25+ 27G EVOLUTION IN BIMANUAL PRIMARY VITRECTOMY FOR RD

A.NIKOLAKOPOULOSPAPANIKOLAOY HOSPITAL

THESSALONIKI GREECEHELLAS

anikolako@yahoo.grANCONA 13-14 SEPTEMBER 2013

Three major factors pushingThree major factors pushing--up up the current widelythe current widely--spread use of MIVS spread use of MIVS

Refinements of surgical instruments Refinements of surgical instruments with engagement of surgical adjuvants with engagement of surgical adjuvants

Improvements in the Improvements in the WideWide--angle viewing systems angle viewing systems

Development of Development of EndoEndo--illumination systemsillumination systems

WideWide--angle viewing systemangle viewing system

Chandelier endoChandelier endo--illuminationillumination

BiBi--manual manipulationmanual manipulation

Perfluorocarbon liquid Perfluorocarbon liquid

Dye staining for membrane visualizationDye staining for membrane visualization

Gas or Silicone oilGas or Silicone oil

KEY INSTRUMENTS AND TECHNIQUES FOR CHALLENGING CASES

Courtesy of Dr. Steve CharlesCourtesy of Dr. Steve Charles

WIDE ANGLE NON CONTACT (EIBOS 2)VIEWING SYSTEM CHANDELIER LIGHTS SCLERAL DEPRESSURE EXELENT PROBE ABILITIES (CONSTELLATION 25+ 7500 CPM) (CONSTELLATION 27G 7500 CPM) EVA DORC 8000 cpm SYNERGETIC 27G OFFICE BASED

INSTRUMENTATION

Variation of wide angle field system for MIVS

EIBOS

light discussion

tissue enhancement brightness in lumen microscope beam splitter no laser filter distance chandelier direction plugging the light xenon 10 min warm up true color and blue lower wavelength 435 distance 4mm x3 at 8 mm chandelier single or double 25-27 30 with trocars or without placement

Variation of chandelier fibers

PHOTON IPHOTON ITM ,TM , PHOTON IIPHOTON IITMTM

Stellaris PC (Xenon & Mercury Vapor)Stellaris PC (Xenon & Mercury Vapor)

AccurusAccurusTMTM & Constellation& ConstellationHBI (Xenon)HBI (Xenon)

2525-- & 27& 27--ga chandelier probega chandelier probe

2323-- & 25& 25--ga microcannulaga microcannula--compatible chandelier probecompatible chandelier probe

2525-- & 23& 23--ga compatible ga compatible chandelier probechandelier probe

2525-- & 27& 27--gagaTwinTwin--light chandelier probelight chandelier probe

29/3029/30--ga dual chandelier fiber ga dual chandelier fiber

0.39 mm

Of these illuminators, because they only have two spectral output peaks (550 nm and 580 nm), illumination generated by a mercury vapor bulb is green-yellow (Figure 5), which produces a less dazzling reflection from the fundus and thus may be comfortable to the surgeon’s eyes. Because yellow and blue are complementary colors, green-yellowish illumination can provide clear contrast during peeling of the ILM stained with brilliant blue G dye.

specialization

. t Working Distance 4 mm Working Distance 8 mm

Alcon Accurus Halogen 20g light pipe High 3 13 m 02 s43 m 32 s

B&L Millennium Metal Halide 20g light pipe on Max 6 m 44 s 22 m 28 s

DORC Hexon Metal Halide 20g light pipe on Max 7 m 13 s 27 m 01 s

Synergetics Xenon 20g light pipe Max 9 m 14 s 30 m 50 s

Synergetics Xenon 25g Awh Chandelier on Max 4 h 17 m 39 s

working distance at max output

72 RETINA TODAY JANUARY/FEBRUARY 2013

COVER STORY

delier illumination (Figure 11; scan QR code for video).11,12 The quality and angle of view of the fundus through a surgical microscope with chandelier endoillumination is at least equal to or much better than that observed through the conventional binocular ophthalmoscope via the condensing lens. The theoretical concerns of the current procedure may include bacterial inoculation into the vitreous cavity during transconjunc-tival insertion of the chandelier fiber tip and vitreous incarceration to the sclerotomy after the fiber removal. In

my opinion, careful disinfection of the ocular surface by repeated irrigation with diluted povidone-iodine and the use of a cannula-compatible smaller gauge fiber would be preferable in this scenario.

