|Year : 2008 | Volume
| Issue : 6 | Page : 529-532
Sutureless vitrectomy: Review of journal abstracts
Rajesh Sinha, Subrato Mandal, Sat Pal Garg
R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
|Date of Web Publication||14-Oct-2008|
492, R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sinha R, Mandal S, Garg SP. Sutureless vitrectomy: Review of journal abstracts. Indian J Ophthalmol 2008;56:529-32
|How to cite this URL:|
Sinha R, Mandal S, Garg SP. Sutureless vitrectomy: Review of journal abstracts. Indian J Ophthalmol [serial online] 2008 [cited 2020 Jun 2];56:529-32. Available from: http://www.ijo.in/text.asp?2008/56/6/529/43392
Vitrectomy surgery with sutureless self-sealing sclerotomy was started in 1996 which consisted of beveled, tunnel-like tangential incision through sclera rather than right-angled incision. Later, multiple modifications of this technique were reported but did not get wide acceptance as suturing of conjunctiva was still required. Then the 23-gauge vitrectomy cutter was introduced, followed by 25-gauge instruments. Since then a lot has been discussed and published about sutureless vitrectomy and hence we would like to review some of the important articles published in the recent past in indexed journals discussing the various aspects of this procedure.
| Case selection/indications|| |
Kim et al. ( Korean J Ophthalmol. 2007;21(4):201-7 ) performed 23-gauge (23G) pars plana vitrectomy in various conditions including idiopathic epiretinal membrane ( n =7), vitreous hemorrhage ( n =11), diabetic macular edema ( n =10), macular hole ( n =5), vitreomacular traction syndrome ( n =5), diabetic tractional retinal detachment ( n =1), and rhegmatogenous retinal detachment ( n =1) and reported good results.
Shah et al. ( Retina 2008;28(5):723-8 ) have used sutureless 25-gauge (25G) vitrectomy system for vitreoretinal surgery with injection of silicone oil for retinal detachment with good results.
Lai et al. ( Retina 2008;28(5):729-734 ) have also reported excellent final anatomical success rate and postoperative visual outcomes of primary rhegmatogenous retinal detachment repairs performed using 25G transconjunctival sutureless vitrectomy (TSV) system.
Riemann et al. ( Retina 2007;27(3):296-303 ) have reported 25G pars plana vitrectomy (PPV) and silicone oil (SO) tamponade in complex vitreoretinal diseases like tractional retinal detachment (11 eyes), macular hole (six eyes), proliferative vitreoretinopathy or recurrent retinal detachment (nine eyes), neovascular glaucoma (three eyes), giant retinal tear (three eyes), and pathologic myopia with epiretinal membrane or macular hole (three eyes).
Kapran et al. ( Retina 2007;27(8):1059-64 ) reported removal of silicone oil effectively and safely with 25G transconjunctival sutureless vitrectomy system.
Kychenthal et al. ( Retina 2008;3:S65-68 ) have reported successful use of 25G lens-sparing vitrectomy for Stage 4A retinopathy of prematurity.
Chang et al. ( J Cataract Refract Surg. 2006;32(12):2054-9 ) have reported that sutureless PPV combined with intracameral triamcinolone stain is a safe, and reliable adjunct in the management of vitreous loss associated with phacoemulsification.
Dada et al. ( J Cataract Refract Surg. 2007;33(6):951-4 ) have reported sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for the management of phacomorphic glaucoma. As these eyes have shallow anterior chamber and positive vitreous pressure, phacoemulsification is difficult and prone to various intraoperative complications. Sutureless single-port transconjunctival parsplana limited vitrectomy before phacoemulsification makes the surgery easy and less complicated.
Chalam et al. ( Ophthalmic Surg Lasers Imaging 2005;36(6):518-22 ) have also reported limited PPV to remove a small amount of retro-lental vitreous (approximately 0.2 to 0.3 cc) with a 25G high-speed cutter before phacoemulsification.
Moreno-Montanes et al. ( J Cataract Refract Surg.2007;33(3):380-2 ) reported combined cataract surgery and 25G sutureless vitrectomy for posterior lentiglobus and found the procedure to be effective.
Lam DS et al. ( Clin Experiment Ophthalmol. 2005;33(5):495-8 ) reported posterior capsulotomy or membranectomy using 25G TSV system to be a safe and effective approach in the management of posterior capsular opacification (PCO) in pseudophakic children.
