retina minimally invasive vitrectomy surgery – the new era...minimally invasive vitrectomy surgery...

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www. dosonline.org l 41 Retina www. dosonline.org l 41 Minimally Invasive Vitrectomy Surgery – The New Era Retina Koushik Tripathy MD, Pulak Agarwal MBBS, Yog Raj Sharma MS, Rohan Chawla MD, Harsh Inder Singh MD, Ravi Bypareddy MD, Babulal Kumawat MD, Rajpal Vohra MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi to ophthalmic surgeries by ‘the father of pars plana vitreous hemorrhage 1 Commercially available sutureless vitrectomy systems History Traditionally vitreous had been thought to be ‘untouchable’ invade the vitreous in 1863 2 . David Kasner 3 in 1968 removed diseased vitreous using sponge and scissors in 2 cases of amyloidosis of vitreous through anterior route The disadvantages of the technique were need of corneal transplant and aphakia, poor intraocular pressure traction. Robert Machemer 4 vitreous cutter (diameter 1.5 mm) inserted through a 2.3 mm scleral incision 5 sharp edges, a stationary outer tube, an infusion system, and manual suction was applied by a syringe. Suction drew vitreous into the openings and the rotating sharp edge cut the vitreous. The rotation speed could be changed by a rheostat. However, a similar vitreous cutter with infusion 6 endoillumination in 1972 as a 2 port procedure 7 . Conor O’Malley and Ralph Heinz introduced 3 port pars sclerotomy 8 9 colleagues in 1999 10 instruments through conventional sclerotomies 11 12 was devised in 2005 by Claus Eckardt 13 . Yusuke Oshima 14 . Creating self-sealing wound 15 the transconjunctival wound has been performed both perpendicular or oblique 16,17 to sclera. Oblique scleral incision has the advantages of better wound closure, reduced risk of hypotony, reduced leakage 18 and better wound apposition 19 under dynamic intraocular pressure when compared to perpendicular incision. However, chances of subretinal or suprachoroidal cannula may increase with very oblique incisions 20 . Shelved sclerotomy can be constructed in a one step or two step technique. One step oblique incision is made Koushik Tripathy MD

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Page 1: Retina Minimally Invasive Vitrectomy Surgery – The New Era...Minimally Invasive Vitrectomy Surgery – The New Era Retina Koushik Tripathy MD, Pulak Agarwal MBBS, Yog Raj Sharma

www. dosonline.org l 41

Retina

www. dosonline.org l 41

Minimally Invasive Vitrectomy Surgery – The New Era

Retina������

Koushik Tripathy MD, Pulak Agarwal MBBS, Yog Raj Sharma MS, Rohan Chawla MD,Harsh Inder Singh MD, Ravi Bypareddy MD, Babulal Kumawat MD, Rajpal Vohra MD

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi

(����$�� ��!�����#��`((�}�����������!���� ��������� �to ophthalmic surgeries by ‘the father of pars plana

!�����#���:�����'����#����?��$�����#����������((��� � ��#� � � � /-�� <$���*� +\ -� ���� � ������� "� ��������vitreous hemorrhage1�� <���� ���� ��!����� ���� � !� �� ����((�������!��!��������������� �����A-��������'� �#������ !���!�� !�����#�� ���"���� `'���}� ��� ��� ����� � � �����!����� ���#�������������� "��������#��̀ ���������}���� ������� ��� � ������ "��� ��� "� #���� ���� /]J� `-��##}*�/8J� `-�8##}*� � �� / J� `-�A##}� ������� � �� �� ������Commercially available sutureless vitrectomy systems � ������;� ������� L<������� `<��� *�>���~���*���%��*���<}*� ��������L'���� ��#� `Q������ � �� [�#�*� :�������*�P�*���<}*�� ��<��������`��:;*������� �*�P������ ��}�

HistoryTraditionally vitreous had been thought to be ‘untouchable’ � �� ¦������� ���� �� � J������ ��� ���� �� ��� ��� ���� ��invade the vitreous in 18632. David Kasner3 in 1968 removed diseased vitreous using sponge and scissors in 2 cases of amyloidosis of vitreous through anterior route �����#�!� "������� ���� ���� ��`¦�$� ������������#�}��The disadvantages of the technique were need of corneal transplant and aphakia, poor intraocular pressure #�� � � ��� `"����� �����$��}*� � �� ��" ���� � !�������traction.

