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

Refining vitrectomy for proliferative diabetic retinopathy

Pars plana vitrectomy (PPV) is the main treatment modality for patients with severe diabetic retinopathy. With the development of systems for microincision, wide-angle viewing, digitally assisted visualization, and intraoperative optical coherence tomography, contemporary PPV for diabetic retinopathy has been performed on a wider range of indications than previously considered. In this article, we reviewed, in conjunction with our collective experiences with Asian patients, the applications of new technologies for PPV in eyes with diabetic retinopathy and highlighted several important procedures and entities not generally reiterated in the literature, in order for vitreoretinal surgeons to optimize their approaches when facing the challenges imposed by the complications in diabetic eyes.

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.

Effect of ILM Peeling on Anatomical and Visual Outcomes in Diabetic Tractional Retinal Detachment

Objectives

The objcetive is to compare the anatomic and functional outcomes of vitrectomy between internal limiting membrane (ILM) peeling and non-ILM peeling in diabetic tractional retinal detachment (TRD).

Methods

Twenty-three eyes with diabetic TRD with ILM peeling were compared with twenty-four eyes with non-ILM peeling. Best-corrected visual acuity (BCVA) was recorded at baseline and 3, 6, 9, 12 months, and end of follow-up. The mean retinal thickness across nine different regions that defined in the Early Treatment Diabetic Retinopathy Study (ETDRS) were obtained. The ETDRS grid was used to determine the extent of macular involvement.

Results

In the 1st month postoperatively, the mean BCVA of eyes with ILM peeling (1.08±0.63 LogMAR) was significantly better than eyes with ILM non-peeling (1.69±0.75 LogMAR, p=0.003). There was also a significant difference at 9 and 12 months between groups in BCVA, in favor of ILM peeling (p=0.012 and p=0.047, respectively). Seven patients (29.2%) developed epiretinal membrane (ERM), and one patient (4.1%) had ERM with the lamellar macular hole in the ILM non-peeling group, while only one patient developed ERM in ILM peeling group during the follow-up.

Conclusion

ILM removal may be considered in diabetic TRD surgery, as it can provide rapid visual recovery. Moreover, post-operative ERM formation was less frequent in ILM peeled eyes within 1 year after surgery.

Clinical Outcomes of 27-Gauge Pars Plana Vitrectomy for Diabetic Tractional Retinal Detachment Repair

Purpose: To analyze the clinical outcomes of 27-gauge pars plana vitrectomy (PPV) repair of diabetic tractional retinal detachment (TRD) of various severities. Methods: This retrospective case series examined the outcomes of 27-gauge PPV to repair diabetic TRD from 2016 to 2020. The effect of medical and ophthalmologic history parameters and baseline detachment characteristics on visual acuity (VA) and retinal reattachment was analyzed. A grading system was established to stage the severity of the baseline vitreoretinal traction or detachment and compare the visual and anatomic outcomes between stages. Results: The study comprised 79 eyes (79 patients). The overall redetachment rate was 10.1% (8/79). The proportion of eyes with severe visual impairment (worse than 20/200) decreased from 81.0% (64/79) preoperatively to 56.9% (37/65) 6 months postoperatively (P < .001). Worse preoperative logMAR VA was associated with greater odds of redetachment (P = .017) and worse postoperative VA (P < .001). Insulin dependence was associated with better VA at 6 months (P = .017). A shorter known duration of diabetes (P = .026) and evidence of neovascularization of the iris (NVI) or angle (P = .004) were associated with worse visual outcomes. Eyes with detachment involving the posterior pole extending beyond the equator had worse VA at 6 months (P = .048). Conclusions: The primary reattachment rate after 27-gauge PPV was 89.9%. There was significant VA improvement, with a roughly 40% reduction in the number of eyes with severe visual impairment by the final follow-up. Insulin dependence, duration of diabetes, presence of NVI before surgery, and baseline posterior pole detachment extending beyond the equator were predictors of visual outcomes.

Risk Factors for Recurrent Vitreous Hemorrhage in Type 2 Diabetes Mellitus Patients after Posterior Vitrectomy

(Background) The aim of this study was to determine the factors related to recurrent vitreous hemorrhage (RVH) in a sample of proliferative diabetic retinopathy (PDR) patients. (Methods) This was a retrospective, review-based study. We studied 183 eyes from 121 type 2 diabetes patients with PDR. We recorded the duration of diabetes, history of hypertension, retinal photocoagulation status, posterior vitreous status, mean HbA1c and hemoglobin levels, renal function, and systemic complications associated with diabetes. We also recorded surgical variables-the presence of tractional retinal detachment, the application of segmentation and diathermy on fibrovascular proliferative tissue, and the use of silicone oil-to study which independent variables were significantly related to the presence of RVH. (Results) The duration of diabetes (p = 0.028), hemoglobin level (p = 0.02), status of the posterior vitreous (p = 0.03), retinal photocoagulation status (p = 0.002), and the presence of tractional retinal detachment (p = 0.03) were significantly associated with the presence of RVH. On the other hand, the use of diathermy was associated with fewer RVH events (p < 0.005). In addition, patients with diabetic polyneuropathy, myocardial infarction, and ischemia in the lower limbs exhibited more vitreous hemorrhage events (p < 0.001). (Conclusions) Patients with PDR and a longer diabetes duration, anemia, attached posterior vitreous, deficient retinal photocoagulation, and prior cardiovascular events were more prone to RVH.

