Influence of orientation of the external linear incision created by the 25-gauge trocar and related factors on sclerotomy closure: A clinical and optical coherence tomographic study

Purpose: To assess the influence of orientation of the external linear incision created by the trocar and related factors on sclerotomy closure in 25-gauge (25G) transconjunctival vitreous surgery (TVS). Methods: A total of 46 eyes of 46 patients who underwent 25G TVS (23 circumferential incisions and 23 radial incisions) were studied. Clinical and anterior segment optical coherence tomography (AS-OCT)-based comparison of self-sealed and sutured sclerotomies was done. The influence of age, ocular surgeries and injections, axial length, cannula type, sclerotomy quadrant, surgery duration, vitreous base excision, and tamponade on suture rates was analyzed. Results: Of the 46 eyes, 23 eyes required suturing [circumferential: 17 (74%) and radial: 6 (26%); P = 0.003]. A significantly lesser proportion of superonasal quadrant and inferotemporal quadrant sclerotomies needed suturing [9 (24%) and 12 (27%)] when compared with superotemporal quadrant [17 (37%)]. Sclerotomies to the left of the surgeon and the infusion port required significantly lesser suturing [10 (25%) and 13 (28%), respectively] when compared with that of surgeon's right [15 (35%)]. Suturing was significantly lesser when gas or oil tamponade was used [5 (36%) and 2 (20%), respectively] when compared with no tamponade [16 (73%)]. In eyes without tamponade, suturing was lesser with radial sclerotomies (P = 0.003). The odds of having an open sclerotomy tract on AS-OCT were ?5 when circumferential sclerotomies were used. Conclusion: Self-sealing was more common with radial external incisions. Tamponade was associated with less suturing. Superotemporal sclerotomies and sclerotomies toward the surgeon's dominant hand were often sutured. In this cohort, other factors did not influence sclerotomy closure.

Midline sclerotomy approach for intraocular foreign body removal in phakic eyes using endoilluminator: A novel technique

Purpose: The objective of this study is to describe the removal of retained intraocular foreign body (RIOFB) by bimanual pars plana vitrectomy through midline sclerotomy in phakic patients. Technique: Four eyes with RIOFB and clear lens underwent microincision vitrectomy surgery. A chandelier illumination was placed through one of the existing ports. The foreign body (FB) was localized by direct visualization (intravitreal) or indentation (pars plana), stabilized using an intraocular magnet/FB forceps introduced through a midline sclerotomy and freed of vitreous from all sides using a vitrectomy cutter through the other port bimanually, reoriented along their long axis and extracted through the midline sclerotomy. Results: All four FBs were removed successfully without slippage or damage to the clear lens. Conclusion: Chandelier illumination-assisted removal of FB through midline sclerotomy helps in easier localization, stabilization and removal, avoiding lens touch even in anteriorly located FBs such as at pars plana.

Full-thickness Sclerotomy for Uveal Effusion Syndrome

To report the surgical outcome of full-thickness sclerotomy in five cases of uveal effusion syndrome (UES). Full-thickness sclerotomy without sclerectomy was performed on five eyes of four patients with UES with or without nanophthalmos. In four of the eyes, exudative retinal detachment associated with UES resolved after the sclerotomy. The subretinal fluid in one eye, which had a normal axial length, was relieved after undergoing three sclerotomy procedures. Full-thickness sclerotomy without vortex vein decompression or sclerectomy is an effective surgical option for the management of significant UES.

Treatment and analysis of risk factors of suprachoroidal hemorrhage induced by intraocular surgery / 中华实验眼科杂志

