Minimally Invasive Vitrectomy Surgery – The New Era

Transcription

Retina
5HWLQD
Minimally Invasive Vitrectomy
Surgery – The New Era
Koushik Tripathy
MD
Koushik Tripathy MD, Pulak Agarwal MBBS, Yog Raj Sharma MS, Rohan Chawla MD,
Harsh Inder Singh MD, Ravi Bypareddy MD, Babulal Kumawat MD, Rajpal Vohra MD
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
(
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to ophthalmic surgeries by ‘the father of pars plana
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# /- <$* +\ - " vitreous hemorrhage1 < ! !
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/8J `-8##}* / J `-A##} Commercially available sutureless vitrectomy systems
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History
Traditionally vitreous had been thought to be ‘untouchable’
¦ J invade the vitreous in 18632. David Kasner3 in 1968
removed diseased vitreous using sponge and scissors in
2 cases of amyloidosis of vitreous through anterior route
#!"`¦$#}
The disadvantages of the technique were need of
corneal transplant and aphakia, poor intraocular pressure
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traction.
Robert Machemer4 +\ + ¦ `;} ; "* "
$ + J $ $ !# # #$" vitreous cutter (diameter 1.5 mm) inserted through a 2.3
mm scleral incision5;"
sharp edges, a stationary outer tube, an infusion system,
and manual suction was applied by a syringe. Suction drew
vitreous into the openings and the rotating sharp edge cut
the vitreous. The rotation speed could be changed by a
rheostat. However, a similar vitreous cutter with infusion
$ $ $ $ +\ +6 ( '# $ # $!
endoillumination in 1972 as a 2 port procedure7.
Conor O’Malley and Ralph Heinz introduced 3 port pars
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sclerotomy8 "* $ $ # ; ; +\\9 < @ #
# ! ) <) colleagues in 199910 Z ?"# ! " /8J
instruments through conventional sclerotomies11>/8J
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was devised in 2005 by Claus Eckardt13. Yusuke Oshima
"/ J/--\14.
Creating self-sealing wound
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the transconjunctival wound has been performed both
perpendicular or oblique16,17 to sclera. Oblique scleral
incision has the advantages of better wound closure,
reduced risk of hypotony, reduced leakage18 and better
wound apposition19 under dynamic intraocular pressure
when compared to perpendicular incision. However,
chances of subretinal or suprachoroidal cannula may
increase with very oblique incisions20.
Shelved sclerotomy can be constructed in a one step or
two step technique. One step oblique incision is made
$ §Z <"#
www. dosonline.org l 41
Retina: Minimally Invasive Vitrectomy Surgery – The New Era
`Z<}#¨$$$#21.
Oblique incisions parallel to limbus is preferred as it
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then the direction is perpendicular once trocar has partially
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by perpendicular entry has also been used. The valved
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mark of 3mm and 4mm at the end opposite to sharp blade
to aid pars plana entry without the use of calipers.
Two step method as described by Eckardt involves
stabilizing displaced conjunctiva with a pressure plate
instrument, while a shelved incision is created using a
sharp angled stiletto blade. Then the cannula is inserted in
the same wound with a blunt trocar. However it may be
$
The infusion
The infusion cannula has a threaded portion to lock it with
the cannula to avoid loosening or accidental slippage of
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The vitrectomy cutter
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less traction on vitreous, control of duty cycle, improved
driving mechanism for cutters and decreased distance from
cutter mouth to tip.
The outer diameters of vitrectomy probes have been made
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Q = Δ P πr4/8 μL
where:

