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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

A Two Forceps Technique For Approaching Tractional Diabetic Membranes

BACKGROUND AND OBJECTIVE

To describe a two-forceps bimanual approach for complex diabetic detachments.

PATIENTS AND METHODS

Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface.

RESULTS

Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient.

CONCLUSION

The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176-e178.].

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Managing dislocated hard lens nuclei: 23-gauge vitrectomy and lens extraction via a corneoscleral limbal incision versus 23-gauge vitrectomy and phacofragmentation

PURPOSE

To compare 23-gauge vitrectomy and lens extraction via a corneoscleral limbal incision (CSLI) with 23-gauge vitrectomy and phacofragmentation to treat dislocation of hard lens nuclei.

SETTING

Ningbo Eye Hospital, Zhejiang, China.

DESIGN

Retrospective case series.

METHODS

The study included consecutive patients with complete posterior dislocation of a hard nucleus (grade ≥ IV) into the vitreous cavity. All patients received 23-gauge 3-channel vitrectomy. Some patients also had phacofragmentation and others had lens extraction through a CSLI.

RESULTS

The CSLI group comprised 21 eyes of 21 patients and the phacofragmentation group, 22 eyes of 22 patients. The median follow-up was 10.8 months (range 6 to 24 months) and 11.3 months (range 5 to 18 months), respectively. Demographic characteristics, reason for lens dislocation, preoperative corrected distance visual acuity (CDVA), preoperative intraocular pressure (IOP), lens nucleus grade, and comorbidities were similar between groups. The CSLI group had a shorter mean surgical time than the phacofragmentation group (42.5 ± 7.2 minutes versus 68.2 ± 16.5 minutes); less frequent use of perfluorocarbon liquid, octafluoropropane, or air tamponade; lower incidence of retinal tears (9.5% versus 31.8%); and better CDVA but worse astigmatism 1 day and 1 week postoperatively (P < .05). The postoperative IOP did not differ between groups. Corneal edema and recurrent retinal detachment were less common in the CSLI group than in the phacofragmentation group.

CONCLUSION

The 23-gauge vitrectomy with lens extraction through a CSLI might have advantages over 23-gauge vitrectomy with phacofragmentation for management of dislocated hard lens nuclei.

Four-port bimanual 23-gauge vitrectomy for diabetic tractional retinal detachment

PURPOSE

Four-port bimanual vitrectomy is a surgical technique that facilitates removal of epiretinal membranes in severe proliferative diabetic retinopathy (PDR). As the illumination is held by the assistant through the fourth scleral incision, fibrovascular membranes are removed by bimanual manipulation techniques. The objective of this study was to evaluate the safety and efficacy of four-port bimanual 23-gauge vitrectomy for patients with tractional retinal detachment (TRD) in severe PDR.

DESIGN

Retrospective, comparative, consecutive, interventional case series.

METHODS

Sixty-six eyes of 58 consecutive patients who underwent primary vitrectomy for severe diabetic TRD. Thirty-six eyes of 31 cases that were treated with four-port 23-gauge vitrectomy were compared with 30 eyes of 27 cases that were treated with 23-gauge pars plana vitrectomy (PPV). Main outcome measures were best-corrected visual acuity (BCVA), retinal status, intraocular pressure, and incidence of intraoperative and postoperative complications with at least 6 months of follow-up.

RESULTS

The primary and ultimate anatomic success rates (94.4% versus 93.3%, and 100% in both groups, respectively) and the mean BCVA changes did not differ significantly between groups. The whole surgical time and the membrane removal time were significantly (p < 0.001, respectively) shorter in the four-port 23-gauge group than in the 23-gauge group. There was no difference in the incidence of intraoperative and postoperative complications in both groups.

CONCLUSIONS

Four-port bimanual 23-gauge vitrectomy offers comparable anatomic success and shortens the surgical time compared with conventional 23-gauge PPV in patients with TRD resulting from severe PDR.

Segmentation and removal of fibrovascular membranes with high-speed 23 G transconjunctival sutureless vitrectomy, in severe proliferative diabetic retinopathy

Aim

To evaluate the effectiveness and safety of high-speed (5,000 cuts per minute) 23 G transconjunctival sutureless vitrectomy (TSV) in severe diabetic fibrovascular proliferation (DFVP).

Patients and methods

In this retrospective consecutive case series, patients who underwent 23 G TSV for severe DFVP between October 2011 and March 2014 at our institution were evaluated. 23 G TSV was performed with a high-speed (5,000 cuts per minute) cutter without a chandelier light.

