. The primary factors included patients' discomfort, operating time and early postoperative complications. Visual acuity and surgically induced astigmatism were chosen as secondary outcomes.

RESULTS

A total of 471 participants with 479 eyes in eight trials between 2005 and 2011 were analyzed. Transconjunctival sutureless vitrectomy was associated with significantly fewer patients suffering from postoperative discomfort at 1 day (odds ratio [OR] 0.07; 95 % confidence interval [CI] 0.01 to 0.49; p = 0.007) and 7 days (OR 0.14; 95 % CI 0.03 to 0.73; p = 0.02) follow-up, and was more effective in reducing surgically induced astigmatism (mean difference -0.23D; 95 % CI -0.31 to -0.15; p < 0.00001) compared to 20-gauge vitrectomy. The sutureless group achieved shorter wound opening (mean difference -1.97 minutes; 95 % CI -2.69 to -1.25; p < 0.00001) as well as wound closure time (mean difference -4.55 minutes; 95 % CI -5.43 to -3.66; p < 0.00001), but the overall surgery time was comparable (mean difference -0.14 minutes; 95 % CI -3.52 to 3.24; p = 0.93). There were no significant differences in the complication rates between the two groups with the exception of postoperative hypotony, which was more likely with the sutureless group (OR 3.73; 95 % CI 1.43 to 9.76; p = 0.007).

CONCLUSIONS

According to the present data, transconjunctival sutureless vitrectomy offered significantly less postoperative discomfort and decreased surgically induced astigmatism without increasing the risk of vision-threatening complications. Further trials with contemporary equipment and larger sample size are suggested to confirm this conclusion.