Practical Handbook for Small-Gauge Vitrectomy: A Step-By-Step Introduction to Surgical Techniques

Part IIntroduction to Small-Gauge Vitrectomy

© Springer International Publishing AG, part of Springer Nature 2018

U. Spandau, H. HeimannPractical Handbook for Small-Gauge Vitrectomyhttps://doi.org/10.1007/978-3-319-89677-9_1

1. Introduction to Small-Gauge Vitrectomy

Ulrich Spandau¹   and Heinrich Heimann²

(1)

University Eye Hospital, Uppsala, Sweden

(2)

Royal Liverpool University Hospital, Liverpool, UK

Keywords

Small-gauge vitrectomy23-gauge vitrectomyProf. EckardtMIVS Bimanual surgery

1.1 History

Since the 1970s, 20-gauge vitrectomy has evolved as the worldwide standard for vitreoretinal surgery. All instruments have a lumen diameter (inside diameter) of 0.9 mm. See also Table 1.1. For this procedure, the conjunctiva is opened, three sclerotomies are placed, and the infusion cannula is sutured to the sclera. In the majority of cases, trocar cannulas are not used, and at the end of the surgery, the sclerotomies are sutured.

Table 1.1

Outer diameter of a needle in gauge and mm

In 2002, Eugene de Juan et al. introduced 25-gauge vitrectomy . The instruments had a lumen diameter of 0.5 mm. Trocars (cannulas) were used for the infusion and the instruments. The trocars were inserted transconjunctivally and transsclerally and remained in place during the entire surgery without the need for suturing them to the sclera. A major advantage of this new technique was the reduced anterior segment trauma during the procedure, because the conjunctiva is not opened and the instruments are smaller. One disadvantage was an increased risk for postoperative hypotony due to the absence of sutures. Another disadvantage was that the instruments were very flexible and not all instruments could be produced in such a small diameter. Meanwhile, more rigid instruments were developed that proved to be easier to handle. The 25-gauge technology is particularly popular in the United States.

In 2004, 23-gauge vitrectomy with a lumen diameter of 0.65 mm was developed at the Eye Clinic Frankfurt- Höchst by Prof. Dr. Claus Eckardt . In 23-gauge vitrectomy, the benefits of 25-gauge vitrectomy (transconjunctival trocar, no suture, reduced surgical trauma) are combined with the advantages of the 20-gauge technology (rigid instruments, more efficient vitrectomy, and easy accessibility of the vitreous base) (Figs. 1.1 and 1.2). Finally, a new incision technique was developed: the sclerotomies are performed in a lamellar fashion (tunnel technique), which results in a better postoperative wound closure and less postoperative hypotony. The 23-gauge technology is particularly popular in the Europe.

Fig. 1.1

An intraoperative image of a retinal detachment surgery with four-port technique: the infusion line at the top right and the fixed fiber-optic chandelier at the top left. Left and right below the two instrument trocar cannulas

Fig. 1.2

A postoperative image of the same detachment surgery: you can recognize the implanted intraocular lens and the almost white conjunctiva. A 20% SF6 tamponade was used

The latest development is 27-gauge vitrectomy. The instruments have a diameter of only 0.4 mm. The companies DORC and Alcon have the 27-gauge vitrectomy with trocars in their product range. The indication of spectrum has expanded vastly in the recent years with the introduction of new vitreoretinal instruments such as scissors and forceps. In addition, the advent of the two-blade vitreous cutter with a cutting frequency of 12–16.000 cuts/min has reduced the time for a 27G vitrectomy significantly. The 27-gauge technology is particularly popular in Japan.

In the recent years, 25G has become the gold standard for small-gauge vitrectomy. 23G is decreasing and 27G is increasing year for year. At the University of Uppsala, 27G is used as standard.

