Ulrich Spandau Mitrofanis Pavlidis. 27-Gauge Vitrectomy. Minimal Sclerotomies for Maximal Results

Transcription

1 27-Gauge Vitrectomy

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3 Ulrich Spandau Mitrofanis Pavlidis 27-Gauge Vitrectomy Minimal Sclerotomies for Maximal Results

4 Ulrich Spandau Department of Ophthalmology Uppsala University Hospital Uppsala Sweden Mitrofanis Pavlidis Augencentrum Köln Cologne Germany Additional material to this book can be downloaded from ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer Cham Heidelberg New York Dordrecht London Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, 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 physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, 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. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (

5 Preface Vitreoretinal surgery is developing rapidly. 23G technique was until recently the golden standard and now many surgeons are converting to the 25G technique. And why not a take a step further to 27G? But why do we, the authors, operate in 27G? I (US) started with 20G pars plana vitrectomy. In 2008, I converted to 23G. I was especially enthusiastic about the trocars in combination with the valves because the eye was watertight and the ports easier to access. I converted then to 25G because I needed to operate a newborn with retinopathy of prematurity and I wanted to operate sutureless. I continued then with macular peeling and finally with detachment surgery. Macular peeling is more difficult with 25G because the forceps is softer. But detachment surgery with 25G is wonderful. The sclerotomies are tight and a gas tamponade lasts much longer than with 23G. But I still used sutures in highly myopic eyes. I converted therefore to 27G in long eyes (AXL >25 mm); the globe was now watertight and the tamponade lasted even longer than with 25G. I continued with pediatric eyes because these eyes have a soft sclera and therefore weaker sclerotomies. Macular peeling was very similar to 25G but detachment surgery was more difficult because the vitreous base was hard to access with the soft vitreous cutters. The beginnings of 27G were similar to the beginnings of 25G. Today the vitreous cutters and most instruments are much stiffer so that 27G feels more and more comfortable. Another main disadvantage of 27G was the slow speed. This obstacle has been overcome with the revolutionary double-cut vitrector making 27G as fast as 23G. Today I operate 40 % of all cases with 25G and 60 % with 27G. I will increase with 27G if all required instruments are available in 27G. I (MP) am using 27G for all cases except for heavy silicone oil extraction. In cooperation with DORC I developed the TDC cutter (Two Dimension Cutter) which is a double cutting, permanent aspiration vitrectome. The TDC cutter increases dramatically the fluid flow, which has been the major limitation of 27G. With the flow problems solved, rigidity of the very thin 27G instruments is almost the last limitation of 27G. New materials and instruments designs are in development and in my opinion 27G will replace 23G and 25G vitrectomy procedures in the next years. v

6 vi Preface The surgical techniques described in this book are not the only possible treatment for the described pathology. They are only recommendations, not guidelines or rules. In our quest for smaller sclerotomies and a less traumatic surgical procedure, the journey goes on. If you wish to visit our surgical units, you are more than welcome. One visit is more worth than ten conferences. We wish every reader, may he or she be a beginner or an advanced surgeon, to enjoy reading this book and watching the surgical videos. Included are a huge amount of commented surgical videos. Our endeavour is to inspire more people to master this amazing surgical technique. Uppsala, Sweden Köln, Germany April 2015 Ulrich Spandau Fanis Pavlidis

7 Acknowledgements I would like to thank my wife Katrin for her patience and moral support and my children Maximilian and Moritz for being less naughty than usual during my work on this book. Ulrich Spandau Department of Ophthalmology Uppsala University Hospital 75185, Uppsala, Sweden vii

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9 Contents Part I 27G 1 Introduction to 27G Does Size Matter? The Dilemma of the Law of Hagen Poiseuille Differences Between 23G, 25G and 27G Double-Cut Vitreous Cutter History of 27G History of Double-Cut Vitrector The New TDC Cutter Is Much Faster Than the Regular Cutter Part II Optimal Tools for 27G 2 Optimal Visualization, Optimal Instruments and Optimal Technique Optimal Visualization Operating Room Red Lights in the Operating Room Inflatable Pillow Location of the Patient, Surgeon, Vitrectomy Machine and Scrub Nurse Carboband Devices Light Source Binocular Indirect Ophthalmo Microscope (BIOM) Systems Instruments for Vitrectomy Vitrectomy Set Trocars Trocar Forceps Scleral Marker Scleral Depressor ix