The Anatomical and Functional Outcomes of 27-Gauge Pars Plana Vitrectomy in Diabetic Tractional Retinal Detachments in the South Asian Population

Objective The objective of this article was to report the clinical and surgical outcomes of diabetic tractional retinal detachment (TRD) with 27-gauge plus pars plana vitrectomy (27G+ PPV) Methods This is a retrospective, consecutive cohort study of 196 eyes of 176 patients that underwent 27G+ PPV for TRD from July 2015 to June 2019 at the ophthalmology department of Shifa International Hospital, Islamabad. The outcomes include primary and secondary anatomical attachment of the retina, best-corrected visual acuity, and post-operative complications. Results The mean age of the patients in this study was 55.3 ± 11.3 years. Out of 176 patients, there were 47.2% (n=83) females. The mean operating time calculated was 60 ± 36 min (range 22-130 min). Of 196 eyes, 64.3% (n=126) also combined phacoemulsification with lens implantation. Internal limiting membrane peeling was done in 11.7% (n=23) of the cases. Post-operatively, 98% (n=192) achieved primary retinal attachment, and 1.5% (n=3) underwent a second procedure to achieve retinal attachment. At three months follow-up, the mean best corrected visual acuity (BCVA) remarkably improved from 1.86 ± 0.59 to 0.54 ± 0.32 logarithm of the minimal angle of resolution (logMAR) (p-value<0.001). Among complications, one patient had intra-operative suprachoroidal oil migration, which was managed successfully, while post-operatively, 11 patients (5.6%) developed a transient rise in intraocular pressure, which was controlled with anti-glaucoma drugs, and one patient had vitreous cavity hemorrhage which resolved on its own with time. Conclusion This study strongly suggests that the 27G+ PPV offers successful repair of eyes with diabetic TRD with statistically significant improvement in visual acuity and minimal rate of complications.

27-gauge microincision vitrectomy surgery compared with 25-gauge microincision vitrectomy surgery on wound closure and need for wound suture and other postoperative parameters in the treatment of vitreoretinal disease: A meta-analysis

We performed a meta-analysis to evaluate the effect of 27-gauge microincision vitrectomy surgery compared with 25-gauge microincision vitrectomy surgery on wound closure and the need for wound suture and other postoperative parameters in the treatment of vitreoretinal disease. A systematic literature search up to June 2022 was performed and 1264 subjects with the vitreoretinal disease at the baseline of the studies; 562 of them were using the 27-gauge microincision vitrectomy surgery, and 722 were using 25-gauge microincision vitrectomy surgery. Odds ratio (OR), and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of 27-gauge microincision vitrectomy surgery compared with 25-gauge microincision vitrectomy surgery on wound closure and the need for wound suture and other postoperative parameters in the treatment of vitreoretinal disease using the dichotomous, and contentious methods with a random or fixed-effect model. The 27-gauge microincision vitrectomy surgery subjects had a significantly lower intraoperative and postoperative wound complication (OR, 6.66; 95% CI, 0.46-0.95, P = .02), and wound suture number (OR, 0.38; 95% CI, 0.20-0.71, P = .002), and best corrected visual acuity (MD, -0.03; 95% CI, -0.05 to -0.001, P = .02) compared with 25-gauge microincision vitrectomy surgery in subjects with vitreoretinal disease. However, 27-gauge microincision vitrectomy surgery subjects had no significant difference in the wound closure time (MD, -8.45; 95% CI, -23.44 to 6.55, P = .27), operation time (MD, 0.85; 95% CI, -1.17 to 2.86, P = .41), intraocular pressure at postoperative day 1 (MD, 0.42; 95% CI, -1.45-2.28, P = .66), primary anatomical success rate (OR, 0.83; 95% CI, 0.42-1.63, P = .58), and central macular thickness (MD, 1.81; 95% CI, -21.76 to 25.37, P = .88) compared to 25-gauge microincision vitrectomy surgery in subjects with vitreoretinal disease. The 27-gauge microincision vitrectomy surgery subjects had a significantly lower intraoperative and postoperative wound complication, wound suture number, and best corrected visual acuity, and no significant difference in the wound closure time, operation time, intraocular pressure at postoperative day 1, primary anatomical success rate, and central macular thickness compared to 25-gauge microincision vitrectomy surgery in subjects with vitreoretinal disease. The analysis of outcomes should be with caution because of the low sample size of 12 out of 15 studies in the meta-analysis and a low number of studies in certain comparisons.

