Step by Step VITRECTOMY PDF

Step by Step
Vitrectomy
Step 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
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Step By Step Vitrectomy

First Edition: 2006
Second Edition: 2013
ISBN 978-93-5090-354-4
Printed at
Dedicated to
All vitreoretinal surgeons
Contributors
Amparo Navea Tejerina MD PhD Carme Guardia MD

Chairman of Vitreoretinal Division Physician of Ophthalmology in the
Fundación Oftalmologíca del Vitreoretinal Section
Meditarraneo Parc Taulí Hospital
Valencia, Spain Sabadell, Barcelona
Vitreoretinal Surgeon in the Instituto
Ana Boixadera MD PhD Oftalmologico Hoyos
Department of Ophthalmology Sabadell, Barcelona, Spain
Hospital Vall d´Hebron
Barcelona, Spain Carmen Desco MD
Physician of Ophthalmology in the
Ana Orive MD Vitreoretinal Section
Physician of Ophthalmology Fundación Oftalmologíca del
Hospital Alcorcon Meditarraneo
Madrid, Spain Valencia, Spain
Anna Grabowoska MD Cristian Fernández-Martínez MD

Vitreoretinal Surgery
Resident of Ophthalmology
Physician
Hospital Universitario la Paz
Hospital General Universitario
Madrid, Spain
de Elche
Alicante, Spain
Anniken Burés MD
David Salom MD
Instituto de Microcirugía Ocular
Barcelona, Spain
Hospital Universitario y Politécnico
Beatriz Manzano MD la Fe
Physician of Ophthalmology Valencia, Spain
Hospital Universitario la Paz
Madrid, Spain Elena palacios MD
Physician of Ophthalmology in the
Carlos Mateo MD PhD Vitreoretinal Section
Vitreoretinal Surgery Fundación Oftalmologíca del
Instituto Microcirugía Ocular Meditarraneo
Barcelona, Spain Valencia, Spain
Step by Step Vitrectomy
viii
Enrique López-Sánchez Javier Orduña MD
Vitreoretinal Surgery Physician of Ophthalmology
Hospital Arnau de Vilanova Hospital Alcorcon
Valencia, Spain Madrid, Spain
Fernando M penha MD Jorge Mataix MD

Vitreoretinal Diseases Sector Physician of Ophthalmology in the
Vision Institute Vitreoretinal Section
Department of Ophthalmology Fundación Oftalmologíca del
Federal University of São Paulo Meditarraneo
São Paulo, Brazil Valencia, Spain
Félix Armadá Maresca MD PhD Josefina Bañuelos Bañuelos MD PhD

Head of Section Vitreoretinal Surgery
Vitreoretinal Surgery Hospital Alcorcon
Hospital Universitario la Paz Madrid, Spain
Madrid, Spain
José García-Arumí MD PhD
J Fernando Arevalo MD FACS Professor of Ophthalmology, UAB
Executive Vice-President of the Head of Ophthalmology Hospital
Pan-American Association of Valle Hebrón, Barcelona, Spain
Ophthalmology Instituto de microcirugía Ocular Bar-
Chief of Vitreoretinal Division celona, Spain
The King Khaled Eye Specialist
Hospital, Riyadh, Kingdom of Saudi José J Martínez-Toldos MD PhD
Arabia, KKESH/WEI Adjunct Chief Service of Ophthalmology
Professor of Ophthalmology Wilmer Hospital General Universitario de Elche
Eye Institute Alicante, Spain
The Johns Hopkins University
Baltimore, MD, USA José María Ruiz Moreno MD PhD
Professor of Ophthalmology
Jairo E Hoyos MD Castilla la Mancha University
Physician of Ophthalmology Albacete Medical School
Instituto Oftalmologico Hoyos Vissum, Alicante Institute of
Sabadell, Barcelona, Spain Ophthalmology
Alicante, Spain
Jaume Catalá MD
Physician of Ophthalmology Juan Carlos Elvira MD PhD
Instituto Oftalmologico Chief of Ophthalmology
HoyosSabadell Hospital del Vilanolopo Elche
Barcelona, Spain Alicante, Spain
Javier Montero Moreno MD Laura Distefano MD

