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   Table of Contents      
ORIGINAL ARTICLE
Year : 2006  |  Volume : 54  |  Issue : 3  |  Page : 185-188

25 gauge vitrectomy under topical anesthesia: A pilot study


Smt. Meenakshiamma Center for Vitreoretinal Diseases, Ranjini Eye Care, Near Powerhouse, Thripunithura Road, Vyttila, Kochi, Kerala, India

Correspondence Address:
Biju Raju
Consultant Vitreoretinal Surgeon, Ranjini Eye Care, Near Powerhouse, Thripunithura Road, Vyttila, Kochi - 682 019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.27070

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  Abstract 

Aims: To evaluate the safety and efficacy of transconjunctival 25 gauge vitrectomy under topical anesthesia.
Settings and Design:
A pilot study of consecutive cases which underwent 25 gauge vitrectomy under topical anesthesia.
Materials and Methods:
Seven eyes of 7 patients underwent 25 gauge vitrectomy under topical anesthesia with a pledget soaked in anesthetic, for vitreous hemorrhage (2 eyes), retained cortex (1 eye) and postoperative endophthalmitis (4 eyes). Subjective pain and discomfort were graded from 0 (no pain or discomfort) to 4 (severe pain and discomfort). Patients underwent an immediate postoperative assessment, followed by day one and one week postoperative evaluation.
Results:
All patients had grade 0 pain during the surgery. Five patients had grade 2 pain during the placement of the sclerotomies. None of the patients required any sedation during the procedure. No inadvertent eye movements were noted during surgery. Except one patient, none required postoperative analgesics. Five eyes had a favorable outcome. No eyes in this pilot study had any procedure-related complications.
Conclusion:
With appropriate case selection, topical anesthesia is a safe and effective alternative to infiltrative anesthesia for 25 gauge vitrectomy. A larger series of patients with a longer follow-up is required to validate the findings of this pilot study.

Keywords: 25 gauge vitrectomy, endophthalmitis, topical anesthesia, transconjunctival sutureless vitrectomy, vitreoretinal surgery.


How to cite this article:
Raju B, Raju N, Raju AS. 25 gauge vitrectomy under topical anesthesia: A pilot study. Indian J Ophthalmol 2006;54:185-8

How to cite this URL:
Raju B, Raju N, Raju AS. 25 gauge vitrectomy under topical anesthesia: A pilot study. Indian J Ophthalmol [serial online] 2006 [cited 2020 Apr 4];54:185-8. Available from: http://www.ijo.in/text.asp?2006/54/3/185/27070



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Intraocular surgeries have been done under retrobulbar, peribulbar and topical anesthesia.[1],[2] Topical anesthesia has now become the preferred technique for clear corneal phacoemulsification procedures.[1] Currently, vitreoretinal surgeries are performed under general anesthesia or under retrobulbar and peribulbar anesthesia.[2] Recently, there have been reports on the safety profile of topical anesthesia, with sedation for conventional 20 gauge vitrectomy.[3] To the best of our knowledge (MEDLINE search), there are no reports in the literature on 25 gauge vitreoretinal surgery under topical anesthesia. This report describes the results of our pilot study on 25 gauge vitreoretinal surgery, performed under topical anesthesia without sedation.


  Materials and Methods Top


Seven eyes of 7 consecutive patients underwent 25 gauge vitrectomy under topical anesthesia. Two eyes underwent the procedure for cataract and vitreous hemorrhage secondary to branch retinal vein occlusion, one case for retained cortex and vitreous hemorrhage and 4 cases for postoperative endophthalmitis [Table - 1]. Patients with deafness, claustrophobia, dementia and those who were not co-operative (as evaluated by the surgeon (BR) during indirect ophthalmoscopy, applanation tonometry, A-scan biometry and fundus photography), were excluded. All patients were informed that they would be aware of the sensation of touch and would be able to move their eyes.

After achieving maximal pupillary dilatation with 1% tropicamide and 5% phenylephrine, the conjunctival cul-de-sac was anesthetized with a drop of 0.5% proparacaine hydrochloride (Paracain 0.5% eye drops, Sunways, Mumbai, India). Commercially available weck-cell sponge (Madhu Instruments, Delhi, India) was cut into 2 x 2 mm pieces and soaked in proparacain drops. Using sterile forceps, three of these sponges soaked in anesthetic were placed in the areas where the sclerotomies were planned. The eye was closed and the pledgets were allowed to remain there for a period of 3 minutes, following which the pledgets were removed. The eye and the surrounding area were then cleaned and painted with povidone iodine 5%.