1.2 Key Features of Microincision Vitrectomy Surgery (MIVS)

The techniques of 23-gauge , 25-gauge, and 27-gauge vitreoretinal surgery are also referred to as microincision vitrectomy surgery (MIVS). The 23-gauge, 25-gauge, and 27-gauge techniques can now be used for the whole spectrum of posterior segment surgeries, including PVR retinal detachment and diabetic vitreoretinopathy with silicone oil. The main features are:

Lamellar and sutureless sclerotomies

Trocar cannulas

Bimanual surgery

1.2.1 Sutureless Sclerotomies

The sclerotomies are performed with a tangential incision (lamellar tunnel incision), i.e., the sclerotomy is self-sealing and does not require suturing (Fig. 1.3).

Fig. 1.3

This histological section of an eye showing a lamellar cut through the sclera for 23-gauge vitrectomy . This tangential incision needs no suture. It is comparable to the tunnel incision in phacoemulsification

1.2.2 Trocar

A trocar is a metal or plastic cannula, which is placed transconjunctivally in the sclerotomy. The trocars are not sutured and remain in the sclerotomy during the entire surgery (Figs 1.1 and 1.4).

Fig. 1.4

23-gauge trocar with blue valve and inserter. This model is from DORC

The trocar system is an essential part of the MIVS. It significantly lowers the anterior segment trauma and is associated with minor postoperative discomfort. Table 1.2 lists the advantages and disadvantages of the trocar. 25-gauge is superior to 23-gauge concerning the sclerotomy closure and the speed of postoperative recovery.

Table 1.2

Advantages and disadvantages of the trocar system

Does size matter? The 23G, 25G, and 27G trocars fit into each other (Fig. 1.5). A 27G trocar creates a sclerotomy size of 25G. A 25G trocar creates a sclerotomy size of 23G and a 23G trocar creates a sclerotomy size of 22G. This fact results in a watertight globe after a 27G sclerotomy. A suture is never required. In contrast, a suture is often required in 23G vitrectomies: in myopic eyes, after silicone oil removal, etc.

Fig. 1.5

The 27G trocar fits into the 25G trocar and the 23G trocar fits into the 25G trocar. A 25G trocar creates a 23G sclerotomy and a 27G trocar creates a 25G sclerotomy

1.2.3 Bimanual Surgery

During conventional vitrectomy procedures, the surgeon holds the light pipe in one hand and the vitreous cutter or a different active instrument in the other hand (Fig. 1.6). In challenging situations, a more active second hand other than holding the light pipe can be useful. By inserting a fixed light probe (chandelier) in the sclera through a fourth sclerotomy port, the surgeon is enabled to use both hands actively (Fig. 1.7). The chandelier light illuminates the entire posterior segment with a panoramic view. Now, procedures such as indenting the retina and simultaneously performing a vitrectomy or bimanual peeling of membranes in PVR retinal detachment or diabetic retinopathy are easier to perform. Remember: No one can indent as good as your second hand.

Fig. 1.6

An example of an operation with a three-port trocar system. One infusion cannula and two instrument cannulas have been inserted. A handheld light pipe is used as a light

Fig. 1.7

An example of a surgery with a four-port trocar system. In the four-port trocar system, the fourth sclerotomy is used for a fiber-optic chandelier enabling the surgeon to work with two free hands. Synergetics.25-Gauge Awh Chandelier 56.20.25

Other advantages of trocar-vitrectomy compared to the non-trocar-vitrectomy are:

Significant reduction of overall surgery time (no opening of conjunctiva, no sutures, and no cauterization of bleeding vessels)

Protects sclerotomies when inserting instruments

Easier to find the sclerotomies

Bias against 23- and 25-gauge vitrectomyv :

A persistent and widespread opinion concerning 25-gauge surgery is that the use of silicone oil is not possible or difficult. This is not correct. A silicone oil tamponade with 1000/1300csts and 5000 csts silicone oil and its removal can easily be performed.

A further notion is that the removal of the vitreous takes longer compared to 20-gauge systems.

In the meantime, this disadvantage has overcome by the introduction of new high-speed cutters.

1.3 23G, 25G, or 27G?

Superficially, the differences between 23G, 25G, and 27G are low. Both use trocars and a lamellar incision. But then the differences begin. With 25G it takes more time for the vitrectomy than with 23G. This time difference is particularly noticeable during passive aspiration with a backflush instrument for fluid-air exchange, so that we always use active aspiration with 25G and 27G. By contrast, working with silicone oil with 25G is easy, both extraction of silicone oil and injection of silicone oil. A modern vitrectomy machine, however, is required. The following table lists the differences between the two systems. See Table 1.3.

