Vitreo-retinal Surgery

241 Pages·2009·12.273 MB·English

by  A. J. Augustin (auth.), Stanislao Rizzo MD, Fabio Patelli MD, David R. Chow MD (eds.)

Essentials in Ophthalmology Vitreo-retinal Surgery
S. Rizzo F. Patelli D. R. Chow
Editors
Essentials in Ophthalmology Glaucoma
G. K. Krieglstein R. N. Weinreb Cataract and Refractive Surgery
Series Editors
Uveitis and Immunological Disorders
Vitreo-retinal Surgery
Medical Retina
Oculoplastics and Orbit
Pediatric Ophthalmology,
Neuro-Ophthalmology, Genetics
Cornea and External Eye Disease
Vitreo-retinal Surgery
Editors Stanislao Rizzo

Fabio Patelli
David R. Chow
With 50 Figures, Mostly in Colour
and 12 Tables
Series Editors Volume Editors
Günter K. Krieglstein, MD Stanislao Rizzo, MD
Professor and Chairman Professor and Chairman of Ophthalmology
Department of Ophthalmology Eye Surgery Clinic
University of Cologne Santa Chiara Hospital
Kerpener Straße 62 Via Roma, 67
50924 Cologne 56100 Pisa
Germany Italy
Robert N. Weinreb, MD Fabio Patelli, MD
Professor and Director Milano Retina Center
Hamilton Glaucoma Center via Pietro Mascagni, 20
Department of Ophthalmology 20122 Milano
University of California at San Diego Italy
9500 Gilman Drive
La Jolla, CA 92093-0946 David R. Chow, MD
USA University of Toronto
23 Ivor Rd., North York
Ontario M4N 2H3
Canada
ISBN 978-3-540-69461-8 e-ISBN 978-3-540-68586-9
ISSN 1612-3212
Library of Congress Control Number: 2008929530
© 2009 Springer-Verlag Berlin Heidelberg
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other way, and storage in data banks. Duplication of this publication or parts thereof is
permitted only under the provisions of the G erman Copyright Law of September 9, 1965, in its current version,
and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution
under the German Copyright Law.
The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and
therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application
contained in this book. In every individual case the user must check such i nformation by consulting the relevant
literature.
Cover picture ‘Oculoplastics and Orbit’ modified from Katowitz, A., Pediatric Oculoplastic Surgery (Springer
New York 2002).
Cover Design: WMXDesign GmbH, Heidelberg, Germany
Printed on acid-free paper
9 8 7 6 5 4 3 2 1
springer.com
Foreword
The Essentials in Ophthalmology series represents readership acceptance of the first two series, each of
an unique updating publication on the progress in all eight volumes. This is a success that was made possible
subspecialties of ophthalmology. predominantly by the numerous opinion-leading
In a quarterly rhythm, eight issues are published cov- authors and the outstanding section editors, as well as
ering clinically relevant achievements in the whole field with the constructive support of the publisher. There
of ophthalmology. This timely transfer of advancements are many good reasons to continue andstill improve
for the best possible care of our eye patients has proven the dissemination of this didactic and clinically rel-
to be effective. The initial working hypothesis of provid- evant information.
ing new knowledge i mmediately following p ublication
in the peer-reviewed journal and not waiting for the G.K. Krieglstein
textbook appears to be highly workable. R.N. Weinreb
We are now entering the third cycle of the Essentials Series Editors
in Ophthalmology series, having been encouraged by September 2008
Preface
“All progress occurs because people dare to be different”. all going to become 23-gauge surgeons? Will 20-gauge
Harry Milner vitrectomy disappear? Can technologic i mprovements
make the 25-gauge experience easier? We have put
together this textbook to try and answer some of
Every so often, changes occur in the technology of
these questions, and to give you some help on when
our day-to-day lives that truly alter how we do things.
