Clinical outcomes of combined sutureless vitrectomy with triamcinolone stain to manage vitreous loss resulting from posterior capsule rupture during phacoemulsification

J CATARACT REFRACT SURG - VOL 32, DECEMBER 2006

Clinical outcomes of combined sutureless vitrectomy with triamcinolone stain to manage vitreous loss resulting from posterior capsule rupture during phacoemulsification Cheng-Jong Chang, MD, PhD, Shang-Yi Chiang, MD, Ching-Long Chen, MD, Teng-Yi Wang, MD

PURPOSE: To investigate the efficacy of sutureless pars plana vitrectomy (PPV) combined with intracameral triamcinolone stain in the management of vitreous loss associated with phacoemulsification. SETTING: Department of Ophthalmology, Tri-Service General Hospital, Taipei, Taiwan, Republic of China. METHODS: This retrospective review comprised the charts of 21 patients who had sutureless PPV combined with intracameral triamcinolone stain to manage vitreous loss resulting from posterior capsule rupture during phacoemulsification. The charts were analyzed for type of cataract, posterior segment pathology, methods of anesthesia, intraocular lens (IOL) placement, postoperative visual acuity, intraocular pressure, and complications. Additional outcome measurements were duration of the surgical procedures, period of postoperative corneal edema, and time to achieve stable vision. RESULTS: Excluding 2 eyes with preexisting conditions, 18 of 19 eyes (94.7%) had a final best corrected visual acuity (BCVA) of 20/40 or better and 42.1% (8/19) had a final BCVA of 20/20 or better. The mean duration of the surgery was 25.3 minutes (range 16 to 40 minutes). Corneal edema was noted in 12 eyes (57.1%) 3 days postoperatively and 3 eyes (14.3%) at 7 days. Eleven eyes (52.4%) had stable vision at 1 week, and 16 eyes (76.2%) had stable vision within 1 month postoperatively. Four eyes (19.0%) had postoperative complications that included a displaced IOL in 3 eyes (14.3%) and cystoid macular edema in 1 eye (4.8%). CONCLUSIONS: Self-sealing, sutureless PPV combined with intracameral triamcinolone stain was a safe, reliable adjunct to manage vitreous loss during phacoemulsification. The surgery led to rapid visual recovery. J Cataract Refract Surg 2006; 32:2054–2059 Q 2006 ASCRS and ESCRS

Vitreous loss is a common complication of cataract surgery, occurring in 1.8% to 10% of cases.1,2 Vitreous loss during cataract surgery increases the incidence of postoperative complications such as vitreocorneal touch, corneal decompensation, peaked pupil, cystoid macular edema (CME), glaucoma, retinal detachment, and endophthalmitis.3–5 To prevent these complications, the vitreous should be removed from the anterior chamber; however, this can be challenging because the vitreous gel is transparent under the operating microscope. Several strategies describe the management of vitreous loss using intracameral triamcinolone stain.6,7 Also reported are techniques to manage vitreous prolapse associated with posterior capsule rupture during phacoemulsification with 25-gauge pars plana vitrectomy (PPV) and a sutureless self-sealing incision in Q 2006 ASCRS and ESCRS Published by Elsevier Inc.

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a closed chamber.8–10 This retrospective study investigated the efficacy and safety of self-sealing, sutureless PPV combined with intracameral triamcinolone stain in consecutive cases with posterior capsule rupture and vitreous loss associated with phacoemulsification. PATIENTS AND METHODS The charts of 2685 consecutive patients who had phacoemulsification with intraocular lens (IOL) implantation between April 2003 and December 2005 were reviewed retrospectively. The study was approved by the Institutional Review Board at the Tri-Service General Hospital and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all participants. Eyes that received sutureless PPV combined with intracameral triamcinolone stain for the management of vitreous loss 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.07.023

