Retina Today - Personal Experience With 27-gauge Nonvitrectomizing Epiretinal Membrane Peeling (January 2011)

[摘要] Microincision vitrectomy surgery (MIVS) wasfirst introduced several years ago: in 2002,Fujii et al1 introduced 25-gauge three-portpars plana vitrectomy (PPV), and in 2005,Eckhart2 introduced 23-gauge PPV. As microincisiontechniques have evolved and become more prevalent,specific benefits and drawbacks of MIVS have becomeevident. The sutureless aspect of the surgery results inseveral advantages.Because a peritomy is not performed and conjunctivaland scleral sutures are often not needed, operative timesmay be shorter. In addition, the lack of sutures may resultin less postoperative inflammation, less astigmatism, andimproved postoperative comfort.3-6The incidence of cataract progression, however, amajor postoperative complication of vitrectomy, remainshigh even with small-gauge instrumentation.7 To preventpostoperative cataract progression, in 2007 Sakaguchiand co-workers8 proposed a nonvitrectomizing vitreoussurgery (NVS) for epiretinal membrane removal using a27-gauge lightpipe and forceps. The use of NVS in caseswith epiretinal membrane has been reported to be safeand efficacious compared with conventional 20-gaugeinstrumentation.9,10In this article, I report my personal experience using27-gauge transconjunctival NVS for epiretinal membrane(ERM) removal.PATIENT SELECTIONIn order for a minimally invasive approach to facilitatepreservation of lens clarity, patient selection is particularlycritical for 27-gauge NVS surgery for ERM removal. Theeye must, of course, be phakic with a clear lens, and theERM must be well visualized and not too thick or multilayered.The surgical approach will also be easier if theposterior vitreous is detached, but this is not an absoluterequirement. The patient must not be symptomatic forvitreous floaters because this surgery may increase thepresence of floaters.SURGICAL TECHNIQUEThe surgical technique is the same reported bySakaguchi and coworkers.8 The illumination systememployed is a 27-gauge chandelier probe (Synergetics,O’Fallon, MO) anchored transconjunctivally at the superiorpars plana region (Figure 1).11 A 27-gauge fiber optic(Synergetics) can be also used and inserted directlythrough the conjunctiva without any pre-sclerotomy(Figure 2). After one scleral penetration using a 27-gaugeneedle, the 27-gauge microforceps are directly introducedinto the vitreous cavity through the sclerotomywithout a transscleral cannula (Figure 3). The 27-gaugechandelier offers clear fundus visibility with sufficientendoillumination driven by a xenon light source. Therigid shaft of the microforceps allowed intraocularmanipulation without prior cutting of the vitreous. Thetip of the grasping end is sufficiently fine to grab theedge of the ERM, allowing easy peeling of the membranefrom the retinal surface without use of additional instrumentssuch as a microhooked needle (Figure 4). Themembrane is then pulled through the sclerotomy site.After removing the microforceps and chandelier probe,the sclerotomy self-seals, and the surgery concludes withoutfurther manipulations.PERSONAL DATAIn the past 24 months, eight eyes affected by idiopathicERM were eligible for 27-gauge NVS. All of the eyesunderwent a complete ocular examination includingvisual acuity, optical coherence tomography, and lensstatus using the Lens Opacities Classification system III.Patients were followed up at 1, 3, 6, and 12 months aftersurgery. Intraoperative and postoperative complicationswere recorded.RESULTSMean preoperative visual acuity was 20/50, and meanpatient age was 55 years. All eight eyes completed12 months of follow-up. The ERM was successfully peeledin all the eyes, but it was necessary to convert to conventional25-gauge surgery in two eyes. One of these eyeshad retinal hemorrhage during peeling, and becausethere is no infusion with this technique a decision wasmade to remove the premacular blood