Table 1.3

Comparison of 23G, 25G, and 27G

We work with one vitrectomy machine and 25G and 27G custom packs. Another important point is the spectrum of pathologies you operate. If it is mainly peelings, we would recommend 27G. If you operate also detachments, difficult diabetics, and trauma patients, 25G is a good choice because more instruments are available and because the instruments are stiffer than 27G.

The 27G vitreous cutter is the best vitreous cutter because it can be used as a vitreoretinal instrument. It helps in delaminating diabetic membranes, it can be used very close to the retina, and a 180 deg. retinotomy is no problem with a 27G vitreous cutter.

The main disadvantage of 27G is lack of stiffness of instruments which makes the removal of the peripheral vitreous difficult in deep eyes.

Part IIEquipment

© Springer International Publishing AG, part of Springer Nature 2018

U. Spandau, H. HeimannPractical Handbook for Small-Gauge Vitrectomyhttps://doi.org/10.1007/978-3-319-89677-9_2

2. Equipment

Ulrich Spandau¹   and Heinrich Heimann²

(1)

University Eye Hospital, Uppsala, Sweden

(2)

Royal Liverpool University Hospital, Liverpool, UK

Keywords

DevicesInstrumentsGasesLiquids

2.1 Devices

2.1.1 Operating Microscope

The optical quality of the surgical microscopes is excellent in all current models of the major manufacturers. More important is the viewing system. The Oculus BIOM can be used with all microscopes, but the Resight viewing system can only be used with a Zeiss microscope, and the EIBOS viewing system can only be used with a Leica microscope.

2.1.2 Binocular Indirect Ophthalmomicroscope (BIOM System)

To obtain a sufficient view of the posterior segment, one needs either a plano-concave contact lens which is directly placed onto the cornea or a highly refractive lens (60D, 90D, 120D) which is placed in front of the lens of the surgical microscope comparable to indirect ophthalmoscopes. This results in an inverted image. By flicking a reversal system (so-called inverter) into the parallel beam path of the operating microscope, an upright image is created (e.g., using the stereo diagonal inverter (SDI) of Oculus) (see Appendix, companies).

We use the BIOM system (binocular indirect ophthalmomicroscope) of Oculus and the EIBOS system by Moeller-Wedel. Both systems offer excellent optical images with a variety of different magnifications and fields of view. Based on our personal experience, the BIOM offers more flexibility and a better view of the retinal periphery. The EIBOS system is extremely robust and has the additional advantage of an inbuilt inverter that avoids the need for manual inversion when changing from the posterior segment to the anterior segment view during the surgery.

Another good option is the Zeiss (Resight) system . It contains two fixed lenses (128D and 60D) that can be rotated into the light beam. The handling is easy with the resolution of high quality especially in an air-filled eye.

With the Oculus BIOM system, we use three different types of lenses: 120D for a wide peripheral view, 90D as our standard lens for most applications, and the 60D high-magnification lens for macular surgery. In addition, an inverter is needed to invert the image for surgery. This must be turned on or off every time one switches between the anterior segment and posterior segment views.

We usually start with a 90D lens for core vitrectomy and posterior vitreous detachment. We then switch to the 120D lens to trim the vitreous base. We then switch to the 60D lens if we perform macular surgery. A good alternative is a plano-concave contact lens, which is placed directly onto the cornea. We then usually switch back to the 120D for complete trimming of the vitreous base and to inspect the peripheral retina for breaks. In cases of retinal detachment surgery, we recommend beginning the surgery with the wide-angle 120D lens to view the peripheral retina and to identify retinal breaks from the beginning of the surgery.

The company Oculus (Germany) has recently introduced a lens which can be used as a 120D lens and at the same time as 60D peeling lens (Fig. 2.1).