SUTURELESS VITRECTOMY AND TRIAMCINOLONE TO MANAGE VITREOUS LOSS DURING PHACOEMULSIFICATION

resulting from posterior capsule rupture during epinucleus or lens cortex removal were included in the study. Patients who received standard 20-gauge PPV for posterior dislocation of nuclear fragments during phacoemulsification were excluded. The phacoemulsification, vitrectomy, and IOL implantation were performed by a single surgeon (C.J.C.). As soon as the posterior capsule rupture or vitreous loss was noticed, the surgery was stopped. The triamcinolone acetonide solution used in the study was made according to a previously described method.6,7 Briefly, the preservative-containing vehicle contained in the vial was exchanged for balanced salt solution (BSS). Captured triamcinolone particles were resuspended in 1 mL of BSS and injected into the anterior chamber through a 30-gauge cannula. Triamcinolone particles were trapped on and within the vitreous gel, making it clearly visible in the anterior chamber and corneal wound (Figure 1, A). Through the side port, an anterior chamber maintainer or infusion cannula was introduced. The first 25-gauge trocar microcannula (25-gauge vitrectomy pack, Alcon Laboratories, Inc., or 25-gauge transconjunctival vitrectomy system, Bausch & Lomb Surgical, Inc.) was introduced nasally 3.0 mm posterior to the limbus through the pars plana; intraocular pressure (IOP) was stabilized by anterior chamber infusion (Figure 1, B). The orifice of the first microcannula was connected to an infusion line to replace the anterior chamber maintainer; the second trocar microcannula was inserted in the temporal side (Figure 1, C). The plug of the second microcannula was removed, and a 25-gauge, high-speed (1500 cuts/minute) vitrectomy cutter (Bausch & Lomb Surgical, Inc.) was introduced temporally through the microcannula. The IOP was adjusted by the height of the infusion bottle through the infusion line. Partial core vitrectomy was performed with the Millennium microsurgical system (Bausch & Lomb Surgical, Inc.) to debulk the prolapsing vitreous under direct visualization of the triamcinolone stain. The corneal wound was cleared by sweeping the vitreous away from the wound with an iris spatula introduced through the side port (Figure 1, D). When required, the anteriorly prolapsed vitreous was removed through the posterior capsule tear. Residual cortical and epinucleus were removed simultaneously with the vitrectomy cutter (Figure 1, E). On completion of the vitrectomy, the goal was a concave anterior vitreous face. In cases with relatively small areas of posterior capsule rupture, a partial posterior continuous curvilinear capsulorhexis (CCC) was made and a foldable 1-piece acrylic posterior chamber IOL (SA60AT, Alcon Laboratories, Inc.) was implanted in the capsular bag (Figure 1, F and G) under the safeguard of the vitreous cutter posteriorly. In contrast, in cases with Accepted for publication July 14, 2006. From the Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China. Supported by grants from Tri-Service General Hospital (TSGH-C94-09 and DOD-94-5-02), National Defense Medical Center, Taipei, and from the National Science Council (NSC-942623-7-016-003 and NSC-95-2623-7-016-002-D), Taiwan, Republic of China. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Cheng-Jong Chang, MD, PhD, Tri-Service General Hospital, 325, Cheng-Gong Rd. Section 2, Taipei 114, Taiwan, China. E-mail: [email protected].

significant posterior capsule rupture, a foldable 3-piece acrylic posterior chamber IOL (MA60BA, Alcon Laboratories, Inc.) was implanted and dialed into the sulcus above the CCC opening. The ophthalmic viscosurgical device (OVD) (Healon GV [sodium hyaluronate 1.4%]) was retained in the anterior chamber and capsular bag to maintain anterior chamber depth during IOL implantation and was completely removed at the end of the procedure. A miotic agent was injected into the anterior chamber to constrict the pupil. The 25-gauge microcannulas were closed with plugs and removed from the pars plana without suturing. In all cases, the stroma around the corneal incision was hydrated to prevent wound leak (Figure 1, H). A prophylactic antibiotic (gentamicin 20 mg) and corticosteroid (dexamethasone sodium phosphate 4 mg) were given subconjunctivally at the conclusion of the procedures. The patients were analyzed for age, sex, type of cataract, posterior segment pathology, method of anesthesia used during surgery, IOL placement, step of surgery which during posterior capsule ruptured, preoperative and postoperative best corrected visual acuity (BCVA), preoperative and postoperative IOP, and postoperative complications. Additional outcome measures were duration of the surgical procedure, period of postoperative corneal edema, and time to achieve stable vision postoperatively. All patients had a minimum follow-up of 6 months. RESULTS

