Clear Corneal Vitrectomy Combined with Pha
coemulsification and
Foldable Intraocular Lens Implantation.
Takeshi Iwase, Tsuyoshi Yoshita and Kazuhisa Sugiyama2
1) Toyama Prefectural Central Hospital, Toyama, Japan2) Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
None of the authors have a financial or proprietary interest in any product mentioned.
PurposeRecently, modification in vitrectomy instruments have led to a decreas
e in size of the instruments and consequently in smaller incisions. It ha
s been introduced a 25-gauge transconjunctival sutureless vitrectomy s
ystem (TSV25) and found it to be a safe surgical procedure in a variety
of vitreoretinal pathologies. However, sclerostomy is still necessary in
the TSV25 and this may induce complications associated with retinal d
isease. On the other hand, in cataract surgery alone, it is possible to red
uce postoperative inflammation with a clear corneal incision rather tha
n a corneoscleral incision. Herein, we have invented a vitrectomy in w
hich all wounds could be closed without suture in simultaneous catarac
t surgery and vitrectomy from clear corneal incision.
PatientsSurgery was carried out based on the approval of the institutional revie
w board and the ethical standard established by the Declaration of Hels
inki. After an explanation of the purpose of the study, informed consent was obtained from all patients. A total of consecutive seven patients who had cataract and epi-retinal membrane (ERM) underwent phacoemulsification, intra-ocular lens (IOL) implantation and vitrectomy. They were followed up over 3 months after surgery.
• History of intraocular surgery
• Uveitis
• Retinitis pigmentosa
• Pseudoexfoliation syndrome
• Retinal tear, retinal detachment
• Lattice degeneration
Excluded criteria
Methods• Performing combined cataract surgery with vitrectomy
( see surgical technique )• Visual acuity
• Intraocular pressure (IOP)
• Corneal endothelial cell were collected for each patient.
(Snellen visual acuity was converted to their logarithm of the minimum angle of resolution (Log MAR) units to create a linear scale of visual acuity.)
Surgical technique
• Retrobulbar anesthesia (2% Xylocaine).
• Corneal side ports (0.5 mm in width, at 2, 4, 10 o’clock ((and 8 o’clock in right eye)).
• CCC (5.0 to 5.5 mm diameter, from the 10 o’clock port).
• clear corneal tunnel of 3.0 mm in width.
• Hydrodissection.
• PEA(a phaco-chop hook was inserted from the 4 o’clock port ) (Fig. 1A).
• I/A.
• Posterior CCC (25-gauge ILM forceps through the 10 o’clock port ) (Fig. 1B).
• Infusion cannula (23-gauge) was inserted from the infero-temporal por
t (Fig. 1C).
• 30°contact lens (the brim was partially cut ) (Fig. 1D).
• 25-G vitrectomy(vitreous cutter and a light guide were inserted from t
he 2 or 10 o’clock ports) (Fig. 1E).
• Replacement to a contact lens for observation of the post pole.
• Peeling of ILM ( ILM forceps) (Fig. 1F).
• Confirmation of the periphery of the vitreoretina (Fig. 1G).
• SA60AT (Alcon) was implanted into the capsular bag (Fig. 1H).
• The viscoelastic substance was aspirated using a Simcoe needle.
• Hydration (all corneal incision wounds).
Results1. Two patients required sutures to close the 10 o’clock port .
2. There was no leakage of aqueous humor from the corneal wounds
and no fibrin formation.
3. The number of inflammatory cells in the anterior chamber seemed
to be similar to the one after cataract surgery .( Fig 2) .
4. The cornea showed neither edema nor wrinkles in the Descemet's
membrane
5. Corneal endothelial cell loss was 8.9 % at the 2 weeks after surger
y.
6. There was neither any residual pre-macular membrane nor retinal
detachment or hemorrhage .
7. The condition of the IOL fixed in the capsule was satisfactory .
8. A paired t test revealed a statistically significant improvement in vis
ual acuity at 1 week (P = 0.011) and 3 months (P = 0.002) postopera
tively.
9. There were no significant differences in IOP throughout the follow-u
p (paired t test).
DiscussionIn the present system, postoperative inflammation was less probably be
cause only corneal incision was performed without conjunctiva and scle
ra disturbance. Only small sutureless clear corneal incision even in vitre
ctomy is of great advantage to both patients and surgeons. For patients,
it causes less postoperative foreign-body sensation, allows a shorter rec
overy time, and absence of incision in the conjunctiva and sclera results
in better appearance of the operated eye after the surgery due to the abs
ence of conjunctival hemorrhage or congestion. For surgeons, it simplif
ies operative procedures, not required peritomy, infusion line fixation a
nd suturing the incisions. In the TSV25, high force is required for incisi
on, because of the needle-like design of the trocar and the stepped-up di
ameter at the transitional area from the trocar to the cannula. In contras
t, high force for incision is not needed
in the present system. Therefore, the set-up in the system is easier than
TSV25.
Sclerostomy is necessary and the wounds are closed by incarcerating th
e vitreous body into the scleral incision ports in the TSV25. Retinal tear
s may also develop due to traction force on the retina accompanying po
stoperative contraction of the vitreous fibers, which are incarcerated int
o the sclerostomy incision. The present system is more advantageous th
an TSV25 from the aspect of preventing postoperative complications as
sociated with retinal disease.
Conclusions
Clear corneal incision vitrectomy caused shorter operating time and les
s postoperative ocular irritation than combined surgery with 25-gauge tr
ansconjuntival vitrectomy. Therefore, this procedure would be a good o
ption for selected cased with cataract and vitreoretinal diseases.