SUTURELESS CLOSURE OF 23- AND 25-GAUGE LEAKING SCLEROTOMIES WITH THE SCLERAL NEEDLING TECHNIQUE.

PURPOSE: To describe and evaluate the efficacy of a novel technique, scleral needling (SN), for securing 23- and 25-gauge leaking sclerotomies in microincision vitrectomy surgery. METHODS: A retrospective comparative review of consecutive cases of 23- and 25-gauge pars plana vitrectomy performed by a single vitreoretinal surgeon before the introduction of the SN technique (pre-SN; November 2016 to January 2017) and after the introduction of the SN technique (post-SN; November 2017 to January 2018) was conducted. The SN technique was implemented as an alternative to suturing, using a 30-gauge needle inserted perpendicularly through the full thickness of the sclera adjacent to the scleral opening, with the needle then immediately removed and sclerotomy closure confirmed. RESULTS: A total of 203 eyes, 105 from pre-SN and 98 from post-SN, were included in the study. The number of eyes requiring suture closure was significantly reduced from 39% in the pre-SN group to 2% in the post-SN group (P < 0.001). The mean postoperative intraocular pressure and incidence of hypotony on Days 1 to 2, Days 3 to 20, and Days 21 to 50 was not significantly different between the pre-SN and post-SN groups. No major complications associated with the SN technique were noted during the study period. CONCLUSION: The SN technique is a safe and simple method for effectively securing leaking sclerotomies in microincision vitrectomy surgery.

Pars plana placement of Ahmed glaucoma valve tube through sclerotomy port in refractory glaucoma: A novel surgical technique.

We describe a case of 34-year-old male with post penetrating keratoplasty glaucoma, post trabeculectomy with aphakia in the only seeing eye, in which a modified surgical technique of inserting Ahmed glaucoma valve (AGV) tube in vitreous cavity was done to reduce the risks associated with pars plana incision during pars plana vitrectomy (PPV). A hybrid 20-25 gauge PPV was done concurrently, implant fixed to sclera, and tube inserted through the 25 gauge sclerotomy port in supero-temporal quadrant. Visual acuity and intraocular pressure remained stable during 1-year follow-up.

Prospective Evaluation of Two iStent® Trabecular Stents, One iStent Supra® Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes.

INTRODUCTION: This study evaluates long-term outcomes of two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin in eyes with refractory open angle glaucoma (OAG). METHODS: Prospective ongoing 5-year study of 80 eligible subjects (70 with 4-year follow-up) with OAG and IOP ≥ 18 mmHg after prior trabeculectomy and while taking 1-3 glaucoma medications. Subjects received two iStent® trabecular micro-bypass stents, one iStent Supra® suprachoroidal stent, and postoperative travoprost. Postoperative IOP was measured with medication and annually following medication washouts. Performance was measured by the proportion of eyes with ≥ 20% IOP reduction on one medication (the protocol-specified prostaglandin) versus preoperative medicated IOP (primary outcome); and the proportion of eyes with postoperative IOP ≤ 15 and ≤ 18 mmHg on one medication (secondary outcome). Additional clinical and safety data included medications, visual field, pachymetry, gonioscopy, adverse events, visual acuity, and slit-lamp and fundus examinations. RESULTS: Preoperatively, mean medicated IOP was 22.0 ± 3.1 mmHg on 1.2 ± 0.4 medications, and mean unmedicated IOP was 26.4 ± 2.4 mmHg. Postoperatively, among eyes without later cataract surgery, mean medicated IOP at all visits through 48 months was ≤ 13.7 mmHg (≥ 37% reduction), and annual unmedicated IOP was ≤ 18.4 mmHg (reductions of ≥ 30% vs. preoperative unmedicated IOP and ≥ 16% vs. preoperative medicated IOP). At all postoperative visits among eyes without additional surgery or medication, ≥ 91% of eyes had ≥ 20% IOP reduction on one medication versus preoperative medicated IOP. At month 48, 97 and 98% of eyes achieved IOP ≤ 15 and ≤ 18 mmHg, respectively, on one medication. Six eyes required additional medication, no eyes required additional glaucoma surgery, and safety measurements were favorable throughout follow-up. CONCLUSION: IOP control was achieved safely with two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin. This microinvasive, ab interno approach introduces a possible new treatment option for refractory disease. TRIAL REGISTRATION: NCT01456390. FUNDING: Glaukos Corporation.