SUMMARYThe utility and efficacy of chandelier endoillumination in

a variety of situations during vitreoretinal surgery has been described herein based on personal experiences and pref-erences. It is clear, however, that there are many different surgical situations in which chandelier endoillumination is beneficial for improving intraocular visibility and thereby achieving favorable surgical outcomes. Nevertheless, sur-geons must still bear in mind that the final goal of illumi-nation is to enhance the efficiency of surgery while main-taining safety. Similar to the introduction of xenon and mercury vapor bulbs in our field, new light-emitting diode light sources (Figure 12) have recently been developed with unique potential. The evolution of next-generation chan-delier illumination systems continues and looks promising for the future.

Yusuke Oshima, MD is an Associate Professor of Ophthalmology at the Osaka University Graduate School of Medicine in Suita, Japan, and an Honorary Director of the Vitreoretinal Division at the Tianjin Eye Hospital, Tianjin, China. He is a member of the Retina Today Editorial Board. Dr. Oshima is a consultant to Topcon Medical Laser Systems and Synergetics. He has received lecture fees and/or travel support from Alcon Laboratories, Bausch and Lomb, Carl Zeiss Meditec, DORC International, Novartis Pharmaceuitical Inc., and Synergetics, when he spoke at sponsored seminars, but he received no propri-etary interests or royalties from any companies in relation to any products mentioned in this article. Dr. Oshima may be reached at yusukeoshima@gmail.com.

1. Eckardt C. Twin lights: a new chandelier illumination for bimanual surgery. Retina. 2003;23:893-894.2. Oshima Y, Awh CC, Tano Y. Self-retaining 27-gauge transconjunctival chandelier endoillumination for panoramic viewing during vitreous surgery. Am J Ophthalmol. 2007;143:166-167.3. Eckardt C, Eckert T, Eckardt U. 27-gauge Twinlight chandelier illumination system for bimanual transconjunctival vitrectomy. Retina. 2008;28:518-519.4. Sakaguchi H, Oshima Y, Nishida K, Awh CC. A 29/30-gauge dual-chandelier illumination system for panoramic viewing during microincision vitrectomy surgery. Retina. 2011;31:231-1233.5. Chow DR. Tips on improving your use of endoillumination. Retinal Physician. 2011:8:43-46.6. Sakaguchi H, Oshima Y. Considering the illumination choices in vitreoretinal surgery: continual improvements allow for better, safer outcomes. Retinal Physician. 2012;3:20-25.7. Witmer MT, Chan P. Chandelier lighting during vitreoretinal surgery. Retina Today. 2012:7:35-37.8. Charles S. Illumination and phototoxicity issues in vitreoretinal surgery. Retina. 2008;28:1-4.9. Oshima Y, Shima C, Maeda N, Tano Y. Chandelier retroillumination-assisted torsional oscillation for cataract surgery in patients with severe corneal opacity. J Cataract Refract Surg. 2007:33;2018-2022.10. Jang SY, Choi KS, Lee SJ. Chandelier retroillumination-assisted cataract extraction in eyes with vitreous hemor -rhage. Arch Ophthalmol. 2010;128:911-4. 11. Venkatesh P, Garg S. Endoillumination-assisted scleral buckling: a new approach to retinal detachment repair. Retinal Physician. 2012;9:34-37.12. Aras C, Ucar D, Koytak A, Yetik H. Scleral buckling with a non-contact wide-angle viewing system. Ophthalmo-logica. 2012; 227:107-110.

Figure 11. A 27-year-old man underwent scleral buckling to treat primary rhegmatogenous retinal detachment. A 25-gauge Awh chandelier fiber (Synergetics) was settled in the pars plana region opposite the region with retinal tears (A). Cryoretinopexy was carried out under chandelier endo-illumination observed through a wide-angle viewing system (B). After suturing the scleral buckle (C), the position of scleral indentation with the buckle was again examined through the wide-angle viewing system under chandelier endoillumination (D).

Figure 12. A light-emitting diode light source (DORC) devel-oped for illumination during vitrectomy, which is a new plat-form of illuminator for safer endoillumination.

eyetube.net

eyetube.net/?v=retej

A

C

B

D

Tips of chandelier illumination settingTips of chandelier illumination setting

.Sakaguch H, Oshima Y, et al. A 29/30Sakaguch H, Oshima Y, et al. A 29/30--gaugegauge dualdual--chandelier illumination system for panoramic viewing chandelier illumination system for panoramic viewing during microincision vitrectomy surgery. during microincision vitrectomy surgery. RetinaRetina 2011,:31;12312011,:31;1231--3.3.

