Vitrectomy Jairo E Hoyos, José J Martínez-Toldos
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1Step by Step Vitrectomy2
3Step by Step Vitrectomy
Second Edition
José J Martinez-Toldos MD PhD Chief Service of Ophthalmology Hospital General Universitario de Elche Alicante, Spain Jairo E Hoyos MD PhD Physician of Ophthalmology Instituto Oftalmologico Hoyos Sabadell, Barcelona, Spain Foreword Borja Corcóstegui
4
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Step By Step Vitrectomy
First Edition: 2006
Second Edition: 2013
9789350903544
Printed at
5Dedicated to
All vitreoretinal surgeons
67Contributors 1011Foreword
Once again, José Juan Martinez-Toldos provides us with a book on vitreoretinal surgery, which is a compilation of the experience of several authors under his supervision in an effort to unify criteria.
This edition covers all aspects of vitreoretinal surgery, from anatomy of the interior eye, the presurgery examination of the patient, complementary tests, passing through an exhaustive analysis of instrumentation and its different uses, to the treatment of commonly-faced problems, such as diabetic retinopathy, retinal detachment with or without proliferative vitreoretinopathy (PVR) and macular disease. New to this edition, we find chapters on 27 gauge vitrectomy instruments, enzyme lysis or new products that are still under investigation or development. The chapter on the organization of the surgical area will be of interest to those freshly starting out in this discipline.
Although theoretical aspects are key to this work, the photographs and footage of surgery provided will be of great practical use to the surgeon who wishes to analyze and improve on given surgical steps or procedures. Only by examining images of a surgical intervention will we be able to discover how a surgeon resolves a given situation or observe the finer details of his/her maneuver, the risks assumed, in other words, the quality of surgery. Personally, I am a great believer in watching surgery in action since it enables us to observe the capacity to resolve the different cases at each moment, in which some have surprisingly made fundamental errors.
Jose Juan has been a good friend of mine since his beginnings in ophthalmology. His capacity for work and study, his fight until the end with each case, and his limitless honesty makes him the ideal person for such an ambitious venture. We hope that it will help young surgeons acquire an in-depth knowledge of their profession without getting caught up in the current search for ever smaller instruments as the only pursuit of this type of surgery.
Borja Corcóstegui md phd
Professor of Ophthalmology
ESASO (European School for Advanced Studies in Ophthalmology)
Lugano, Switzerland
Chairman
Instituto de Microcirugia Ocular
Barcelona, Spain
1213Foreword
More than six years have passed since the first edition of Step by Step Basic Vitrectomy. As expected, vitrectomy has continued its fast development and it is at this point that an update of its techniques an understanding is required.
In this edition, we discuss the new high-speed vitreotomes with duty cycles that provide good control of eye tissues and thus avoid retinal damage. We describe the new techniques that have appeared on the scene such as 27 gauge vitrectomy. This approach allows a 0.4 mm incision, minimizing ocular pain and along with the use of valved trocars, enables a vitrectomy with little fluid and scarce turbulence within the eye. Also discussed are the new 23, 25 and 27 gauge instruments and the new illumination systems that allow the surgeon to more safely work inside the ocular globe fulfilling the prerequisite of good vision needed for a good vitrectomy.
The new chapters introduced in this update include one on vitrectomy for eye trauma and another on the knowledge needed to efficiently treat patients with myopia. Besides these, the reader will find chapters dealing with new drugs, such as antiangiogenic compounds, sustained-release agents, and with current trends in enzymatic vitrectomy.
As in its first edition, rather than an extensive review of the art state, the objective of this book is to provide a descriptive reference of all the necessary procedures and how these should be used in basic vitreoretinal surgery along with our opinions and personal preferences.
Finally, we would like to remind all vitreoretinal surgeons of the need to constantly improve our knowledge of the technique, which day-by-day is becoming safer and offers better outcomes to our patients.
José J Martinez-Toldos
Jairo E Hoyos
1415Preface to the Second Edition
The topic of vitrectomy includes both diagnostic and therapeutic approaches and requires a profound understanding of the anatomy and physiology of the eye. The vitreoretinal surgeon needs to master classic diagnostic tools, such as indirect ophthalmoscopy and examination of the retina and vitreous through contact and noncontact biomicroscopy. More recent developments have also led to a need for a sound knowledge of ultrasonography, and optical coherence tomography, especially its prognostic use for macular problems.
Any specialist new to the technique will be certainly overwhelmed by the speed at which the field advances to constantly generate new visualization systems, microscopes, vitrectomy machines, minimum incision approaches (23, 25 gauges), hand-held instruments, and tissue stains and drugs.
Embarking on a vitrectomy without the appropriate prior knowledge is the road to disaster, since the most simple of cases may become complicated and could lead to the loss of vision with all the legal implications this entails.
José J Martinez-Toldos
Jairo E Hoyos
1617Preface to the First Edition
Vitrectomy is a wide subject that includes diagnostic and therapeutic approaches as well as the need for an in-depth understanding of the anatomical and physiological features of the eye. The vitreoretinal specialist needs to be able to dominate classic diagnostic tools such as indirect ophthalmoscopy and explore the vitreous and retina through contact lens and noncontact biomicroscopy. Developments in the last few years have also meant a need to be adequately handle the use of ocular ultrasonography and optical coherence tomography.
Any surgeon embarking on the technique of vitrectomy will certainly be overwhelmed by the staggering recent advances made in the field, along with the vast array of approaches offered by the different visualization systems, high cutting speed vitrectomy machines, minimal incision procedures (23–25 gauge), new manual instruments, tissue stains and intraocular drugs. This ever-increasing surge of information, besides being difficult to assimilate, requires the appropriate ordering of all these new concepts to tackle this challenging and extraordinary technique.