10 x Contents G Standard Instruments Vitreous Cutter Endoillumination Peeling Instruments Miscellaneous Backflush Instrument (=Charles Flute Needle) Endodiathermy Probe Laser Probe Fragmatome Foreign Body Forceps Instruments for Gas Tamponade Instruments for Silicone Oil Tamponade Dyes Sutures Part III Optimal Techniques for 27G 3 Usage of 27G Instruments Insertion of Trocars Valve Removal and Replacement Removal of Trocar Cannulas Endoillumination Usage of a Light Fibre Insertion of Chandelier Light in Sclera or Trocar FAQ Usage of a Double-Cut Vitreous Cutter Usage of a Charles Flute Instrument Important Vitreoretinal Techniques with 27G Induction of Posterior Vitreous Detachment Trimming of Vitreous Base Complications Staining of Membranes Peeling of Membranes Endodiathermy Laser Treatment Intraoperative Tamponade Basics of Intraoperative Tamponade Air < = > PFCL Air Tamponade (Exchange of Water Against Air) BSS Tamponade (Exchange of Air Against BSS) PFCL Tamponade (Exchange of Fluid Against PFCL) Removal of PFCL Complications

11 Contents xi 6 Postoperative Tamponade Basics of Postoperative Tamponades Gases and Liquids Physiologic Characteristics of Gases and Liquids: Specific Gravity Surface Tension Pressure Expanding Gases Air Tamponade (Exchange of Water Against Air) Gas Tamponade Basics of a Gas Tamponade Physics of a Gas Tamponade (Exchange of Air Against Gas) Practical Approach for a Gas Tamponade Gas Tamponade (Exchange of Air Against Gas) Silicone Oil Tamponade Basics of a Silicone Oil Tamponade Physics of a Silicone Oil Tamponade (Exchange of Air Against Silicone Oil) Light Silicone Oil Tamponade Heavy Silicone Oil Tamponade Practical Approach for a Silicone Oil Tamponade Part IV Surgeries for 27G 7 Vitrectomy for Floaters Introduction Surgery Complications FAQ VMTS Introduction Instruments Surgery Complication Macular Peeling General Introduction Epiretinal Membranes Introduction Surgery Complications FAQ

12 xii Contents 9.3 Macular Holes Introduction Surgery Complications FAQ Membrane Peeling with Intraoperative OCT Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G General Introduction Special Instruments for Iris-Claw IOL Implantation Instruments for Iris-Fixated IOL Enclavation Spatula Caliper Serrated Jaw Forceps Endgripping Forceps Iris-Claw IOL Implantation Surgery Instruments Material The Surgery Step by Step Complications FAQ Endophthalmitis General Introduction Antibiosis Preparation of Antibiotic Therapy Surgery Step by Step Complications FAQ Reference Retinal Detachment General Introduction Pneumatic Retinopexy with BIOM General Introduction Practical Procedure The Surgery Complications FAQ Episcleral Buckling for Detachment Surgery with BIOM General Introduction Instruments Material The Surgery Complications FAQ

13 Contents xiii 13.4 Vitrectomy for Detachment Surgery General Introduction Surgery Complications FAQ References Diabetic Retinopathy Combined Phacoemulsification and Anti-VEGF Treatment Easy PDR The Surgery Step-by-Step Complications FAQ Difficult PDR General Introduction The Surgery Step-by-Step Complications FAQ Silicone Oil Tamponade Different Indications, Different Methods Primary Retinal Detachment PVR Detachment Diabetes Macular Hole Duration of Silicone Oil Tamponade Air Against Light and Heavy Silicone Oil Exchange Introduction Exchange of Air Against Silicone Oil with Chandelier Illumination (Under BIOM View) Exchange of Air Against Silicone Oil Without Chandelier Illumination (Without BIOM View) PFCL Against Light and Heavy Silicone Oil Exchange with DORC Infusion Line Introduction Surgery Silicone Oil Removal Light Silicone Oil (1000, 1300 and 5000 cst) Removal Heavy Silicone Oil (Densiron 68 ) Removal Active Removal of Heavy Silicone Oil (e.g. Densiron 68 ) FAQ Paediatric Vitrectomy General Introduction Physiology of a Neonate Eye