Ophthalmology Unit Department of Ophthalmology
Pio del Rio Hortega University Hospital Vall d´Hebron
Valladolid, Spain Barcelona, Spain
Contributors
ix
Manuel Diaz-Llopís MD PhD patricia Udaondo MD
Professor of Ophthalmology Physician of Ophthalmology
University of Valencia Vitreoretinal Surgery
Hospital Universitario y Politécnico la Hospital Universitarioy Politécnico
Fe de Valencia la Fe
Valencia, Spain Valencia, Spain
María Granados MD
Reinardo A García MD
Hospital Universitario la Paz Vitreoretinal Section
Madrid, Spain Clínica Oftalmológica Centro
Caracas
Mauricio Maia MD PhD Caracas, Venezuela
Vitreoretinal Disease Unit
Brazilian Institute of Fighting against Salvador Garcia-Delpech MD
Blindess and Physician of Ophthalmology
Hospital de Olhos Oeste Paulista Hospital Universitarioy Politécnico
Assis and Presidente Prundente la Fe
Sao Paulo, Brazil Valencia, Spain
Melania Cigales MD PhD
Verónica Oria MD
Instituto Oftalmologico Hoyos Vitreoretinal Section
Sabadell, Barcelona, Spain Clínica Oftalmológica Centro
Caracas
Miguel Angel Zapata MD Caracas, Venezuela
Department of Ophthalmology
Hospital Vall d´Hebron Vicente Chaqués Alepuz MD PhD
Barcelona, Spain Head of Ophthalmology
Hospital Arnau de Vilanova
Natalia pastora MD Valencia, Spain
Hospital Universitario la Paz,
Vicente Martinez-Castillo MD PhD
Madrid, Spain
patricia Martínez-García MD Hospital Vall d´Hebron
Physician of Ophthalmology Barcelona, Spain
Hospital Alcorcon
Madrid, Spain
Foreword
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
Foreword
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.
We have also prepared a video showing the different surgical procedures
featuring experts who describe the techniques of tissue staining, removing
epiretinal and internal limiting membranes, treating the various forms of
proliferative retinopathy, lensectomy procedures, how to manage myopic
maculoschisis and the use of new medications.
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
Preface 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.
This book offers to the reader descriptions of all the procedures of basic
vitreoretinal surgery and how they should be used. These step-by-step
descriptions are related from our own experience and include our opinion
about which methods should be preferentially used for each step. Apart from
its illustrations and photographs, several video recordings are provided on
two DVDs in which the reader will be able to see the most frequently used
procedures, such as those performed to treat cataract surgery complications,
retinal detachment, problems related to diabetic retinopathy and macular
disease, along with the use of tissue dyes, such as brilliant blue, trypan blue
and triamcinolone, to visualize the eye structures during surgery.
Finally, we recommend continuing education through the different specialist
journals and Internet sites offering information and videos on novel surgeries
as the best way to refine and improve this extraordinary surgical technique.
Jairo E Hoyos
Preface 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.
Apart from the images and photographs obtained during surgery, we also
include several video recordings on a CD, in which the reader may directly
observe the most common maneuvers performed, such as those undertaken to
rescue complications arising from cataract surgery, treating different types of
detached retina, diabetic retinopathy, macular disease, the use of tissue stains,
such as indocyanine green and trypan blue, and the use of triamcinolone in
vitreoretinal surgery.
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.
Jairo E Hoyos
Contents
1. Surgical Anatomy 1
Cristian Fernández-Martinez, José Juan Martinez-Toldos
Introduction 1
Anatomy of the Vitreous 1
Vitreous Base and Vitreoretinal Interface 2
Anatomical Distances in Vitrectomy 4
Crystalline Lens 4; Extraocular Muscles 4; Ciliary Body 5; Blood Vessels 5
2. presurgery Examination 9
Manolo Baeza Diaz, José Juan Martinez-Toldos
Medical History 9
Visual Acuity 9
Pupil Reflexes 9; Color Perception 10; Vascular Entoptic Test 10; Slit Lamp
Microscopy 10; Tonometry 10
Examining the Fundus 11
Indirect Ophthalmoscopy 11; Biomicroscopy of the Retina 11
Ultrasonography 11
Vitreous Disorder 12
Fluorescein Angiography 16
Electrophysiology 17
Electroretinography 17; Evoked Visual Potentials 17
3. Vitrectomy and Optical Coherence Tomography 19