Robert Machemer4� � � +\ +� ���������� ¦�������� � ����� ������ � ����� `���;}��� ���;� ���� �� ������� "����*� �� "���$��� + J� $���� $�� �� !�����#�� ����#� ��#$���� "� ��� ��vitreous cutter (diameter 1.5 mm) inserted through a 2.3 mm scleral incision5�����;����������� "�� �����������sharp edges, a stationary outer tube, an infusion system, and manual suction was applied by a syringe. Suction drew vitreous into the openings and the rotating sharp edge cut

the vitreous. The rotation speed could be changed by a rheostat. However, a similar vitreous cutter with infusion � �� ��$����� � ���� ��� � ����� ��� ������� � � �$� � � ��$��������� � � �$� ���� ��������� ������� +\ +6�� (����� � ��'����#��� �� ��� ���������� �������$��� ����#� ��$��!����endoillumination in 1972 as a 2 port procedure7.

Conor O’Malley and Ralph Heinz introduced 3 port pars $�� ��!�����#����� "�/-J�!�����#�������� ��+�A##�sclerotomy8�� ���������� "*� $���� $�� �� �������#�� �����������������;�� � ;� � �+\\�9��<� ��� �@������#����������������� �������#�� ���� ��!����� ��� )���� <)� � ��colleagues in 199910�� ��� �� � Z� � �� ?���� "����#� ����!����� ��������� ����� ������� ������" �� ������/8J�instruments through conventional sclerotomies11��>����/8J��� ��� X� ��!��� ���������� !�����#�� `���}� ����#� ����� !� ������>�X���J��� ��������"����� �/--/12��/]J�����was devised in 2005 by Claus Eckardt13. Yusuke Oshima � ��������"��������������/ J������ �/--\14.

Creating self-sealing wound���������� "���� ������������������#��������� �����#���*� � ��!����$$� "� �� X� ��!��� � �� �������� ��� �*� � ��#����$�� ��� � ����� 15�� <���� �� X� ��!��� ���$����#� �the transconjunctival wound has been performed both perpendicular or oblique16,17 to sclera. Oblique scleral incision has the advantages of better wound closure, reduced risk of hypotony, reduced leakage18 and better wound apposition19 under dynamic intraocular pressure when compared to perpendicular incision. However, chances of subretinal or suprachoroidal cannula may increase with very oblique incisions20.

Shelved sclerotomy can be constructed in a one step or two step technique. One step oblique incision is made ���� ����$� ������ � �� �� ���� §Z ��� ���� <��" #� �

Koushik TripathyMD

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42 l DOS Times - Vol. 20, No. 5 November, 2014

`Z�<}�����#¨�������$��$� �����������$������������#���21. Oblique incisions parallel to limbus is preferred as it ���$������ �������� ������ ���� ��� �����#���� �����*� �������� ���� "����������� ���������� ���������#�"������ ����� ��� ���� ����$� � ����� ��� ����#�������$�� ����<�������$���� "� ��� �� X� ��!�� ��������*� � ������� ��� �������� �������� ����������@�����$������������#������]-¢*�� ��then the direction is perpendicular once trocar has partially � ����������������<�#���������`8¢}�� ������ "������������by perpendicular entry has also been used. The valved �� ���� �� "��#������A##�����##�����/]J*�/8J����/8J� `<��� *� >��� ~���*� ��%��*� ��<}�� ���� ������� ��!��mark of 3mm and 4mm at the end opposite to sharp blade to aid pars plana entry without the use of calipers.

Two step method as described by Eckardt involves stabilizing displaced conjunctiva with a pressure plate

instrument, while a shelved incision is created using a sharp angled stiletto blade. Then the cannula is inserted in the same wound with a blunt trocar. However it may be �������������������� �����$�� �������������� ���

The infusionThe infusion cannula has a threaded portion to lock it with the cannula to avoid loosening or accidental slippage of � ����� � �� ���� ���� "� ���"����� <��� � /]J� � ����� ��� �������A�##��� "*�� ��/8J��� �������8�##��� "�

The vitrectomy cutter����!�����#�������� �'����������� ��#$��!���� ���#����� �#������ ����� ���#����*� _������*� � �������� ��� ����*�less traction on vitreous, control of duty cycle, improved driving mechanism for cutters and decreased distance from cutter mouth to tip.

