Jpn J Ophthalmol 2005;49:257–260 © Japanese Ophthalmological Society 2005
DOI 10.1007/s10384-004-0183-7
BRIEF COMMUNICATION
Twenty-gauge Transconjunctival Vitrectomy Hiroyuki Shimada, Hiroyuki Nakashizuka, Masami Nakajima, Ryuzaburo Mori, and Yoshihiro Mizutani Department of Ophthalmology, School of Medicine, Nihon University, Tokyo, Japan
Abstract Purpose: To describe a new 20-gauge transconjunctival vitrectomy procedure that we designed, to evaluate its usefulness, and to compare two different methods of use. Methods: The records of 431 patients (433 eyes) who underwent 20-gauge transconjunctival vitrectomy at the Surugadai Hospital of Nihon University between March 2003 and January 2004 were studied retrospectively. In surgical method 1, 20-gauge wounds were made through the conjunctiva and sclera together. In surgical method 2, 20-gauge conjunctival openings were made 2 mm posterior to the sclerotomies. Absorbable sutures were used to stitch the scleral and conjunctival openings simultaneously in both methods. Results: A 20-gauge transconjunctival vitrectomy has various benefits and is indicated for nearly all ocular diseases. Moreover, it is not limited by the intraocular instruments required. However, since cannulas were not placed in all ports, conjunctival edema occurred more easily with surgical method 2 owing to the leakage of perfusion fluid. Conclusions: This new 20-gauge transconjunctival vitrectomy procedure has various benefits and is indicated for nearly all ocular diseases. It is not limited by the intraocular instruments required. Jpn J Ophthalmol 2005;49:257–260 © Japanese Ophthalmological Society 2005 Key Words: edema
20-gauge transconjunctival vitrectomy, 25-gauge transconjunctival vitrectomy, conjunctival
Introduction In conventional 20-gauge vitrectomy using a three-port system, since a large incision is made in the conjunctiva for the vitrectomy, problems of postoperative foreign body sensation, congestion, and hemorrhage due to the sutures are commonly encountered. In addition, the wide incision in the conjunctiva may interfere with subsequent glaucoma filtering surgery. The conventionally reported sutureless vitrectomy by self-sealing 20-gauge sclerotomies uses the sclerotomy tunnel method. However, resulting complications such as intraocular fluid leakage from the wound, hemorrhage, vitreal or retinal incarceration, and retinal break have been reported.1–3 Received: April 7, 2004 / Accepted: August 18, 2004 Correspondence and reprint requests to: Hiroyuki Shimada, Department of Ophthalmology, Surugadai Hospital of Nihon University, 1-813 Surugadai, Kanda, Chiyoda-ku, Tokyo 101-8309, Japan e-mail:
[email protected]
We have designed a new 20-gauge transconjunctival vitrectomy procedure using the conventional three-port system. The characteristics of this method are that 20-gauge wounds are made through the conjunctiva and sclera together, and absorbable sutures are used to close the scleral and conjunctival wounds simultaneously at the end of surgery. In the present study, we evaluated the usefulness of this new 20-gauge transconjunctival vitrectomy procedure.
Subjects and Methods The records were studied of 431 consecutive patients (433 eyes; 234 men and 197 women) from 27 to 89 years of age (mean, 62 years) who underwent 20-gauge transconjunctival vitrectomy at the Surugadai Hospital of Nihon University between March 2003 and January 2004. Primary operations were performed on 393 eyes, while 40 eyes underwent reoperations. Cataract surgery was performed simultaneously in 252 eyes. Retrobulbar anesthesia with
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a
a b Figure 1. a At three sites on the conjunctiva, transconjunctival openings are made in the conjunctiva and sclera together using a 20-gauge microvitreoretinal (MVR) blade. At the completion of surgery, absorbable sutures are used to close the scleral wound and conjunctival wound simultaneously. b Using a 20-gauge MVR blade, conjunctival openings are placed 2 mm posterior to the sclerotomies. At the completion of surgery, absorbable sutures are used to stitch the scleral and conjunctival wound simultaneously.