14 xiv Contents 17.3 Retinal Detachment Secondary to ROP Timing of Surgery Surgery Complications FAQ Vitrectomy of Myopic Eyes Part V Hybrid Procedures 19 Dropped Nucleus General Introduction Extraction of a Posteriorly Dislocated Nucleus with Fragmatome Introduction The Surgery Step by Step Extraction of a Posteriorly Dislocated Nucleus with PFCL Introduction The Surgery Step by Step Complications FAQ Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR) General Introduction The Surgery Step by Step Inferior Redetachment Complications FAQ Neovascular Glaucoma Treated Under View of a BIOM General Introduction The Surgery Step by Step Submacular Haemorrhage Secondary to CNV General Introduction Surgery of a Small Submacular Haemorrhage Medication The Surgery Step by Step Postoperative Therapy Follow-Ups Surgery of a Large Submacular Haemorrhage The Surgery Step by Step FAQ Surgery of a Massive Submacular Haemorrhage The Surgery Step by Step In Case of Residual Submacular Haemorrhage

15 Contents xv Complications FAQ Submacular Haemorrhage Secondary to Arterial Macroaneurysm General Introduction Suprachoroidal Haemorrhage General Introduction Instruments Tamponade The Surgery Step By Step Complications FAQ Part VI Ocular Trauma 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB); Delayed, Stepwise Surgery General Introduction Instruments Tamponade The Surgery Step By Step The Surgery Step By Step IOFB Extraction, Immediate Surgery Instruments Tamponade The Surgery Step By Step Complications FAQ Case Reports of Penetrating and Blunt Ocular Trauma General Introduction Surgical Management of a Corneal Perforation Surgical Management of a Traumatic Cataract Surgical Management of a Scleral Wound at Pars Plana Surgical Management of Aphakia and Distorted Pupil Surgical Management of a Traumatic Mydriasis with Suture Net Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis Implantation of a Foldable Iris Prosthesis (Human Optics ) Scleral Fixation of a Combo Iris IOL Prosthesis Implantation of an Iris Prosthesis in the Sulcus Implantation of an Iris Prosthesis in the Lens Capsule Non-foldable Iris IOL Prosthesis (Ophtec )

16 xvi Contents 26.8 Surgical Management of a Traumatic Mydriasis with Suture (Iridoplasty) Surgical Management of an Iridodialysis Surgical Management of a Cyclodialysis Surgical Management of a Traumatic Retinal Detachment Part VII Miscellaneous 27 Frequently Asked Questions (FAQ) Materials (in Alphabetical Order) Dyes Forceps Knives Scissors Tamponade Miscellaneous Company Addresses (in Alphabetical Order) Index

17 Abbreviations BIOM Binocular indirect ophthalmo microscope C 2 F 6 Perfluoroethane, gas for retinal tamponade CF Counting fingers cst Kinematic viscosity of a fluid (unit = centistoke) HM Hand movement ILM Internal limiting membrane IOFB Intraocular foreign body IOL Intraocular lens IOP Intraocular pressure LE Left eye LIO Laser indirect ophthalmoscopy MICVIT MicroIncisional Cataract Vitrectomy MIVS Micro-incision Vitrectomy Surgery OD Oculus dexter, right eye OS Oculus sinister, left eye OU Oculus uterque, both eyes PDR Proliferative diabetic retinopathy PDVR Proliferative diabetic vitreoretinopathy PFCL Perfluorocarbon liquid PPV Pars plana vitrectomy PRP Pan-retinal photocoagulation PVD Posterior vitreous detachment RE Right eye rpa r(t)pa recombinant (tissue) Plasminogen Activator SF 6 Sulphahexafluoride, gas for retinal tamponade TDC Two Dimensions Cutter (=double cut vitreous cutter) TRD Tractional retinal detachment xvii

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19 Video List Videos are accessible online at by searching via the ISBN Video 1.1 Flow regular cutter Video 1.2 Flow TDC cutter Video 1.3 TDC cutter without fluid Video 1.4 Left regular cutter Right TDC cutter 6000 cpm_450 mmhg Video 1.5 Comparison_23G regular cutter vs 25G TDC cutter Video 3.1 Insertion of a chandelier light (audio) Video 3.2 Regular cutter Video 3.3 TDC cutter Video 4.1 PVD with Atkinson cannula (no audio) Video G difficult PVD (audio) Video 4.3 Diabetic peeling Video 4.4 PFCL bubble and membrane peeling 27G retinal scraper (Atkinson cannula) Video 7.1 Vitreous floaters-27g_old cutter Video G-asteroid hyalosis_tdc cutter Video 7.3 Vitreous floaters Video G-Difficult PVD Video 8.2 VMTS with many complications_no audio Video G-peeling surgery Video G macular peeling Video 9.3 Macular hole 27G Video 9.4 Anterior dislocated IOL and macular hole with 27G Video 10.1 Intraoperative OCT Video 11.1 Anterior dislocated IOL and macular hole with 27G Video 11.2 Bimanual extraction of anterior dislocated IOL Video G posterior dislocated IOL Video 12.1 Candida endophthalmitis Video 12.2 Endophthalmitis Video 12.3 Endophthalmitis and subchoroidal haemorrhage Video 13.1 Pneumatic retinopexy with Biom Video 13.2 Episcleral buckling with BIOM 1 Video 13.3 Episcleral buckling with BIOM 2 xix