David Salom, Patricia Udaondo, Manuel Díaz Llopis, José Juan Martínez-Toldos
Introduction 19
Optical Coherence Tomography in Macular Holes 20
Optical Coherence Tomography in Epiretinal Membranes 21
Optical Coherence Tomography in Vitreoretinal Traction Syndrome 22
Intraoperative 25
4. Anesthesia 28
Manuel Baeza, José Juan Martínez-Toldos
Introduction 28
Types of Anesthesia 29
General Anesthesia 29; Local Anesthesia 30; Retrobulbar Block 33;
Peribulbar Anesthesia 35; Sub-Tenon’s Anesthesia 36
5. Instrumentation 43
José Juan Martínez-Toldos, Cristian Fernández-Martínez
5.1. Operating Room 43

Introduction 43
xx
Requirements 43
Ophthalmologic Surgery Table 43; Instrument Column 45; Integrated
Vitrectomy Systems 45; Image Recorder 45; Operating Microscope 46
5.2. Visualization Systems 49

Introduction 49
Upright Image Contact Lenses 50
Landers Biconcave Lens 50; Machemer Magnifying Lens 51; Peyman
Wide-angle Lens 52; Machemer Plano-concave Lens 52; Tolentino
Twenty Degree Prism Lens 52; Tolentino Thirty Degree Prism Lens 52;
Woldoff Biconcave Prism Lens 52
Wide-Angle-Viewing Systems 52
Use of the Erect Indirect Binocular Ophthalmic System 56
Other Visualization Systems 58
Combined Procedures 61
5.3. Endoillumination Systems 65
Introduction 65
External Systems 65
Internal Systems 65
Chandelier System 67
5.4. Infusion pressure Systems 71

Introduction 71
Hydrostatic Pressure 71
Infusion Pump or Gas Forced Infusion 72
Pressure Control 75
Low Intraocular Pressure 75; High Intraocular Pressure 75
5.5. Infusion Devices Systems 76

Twenty-Gauge Incisions 76
Opening the Conjunctiva 76
Twenty-Gauge Transconjunctival Vitrectomy 78
5.6. Suction and Cutter Systems 79

Introduction 79
Active Aspiration 79
Passive Aspiration 83
Vitrectomy Probes 84
Constellation Vision System 85; Stellaris PC Vision Enhancement System 88
5.7. Diathermy 90
Introduction 90
5.8. Retinopexy 93
Contents
xxi
Introduction 93
Laser Endophotocoagulation 93
Argon Laser 96; Diode Laser (810 nm) 96; Green Diode Laser (532 nm) 96;
Yellow Laser (577 nm) 97
5.9 phacoemulsification 99
Introduction 99
5.10 Ultrasonic Fragmentation 102
Introduction 102
5.11 Forceps and Scissors 104

Introduction 104
5.12 Vitreous Substitutes: Manipulators of Tissues 109

Introduction 109
Hyaluronic Acid 109
Perfluorocarbon Liquids 109
5.13 Vitreous Substitutes: Tamponades 113

Introduction 113
Intraocular Gases 113
Silicone Oil 115
Silicone Solvent 116; Heavy Silicone Oil 117; Densiron 119
6. Basic Vitrectomy 121