The retrospective noncomparative chart review identified the initial consecutive 21 eyes of 21 patients who had self-sealing, sutureless PPV combined with intracameral triamcinolone stain to manage posterior capsule rupture and vitreous loss during phacoemulsification from April 2003 to December 2005. Of the 21 patients, 12 were men (57.1%) and 9 were women (42.9%). The mean patient age at the time of surgery was 64.8 years (range 24 to 83 years). Ten surgeries (47.6%) were performed in the right eye and 11 (52.4%) in the left eye. Eighteen eyes (85.7%) had no vision-threatening coexisting intraocular pathology. Two eyes (9.5%) had age-related macular degeneration (ARMD), and 1 eye (4.8%) had insignificant nonproliferative diabetic retinopathy. There were 4 relatively young patients (19.0%) with high myopia and 1 with posterior polar cataract (Table 1). Peribulbar anesthesia with lidocaine 2% was used for cataract surgery in 5 eyes (23.8%), and topical anesthesia was used in 16 eyes (76.2%). In 9 eyes (42.9%) in which satisfactory anesthesia was not achieved, a sub-Tenon’s injection of lidocaine 2% was given at the sclerotomy site. Posterior capsule rupture was detected in 4 eyes (19.0%) during epinucleus removal and in 17 eyes (80.9%) during lens cortex removal (Table 2). Vitreous loss was observed in all 21 eyes with posterior capsule rupture using intracameral triamcinolone stain. A foldable 1-piece acrylic posterior chamber IOL was successfully placed in the capsular bag in 3 eyes (14.3%). Eighteen eyes (85.7%) had implantation of a foldable 3-piece acrylic posterior chamber IOL in the sulcus. The mean duration of the surgical procedure, including

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SUTURELESS VITRECTOMY AND TRIAMCINOLONE TO MANAGE VITREOUS LOSS DURING PHACOEMULSIFICATION

Figure 1. Sequential images of an eye with posterior capsule rupture and vitreous prolapse show the use of intracameral triamcinolone stain for visualizing the vitreous and assisting 25-gauge sutureless PPV. A: Triamcinolone is injected into the anterior chamber to visualize prolapsed vitreous. B: The first 25-gauge trocar microcannula is introduced nasally after IOP is stabilized by anterior chamber infusion through the side port. C: The second 25-gauge trocar microcannula is introduced with the first microcannula connected to an infusion line. D: Partial core vitrectomy is performed to debulk the prolapsing vitreous under direct visualization of triamcinolone stain. The corneal wound is cleared by sweeping the stained vitreous away from the wound with an iris spatula introduced through the side port. E: Residual cortical and epinucleus matter are simultaneously removed with the vitreous cutter. F: A one-piece foldable IOL is implanted in the capsular bag with an injector under the safeguard of a vitreous cutter posteriorly. G: The IOL is dialed into its proper position by the support of the vitreous cutter posteriorly; the IOL position is checked before the pupil is constricted. H: Postoperative picture of the eye after the OVD in the anterior chamber is removed and all microcannulas are removed from sclerotomies. Arrowheads represent sutureless corneal wounds for phacoemulsification. Arrows denote sutureless sclerotomies for vitrectomy.

vitrectomy and IOL implantation, was 25.3 minutes (range 16 to 40 minutes). The mean postoperative follow-up period was 13.5 months (range 6 to 31 months) (Table 1). Excluding the 2 eyes with preexisting conditions (ie, ARMD) that precluded good vision, 18 eyes (94.7%) had a final BCVA of 20/40 or better and 8 eyes (42.1%) had a final BCVA of 20/20 or better after phacoemulsification and sutureless PPV combined with intracameral triamcinolone stain. Eleven eyes (52.4%) achieved stable vision at 1 week and 16 eyes (76.2%), within 1 month. On the first postoperative day, minimal inflammation was found; none of the vitreous body remained in the anterior chamber in any eye. A few triamcinolone acetonide particles were found in 2 eyes; the IOP in these cases was

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within the normal range. The mean preoperative IOP was 16.7 mm Hg (range 12 to 20.7 mm Hg) and the mean IOP on the first postoperative day, 13.7 mm Hg (range 8.5 to 18.4 mm Hg). Transient postoperative low pressure (less than 10 mm Hg) occurred in 1 case; IOP returned to within normal limits without treatment in 3 days (Table 2). No eye had corneal decompensation, postoperative hypotony, glaucoma, or endophthalmitis. Corneal edema was noted in 12 eyes (57.1%) 3 days postoperatively and in 3 eyes (14.3%) at 7 days postoperatively. Postoperative complications occurred in 4 eyes (19.0%) and included displaced IOLs in 3 eyes (14.3%) and CME in 1 eye (4.8%) (Table 2). No displaced IOL had to be repositioned or replaced because none caused visual symptoms of the

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SUTURELESS VITRECTOMY AND TRIAMCINOLONE TO MANAGE VITREOUS LOSS DURING PHACOEMULSIFICATION

Table 1. Characteristics of eyes that had sutureless vitrectomy with intracameral triamcinolone stain.