In preparing this book, we have tried to provide descriptions of all the elements needed for basic vitreoretinal surgery. These descriptions are presented according to our own experience and from the perspective of our personal thoughts on which procedure should be used in each step undertaken. In no case would we recommend initiating a vitrectomy without first completing all the preceding requisites, since the simplest of cases can in theory become complicated and lead to vision loss with all the legal implications this entails.
Finally, we would like to point out to the vitreoretinal surgeon, the importance of an open mind to keep up with the speed of developments in this field.
José J Martinez-Toldos
Jairo E Hoyos
27Introduction
Evidence that the eye could tolerate, practically, complete removal of the vitreous was provided in 1962, when Kasner, introduced the concept of open vitrectomy by removing the vitreous using a cellulose sponge and scissors.
Almost a decade later in 1971, Machemer reported the first closed vitrectomy, conducted through the pars plana, using a multipurpose instrument capable of cutting, infusing and producing enough suction to grasp, cut, and extract the vitreous. With the introduction in 1972 of a fiber optics illumination system, the method was able to achieve the four basic functions of aspiration, cutting, infusion and endoillumination.
The set up used by Machemer was later adapted by O'Malley and Heintz to separate the cutting and aspiration functions from endoillumination. Infusion was also separately achieved by a cannula sutured to the sclera, thus transforming the technique into a more precise and controllable bimanual procedure.
Subsequent developments served to further improve these instruments to enable better control of suction power during vitrectomy. Among these developments, we should also mention endophotocoagulation systems, wide-angle contact and noncontact visualization systems, intraocular pressure control pumps, substances for manipulating the retina (liquid perfluorocarbons) and gases or silicone oils used for tamponade; introduced using fluid injection pumps.
The last two years have seen the introduction of vitrectomy machines showing improved flow control through the possibility of varying the duty cycle. The cutting speeds achieved using this system are some 5000–7000 cuts per minute and reports exist of even 10,000 cuts per minute. These developments add safety to the technique.
For more than 10 years, 25-gauge instruments have been available that permit surgery through a 0.5 mm incision and avoid the need for any scleral or conjunctival sutures. For more complex cases, the 23-gauge instrument vitrectomy procedure, developed by Eckart, has been widely accepted and is today amongst the most frequently used systems by surgeons worldwide.
Tano recently described a membrane peeling procedure based on the use of 27-gauge instruments and currently we have 27-gauge instruments available that allow a surgeon to conduct a complete vitrectomy in selective cases.
Today's therapeutic armamentarium has also been expanded by the introduction of dyes, to stain the epiretinal membranes and the internal limiting membranes, such as trypan blue, indocyanine green and brilliant blue, the later being the most notable.28
Finally, nonstaining agents aiming at improving a surgeon's visualization of the vitreous and other membranes include the synthetic corticosteroid triamcinolone, whose crystals are deposited on these structures thus facilitating their removal. Other new medications worthy of mention are sustained drug delivery systems, such as dexamethasone or fluocinolone implants, that treat inflammatory diseases and macular edema. However, the greatest stars of all have been antiangiogenic or antivascular endothelium growth factor agents used initially to treat the wet form of age-related macular degeneration but that are today used to treat any vessel proliferation process, mainly diabetic retinopathy. Special mention should also be made of the use of enzymes, such as plasmin, to detach the posterior hyaloid, resolving certain macular problems.
Research efforts in improving instrumentation and measurement devices continue to grow and so do the number of indications for surgery. This rapid pace has been set by the significant improvement in data communication so that changes produced can be transmitted to the scientific community on an almost daily basis. Continuing education programs have also forced the constant training of the vitreoretinal experts. Finally, we should also mention the emergence of new computer simulators, which are proving extremely useful for surgeons embarking on this technique.,
REFERENCES
  1. Kasner D. Vitrectomy a new approach to the management of vitreous (Interview) Highlights Ophthalmol. 1969;11:304.
  1. Kasner D, Miller GR, Taylor WH, et al. Surgical treatment of amyloidosis of the vitreous. Trans Am Acad Ophthalmol Otolaryngol. 1968;72(3):410–8.
  1. Machemer R, Buettner H, Norton EW, et al. Vitrectomy: a pars plana approach. Trans Am Acad Ophthalmol Otolaryngol. 1971;75(4):813–20.
  1. Machemer R, Parel JM, Buettner H. A new concept for vitreous surgery. I. Instrumentation. Am J Ophthalmol. 1972;73(1):1–7.
  1. Machemer R. A new concept for vitreous surgery. 7. Two instrument techniques in pars plana vitrectomy. Arch Ophthalmol. 1974;92(5):407–12.
  1. O'Malley C, Heintz RM. Vitrectomy with an alternative instrument system. Ann Ophthalmol. 1975;7(4):585-8, 591-4.
  1. Fugii GY, De Juan E, Humayun MS, et al. A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology. 2002;109(10):1807–12.
  1. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;25(2):208–11.
  1. Oshima Y, Wakabayashi T, Sato T, et al. A 27-gauge instrument system for transconjunctival sutureless microincision vitrectomy surgery. Ophthalmology. 2010;117(1):93–102.
  1. Verma D, Wills D, Verma M. Virtual reality simulator for vitreoretinal surgery. Eye (Lond). 2003;17(1):71–3.
  1. Hikichi T, Yoshida A, Igarashi S, et al. Vitreous surgery simulator. Arch Ophthalmol. 2000;118(12):1679–81.
  1. Rossi JV, Verma D, Fujii GY, et al. Virtual vitreoretinal surgical simulator as a training tool. Retina. 2004;24(2):231–6.