Cristian Fernández-Martínez, José Juan Martínez-Toldos
Check List 121
Positioning the Patient 122
Visualization Systems 122
Contact Systems 122; Noncontact Systems 122
Conjunctival Incisions 123
Sclerotomy 124
Pupil Management 127
Phacoemulsification 128
Surgical Technique 128; Special Cases 129
Removing The Vitreous Humor: Basic Concepts 129
Aspiration Systems 131
Active Aspiration 131; Passive Aspiration 132
Peeling Membranes in Vitrectomy 132
Segmenting Membranes 134; Delaminating Membranes 135; Staining
Membranes 136
Perfluorocarbon Liquids 140
Uses of Perfluorocarbon Liquids 141; Intraoperative Management of
Perfluorocarbon Liquids 142; Potential Problems during the Use of
Perfluorocarbon 146
Fluid-Air Exchange 146
xxii
Use of Gas in Vitrectomy 147
Nonexpanding Gas 147; Expanding Gas 148; Clinical Indications
of Gases 148; Air–Gas Exchange 148; Postoperative Management of
Patients Receiving Intraocular Gas 149
Silicone Oil in Vitrectomy 149
Injection of Silicone Oil 149; Emulsification of the Silicone Oil 150;
Indications of Silicone Oil Tamponade 150; Inferior Peripheral
Iridectomy 151; Removal of Silicone Oil 151
Closure After Surgery 152
7. pars plana Lensectomy 156
Carlos Mateo, Anniken Burés
Introduction 156
Surgical Technique 156
Advantages of Pars Plana Lensectomy 158
Pars Plana Lensectomy Indications 159
Vitreoretinal Proliferation 159; Perforating Ocular Trauma with or without
Intraocular Foreign Body 160; Proliferative Diabetic Retinopathy 162
8. Basic Endoscopic Vitrectomy 164
Vicente J Chaqués-Alepuz, Enrique V López-Sánchez
Basic Equipment for Endoscopy 164
Technical Aspects: Visualization 166
Image Rotation 167; Image Artifacts 168; Technical Tips for
the Beginners 169
Endoscopic Posterior Vitrectomy: Basic Concepts and Indications 170
Surgeon’s Position 170; Image Size and Lighting 171; Blurred Image 171
Complications of Vitreoretinal Surgery that can be Avoided by
Endoscopy 171
Vitreous Incarceration 171; Controlling Intraoperative Bleeding 172
Techniques and Maneuvers of Vitrectomy and Endoscopy 173
Vitrectomy 173; Membranectomy 174; Fluid-Air
Exchange 174; Endophotocoagulation 174; Pars Plana Lensectomy 175
Capsulectomy 175; Introducing Silicone Oil 175; Introducing
Perfluorocarbon Liquid 176; Diabetic Retinopathy and Endoscopic
Vitrectomy 176; Vitreous Hemorrhage 177; Neovascularization of the
Iris with Opacity of the Media 177; Retinal Detachment Surgery 177;
Proliferative Vitreoretinopathy 178; Endoscopic Vitrectomy for Crystalline
Lens Fragments Luxated in the Vitreous Cavity 180; Endoscopic Vitrectomy
in Endophthalmitis 181
9. Minimal Incision Vitrectomy Surgery: Twenty-Three,

Twenty-Five and Twenty-Seven Gauge 184
José Juan Martínez-Toldos, Javier A. Montero-Moreno, José M Ruiz-Moreno,
Félix Armadá-Maresca, Natalia Pastora-Salvador, Anna Grabowoska, María
Granados-Fernandez, Beatriz Manzano Muñoz
9.1 Twenty-Three Gauge Vitrectomy 184

José Juan Martínez-Toldos
Introduction 184
Incision Construction 185
Vitrectomy 186
Closing the Incision 187
Contents
xxiii
Benefits of Twenty-Three Gauge Surgery 187
Complications 187
9.2 Twenty-Five Gauge Vitrectomy 189
Javier A Montero-Moreno, José M Ruiz-Moreno
Introduction 189
Benefits of Microincision Vitrectomy 192
Drawbacks of Microincision Vitrectomy 192
Complications 192
Future Perspectives 193
9.3 Twenty-Seven Gauge Vitrectomy 196
Armadá Maresca Félix, Natalia Pastora-Salvador, Anna Grabowoska,
María Granados-Fernandez, Beatriz Manzano Muñoz
Introduction 196
Instrumentation 196
Indications 199
10. Vitrectomy in Anterior Segment Surgery Complications 202

José Juan Martínez-Toldos, Juan Carlos Elvira-Cruañes
Introduction 202
Ocular Perforation in Retrobulbar Anesthesia 202
Transconjunctival Sub-Tenon’s Anesthesia 203; Ocular
Perforation 203; Treatment 204
Retrobulbar Hemorrhage 205
Anterior Vitrectomy 205
Vitrectomy Following Vitreous Loss 206
Retained Lens Fragments 209
Surgical Indications 211; Associating Surgery at the Time of Lens
Dislocation 211; Surgical Technique 212
Intraocular Lens Dislocation 216
Surgical Technique 219; Late Intraocular Lens Dislocation with the Capsular
Bag 222; Mechanisms 223; Prevention 223; Treatment 224
Endophthalmitis 225
Etiology 226; Treatment 227; Vitrectomy 228; Late-Onset
Endophthalmitis 229
11. Eye Trauma Vitrectomy 235