The outer diameters of vitrectomy probes have been made �#������� ���#������`������+}�����'����

���� _��� ��� �� � ���#$��������� _���� ����"�� �� ���� ���"�!�� ������(����������?�"� ����#���*���������������

Q = Δ P πr4/8 μLwhere:

�� ©�ª�!���#�����_������

�� «�(�ª�$��������"����� ���� "�������

�� [�ª��� "�����$�$�

�� ��ª��� �#���!�������

�� ��ª�������

�� ¬�ª�#���#�������� �� �(�

However, as vitreous does not behave like liquid, vacuum pressure, cut rate and duty cycle of the vitrector also ����#� �����_�������"�����������

According to Poiseuille�?�"� ����#����_������������"��/]J����#������ �/8J�����������������#����� �/]J�

Higher vacuums (pressure gradient along the cutter) � ��������_����?�"������������`8---�$#}�����������������$����� � ��� _��� `� � ���!�� #���}� $�������� ������turbulence, decreases movement of mobile retina, less traction during vitreous base shaving and the decreasing ������������"� ������ ������������������ �������� ����

The duty cycle (the percentage of time the cutter port is open relative to each cutting cycle) can be controlled in modern vitrectomy probes which are pneumatically driven and not electrically driven. The vitrectomy modes � �;� ������� ­�`<��� *�>���~���*���%��*���<}��� ����Core (cutter is open for maximum time ensuring greater _���� �������� ��}*�8-�8-*�� �����!�� `$����$� � �#�� ����������*� _��� ��� �������� ���� ����� "� �� !������� ����� ��create less pull).

���� ������ ��� <������®� $����� `<��� }� ���� ������ ���pneumatic probe design where spring controls the cutter �$� � �#� "� ���� #�%�#�#� /8--�$#�� (��$�����������!�®�̀ <��� }�����" ������!��������$�� "�#���� ��#�� ��has maximum 5000cpm cut rate, in which the air controls both cutter open and cutter close time enabling duty cycle control.

~���'����$��������������#�������������������������$�enabling dissection very near to retina (Figure 1). Increased !�����#�� ��� ����� � �� �#$��!��� _������� ��!�� #���� ��safer to operate closer to the retina.

IlluminationThough issues had been raised about reduced brightness of /8J�� �������#� �����������������#���������#�������� ���#$����� ��/-J����/]J*����"� ����������� � �#$��!���by xenon and metal halide light sources. Chandelier illumination is an innovative strategy for illumination during ���"�������$�������� ��"#� �� �� ��� ����!�������� � �/8J*�/ J�� ��/\J�`-�]]##}�`(��� ®*��� ��"����*���>���� *�'�*���<}�������� ���� X� ��!���� ���������������� "�� ��both hands of the surgeon are free for bimanual surgery. ������������� ���$�����%������������ ����������#� �� "���������#���� ������ ���������;�� ������������##����������!��������� ������� "��������� ��������������#������

25 G TSV��������� �/8J����#������� "�$����#����#������ �����

Table 1: Outer diameter of various vitrectomy systems

+ J 1.47mm

/-J 0.9mm

/]J 0.6mm

/8J 0.5mm

/ J 0.4mm

Retina: Minimally Invasive Vitrectomy Surgery – The New Era

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Retina

with insertion trocars. The microcannulae have an external ���������������� "��(����$��#������ �����`'���� ��#®����� /8®� ����#*� Q������ � �� [�#�*� :�������*� P�*���<}� ���� ]��� ##� �� "�� ���� � ��L����� ���#����� ���-�8 ##L-��/�##22��<�#������� � ����� ��� �������8##��� "������ � ��L��������#��������-�] ##L-�8��##����usually used through inferotemporal cannula. The trocar ��� �� � ��#�!���� (��"�� ���� ����� �� ������ ��� �� �����Cannulae with valves are also available which do not ����$��"� �����������������"����� ����#��'���� �/8J�instruments include, but are not limited to vitrectomy cutters, endoilluminator, scissors, diathermy probe, laser $����*�� ��"��$$� "������$�*�� �� ���[�#� � "�'�#��� ��`�['}� �����$�*� '����� (��� �����$�*� <��##������� (���� "�>����$�*� '����� >����$�*� Q���_���� ;� ���*� '�#��� ��(���*� '����!������� ��� `'�:}� �����*� !������� _����� X���� L�%����� ������ ������������ ���$�������$���� "�_�����

23G��� �������� ���������� ��"�� � �� ��"����� ���� /8J*� /]J����� ���� ��!���$���� ~��� /]J*� ��� ���� �� � ��� �������rotated without bending of the instrument for working � � !������� ����� � �� $���$������ ��� ��� <�¯��¯�� ����*����� ������ "��� !���� "� ����#�*� $���$������ ���!� "� ������ !������� ����� �� � ��� $�����#���� <���*� � ¯��������located pathology can be accessed without bending of the � ����#� �������#������ ����� ������ ����������#������������`��:;*������� �*�P������ ��}�������� "��������$����$���� ���� ���A�##*����� � ��L��������#�������-��8� ##L-� 8� ##�� ���� �%�� ��� �$� � "�� ��� ��� ��� ���three cannulas were funnel shaped for easy insertion of

��"��$�$��� �����������/]J�� ���#� ��� �������������not limited to vitrectomy cutters, endoilluminator, scissors, diathermy probe, laser probe, end gripping forceps, Internal [�#� � "� '�#��� �� `�['}� �����$�*� '����� (��� �����$�*�<��##������� (���� "� >����$�*� '����� >����$�*� Q���_����;� ���*�'�#��� ��(���*�'����!������� ���`'�:}������*�!�������_���� � X���� L�%����� ����� � �� ���� ������ �� �$�������$���� "�_�����/]J����� �����!� �"����������/-J�� ��/8J�

27G������� ����#�� � �� ������"���� ���������� / J�transconjunctival nonvitrectomizing vitreous surgery for �$���� ���#�#��� ����#�!��������������$���!�����#��nuclear sclerosis in 200723. In 2009, Y. Oshima in collaboration with DORC (Dutch Ophthalmic Research ;� ���� �� ��� ���Q�*������� �*�P������ ��}���!���$����� $����$�� $ ��#���� / J� ������ ;�#$����� ���� ���/8�"��"�� !�����#�� $��*� ��� / �"��"�� !�����#�� $���is larger and closer to the cutter tip to help dissection !���� ������ �� ��� ��� ���� ���� ������ ��� ��� / J� ����������@������������"����������� ���������/8J��������1000 or 1500 cpm. 28 eyes of 28 patients were operated epiretinal membrane proliferation, idiopathic macular ����*� �������� !������� ��#�����"�� ���� ����!��������membrane proliferation, and nonclearing vitreous opacity. P����������� �������$���$����!����� "�������������!������� "� ��������$�� < ��#��� �������� ���� �����!��� � � ����study eyes, including visual improvement by three lines or more in 70%. Because of the smaller gauge, diminished � ������#� ��� � � �� _��� ����� ���� ���������� ��� / J��Xenon or mercury vapor bulbs may improve illumination. ����#$��!����"��������/ J*����������� "��������/ �"��"��vitreous cutter was reduced from 32 mm to 25 mm. Oshima � ��������"������!������+���$*�/ J�� ����� ���� �@���� � ��� "� ��� #��$��� ����� ���� �� � ������� � �� ��@������!������� "��� ��� � � _���������� ����� ����� !�����#�� ����extensive removal of peripheral vitreous24��<�������$���� "������ X� ��!��� �������*� ���������� ��������\-¢������sclera, facing directly toward the vitreous cavity, parallel to �����#�����<!��������/ J�� ���#� ��� ��������"���$����!�����������*�� ����$�� ����� ��� �*�� ����$�������������"�� $�$�*� #���������$�� `���##����*� � ��"��$$� "*� $����forceps type), membrane spatula, endophotocoagulation $����� `��� � �$*�����$� �$}*� �������� ��������#*�#�����!���������������*�� ������$�$�� �������#��$�����

Indications of MIVS-;���� ��� ���� !������� ���"������ �� � ��� �� �� ���� '����including but not limited to vitreous hemorrhage, endophthalmitis, epiretinal membranes, macular holes, rhegmatogenous retinal detachments including complex � �� ���� $���������!�� !������� �$���� `(�:}*� ����� ���retinal detachments, recalcitrant diabetic macular edema, !����#������� ����� *� �!���L!������� ���$��*� ������ ��

Figure 1: Comparative photos of various vitrectomy cutters shows that cutter mouth has been made larger and nearer to

the tip with 25G.