Background Suprachoroidal hemorrhage (SCH)is a rare but devastating complication of ophthalmic surgery,and it is crucial to be aware of the risk factors and select effective treatment. Objective Present study was to assess the treatment and risk factors of SCH induced by intraocular surgery. Methods Retrospective case series were carried out to investigate the clinical data of 15 eyes from 15 patients with SCH at Peking Union Medical College Hospital.The risk factors of SCH were analyzed.Written informed consent was obtained before any medical examination and treatment.SCH was occurred in 10 eyes during intraocular surgery,while the SCH was diagnosed in other 5 eyes 1-3 days after operation.Surgical drainage was carried out in 8 eyes,of which 3 eyes combined with vitrectomy besides surgical drainage and other 5 eyes were treated with medication alone.Results SCH was completely removed and absorbed in 12 eyes.The visual acuity was improved in 6 eyes,unchanged in 6 eyes and decreased in 3 eyes.Nine eyes complicated with retinal detachment and reattached in 6 eyes after treatment.Seven eyes combined with hypermyopia,6 eyes combined with glaucoma,and 1 eye was aphakia.Four patients combined with hypertension,and 2 patients had diabetes mellitus. Conclusions SCH induced by intraocular surgery develops rapidly and violently,and it can result in vision loss without effective treatment.Suturing surgical incision immediately,applying hypertonic agents and sclerotomy drainage are the urgent approaches to treat SCH.Medicines and/or sclerotomy could be optional according to the amount of bleeding and other ocular complication.The risk factors of SCH include myopia,glaucoma and the instantly dropping of intraocular pressure.

Dilated episcleral veins with secondary open angle glaucoma.

We report a case of dilated episcleral vein with secondary open angle glaucoma. A 65-year-old female presented with redness of both the eyes without any prior systemic history. Her ocular examination revealed dilated episcleral veins and a high intraocular pressure (IOP) of 38 mm Hg in the right eye. Systemic examination was negative for carotid cavernous fistula, low-grade dural arteriovenous fistula, dysthyroid ophthalmopathy, and primary pulmonary hypertension. During follow-up, her IOP remained in high thirties despite maximum medications. She underwent right eye trabeculectomy with partial thickness sclerectomy with sclerotomy. In the beginning, the sclerotomy incision was not deepened into the suprachoroidal space. She developed choroidal effusion during surgery and the sclerotomy was deepened into suprachoroidal space and straw color fluid was drained. Postoperatively, she developed choroidal effusion, which resolved with conservative management. This case highlights the importance of sclerotomy in such cases of high episcleral venous pressure.

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.

Prevention for occurrence of sclerotomy-related complications during vitrectomy / 眼科

Pars plana vitrectomy (PPV) is a common vitreoretinal surgical procedure. With its rapid advances many vitreoretinal diseases that have the potential to blind can now be treated. Although surgical complications are decreasing due to the improvement of surgical tools and techniques, these are not uncommon in our daily clinical practice. The sclerotomy-related complications, for example, are of great concern because they can result in retinal detachment and loss of vision. This article will review the common sclerotomy-re-lated complications including the sclerotomy-related retinal breaks and detachment, fibrovaacular ingrowth into the sclerotomy site, and vitreous incarceration. The risk factors and the practical measures to prevent these complications are also discussed. (Ophthalmol CHN, 2009, 18: 225-228)

Sclerotomy-related Retinal Breaks in Vitrectomy for Proliferative Diabetic Retinopathy: 20- vs 23-Gauge Systems

PURPOSE: To compare the rate of intraoperative sclerotomy-related retinal breaks (SRRB) between 20- and 23-gauge vitrectomy for proliferative diabetic retinopathy (PDR). METHODS: Medical records of 62 consecutive eyes of 54 patients who underwent 20-gauge pars plana vitrectomy (PPV) and 63 consecutive eyes of 55 patients who received 23-gauge transconjunctival sutureless vitrectomy were retrospectively reviewed. RESULTS: Three (4.8%) out of 62 eyes in the 20-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 4 months postoperatively, while 2 (3.2%) out of 63 eyes in the 23-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 3 months postoperatively. CONCLUSIONS: There were no significant differences in the rates of sclerotomy-related retinal breaks and sclerotomy-related retinal detachments between 20-gauge PPV and 23-gauge PPV for PDR.