Outcomes for Ab Interno Bleb Revision With a Novel Translimbal Sclerostomy Spatula.

PURPOSE: To report outcomes for a novel ab interno bleb revision technique and spatula. PATIENTS AND METHODS: This is a retrospective chart review. RESULTS: A total of 21 eyes of 21 patients underwent ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula. Mitomycin C was given at least 1 week preoperation. The mean age of the patients and blebs were 67 and 6.75 years, respectively. The mean follow-up is 10.6 months (range: 3 to 17 mo). Mean preoperative intraocular pressure (IOP) (SD) was 21.9 (9.1) mm Hg on 3.7 (1.2) glaucoma medications. At 12 months follow-up, the mean IOP was 12.1 mm Hg on 0.86 medications. Four eyes failed due to uncontrolled IOP needing a tube shunt. One eye failed due to uncontrolled IOP but was lost to follow-up before a tube shunt could be performed. All failures occurred within 3 months. Two eyes had an IOP of <5 mm Hg after 1 month with no evidence of hypotony maculopathy. These cases resolved after 3 months without surgical intervention. All successful cases had blebs that were low, diffuse, and posterior. CONCLUSIONS: After a failed filtration surgery, a low-diffuse bleb was reestablished by pretreating with subconjunctival mitomycin C followed by ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula, decreasing further more invasive glaucoma procedures.

VITREOUS INCARCERATION IN SCLEROTOMIES AFTER VALVED 23-, 25-, OR 27-GAUGE AND NONVALVED 23- OR 25-GAUGE MACULAR SURGERY.

PURPOSE: To study the patterns of vitreous incarceration at sclerotomy sites by ultrasound biomicroscopy in patients subjected to valved or nonvalved small-gauge pars plana vitrectomy. METHODS: A prospective comparative study of 88 eyes affected by epiretinal membrane and macular hole. Patients were divided into four groups: valved or nonvalved 23-gauge (16 eyes each) and valved or nonvalved 25-gauge (20 eyes each); their vitreal disposition was compared by ultrasound biomicroscopy. Vitreal disposition was also assessed in 16 eyes of 16 patients subjected to valved 27-gauge pars plana vitrectomy. RESULTS: Three vitreal patterns were identified: P0 (vitreous not visible or vitreous strand distant from the sclerotomy site), P1 (vitreous strand parallel to and in contact with the sclerotomy site), and P2 (vitreous strand entrapped in the sclerotomy site). The effect of valved trocar use on vitreous incarceration seemed to be somewhat beneficial, but no statistically significant effect could be shown (odds ratio: 0.85, 95% confidence interval: 0.42-1.74, P = 0.657). Similarly, no differences in vitreous incarceration were shown among vitrectomy gauges (23, 25, or 27) both in a model including valved trocars only (P = 0.858) and in a model with all available data (P = 0.935). CONCLUSION: In 23- and 25-gauge macular surgeries, postoperative vitreous incarceration does not seem to be reduced using valved cannulas and was similar to that observed in 27-gauge surgery.

SCLEROTOMY LEAKAGE IN TRANSCONJUNCTIVAL SMALL-GAUGE PARS PLANA VITRECTOMY: Effect of Removing the Cannula Over the Light Pipe.