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44 l DOS Times - Vol. 20, No. 5 November, 2014

���� ��#�!��L� X���� � � �� ���#������� ��#�����"��� ����intraocular foreign bodies can be removed with hybrid ��� �@��� ��� "� � �� /-J� $��� �� � ������� � �� ���magnet or foreign body forceps. Dropped nucleus can be ������ ����������"#� ��������#������ ��/-J����/]J�$���for ultrasonic fragmenter. In huge choroidal detachments ���/-J��� "��##�� ����� ��� ������ �������������� ����� �to avoid the cannula going subretinal or suprachoroidal. In pediatric population the small gauge vitrectomy systems �� ���������������� �$�������$��#������`:�(}*��������extraction, persistent fetal vasculature, and familial exudative vitreoretinopathy.

Advantages of sutureless vitrectomy~�� �� ������ ~�� �� ���#���� ���� /]J*� /8J*� � �� / J�vitrectomy systems are 0.6 mm, 0.5 mm, and 0.4 mm, respectively25����������������������<��� �$���������������`/-J}*� ��� "�� `/]J}*� ����� `/]J}*� � �� $��$��� `/ J}�� ����smaller sclerotomy leads to:

�� ����������$�������������#�������!������#������ "�

�� P�����������������#$������ �

�� [����� _�##���

�� [����$����$����!��$�� �

�� ����������$����$����!���� "����

�� >���������� "

�� ������������ X� ��!�������

�� :�$�������!���

�� :�������$����$����!�����"#���#*�

�� ������������� ����`>�"����/}

�� ����������������������#���

�� ���������� ������� ���#�� `�� �� X� ��!�*� ������� � ��others)

�� � ���#����������������!����������!���

�� �������������"������#��

�� � ��������$��� ����������

�� Q�������#����

�� ;�#�� ��� � ������ ��"#� � ���"������`(�����#��������� � ��� "�����#�� ���"���}� �� � ���undertaken.

�� [������#�"��������� "�����

�� Z���� � � $�������� ��� ��� ���"������ `��$�������� :�(� � �very small eyes)

Concerns'����������� ��� ����������������'���������##�������in current scenario. Higher cost may be a limiting factor in ��#�����$��[��������!�����#��$����������'������ �������

iatrogenic retinal break formation, retinal detachment, and cataract.

Intraoperative<������ ���#� �������� �������'��������������� ���of bending or breakage especially during vitreous base �������� � ��� ��#�!��� ��� ����� #�#��� ��� � � (�:�� ~���/8�J�����#� `<��� }� ����8-�\-¡� ���� ���� �#$��!�#� ����#�/8J*��������!��� �/8J������̀ / ##}�������� ������ ��������#$��!����� ������ ����� ��� ������ ����$�� ��"������inserted leading to globe collapse, choroidal detachment, suprachoroidal hemorrhage, vitreous hemorrhage and accidental trauma to retina with instrument tip. The infusion �� ���� #��� �!� � ����� �� ��$������������ �$���� � ���operatively resulting in choroidal detachment. Dissection � �� !���������� � ��� � ������ $�����"���� #������������������ �� _�%������� ��� � ���#� ��� ������ �� ���� � X���� �#��� ���� �� "��� �#�� ���� '����� ����� � ����$����!��complications include decompression retinopathy26. Though issues had been raised about less brightness of /8J� � ������#� ����� ��� � ��#$����� �� /-J� ��� /]J*�brightness has been improved by xenon and metal halide light sources. Concerns were also raised about reduced � ����� � _��*� �� � /-J*� ������ ���� ��� � $��$����� ��� ������ ��� ��� ��� #���� � _�������� ;���#�� ��� /8J� �����$��can hold less amount of tissue, vitrectomy itself takes �� "��������� �� ������������� ���� ����� ������ �� �/-J�are myths. Rare theoretical complications include thermal injury to sclera from Chandelier tube and inability to shave vitreous base properly in vitreoretinal surgery resulting in ���������������� �$����$����!����� ��������#� �

Postoperative?�$�� ������ ����� �� ������� ������� � �]�=¡�+�¡�� �/8J� !�����#�� ��� ��� ��� ���� �� �������� �� ��� ���������� ��� *������!� "����� ��������$����$������������ ���heal. In a study by Woo and colleagues27 risk factors for intraoperative sclerotomy leakage requiring suture $����#� � ����� /]J� !�����#�� ����� $����� !�����#�*�a young age at operation, and vitreous base dissection.