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However, as vitreous does not behave like liquid, vacuum
pressure, cut rate and duty cycle of the vitrector also
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42 l DOS Times - Vol. 20, No. 5 November, 2014
Table 1: Outer diameter of various vitrectomy systems
+ J
1.47mm
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0.9mm
/]J
0.6mm
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0.5mm
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0.4mm
According to Poiseuille?"#_"
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Higher vacuums (pressure gradient along the cutter)
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$ _ ` ! #} $ turbulence, decreases movement of mobile retina, less
traction during vitreous base shaving and the decreasing
"
The duty cycle (the percentage of time the cutter port is
open relative to each cutting cycle) can be controlled
in modern vitrectomy probes which are pneumatically
driven and not electrically driven. The vitrectomy modes
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Core (cutter is open for maximum time ensuring greater
_ }* 8-8-* ! `$ $ # * _ " ! create less pull).
<® $ `<} pneumatic probe design where spring controls the cutter
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has maximum 5000cpm cut rate, in which the air controls
both cutter open and cutter close time enabling duty cycle
control.
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enabling dissection very near to retina (Figure 1). Increased
!# #$! _ ! # safer to operate closer to the retina.
Illumination
Though issues had been raised about reduced brightness of
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by xenon and metal halide light sources. Chandelier
illumination is an innovative strategy for illumination during
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both hands of the surgeon are free for bimanual surgery.
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25 G TSV
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Retina
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not limited to vitrectomy cutters, endoilluminator, scissors,
diathermy probe, laser probe, end gripping forceps, Internal
[#" '# `['} $* ' ( $*
<## (" >$* ' >$* Q_
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/8J
27G
Figure 1: Comparative photos of various vitrectomy cutters
shows that cutter mouth has been made larger and nearer to
the tip with 25G.
with insertion trocars. The microcannulae have an external
"($#`'#®
/8® #* Q [#* :* P*
<} ] ## " L # -8 ##L-/ ##22 < # 8##
" L # -] ##L-8 ## usually used through inferotemporal cannula. The trocar
#! (" Cannulae with valves are also available which do not
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instruments include, but are not limited to vitrectomy
cutters, endoilluminator, scissors, diathermy probe, laser
$*"$$"$*[#"'#
`['} $* ' ( $* <## ("
>$* ' >$* Q_ ;* '#
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23G
" " /8J* /]J
!$ ~ /]J* rotated without bending of the instrument for working
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located pathology can be accessed without bending of the
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$$ A ##* L # -8 ##L- 8 ## % $" three cannulas were funnel shaped for easy insertion of
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transconjunctival nonvitrectomizing vitreous surgery for
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nuclear sclerosis in 200723. In 2009, Y. Oshima in
collaboration with DORC (Dutch Ophthalmic Research
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is larger and closer to the cutter tip to help dissection
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1000 or 1500 cpm. 28 eyes of 28 patients were operated
epiretinal membrane proliferation, idiopathic macular
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membrane proliferation, and nonclearing vitreous opacity.
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" $ <# ! study eyes, including visual improvement by three lines or
more in 70%. Because of the smaller gauge, diminished
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Xenon or mercury vapor bulbs may improve illumination.
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vitreous cutter was reduced from 32 mm to 25 mm. Oshima
"!+$*/ J@
" #$ @
! " _ !# extensive removal of peripheral vitreous24<$"
X!*\-¢
sclera, facing directly toward the vitreous cavity, parallel to
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forceps type), membrane spatula, endophotocoagulation
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Indications of MIVS; ! " '
including but not limited to vitreous hemorrhage,
endophthalmitis, epiretinal membranes, macular holes,
rhegmatogenous retinal detachments including complex
$! !$ `(:}* retinal detachments, recalcitrant diabetic macular edema,
!# * !L! $* www. dosonline.org l 43
#!LX # #" intraocular foreign bodies can be removed with hybrid
@ " /-J $ magnet or foreign body forceps. Dropped nucleus can be
"##/-J/]J$
for ultrasonic fragmenter. In huge choroidal detachments
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to avoid the cannula going subretinal or suprachoroidal. In
pediatric population the small gauge vitrectomy systems
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extraction, persistent fetal vasculature, and familial
exudative vitreoretinopathy.
Advantages of sutureless vitrectomy
~ ~ # /]J* /8J* / J
vitrectomy systems are 0.6 mm, 0.5 mm, and 0.4 mm,
respectively25<$
`/-J}* " `/]J}* `/]J}* $$ `/ J} smaller sclerotomy leads to:
Figure 2: Post-operative clinical picture of
20G and 25J
iatrogenic retinal break formation, retinal detachment, and
cataract.
Intraoperative