A Combination of 23-gauge and 20-gauge Transconjunctival Sutureless Vitrectomy

PURPOSE: To describe the clinical experience and safety profile of a combination of 23-gauge and 20-gauge transconjunctival sutureless vitrectomy (TSV) METHODS: Thirty-seven eyes of thirty-seven consecutive patients who underwent 23-gauge combined with 20-gauge transconjunctival vitrectomy surgery by a single surgeon from August 2006 through December 2006 were reviewed retrospectively for surgical indications, wound problems, and postoperative complications. RESULTS: Thirty-seven eyes, including eyes with proliferative diabetic retinopathy (n=24), macular hole (n=3), epiretinal membrane (n=3), vitreous hemorrhage due to branch retinal vein occlusion and choroidal neovascular membrane (n=3), vitreous opacity secondary to uveitis (n=1), rhegmatogenous retinal detachment (n=1), and vitreoretinal traction syndrome (n=1), underwent operation. Seven eyes at 23-gauge sclerotomy sites and 15 eyes at 20-gauge sclerotomy sites had subconjunctival hemorrhage. Three eyes required sutures at 20-gauge sclerotomy sites intraoperatively due to wound leakage. One wound hemorrhage occurred at a 23-guage sclerotomy site. Vitreous hemorrhage (4 eyes), hyphema (2 eyes), and vitreous hemorrhage with hyphema (1 eye) occurred postoperatively. Postoperative hypotony, retinal detachment, and other complications did not occur. CONCLUSIONS: A combination of 23-gauge and 20-gauge transconjunctival sutureless vitrectomy which was created by modifying transconjunctival sutureless vitrectomy systems published previously guarded against sclerotomy wounds and a variety of vitreoretinal surgical indications.

Two Cases of Uveal Effusion Syndrome

PURPOSE: To report a case of uveal effusion syndrome associated with hypotony and a case of uveal effusion syndrome in nanophthalmos. METHODS: The first case was a 25-year-old man who presented with decreased visual acuity in the left eye and hypotony. Fundus examination revealed choroidal effusion and retinal detachment with a thickened eyeball. Partial thickness sclerotomy and sclerectomy were performed. The second case was a 13-year-old boy who had uveal effusion syndrome with a nanophthalmic eye. RESULTS: In the patient with hypotony, intraocular pressure was well maintained following partial thickness sclerotomy and sclerectomy, and choroidal effusion and retinal detachment were reduced. The visual acuity of the nanophthalmic patient was well maintained during a 3-year follow-up period without treatment. CONCLUSIONS: appropriate treatment modalities should be considered depending on the ophthalmic condition of the individual patient.

Ultrasound Biomicroscopy of Sclerotomy Site

PURPOSE: Complications after pars plana vitrectomy are causes that courses heal the wound of sclerotomy site. It is difficult to diagnose abnormal finding at sclerotomy site because of its anatomical location. This study was aimed at assessing changes at the sclerotomy site using ultrasound biomicroscope (UBM) in eyes that underwent pars plana vitrectomy. METHODS: A dynamic in vivo examination using ultrasound biomicroscope (Model P45 UBM plus, Paradigm, U. K.) was performed on 120 sclerotomy sites of 40 eyes of 39 patients after pars plana vitrectomy. Average age was 52.56 years old, average post-operative period was 6.45 +/- 5.71months. RESULTS: In 120 sclerotomy site, vitreous incarceration, fibrovascular proliferation, scleromalacia was detected using UBM at 30%. Abnormal fidings of proliferative diabetic retinopathy group are more frequent than non-diabetic retinopathy group. After post-vitrectomy hemorrhage patient group is more abnormal finding. CONCLUSIONS: Ultrasound biomicroscope is a useful tool for the evaluation of sclerotomy site, which is difficult by ordinary method and is an invaluable tool in assessment of the patient before reoperation.

Evisceration with Hydroxyapatite Implant

In contrast to the literature on the use of hydroxyapatite orbital implants with enucleation, reports of the use of hydroxyapatite implants with evisceration are limited and those that have been published reported high exposure rates. The authors described modified surgical technique of primary evisceration with hydroxyapatite implant and evaluated its effects on cosmetic appearance and the prevention of implant exposure. All 28 consecutive patients underwent evisceration with hydroxyapatite implant between December 1994 and April 1998. To place an appropriate hydroxyapatite implant into the scleral shell without tension we made a saw-tooth shaped large posterior sclerotomy around the optic nerve sparing 6-o`clock position to minimize the inferior displacement of the implant. In cases with very small globes we made 3 to 4 additional radial posterior sclerotomies. During the mean follow-up of 13.5 months, none of the patients experienced complications such as conjunctival erosion, hydroxyapatite exposure, implant extrusion, significant enophthalmos, or superior sulcus deformity. The authors have had good success without major complications using our modified surgical technique for hydroxyapatite orbital implants with evisceration.

