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ARTICLE
Year : 1969  |  Volume : 17  |  Issue : 5  |  Page : 216-221

Trans-vitreal surgery


Christian Medical College and Brown Memorial Hospital, Ludhiana, India

Date of Web Publication11-Jan-2008

Correspondence Address:
K R Mehta
Christian Medical College and Brown Memorial Hospital, Ludhiana
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Mehta K R, Franken S. Trans-vitreal surgery. Indian J Ophthalmol 1969;17:216-21

How to cite this URL:
Mehta K R, Franken S. Trans-vitreal surgery. Indian J Ophthalmol [serial online] 1969 [cited 2020 Jun 4];17:216-21. Available from: http://www.ijo.in/text.asp?1969/17/5/216/38543


  Definition Top


The term applies to all surgical ma­nipulations inside or extending through the vitrous body, whether it is in its normal anatomical position or has prolapsed either into the anterior chamber or in a wound.

To date, the surgery of the vitreous is in itself, almost exclusively concern­ed with the management of complica­tions of other phases of ophthalmic surgery.

Vitreous loss, during intra-ocular surgery on the iris, cornea, lens or sclera is correctly considered as a se­rious event, which is likely to open the door to further complications, such as, vitreous touch syndrome, updrawn pupil, glaucoma and retinal detach­ment with poor prognosis.

In traumatic injuries with vitreous loss, excision of the vitreous which has prolapsed out of the wound has to be done before scleral suturing is contem­plated and even following the repair the eye has to be watched for long periods under the omen of a guarded prognosis.

It is not, however, this type of un­pleasant interference forced upon the surgeon which I wish to discuss today, but that for which the term `Elective', can be applied, that is, vitreal surgery as a procedure carried out in a well-­contemplated planned way under care­ful ophthalmoscopic control.

Indications

The possible indications for Trans. Vitreal surgery can be :­

(1) Approach and removal of a non - magnetic or magnetic intra-ocular foreign body.

(2) Removal of a parasite located in the vitreous body.

(3) Cutting of Vitreous traction bands which prevent a detached retina from settling after rou­tine procedure for re-attach­ment has been carried out pro­perly.

(4) Injection of saline solution, vitreous transplant/implant or liquid silicone into the vitreous space.

(5) Retinopexy of a retina in the case of giant tears where the vitreous body is continuous and perhaps identical with the sub­retinal fluid.

Site of Operative Access

Various methods of entry have been propounded by many authors for Trans-Vitreal manipulation. Probably, the safest and most promising entry is through the sclera and pars-plana of the ciliary body. After opening of the conjunctiva, the incision can be made parallel to the limbus at a distance of 6 mm from the same and as small an incision as would be adequate for the manoeuvre contemplated. This site is chosen because direct injury to the retina is thus avoided as the site is anterior to the ora serrata. It equally avoids the secretory part of the ciliary body with its rich blood supply and bulk of its muscle. Preplacing of a scleral mattress suture (4-0 silk/ Dacron) should be done before penetration of the choroid which would permit immediate and firm closure of the wound if and when desired.

Diathermy of the underlying flat por­tion of the ciliary body not only coagu­lates the blood vessels in this area, but also usually suffices to open the globe and permit introduction of the instrument desired.

A different approach may have to be contemplated for removal of an intra-ocular vitreal foreign body, de­pending upon its site in the globe and wound of entry. Each surgeon varies in his preference for an individual ro­entgenographic localisation technique, but as long as an adequate proficiency is attained in accurate localisation, any procedure would suffice.

The visual control for various pro­cedures differ. In general, the binocu­lar distant direct ophthalmoscopy (Schepens/Keeler) is satisfactory as it permits, being worn on the head, both hands of the observer free for surgi­gical manipulation, at the same time giving sterioscopic visualisation. One hand is used to steady and/or rotate the globe while the other holds the in­struments for removal of the foreign body the tip of which is in the Vitre­ous. The undisturbed corneal curva­ture and moistened surface of the cor­nea is a necessary requisite for this procedure.

The surgical manoeuvre for magnetic foreign bodies would be to utilise an electromagnet, preferably through the route of entrance, or an incision placed through the pars-plana; but if im­bedded in the retina over any place, a circum-diathermic barrage and an ap­propriate incision over the site of the foreign body would suffice, care being taken to exclude the 3 o'clock and 9­ o'clock positions to prevent injury to the long ciliary vessels and nerves.

A third approach in exceptional cases may be through the anterior seg­ment. After opening of the cornea at the limbus and a broad iridectomy, the lens is delivered in its capsule. There­after manipulation through the vitreous surface can take place.

In this type of approach through the open cornea and anterior vitreous sur­face the use of an operating microscope is imperative especially one with a co­axial arrangement for illumination and observation, (e.g. Zeiss). Later I shall illustrate this approach with case re­cords.