Figure 2: Post-operative clinical picture of 20G and 25J

Retina: Minimally Invasive Vitrectomy Surgery – The New Era

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www. dosonline.org l 45

Retina

Factors predisposing to hypotony include28 –

�� [� �������� �������$�� �� � �$������*�#���������� ��limited peripheral vitrectomy to avoid lens touch in such cases

�� ?���������$��!�����!�����#������������ "���� ����elasticity and regenerative capacity of scleral tissue, leading to wound leakage. In 2nd vitrectomy more thorough vitreous removal is done leading to less vitreous plugging of the scleral wound.

�� ���������������������

�� '��$�������"����#$� ���

�� Z���� ���� � � _���� $����${� � �������� �������� � ��� �of air or gas prevents leakage and hypotony. Most ���"�� ����!�����$������_���������%��� "��������#����gauge vitrectomy.

�� (��$� ����������� �

�� ����� "�������� "�'������� �������"����$���������prevent hypotony.

Classically endophthalmitis rate has been quoted as 0.1% ���� $����$����!�� � ��$����#���� � �� -�-]\¡� $���!�����#���~���/8J����� ��$����#���������������� ���$��������-�/]�-�=A¡��)� �#���� ��������"�����������+/� ����� ��"���� ���� ��� � ��$����#���� � � ��� /8¯J�`-�/]¡}������#$����� ��/-J�`-�-+=¡}� � ��� �����$���!��study. However, retrospective nature of study is not optimal to study incidence of such a rare complication, all ��������������� �_���*����� ���� ������� ��$����#����� �/-J��������� ����-�-+=¡������������#���±���+L]����������� ����������`-�-8�-�-8¡}29 and incisions were largely nonbeveled. Intravitreal triamcinolone was used in 38% of endophthalmitis cases, which may have caused a sterile � _�##��� � #�#���� "� � ��$����#���� ��� #��� ��!��predisposed to infectious endophthamlitis. Mention about predisposing factors like dacryocystitis, ocular surface ��������*����� ��#�����~�� �������� �������������_���rates, resulting in decreased washing effect by the infusion have been postulated as the cause of endophthalmitis in '�����:�������� ��$����#���������'������ ������������������ �� "�����������@������ �����!���������"��� ��_�����������_����"����%��� "���>����������%��� "���#$��!����������¯������ "� ���������������@������ ������$����� "����wound lips together.

����� $����$����!�� ��#$������ �� ��� '���� ���� ��� ���detachment, and retinal toxicity (macular infarct with gentamycin) due to seepage of subconjunctival gentamicin from sutureless scleral port.

Conclusion'���� ���� �$� ��� ��� �!� ���� ���� ��!� ���� !����������"����� ;���� ��� '���� ��� ����#� "� ��� �� ����� ����vitrectomy surgery worldwide.

References1. Vitrectomy pioneer inducted into Ophthalmology Hall of Fame

[Internet]. Available from: http://www.eyeworld.org/article.php?sid=1784&strict=&morphologic=&query=Vitrectomy%20pioneer%20inducted%20into%20Ophthalmology%20Hall%20of%20Fame

%��� ������`������"������{������X����������`�����������machine parameters- Optimizing performance. In: Principles and Practice of Vitreoretinal Surgery. JP Medical Ltd; 2014.

3. Trikha R, Beharry N, G. D. Small Gauge Pars Plana Vitrectomy [Internet]. In: Song Z, editor. Vitrectomy. InTech; 2012 [cited 2014 Dec 8]. Available from: http://www.intechopen.com/books/vitrectomy/small-gauge-pars-plana-vitrectomy

4. Machemer R, Buettner H, Norton EW, Parel JM. Vitrectomy: a pars plana approach. Trans - Am Acad Ophthalmol Otolaryngol Am Acad Ophthalmol Otolaryngol 1971;4:813–20.