Fig. 2.1

The novel combined 120D and 60D lens from Oculus, Germany. The lens can be used for the BIOM (Oculus, Germany) and for the Resight (Zeiss, Germany) viewing system

Important: The viewing systems BIOM and Resight provide a mirror image. Therefore, an inverter is installed in the microscope, which turns the mirror image of the BIOM. If you flick the BIOM in, activate the inverter to gain an accurate image. Similarly, if you flick the BIOM out, you must activate the inverter in order to get an upright image. The EIBOS viewing system does not require an inverter.

2.1.3 Vitrectomy Machine

An extensive range of high-quality vitrectomy machines by several manufacturers is now available on the market. They have a cutting speed of approximately 2500 cuts/min. Of great importance is the fluidics (vacuum, flow rate) of the machine. A sophisticated coordination of these parameters allows a high-speed and less traumatic vitrectomy in a closed system. Further, an easy switch between phaco and vitrectomy mode is important. In addition, the vitrectomy machines should have an active injection and extraction feature. This is utilized to inject or remove silicone oil. One can also connect the backflush instrument to the active aspiration and work with active suction. This generation of vitrectomy machines has an integrated light source, which is sufficient for a light pipe but not for a chandelier light . An external light source and a laser must therefore be purchased separately.

The latest generation of vitrectomy machines such as Constellation from Alcon, Stellaris PC from Bausch & Lomb, and EVA from DORC has a cutting speed of 5000–8000 cuts/min. With the novel TDC vitreous cutter , the EVA machine has a cutting speed of 12.000–16.000 cuts/min. They all provide an integrated light source that is strong enough for a chandelier light.

One unfortunate trend in modern vitrectomy machines is that there are no international standards and the essential parts of the instrumentation are usually not interchangeable between different manufacturers. Moreover, some manufacturers provide some of the essential tools as part of an all-in-one vitrectomy pack only. This means, for example, that a broken light pipe or a vitreous cutter that inadvertently touched the non-sterile part of the microscope can only be replaced by opening another surgical pack, which is more expensive than an individually packed single-use instrument. Therefore, the cost and availability of vitrectomy packs and the provision of spare instruments as individually packed units should be included in the negotiations regarding the purchase of a new vitrectomy machine.

2.1.4 Laser Device

Again, there are numerous providers of laser devices . A frequently used device is the 532-nm diode laser OcuLight GL from Iridex (see Chap. 7).

2.1.5 Cryo Console

A cryo machine (DORC, ERBE) should be at our disposal in the operating room. Indications are a cryopexy of a retinal break, the retina, or the ciliary body due to neovascular glaucoma. Cryopexy is nowadays performed less frequently during vitrectomies, because cryotherapy leads to more anterior segment trauma and is more difficult to perform through a closed conjunctiva compared to 20-gauge surgery with conjunctival incisions. In addition, cryotherapy has been associated with a higher rate of PVR formation in some studies of retinal detachment surgery. Finally, the chorioretinal scar formation appears several days later following cryotherapy compared to laser retinopexy.

2.1.6 Light Source

The light source is either external or can be integrated into the vitrectomy machine. In general, the internal light sources have traditionally been weaker than external light sources. When using a chandelier light, one must use a very powerful light source. Synergetics offer an external photon source, and DORC and Alcon offer an external xenon light source (see Chap. 7). The new vitrectomy machines Constellation of Alcon, Stellaris PC from Bausch & Lomb, and EVA from DORC have an internal light source that is strong enough for use with a chandelier light.

2.2 Standard Instruments for Pars Plana Vitrectomy

Retinal surgery is a very instrumental field and necessitates that you acquaint yourself with the variety of high-quality microsurgical instruments designed for specific tasks, many more than with phacoemulsification. To become a good retinal surgeon, you need to know the different applications of this wide range of instruments and consequently increase your skills in this field of surgery. In addition, retinal surgery is neurosurgery in that one comes into direct contact with neural tissue. In general, such surgery is associated with the risk of transmitting Creutzfeldt-Jakob disease in countries where this disease is present. Therefore, there is an increasing trend to use single-use instruments in vitreoretinal surgery wherever possible. Reusable instruments, which used to be the norm just a few years ago, are disappearing from the market. This is especially the case in the UK and France. The positive side effect for the surgeon is that one is always provided with new and sharp instruments of very high quality nowadays. On the downside, this can reduce the number of available instruments and options available to the surgeon. Further, this trend is also associated with higher costs. In the following section, various surgical instruments are introduced.

