- Email: [email protected]
Intraoperative breakage of a 25-gauge vitreous cutter
TABLE 1. The Surgical Procedures in Which the Modified Self-sealing Sclerotomies Were Used Procedure
No. of Cases
Vitrectomy ERM/ILM peeling Cataract extraction ⫹ IOL/PC Intraocular laser Fluid-air exchange Gas injection Silicone oil injection Implantation of anterior chamber IOL Cryotherapy Retinectomy Removal of IOL dislocated into vitreous Removal of anterior chamber IOL Seleral buckling Radial optic neurotomy
35 19 15 12 12 7 4 3 3 3 2 1 1 1
REFERENCES
ERM ⫽ epiretinal membrane; ILM ⫽ internal limiting membrane; IOL ⫽ intraocular lens; PC ⫽ posterior chamber.
vitrectomy probe, and their inlet and roof were dried and gently massaged with a cotton-tipped applicator. The surgical procedures are summarized in Table 1. A total of 67 sclerotomies were created for insertion of instruments, which all were standard, designed for 20G pars plana vitrectomy. There were no cases in which an instrument’s utilization was limited because of the shape of the sclerotomy. Two sclerotomies (2.9%) through which repeated surgery was performed needed suturing. No intraoperative complication related to the sclerotomies was recorded. Postoperative follow-up was 2.7 months (range, 1– 8 months; median, 3 months). A self-resolving conjunctival bleb, not associated with hypotony, was observed over one sclerotomy during the first postoperative week. Hypotony (⬍6 mm Hg) was recorded in three cases, which had repeated surgeries for PVR and 0 mm Hg intraocular pressure preoperatively. None showed signs indicative of active leakage. Two patients developed RRD following surgery. In both cases, a retinal break was identified distant to the sclerotomy site and with no apparent relation to it. The modification introduced here has several rationales. A crescent knife is designed to dissect along lamellae of tissue; therefore, when the tunnel is begun too superficially, its roof will remain thin all along its course, making it susceptible to stretching and sometimes tearing, with resulting loss of watertightness. An MVR blade advanced across scleral lamellae results in a roof progressively thicker and more resistant to stretching and tearing. In addition, with crescent knife– constructed tunnels, globe penetration is made with an MVR blade guided into the preconstructed tunnel, which is then rotated to be perpendicular to the scleral surface. The opening so created is almost never located at the end of the tunnel but somewhat VOL. 138, NO. 5
nearer the tunnel inlet, making instrument insertion fairly challenging. With our technique, the tunnel leads directly into the vitreous cavity, making insertion of instruments straightforward. We conclude that by our technique, sclerotomies are more easily and rapidly created, are more resistant to stretching and tearing, rarely need suturing, and allow easier insertion of instruments into the eye.
1. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol 1996;114:1273–1275. 2. Van Kuijk FJG, Uwaydat S, Goldey BF. Self-sealing sclerotomies in pars-plana vitrectomy. Retina 2001;21:547–550. 3. Rahman R, Rosen PH, Riddel C, Towler H. Self-sealing sclerotomies for sutureless pars plana vitrectomy. Ophthalmic Surg Lasers 2000;31:462– 466. 4. Kwok AK, Tham CC, Lam DS, Li M, Chen JC. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999;127:731–733. 5. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies [letter]. Arch Ophthalmol 1998;116:119.
Intraoperative Breakage of a 25-gauge Vitreous Cutter Makoto Inoue, MD, Kousuke Noda, MD, Susumu Ishida, MD, Norihiro Nagai, MD, Yutaka Imamura, MD, and Yoshihisa Oguchi, MD PURPOSE: To report breakage of a 25-gauge vitreous cutter during vitreous surgery. DESIGN: Interventional case report. METHODS: A 60-year-old woman was referred for management of an epiretinal membrane at the macula. Visual acuity was 20/100 in the affected left eye. Vitreous surgery using a 25-gauge vitrectomy system was carried out with a combination of conventional cataract surgery. RESULTS: The vitreous cutter was lodged within the sclerotomy cannula after peripheral vitrectomy and was pulled together with the cannula. The cannula was reinserted by trocar, but as the floating peeled epiretinal membrane was dissected with the vitreous cutter, the tip of the cutter was broken and was aspirated with the membrane. Stereoscopic microscopy and scanning electron microscopy demonstrated that the edge that had broken at the cutter port was smooth.