Case

Age/Sex/Eye

1

54/M/LE

2

80/M/LE

3

79/M/LE

4 5

51/M/RE 46/M/RE

6

42/F/RE

7

78/M/LE

8

68/F/LE

9

70/F/RE

10

72/M/RE

11 12 13 14 15 16

44/M/RE 83/F/LE 75/M/RE 73/M/LE 72/M/LE 24/M/LE

17

75/F/RE

18 19

65/F/LE 63/F/LE

20 21

78/F/RE 68/F/RE

Cataract Type 3C PSC 1C NS 1C PSC 4C NS 2C PSC 3C NS 4C PSC 3C PSC 3C NS 4C PSC 1C NS 1C PSC 3C NS 3C PSC 1C NS 1C PSC 3C NS 2C PSC 2C NS 3C PSC 4C NS 3C NS 3C NS 3C NS 4C PSC 2C PSC 1C NS 3C NS 1C PSC 2C NS 4C NS 1C PSC 3C NS

BCVA

Stable Vision (Wk)

OP Time (Min)

Follow-up (Mo)

IOL

Postoperative Complications

Comment

Preop

Final

Corneal Edema (D)

20/200

20/25

3

1

40

31

3 piece

d

High myopia

20/400

20/100

3

!4

29

25

3 piece

d

ARMD

20/100

20/40

3

1

35

24

1 piece

Displaced IOL

d

20/200 20/100

20/25 20/20

d 3

O4 1

20 18

22 19

3 piece 3 piece

d d

High myopia d

20/400

20/25

7

!4

33

18

3 piece

d

High myopia

20/100

20/15

d

1

18

18

3 piece

d

d

20/100

20/20

7

O4

37

15

3 piece

d

d

20/80

20/30

3

1

31

14

3 piece

d

d

20/80

20/40

d

O4

25

13

3 piece

d

d

20/80 20/400 20/100 20/200 20/80 20/200

20/20 20/25 20/20 20/70 20/25 20/40

d 3 d 3 d 3

1 O4 1 O4 1 1

17 23 18 19 24 20

11 10 9 9 8 8

3 piece 3 piece 3 piece 3 piece 3 piece 1 piece

Displaced IOL d d CME Displaced IOL d

20/200

20/20

7

!4

32

7

3 piece

d

High myopia d NPDR d d Posterior polar cataract d

20/200 20/200

20/20 20/20

d d

!4 1

16 23

6 6

3 piece 1 piece

d d

d d

20/300 20/80

20/100 20/25

3 d

!4 1

18 35

6 6

3 piece 3 piece

d d

ARMD d

ARMD Z age-related macular degeneration; BCVA Z best corrected visual acuity; CME Z cystoid macular edema; corneal edema Z period of postoperative corneal edema; IOL Z intraocular lens; NPDR Z nonproliferative diabetic retinopathy; NS Z nuclear sclerosis; OP time Z surgical time for vitrectomy and IOL implantation; preop Z preoperative; PSC Z posterior subcapsular cataract; 1 piece Z foldable 1-piece acrylic posterior chamber IOL; Stable Vision Z time to achieve stable vision; 3 piece Z foldable 3-piece acrylic posterior chamber IOL

patients. All eyes except 3 had a final BCVA better 20/40. The 1 eye with CME was treated with topical steroidal antiinflammatory medication and had a visual acuity of 20/70; 2 eyes with ARMD had a BCVA of 20/100 (Table 1).

than nonfinal final

DISCUSSION

Vitreous visualization is useful in minimally invasive surgical techniques to clear the vitreous, avoiding

excessive surgical intervention during the management of posterior capsule rupture. Peyman et al.11 report the usefulness of triamcinolone acetonide as an aid in visualizing the vitreous during PPV. This technique was also applied to visualize the vitreous body in the anterior chamber after posterior capsule rupture.6,7 Chalam et al.8,9 and Shah et al.10 describe how self-sealing, sutureless PPV is used to manage vitreous loss during phacoemulsification under topical and peribulbar anesthesia. Our study combined these 2 new techniques in cases with vitreous loss associated with

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SUTURELESS VITRECTOMY AND TRIAMCINOLONE TO MANAGE VITREOUS LOSS DURING PHACOEMULSIFICATION

Table 2. Summary of eyes that had sutureless vitrectomy with intracameral triamcinolone stain (N Z 21).