Here you find all details of our PPV instrument set (only and combined), which we use at the University Hospital of Uppsala (Fig. 2.2):

1.

1× Lid speculum Liebermann. Geuder G-15960

2.

1× Irrigating cannula. Geuder G-15180 (for irrigation of the eye)

3.

1× Dressing forceps, serrated. Geuder G-18781

4.

1× Tissue forceps, 1 × 2 teeth. Geuder G-18791

5.

1× Castroviejo suturing forceps, straight. Geuder G-19023

6.

1× Barraquer cilia forceps. Geuder G-18750 (for suturing)

7.

1× Trocar forceps. DORC 1276.2 (for removal of the trocars)

8.

1× Eye scissors, straight pointed-pointed. Geuder G-19350

9.

1× Vannas capsulotomy scissors. Geuder G-19760

10.

1× Halsted mosquito forceps, curved serrated. Geuder G-18181

11.

1× Hartmann mosquito forceps, straight serrated. Geuder G-18170 (for washing the eye)

12.

1× Barraquer needle holder, curved, without lock. Geuder G-17500

13.

1× Sclera depressor, double ended. Geuder G-32715

14.

1× Braunstein fixed caliper. Bausch & Lomb E2402 (Scleral marker 3.5 mm and 4.0 mm)

Fig. 2.2

Vitrectomy Instrument set from the University of Uppsala, Sweden

2.2.1 Trocar Cannulas

Trocars with valves have become standard today, but you can still purchase trocars without valves (Alcon, DORC, Geuder, Oertli; Fig. 2.3).

Fig. 2.3

The Alcon Edgeplus trocar with hand piece and 3.0/4.0 mm marker. Available for 23-gauge, 25-gauge and 27-gauge

Trocars with valves are particularly useful for beginners, as they prevent hypotension and collapse of the globe during the surgery (Fig. 2.4). It is, however, important to notice that with valved trocars, one works within a closed system. For example, when injecting fluid or gas, corresponding drainage or pressure control has to be ensured via the second port or the infusion system to avoid a significant rise in intraocular pressure. Using trocars without valves requires some manipulatory practice, as in certain situations a plug needs to be inserted into the trocar to avoid hypotension (Fig. 2.5). The advantage of trocars without valves is that an intraocular hypertension, for example, when injecting silicone oil, is easier to control and to avoid.

Fig. 2.4

DORC 23G trocars with valves. Intraocular fluid remains in the eye. The valves can be removed

Fig. 2.5

ALCON 25G trocars without valves. Intraocular fluid is flowing out of the trocars

Today there is a clear tendency toward trocars with valves. We therefore recommend to get acquainted working with valved trocars.

Surgical Pearls No. 1

23G and 25G: If you use 23G trocars, then you can work with 23G and 25G instruments. If you use 25G trocars, then you can only work with 25G instruments.

2.2.2 Trocar Forceps (Fig. 2.6a, b)

Indication: Manipulation of trocars. A very useful forceps for any kind of manipulations of the trocars. DORC 1276.2

Fig. 2.6

(a, b) A very Pars plana vitrectomy (PPV): trocar forceps useful forceps for manipulation of trocars (DORC, NL)

2.2.3 Scleral Marker (Fig. 2.7)

Easy-to-use instrument to mark the position of the sclerotomy on the sclera: 3.5 mm for pseudophakic eyes and 4.0 mm for phakic eyes. Most manufacturers incorporate a marker in the handle of the trocar blade, thereby avoiding the need for changing instruments at the beginning of the surgery (Fig. 2.7).