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of bending or breakage especially during vitreous base
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inserted leading to globe collapse, choroidal detachment,
suprachoroidal hemorrhage, vitreous hemorrhage and
accidental trauma to retina with instrument tip. The infusion
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complications include decompression retinopathy26.
Though issues had been raised about less brightness of
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brightness has been improved by xenon and metal halide
light sources. Concerns were also raised about reduced
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can hold less amount of tissue, vitrectomy itself takes
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are myths. Rare theoretical complications include thermal
injury to sclera from Chandelier tube and inability to shave
vitreous base properly in vitreoretinal surgery resulting in
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Postoperative

Z $ " `$ :( very small eyes)
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heal. In a study by Woo and colleagues27 risk factors
for intraoperative sclerotomy leakage requiring suture
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a young age at operation, and vitreous base dissection.
Concerns
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in current scenario. Higher cost may be a limiting factor in
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Retina
Factors predisposing to hypotony include28 –
References

[ $ $* # limited peripheral vitrectomy to avoid lens touch in
such cases
1.

?$!!#"
elasticity and regenerative capacity of scleral tissue,
leading to wound leakage. In 2nd vitrectomy more
thorough vitreous removal is done leading to less
vitreous plugging of the scleral wound.

'$"#$

Z _ $${ of air or gas prevents leakage and hypotony. Most
"!$_%"#
gauge vitrectomy.

