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Vitrectomy with advanced technology manages complicated retinal detachments
The reported success rate was nearly double compared with previous one-hand techniques.
 Athanasios Nikolakopoulos |
A bimanual vitrectomy technique with updated technology allows for better results in combined traction and rhegmatogenous retinal detachment surgery, according to a surgeon.
“Dealing with this combination, which may present as a complication of proliferative diabetic retinopathy, is one of the most challenging procedures in eye surgery. The neovascular tissue is heavily bleeding, there are tractional tears near and away from the working area, and retina and membranes are like one tissue. We have to deal with a very thin retina and, possibly, with atrophic scars produced by previous laser treatments,” Athanasios Nikolakopoulos, MD, said at the Euretina meeting in London.
Severe hemorrhages and untreated iatrogenic tears that lead to persistent postoperative retinal detachment and neovascular glaucoma are common causes of surgical failure.
“It’s like removing cement from cigarette paper without tearing the paper,” he said.
Current technology
Modern advances in technique and technology, however, can prevent these complications. Dr. Nikolakopoulos recommended a combination of small-gauge and bimanual surgery, which allows for controlled, safe and minimally invasive maneuvers.
“Today’s small-gauge instruments, 25-gauge or even 27-gauge, are stiffer, and the control we have with them is fantastic. The size is so small that you can see underneath and behind them very clearly, while larger-gauge instruments created a huge shadow that blocked the view,” he said.
Dr. Nikolakopoulos has previously used the Alcon Accurus system and has now switched to the Constellation system (Alcon). Although the Accurus was a good machine, he said, improvements in the Constellation have advanced the quality and safety of surgery.
For example, the vitrectomy probe has optimized duty cycle control, an 8% higher aspiration vacuum and a port size that is wider and closer to the retinal surface. The cutting rate has doubled, now achieving 5,000 cpm, further minimizing tissue traction.
The new integrated IOP control system uses flow sensors to automatically provide a balance between aspiration and flow, maintaining a constant pressure. Another feature is the simultaneous two-step exchange of perfluorocarbon liquid, air and silicone oil.
Technique
According to Dr. Nikolakopoulos, bimanual surgery is the latest evolution of small-gauge technology. A 25- to 27-gauge chandelier light, guided by an assistant, leaves the surgeon free to perform vitrectomy maneuvers with both hands, using high magnification and the EIBOS non-contact, wide-angle viewing system (Möller-Wedel).
“In this kind of surgery there is a need to focus on the center but at the same time see what’s happening far away from the center,” he said. “Having both hands free, I can lift membranes with one hand to view the exact plane between the retina and the membrane and do the cutting with the other hand. In this way, there is no risk of iatrogenic retinal tears.”
Vitreous cutting is carried out with the 5,000 cpm and 600 mm Hg vacuum settings, always under visual control. There is no need for scissors, which is an advancement with this technique. During dissection, traction is always applied in one direction.
The exchange of fluid, air and 5,700 cSt silicone oil is carried out under direct visualization, keeping the air infusion at 20 mm Hg and the silicone oil injection at 60 psi. Sutures are usually not needed at the end of the procedure.
“We retrospectively analyzed the results of 120 cases in which 25-gauge single-hand vitrectomy was performed using the Accurus system and compared them with those of 142 cases treated in the last 2 years using bimanual 25-gauge vitrectomy with the Constellation and 5,700 cSt silicone oil injection. We had 35% less iatrogenic tears, 50% better visual outcome after silicone oil removal, 40% less [postoperative] early re-bleeding,” Dr. Nikolakopoulos said. – by Michela Cimberle
For more information:
Athanasios Nikolakopoulos, MD, chairman of the ophthalmology department at Papanikolaou Hospital in Thessaloniki, Greece, can be reached at anikolako@yahoo.gr.
Disclosure: Dr. Nikolakopoulos has no relevant financial disclosures.
Perspective
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Several years ago, during my early experiences in ophthalmic surgery, a very talented anterior segment surgeon gave me simple but clever advice: Humans have been created with two hands; let us use both of them. It was the era of the transition from extracapsular cataract surgery to phacoemulsification surgery, and the majority of ophthalmologists soon understood that bimanual surgery was the way to go. Many years have passed, and a variety of technological advancements have characterized the world of vitreoretinal surgery. Machines have become more efficient, wide-angle visualization and illumination systems are available, and small-gauge instruments are now used even for complicated cases. Dr. Nikolakopoulos’ message is very clear: Thanks to this improved human-machine interaction, surgeons now have the possibility to improve their surgical skills and address complicated cases with an increased rate of success and minimal trauma.
However, although the newer techniques look promising, we still need evidence to prove that they can safely and effectively replace standard approaches of vitreoretinal surgery. Also, many unsolved questions on pharmacotherapy of proliferative vitreoretinopathy and vitreomacular adhesion still need extensive research.