Sakaguchi H, Oshima Y. Considering the illumination choices in vSakaguchi H, Oshima Y. Considering the illumination choices in vitreoretinal surgery. itreoretinal surgery. Retinal Physicians Retinal Physicians 2012: March issue: 202012: March issue: 20--24.24.

Oshima Y. Chandelier Endoillumination in Vitreoretinal Surgery. Retina Today 2013: January;68-72

Stellaris PC (Bausch+Lomb) Stellaris PC (Bausch+Lomb) Constellation Vision System (Alcon)Constellation Vision System (Alcon)

The The direction of the illumination focusing on the posterior pole (A) or periphery (B) can be optimized easily by changing the curvature of the chandelier fiber outside the eyeball with this flexible type of chandelier fiber.

EACH SURGEON HAS HIS OWN COLOR VISION

FILTERS COBINED WITH DYE IN MACULA SURGERY

ENHANSMENTS IN TISSUE VISUALIZATION

EVOLUTION //

DAVID C CHOW

The 19.5-gauge probe originally delivered 10 000 pixels with a 125° field of view, and now with the high-resolution camera this has been improved to 17 000 pixels with a 140°field of view. The 23-gauge probe currently offers only 6000 pixels for a modest 90° field of view. Also with this smaller probe the 300 W xenon light source is needed to adequately illumi- nate structures. The 23-gauge probe to date works best for laser delivery and is of limited use for other application

AROYO

ENDOSCOPY TODAY

Ocriplasmin, like any medication,is not 100% guaranteed to work in all patients. We know from the clinical trials that patient selection is key to successful outcomes. As with any procedure, surgical or medical, it is critical to carefully weigh the risks and benefits and to disc cuss all options with the patient.

ALLEN. C. HO RETINA TODAY JAN 2013

OCRIPLASMINE

ocriplasmine in strongcortical vitreous attachments

BIMANUAL PRIMARY VITRECTOMY SET UP

ANOTHER SURGICAL HAND SCLERAL DIPRESSURE BY THE SURGEON DUAL SIMULTANEOUS INFUSION EXTRUSION LASER AND BLOOD EXTRUSION CRYO AND VITRECTOMY SIMULTANEOUS EXCHANGE OF PFCL AND 5700

SILICON OIL UNDER VISUAL CONTROL C O N T R O L B Y T H E S U R G E O N

WHY BIMANUAL

DETECTION OF TEARS SAFER SHAVING MANIPULATIONS VERY CLOSE TO THE RETINA MINIMAZING IATROGENIC TEARS

EXTENSION OF OUR ABILITIES

SUBRETINAL FLUID REMOVAL

READY

HIGH SPEED CONTROL SHAVING

AIR EXCHANGE

ALCON 27GCONSTELLATION

ALCON 27 G+ STIFER REINFORCED PROBE FLOW RATE SIMILAR TO OLD 25 LESS OBSCURING, DELICATE MANIPOULATION IN

SURFACE TABLE TOP MEMBRANES ,AS IN TRD LESS HYPOTONY FINALLY BECAUSE IT IS THERE AND GET READY FOR THE NEXT STEP - IN OFFICE BASED- VITRECTOMY SYNERGETIC??

IS THERE A NEED FOR 27G ?

2.8 FLOW RATE

4,2 FLOW RATE

RIHGT HAND DETECTION

OTHER HAND SHAVING

IC 22Bimanual small g surgery evolution towards better results - a

video course by experts IC 22Organiser(s): A. Nikolakopoulos GREECE | Room: E 16-

18 SATURDAYBimanual small g surgery evolution towards better results -

a video course by experts. P. Lanzetta ITALY S. Natarajan INDIA S. Rizzo ITALY C. Claes BELGIUM T. Nikolakopoulos GREECE C. Riemann USA S. Gotzaridis

GREECE M. Mura NETHERLANDS K. Suleyman TURKEY F. Boscia ITALY V. Ferrara ITALY C. Forlini ITALY K. Rezaei USA F. Balta ROMANIA Z. Kapran TURKEY F. Faisal JORDAN C. Awh USA