Accepted for publication May 14, 2004. From the Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan. Inquiries to Makoto Inoue, MD, Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo 160 – 8582, Japan; fax: (⫹81) 33359 – 8302; e-mail: [email protected]
BRIEF REPORTS
867
Although 25-gauge instruments remain useful, care should be taken against rare surgical complications related to their fragility. (Am J Ophthalmol 2004;138:867– 869. © 2004 by Elsevier Inc. All rights reserved.)
CONCLUSION:
N
EW INSTRUMENTS FOR A 25-GAUGE VITRECTOMY SYS-
tem first were described by De Juan and Hickingbotham1; the system later was altered to permit transconjunctival sutureless vitrectomy.2,3 The system, commercially available as the Millenium TVS25 (Bausch & Lomb, St. Louis, Missouri, USA), has been reported to be effective in reducing invasiveness of surgery. However, the instruments are fragile and may become bent or damaged. We experienced intraoperative breakage of a 25-gauge vitreous cutter manufactured by DORC, which may have been damaged within the sclerotomy cannula. A 60-year-old Japanese woman was referred in December 2003 by a local ophthalmologist for management of an epiretinal membrane in the left eye that had decreased visual acuity to 20/100. Funduscopic examination confirmed the presence of an epiretinal membrane at the macula. Vitreous surgery combined with a conventional cataract surgery, including phacoemulsification, aspiration, and intraocular lens implantation, was carried out in February 2004. The vitreous surgery was performed using a 25-gauge vitrectomy system (DORC International, The Netherlands) driven by a vitrectomy device (Accurus 800CS, Alcon, Fort Worth, Texas, USA). This 25-gauge system consisted of a 25-gauge cannula, trocar, pneumatic cutter (1267-NMD), endoilluminating light probe, and the instruments, including forceps and scissors. The cataract surgery was performed first, and then a 25-gauge cannula was inserted at the transconjunctival sclerotomy sites. Core vitrectomy and subsequent peripheral vitrectomy were performed through the area where the vitreous gel could be seen through a prism contact lens by tilting the eye. Upon attempting to remove the vitreous cutter from the eye after peripheral vitrectomy, the cutter was lodged firmly within the sclerotomy cannula. Although effort was made to separate the cutter from the cannula, the cutter had to be pulled from the sclerotomy site with the cannula (Figure 1). The cannula was reinserted by trocar, and the epiretinal membrane was peeled. As the floating membrane was dissected with the vitreous cutter, the cutter tip was broken and was aspirated with the membrane. No metal fragments were found within the eye or the cannula, and surgery was completed in the usual manner. Postoperatively vision improved to 20/40 after 1 month, and no other complications occurred. Stereoscopic microscopy and scanning electron microscopy revealed that the edge where the cutter had broken at the cutter port was smooth (Figure 2). Fragility is a disadvantage of a system using 25-gauge instruments. Initially the system was intended to decrease surgical invasiveness in patients not requiring peripheral
868
AMERICAN JOURNAL
FIGURE 1. Intraoperative photograph after the vitreous cutter became lodged at a polyamide connection within the cannula (arrow) and was removed with the cannula. The cutter was pulled from the sclerotomy site (arrowhead) together with the bent cannula.