PURPOSE: To determine the effect of cannula removal over the light pipe on the incidence of sclerotomy leakage and to evaluate other factors that may influence the incidence of sclerotomy leaks and hypotony on conclusion of small-gauge transconjunctival pars plana vitrectomy. METHODS: Retrospective, interventional clinical study of consecutive patients who underwent small-gauge transconjunctival pars plana vitrectomy at a single academic center. Eyes were divided into a group in which cannulae were removed over the light pipe (Group L) and a group in which cannulae were simply pulled out (Group N). The primary comparison was the comparison in requirement for suturing of sclerotomies between Groups L and N. RESULTS: Forty-eight eyes of 48 patients were included in the study (Group L: 21 eyes; Group N: 27 eyes). In Group L, 14/42 (33%) superior sclerotomies required suturing compared with 7/54 (13%) sclerotomies in Group N (P = 0.024). Superior sclerotomy leaks were also more common in Group L (28/42, 67%) compared with Group N (23/54, 43%, P = 0.024). Similarly, more eyes had hypotony after cannula removal in Group L (11/21; 52%) compared with Group N (5/27; 19%, P = 0.03). There were no differences in any of these measures when comparing fluid-filled to air- or gas-filled eyes. CONCLUSION: Removing the cannula over the light pipe results in a greater frequency of leaking, including leaking that results in hypotony or that requires suturing. The technique of cannula removal affects the risk of leakage and the risk of requiring suturing of a sclerotomy.

[Long-term follow-up after deep sclerectomy]. / Langzeitverlauf nach tiefer Sklerektomie.

BACKGROUND: The aim of this study was to evaluate the long-term outcome of deep sclerectomy (DS) with a follow-up of up to 8 years. PATIENTS AND METHODS: All patients who underwent a deep sclerectomy between February 2004 and October 2005 and who attended a follow-up visit between August 2009 and October 2011 were included in this study. RESULTS: This study evaluated 74 eyes of 65 patients with a mean postoperative follow-up of 76.28 ± 10.6 (53.65-92.02) months. Preoperative IOP was 18.37 ± 6.36 mmHg, postoperative IOP at the last follow-up was 12.85 ± 3.5 mmHg, corresponding a 30 % reduction. The number of IOP-lowering eye drops was reduced from 2.36 ± 1.24 to 1.66 ± 1.21 after more than 6 years (p < 0.05). The visual fields showed a mean deviation of - 9.16 ± 8.48 dB initially and - 9.43 ± 8.07 dB at the last follow-up (p > 0.05). Complete success (IOP ≤ 15 mmHg without eye drops or additional surgery) was achieved in 5 % of patients. Qualified success (IOP ≤ 15 mmHg with eye drops or additional surgery) was achieved in 81 %. 53 % (n = 39) underwent cyclophotocoagulation and 20 % (n = 15) needed revision surgery during the follow-up period. CONCLUSION: DS is an effective long-term IOP-lowering procedure leading to visual field stabilisation.

[Secondary intraocular lens implantation using scleral suture fixation]. / Sekundäre Intraokularlinsenimplantation von Sklera-nahtfixierten Intraokularlinsen.

Scleral suture fixation is one of several techniques used for secondary lens implantation in cases of inadequate capsular support for which many variations have been published. A transscleral suture can be accomplished using either an external or internal approach. The lens can be implanted using an injector with large incisions for unfolding lenses or also via small self-sealing incisions. Episcleral fixation of the suture can be accomplished by protecting the knot under scleral flaps, intrascleral rotation of the knot and using sclerocorneal pockets or scleral grooves. The intrascleral Z-suture with five intrascleral passes of the suture is a knotless technique providing several advantages.

[Intrascleral haptic fixation of intraocular lenses]. / Intrasklerale Haptikfixation von Intraokularlinsen.

Scharioth's intrascleral haptic fixation in cases of no or insufficient capsular support has become a standardized and safe procedure for long-term fixation of intraocular lenses. The surgical technique is explained in detail. The postoperative results have demonstrated a low complication rate and a lack of contraindications for this technique.