Joséfina Bañuelos Bañuelos, Patricia Martínez-García, Javier Orduña-Azcona,
Ana Orive-Bañuelos
Introduction 235
Vitrectomy in Open Traumatisms 235
Clinical History and Initial Examination 235; Presurgical
Considerations 236; Surgical Technique 237
Special Situations 240
Trauma and Dense Vitreous Hemorrhage 240; Trauma and Retinal
Detachment 241; Trauma and Intraocular Foreign Body 241; Trauma and
Endophthalmitis 244
Vitrectomy and Compliactions of the Ocular Trauma 246
Macular Hole 246; Ocular Hypotony and Bulb Phthisis 247
12. Basic Vitrectomy in Diabetic Retinopathy 250

Jose Garcia-Arumi, Anna Boixadera, Laura Distefano, Vicente Martinez-Castillo,
Miguel Angel Zapata
xxiv
Introduction 250
Surgical Approach 251
Vitrectomy for Diabetic Macular Edema 257
13. Macular Surgery 261

Amparo Navea, Elena Palacios, Carmen Desco, Jorge Mataix
Surgery on the Surface of the Macula 261
Preliminary Considerations 261
Interview with the Patient 262
Surgery Preparation 263
Technical Requirements 263; Human Requirements 263; Patient
Preparation 263; Surgeon Preparation 263
Vitrectomy 264
Specific Technical Points in Macular Hole 265
Surgery in the Subretinal Macular Space 267
Severe Submacular Hemorrhage Located into the Macular Area 267
Masive Subretinal Hemorrhage that also Affects the Macula 269
Subfoveal Perfluorocarbon Bubbles 270
14. Vitrectomy for Retinal Detachment with and without
proliferative Vitreoretinipathy 272
J Fernando Arevalo, Reinaldo A Garcia, Veronica Oria
Introduction 272
Combined Vitrectomy and Scleral Buckling 273
Scleral Buckling Technique 273; Encircling Exoplants 275
Scleral Suture Technique 277
Primary Vitrectomy 277
Basic Operative Steps in Primary Vitrectomy 277
Intraocular Tamponade 283
Small-Gauge Pars Plana Vitrectomy 283
Sclerotomies with 23-Gauge Vitrectomy 284; Sclerotomies with 25-Gauge
Vitrectomy 284
New Considerations in Fluid Dynamics During Small-Gauge
Vitrectomy 285
Increasing Safety 286; Wound Closure 286; Retinal
Tears 287; Hypotony 288; Endophthalmitis 288
Vitrectomy for Retinal Detachment with Proliferative
Vitreoretinopathy 288
Risk Factors for the Development of Proliferative
Vitreoretinopathy 289
Diagnosis of Proliferative Vitreoretinopathy 290
Classification of Proliferative Vitreoretinopathy 290
Type 1 291; Type 2 293; Type 3 293; Type 4 293; Type 5 295
Surgery for Proliferative Vitreoretinopathy 295
Timing of Surgery 295; Scleral Buckling in Proliferative
Vitreoretinopathy 296; Lensectomy and Intraocular Lens 296
Vitrectomy for Proliferative Vitreoretinopathy 297
Removal of Posterior Epiretinal Proliferation 298; Removal of
Anterior Epiretinal Proliferation 298; Removal of Subretinal
Proliferation 298; Relaxing Retinotomies and Retinectomies 299;
Creating a Chorioretinal Adhesion 302; Intraocular Tamponade 302;
Removal of Silicone Oil 303; Reoperations for Recurrent Retinal
Detachment from Proliferative Vitreoretinopathy 304
Adjunctive Treatment in Proliferative Vitreoretinopathy 304
Contents
xxv
Giant Retinal Tears 305
Postoperative Complications 306
Summary 306
15. Current Indications of Antiangiogenics in Vitrectomy 313

