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Year : 2004  |  Volume : 52  |  Issue : 4  |  Page : 337-8

A simple technique to fixate the bullet pipe and perform bimanual vitreous surgery.

Correspondence Address:
Joerg C Schmidt

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Source of Support: None, Conflict of Interest: None

PMID: 15693332

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How to cite this article:
Schmidt JC, Rodrigues EB, Meyer CH. A simple technique to fixate the bullet pipe and perform bimanual vitreous surgery. Indian J Ophthalmol 2004;52:337

How to cite this URL:
Schmidt JC, Rodrigues EB, Meyer CH. A simple technique to fixate the bullet pipe and perform bimanual vitreous surgery. Indian J Ophthalmol [serial online] 2004 [cited 2020 Jun 3];52:337. Available from: http://www.ijo.in/text.asp?2004/52/4/337/14555

Dear Editor,

While standard pars plana vitrectomy (PPV) is usually performed by three-port system, bimanual maneuvers in cases of proliferative diabetic retinopathy (PDR) membranes, macular translocation surgery (MTS), or traumatic proliferative vitreo-retinopathy (PVR) are not possible because in the three-port system one hand must hold the endoillumination.

There are several ways to free the second hand from the light pipe, thus allowing bimanual surgery. Although Gayon et al introduced a sutured-secured fiberoptic endoilluminator to be fixated in a fourth sclerotomy in the inferior quadrants, it has not gained wide acceptance.[1] Others have tried to illuminate the infusion cannula by adding light to its wall, but the resultant light was not very bright, and the illuminating angle was small.[2] Koch et al presented a multi-port illumination system (MIS) for bimanual surgery where two tubes carrying 20 light fibers were fixated in the two superior sclerotomies.[3] This technique also had disadvantages; it increased surgery costs and required a larger sclerotomy opening for the insertion of instruments. Light fibers have been incorporated to surgical instruments such as forceps, laser probes and picks.[4] However, the light usually goes very close to the retinal tissue inducing light stress, and the area of illumination is restricted. The use of external diaphanoscopic illumination allows a nice view of the peripheral retina because with one hand surgeon indents and illuminates the peripheral retina, while the second hand can be used for the vitreous cutter inside the eye.[5] But, a bimanual intraocular manipulation is not possible with this approach. When surgeons have to execute bimanual intraocular maneuvers, they usually have an assistant to hold the intraocular light pipe through a fourth sclerotomy. Nevertheless, the room in the surgical field is very restricted, and not every retinal surgeon has a trained assistant available. We report here a simple and low cost system to place the fourth sclerotomy intra-operatively.

Our approach is used when bimanual-technique is needed, and a fourth sclerotomy is made in the nasal inferior quadrant additional to the three-port standard system. A bullet light pipe is prepared by placing a rubber tube around the glass side of the light pipe, leaving 6 mm rubber free, so that only 6 mm of the light pipe remains inside the eye at the forth sclerotomy [Figure - 1]. Two adhesive steristrips are used to fixate the light pipe, one to the rubber tube, and a second to the operative field onto the nose [Figure - 2]. The steristrips fixate the eye globe so that no abrupt eye movement during bimanual dissection is permitted. As the nose wings form a 45 degree angle to the sagittal anatomy, the illumination remains facing the posterior pole.

This technique has been used for the last three years in our clinic in over 300 cases of PDR membranes, MTS, and traumatic PVR membranes. Neither does it obstruct the surgical field nor interferes with the surgeon's maneuver. Light pipe fixation was always stable, and in no case release or loosening of the light pipe was observed. The homogeneous illumination allowed a quick and safe bimanual manipulation on the retinal surface. PVR membranes were removed in a short time, under 20 minutes. In cases of MT surgery, the retinal rotation movement was performed easily. This illumination was used over one hour in MT surgery, and we have not observed any signs of light toxicity.

This technique has minor limitations that should be highlighted. First, the nasal-inferior area of the fundus is less illuminated because of the light-pipe bending; and in the temporal periphery there is an area of temporal shadow with poor retina visualisation. Second, a fourth sclerotomy itself may pose an additional trauma to the adjacent tissues. Third, in patients with wide pupil the surgeon should often expect a light blending of the fixed light pipe.

This simple system provides diffuse and adequate intraocular illumination. It may be performed by every retinal surgeon since no special equipment is necessary.

  References Top

Gayon MW, Schepens CL, Hirose T. Four-port bimanual vitrectomy. Arch Ophthalmol 1986;104:1088-89.  Back to cited text no. 1
Zinn KM, Grinblat A, Katzin HM, Epstein M, Kot C A new endoillumination infusion cannula for pars plana vitrectomy. Ophthalmic Surg 1980;11:850-55.  Back to cited text no. 2
Koch FH, Pawlowski D, Spitznas M. A multiport illumination system for panoramic bi-manual vitreous surgery. Graefes Arch Clin Exp Ophthalmol 1991;229:425-29.  Back to cited text no. 3
Wirostko WJ, Mittra RA, Rao PK, Borrillo JL, Dev S, Mieler WF. A combination light-pipe, soft-tipped suction, and infusion cannula instrument for macular translocation. Am J Ophthalmol 2000;129:549-51.  Back to cited text no. 4
Schmidt JC, Nietgen GW, Hesse L, Kroll P. External diaphanoscopic illuminator: a new device for visualization in pars plana vitrectomy. Retina 2000;20:103-06.  Back to cited text no. 5


  [Figure - 1], [Figure - 2]

This article has been cited by
1 ŠAb infernoŠ intravitreal suturing of a large traumatic scleral perforation at the posterior pole [12]
Schmidt, J.C., Mennel, S., H÷rle, S., Meyer, C.H.
British Journal of Ophthalmology. 2007; 91(12): 1721-1722
2 Pars-plana vitrectomy with anterior chamber infusion via a paracentesis in pseudophakic eyes | [Pars-plana-vitrektomie mit Infusionszugang über eine Korneale Parazentese bei Pseudophaken Augen]
Schmidt, J.C., Meyer, C.H., Mennel, S.
Ophthalmologe. 2007; 104(3): 222-225
3 simple technique to fixate the bullet pipe and perform bimanual vitreous surgery
Raju, B., Raju, N.S.D., Raju, A.S.
Indian Journal of Ophthalmology. 2006; 54(1): 66-67


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