with the vitrectorand intraocular infusion. In the other eye, the membraneslipped from the forceps during removal and could notbe regrasped. It must be noted that, with this technique,it is difficult or impossible to remove a membrane fromthe formed vitreous because the vitreous pushes themembrane away from the forceps.No postoperative complications were seen. At12 months follow-up, mean visual acuity was 20/30,and only one patient, who had been converted to vitrectomy,developed a cataract at 10 month’s follow-up.WATCH IT ON NOW ON THE RETINA CHANNELAT WWW.EYETUBE.NET27-gauge NonvitrectomizingEpiretinal Membrane PeelingBy Fabio Patelli, MDdirect link to video:http://eyetube.net/?v=rivusFINAL CONSIDERATIONSTwenty-seven–gauge NVS for idiopathic ERMappears to be a safe and effective procedure. Werecognize that the number of patients in our studywas small, but the absence of early cataract progressionin these eyes is most encouraging. Only twopatients in our series required intraoperative conversionto full 25-gauge vitrectomy, and the original planto avoid vitreous removal was accomplished in theremaining six patients.In my opinion, 27-gauge vitrectomy is much lessinvasive than 25-gauge, and fully preserves the globepressure. The peeling, however, is more difficult dueto the flexibility of the forceps and the friction at thescleral entry point, which renders the fine intraocularmovement of the forceps more complicated.For these procedures, it is important to selectpatients carefully and to prepare them for the smallpossibility of postoperative floaters. One may find theinitial peeling itself more challenging in the presenceof vitreous; it is not yet possible to stain and removeILM with a 27-gauge technique.The 27-gauge technique is promising due to thegreatly minimized surgical trauma. Like all new techniques,it presents several initial difficulties; however,these may be overcome with additional study and withimprovements in the very fine forceps.Fabio Patelli, MD, is with the Milano RetinaCenter in Milan, Italy. Dr. Patelli reports thathe has no financial relationships to disclose inrelation to this article. He can be reached at+39 0276318174; fax: [phone]; or viae-mail at [e-mail] GY, De Juan E Jr, Humayun MS, et al. A new 25-gauge instrument system fortransconjunctival sutureless vitrectomy surgery. Ophthalmology. 2002;109:(10)1807-1812;discussion 1813. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;25(2):208-211. Misra A, Ho-Yen G, Burton RL. 23-gauge sutureless vitrectomy and 20-gauge vitrectomy:a case series comparison. Eye (Lond). 2009;23:1187-1191. Yanyali A, Celik E, Horozoglu F, et al. 25-gauge transconjunctival sutureless pars plana vitrectomy.Eur J Ophthalmol. 2006;16:141-147. Yanyali A, Celik E, Horozoglu F, et al. Corneal topographic changes after transconjunctival(25-gauge) sutureless vitrectomy. Am J Ophthalmol. 2005;140:939-941. Okamoto F, Okamoto C, Sakata N, et al. Changes in corneal topography after 25-gaugetransconjunctival sutureless vitrectomy versus after 20-gauge standard vitrectomy.Ophthalmology. 2007;114(12):2138-2141. Gupta OP, Weichel ED, Regillo CD, et al. Postoperative complications associated with 25-gauge pars plana vitrectomy. Ophthalmic Surg Lasers Imaging. 2007;38(4):270-225. Sakaguchi H, Oshima Y, Tano Y. 27-gauge transconjunctival nonvitrectomizing vitreoussurgery for epiretinal membrane removal. Retina. 2007;27(8):1131-1132. Saito Y, Lewis JM, Park I, et al. Nonvitrectomizing vitreous surgery: a strategy to preventpostoperative nuclear sclerosis. Ophthalmology. 1999;106(8):1541-1545. Sawa M, Ohji M, Kusaka S, et al. Nonvitrectomizing vitreous surgery for epiretinal membranelong-term follow-up. Ophthalmology 2005;112(8):1402-1408. Oshima Y, Awh CC, Tano Y. Self-retaining 27-gauge transconjunctival chandelier endoilluminationfor panoramic viewing during vitreous surgery. Am J Ophthalmol. 2007;143(1):166-167.

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