  Illustrative Case Records Top


Case I

(1) Recently a young man visited our clinic who had a cysticercous un­der the foveal area. The photograph taken at that time [Figure - 1] revealed that the head of the parasite had per­forated the retina and obscured one of the retinal vessels from view. [Figure - 1]a is a schematic representation to demon­strate its probable site of origin prior to perforation. Later, [Figure - 2] the pa­rasite moved out from its place be­tween the choroid and retina and was found surrounded by vitreous. [Figure - 2]a shows the parasite in a different position to demonstrate its free move­ment in the vitreous. The vitreous re­mained fairly clear and there was just a mild aqueous flare. The retina in the meantime became detached [Figure - 3], a and the fundus sketch displays the cysticercus and the para-foveal retinal folds. There was a question whether there was exudate covering the hole in the fovea or a second cyst underneath. [Figure - 3]a a schematic sketch demon­strates the free floating cysticercus and para-foveal retinal folds which gave rise to the illusion. It was decided to attempt removal of the cyst through the pars-plana of the ciliary body. If an exudate covered the hole in the fovea, the retina might settle sponta­neously, otherwise light coagulation might take care of the hole later.

After opening the sclera, 6 mm from the limbus at the pars-plana, the inci­sion was made 9 mm long [Figure - 4] and penetrated with diathermy. An eriso­phake was introduced in the vitreous body [Figure - 5] under sterioscopic visual control of a binocular distant direct ophthalmoscope. There was virtually no vitreous loss and the cyst appeared in the first attempt with the cup of the erisophake in the scleral wound. What­ever vitreous presented in the wound, settled back after the parasite (still moving) was lifted from the wound. The preplaced sutures were closed and sub-conjunctival penicillin was given. The parasite lived and moved for an­other half hour in warm saline solu­tion, ultimately ending its life, in formo-saline mixture in which it shrunk to about 1/2 its original dia­meter. The recovery from this surgery was without complication. The vitre­ous remained clear, however, the retinal folds were fixed and the eye re­tained only peripheral function.

Case II

A young lady of 20 years came to us having in her left eye a cysticercus cellulosae which was embedded in the vitreous body, barely discernable through a lens in the process of deve­loping a complicated cataract. Light projection was still present, but that was the best to be said.

Surgery was carried out by an an­terior segment incision as close to the limbus as possible followed by a broad iridectomy and intra-capsular lens ex­traction. The corneal flap was kept aside by a traction suture under dir­ect microscopic control, the cyst mea­suring about 8 mm was brought out in a suction cup. There was negligible vitreous loss. The cornea was secured in its place and recovery was unevent­ful. The intra ocular pressure remain­ed normal. No visual improvement oc­curred. A partial optic atrophy (pro­bably of a toxic nature) could be seen.

Case III

A 48 year old man came with a metallic intra-ocular foreign body in his right eye. Radiographic visualisa­tion revealed a radio-opaque elongated foreign body at least 15 mm in size with jagged edges lying horizontally in the vitreous. The entry wound belied the size of the foreign body and there was an irregular tear, 6 mm in size. Such a removal would necessitate an extremely large incision with doubtful prognosis. Extraction via the anterior route was done following corneal sec­tion, broad iridectomy and intra-cap­sular lens extraction. The eye retained vision of finger counting at four meters when the patient was last seen 3 months after surgery.

Case I V

As a fourth case illustration, I men­tion the case of a young boy who had complete retinal detachment with giant disinsertion over 180°. The retina could be seen flapping behind the lens sometimes obscuring the retina. There was apparently [Figure - 6] direct conti­nuity between the subretinal fluid and the vitreous body. The retina did not settle with bed rest.

The following surgical procedure was followed. After opening of the conjuntiva the lateral rectus muscle was secured in a cat gut suture and de­tached from its insertion. A narrow lamellar scleral resection was done over the same extent as the disinsertion l mm beyond the ora serrata. An ordinary SWG 24 needle was taken and its tip was turned into a minia­ture hook. [Figure - 7] Following diathermy of that area, the needle was introduced and the retina was hooked [Figure - 8] and secured on the scleral resection with diathermy through the same im­provised needle. There would have been no other way to bring the retina back to its position. A haemorrhage from a site which received inadequate diathermy obscured the view later on. The patient did not come for a follow­-up.


  Instruments for Transvitreal Surgery Top


Among the instruments being design­ed for Trans-Vitreal surgery by the 'Schepens' Group is a scissors for cut­ting vitreal bands with which they have had some success. The blades of the same are less than 2 mm long.

Another is the microforceps design­ed to grasp intra vitreal, non-magnetic foreign bodies having a horizontal ac­tion obviating any trauma to the scle­ral entrance site, and permitting ade­quate movement with a minimal sized entry incision.

There will probably be an exten­sive further development in this field.


  Summary Top


Trans-vitreal surgery, perhaps is a drastic measure but where it is indi­cated, it is indispensable and should be attempted in a well contemplated pro­per way.

The required type of surgery is illus­trated by case-records of 4 cases.


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]



 

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