FIGURE 2. (Left) Stereoscopic micrograph. The tip of vitreous cutter is absent from the edge of the cutting port. (Right) scanning electron micrograph. The broken tip of the cutter shows an even surface (360 m).
vitrectomy, but refinements in instrumentation have expanded surgical indications. In addition to intrinsic fragility, breakage of the vitreous cutter may have resulted from damage to the cannula during peripheral vitrectomy from being bent with the inserted vitreous cutter, especially at the connection of the polyamide tube with the plastic plug. Intraoperatively, the tip of the vitreous cutter became lodged at this interface. When a broken tip is found within the eye, this foreign body should be removed to avoid further complications. Despite continued usefulness of 25-gauge vitrectomy systems, fragility of instruments predisposing to damage from sclerotomy cannula should be kept in mind. REFERENCES
1. De Juan E Jr, Hickingbotham D. Refinements in microinstrumentation for vitreous surgery. Am J Ophthalmol 1990;109: 218 –220. OF
OPHTHALMOLOGY
NOVEMBER 2004
2. Fujii GY, De Juan E Jr, Humayun MS, et al. A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology 2002;109:1807–1812. 3. Fujii GY, De Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002;109:1814 –1820.
An Explanation of Transient Visual Loss Associated With Leaking Filtering Bleb Adriana Paula Grigorian, and MD, and George Spaeth, MD To report a presumed cause for the transient visual loss noted by a patient with a leaking bleb following trabeculectomy. DESIGN: Case report. METHODS: Description of an otherwise healthy woman who developed delayed-onset transient visual loss associated with a leaking filtering bleb. RESULTS: A 62-year-old woman who underwent trabeculectomy with mitomycin C in her right eye 5 years earlier (Feb 23, 1999) presented with a 3-month history of transient decreased vision. The apparent cause was a periodic gush of aqueous flowing across the surface of the cornea. CONCLUSIONS: One cause of bleb-associated transient visual loss can be aqueous leaking from the bleb on to the anterior surface of the cornea, disturbing vision as it flows past the visual axis. This is temporarily relieved by blinking. (Am J Ophthalmol 2004;138:869 – 870. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
T
RANSIENT VISUAL LOSS IN PATIENTS WITH FUNCTION-
ing filtration blebs has been reported previously.1– 4 We describe such a patient in whom transient visual loss was caused by a periodic leak from the conjunctival bleb. Because of continuing visual loss despite medicinal and laser treatment, a 62-year-old woman with advanced, average-pressure glaucoma had guarded filtration procedures performed in both eyes. Preoperative intraocular pressure was 15 mm Hg in both eyes; postoperatively, it was 9 mm Hg. Five years later she noted a visual disturbance in her right eye, specifically, a “veil” causing a blur that lasted several seconds, relieved by blinking. With every blink the veil disappeared, but it returned minutes or hours later. Visual acuity with correction was 20/60 right
Accepted for publication May 14, 2004. From Carol Davila-Central Clinical Emergency Military Hospital, Bucharest, Romania (A.P.), and William and Anna Goldberg Glaucoma Service, Wills Eye Hospital/Jefferson Medical College, Philadelphia, Pennsylvania (G.S.). Inquiries to George L. Spaeth, MD, Glaucoma Service, Wills Eye Hospital, 840 Walnut St, Philadelphia, PA 19107; fax: (215) 928-0166; e-mail: [email protected]
VOL. 138, NO. 5
FIGURE 1. Aqueous spreading over the corneal surface. (Top) Slit-lamp examination of the right eye with fluorescein staining shows the wave of fluid descending over the cornea a crescentic fashion. Wave of aqueous passing the visual axis. (Bottom) This photograph, taken 2 seconds after that in Figure 1 (top), shows the liquid wave passing the visual axis.