3 ml of 2% lidocaine and 3 ml of 0.5% bupivacaine was used. Surgery was conducted after obtaining informed consent from each patient. The reasons for surgery were neovascular maculopathy in 98 eyes, retinal detachment and proliferative vitreoretinopathy in 84, proliferative diabetic retinopathy in 63, epiretinal membrane in 40, retinal vein occlusion in 41, macular hole in 33, vitreous opacity in 29, and other reasons in 45.Vitrectomy and cataract surgery were conducted using Accurus 400US/600DS (Alcon Surgical, Fort Worth, TX, USA). Surgical method 1 (Fig. 1a) was conducted in 358 patients (360 eyes) (193 men and 165 women). First, the cataract operation was performed through an incision in the superior cornea, and a foldable intraocular lens (SA60AT, Alcon Surgical) was implanted. Then, at three sites on the conjunctiva, openings were made through the conjunctiva and sclera together using a 20-gauge microvitreoretinal (MVR) blade (Alcon). A Korobelnik self-retaining infusion cannula (Dorc, Zuidland, the Netherlands) was inserted, and vitrectomy was then conducted. Next, the conjunctival and scleral wounds were closed together with Vicryl 8–0 (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA). Surgical method 2 (Fig. 1b) was conducted in 73 patients (73 eyes) (41 men and 32 women). First, the cataract operation was conducted through an incision in the superior cornea, and a foldable intraocular lens (SA60AT, Alcon) was implanted. Then, three 20-gauge sclerotomies were made through the conjunctiva using a 20-gauge MVR blade. A sclerotomy was made by pulling the conjunctiva with forceps toward the limbus and inserting an MVR blade 3.5
b Figure 2. a Using a 20-gauge MVR blade, a conjunctival opening is made 2 mm posterior to the scleral opening. A Korobelnik selfretaining infusion cannula is placed. At two other sites, conjunctival openings are made 2 mm posterior to the scleral openings. b After fluid–air exchange, there is little bleeding from the conjunctiva. The conjunctiva covers the scleral wound.
mm from the limbus. Alternatively, a sclerotomy was made by inserting an MVR blade lightly into the conjunctiva at a site 2 mm posterior to the site of the sclerotomy and then moving the blade anteriorly to 3.5 mm from the limbus and puncturing the sclera. A Korobelnik self-retaining infusion cannula (5 mm) was inserted, and vitrectomy was conducted (Fig. 2a). Surgery was performed using a vitrectomy lens with an infusion handle. Excision of the peripheral vitreous and laser coagulation were done with the conjunctiva compressed by plug forceps. At the completion of surgery, since the scleral wounds were naturally covered by the conjunctiva, the scleral and conjunctival wounds were closed simultaneously using Vicryl 8–0 (Ethicon) (Fig. 2b).
Results Nearly all of the 431 patients (433 eyes) who underwent vitrectomy between March 2003 and January 2004 had indica-
H. SHIMADA ET AL. 20-GT TRANSCONJUNCTIVAL VITRECTOMY
tions for this procedure. Only four eyes with proliferative vitreoretinopathy needed additional buckling. The 20-gauge transconjunctival vitrectomy was indicated for nearly all of the ocular diseases and was not limited by the intraocular instruments required.
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With method 1, in which scleral and conjunctival wounds are common, there were concerns over infection and invagination of conjunctival tissue in the scleral wound. However, neither infection nor conjunctival tissue invagination occurred. With method 2, the conjunctiva was observed to cover the scleral wound on the first postoperative day.
Intraoperative Complications
Discussion With both methods, there was extensive conservation of the conjunctiva, and good filtering blebs could be maintained in eyes undergoing filtering surgery (three eyes) or simultaneous glaucoma filtering surgery (four eyes). Method 2, with conjunctival openings placed 2 mm posterior to the sclerotomies, was difficult to perform in 8 of 40 reoperated eyes because of the marked adhesion of the conjunctiva and sclera. Since the conjunctiva was not incised, the peripheral conjunctiva had to be compressed during treatment of the peripheral vitreous. Plug forceps were used to compress the conjunctiva, and excision of the peripheral vitreous and photocoagulation were conducted. Although compression was difficult on the inferior nasal side, none of our cases required conjunctival incision due to failure of compression. Conjunctival edema, including mild cases, occurred in all cases that required prolonged surgery. Conjunctival edema was especially common in cases requiring supplemental sub-Tenon’s anesthesia. In method 1, perfused fluid passed from the sclerotomy directly through the conjunctival opening to be discharged out of the eye. In method 2, however, since the perfused fluid passed under the conjunctiva before it was discharged, conjunctival edema developed more easily. Intraocular insertion of an intraocular instrument through the conjunctiva was more difficult in method 2 than in method 1. Therefore, when method 2 was used, intraocular instruments were inserted while lifting the conjunctival wound. In 23 eyes, conjunctival edema hindered the insertion of instruments from the scleral/conjunctival port, and a 3-mm incision was made in the conjunctiva to reduce the conjunctival edema. The 3-mm incision was easily closed by suturing the conjunctival and scleral wounds together. In patients developing conjunctival edema during surgery, air may enter the conjunctiva by a fluid-air exchange. In these cases, the conjunctiva was incised in such a manner that silicone oil did not infiltrate below the conjunctiva.