and how these new sutureless vitrectomy systems can
As retinal surgeons, the development of sutureless
be used. To aid us in this endeavour, we have recruited
vitrectomy systems is one of these revolutionary
the leading surgeons in our field to offer their insights
changes that have altered how most of us perform
into the sutureless techniques they perform. We think
surgery. Since Dr Eugene de Juan introduced us to
you will enjoy the practical approach that many of
a 25-gauge transconjunctival sutureless cannula sys-
the authors have taken in their chapters, and the “sur-
tem, there has been almost a dizzying pace of change
gical tips” that are offered that can be used in your
in our field, as instrumentation companies refine and
operating room right away.
improve the 25-gauge experience. Given some of the
Enjoy the textbook!
early l imitations of 25-gauge technologies, Dr Claus
Eckardt introduced us to an alternative, a 23-gauge
sutureless cannula system, which is becoming increas- Stanislao Rizzo
ingly popular. At the present time, there is consider- Fabio Patelli
able debate and confusion amongst our community David R. Chow
about the direction our field is going to take. Are we September 2008
Contents
Chapter 1 Chapter 3
Historical Overview of Microincision Surgery 25-Gauge, Sutureless, Trans-Conjunctival
Vitrectomy
A.J. Augustin
S. Charles
1.1 Introduction ................................................. 1
1.2 Pros and Cons of 25-Gauge 3.1 Introduction ................................................. 31
Vitrectomy Systems ................................... 3 3.2 Surgical Indications.................................... 31
1.3 2 3-Gauge Vitrectomy Systems: 3.3 Wound Construction ................................. 32
The Future Gold Standard? ..................... 5 3.4 Fluidics ............................................................ 33
References ..................................................... 7 3.5 Cutter Design Issues .................................. 33
3.6 Tool and Visualization
Tradeoffs ........................................................ 34
Chapter 2 3.7 Tool Flexion ................................................... 34
25-Gauge Instrumentation: Engineering 3.8 20/25 Vitrectomy ........................................ 34
Challenges and Tradeoffs 3.9 Visualization ................................................. 35
A.C. Barnes, C.M. DeBoer, P.R. Bhadri, 3.10 Wound Leak Issues ..................................... 35
O. Magalhaes Jr., R.M. Kerns, M.T. McCormick, 3.11 C annula Withdrawal and
L.P. Chong, M.S. Humayun Wound Closure ............................................ 36
References ..................................................... 36
2.1 Introduction ................................................. 9
2.2 Microcannula System ................................ 9
2.3 Entry ................................................................ 11 Chapter 4
2.4 I nfusion .......................................................... 13 Transconjunctival 23-Gauge Vitrectomy
2.5 Fluid Dynamics Sidebar ............................ 14 C. Eckardt
2.6 Vitreous Cutter ............................................. 16
2.6.1 Drive Mechanism ........................................ 17 4.1 Placement of the Microcannulas:
2.6.2 Flow Rate ....................................................... 19 Two-Step Technique .................................. 37
2.7 Traction .......................................................... 19 4.2 Placement of the Microcannulas:
2.8 Illumination .................................................. 20 One-Step Technique .................................. 38
2.8.1 Terminology ................................................. 21 4.3 Course of the Scleral Tunnel
2.8.2 System Approach ....................................... 21 Incision ........................................................... 38
2.8.3 Power Supply Module ............................... 22 4.4 Instrumentarium ........................................ 39
2.8.4 Illumination Source.................................... 22 4.5 C ombined Phacoemulsification/
2.8.5 Optical System ............................................. 23 Vitreoretinal Surgery ................................. 40
2.8.6 Optical Fiber ................................................. 24 4.6 Scleral Indentation ..................................... 40
2.8.7 System Loss .................................................. 25 4.7 Silicone Oil Injection and
2.8.8 System Compatibility ................................ 27 Removal ......................................................... 40
2.9 Instrument Rigidity .................................... 27 4.8 Removal of the Microcannulas .............. 41
2.10 Discussion ..................................................... 28 4.9 23-g Vitrectomy Compared to