[Can an intrascleral implant and/or the combined cataract surgery improve the long-term outcome of viscocanalostomy in glaucoma?]. / Kann ein intrasklerales Implantat und/oder die kombinierte Katarakt-OP die Langzeitprognose der Viskokanalostomie beim Glaukom verbessern?

BACKGROUND: Beside the established methods in glaucoma surgery, several procedures have been developed in the recent past including viscocanalostomy as a non-penetrating surgery. The efficiency of a combination of this procedure with an intrascleral implant and/or with cataract surgery was examined in this retrospective study over a period to 60 months postoperatively. PATIENTS AND METHODS: 67 eyes from 49 patients with glaucoma were operated in two different operational groups. 39 eyes had a viscocanalostomy (Group "V"). 16 eyes in this group additionally got a T-Flux implant ("ViskoT"), 23 did not ("Visko"). A combined cataract extraction and viscocanalostomy was undertaken in 28 eyes (Group "VK"), 18 of which did not ("ViskoKa"), and 10 of which did receive a T-flux implant ("ViskoKaT"). RESULTS: The mean preoperative intraocular pressure was 27.1 ± 4.5 mmHg and went down to 17.4 ± 2.9 mmHg postoperative up to the point of 60 months: there was a significant difference in the overall postoperative intraocular pressure in comparison to the preoperative intraocular pressure. There was, however, no significant effect to be found until after 5 years on the postoperative intraocular pressure by cataract extractions and also not by the implantation of a T-Flux. However, significantly less medication was applied up to the postoperative point of 12 and 36 months in the group with cataract surgery (VK). This difference was lost in the course of time and was no longer detectable after 60 months. However, an overall rise in both medication and goniopuncture (31.3 %) of the Descemet using YAG laser was necessary in the course of time, in order to keep a constant level of the postoperative intraocular pressure. CONCLUSIONS: Viscocanalostomy represents a safe surgical antiglaucomatous method for improving the intraocular pressure. A respective clinical improvement could be observed during the follow-up period of up to 60 months. The prognosis of intraocular pressure does not improve by the use of intrascleral implants and viscocanalostomy with simultaneous cataract surgery, however.

Evaluation of human sclera after femtosecond laser ablation using two photon and confocal microscopy.

Glaucoma is the second-leading cause of blindness worldwide and is often associated with elevated intraocular pressure (IOP). Partial thickness intrascleral channels can be created with a femtosecond laser operating at a wavelength of 1700 nm. Such channels have the potential to increase outflow facility and reduce elevated IOP. Analysis of the dimensions and location of these channels is important in understanding their effects. We describe the application of two-photon microscopy and confocal microscopy for noninvasive imaging of the femtosecond laser created partial-thickness scleral channels in human cadaver eyes. High-resolution images, hundreds of microns deep in the sclera, were obtained to allow determination of the shape and dimension of such channels. This demonstrates that concept of integrating femtosecond laser surgery, and two-photon and confocal imaging has the future potential for image-guided high-precision surgery in transparent and translucent tissue.

Influence of the interposition of a nonhollow probe during cannula extraction on sclerotomy vitreous incarceration in sutureless vitrectomy.

PURPOSE: To evaluate the effect of the cannula removal technique on postoperative vitreous incarceration using an experimental model of vitrectomized eye. METHODS: In a prospective, experimental, randomized, and observer-masked study, 118 cadaveric pig eyes were vitrectomized through 23-gauge transconjunctival sclerotomies. Once vitrectomy was finished, one of the superior cannulas was extracted with the illumination probe inserted through it, and the other cannula was removed with a cannula plug inserted. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2). RESULTS: Considering the sclerotomies whose cannulas were extracted with the light probe inside, vitreous incarceration was detected in 93.2% (73.7% G1, 19.5% G2) of the incisions. In turn, vitreous entrapment was observed in 95.8% (43.2% G1, 52.6% G2) of the entry sites whose cannulas were extracted with the plug inserted. Statistical analysis showed significant differences when comparing postvitrectomy vitreous incarceration grades in sclerotomies according to the cannula extraction technique (P < 0.0001). CONCLUSIONS: Interposing the light probe through the cannula during its removal reduces vitreous incarceration grade in our experimental model. This simple maneuver may decrease complications related to vitreous entrapment, such as peripheral retinal tears and acute endophthalmitis.

