Evolutionary and Revolutionary Trends in Vitreoretinal Surgery

PAWAN BHATNAGAR, MD, HOWARD F. FINE, MD, MHSc, & I-VAN HO, MBBS INTRODUCTION In the 35 years that have elapsed since Machemer first reported successful closed vitreoretinal surgery, the field has seen tremendous growth.1 The advent of vitreoretinal surgery has allowed for the management of previously incurable conditions and has expanded the treatment options in others. Herein, we describe the revolutionary and evolutionary trends in vitreoretinal surgery that have and will continue to define the face of the field in the coming years. Revolutions are defined as advances that are major steps forward that brought or will bring widespread change in surgical practice, while evolutions are those that reflect the continued refinement of surgical patient care. As innovations in technology and equipment often pave the way for progress in surgical techniques, we will begin our discussion with the changes in surgical equipment that have and will continue to redefine vitreoretinal surgery. HEAVY LIQUIDS

Figure 1. Intraoperative photographs of technique to stain theinternal limiting membrane while protecting the macular hole with a bubble of perfluorocarbon liquid. This prevents the ICG from reaching the RPE or subretinal space during

The introduction of perfluorocarbon liquids into the surgical arena has spurred a new era in retinal surgery.2 Beyond having staining. revolutionized the treatment of retinal detachments with giant tears by obviating the need for the surgeon to operate in the supine position, it has also affected great change in the management of many other conditions. New evolutionary applications of this compound have been devised to harness perfluorocarbon liquid as a "third instrument." These approaches include its use in aiding the management of dislocated lenses, in the removal of intraocular foreign bodies, and for stabilization of bullous retinal detachments during vitreous base shaving. In subretinal or suprachoroidal hemorrhages, perfluorocarbon liquids are used to displace hemorrhage through retinotomies or sclerotomies for evacuation.3,4 Others have used perfluorocarbons in macular hole surgery for safer application of indocyanine green (ICG) to stain the inner limiting membrane (ILM) while minimizing the risk of retinal pigment epithelium (RPE) exposure with good results (Figure 1). Its use as a short-term tamponade of inferior retinal pathologies is also an area of continued investigation.5

A natural evolutionary focus includes the search for perfluorocarbon-related liquids with safer profiles for longer-term postoperative tamponade of inferior retinal breaks.5 Though the search for an ideal compound continues, some progress has been made. The recent introduction of heavy oil mixtures as inferior tamponade agents has shown initial promise in the management of cases with proliferative vitreoretinopathy as well as those with inferior retinal breaks.6-8 Although attractive as a tamponade agent, the long-term effects of heavy silicone oil are unknown and its subsequent removal from the eye is a very challenging maneuver, particularly in the setting of an underlying re-detached retina. SUTURELESS SURGERY A recent revolutionary trend in vitreoretinal surgery was the introduction of the transconjunctival sutureless25gauge vitrectomy system (Figure 2).9 This technique has allowed for reduced surgical trauma, duration of surgery, and postoperative healing time. The success of 25-g vitrectomy has been well described, but its application for more complex vitreoretinal diseases, such as complex retinal detachment with proliferative vitreoretinopathy, has been limited. The main limiting factors with the 25-gsystem are the relative lack of instrument rigidity, slower vitreous cutting ability, and suboptimal fluidics inherent to the reduced caliber of the instrumentation. The risk of postoperative hypotony from leaking wounds that persist despite partial fluid-air exchange has been reported as well.

Some retinal surgeons have described the technique of 20-g sutureless vitrectomy to overcome some of the limitations of 25-g systems, but inconsistencies in the application of this technique have limited its widespread use. This has led to the evolutionary compromise between these two techniques: 23-g transconjunctival sutureless vitrectomy.10 This system combines the advantages of decreased surgical trauma and recovery time enjoyed with 25-g sutureless vitrectomy with the sturdier instrumentation and improved fluidics of the 20-g vitrectomy systems. These characteristics make 23-g vitrectomy a promising approach to efficiently and safely tackle the complete range of vitreoretinal surgical procedures with a single system (Figure 3). VISUALIZATION Optimal visualization is the starting point of any successful retinal surgery; as such, the development of wide-angle viewing systems has greatly expanded the scope and safety of vitreoretinal surgery. Today, the 2 types of wide-angle systems include both contact and noncontact lenses.11 Both deliver a large field (up to 150) of view during vitreoretinal surgery, leading to a safer and more complete vitrectomy. Modern contact lenses include those that are more compact, allowing the surgeon to visualize the scleral ports at all times, hence facilitating

Figure 2. This patient presented with an idiopathic epiretinal membrane and preoperative visual acuity of 20/100. A. Placement of the first microcannula. The microcannula is being held by its collar to stabilize it while the trocar is withdrawn. B. An infusion cannula has been placed in the infe-rotemporal quadrant. No suture is required to hold it in place, because it fits tightly into the microcannula. In the same frame, a second microcannula is being placed. The insertion of the microcannula is transconjunctival, and no previous dissection is required. C. After insertion of the second microcannula, its orifice was temporarily closed with a plug (black arrow), and a third microcannula was inserted (white arrow). D. After vitrectomy and membrane peel, all the microcannulae were simply removed. No suture was required at any conjunctival and scleral opening site. In this frame, the superonasal microcannula is being removed.E. Last, the inferotemporal microcannula is being removed in conjunction with the infusion cannula held by its collar.F. The eye immediately after the removal of all microcannulae. This sutureless and self-sealing system allowed for minimal postoperative discomfort and hastened the recovery by minimizing the surgically induced trauma. Intraocular pressure at first postoperative visit was 12 mm Hg. Visual acuity was measured at 1 week in this case and improved to 20/40.