Tan et al. ( Eye 2008;22(1):150-1 ) reviewed the outcomes of 23G TSV in patients with postoperative endophthalmitis and found it to be a useful technique. There was no case of postoperative hypotony or wound leak.
| Procedure|| |
Pars plana vitrectomy is usually performed under peribulbar block. But with the introduction of sutureless vitrectomy, surgeries under topical anesthesia with or without sedation have been tried.
Raju et al. ( Indian J Ophthalmol. 2006;54(3):185-8 ) have reported seven cases who underwent 25G vitrectomy under topical anesthesia without sedation. None of their patients had significant pain during the placement of the sclerotomies and the rest of the surgery.
Tang et al. ( Ophthalmologica 2007;221(1):65-8 ) have evaluated the safety and feasibility of topical anesthesia (2% Alcaine) in vitrectomy using the transconjunctival sutureless 25G vitrectomy system (TSV 25G) in 46 eyes of 46 patients with macular-based disorders (macular holes, n =31, idiopathic epiretinal membranes, n =11, and vitreoretinal traction syndrome n =4). Thirty-one patients (67.4%) tolerated the procedure well; 13 patients (28.3%) required additional topical anesthesia and two patients (4.3%) required a systemic sedative. They concluded that topical anesthesia permits successful management of some surgically less complex vitreoretinal disorders when the TSV 25G is used.
Theocharis et al. ( Graefes Arch Clin Exp Ophthalmol. 2007;245(9):1253-8 ) evaluated the efficacy of topical lidocaine 2% gel with or without per oral preoperative sedation (morphine and dixyrazine) as an alternative anesthetic method and compared it to peribulbar anesthesia for 25G and 23G sutureless vitrectomy. They found no statistically significant difference in the level of pain and concluded that lidocaine 2% jelly with or without per oral preoperative sedation offers adequate analgesia to perform sutureless vitrectomy.
Byeon et al. ( Ophthalmologica 2006;220(4):259-65 ) after reviewing the medical records and surgical videotapes of 50 consecutive patients who underwent 25G TSV, noted intraoperative problems like difficulty in inserting the microcannula, which led to deformity, and instability of the microcannula, self-disconnection of the infusion tip and resultant lens damage, and required conversion to 20-gauge (20G) conventional vitrectomy.
Hubschman et al. ( Ophthalmic Surg Lasers Imaging. 2007;38(4):345-8 ) have described a new sutureless vitrectomy technique involving combined 25- and 23G surgery. In 53 patients using two 25G ports for infusion and light probe and one 23G port for the vitreous cutter and various instruments, they found no intraoperative or postoperative complications and no case required conversion to another technique.
Lopez-Guajardo et al. ( Am J Ophthalmol. 2006;141(6):1154-6 ) performed oblique sclerotomy technique for prevention of inadequate wound closure in transconjunctival 25G vitrectomy. This technical variation resulted in no intraoperative leakage after cannula removal in any of the 36 sclerotomies performed.
| Results|| |
Williams ( Eye 2008;22 [Epub ahead of print] ) performed a literature review and observed that 25- and 23G vitrectomy techniques may shorten operating time, improve patient comfort, and speed visual recovery. However, increased complication rates involving hypotony and endophthalmitis have also been reported.
Ibarra et al. ( Am J Ophthalmol. 2005;139(5):831-6 ) in a retrospective, noncomparative case series of 45 consecutive eyes that underwent 25G TSV surgery, observed minimal complications, and none specifically related to the sutureless nature of the procedure after a mean follow-up of more than one year. They commented that less surgically complex vitreoretinal pathology may be successfully repaired with TSV.
Patelli et al. ( Retina 2007;27(6):750-4 ) evaluated the surgical outcome of 25G TSV for different macular conditions (108 eyes for idiopathic macular pucker, 24 for idiopathic macular hole, and 28 for tractional diabetic macular edema). Over a mean follow-up period of 10 months, mean postoperative visual acuity improved to 20/40 from mean preoperative visual acuity of 20/70. Mean operative time was 21±11min. In no patient the intraocular pressure (IOP) was <8 mmHg on postoperative Day 1.
Lai et al. ( Retina 2008;28(5):729-734 ) have evaluated the anatomical and visual outcomes of primary rhegmatogenous retinal detachment repairs performed using 25G TSV. The retina was reattached with a single operation in 39 (74%) eyes. The final anatomical success rate was 100%. Proliferative vitreoretinopathy (64%) and development of new retinal breaks (43%) were the most common reasons associated with redetachment. They concluded that though 25G TSV resulted in excellent final anatomical success rate and postoperative visual outcomes, redetachments due to new tears and/or proliferative vitreoretinopathy resulted in a lower single-operation success rate than those reported with 20G systems.