Outcomes and Complications of Pars Plana Vitrectomy for Tractional Retinal Detachment in People With Diabetes: A Systematic Review and Meta-analysis

Importance

Tractional retinal detachment (TRD) occurs in approximately 5% of people with proliferative diabetic retinopathy and poses a threat to vision. Pars plana vitrectomy (PPV) is the treatment of choice for TRD.

Objective

To determine anatomic and functional outcomes of PPV for the treatment of TRD in people with diabetes (dTRD).

Data Sources

MEDLINE and Embase were searched systematically from January 1, 2000, to February 20, 2022. In addition, a reference list of eligible studies were screened.

Study Selection

Eligible studies were those published in English, those reporting outcomes of PPV for dTRD, and those that included more than 25 eyes and with a minimum follow-up of 3 months.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction/synthesis were followed, and the National Institute for Health quality assessment tool was used to assess risk of bias. Study eligibility was determined independently by 2 reviewers; data extraction was conducted by 1 reviewer and entries checked for accuracy by another. Data were pooled using a random-effects model.

Main Outcomes and Measures

Main outcomes included rate of failure of retinal reattachment following 1 surgery and final visual acuity (VA). The association of baseline patient characteristics and surgical maneuvers with postoperative surgical outcomes was investigated.

Results

Of the 406 studies identified, 38 (3839 eyes) were eligible and included for analysis. Patients had a median (IQR) age of 52.2 (49.6-55.7) years. In the studies reporting patient sex (31 of 38 studies), 1441 were female individuals (50.1%). The overall failure rate of retinal reattachment after 1 surgery was 5.9% (95% CI, 1.4%-8.3%), and the mean final VA was 0.94 (95% CI, 0.82-1.05) logMAR (approximate Snellen equivalent, 6/53; 95% CI, 6/39-6/71). People with higher preoperative VA achieved higher postoperative vision (0.66 logMAR worse final vision; 95% CI, 0.39-0.84 per 1.0 logMAR worse at baseline; P <.001). On multivariable analysis, no other patient characteristics or surgical variables had a statistically significant association with outcomes.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggest that PPV was an effective strategy to achieve retinal reattachment in people with dTRD. Given that higher preoperative VA was the only factor associated with higher postoperative vision, early intervention should be considered and discussed in detail with patients. Overall, final postoperative VA remains low, and patients should be counseled on the guarded prognosis of dTRD.

Mechanical Property Comparison of 23-, 25-, and 27-Gauge Vitrectors across Vitrectomy Systems

OBJECTIVE

To investigate the mechanical properties of 23-, 25-, and 27-gauge vitrectomy vitrectors across 3 different vitrectomy systems to inform surgical techniques.

DESIGN

An experimental study that did not involve any human subjects.

METHODS

Nine vitrectors (3 each of 23-, 25-, and 27 gauge) from Alcon, Dutch Ophthalmic Research Center (DORC), and Bausch & Lomb (B/L) were measured. Measurements were performed using electroforce displacement at the tip and 15 mm from the tip. Five measurements were performed at each location, and fully elastic deformation was ensured.

MAIN OUTCOME MEASURES

The main parameter being measured was the force in grams (gf) necessary to deflect the vitrectors vertically downward by 1 mm, either at the tip of the vitrector or 15 mm from the tip.

RESULTS

A total of 90 measurements were performed. Across brands, B/L demonstrated the least stiffness at both the tip and at the 15-mm point for 23-gauge (8.0±0.3gf, 67.3±1.0gf), 25-gauge (6.8±0.3gf, 60.5±0.4gf), and 27-gauge (3.3±0.1gf, 33.9±0.5gf) vitrectors. Although there was only a small decrease in the stiffness in the 25-gauge vitrector compared with the 23-gauge vitrector at the 15-mm point, this difference was statistically significant for Alcon (P < 0.001), DORC (P < 0.001), and B/L (P < 0.001).

CONCLUSIONS

Based on this study, 25-gauge vitrectors, although larger than the 27-gauge vitrectors and less stiff than the 23-gauge vitrectors, may offer favorable compromise between stiffness and gauge size. However, surgeon experience, preference, and the type of surgery being performed should be paramount when making the final vitrector selection. Knowledge of these mechanical properties may aid surgeons in choosing between gauge size and vitrectomy system to optimize their comfort and efficiency.