References ..................................................... 29 Conventional 20-g Vitrectomy ............... 41
x Contents
4.9.1 A dvantages in Cases Requiring Chapter 8
Multiple Interventions .................................... 41 25-Gauge Vitreous Surgery: Getting Started
4.9.2 Drawbacks and Shortcomings
C.C. Awh
of 23-Gauge Vitrectomy ................................. 42
4.9.3 P ostoperative Hypotony, 8.1 Introduction ....................................................... 69
Endophthalmitis ............................................... 42 8.2 Case Selection .................................................... 70
4.10 2 3-Gauge Vitrectomy vs 8.3 Preoperative Preparation ............................... 70
25-Gauge Vitrectomy ...................................... 43 8.3.1 Anesthesia ........................................................... 70
4.10.1 Instrument Size ................................................. 43 8.3.2 Patient Position ................................................. 70
4.10.2 Sclerotomies ....................................................... 43 8.3.3 Surgical Prep ...................................................... 70
4.11 Conclusion .......................................................... 44 8.4 Intraoperative Considerations ..................... 71
References ........................................................... 44 8.4.1 Cannula Insertion ............................................. 71
8.4.2 Instrument Insertion, Manipulation,
and Removal....................................................... 71
Chapter 5 8.4.3 Instrument Manipulation .............................. 72
23-Gauge One-Step Instrumentation 8.4.4 Visualization ....................................................... 72
S. Rizzo, M. Palla 8.4.5 Illumination ........................................................ 72
8.4.6 Fluidic Considerations .................................... 73
5.1 Introduction ....................................................... 45 8.4.7 Membrane Peeling ........................................... 74
5.2 Trocar .................................................................... 45 8.4.8 Concluding the Case ....................................... 74
5.3 Vitrectome........................................................... 45 8.5 Postoperative Management ......................... 75
5.4 Endoilluminator and Endolaser ................... 47 8.5.1 Postoperative Antibiotics and
5.5 Summary ........................................................ 48 Dressing ............................................................... 75
8.5.2 Postoperative Examination ........................... 75
8.6 Conclusion .......................................................... 76
Chapter 6 References ........................................................... 76
Small Gauge Vitrectomy: Anesthesia, Incision
Technique and Cannula Removal Chapter 9
S. Rizzo, F. Genovesi-Ebert, F. Patelli 25-Gauge Macular Surgery: Principles
and Instrumentations
6.1 Introduction ....................................................... 49
Y. Oshima, Y. Tano
6.2 Anesthesia ........................................................... 50
6.3 Surgical Technique ........................................... 50 9.1 Introduction ....................................................... 77
6.3.1 2 5-Gauge Trocar Insertion 9.2 Principles of 25-Gauge Macular
Techniques .......................................................... 50 Surgery ................................................................. 77
6.3.2 23-g Trocars Insertion 9.2.1 P reoperative Examination,
Techniques .......................................................... 52 Considerations, and Informed
6.3.3 Insertion of the 25–23-Gauge Consent ................................................................ 77
Chandelier ........................................................... 54 9.2.2 Surgical Procedures for 25-Gauge
6.3.4 Complications of Trocar Insertion .............. 54 Macular Surgery ................................................ 78
6.3.7 Cannula Removal .............................................. 55 9.2.3 N onvitrectomizing Vitreous Surgery
References ........................................................... 55 for ERM Removal Using the
25-Gauge System ............................................. 80
9.2.4 Internal Limiting Membrane
Chapter 7 (ILM) Peeling ....................................................... 81
Comparison of 25-Gauge Trocar/Cannula 9.2.5 Submacular Surgery ........................................ 81
Wound Healing and Remodeling with 9.3 25-Gauge Instrumentation and
In Vivo Vitrector Flow Analysis Devices for Macular Surgery ......................... 82
P.J. Ferrone 9.3.1 Basic Instruments ............................................. 82
9.3.2 Special Instruments and Devices