eye and 20/50 left. Intraocular pressure was 8 mm Hg in both eyes. The corneas were clear, and the anterior chamber was deep and quiet. An incipient cataract was noted in both eyes. There was a high bleb (two corneal thicknesses), avascular and transparent but not multicystic, at the 12-o’clock position. When the lid was lifted gently, a point of leakage on the bleb surface was noted. Occasionally, there would be a small gush of aqueous from the leak, following which a wave of aqueous descended down over the surface of the cornea in a crescentic fashion (Figure 1). As the wave front passed the visual axis the patient commented that her vision became blurred. After the wave front passed, vision returned to normal. After around 30 seconds, perhaps related to the discomfort of the prolonged folding of the lid, another gush of aqueous out
BRIEF REPORTS
869
No. of Cases
Vitrectomy ERM/ILM peeling Cataract extraction ⫹ IOL/PC Intraocular laser Fluid-air exchange Gas injection Silicone oil injection Implantation of anterior chamber IOL Cryotherapy Retinectomy Removal of IOL dislocated into vitreous Removal of anterior chamber IOL Seleral buckling Radial optic neurotomy
35 19 15 12 12 7 4 3 3 3 2 1 1 1
REFERENCES
ERM ⫽ epiretinal membrane; ILM ⫽ internal limiting membrane; IOL ⫽ intraocular lens; PC ⫽ posterior chamber.
vitrectomy probe, and their inlet and roof were dried and gently massaged with a cotton-tipped applicator. The surgical procedures are summarized in Table 1. A total of 67 sclerotomies were created for insertion of instruments, which all were standard, designed for 20G pars plana vitrectomy. There were no cases in which an instrument’s utilization was limited because of the shape of the sclerotomy. Two sclerotomies (2.9%) through which repeated surgery was performed needed suturing. No intraoperative complication related to the sclerotomies was recorded. Postoperative follow-up was 2.7 months (range, 1– 8 months; median, 3 months). A self-resolving conjunctival bleb, not associated with hypotony, was observed over one sclerotomy during the first postoperative week. Hypotony (⬍6 mm Hg) was recorded in three cases, which had repeated surgeries for PVR and 0 mm Hg intraocular pressure preoperatively. None showed signs indicative of active leakage. Two patients developed RRD following surgery. In both cases, a retinal break was identified distant to the sclerotomy site and with no apparent relation to it. The modification introduced here has several rationales. A crescent knife is designed to dissect along lamellae of tissue; therefore, when the tunnel is begun too superficially, its roof will remain thin all along its course, making it susceptible to stretching and sometimes tearing, with resulting loss of watertightness. An MVR blade advanced across scleral lamellae results in a roof progressively thicker and more resistant to stretching and tearing. In addition, with crescent knife– constructed tunnels, globe penetration is made with an MVR blade guided into the preconstructed tunnel, which is then rotated to be perpendicular to the scleral surface. The opening so created is almost never located at the end of the tunnel but somewhat VOL. 138, NO. 5
nearer the tunnel inlet, making instrument insertion fairly challenging. With our technique, the tunnel leads directly into the vitreous cavity, making insertion of instruments straightforward. We conclude that by our technique, sclerotomies are more easily and rapidly created, are more resistant to stretching and tearing, rarely need suturing, and allow easier insertion of instruments into the eye.
1. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol 1996;114:1273–1275. 2. Van Kuijk FJG, Uwaydat S, Goldey BF. Self-sealing sclerotomies in pars-plana vitrectomy. Retina 2001;21:547–550. 3. Rahman R, Rosen PH, Riddel C, Towler H. Self-sealing sclerotomies for sutureless pars plana vitrectomy. Ophthalmic Surg Lasers 2000;31:462– 466. 4. Kwok AK, Tham CC, Lam DS, Li M, Chen JC. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999;127:731–733. 5. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies [letter]. Arch Ophthalmol 1998;116:119.
Intraoperative Breakage of a 25-gauge Vitreous Cutter Makoto Inoue, MD, Kousuke Noda, MD, Susumu Ishida, MD, Norihiro Nagai, MD, Yutaka Imamura, MD, and Yoshihisa Oguchi, MD PURPOSE: To report breakage of a 25-gauge vitreous cutter during vitreous surgery. DESIGN: Interventional case report. METHODS: A 60-year-old woman was referred for management of an epiretinal membrane at the macula. Visual acuity was 20/100 in the affected left eye. Vitreous surgery using a 25-gauge vitrectomy system was carried out with a combination of conventional cataract surgery. RESULTS: The vitreous cutter was lodged within the sclerotomy cannula after peripheral vitrectomy and was pulled together with the cannula. The cannula was reinserted by trocar, but as the floating peeled epiretinal membrane was dissected with the vitreous cutter, the tip of the cutter was broken and was aspirated with the membrane. Stereoscopic microscopy and scanning electron microscopy demonstrated that the edge that had broken at the cutter port was smooth.