In combined phacovitrectomy procedures (2 eyes), a stop and chop phacoemulsification technique was first performed under conventional topical anesthesia, with 0.5% paracain drops. A foldable intraocular lens was implanted in both these eyes. Prior to the start of the vitrectomy, topical anesthesia was augmented by placing the sterile pledgets soaked in anesthetic over the sclerotomy sites for 3 minutes.

Using the 25 gauge trocar and cannula system (Alcon Labs, USA), 3 direct transconjunctival sclerotomy entries were made, 3.0 mm posterior to the limbus at the inferotemporal, superonasal and superotemporal locations, taking care to stretch the overlying conjunctiva with a sterile cotton bud. The trocar and cannula were pushed through the sclera into the vitreous cavity and the trocar was removed [Figure - 1]. The infusion was maintained through the inferotemporal sclerotomy, employing the vented gas fluid infusion (VGFI), to overcome the resistance of flow in the smaller lumen of the 25 gauge infusion line. The vitrectomy was performed using the dual dynamic drive technology on the accurus machine (Alcon Labs, USA), with the new xenon illumination system as the endoillumination light source. After completion of vitrectomy, endolaser photocoagulation was performed in 2 cases using 532 nm frequency doubled Nd:YAG laser through a 25 gauge laser endoprobe (Iridex Corporation, USA). A 25 gauge forceps (Alcon Labs, USA) was used for membrane- peeling in one case. Cases of endophthamitis underwent a vitreous biopsy prior to the vitrectomy and intraocular injection of antibiotics at the end of the procedure. Fluid air exchange was performed for one case of vitreous hemorrhage with cataract.

At the end of the procedure, the superotemporal and superonasal cannulae were removed first, followed by the removal of the inferotemporal cannula with the infusion line, after closing the infusion. A drop of gatifloxacin eye drops and cyclopentolate hydrochloride 1% was instilled into the cul-de-sac and the eye was left open without any patch. The patients were instructed to wear clear protective spectacles. They then underwent an immediate postoperative visual acuity testing and slit lamp evaluation by an ophthalmologist (ASR) and were asked questions from a standard written form. Each patient was shown a 5-point subjective pain and discomfort scale: 0 = no pain or discomfort, 1 = no pain but mild discomfort, 2 = mild pain and discomfort, 3 = moderate pain and discomfort and 4 = severe pain and discomfort. Each patient was then asked to grade the level of pain and discomfort during the surgical procedure.[3] All patients were started on prednisolone acetate eye drops every 2 hours and gatifloxacin eye drops every 2 hours. The topical medications were started within 10 minutes after the surgery. The patients with endophthalmitis received atropine sulfate 1% eye drops in addition to the above medications. The topical antibiotics were stopped after 1 week and the prednisolone acetate was tapered over 3 weeks. The patients with endophthalmitis were continued on the medications until the inflammation subsided completely. All the surgeries were done as an outpatient procedure. The patients were discharged after the immediate postoperative evaluation and were called back at day one and week one for postoperative reviews. None of the patients required any sedation intraoperatively or in the postoperative period. Intraocular pressures recorded (4 of the 7 eyes) at day one and week one postoperative visits were normal (mean 18 + 2.6 mm Hg, range14 to 20 mm Hg). Intraocular pressure was not recorded in eyes with acute postoperative endophthalmitis.


  Results Top


The mean age of the patients was 64 years (60 to 78 years). All patients reported grade 0 pain (no pain and discomfort) throughout the procedure. During sclerotomy, 5 out of 7 patients had grade 2 pain. One of the patients with advanced postoperative endophthalmitis had grade 3 pain during sclerotomy. All patients co-operated well, though there was a mild squeezing of lid at the time of sclerotomy. However, after the sclerotomies were made, none of them complained of pain throughout the procedure, even at the time of removal and reintroduction of instruments through the sclerotomies. No inadvertent eye movements were noted during surgery. Only one patient in this series required postoperative oral analgesics. None of the other patients had pain during the postoperative period.