Mauricio Maia, Fernando M Penha, J Fernando Arevalo
Antiangiogenics: Overview 313
Introduction: Vascular Endothelium Growth Factor 313; Role of
Bevacizumab and Ranibizumab in the Angiogenesis Process 313
Intraoperative Bleeding During Pars Plana Vitrectomy In Proliferative
Diabetic Retinopathy 315
Introduction 315; Vitreoretinal Bleeding 315
Preoperative Procedures to Minimize the Possibility of Intraoperative
bLeeding 316
Blood Pressure Control 316; Antiplatelet and Anticoagulants—Is it
Necessary to Discontinue Them before Surgery? 316; Intravitreal
Injection of Anti-VEGF Inhibitors in Proliferative Diabetic Retinopathy 317
Intravitreal Injection of Anti-Vegf Before Surgery in Proliferative
Rationale 317; Intravitreal Bevacizumab Before Pars Plana Vitrectomy in
Proliferative Diabetic Retinopathy 317; Intravitreal Ranibizumab
before Pars Plana Vitrectomy in Proliferative Diabetic Retinopathy 319;
Technique of Preoperative Intravitreal Anti-VEGF Injection 319;
Care During Preoperative Intravitreal Anti-VEGF Injection Before
Pars Plana Vitrectomy in Proliferative Diabetic Retinopathy 320
Conclusion of Intravitreal Injection of Anti-VEGF Before Proliferative
Techniques of Intraoperative Posterior Segment Bleeding Control 320
Rising the Intraocular Pressure 321; Fluid-Air Exchange 322;
Perfluorocarbon Liquids 323; Endodiathermy and Cauterization 323;
Laser Photocoagulation 325; Combination of Techniques 326
16. Use of Sustained Drug Release Implants in Vitrectomized Eyes 331

Jose Maria Ruiz-Moreno, Javier A Montero
Introduction 331
Clinical Case 334
17. Enzymatic Vitrectomy 337

Patricia Udaondo, David Salom, Salvador Garcia-Delpech, Manuel Díaz-Llopis
Introduction 337
Concept of Enzymatic Vitrectomy 339
Methods and Mechanism of Action 339
18. posterior Vitrectomy Complications 343

Carme Guardia, Jaume Catalá, Jairo Hoyos-Chacón
Introduction 343
Intraoperative Complications 343
Sclerotomy Complications 343
Visualization Problems 346
Retinal Tears 352; Retinopexy Complications 354
Postoperative Complications 354
Corneal Complications 354; Ocular Hypertension and Glaucoma 355;
Vitreous Hemorrhage 357; Retinal Detachment 358; Proliferative
Vitreoretinopathy 359; Intraocular Inflammation and Fibrinoid
Reaction 360; Tamponade and Manipulator
Agents Complications 360; Endophthalmitis 364; Cataract 364
To Prevent Vitroretinal Surgery Complications 365
Introduction
Evidence that the eye could tolerate, practically, complete removal of the
vitreous was provided in 1962, when Kasner1, 2 introduced the concept of open
vitrectomy by removing the vitreous using a cellulose sponge and scissors.
Almost a decade later in 1971, Machemer3-5 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 Heintz6
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.7 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.8
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.9
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.
xxviii
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.10 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.11,12
REFERENCES
1. Kasner D. Vitrectomy a new approach to the management of vitreous (Interview)
Highlights Ophthalmol. 1969;11:304.
2. 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.
3. Machemer R, Buettner H, Norton EW, et al. Vitrectomy: a pars plana approach.
Trans Am Acad Ophthalmol Otolaryngol. 1971;75(4):813-20.
4. Machemer R, Parel JM, Buettner H. A new concept for vitreous surgery. I.
Instrumentation. Am J Ophthalmol. 1972;73(1):1-7.
5. Machemer R. A new concept for vitreous surgery. 7. Two instrument techniques
in pars plana vitrectomy. Arch Ophthalmol. 1974;92(5):407-12.
6. O’Malley C, Heintz RM. Vitrectomy with an alternative instrument system. Ann
Ophthalmol. 1975;7(4):585-8, 591-4.
7. 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.
8. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina.
2005;25(2):208-11.
9. 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.
10. Verma D, Wills D, Verma M. Virtual reality simulator for vitreoretinal surgery.
Eye (Lond). 2003;17(1):71-3.
11. Hikichi T, Yoshida A, Igarashi S, et al. Vitreous surgery simulator. Arch Ophthalmol.
2000;118(12):1679-81.
12. Rossi JV, Verma D, Fujii GY, et al. Virtual vitreoretinal surgical simulator as a
training tool. Retina. 2004;24(2):231-6.
chapter 1
Surgical Anatomy
Cristian Fernández-Martínez, José Juan Martínez-Toldos
INTRODUCTION
The anatomy of the ocular globe essentially determines the surgical approach
to vitreoretinal diseases. Hence, a good knowledge of the different anatomical
relations will help the vitreoretinal surgeons perform many of the maneuvers
and procedures described in this book. In this chapter, we review the anatomical
features that are most relevant for a vitrectomy.
ANATOMY OF THE VITREOUS