Gotzaridis ( Semin Ophthalmol. 2007;22(3):179-83 ) has reported a technique of sutureless transconjunctival 20G vitrectomy that reduces the operating time and the postoperative inflammation. The microvitreoretinal (MVR) blade was introduced into the conjunctiva-sclera in a beveled direction. The tunnel incision that was created was left without a suture at the end of the operation. Three out of 84 eyes (5%) had hypotony (2-6 mmHg) on Day 1 that was normalized three days later. Two of them had a bleb formation and the rest a very minor leakage through a flat conjunctiva.
Kychenthal et al. ( Retina 2008;3:S65-68 ) have reported use of a 25G system for lens-sparing vitrectomy in Stage 4A retinopathy of prematurity. Twelve (92%) out of 13 eyes obtained total retinal reattachment.
Bahar et al. ( Ophthalmic Surg Lasers Imaging 2006;37(5):364-9 ) performed a comparative study of the three techniques (25G, 23G, 20G) for the treatment of diabetic vitreous hemorrhage. They concluded that all the three techniques are similarly effective and the specific technique used should be selected on the basis of the clinical status of the patient and the skills of the surgeon.
Kellner et al. ( Br J Ophthalmol. 2007;91(7):945-8 ) however, have reported that the duration of vitrectomy was significantly longer in the 25G group than in the 20G group. They concluded that though the 25G vitrectomy system offered significantly improved patient comfort during the first postoperative week, duration of surgery was comparable between the two systems- the shorter time needed for wound opening and closure in the 25G group being equalized by the longer vitrectomy duration.
| Advantages|| |
Quick wound healing
In an experimental model, Wan et al. ( Yan Ke Xue Bao. 2007;23(1):37-42 ) have shown that the smaller sclerotomy sites in 25G TSV heal faster (10 days) and have lighter inflammatory reaction in comparison to 20G vitrectomy (more than 20 days).
Lopez-Guajardo et al. ( Am J Ophthalmol. 2007;143(5):881-3 ) have reported that 25G sclerotomies heal by Day 15 in most cases with no difference between direct and oblique sclerotomy wounds.
Keshavamurthy et al. ( BMC Ophthalmol. 2006;6:7 ) have done ultrasound biomicroscopy of sclerotomies with 20G and 25G instruments in the same patients and showed rapid healing of a 25G sclerotomy, with inability to detect the site of sclerotomy in a short duration of two weeks postoperatively. This is as opposed to conventional sclerotomies, which might take up to six to eight weeks for complete apposition.
Shorter surgical time
Rizzo et al. ( Graefes Arch Clin Exp Ophthalmol. 2006;244(4):472-9 ) have compared the results of 25G sutureless vitrectomy with standard 20G PPV in 46 consecutive eyes with idiopathic epiretinal membrane. Operating time was shorter in Group 1 compared to Group 2 (mean 15.6 and 29.6 min respectively). Postoperative discomfort and intraocular inflammation were significantly lesser in the 25G group.
Shinoda et al. ( Acta Ophthalmol. 2008;86(2):151-5 ) in their comparative study in macular hole surgery with 25G and 20G instruments found that operating time was significantly shorter in the 25G group (56±16 min) than in the 20G group (85±28 min).
Romero et al. ( J Fr Ophtalmol. 2006;29(9):1025-32 ) compared 25G TSV with 20G system and concluded that TSV system decreases surgical time and postoperative inflammation, with optimal postoperative patient comfort.
Less surgically-induced astigmatism
Okamoto et al. ( Ophthalmology 2007;114(12):2138-41 ) have reported that for regular astigmatism, asymmetry, and higher-order irregularity, the 20G group showed significantly greater surgically-induced changes than the 25G group at two weeks postoperatively.
Yanyali et al. ( Am J Ophthalmol. 2005;140(5):939-41 ) also have reported that there was no significant change in average corneal power, corneal surface cylinder, surface asymmetry index, and surface regularity index parameters at first day, first week, and first month after 25G vitrectomy. Mean induced astigmatism was 0.38 diopters at 15 degrees.
Rapid visual recovery
Shinoda et al. ( Acta Ophthalmol. 2008;86(2):151-5 ) retrospectively evaluated medical records of 46 consecutive eyes operated for macular hole (MH). Vitrectomy had been performed with a 25G instrument in 23 eyes (25G group) and with a 20G instrument in 23 eyes (20G group). One week after surgery, visual acuity was significantly better in the 25G group than in the 20G group. This significant difference was maintained until nine months after surgery, but was no longer evident at 12 months. They concluded that the use of 25gauge vitrectomy instruments leads to better postoperative visual recovery following surgery for MH during the first nine months.
| Complications|| |
Higher incidence of retinal detachment/breaks
Ibrara et al. ( Am J Ophthalmol. 2005;139(5):831-6 ) have hypothesized that less vitreous removal in TSV surgeries may cause increased risk of postoperative retinal breaks or detachments. They have reported an incidence of retinal detachment in 2.2% of cases.