References ........................................................... 66 for Macular Surgery ......................................... 82
Contents xi
9.4 Prevention and Management of Chapter 12
Complications Related to 25-Gauge Perfluorocarbon-Perfused 25-Gauge Vitrectomy
Macular Surgery ................................................ 86
G. Garcia-Aguirre, H. Quiroz-Mercado
References ...................................................... 86
12.1 Physical and Chemical Characteristics
of Perfluorocarbon Liquids ......................... 111
12.2 History ................................................................ 111
Chapter 10
12.3 Uses of Perfluorocarbon Liquids in
25-Gauge Sutureless Vitrectomy
Vitreoretinal Surgery ..................................... 111
for Diabetic Retinopathy
12.4 Ocular Toxicity of
T.S. Hassan Perfluorocarbon Liquids .............................. 112
12.5 Perfluorocarbon-Perfused
10.1 Introduction ....................................................... 89
Vitrectomy .......................................................... 112
10.2 25-Gauge Surgical Indications ..................... 90
12.6 Perfluorocarbon-Perfused 25-Gauge
10.3 Instrumentation .............................................. 90
Vitrectomy (PCP25GV): Technique ........... 113
10.4 2 5-Gauge Vitrectomy for 12.6.1 Preparation for Vitrectomy .......................... 113
Nonproliferative Diabetic 12.6.2 Core Vitrectomy............................................... 113
Retinopathy ...................................................... 90 12.6.3 Posterior Hyaloid Separation ..................... 114
10.4.1 Why Vitrectomy? ............................................. 91
12.6.4 Membrane Peeling and
10.4.2 Procedure .......................................................... 91 Dissection .......................................................... 114
10.4.3 Why Does Vitrectomy Work? ...................... 93 12.6.5 Additional Procedures .................................. 114
10.5 25-Gauge Vitrectomy for Proliferative 12.6.6 Fluid–Air Exchange ........................................ 114
Diabetic Retinopathy .................................... 94 12.6.7 Closing ................................................................. 115
10.5.1 Vitreous Hemorrhage .................................... 94
12.7 Advantages of Performing Perfluoro-
10.5.2 L oculated Premacular
carbon-Perfused Vitrectomy with
Vitreous Hemorrhage .................................... 94 25-Gauge Instruments .................................. 115
10.5.3 Ghost-Cell Glaucoma .................................... 95 12.8 Complications .................................................. 116
10.5.4 Tractional Retinal Detachment ................. 95 12.9 Conclusion ........................................................ 116
10.6 Complications .................................................. 99 References ......................................................... 116
10.7 Summary ........................................................... 99
References ......................................................... 100
Chapter 13
Chapter 11 Primary 25-Gauge Vitrectomy with
Small-Gauge Vitrectomy for Topical Anesthesia for Persistent
Retinal Detachment Vitreous Floaters
F. Patelli, P. Radice G. Garcia-Aguirre, V. Morales-Canton,
H. Quiroz-Mercado
11.1 Historical Perspective .................................... 105
11.2 U ncomplicated Primary 13.1 Introduction ..................................................... 119
Rhegmatogenous Retinal 13.2 History ................................................................ 119
Detachment ...................................................... 105 13.3 Surgical Trends ................................................ 119
11.2.1 S mall-Gauge Vitrectomy vs 13.4 Advantages of 25-Gauge
Scleral Buckle ................................................... 105 Vitrectomy ......................................................... 119
11.2.2 Surgical Technique ......................................... 106 13.5 Patient Selection ............................................. 120
11.3 C omplicated Rhegmatogenous 13.6 Technique .......................................................... 120
Retinal Detachment ....................................... 109 13.6.1 Variation with 2-Port
11.3.1 Small-Gauge vs 20-Gauge Vitrectomy ......................................................... 120
Vitrectomy ......................................................... 109 13.7 Complications .................................................. 121
11.4 Conclusion ........................................................ 109 13.8 Conclusion ........................................................ 121
References ......................................................... 110 References ......................................................... 121