Fig. 2.7

A scleral marker (storz)

2.2.4 High-Speed Vitreous Cutter (Figs. 2.8 and 2.9)

High-speed vitreous cutters have a cut rate of 5000 cuts/min (Fig. 2.9). Most recent vitreous cutters from DORC (Holland) and Geuder (Germany) have a cut rate of 10,000–16,000 cuts/min. This new vitreous cutter has two open cutting ports and a second cutting blade (Figs. 2.9 and 2.10). It is named twin duty cycle (TDC) cutter . This new invention comprises two new features: (1) a permanent flow and (2) two cutting blades. The two cutting blades have the result that the cutter cuts two times during one movement, effectively doubling the cutting speed. The vitreous cutter has a cutting rate of 8000 cuts/min. But the actual cutting rate with two cutting blades is 8000 × 2 = 16,000 cuts/min, which reaches new dimensions. The second novelty is a continuous and even flow due to the two open cutting ports. This novel technology reduces vitreous traction, decreases the surgical time, and increases the safety of surgery.

Fig. 2.8

Illustration of a TDC cutter in action. One movement (forward and backward) results in two cuts. In old cutters one movement (forward and backward) results in one cut

Fig. 2.9

The novel twin duty cycle (TDC) cutter. The cutter has two open cutting ports and a second cutting blade. The novel two-blade cutters have therefore the same movement frequency like old cutters but a double cutting frequency: 5.000 × 2 = 10.000 cuts/min

Fig. 2.10

Fragmatome hand piece. Indication: removal of a dropped nucleus. Alcon Accurus fragmatome. In addition, you need the fragmatome accessory pack (REF 1021HP)

With the foot pedal, you can switch between the two functions of the vitreous cutter: firstly, you can cut and aspirate (vacuum), and secondly you can only aspirate. Indications for combined cutting and aspirating are the removal of the vitreous, blood clots or soft lens fragments, iridectomy, etc. Indications for aspirating are induction of PVD, aspiration of liquefied blood, subretinal fluid, etc. The vitreous cutter cannot cut solid tissue such as fibrosed lens capsule or hard lens fragments. A fibrosed lens capsule is segmented and removed with scissors and forceps. Hard lens fragments necessitate the use of a fragmatome.

2.2.5 Fragmatome (Fig. 2.10)

The fragmatome can be used to emulsify a dropped nucleus in the vitreous cavity. It is available in 20G and 23G but is used without a trocar cannula. A fragmatome is difficult to use. On the one hand, it is less powerful than a normal phaco hand piece. On the other hand, it can exert high levels of suction in the posterior segment. Aspiration of the vitreous or the retina into the hand piece must be avoided. Lens fragments tend to jump away from the needle tip. In such cases, one must aspirate the fragments in the needle tip before emulsification (see Appendix, Materials).

2.2.6 Light Fibers (Endoillumination)

There are two types ofendoillumination : handheld light pipes (light probes) and fixed endoillumination (chandeliers) .

Light pipes are available with different sized cones of light. For routine cases, one holds the light pipe with the non-dominant hand and the vitreous cutter with the dominant hand. A chandelier light is fixed in the sclera and illuminates the entire fundus. This enables bimanual surgery and allows the surgeon to use a second active instrument in addition to the vitreous cutter. Chandelier lights are available from many different suppliers. The 25-gauge chandelier light of Synergetics has the great advantage of a rigid cable and a broad baseplate, which sticks firmly in the sclera. A good alternative is the 25-gauge chandelier light of Alcon and the 23-gauge chandelier light of DORC which are easily inserted into a 25-gauge and 23-gauge trocar, respectively (for details, see materials). More difficult to insert is the 27-gauge twinlight from DORC. It consists of two light fibers, which are both inserted at the 12 o’clock position. For optimal illumination of a chandelier light, an external light source (photon, xenon) is required (Fig. 2.11).

Fig. 2.11

An external light source (Photon from Synergetics, USA)

The choice of light source depends on the difficulty of the case and the personal preference of the surgeon. While chandelier lights have their definite advantages of freeing up your non-dominant hand to use a second instrument and provide better illumination for video recording of the surgery, a handheld light probe still provides a more focused and brighter light for most situations, for example, membrane peeling and delamination. It also depends on your routine method of trimming the vitreous base. One of the authors (HH) uses traditional handheld endoillumination for the clear majority of routine cases (macular holes, retinal detachment, proliferative diabetic retinopathy) and performs trimming of the vitreous base using