In a report by Lommatzsch et al. ( Ophthalmologe 2008;105(5):445-51 ), seven eyes out of 329 eyes undergoing TSV surgery for epiretinal membrane developed retinal detachment.
Okuda et al. ( Graefes Arch Clin Exp Ophthalmol. 2007;245(1):155-7 ) have reported retinal breaks not accompanied by retinal detachment postoperatively in four out of 75 eyes. All the patients were operated for idiopathic macular hole. In all the cases, there was no vitreous traction around the retinal break and photocoagulation was performed.
In a report by Oshima et al. ( Ann Acad Med Singapore. 2006;35(3):175-80 ) only one eye (0.67%) out of 150 eyes developed retinal detachment.
Singh et al. ( Retina 2008;28(4):553-7 ) in their study reported that 25G TSV incisions, with or without conjunctival displacement, allowed the entry of ocular surface fluid into the eye in their laboratory model. They feared that this technique may carry an increased risk of bacterial contamination that could predispose to endophthalmitis.
Kunimoto et al. ( Ophthalmology 2007;114(12):2133-7 ) compared the rates of endophthalmitis after 25G and 20G PPV in a retrospective, interventional, comparative cohort study. Endophthalmitis developed in 0.018% eyes after 20G vitrectomy and in 0.23% eyes after 25G vitrectomy ( P= 0.004). They concluded that 25G vitrectomy had a statistically significant 12-fold higher incidence of endophthalmitis compared with 20G vitrectomy. They thought that the potential risk factors included lack of wound closure, hypotony, higher amount of retained vitreous and less infusate used minimizing the washing effects.
Scott et al. ( Retina 2008;28(1):138-42 ) have also reported that the rate of endophthalmitis after 25G vitrectomy was significantly higher than that after 20G vitrectomy. In their study the incidence of endophthalmitis during the study period was 0.03% for 20G vitrectomy and 0.84% for 25G vitrectomy ( P < 0.0001). Endophthalmitis after 25G vitrectomy occurred within 15 days of vitrectomy, and was usually due to coagulase-negative staphylococci sensitive to vancomycin in contrast to more virulent organisms reported after 20G vitrectomy, and was associated with variable visual outcomes.
Wound leakage and hypotony
Acar et al. ( Retina 2008;28(4):545-52 ) have evaluated associated postoperative hypotony after 25G sutureless vitrectomy with straight incisions in 111 eyes in a retrospective, interventional, institutional case series. They found a hypotony rate of 26.12% at 2 h that decreased to 17.11% on Day 1 and to 8.10% at Week 1 but hypotony did not increase the incidence of other postoperative complications.
Lakhanpal et al. ( Ophthalmologe 2008;105(5):445-51 ) have reported that 7.1% patients in their study required single-site sclerotomy suture due to bleb formation at the end of surgery.
In a retrospective study by Yanyali et al. ( Eur J Ophthalmol. 2006;16(1):141-7 ), IOP was below 10mmHg (between 6 and 9mmHg) in 12 eyes (16.9%) on the first postoperative day; however in all the eyes, IOP normalized within one week without affecting the visual outcome.
Batman et al. ( Ophthalmic Surg Lasers Imaging 2008;39(2):100-6 ) have reported efficacy of tissue glue for closing port site when wound leakage was observed in TSV. In their report wound leakage occurred at the sclerotomy sites at the end of the surgery in six out of 46 eyes with 23G and seven out of 38 eyes with 25G transconjunctival sutureless vitrectomy, all of which were effectively closed with tissue glue. Ultrasound biomicroscopy could not detect any fibrous ingrowth at the sclerotomy sites in any of the cases.
Byeon et al. (Ophthalmic Surg Lasers Imaging 2008;39(2):94-9 ) evaluated the factors related to postoperative hypotony after 25G TSV. Among the various factors they studied (including order of infusion removal, age, sex, axial length, preoperative IOP, previous vitrectomy, indications for vitrectomy and lens status), only age was significantly correlated with IOP on postoperative Day 1 ( P=0.019). They concluded that younger patients were more likely to experience early postoperative hypotony.