All, except two patients had improvement in visual acuity at immediate postoperative evaluation. The preoperative visual acuity ranged from perception of light, to counting fingers at 3meters. The postoperative visual acuity ranged from perception of light to 20/40 at one week postoperative evaluation [Table - 1]. Two patients had an unfavorable outcome in terms of visual acuity. One of the patients had undergone phacoemulsification with vitrectomy and endolaser photocoagulation with fluid air exchange, for cataract and vitreous hemorrhage secondary to branch retinal vein occlusion. After two weeks, there was a recurrent vitreous hemorrhage due to a sudden spike of hypertension. The other patient was an advanced case of postoperative endophthalmitis, which did not improve in spite of repeating the intravitreal injection after the initial vitrectomy. None of these patients had any procedure- related complications.

Two of the patients had a remarkable improvement in the immediate postoperative vision and this improvement continued to the postoperative first week visit. One patient underwent posterior capsulotomy with pars plana vitrectomy and vitreous biopsy, along with vancomycin injection into the capsular bag, for multiple episodes of low grade postoperative inflammation due to presumed Propionibacterium acnes endophthalmitis. This patient improved from counting fingers at 10 feet to 20/120 at immediate postoperative evaluation. At the first day postoperative evaluation, the vision improved to 20/40. There was a minimal intraocular inflammation [Figure - 2]. The other patient had a preoperative vision of counting fingers at 17 feet and underwent 25 gauge vitrectomy for retained cortex and vitreous hemorrhage. The visual acuity improved to 20/80 at immediate postoperative period and to 20/60 at day one postoperative evaluation.


  Discussion Top


There are several techniques of anesthesia for performing vitreoretinal surgeries. Earlier surgeries were performed under general anesthesia. With refinements in techniques and technology, these complex surgical procedures could be performed under retrobulbar, peribulbar, subtenons or topical anesthesia.[2] Conventional 20 gauge vitrectomies have been successfully done under topical anesthesia, with sedation. Most of these reports have recorded grade 2 level of pain and discomfort during cauterization of the scleral bed, sclerotomy incision, suturing of sclerotomy and conjunctival suture placement.[3] In this study, we found that the prolonged contact of an anesthetic- soaked pledget at the site of the sclerotomies, was adequate to perform the 25 gauge procedures without causing much discomfort or pain to the patient. None of them required sedation and except for one patient, none needed postoperative analgesics. The pledget delivery of anesthetic has the added advantage of prolonged delivery[4] of the anesthetic to the areas where the sclerotomies are planned and thus would contribute to reduced pain and discomfort during the procedure.

In conventional 20 gauge vitrectomy,[5],[6] three 1.9 mm sclerotomy incisions are made with the microvitreoretinal blade (MVR), after cauterizing the scleral bed. The infusion cannula is sutured on to the inferotemporal sclerotomy with 6/0 polyglactin sutures. Introduction of the instruments through the sclerotomies results in repeated contact of the instruments on the sclera and would also cause microtrauma at the pars plana. In contrast, the 25 gauge vitrectomy system relies on the trocar and cannula system for the placement of the sclerotomies. This avoids the conjunctival incision and cauterization of the scleral bed. Once the sclerotomies are made, the trocar is removed and the cannula remains at the sclerotomy site. The tip of the trocar and cannula are beveled and the trocar is designed to be introduced into the eye in a noncoring fashion (modified MVR design).This results in an easy and smooth entry of the trocar and cannula with very less pressure on the sclera. During the introduction of the instruments, the flared funnel design of the cannula facilitates easy entry, with no trauma to the sclera or the pars plana. The infusion cannula is easily snapped fit to the 25 gauge sclerotomy cannula and requires no sutures to hold it in position. These features make 25 gauge vitrectomy less traumatic and thus ideal for topical vitreoretinal procedures. As the instruments do not come in contact with the sclera or pars plana, prolonged anesthesia is not required and therefore extended surgical time may not be a contraindication for performing 25 gauge vitrectomy. However, this needs to be confirmed by a large series of 25 gauge topical vitrectomy procedures. The dual dynamic drive helps the surgeon simultaneously control both suction and cut rate linearly. Varying the cut rate and suction judiciously, helps to remove larger bits of vitreous or intraocular tissues faster with the 25 gauge cutter. With the VGFI, it was not necessary to raise the bottle to achieve good infusion volume while performing the surgery.

