Micro-Surgical Safety Task Force focuses on sutureless vitrectomy

Twenty-five-gauge sutureless vitrectomy has been increasing inpopularity. In conjunction with this surge, however, is theobservation that the procedure is associated with increasedpostoperative complications such as hypotony, choroidaldetachment, and an increased incidence of endophthalmitis.Richard Kaiser, MD, from the Retina Service of Wills EyeInstitute, Philadelphia, focused on endophthalmitis and notedthat the 25-gauge procedure has a risk of infection that is 12.4times greater than the 20-gauge procedure.

In light of this, the Micro-Surgical Safety Task Force, composedof experienced retina surgeons, undertook the task ofdisseminating guidelines to reduce the high rate ofendophthalmitis associated with 25-gauge vitrectomy.

Regarding ocular preparation, task force members suggested thatthe lidocaine gel should be rinsed off the ocular surface toallow direct contact of povidone iodine 10% with theconjunctiva.

Intraoperatively, all members of the task force agreed on thefollowing:

• Conjunctival displacement is important with a cotton tip ratherthan instruments such as forceps or a caliper, thus facilitatingconjunctival displacement without causing microholes.
• Angled incision may be advantageous over straight-entryincisions because of improved wound closure and for maintainingthe initial postoperative IOP level.
• Use of antibiotics are important at the end of the case andpostoperatively, but the location varied by surgeon andgentamicin should be avoided because of the potential fortoxicity.
• An air-fluid exchange at the end of the case may be superiorto filling eyes with fluid, which seem to have a high risk ofdeveloping endophthalmitis, and IOP can be maintained.
• Using a tapered exit may eliminate vitreous incarceration inthe wound that can occur when the trocar is pulled straight outas the result of a suction effect.
• Surgeons should maintain a low threshold for placing a sutureat the end of the case.

"There appears to be a higher rate of endophthalmitis followingsutureless vitrectomy," Dr. Kaiser said. "This is an evolvingtechnique. There is a need for continued improvement. TheMicro-Surgical Task Force might be a step in the rightdirection."