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Small-gauge vitrectomy system allows less invasive procedures
Technique appropriate for most but not all patients, surgeon says.
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NEW YORK – A 25-gauge vitrectomy system enables surgeons to perform less invasive surgery, but it carries a significant learning curve and may not be feasible for all procedures, according to a poster presentation here.
Atsushi Hayashi, MD, and colleagues presented the results of 23 three-port pars plana vitrectomies (21 patients) using a 25-gauge system at the meeting of the American Society of Retina Specialists. The system is the TSV25 from Bausch & Lomb.
In the study, conducted at the Meiwa Hospital in Hyogo, Japan, only the first case required Dr. Hayashi to switch to a conventional, 20-gauge system.
Vitreoretinal pathologies included persistent macular edema due to proliferative diabetic retinopathy (eight eyes) and branch retinal vein occlusion (three eyes), macular holes (five eyes), epiretinal membranes (three eyes), vitreous hemorrhage (three eyes) and submacular hemorrhage from macroaneurysm (one eye).
In an e-mail interview, Dr. Hayashi noted that the TSV25 induced less astigmatism and allowed a shorter time to visual acuity recovery than conventional surgery. He added that improvements in VA ranged from subtle to dramatic, depending on the nature of the disease.
VA results
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Over a mean 11.8-month follow-up, 14 eyes (61%) experienced an improvement in VA (defined as a change of more than 0.2 logMAR), 8 eyes (35%) had no change and one eye (4%) experienced a decrease in VA, according to Dr. Hayashi.
“[It is] my impression [that] patient comfort is pretty high in 25-gauge, and recovery time (time to reach maximum visual acuity) is shorter in 25-gauge cases,” Dr. Hayashi told Ocular Surgery News in an e-mail interview.
Even in three eyes that required a scleral port suture, “TSV25 vitrectomy clearly (caused) less astigmatism,” he added.
Investigators observed a decrease in IOP in seven eyes (30%) and bleb formation in five eyes (22%). Two eyes experienced both a decrease in IOP as well as bleb formation.
The IOP decrease resolved spontaneously in all cases within 1 week postoperatively.
IOP decreases
Dr. Hayashi acknowledged that the incidence of IOP decreases, a dip of 4 mm Hg to 6 mm Hg, is “clearly higher” among TSV25 patients than those who undergo the conventional procedure. He noted that the two systems cause a decrease for different reasons.
He attributed the higher incidence with the often-sutureless TSV25 to leakage at the scleral ports. “Usually we never see leakage from scleral ports of 20-gauge because we suture tightly,” he said.
To reduce the risk of hypotony, Dr. Hayashi said, “I always check leakage from the scleral ports just after removal of the microcannula, and if leakage is found, I do not hesitate to place a suture at the leaking scleral port.”
With the 20-gauge system, most cases of IOP decreases result from an injury to the ciliary body, Dr. Hayashi said. He added that, so far, injury has been less common with the TSV25 system because it is reserved for less severe cases.
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(All images courtesy of Atsushi Hayashi, MD.) |
Difficult cases
Dr. Hayashi said he has been more cautious about using the TSV25 in more difficult cases because there are currently an insufficient number of peripheral instruments that are compatible with it. For instance, if a procedure requires the introduction of an endoscope, a laser probe with a light source or a fragmatome, the surgeon must enlarge at least one of the scleral ports to accommodate these 20-gauge instruments.
“Other situations in which surgeons may want to change to 20 gauge will be the need to … observe the peripheral retina and pars plana area in 360° with indentation of sclera,” he said, adding that scleral indentation is more difficult without a conjunctival incision.
In the case that required Dr. Hayashi to switch to 20-gauge surgery, a retinal tear was encountered that required laser treatment. A laser probe is now available that is compatible with the TSV25, he noted.
Selective use
Possible complications with the TSV25 include endophthalmitis, late retinal tears and recurring vitreous hemorrhage, according to Dr. Hayashi. None of these complications were seen in the study.
He urged surgeons, particularly if they are less experienced with the 20-gauge system, to proceed slowly. While experienced surgeons may be able to learn the technique after 10 procedures, “I think 25-gauge surgery is not for beginners,” Dr. Hayashi said.
He also noted that research on the TSV25 has been largely limited to less severe cases. “I think we should wait to apply TSV25 for very active (proliferative diabetic retinopathy) cases which require gas or silicone oil injection and [multiple] surgeries,” he said. “Twenty-five-gauge surgery at present cannot be applied to all patients.”
Nevertheless, Dr. Hayashi expressed enthusiasm for the procedure.
“So far I have used the TSV25 in more than 50 cases, and I believe this system has many advantages and few disadvantages and can be the first choice for more than 50% of vitrectomy cases,” he said.
For Your Information:
- Atsushi Hayashi, MD, can be reached at Meiwa Hospital, Department of Ophthalmology, 4-31 Age Naruo-cho, Nishinomiya 663-8186 Japan; 81-7-98-47-17-67; fax: 81-7-98-47-76-13; e-mail: ahayashi@meiwa-hospital.com. Dr. Hayashi has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Bausch & Lomb, maker of the TSV25, can be reached at 1400 N. Goodman St., Rochester, NY 14609; 585-338-5212; fax: 585-338-0898; Web site: www.bausch.com.