Ab externo scleral fixation of intraocular lens.

UNLABELLED: We describe an ab externo technique that facilitates IOL scleral fixation and reduces the risk associated with previous ab externo scleral fixation techniques. This technique uses a microvitreoretinal blade and an internal limiting membrane forceps to create sclerotomies and retrieve the suture, respectively. FINANCIAL DISCLOSURE: Dr. Cionni is a consultant to Morcher GmbH, Stuttgart, Germany. Dr. Crandall is a consultant to Alcon Laboratories, Inc., Ft. Worth, Texas, USA. No other author has a financial or proprietary interest in any material or method mentioned.

Effect of interposition maneuver during cannula removal on vitreous incarceration rate in vitrectomized eyes measured by ultrasound biomicroscopy.

PURPOSE: To evaluate the influence of the cannula removal maneuver on the postoperative incisional vitreous incarceration using an experimental model of vitrectomized eye. METHODS: Prospective, experimental, randomized and observer-masked experimental study in which 23-gauge transconjunctival sutureless vitrectomy was performed through oblique sclerotomies in cadaveric pig eyes. Once the vitrectomy was finished, one of the superior cannulas was removed with the light probe introduced through it, and the other cannula was extracted with the cannula plug inserted. Postoperative incisional vitreous incarceration was evaluated by ultrasound biomicroscopy (UBM). RESULTS: 60 eyes included. Considering the 60 superior sclerotomies whose cannulas were extracted with the light pipe inserted, vitreous incarceration was observed in 35% of them. On the other hand, 71.6% of the incisions whose cannulas were removed with the cannula plug inserted showed vitreous incarceration (p = 0.00013). CONCLUSIONS: Interposing the light probe through the cannula when it is removed seems to reduce the postoperative wound vitreous incarceration rate in our experimental model.

Miyake-Apple view of inner side of sclerotomy during microincision vitrectomy surgery.

PURPOSE: To examine the inner surface of the sclerotomy during microincision vitrectomy surgery by Miyake-Apple view. METHODS: The anterior half of porcine eyes was attached to a transparent acrylic plate with cyanoacrylate glue. Then, either a 23-gauge or a 25-gauge trocar-cannula was inserted through the sclera obliquely. The inner surface of the entrance site was observed posteriorly by Miyake-Apple view. These images were compared with the endoscopic view of two patients who underwent vitreous surgery for an epiretinal membrane. RESULTS: When the trocar-cannula was inserted obliquely, the Miyake-Apple view showed that the ciliary epithelium at the sclerotomy site was stretched. When the trocar-cannula was inserted vertically, the ciliary epithelium was folded, and the folds remained even after the trocar was removed. Vitreous strands were seen incarcerated into the sclerotomy site. In human eyes, a folding of the ciliary epithelium was not clearly seen with the endoscopic view but the incarcerated vitreous was seen. CONCLUSION: The Miyake-Apple view provided a precise, in vivo, observation of the inner surface of the entry site. It disclosed the morphological stress on the ciliary epithelium by the sclerotomy.

Presumed sclerotomy site bleeding inflowing into the anterior chamber after the removal of a 23-gauge microcannula in 23-gauge sutureless vitrectomy.

We experienced two cases of the influx of the sclerotomy site bleeding into the anterior chamber during 23-gauge sutureless vitrectomy for pseudophakic rhegmatogenous retinal detachment. Soon after the removal of a 23-gauge microcannula at the end of the surgery, presumed sclerotomy site hemorrhage was rapidly fluxed into the anterior chamber. The anterior chamber bleeding might come from the sclerotomies rather than from episcleral vessels. The posterior pressure in the gas-filled pseudophakic eye might have pushed the sclerotomy site bleeding into the anterior chamber. We could not find any vitreous hemorrhages. The hemorrhage within the anterior chamber spontaneously absorbed within 14 days.

