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Sutureless vitrectomy surgery: author reply
Letters to the Editor Sutureless Virectomy Surgery Dear Editor: An article by Gildo Y. Fujii and colleagues reports a new 25-gauge instrument system for transconjunctival sutureless vitrectomy.1 The article is somewhat misleading in claiming that the authors’ is the first sutureless vitrectomy system. They credit Dr Chen, in 1966, for using a sutureless sclerotomy for pars plana vitrectomy. In 1989, I designed a 23-gauge sutureless, transjunctival portable vitrectomy system. Early in 1993, along with the VisiTec (now owned by Becton Dickinson [Franklin Lakes, NJ]), I developed and patented the first pars plana transconjunctival sutureless vitrectomy system. It was electrically operated, affordable, and portable. I described every advantage at that time for sutureless vitrectomy. Presentations to the Vitreous Society were made at the August 14, 1995 meeting in London. Three patents were issued in the mid1990s, and articles were written in Ophthalmology Times about the system in 1996. The product and its descriptions won numerous awards, including the Top 10 Papers of the Year, presented by Ophthalmology Times at the annual meeting of the American Academy of Ophthalmology in Chicago in 1996. A film of the system also received recognition as one of the top videos at the Vitreous Society meeting in Rome several years ago. ROBERT G. JOSEPHBERG, MD Valhalla, New York Reference 1. 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 –20.
Author reply Dear Editor: We are happy to acknowledge Dr Josephberg’s contribution to the field of vitreoretinal ophthalmology. It is clear that he was the first to commercialize the idea of an integrated vitreous cutter and penetrating needle for transconjunctival vitreous surgery. This system has a place and is useful, particularly for vitreous biopsy. Although his system is transconjunctival and sutureless, it was not a fully functional multi-instrument system, such as the one we have described. Our key component is the entry site alignment system. This allows the smooth exchange of instruments during the entire procedure. It allows placement of forceps, scissors, laser, picks, and the like. EUGENE DE JUAN, JR, MD Los Angeles, California Dear Editor: Dr Fujii et al has introduced a new 25-gauge transconjunctival sutureless vitrectomy (TSV) system,1 consisting of
microcannulas for pars plana vitrectomy and a variety of newly designed vitreoretinal instruments with a 25-gauge diameter. With this device, the tip of the microcannula is inserted with a trocar through the conjunctiva, sclera, and retina into the vitreous to provide a stable alignment during surgery. The incision, of approximately 0.5 mm, is selfsealing and requires no additional suturing. The initial response to this system is very enthusiastic, and we congratulate the authors for their new invention. In a retrospective study, the authors report their initial experience of successful surgery with the TSV system in a variety of vitreoretinal cases.2 In selected cases the intraocular pressure was lowered during the first postoperative days. Overall, the duration of surgery and postoperative local inflammation was reduced relative to the conventional technique. As the follow-up period was short, the authors speculated that self-sealing sutureless sclerotomies may possibly serve as conduits for bacterial infections. Since 1997, we have used sutureless sclerotomies for most pars plana vitrectomies at our clinic.3 More than 500 cases have been performed with this technique. Adapted from cataract surgery, we create a scleral tunnel after a conjunctival dissection. Similar to Fujii et al, we rarely observe mild hypotony on the first postoperative day. No endophthalmitis or wound dissection occurred during our entire 5-year experience, indicating the safety and feasibility of self-sealing sclerotomies over the long term. However, we also concur with Dr Trese’s discussion of Fujii’s articles.4 He observed an imperceptible wound, in rabbit eyes with normal pressure, a few days after a 25gauge incision. In our hospital we observed a case of a 55-year-old patient with a submacular hemorrhage who received intravitreal tissue plasminogen activator and 2 days later an air injection, both through a syringe with a 30-gauge needle.5 The patient developed a diffuse vitreous hemorrhage, and a pars plana vitrectomy was performed 5 weeks later. After the peritomy, we observed an unsealed scleral hole with remarkable vitreous prolapse and scleral incarceration at the site of previous injections. This observation shows that even a 30-gauge needle can incarcerate vitreous at the sclerotomy site. Fujii et al removed the vitreous with a 25-gauge vitreous cutter through a trocar system, which may prevent the vitreous incarceration. Trese emphasized that an imperceptible wound only developed in eyes with normal pressure; therefore, in our case, the second air injection may have created elevated intraocular pressure leading to a vitreous prolapse and scleral incarceration. We admire the efforts by Fujii and coworkers to achieve a major step in vitreoretinal surgery. The development of smaller instruments, such as the 25-gauge TSV system, has many advantages, including decreased time of surgery and less postoperative inflammation. Although Dr Fujii and coworkers demonstrated the capability of their attractive 25-gauge system, we agree with Dr Trese’s statement that this proposed “minimally invasive” TSV system has risk
