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Endoscopy aids visualization and spares delay in ocular trauma surgery
A new autoclavable, high-resolution fiber optics probe will be available soon, investigator says.
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Endoscopy allows surgeons to achieve their goals in post-traumatic vitreoretinal surgery, such as the prevention of proliferative vitreoretinopathy development, ciliary scarring and secondary hypotony, according to one of the pioneers of the use of this technique.
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Images: Boscher CR |
“Endoscopy completely bypasses the problem of media transparency. Even in the case of a completely damaged cornea, one can operate inside the eye without performing a corneal transplant, and eventually select for keratoplasty only the eyes where retinal problems have been successfully overcome,” said Claude R. Boscher, MD, at the meeting of the International Society of Ocular Trauma.
With the endoscope, “the eye of the surgeon is inside the eye of the patient,” and he can look in all directions, using panoramic or high-magnification viewing, Dr. Boscher said.
“It allows you to perform an early removal of blood and an early removal of the entire vitreous base, whatever the conditions of the anterior segment. In case of intravitreal hematoma, one can also explore the posterior pole and evaluate the conditions of the retina before removing the blood or injecting [perfluorocarbon liquids],” she said.
“The direct view and perfect control of all stages of vitrectomy, of all subretinal maneuvers and of any unplanned incident occurring in the course of surgery has a tremendous impact on the safety and final success of the procedure,” Dr. Boscher said.
Anterior PVR development can be prevented, rather than treated, if endoscopy is used as a primary procedure.
“With the endoscope, you don’t need scleral depression to visualize the anterior vitreous base, and therefore its real depth can be displayed, especially under high magnification. You can do a complete [anterior vitreous base] peeling and dissect all connections with the anterior segment on 360°, which is mandatory to prevent PVR development,” she said.
If left there, even small quantities of vitreous are able to re-detach the retina, even when high scleral buckles have been placed, or to cause hypotony even in presence of an attached retina. A thorough cleansing of the ciliary margin, where stem cells are produced, also removes all the inflammation that has been stimulated by the trauma. These maneuvers cannot be performed as accurately and thoroughly with conventional vitrectomy, she said.
Silicone oil removal can be performed more easily and thoroughly, she said, because the instrument is able to detect and guide the removal of all the droplets of silicone oil trapped into the zonular system, over the ciliary processes and pars plana, preventing the risk of secondary glaucoma.
Endoscopy-assisted surgery can also be used in the management of the late complications of trauma, such as secondary glaucoma, with the laser probe integrated inside the endoscopic probe to perform endocyclophotocoagulation.
It can also be used as a secondary procedure if conventional vitrectomy fails to treat established anterior PVR.
“Whenever I use the endoscope in a secondary procedure after conventional vitrectomy has failed and see the damage that has been caused by an incomplete vitrectomy, I say to myself that I’d never run that risk again. No matter how good you are as a surgeon, a blind procedure where you cannot see what you are doing is always a problem,” she said.
A new probe
Dr. Boscher first used endoscopy-assisted vitreoretinal surgery in 1993 and presented it to retina surgeons at the 1994 meeting of the Club Jules Gonin.
“When I started talking about this technique, I knew I would encounter a lot of resistance,” she said
Sterilization, particularly after the outbreak of Creutzfeldt-Jakob disease, was a major concern, and no hospital in France would acquire a technology that was not autoclavable.
“The American Hospital of Paris took the challenge and developed a protocol of sterilization using caustic soda, the only active agent against the prion. However, this procedure is complicated and time-consuming,” Dr. Boscher said.
Endoscopy-guided surgery was also regarded as a difficult technique that required a long learning curve, and this discouraged many surgeons from using it.
“As a matter of fact, learning to use the endoscope is easier than one might think, especially when one is trained already in ultrasound and video games,” she said.
Outside of France, Dr. Boscher has made more converts to endoscopy. After being contacted by an Italian company, she recently developed with it and a German partner company a new autoclavable, fiber optics probe with improved features for image sharpness and maneuverability.
The new prototype, she said, has a 30% to 40% higher resolution (17,000 pixels compared with 10,000 pixels) than previous models and allows for both panoramic viewing and high magnification with a more powerful endoillumination system. It is easy to handle and has an incorporated endolaser fiber.
This new probe, currently used by Dr. Boscher and a few other surgeons in Europe, will soon be commercially available.
A DVD illustrating the various stages of endoscopy-guided viteoretinal surgery training will be provided with the probe.
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Within everybody’s reach
“With this video and through a series of training courses, I want to reassure and encourage the colleagues who want to approach this technique. Endoscopy-assisted surgery is within everybody’s reach, provided that they accept to approach vitrectomy as something completely new, with its own rules,” Dr. Boscher said.
The learning curve will vary in length according to the individual skills and ability of the surgeons, as it happened when phaco was first introduced.
Dr. Boscher recommends that surgeons start to gain confidence with the probe and learn how to orient it by using a model eye.
“When you feel sufficiently confident, you can start with a fairly simple case, possibly in a pseudophakic eye, alternating microscopic and endoscopic viewing,” she said.
The possibility of being trained in this technique should be given to everyone, she said. It will then be up to the individual surgeons to choose whether to use endoscopy or not in their routine practice.
“I think I have fulfilled my duties,” Dr. Bosher said. “I have provided the community with a new, more manageable instrument for routine surgery, with a sharper image and the safety of sterilization. I have also given the guidelines, which are the result of a long, wide and intense experience.”
The technology of endoscopy is improving quickly, she said.
“For the near future, we are aiming at a disposable 30,000-pixel probe for routine surgery,” Dr. Boscher said.
For more information:
- Claude R. Boscher, MD, is the head of the ophthalmology department at the American Hospital of Paris. She can be reached at Centre Ophtalmologique Étoile, 28 Ave. Hoche, Paris 75008 France; +33-1-56883625; fax: +33-1-56883629; e-mail: cboscher@wanadoo.fr.
- Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.