Accepted for publication May 14, 2004. From the Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan. Inquiries to Makoto Inoue, MD, Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo 160 – 8582, Japan; fax: (⫹81) 33359 – 8302; e-mail: [email protected]
BRIEF REPORTS
867
Although 25-gauge instruments remain useful, care should be taken against rare surgical complications related to their fragility. (Am J Ophthalmol 2004;138:867– 869. © 2004 by Elsevier Inc. All rights reserved.)
CONCLUSION:
N
EW INSTRUMENTS FOR A 25-GAUGE VITRECTOMY SYS-
tem first were described by De Juan and Hickingbotham1; the system later was altered to permit transconjunctival sutureless vitrectomy.2,3 The system, commercially available as the Millenium TVS25 (Bausch & Lomb, St. Louis, Missouri, USA), has been reported to be effective in reducing invasiveness of surgery. However, the instruments are fragile and may become bent or damaged. We experienced intraoperative breakage of a 25-gauge vitreous cutter manufactured by DORC, which may have been damaged within the sclerotomy cannula. A 60-year-old Japanese woman was referred in December 2003 by a local ophthalmologist for management of an epiretinal membrane in the left eye that had decreased visual acuity to 20/100. Funduscopic examination confirmed the presence of an epiretinal membrane at the macula. Vitreous surgery combined with a conventional cataract surgery, including phacoemulsification, aspiration, and intraocular lens implantation, was carried out in February 2004. The vitreous surgery was performed using a 25-gauge vitrectomy system (DORC International, The Netherlands) driven by a vitrectomy device (Accurus 800CS, Alcon, Fort Worth, Texas, USA). This 25-gauge system consisted of a 25-gauge cannula, trocar, pneumatic cutter (1267-NMD), endoilluminating light probe, and the instruments, including forceps and scissors. The cataract surgery was performed first, and then a 25-gauge cannula was inserted at the transconjunctival sclerotomy sites. Core vitrectomy and subsequent peripheral vitrectomy were performed through the area where the vitreous gel could be seen through a prism contact lens by tilting the eye. Upon attempting to remove the vitreous cutter from the eye after peripheral vitrectomy, the cutter was lodged firmly within the sclerotomy cannula. Although effort was made to separate the cutter from the cannula, the cutter had to be pulled from the sclerotomy site with the cannula (Figure 1). The cannula was reinserted by trocar, and the epiretinal membrane was peeled. As the floating membrane was dissected with the vitreous cutter, the cutter tip was broken and was aspirated with the membrane. No metal fragments were found within the eye or the cannula, and surgery was completed in the usual manner. Postoperatively vision improved to 20/40 after 1 month, and no other complications occurred. Stereoscopic microscopy and scanning electron microscopy revealed that the edge where the cutter had broken at the cutter port was smooth (Figure 2). Fragility is a disadvantage of a system using 25-gauge instruments. Initially the system was intended to decrease surgical invasiveness in patients not requiring peripheral
868
AMERICAN JOURNAL
FIGURE 1. Intraoperative photograph after the vitreous cutter became lodged at a polyamide connection within the cannula (arrow) and was removed with the cannula. The cutter was pulled from the sclerotomy site (arrowhead) together with the bent cannula.