Gupta et al. ( Ophthalmic Surg Lasers Imaging 2007;38(4):270-5) found that fluid-filled eyes appear to have a higher risk of wound leakage and postoperative hypotony after 25G PPV ( P=0.031) than eyes with air ( P =0.30) or gas ( P=0.52) tamponade.
Amato et al. ( Ophthalmic Surg Lasers Imaging 2007;38(2):100-2 ) have reported that sclerotomy leakage and hypotony with choroidals were only encountered in cases involving previously vitrectomized eyes, whereas none of the eyes without previous vitrectomy had leakage-related complications.
Oshima et al. ( Ann acad med Singapore 2006;35:175-80 ) have performed a retrospective review of 150 eyes having previously undergone 25G vitrectomy, phacoemulsification and intraocular lens implantation. They observed postoperative transient hypotony in 13% of cases one week after surgery.
Flavio et al. ( Arch Ophthalmol. 2007;125(5):699-700 ) have reported two cases of ocular decompression retinopathy immediately after 25G TSV performed for retained lens fragments and elevated IOP after complicated phacoemulsification.
Cardascia et al. ( Int Ophthalmol. 2007;16 [Epub ahead of print] ) reported a case of gentamicin-induced macular infarction after 25G TSV and postoperative subconconjunctival injection of gentamicin sulfate (0.4 mg/ ml) adjacent to sclerotomies.
Lakhanpal et al. ( Ophthalmology 2005;112(5):817-24 ) in their study reported that five out of 140 eyes (3.8%) presented on Day 1 with shallow choroidal detachments after TSV, but all resolved by Day 7 and none required volume infusion during the postoperative period.
In a report by Lommatzsch et al. ( Ophthalmologe 2008;105(5):445-51 ) nine out of 329 eyes undergoing surgery for epiretinal membrane developed postoperative hypotony and choroidal detachment for which a suture was placed at the sclerotomy site.
Kapamajian et al. ( Semin Ophthalmol. 2007;22(3):197-9 ) have reported intraoperative suprachoroidal hemorrhage during a vitreous biopsy procedure with 25G system for chronic intraocular inflammation in an 80-year old pseudophakic man.
Liu et al. ( Eye 2005; 19: 825-27 ) have also reported a patient with 360° choroidal detachment on the first postoperative day after TSV, suspected to be due to postoperative hypotony.
Conjunctival blebs formations
Lopez-Guajardo et al. ( Am J Ophthalmol. 2007;143(5):881-3 ) performed in vivo ultrasound biomicroscopy (UBM) study in direct and oblique sclerotomy incisions by 25G and showed that conjunctival blebs developed over 64% of direct sclerotomies, and 25% of oblique, but all resolved spontaneously by Day 15.
In a similar study, Riemann et al. ( Retina 2007;27(3):296-303 ) also identified a small subconjunctival bleb in two out of 35 eyes after TSV.
| Limitations|| |
Inoue et al. ( Am J Ophthalmol. 2004;138(5):867-869 ) reported breakage of the tip of the 25G vitreous cutter while performing surgery. They concluded that the new instruments are designed much thinner than 20G system resulting in increased flexibility and bending of the instruments. As a result, it is more difficult to perform procedures that put stress on the instruments at the sclerotomy sites, such as removal of anterior fibrovascular proliferation.
Shinoda et al. ( Acta Ophthalmol. 2008;86(2):160-4 ) have reported the jamming of 25G instruments in the cannula during vitreous surgery for non-clearing vitreous hemorrhage. The 25G vitreous cutter or light pipe became jammed in the cannula in three eyes (7%) in the vitreous hemorrhage group and the instrument locked inside the cannula had to be removed with the cannula.
Perez-Gonzalez and Lajara-Blesa ( Arch Soc Esp Oftalmol. 2007;82(7):437-42 ) reported good success rate of trans-scleral sutureless vitrectomy with a 25G system for rhegmatogenous retinal detachment. However, they observed that the procedure carries some limitations like the need for a learning period and a high incidence of cataracts.
Cost of surgery
Lewis ( Am J Ophthalmol. 2007;144(4):613-5 ) has reported in an editorial of the American journal of ophthalmology that the cost of sutureless vitrectomy is 3.4 times higher than that of sutured 20G vitrectomy surgeries.
| Future|| |
More recently 27/29G instruments are coming into the market.
Oshima et al. ( Retina 2008;28(1):171-3 ) have reported 27G self-retaining transconjunctival chandelier endoilluminator and novel mercury vapor illuminator combined with a 27/29G chandelier light fiber for vitreous surgery.