($

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prevent hypotony.
Classically endophthalmitis rate has been quoted as 0.1%
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$-/]-=A¡)#"
+/ " $# /8¯J
`-/]¡} #$ /-J `--+=¡} $!
study. However, retrospective nature of study is not
optimal to study incidence of such a rare complication, all
_*$#
/-J--+=¡#±+L]
`--8--8¡}29 and incisions were largely
nonbeveled. Intravitreal triamcinolone was used in 38%
of endophthalmitis cases, which may have caused a sterile
_## ##" $# # !
predisposed to infectious endophthamlitis. Mention about
predisposing factors like dacryocystitis, ocular surface
*#~_
rates, resulting in decreased washing effect by the infusion
have been postulated as the cause of endophthalmitis in
':$#'
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_"%">%"#$!
¯"@$"
wound lips together.
$$! #$ ' detachment, and retinal toxicity (macular infarct with
gentamycin) due to seepage of subconjunctival gentamicin
from sutureless scleral port.
Conclusion
' $ ! ! !
" ; ' #" vitrectomy surgery worldwide.
Vitrectomy pioneer inducted into Ophthalmology Hall of Fame
[Internet]. Available from: http://www.eyeworld.org/article.ph
p?sid=1784&strict=&morphologic=&query=Vitrectomy%20
pioneer%20inducted%20into%20Ophthalmology%20Hall%20
of%20Fame
% `"
{X
`
machine parameters- Optimizing performance. In: Principles and
Practice of Vitreoretinal Surgery. JP Medical Ltd; 2014.
3.
Trikha R, Beharry N, G. D. Small Gauge Pars Plana Vitrectomy
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4.
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Acad Ophthalmol Otolaryngol 1971;4:813–20.
5.
Warrier SK, Jain R, Gilhotra JS, Newland HS. Sutureless vitrectomy.
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STEVE CHARLES, MD. The History of Vitrectomy: Innovation
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7.
Parel JM, Machemer R, Aumayr W. A new concept for vitreous
surgery. 4. Improvements in instrumentation and illumination. Am J
Ophthalmol 1974;1:6–12.
8.
O’Malley C, Heintz RM. Vitrectomy with an alternative instrument
system. Ann Ophthalmol 1975;4:585–8, 591–4.
9.
Chen JC. Sutureless pars plana vitrectomy through self-sealing
sclerotomies. Arch Ophthalmol 1996;10:1273–5.
& ~|] !~ {{ \ \ {
{ sclerotomies in pars plana vitrectomy. Am J Ophthalmol
1999;6:731–3.
]
`_^
for vitreous surgery. Am J Ophthalmol 1990;2:218–20.
12. Fujii GY, De Juan E, Humayun MS, Pieramici DJ, Chang TS, Awh
C, et al. A new 25-gauge instrument system for transconjunctival
sutureless vitrectomy surgery. Ophthalmology 2002;10:1807–1812;
discussion 1813.
13. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina
Phila Pa 2005;2:208–11.
14. Oshima Yusuke. 27-gauge Vitrectomy [Internet]. Available from:
http://retinatoday.com/pdfs/0409_09.pdf
15. Khanduja S, Kakkar A, Majumdar S, Vohra R, Garg S. Small gauge
vitrectomy: Recent update. Oman J Ophthalmol 2013;1:3–11.
16. Hsu J, Chen E, Gupta O, Fineman MS, Garg SJ, Regillo CD. Hypotony
after 25-gauge vitrectomy using oblique versus direct cannula
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17. Inoue M, Shinoda K, Shinoda H, Kawamura R, Suzuki K, Ishida
S. Two-step oblique incision during 25-gauge vitrectomy reduces
incidence of postoperative hypotony. Clin Experiment Ophthalmol
2007;8:693–6.
18. Gupta OP, Maguire JI, Eagle RC, Garg SJ, Gonye GE. The competency
of pars plana vitrectomy incisions: a comparative histologic and
spectrophotometric analysis. Am J Ophthalmol 2009;2:243–250.
19. Taban M, Sharma S, Ventura AACM, Kaiser PK. Evaluation of wound
closure in oblique 23-gauge sutureless sclerotomies with visante
optical coherence tomography. Am J Ophthalmol 2009;1:101–107.
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20. Charles S. Chapter 101 – Principles and Techniques of Vitreoretinal
Surgery. In: Retina. Elsevier Health Sciences; 2012.
CL Gupta Eye Institute
21. López-Guajardo L, Pareja-Esteban J, Teus-Guezala MA. Oblique
sclerotomy technique for prevention of incompetent wound
closure in transconjunctival 25-gauge vitrectomy. Am J Ophthalmol
2006;6:1154–6.
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ILOLL W G W / 9 3
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WL W + G E G
The state of the art multispecialty Eye Hospital
22. O’ Reilly P, Beatty S. Transconjunctival sutureless vitrectomy: initial
experience and surgical tips. Eye 2006;4:518–21.
23. Sakaguchi H, Oshima Y, Tano Y. 27-gauge transconjunctival
nonvitrectomizing vitreous surgery for epiretinal membrane
removal. Retina Phila Pa 2007;9:1302–4.
24. Oshima Y, Wakabayashi T, Sato T, Ohji M, Tano Y. A 27-gauge
instrument system for transconjunctival sutureless microincision
vitrectomy surgery. Ophthalmology 2010;1:93–102.
Retina
Glaucoma
Cornea
Pediatric Ophthalmology
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en.wikipedia.org/wiki/Needle_gauge_comparison_chart
26. Rezende FA, Regis LT, Kickinger M, Alcântara S. Decompression
retinopathy after 25-gauge transconjunctival sutureless vitrectomy:
Report of 2 cases. Arch Ophthalmol 2007;5:699–700.
27. Woo SJ, Park KH, Hwang J-M, Kim JH, et al. Risk factors associated
with sclerotomy leakage and postoperative hypotony after 23-gauge
transconjunctival sutureless vitrectomy. Retina Phila Pa 2009;4:456–
63.
28. Bamonte G, Mura M, Stevie Tan H. Hypotony after 25-gauge
vitrectomy. Am J Ophthalmol 2011;1:156–60.
29. Martidis A, Chang TS. Sutureless 25-gauge vitrectomy: risky or
rewarding? Ophthalmology 2007;12:2131–2.
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