FIGURE 2. (Left) Stereoscopic micrograph. The tip of vitreous cutter is absent from the edge of the cutting port. (Right) scanning electron micrograph. The broken tip of the cutter shows an even surface (360 m).
vitrectomy, but refinements in instrumentation have expanded surgical indications. In addition to intrinsic fragility, breakage of the vitreous cutter may have resulted from damage to the cannula during peripheral vitrectomy from being bent with the inserted vitreous cutter, especially at the connection of the polyamide tube with the plastic plug. Intraoperatively, the tip of the vitreous cutter became lodged at this interface. When a broken tip is found within the eye, this foreign body should be removed to avoid further complications. Despite continued usefulness of 25-gauge vitrectomy systems, fragility of instruments predisposing to damage from sclerotomy cannula should be kept in mind. REFERENCES
1. De Juan E Jr, Hickingbotham D. Refinements in microinstrumentation for vitreous surgery. Am J Ophthalmol 1990;109: 218 –220. OF
OPHTHALMOLOGY
NOVEMBER 2004
2. Fujii GY, De Juan E Jr, Humayun MS, et al. A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology 2002;109:1807–1812. 3. Fujii GY, De Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002;109:1814 –1820.
An Explanation of Transient Visual Loss Associated With Leaking Filtering Bleb Adriana Paula Grigorian, and MD, and George Spaeth, MD To report a presumed cause for the transient visual loss noted by a patient with a leaking bleb following trabeculectomy. DESIGN: Case report. METHODS: Description of an otherwise healthy woman who developed delayed-onset transient visual loss associated with a leaking filtering bleb. RESULTS: A 62-year-old woman who underwent trabeculectomy with mitomycin C in her right eye 5 years earlier (Feb 23, 1999) presented with a 3-month history of transient decreased vision. The apparent cause was a periodic gush of aqueous flowing across the surface of the cornea. CONCLUSIONS: One cause of bleb-associated transient visual loss can be aqueous leaking from the bleb on to the anterior surface of the cornea, disturbing vision as it flows past the visual axis. This is temporarily relieved by blinking. (Am J Ophthalmol 2004;138:869 – 870. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
T
RANSIENT VISUAL LOSS IN PATIENTS WITH FUNCTION-
ing filtration blebs has been reported previously.1– 4 We describe such a patient in whom transient visual loss was caused by a periodic leak from the conjunctival bleb. Because of continuing visual loss despite medicinal and laser treatment, a 62-year-old woman with advanced, average-pressure glaucoma had guarded filtration procedures performed in both eyes. Preoperative intraocular pressure was 15 mm Hg in both eyes; postoperatively, it was 9 mm Hg. Five years later she noted a visual disturbance in her right eye, specifically, a “veil” causing a blur that lasted several seconds, relieved by blinking. With every blink the veil disappeared, but it returned minutes or hours later. Visual acuity with correction was 20/60 right
Accepted for publication May 14, 2004. From Carol Davila-Central Clinical Emergency Military Hospital, Bucharest, Romania (A.P.), and William and Anna Goldberg Glaucoma Service, Wills Eye Hospital/Jefferson Medical College, Philadelphia, Pennsylvania (G.S.). Inquiries to George L. Spaeth, MD, Glaucoma Service, Wills Eye Hospital, 840 Walnut St, Philadelphia, PA 19107; fax: (215) 928-0166; e-mail: [email protected]
VOL. 138, NO. 5
FIGURE 1. Aqueous spreading over the corneal surface. (Top) Slit-lamp examination of the right eye with fluorescein staining shows the wave of fluid descending over the cornea a crescentic fashion. Wave of aqueous passing the visual axis. (Bottom) This photograph, taken 2 seconds after that in Figure 1 (top), shows the liquid wave passing the visual axis.
eye and 20/50 left. Intraocular pressure was 8 mm Hg in both eyes. The corneas were clear, and the anterior chamber was deep and quiet. An incipient cataract was noted in both eyes. There was a high bleb (two corneal thicknesses), avascular and transparent but not multicystic, at the 12-o’clock position. When the lid was lifted gently, a point of leakage on the bleb surface was noted. Occasionally, there would be a small gush of aqueous from the leak, following which a wave of aqueous descended down over the surface of the cornea in a crescentic fashion (Figure 1). As the wave front passed the visual axis the patient commented that her vision became blurred. After the wave front passed, vision returned to normal. After around 30 seconds, perhaps related to the discomfort of the prolonged folding of the lid, another gush of aqueous out
BRIEF REPORTS
869