Parameter Anesthesia Topical Peribulbar Sub-Tenon’s Step during surgery PCR detected Epinucleus removal Cortex removal Postoperative complication Transient low IOP Corneal edema (3 d) Corneal edema (7 d) IOL displacement Cystoid macular edema

Number

(%)

16 5 9

(76.2) (23.8) (42.9)

4 17

(19.0) (81.0)

1 12 3 3 1

(4.8) (57.1) (14.3) (14.3) (4.8)

AC Z anterior chamber; IOP Z intraocular pressure; PC IOL Z posterior chamber intraocular lens; PCR Z posterior capsule rupture

phacoemulsification and then investigated the efficacy and safety of the combined procedure retrospectively. In our study, the triamcinolone stain provided direct observation of the vitreous and assisted surgeons in identifying and completely removing vitreous in the anterior segment intraoperatively. However, visualizing the vitreous body using triamcinolone has a potential risk for postoperative steroid-related complications such as glaucoma and infection. In addition, the side effects of the antiseptic and emulsifying agents in the suspension must be considered.12–16 There was no IOP increase in our patients, which indicates intracameral triamcinolone acetonide might not induce an IOP increase when the triamcinolone acetonide granules and preservative are sufficiently removed. In our series, intracameral triamcinolone acetonide in the management of vitreous loss during phacoemulsification was not related to postoperative endophthalmitis during the follow-up period. The 25-gauge sutureless approach is a new, promising method that is less invasive than the conventional 20-gauge system for posterior segment surgery. The natural elasticity of the sclera adequately approximates the 25-gauge sclerotomy and does not require sutures for closure.17 The sutureless technique is fast and less painful and offers immediate visual rehabilitation compared with a 20-gauge wound created with the conventional vitrectomy system.18 However, the 25-gauge system has limitations and potential complications. The main potential complications, postoperative hypotony caused by wound dehiscence and endophthalmitis, did not occur in our study. Several steps should be emphasized: (1) We always moved the conjunctiva laterally before introducing the 25-gauge trocar microcannula. On removal of the microcannula, the intact conjunctiva

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overlapped the sclerotomy, preventing a continuous track for fluid leakage or influx. (2) Optimum IOP was maintained at the end of surgery. (3) Prophylactic antibiotics (gentamicin 2 mg) and corticosteroids (dexamethasone sodium phosphate 4 mg) were given subconjunctivally at the conclusion of the procedures. Inadequate removal of vitreous from the anterior chamber and corneal wound increases the likelihood of immediate and long-term complications. Continuous infusion and aspiration through the anterior vitrectomy cutter and corneal incision encourages vitreous prolapse into the corneal wound. In addition, it tends to hydrate the vitreous and exerts more traction on the peripheral vitreous, which increases the potential for postoperative retinal detachment.19 Self-sealing, sutureless PPV combined with intracameral triamcinolone stain offers the advantages being performed in a closed chamber, avoiding IOP fluctuations, and reducing the risk for hypotony or ocular hypertension. In addition, IOP can be adjusted by the height of the infusion bottle during insertion of trocar microcannulas, partial core vitrectomy, and IOL implantation. The high-speed cutter (1500 cuts/minute) exerts minimum vitreous traction during vitrectomy, improving the procedure’s safety and efficacy. The pars plana approach combined with intracameral triamcinolone stain improves visualization and results in more complete vitreous cleanup than the anterior approach. Subincisional areas that are hard to access through a clear corneal incision are easily reached using this technique. When PPV is performed in the vitreous cavity, the corneal endothelium is spared from additional surgical manipulation of the anterior approach. Under the safeguard of the vitreous cutter posteriorly, the foldable IOL can be securely implanted, preventing its dislocation into the vitreous cavity. Although direct visualization of the vitreous body in the anterior chamber is difficult with the surgical microscope, several techniques other than intracameral triamcinolone have been discussed. Kaji et al.20,21 developed a technique of visualizing the vitreous body using 11deoxycortisol, a precursor of cortisol devoid of steroid activities that does not contain preservative and emulsifying agents. A study comparing the efficacy, toxicity, and reduction in the postoperative incidence of residual vitreous body in a large number of cases with posterior capsule rupture and vitreous loss would be helpful. Limitations of this study include its retrospective nature, limited follow-up, and relatively small sample size. Delayed complications, such as corneal decompensation, retinal detachment, and CME, can occur after 6 months postoperatively. The complication rate in our study may be low because we excluded eyes that had retained nucleus in the vitreous cavity after the posterior capsule rupture.