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Author reply Dear Editor: We are happy to acknowledge Dr Josephberg’s contribution to the field of vitreoretinal ophthalmology. It is clear that he was the first to commercialize the idea of an integrated vitreous cutter and penetrating needle for transconjunctival vitreous surgery. This system has a place and is useful, particularly for vitreous biopsy. Although his system is transconjunctival and sutureless, it was not a fully functional multi-instrument system, such as the one we have described. Our key component is the entry site alignment system. This allows the smooth exchange of instruments during the entire procedure. It allows placement of forceps, scissors, laser, picks, and the like. EUGENE DE JUAN, JR, MD Los Angeles, California Dear Editor: Dr Fujii et al has introduced a new 25-gauge transconjunctival sutureless vitrectomy (TSV) system,1 consisting of
microcannulas for pars plana vitrectomy and a variety of newly designed vitreoretinal instruments with a 25-gauge diameter. With this device, the tip of the microcannula is inserted with a trocar through the conjunctiva, sclera, and retina into the vitreous to provide a stable alignment during surgery. The incision, of approximately 0.5 mm, is selfsealing and requires no additional suturing. The initial response to this system is very enthusiastic, and we congratulate the authors for their new invention. In a retrospective study, the authors report their initial experience of successful surgery with the TSV system in a variety of vitreoretinal cases.2 In selected cases the intraocular pressure was lowered during the first postoperative days. Overall, the duration of surgery and postoperative local inflammation was reduced relative to the conventional technique. As the follow-up period was short, the authors speculated that self-sealing sutureless sclerotomies may possibly serve as conduits for bacterial infections. Since 1997, we have used sutureless sclerotomies for most pars plana vitrectomies at our clinic.3 More than 500 cases have been performed with this technique. Adapted from cataract surgery, we create a scleral tunnel after a conjunctival dissection. Similar to Fujii et al, we rarely observe mild hypotony on the first postoperative day. No endophthalmitis or wound dissection occurred during our entire 5-year experience, indicating the safety and feasibility of self-sealing sclerotomies over the long term. However, we also concur with Dr Trese’s discussion of Fujii’s articles.4 He observed an imperceptible wound, in rabbit eyes with normal pressure, a few days after a 25gauge incision. In our hospital we observed a case of a 55-year-old patient with a submacular hemorrhage who received intravitreal tissue plasminogen activator and 2 days later an air injection, both through a syringe with a 30-gauge needle.5 The patient developed a diffuse vitreous hemorrhage, and a pars plana vitrectomy was performed 5 weeks later. After the peritomy, we observed an unsealed scleral hole with remarkable vitreous prolapse and scleral incarceration at the site of previous injections. This observation shows that even a 30-gauge needle can incarcerate vitreous at the sclerotomy site. Fujii et al removed the vitreous with a 25-gauge vitreous cutter through a trocar system, which may prevent the vitreous incarceration. Trese emphasized that an imperceptible wound only developed in eyes with normal pressure; therefore, in our case, the second air injection may have created elevated intraocular pressure leading to a vitreous prolapse and scleral incarceration. We admire the efforts by Fujii and coworkers to achieve a major step in vitreoretinal surgery. The development of smaller instruments, such as the 25-gauge TSV system, has many advantages, including decreased time of surgery and less postoperative inflammation. Although Dr Fujii and coworkers demonstrated the capability of their attractive 25-gauge system, we agree with Dr Trese’s statement that this proposed “minimally invasive” TSV system has risk
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