Simplified vitrectomy technique garners positive results in study

October 1, 2008

Twenty-three gauge transconjunctival sutureless vitrectomy performed in pseudophakic eyes offers faster recovery times and increased patient comfort regarding suture-related and sclerotomy-related complications, according to one surgeon.

Key Points

Dr. Chakrabarti and associates from the Chakrabarti Eye Care Centre, Trivandrum, India, conducted a retrospective comparison of 20 cases of 20- and 23-gauge pars plana vitrectomy that were performed in pseudophakic patients.

The surgical indications included dislocated IOLs, recalcitrant cystoid macular edema, epiretinal membranes, pseudophakic retinal detachments, phacovitrectomy for complications of proliferative diabetic retinopathy and diabetic macular edema, and removal of silicone oil. The choice of procedure was determined by the patients and surgeon.

Related complications

The complications associated with the procedure primarily were related to insertion and withdrawal of the microcannula and included episcleral bleeding (30%), conjunctival slippage (10%), peritomy (5%), difficult globe rotation (30%), lost sclerotomy (30%), subconjunctival hemorrhage (30%), need for a suture (5%), oozing of silicone oil associated with cannula withdrawal, and hypotony (5%).

"We had some difficulty with rotating the globe superiorly to perform vitrectomy in the superior quadrants," Dr. Chakrabarti said.

The main outcomes measured for the 23-gauge group were the mean time to rehabilitation, the average surgical time, the irrigation fluid used, absence of inflammation postoperatively, and better patient comfort.

"The mean IOP stabilized at 16 mm Hg by the third postoperative day in the 23-gauge group. The most difficult step for us was inserting the microcannula, and the complications of lost sclerotomy, peritomy, and conversion to the 20-gauge procedure all occurred during the early learning curve," she said.

The investigators found that the 23-gauge procedure is associated with shorter and simplified surgeries with excellent patient comfort postoperatively regarding suture- and sclerotomy-related complications. Phacovitrectomy can be performed in combination with 20- and 23-gauge surgery and is ideal for patients with pre-existing filtering blebs, according to Dr. Chakrabarti.

Outcome analysis

The challenges associated with the procedure were the lack of endolaser probes in India during the early learning curve associated with the procedure, the difficulty of rotating the globe superiorly, and the flexibility of the thin instruments.

"Our experience showed that the procedure cannot be used in patients who needed extensive vitrectomy for complex retinal pathologies," she said.

Generally, the initial experience with the 23-gauge transconjunctival sutureless vitrectomy procedure was very positive.

"This is a safe and simplified procedure that provides increased patient comfort and no suture-related and sclerotomy-related complications. The indications can include 20 and 23 gauge. Less complex retinal pathologies can be addressed very effectively," Dr. Chakrabarti concluded.

The comparison of the 20- and 23-gauge procedures favored the 23-gauge vitrectomy regarding rehabilitation (1 week versus 8 weeks), shorter surgical time (30 minutes versus 45 minutes), less irrigating fluid used (200 ml versus 400 ml), no postoperative inflammation, and better patient comfort.

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