The SuperCrescent diamond knife: an innovative blade for glaucoma surgery.

Diamond blades have been used extensively in cataract surgery but their routine use in glaucoma surgery has been limited owing to the lack of controlled sharpness. The SuperCrescent knife is an ultrathin (100 µm) diamond blade that is an innovative modification of conventional blade design. Its pentium faceted trapezoidal design along with the square front surface area affords better control during dissection and has been used with success in both traditional trabeculectomies and nonpenetrating glaucoma procedures.

[Scope and limititions of innovative vitrectomy systems]. / Möglichkeiten und Grenzen der innovativen Vitrektomiesysteme.

PURPOSE: The aim of the present article is to review the methodical and technological development of pars plana vitrectomy. Special attention is drawn to safety, efficiency and functionality of the innovative 25-gauge und 23-gauge vitrectomy systems which are compared to the standard 20-gauge vitrectomy system. This was done based on clinical studies and case reports. METHODS: A literature search was conducted in a cluster of different medical databases (XMedall; XPharmall). Focus of the research was the "development" and "status quo" of pars plana vitrectomy. In particular, clinical studies and case reports dealing with safety and efficiency of 20-, 23- and 25-gauge vitrectomy systems have been evaluated. Only peer-reviewed articles from 1966 until today were investigated. Finally, a descriptive analysis of the relevant studies was made. RESULTS: Both innovative vitrectomy systems are safe and effective and help to reduce operating time. There was no significant difference in postoperative complications following 25-gauge vitrectomy and 20-gauge vitrectomy. 25-gauge instruments, however, show a greater flexibility. For this reason a certain learning curve is required and the range of application is limited. Due to its greater stiffness and larger diameter, the 23-gauge system - while still allowing a transconjunctival access - may overcome the disadvantages of the 25-gauge system. However, the use of silicone oil may lead to leakage of the sclerotomies and thus necessitate additional suturing. CONCLUSION: The use of both innovative vitrectomy systems offers the advantage of a faster and less invasive surgical procedure. However, there are disadvantages which limit the indications for 25-gauge vitrectomy. The 23-gauge vitrectomy may overcome these disadvantages and - due to its wider range of application - may be used instead of conventional 20-gauge vitrectomy in most cases. It may therefore become the new standard for vitrectomy.

[A comparison between absorbable and non-resorbable scleral implants in deep sclerectomy (T-Flux and SK-Gel)]. / Vergleich von resorbierbaren und nichtresorbierbaren skleralen Implantaten bei tiefer Sklerektomie (SK-Gel und T-Flux).

BACKGROUND: The intraocular pressure (IOP) lowering effects of deep sclerectomy (partially combined with phacoemulsification) with different scleral implants (T-Flux- or SK-Gel) were investigated. PATIENTS AND METHODS: In a retrospective study, 72 patients with medically uncontrollable glaucoma underwent non-penetrating deep sclerectomy. Of these, 54 patients received T-Flux implants and 18 SK-Gel implants. Examinations were carried out shortly before and after surgery, as well as after 12 months. RESULTS: Prior to surgery IOP was 18.4+/-5.5 mmHg (n=72) and 12 months after surgery it was 13.1+/-3.8 mmHg (n=65). The number of antiglaucomatous eyedrops used prior to surgery was 2.3+/-1.3 (n=72) and 12 months after surgery 0.2+/-0.6 mmHg (n=65). Secondary IOP-lowering surgery after 12 months was carried out on 15.3% of the operated eyes, and consecutive goniopunctures after 12 months were 25%. No significant differences were found between the two groups. CONCLUSIONS: The short- and mid-term IOP lowering effects in deep sclerectomy with scleral implants were quite satisfying no matter which implant was used. There was no difference in deep sclerectomy whether or not combined with cataract surgery.