5. Warrier SK, Jain R, Gilhotra JS, Newland HS. Sutureless vitrectomy. Indian J Ophthalmol 2008;6:453–8.

6. STEVE CHARLES, MD. The History of Vitrectomy: Innovation and Evolution [Internet]. Available from: http://retinatoday.com/pdfs/0908_05.pdf

7. Parel JM, Machemer R, Aumayr W. A new concept for vitreous surgery. 4. Improvements in instrumentation and illumination. Am J Ophthalmol 1974;1:6–12.

8. O’Malley C, Heintz RM. Vitrectomy with an alternative instrument system. Ann Ophthalmol 1975;4:585–8, 591–4.

9. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol 1996;10:1273–5.

�&��� ~|�]�!~������{{��\�� ���\�����{��� �{���������������������sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999;6:731–3.

����� �����������]�`_����� ��^���������������������������for vitreous surgery. Am J Ophthalmol 1990;2:218–20.

12. Fujii GY, De Juan E, Humayun MS, Pieramici DJ, Chang TS, Awh C, et al. A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology 2002;10:1807–1812; discussion 1813.

13. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina Phila Pa 2005;2:208–11.

14. Oshima Yusuke. 27-gauge Vitrectomy [Internet]. Available from: http://retinatoday.com/pdfs/0409_09.pdf

15. Khanduja S, Kakkar A, Majumdar S, Vohra R, Garg S. Small gauge vitrectomy: Recent update. Oman J Ophthalmol 2013;1:3–11.

16. Hsu J, Chen E, Gupta O, Fineman MS, Garg SJ, Regillo CD. Hypotony after 25-gauge vitrectomy using oblique versus direct cannula ���������������[������������^�����������%&&X?��'Q��=&��

17. Inoue M, Shinoda K, Shinoda H, Kawamura R, Suzuki K, Ishida S. Two-step oblique incision during 25-gauge vitrectomy reduces incidence of postoperative hypotony. Clin Experiment Ophthalmol 2007;8:693–6.

18. Gupta OP, Maguire JI, Eagle RC, Garg SJ, Gonye GE. The competency of pars plana vitrectomy incisions: a comparative histologic and spectrophotometric analysis. Am J Ophthalmol 2009;2:243–250.

19. Taban M, Sharma S, Ventura AACM, Kaiser PK. Evaluation of wound closure in oblique 23-gauge sutureless sclerotomies with visante optical coherence tomography. Am J Ophthalmol 2009;1:101–107.

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46 l DOS Times - Vol. 20, No. 5 November, 2014

20. Charles S. Chapter 101 – Principles and Techniques of Vitreoretinal Surgery. In: Retina. Elsevier Health Sciences; 2012.

21. López-Guajardo L, Pareja-Esteban J, Teus-Guezala MA. Oblique sclerotomy technique for prevention of incompetent wound closure in transconjunctival 25-gauge vitrectomy. Am J Ophthalmol 2006;6:1154–6.

22. O’ Reilly P, Beatty S. Transconjunctival sutureless vitrectomy: initial experience and surgical tips. Eye 2006;4:518–21.

23. Sakaguchi H, Oshima Y, Tano Y. 27-gauge transconjunctival nonvitrectomizing vitreous surgery for epiretinal membrane removal. Retina Phila Pa 2007;9:1302–4.

24. Oshima Y, Wakabayashi T, Sato T, Ohji M, Tano Y. A 27-gauge instrument system for transconjunctival sutureless microincision vitrectomy surgery. Ophthalmology 2010;1:93–102.

25. Needle gauge comparison chart [Internet]. Available from: http://en.wikipedia.org/wiki/Needle_gauge_comparison_chart

26. Rezende FA, Regis LT, Kickinger M, Alcântara S. Decompression retinopathy after 25-gauge transconjunctival sutureless vitrectomy: Report of 2 cases. Arch Ophthalmol 2007;5:699–700.

27. Woo SJ, Park KH, Hwang J-M, Kim JH, et al. Risk factors associated with sclerotomy leakage and postoperative hypotony after 23-gauge transconjunctival sutureless vitrectomy. Retina Phila Pa 2009;4:456–63.

28. Bamonte G, Mura M, Stevie Tan H. Hypotony after 25-gauge vitrectomy. Am J Ophthalmol 2011;1:156–60.

29. Martidis A, Chang TS. Sutureless 25-gauge vitrectomy: risky or rewarding? Ophthalmology 2007;12:2131–2.

Retina: Minimally Invasive Vitrectomy Surgery – The New Era

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