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In summary, this initial study suggests that self-sealing, sutureless PPV combined with intracameral triamcinolone stain was a relatively effective technique that resulted in quick rehabilitation and good visual results in patients with posterior capsule rupture and vitreous loss during phacoemulsification. A more detailed study with a larger number of cases is essential to establish the improved safety of the procedure. REFERENCES 1. Yap EY, Heng W-J. Visual outcome and complications after posterior capsule rupture during phacoemulsification surgery. Int Ophthalmol 1999–2000; 23:57–60 2. Ng DT, Rowe NA, Francis IC, et al. Intraoperative complications of 1000 phacoemulsification procedures: a prospective study. J Cataract Refract Surg 1998; 24:1390–1395 3. Chitkara DK, Smerdon DL. Risk factors, complications, and results in extracapsular cataract extraction. J Cataract Refract Surg 1997; 23: 570–574 4. Drolsum L, Haaskjold E. Causes of decreased visual acuity after cataract extraction. J Cataract Refract Surg 1995; 21:59–63 5. Ionides A, Minassian D, Tuft S. Visual outcome following posterior capsule rupture during cataract surgery. Br J Ophthalmol 2001; 85:222– 224 6. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 7. Yamakiri K, Uchino E, Kimura K, Sakamoto T. Intracameral triamcinolone helps to visualize and remove the vitreous body in anterior chamber in cataract surgery. Am J Ophthalmol 2004; 138:650–652 8. Chalam KV, Shah VA. Successful management of cataract surgery associated vitreous loss with sutureless small-gauge pars plana vitrectomy. Am J Ophthalmol 2004; 138:79–84 9. Chalam KV, Gupta SK, Vinjamaram S, Shah VA. Small-gauge, sutureless pars plana vitrectomy to manage vitreous loss during phacoemulsification. J Cataract Refract Surg 2003; 29:1482–1486

10. Shah VA, Gupta SK, Chalam KV. Management of vitreous loss during cataract surgery under topical anesthesia with transconjunctival vitrectomy system. Eur J Ophthalmol 2003; 13:693–696 11. Peyman GA, Cheema R, Conway MD, Fang T. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000; 20:554–555 12. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 1986; 101:190–195 13. Wingate RJB, Beaumont PE. Intravitreal triamcinolone and elevated intraocular pressure. Aust NZ J Ophthalmol 1999; 27:431–432 14. Benz MS, Murray TG, Dubovy SR, et al. Endophthalmitis caused by Mycobacterium chelonae abscessus after intravitreal injection of triamcinolone. Arch Ophthalmol 2003; 121:271–273 15. Zhu MD, Cai FY. Development of experimental chronic intraocular hypertension in the rabbit. Aust NZ J Ophthalmol 1992; 20:225– 234 16. Quiroga R, Klintworth GK. The pathogenesis of corneal edema induced by Tween 80. Am J Pathol 1967; 51:977–999 17. Lakhanpal RR, Humayun MS, de Juan E Jr, et al. Outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. Ophthalmology 2005; 112:817–824 18. Chang C-J, Chang Y-H, Chiang S-Y, Lin L-T. Comparison of clear corneal phacoemulsification combined with 25-gauge transconjunctival sutureless vitrectomy and standard 20-gauge vitrectomy for patients with cataract and vitreoretinal diseases. J Cataract Refract Surg 2005; 31:1198–1207 19. Berger BB, Zweig KO, Peyman GA. Vitreous loss managed by anterior vitrectomy; long-term follow-up of 59 cases. Arch Ophthalmol 1980; 98:1245–1247 20. Kaji Y, Hiraoka T, Okamoto F, et al. Clinical application of 11-deoxycortisol in visualizing prolapsed vitreous body after posterior capsule rupture in cataract surgery. J Cataract Refract Surg 2005; 31:1133– 1138 21. Kaji Y, Hiraoka T, Okamoto F, et al. Visualizing the vitreous body in the anterior chamber using 11-deoxycortisol after posterior capsule rupture in an animal model. Ophthalmology 2004; 111:1334–1339

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