Surgeons advance on frontlines of vitreoretinal care

Changes in gauge preference, incision size, need for sutures and a developing pipeline revolutionize field.

Seenu M. Hariprasad

Almost a decade since it was first developed, microincision vitrectomy surgery has revolutionized the way surgery is performed, according to a specialist.

“We are very fortunate to practice vitreoretinal surgery in this decade,” Seenu M. Hariprasad, MD, told Ocular Surgery News.

Significant advances in vitrectomy platforms, instrumentation and illumination have improved methods for performing challenging surgical cases involving vitrectomy surgery.

“Our current platforms for vitrectomy are exceptional. We have great machines, our tools are exquisite and visualization systems are as good as they have ever been,” Dr. Hariprasad said.

Vitrectomy is used in the treatment of conditions such as retinal detachment, macular holes, epiretinal membranes and vitreous hemorrhage.

Changes in the field

The ability to perform less invasive surgery via microincision sutureless procedures and by using smaller gauges is a hot topic in the field of vitrectomy, according to Allen C. Ho, MD, OSN Retina/Vitreous Board Member.

Microincision vitrectomy surgery has gained widespread use and popularity due to its many advantages, including faster healing and increased comfort for the patient and greater efficiency for the surgeon. It has aided in improving vitrectomy cutters, blade and wound designs, and active IOP and flow control, and it has inspired the development of new accessories such as valves, chandeliers and illuminated endolasers.

Allen C. Ho

“The new microincision vitrectomy technology improves surgical capabilities and safety, with more surgeon control,” Dr. Ho said.

Additionally, using a 23- or 25-gauge probe over the traditional 20-gauge probe enables faster recovery and less discomfort and trauma to the eye. It also offers improved performance and rigidity, according to Dr. Ho.

“Increasingly, with the evolution of the hardware and handheld instruments and vitrectomy systems, the ability to manipulate tissue in the eye is improved,” he said.

The sutureless procedure allows for quick entry and exit from the eye, providing more time to work on the back of the eye. In addition, it offers improved patient comfort, less postsurgical astigmatism and reduced trauma to the conjunctiva, with less scarring and a quicker recovery.

“Twenty-gauge vitrectomy was the gold standard for many years,” Dr. Hariprasad said. “However, given the numerous advantages of 23- and 25-gauge vitrectomy such as quicker patient recovery, improved patient comfort and more rapid visual gain, this approach is now my first-line approach to do vitrectomy surgery in 2011.”

Dr. Ho agreed, saying that his preferred method of opening the wound is with the 23- or 25-gauge trocar cannula present with the new sutureless systems. “Generally I perform sutureless, unless there is evidence of a wound leak,” Dr. Ho said.

The major platforms that vitreoretinal surgeons use for microincisional surgery are the Bausch + Lomb Stellaris and the Alcon Constellation and Accurus systems. Both the Alcon and Bausch + Lomb platforms have vitreous cutting speeds of 5,000 cpm.

However, with the benefits of microincision vitrectomy surgery come potentially increased risks for endophthalmitis and other infection. Dr. Ho said he prefers the advantages of the microincision surgical platform compared to first-generation 20-gauge vitrectomy despite these risks.

“The benefits simply outweigh the risks,” he said.

In the pipeline

A variety of companies are working on pharmacosurgical applications to help bring biologics and pharmacology into our surgical arena, according to Dr. Ho.

“We use some of these now with tissues, but this is an open area that can be acknowledged later in the ophthalmology arena,” Dr. Ho said. “There is great potential in pharmacosurgical applications, for example in reducing complications such as proliferative vitreoretinopathy.”

Research is under way for surgical accessories.

An in situ forming hydrogel bandage, the ReSure Adherent Ocular Bandage (Ocular Therapeutix), is currently awaiting U.S. Food and Drug Administration approval and is already approved in Europe. This product creates a temporary soft and lubricious barrier to protect ocular surface incisions. Microincision vitrectomy surgery combined with hydrogel ocular bandages potentially decreases the theoretical risk of endophthalmitis, according to Dr. Hariprasad.

Because of recent advancements and new technology in development, patients are now able to receive high-level care in many places throughout the country.

“One of the great things in contemporary vitrectomy surgery is there has been dissemination of technology and surgical skill sets. No longer are complex procedures being done at just a handful of centers around the country, but rather there is a greater level of care being delivered throughout the United States and world, with potential advancements in the pipeline,” Dr. Ho said. – by Tara Grassia

• Seenu M. Hariprasad, MD, can be reached at University of Chicago, Department of Surgery, Section of Ophthalmology and Visual Science, 5841 S. Maryland Ave., MC2114, Chicago, IL 60637; 773-795-1326; email: retina@uchicago.edu.
• Allen C. Ho, MD, can be reached at the Retina Service, Wills Eye Hospital, 900 Walnut St., Philadelphia, PA 19107; 215-233-4300; fax: 215-836-1991; email: acho@att.net.
• Disclosures: Dr. Hariprasad is a consultant for Alcon Laboratories, Allergan, Genentech, Optos, Bayer, OD-OS and Regeneron. Dr. Ho is a consultant for Alcon Laboratories.

Role of scleral buckling

Scleral buckling is the most common treatment for retinal detachment, closing breaks and flattening the retina to prevent fluid leakage.

“Scleral buckling plays a very important role in retinal detachment,” Allen C. Ho, MD, OSN Retina/Vitreous Board Member, said.

While it is effective for treating retinal detachment, it is considered by many to be an “old school” method. For younger patients, the risks of entering the eye via vitrectomy are avoided with scleral buckling.

“It is the tried and true way to fix a retina and will always be a part of our tool box to reattach a retina,” Seenu M. Hariprasad, MD, said. “However, the number of buckles I am doing over the years has decreased given the excellent outcomes with vitrectomy alone.”

Scleral buckling does poses some short-term and long-term risks as well. The most common cause of failure is proliferative vireoretinopathy, which can cause the retina to re-detatch and usually requires additional treatment via vitrectomy surgery.

Typically vitrectomy is necessary only when the surgeon’s view of the damage to the retina is hindered.

“Sometimes ‘old school’ is still the way to go,” Dr. Hariprasad said. – by Tara Grassia