20 xx Video List Video G retinal detachment without PFCL Video 13.5 Retinal detachment high myopia with PFCL Video G retinal detachment Video G Retinal detachment Constellation Video G redetachment Video 14.1 Phaco and Avastin (no audio) Video G lens-sparing vitrectomy of a type I diabetic Video G lens-sparing vitrectomy PDR easy-difficult Video 14.4 Difficult PDR with 27G monomanual vitrectomy Video 14.5 Difficult PDR Constellation 27G Video G-CRVO Video 14.7 PVD induction (audio) Video 14.8 PVD no blood (audio) Video 14.9 PVD with blood (audio) Video Delamination of membranes with 25G blunt cannula (Atkinson) (no audio) Video Bimanual peeling with vacuum cleaner and forceps (audio) Video Bimanual peeling with knob spatula audio Video Diabetic peeling with scissors 1 (audio) Video Bimanual peeling with scissors 2 (no audio) Video Bimanual peeling with scissors_3_no audio Video Bimanual peeling with cutter (audio) Video Hemostasis Video Knob spatula Video PFCL laser audio Video Tamponade air (audio) Video Tamponade silicone oil (audio) Video G silicone oil injection Video G silicone oil removal Video 16.2 Densiron 68 removal with 25G Video 17.1 ROP_RE Video 17.2 ROP_LE Video 17.3 Neurofibromatosis 2 Video 17.4 Intraoperative OCT Video 17.5 Pediatric cataract with 27G Video 17.6 PHPV with 27G Video G IOL exchange high myopia Video 18.2 Retinal detachment high myopia Video G lens sparing vitrectomy of a type I diabetic Video 19.1 Extraction of dropped nucleus with fragmatome and sulcus IOL Video 19.2 Extraction of dropped nucleus with ICCE and retropupillar Verisyse IOL Video 19.3 ICCE and iris-claw IOL Video 20.1 PVR detachment Video 20.2 Peeling techniques for PVR detachment Video 20.3 PVR peeling

21 Video List xxi Video 20.4 PVR-detachment secondary to trauma Video 20.5 Traumatic detachment Video 21.1 Retinal cryopexy (no audio) Video 22.1 Submacular rtpa Video 22.2 Traumatic submacular hemorrhage Video 23.1 Submacular hemorrhage secondary to macroaneurysm Video 24.1 Endophthalmitis and subchoroidal hemorrhage Video 24.2 Open globe Video 24.3 Globe rupture Video 25.1 IOFB case 1 stepwise surgery Video 25.2 IOFB case 2 Video 25.3 IOFB case 3 Video 26.1a Lens injury after intravitreal injection Video 26.1b Traumatic cataract Video 26.2 Iridoplasty and iris-claw IOL Video 26.3 Combo IOL-iris prosthesis (long version) Video 26.4 Foldable iris and IOL prosthesis (very short version) Video 26.5 Extraction and reimplantation of iris prosthesis Video 26.6 Old traumatic mydriasis Video 26.7 Iridoplasty for traumatic mydriasis Video 26.8a Explosive trauma (no audio) Video 26.8b Explosive trauma (audio) Video 26.8c Cyclodialysis Video 26.9 Trauma with kick scooter Video 26.10a Intraocular nail part 1 Video 26.10b Intraocular nail part 2 Video Trauma with snow blower Video 27.1 PFCL bubble and membrane peeling 27G retinal scraper_atkinson cannula

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23 List of All Surgical Pearls 1. Insertion of a Synergetics chandelier light PVD PVD and dye Difficult PVD G Iatrogenic break Laser therapy BIOM and air Posterior capsular defect during anterior vitrectomy PFCL injection Gas tamponade Gas filling with 27G Infusion line and silicone oil Instrument trocars towards 12 o clock Trypan blue PVD Membrane and dye Peeling of ERM and ILM PVD Staining in air-filled eye ILM peeling and dot haemorrhages Peeling with chandelier light Backflush instrument Tamponade for macular hole Posterior dislocated IOL Difficult IOL extraction from posterior pole Enclavation of iris-claw IOL Do not enclavate too much iris tissue Pus and fibrin in the anterior chamber Pars plana infusion Treat the retinal tears and not the detachment Retinal tear under a muscle Corneal suture xxiii

