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Discussion by Michael T. Trese, MD
Singh et al 䡠 VHL Disease Discussion by Michael T. Trese, MD1,2 Dr. Fujii and coworkers have presented their initial experience using what they refer to as a minimally invasive vitrectomy system. They have demonstrated that this sutureless 25-gauge system is capable of performing vitrectomy in an effective fashion for multiple indications for vitreous surgery, both for adult and pediatric indications. The authors have used the modifiers of “simplifying the technique,” “sutureless,” and “minimally invasive” to describe their technique, anticipating that this smaller wound may minimize surgical trauma and decrease the convalescence period and time in the operating room. They do point out the mechanics of increased resistance of a smaller gauge system necessitating higher suction and higher cutting rates. In addition, the authors point out the potential benefit of this small-gauge system in an anatomically smaller pediatric eye. This 25-gauge system, with its sutureless entry through the conjunctiva, in my opinion potentially offers many advantages for the future of vitreous surgery. Although the sutureless 25-gauge system may reduce the operative time by reducing the time necessary for entry into the eye and closure of wounds, it has the potential to increase the time spent within the vitreous cavity because of increased resistance. It may be that pharmacologic treatment of the vitreous to achieve liquefaction and/or manipulation of the vitreoretinal juncture may be useful with such a 25gauge system to reduce resistance and even decrease the intraocular operative time. This has been our experience comparing the 25-gauge Dutch Ophthalmic Research Center (DORC) cutter in enzymatically treated and nontreated vitreous. Although the operative time with this technique reduces the entry and exit time, the 1 Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, Michigan 2
Eye Research Institute, Oakland University, Rochester, Michigan Address correspondence to Michael T. Trese, MD, 632 Wm. Beaumont Medical Building, 3535 W. 13 Mile Road, Royal Oak, MI 48073.
period of intense concentrated intraocular vitreous surgery effort may be unchanged or increased without enzymatic manipulation of the vitreous. This small-gauge instrumentation may have many advantages in addition to reducing the time necessary for opening and closure of the wounds. Using this sutureless technique may allow some vitreous surgery procedures to be done in an office environment, which may prove to be an advantage to patients, physicians, and third-party payers, despite the added burden on the ophthalmologist of monitoring patients and anesthesia. For many years we have been very interested in small-gauge vitreous instrumentation and have conducted animal experiments looking at wound healing in this setting. In the 25-gauge wound studies we have done, even in a rabbit eye with a much thinner sclera than humans, the wound is imperceivable only a few days after a 25-gauge instrument wound. Notably, histologically, we did not see any unusual vitreous adhesions at the wound in these eyes with normal intraocular pressure. This suggests that suturing this wound is indeed unnecessary when using a small incision vitrectomy system.1 The concept, however, of “minimally invasive” vitreous surgery is somewhat misleading. The major risks of vitreous surgery of endophthalmitis and retinal detachment it would seem are still equally present with this surgical technique compared with 20gauge or 19-gauge vitreous surgery. So I think that the term “minimally invasive” is not appropriate for this small-gauge vitreous system. I would propose that a more appropriate term is “micro incision vitrectomy system.” The authors are to be congratulated for once again showing their ability to make significant contributions to the area of vitreous surgery instrumentation. Reference 1. Yousef T, Trese MT, Hartzer MK. Do we need to suture 25-gauge sclerotomies? Retina (submitted 2002).
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Eye Research Institute, Oakland University, Rochester, Michigan Address correspondence to Michael T. Trese, MD, 632 Wm. Beaumont Medical Building, 3535 W. 13 Mile Road, Royal Oak, MI 48073.
period of intense concentrated intraocular vitreous surgery effort may be unchanged or increased without enzymatic manipulation of the vitreous. This small-gauge instrumentation may have many advantages in addition to reducing the time necessary for opening and closure of the wounds. Using this sutureless technique may allow some vitreous surgery procedures to be done in an office environment, which may prove to be an advantage to patients, physicians, and third-party payers, despite the added burden on the ophthalmologist of monitoring patients and anesthesia. For many years we have been very interested in small-gauge vitreous instrumentation and have conducted animal experiments looking at wound healing in this setting. In the 25-gauge wound studies we have done, even in a rabbit eye with a much thinner sclera than humans, the wound is imperceivable only a few days after a 25-gauge instrument wound. Notably, histologically, we did not see any unusual vitreous adhesions at the wound in these eyes with normal intraocular pressure. This suggests that suturing this wound is indeed unnecessary when using a small incision vitrectomy system.1 The concept, however, of “minimally invasive” vitreous surgery is somewhat misleading. The major risks of vitreous surgery of endophthalmitis and retinal detachment it would seem are still equally present with this surgical technique compared with 20gauge or 19-gauge vitreous surgery. So I think that the term “minimally invasive” is not appropriate for this small-gauge vitreous system. I would propose that a more appropriate term is “micro incision vitrectomy system.” The authors are to be congratulated for once again showing their ability to make significant contributions to the area of vitreous surgery instrumentation. Reference 1. Yousef T, Trese MT, Hartzer MK. Do we need to suture 25-gauge sclerotomies? Retina (submitted 2002).
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