Results

The mean follow-up period was 8 months (range: 4–23 months). Of the 27 eyes of 27 patients, 14 eyes (52%) underwent concomitant phacoemulsification with posterior chamber intraocular lens implantation, nine eyes (33%) were pseudophakic, and four eyes were phakic (15%). DFVP was removed with ease in all, and visual acuity was improved in 18 (67%) eyes. Iatrogenic retinal tear was observed in four eyes (15%) and treated successfully during surgery. Suture placement to a single sclerotomy was performed in eight eyes (30%). Postoperative intraocular hemorrhage was observed in five eyes (18%). Cataract formation was observed in two of the four phakic eyes. Three (11%) patients had postoperative intraocular pressure rise. Postoperative hypotony (≤6 mmHg) and endophthalmitis were not observed in any eye.

Conclusion

The segmentation and removal of fibrovascular membranes with high-speed 23 G TSV seems to be a safe and easy method in severe diabetic eye disease.

Surgical outcomes of 25-gauge pars plana vitrectomy for diabetic tractional retinal detachment

PURPOSE

To evaluate the outcomes and complications of 25-gauge (G) pars plana vitrectomy (PPV) for repair of diabetic tractional retinal detachment (TRD).

METHODS

Retrospective review of consecutive, single-surgeon 25-G PPV cases between July 2007 and July 2014. Seventy eyes from 55 patients were operated on for diabetic TRD; all eyes were tamponaded with sulfur hexafluoride, octofluoropropane, silicone oil, or balanced salt solution. Mean age at surgery was 47.7 years (range 23-76 years), and mean length of follow-up was 713 days (range 90-2368 days; median 671 days). Primary outcomes included best-corrected visual acuity (BCVA), intraocular pressure (IOP), anatomic success, redetachment, and endophthalmitis.

RESULTS

Preoperatively, 49 eyes (70%) had a concurrent rhegmatogenous component (8 of which also had proliferative vitreoretinopathy (PVR)). Mean BCVA improved from logarithm of the minimal angle of resolution 1.59 (20/800, SD 0.88) to 0.68 postoperatively (20/100, 0.77), P-value<0.001. Mean IOP increased from 15.9 to 20 mm Hg 1 day after surgery. Elevated postoperative IOP (≥ 22 mm Hg) occurred in 25 eyes, and low IOP (≤ 5 mm Hg) occurred in 2 eyes. Primary reattachment was achieved in 63 eyes (90%), and final anatomical success occurred in 69 eyes (99%). There were no cases of endophthalmitis.

CONCLUSIONS

Twenty-five-G PPV repair was safe and effective in the repair of diabetic TRD, including eyes with a combined rhegmatogenous detachment or PVR. Gas, silicone oil, and balanced salt solution tamponading agents all proved to be efficacious in this surgical population.

23-gauge transconjunctival sutureless vitrectomy: visual outcomes and complications

PURPOSE

To report results and complications of 23-gauge transconjunctival sutureless pars plana vitrectomy for a variety of vitreoretinal diseases.

METHODS

A prospective consecutive case series study was performed in 66 eyes of 66 patients. Indications for surgery were epiretinal membrane (n = 20), rhegmatogenous retinal detachment (n = 19: 14 pseudophakic, 5 phakic), macular hole (n = 16), vitreous hemorrhage (n = 5), cyclodialysis (n = 1), intraocular lens luxation (n = 1), asteroid hyalosis (n = 1), congenital retinoschisis (n = 1), and endophtalmitis (n = 2). Main outcome measures included visual acuity, intraocular pressure, and intra- and post-operative complications.

RESULTS

Mean patient age at time of operation was 68 ± 12 years. Overall, visual acuity improved from 1.03 ± 1.00 logMAR preoperatively to 0.32 ± 0.33 logMAR postoperatively (p < 0.01) after a mean follow-up time of 9.3 ± 4.7 months. Mean preoperative intraocular pressure was 13.9 ± 3.5 mmHg, and mean postoperative intraocular pressure was 17.9 ± 9.6 mmHg on day 1 (p < 0.01) and 14.7 ± 2.8 mmHg (p = 0.05) at final visit. Concerning complications, 2 cases of hypotony and 7 of hypertony occurred on day 1, a macular hole reopened some weeks later, and a retinal detachment recurred in one case.

CONCLUSION

23-gauge transconjunctival sutureless vitrectomy is an effective and safe technique for a variety of vitreoretinal diseases.

Advantages and limitations of small gauge vitrectomy

Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages, but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusion and aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. The advantages include decreased surgical times, less tissue manipulation, reduced inflammation and pain postoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than 20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreous opacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also some increased complications related to small gauge vitrectomy, including dislocation of cannulas intraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.