Evisceration with Hydroxyapatite Implant

In contrast to the literature on the use of hydroxyapatite orbital implants with enucleation, reports of the use of hydroxyapatite implants with evisceration are limited and those that have been published reported high exposure rates. The authors described modified surgical technique of primary evisceration with hydroxyapatite implant and evaluated its effects on cosmetic appearance and the prevention of implant exposure. All 28 consecutive patients underwent evisceration with hydroxyapatite implant between December 1994 and April 1998. To place an appropriate hydroxyapatite implant into the scleral shell without tension we made a saw-tooth shaped large posterior sclerotomy around the optic nerve sparing 6-o`clock position to minimize the inferior displacement of the implant. In cases with very small globes we made 3 to 4 additional radial posterior sclerotomies. During the mean follow-up of 13.5 months, none of the patients experienced complications such as conjunctival erosion, hydroxyapatite exposure, implant extrusion, significant enophthalmos, or superior sulcus deformity. The authors have had good success without major complications using our modified surgical technique for hydroxyapatite orbital implants with evisceration.

Serous Retinal Detachment Following Trabeculectomy in a Case of Sturge-Weber Syndrome with Glaucoma

A trabeculectomy with mitomycin (0.2mg/ml, 5 minutes) was performed in a 28-year-old man with glaucoma associated with Sturge-Weber syndrome. Two prophylactic posterior sclerotomies were made in an attempt to prevent sudden uveal effusion. The surgery was uncomplicated. On the first postoperative day, however, the anterior chamber became shallow with hypotony (<4mmHg). A 360 degrees choroidal detachment with serous retinal detachment encroaching upon macula was recognized. On the third postoperative day, evacuation of the suprachoroidal space was performed. However, the eye remained hypotonus and choroidal expansion with overlying retinal detachment occured again. The bleb decreased in size with time and the intraocular pressures(IOPs) rose gradually (10-14mmHg). The choroidal and retinal detachment resolved spontaneously with the increased IOP in 40 days. Twenty seven monthes after trabeculectomy, he has a small localized. bleb. The IOP is maintained in the high-teens(15-20mmHg) without any medication.

A Case of Post. Scleritis Associated with Ciliochoroidal Detachment and Ant. Uveitis in Background Diabetic Retinopathy Patient

Posterior scleritis is an uncommon disease. Its clinical manifestations may include pain. reduced visual acuity, cellular infiltration in the aqueous and vitreous humor, serous retinal detachment, chorioretinal lesions, and disc or macular edema. The diagnosis of posterior scleritis is often difficult due to its rarity and the diversity of symptoms. However, ultrasography and computed tomography are noninvasive methods for diagnosis of posterior scleritis. We treated posterior scleritis associated with ciliochoroidal detachment and anterior uveitis with sclerotomy, drainage of ciliochoroidal fluid in a background diabetic retinopathy patient.

Experimental intraocular fibrovascular proliferation through sclerotomy wound

In the process of closing scleral wounds caused by various conditions, incarceration of conjunctiva, Tenon's capsule, or vitreous in the wound can occur unexpectedly. We created such conditions experimentally in order to discover their intraocular complications. The experimental materials consisted of 12 albino rabbits (24 eyes) divided into two groups (Groups I & II). Vitrectomy was performed in the Group I rabbits (12 eyes) but not in the Group II rabbits (12 eyes). Flaps of conjunctiva and Tenon's capsule were made and inserted into the vitreous cavity through the sclerotomy site, which was soon closed. Fundal examination of the rabbits was carried out using an indirect ophthalmoscope at intervals after the procedure; first at 3 days, then at 1, 3, and 6 weeks, and then at 3 months and 6 months, respectively. Enucleation of the rabbits' eyes 4 from two different rabbits at each of these intervals was carried out, and the extracted eyes were examined under a light microscope at each interval. The results are summarized as follows: 1. All rabbit eyes studied showed intraocular fibrovascular proliferation. 2. The extent of tissue proliferation, which was proportional to the amount of vitreous hemorrhage, was greater in Group II than in Group I. 3. The proliferated tissue developed to "band" by three weeks postexperiment, after which it gradually regressed. 4. The fibrovascular band was made of fibroblasts, stromal matrix, and capillaries.