Postoperative Complications No incomplete closure of the conjunctival/scleral sutures occurred. Postoperative low ocular pressure was observed in 3 of 84 eyes with retinal detachment and proliferative vitreoretinopathy in which conjunctival/scleral suturing was difficult owing to conjunctival edema. However, low ocular pressure was restored to normal 2 to 3 days after surgery.
The 20-gauge transconjunctival vitrectomy procedure is a modification of the conventional 20-gauge vitrectomy using a three-port system, with the purpose of making the procedure less invasive. With the 20-gauge transconjunctival vitrectomy procedure, peripheral vitrectomy is possible. This procedure is not limited by the surgical instruments required and therefore has broad indications, whereas the 25-gauge transconjunctival vitrectomy4,5 is limited by required surgical instruments. Twenty-five-gauge transconjunctival vitrectomy requires that a cannula be placed in each of the three ports.4,5 As a result, conjunctival edema is uncommon. On the other hand, in 20-gauge transconjunctival vitrectomy, there is no cannula placement in the cutter and light guide ports. Consequently, conjunctival edema occurs more readily. Although a 20-gauge infusion cannula (Grieshaber) is commercially available, this cannula was not used because a sclerotomy exceeding 1 mm is required and the flow of fluid perfusion is so great that it interferes with surgery. Owing to the lack of a cannula, conjunctival edema, including mild cases, occurred in all the cases that required prolonged surgery. In particular, when sub-Tenon’s anesthesia was used during surgery, conjunctival edema was especially common. In method 1, the perfusion fluid passed from the scleral wound directly through the conjunctival wound to be discharged out of the eye, but in method 2, the perfusion fluid passed below the conjunctiva before it was discharged; thus, there was a predisposition to the development of edema. When conjunctival edema hindered the insertion of instruments from the scleral/conjunctival port, a 3-mm incision in the conjunctiva reduced this conjunctival edema. As air might enter the conjunctiva during a fluid–air exchange in such cases, the conjunctiva was incised to assure that silicone oil did not infiltrate below the conjunctiva. The sclera is sutured in the 20-gauge transconjunctival vitrectomy. In 25-gauge transconjunctival vitrectomy, a small part of the peripheral vitreous is left behind and is impacted into the scleral wound, meaning that the surgery can be terminated without suturing. However, in 25-gauge transconjunctival vitrectomy, leakage of intraocular fluid may occur even when peripheral vitrectomy is done adequately. In 20-gauge transconjunctival vitrectomy, one stitch is placed for the infusion cannula port and two sutures each for the cutter and light guide ports. For this reason, foreign body sensation, congestion, and bleeding may be slightly more prominent than with the 25-gauge transconjunctival vitrectomy, but the frequency of incomplete closure and low ocular pressure are lower because of the sutures.
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Both surgical methods resulted in extensive conservation of the conjunctiva, and good filtering blebs could be maintained in eyes undergoing filtering surgery (three eyes) or simultaneous glaucoma filtering surgery (four eyes). The achievement of wide preservation of the conjunctiva with simultaneous glaucoma filtering surgery results from the performance of the cataract surgery through a keratotomy. The 20-gauge transconjunctival vitrectomy is expected to achieve even more extensive preservation of the conjunctiva. The above findings show that the 20-gauge transconjunctival vitrectomy has various benefits including the broad conservation of the conjunctiva. It is indicated for nearly all ocular diseases, and is not limited by the intraocular instruments required to carry it out.
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