Performance of the no patch 25 gauge vitrectomy under topical anesthesia did not result in any adverse outcome. The two patients, who did not do well after surgery, would have had the same outcome even with the 20 gauge procedure. One had a recurrent vitreous hemorrhage following uncontrolled hypertension in the postoperative period and the other had persistent intraocular infection. We found that the no patch 25 gauge technique to be of immense value, especially in patients with endophthalmitis. In these patients, 25 gauge vitrectomy may become the procedure of choice, as the postoperative inflammation is much less than that seen with the conventional 20 gauge vitrectomies with polyglactin sutures. In addition, topical anti-inflammatory as well as antibiotic therapy can be instituted immediately after the surgery, thus resulting in better inflammatory control.

Though this study was not designed to assess the postoperative inflammation following 25 gauge vitrectomy, we noticed near normal appearance of the eyes after the procedure. The inflammatory response was minimal, even in the cases of combined phacovitrectomies [Figure - 3]. We believe that the inflammatory response in the cases of endophthalmitis, were also less than that expected from a conventional 20 gauge procedure. The immediate delivery of topical anti-inflammatory drugs may also have added to the less traumatic surgical procedure in reducing the postoperative inflammation. Previous studies have also documented the faster postoperative recovery time and relatively less postoperative inflammation with 25 gauge vitrectomy.[6],[7]

Our initial experience with topical anesthesia sutureless 25 gauge vitrectomy is encouraging. This study did not focus on the long term results of 25 gauge vitrectomy under topical anesthesia. We also had selected eyes which did not require the full capability of a conventional 20 gauge vitrectomy. A larger series of patients with a longer follow-up is recommended and will help us evolve this technique of vitrectomy. With good case selection and a well informed patient, no patch topical 25 gauge vitrectomy results in a good outcome. Moreover, with this technique, vitreoretinal surgeries can be done as an out-patient, ambulatory procedure. In addition, it avoids all the complications[8] associated with periocular infiltrative anesthesia.


  Conclusion Top


No patch sutureless 25 gauge vitrectomy was found to be safe and effective in selected cases. A larger series of patients with a longer follow-up is recommended to validate the findings of this pilot study.

 
  References Top

1.
Patel BC, Burns TA, Crandall A, Shomaker ST, Pace NL, van Eerd A, et al . A comparison of topical and retrobulbar anesthesia for cataract surgery. Ophthalmology 1996;103:1196-203.  Back to cited text no. 1
    
2.
Nicholson AD, Singh P, Badrinath SS, Murugesan R, Sundararaj I, Vardarajan S, et al . Peribulbar anesthesia for primary vitreoretinal surgery. Ophthalmic Surg 1992;23:657-61.   Back to cited text no. 2
    
3.
Yepez J, Yepez CJ, Arevalo JF. Topical anesthesia for phacoemulsification, intraocular lens implantation and posterior vitrectomy. J Cataract Refract Surg 1999;25:1161-4.  Back to cited text no. 3
    
4.
Auffarth GU, Vargas LG, Klett J, Volcker HE. Repair of a ruptured globe using topical anesthesia. J Cataract Refract Surg 2004;30:726-9.  Back to cited text no. 4
    
5.
O'Malley C, Heintz Sr RM. Vitrectomy with an alternative instrument system. Ann Ophthalmol 1975;7:585-8,591-4.  Back to cited text no. 5
    
6.
Fujii GY, De Juan E Jr, Humayun MS, Chang TS, Pieramici DJ, Barnes A, et al . Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002;109:1814-20.  Back to cited text no. 6
    
7.
Lakhanpal RR, Humayun MS, de Juan E Jr, Lim JI, Chong LP, Chang TS, et al . Outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. Ophthalmology 2005;112:817-24  Back to cited text no. 7
    
8.
Morgan CM, Schatz H, Vine AK, Cantrill HL, Davidorf FH, Gitter KA, et al . Ocular complications associated with retrobulbar injections. Ophthalmology 1988;95:660-5.   Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]


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