24 xxiv List of All Surgical Pearls 34. Capsular tension ring Corneal lubrication PVD in RRD Triamcinolone and RRD Unseen breaks and Schlieren phenomenon PFCL Iatrogenic break Laser Laser cerclage Laser necrosis Trimming of vitreous base Active aspiration Removal of PFCL Air as tamponade Air test for detachment Gas vs silicone oil Bilateral PDR B-scan Blocked infusion Removal of anterior hyaloid How should epiretinal blood be removed? Small pupil Recurrent vitreous haemorrhage BSS damages the phakic lens Corneal lubrication Peeling and choroidal haemorrhage Intraoperative haemorrhage and adrenaline Postoperative vitreous haemorrhages Lens-sparing vitrectomy o clock iridectomy for light silicone oils o clock iridectomy for heavy silicone oils Methylcellulose in anterior chamber Silicone oil in the anterior chamber Infusion line and silicone oil PFCL against silicone oil exchange PFCL against silicone oil exchange PFCL against silicone oil exchange with 20G Clogged infusion line Removing Densiron Location of infusion cannula in paediatric vitrectomy Anti-VEGF dose for ROP Complicated cataract surgery Dropped nucleus Residual nuclear fragment One-piece IOL vs three-piece IOL

25 List of All Surgical Pearls xxv 79. Posterior synechiae Removal of PVR membranes Eckardt ILM forceps Air bubbles behind IOL Doughnut shape of the anterior retina Laser cerclage encircling band Laser cerclage Cyclocryopexy Anterior chamber maintainer mm trauma trocars Difficult removal of suprachoroidal blood Subepithelial location of trocars Chandelier light Hypotony with phthisis bulbi Cyclitic membranes Inflamed or vascularly active eye Seidel test Anterior chamber haemorrhage Scleral defect Scleral defect and silicone sponge Open globe injury Combo iris IOL prosthesis IOL iris prosthesis and Scharioth

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27 List of All Case Reports Case Report No. 1: VMTS Case Report No. 2: Neurofibromatosis Type Case Report No. 3: Endophthalmitis and Choroidal Haemorrhage Case Report No. 4: Ozurdex Endophthalmitis Case Report No. 5: A pseudo-endophthalmitis Case Report No. 6: ROP Stage Case Report No. 7: Neurofibromatosis Type Case Report No. 8: Traumatic Cataract Case Report No. 9: PHPV Case Report No. 10: Traumatic PVR Detachment Case Report No. 11: Large Submacular Haemorrhage Case Report No. 12: Massive Submacular Haemorrhage Case Report No. 13: Massive Submacular Haemorrhage Case Report No. 14: Traumatic Choroidal Haemorrhage Case Report No. 15: Retinal Macroaneurysm Case Report No. 16: Retinal Macroaneurysm Case Report No. 17: Corneal Perforation and Large Iris Defect Case Report No. 18: Corneal Perforation in a Child Case Report No. 19: Traumatic Cataract Case Report No. 20: Traumatic Cataract Case Report No. 21: Scleral Wound at Pars Plana Secondary to IOFB Case Report No. 22: Aphakia and Distorted Pupil Case Report No. 23: Suture Net Case Report No. 24: Traumatic Mydriasis and Aphakia Case Report No. 25: Traumatic Mydriasis and Aphakia Case Report No. 26: Iris Defect Case Report No. 27: Traumatic Mydriasis and Cataract Case Report No. 28: Traumatic Mydriasis Case Report No. 29: Traumatic Mydriasis and Sulcus Implantation Case Report No. 30: Dislocated Nucleus and Traumatic Mydriasis Case Report No. 31: Iridodialysis Case Report No. 32: Dislocated Nucleus, Traumatic Mydriasis and Cyclodialysis xxvii

28 xxviii Case Report No. 33: Case Report No. 34: Case Report No. 35: List of All Case Reports Globe Rupture, Traumatic Cataract and Incarcerated Retina with Total Detachment Corneal Perforation with IOFB, Traumatic Cataract and Retinal Perforation Corneal Perforation, Traumatic Mydriasis, Dislocated Nucleus and Retinal Detachment