The vitreous humor (4 ml by volume) occupies 80% of the ocular volume and
is really a connective tissue, whose most important functions are to confer
optical transparency to the larger globe cavity, to act as a nutrition source for
the crystalline lens and probably to take part in the retinal metabolic processes.
Its gel-like consistency is the result of its composition—98% water and 0.15%
macromolecules such as hyaluronic acid, collagen and soluble proteins. The
rest of the vitreous humor is made up of ions and low molecular weight solutes.
Recently, the presence of other noncollagen soluble proteins has been described
such as fibronectin, fibulin, opticin and VIT1, which likely plays a key role at
the vitreoretinal interface.1, 2
Vitreous collagen is organized as fibrils comprised of collagen type II
mostly but also of collagen types IX, V and XI. To form each vitreous fibril,
these three collagen types need to be assembled. Collagen fibrils aggregate to
form numerous fibers of greater diameter. These fibers are randomly distributed
and interwoven to form a large collagen network or mesh, which constitutes
the vitreous scaffold (Fig. 1).3 The density of these fibers varies among the
different vitreous zones, being lower in the central vitreous zone, and greater
in the anterior (zonule, posterior capsule of the crystalline lens) and posterior
2
(adjacent to the retina) vitreous cortex. The region with the highest density
of fibers is the vitreous base (anterior and posterior to the ora serrata).2, 3 This
density gradient has important implications during vitrectomy since a great
concentration of fibers will mean greater adhesion among these fibers and their
greater attachment to the underlying retina, thus offering greater resistance to
aspiration, with the consequent risk that the vitreotome will produce traction
on the retina leading to its iatrogenic rupture.
The anterior vitreous surface, or anterior hyaloid is inserted in the posterior
capsule of the crystalline lens forming a circular zone 8–9 mm in diameter
known as Wieger’s hyaloidocapsular ligament. This ligament constitutes
the union between the anterior hyaloid and the anterior-most portion of the
Cloquet’s canal, leaving a space between the two, called Berger’s space. The
Cloquet’s canal is the embryonic remnant of the hyaloid artery, which runs
from the optic nerve, where it originates in the shape of a funnel and creates
the prepapillary space of Martegiani, and narrows as it passes through the
central vitreous until it reaches the retrocrystalline lens zone as described
above (Fig. 2).4
Vitreous Base and Vitreoretinal Interface

The vitreous base accommodates the insertion of collagen fibers on both sides
of the ora serrata along 360° of the ocular circumference. It is the region with
Figure 1 Meshwork of collagen fibers or filaments interspersed with large

molecules of hyaluronic acid, which absorb large quantities of water to give the
vitreous humor a gel-like consistency
Chapter 1  Surgical Anatomy
3
Figure 2 Anatomy of the vitreous humor
the highest concentration and density of vitreous fibers. Its most anterior edge
occurs 2 mm in front of the ora in all four quadrants; its most posterior margin
appears some 2–3 mm behind the ora in the temporal quadrants and at some
3–4 mm in the nasal quadrants. The vitreous base is contained within a 5–10
mm zone behind the limbus in the temporal quadrants and occurs 5–12 mm
behind the limbus in the nasal quadrants.3,4 This needs to be taken into account
specially when using a scleral indentation device whose main objective is to
relax the base of the vitreous and bring it toward the underlying retina.
The so-called vitreoretinal interface refers to the existing connections
between vitreous cortex and underlying retina. The collagen fibers of the
vitreous cortex run parallel to the inner surface of the retina across all but one
region of the interface, the vitreous base. While at the rest of the interface, the
stability of the vitreoretinal junction is attributed to chemical bonds between
the collagen type II of the cortex and collagen type IV of the internal limiting
membrane, at the vitreous base, the cortex fibers do not run parallel to the inner
retina, rather they appear at right angles to it, directly inserting in the retinal
tissue and intermixing with the basement membranes of the Müller cells without
any apparent chemical bonds.2,3 This real anatomical binding explains why the
vitreous base is surgically nonresectable and inseparable from the retina, even
after severe eye trauma (Fig. 3).
The most posterior vitreous is firmly attached to the adventitia of the
retinal blood vessels, and to the margins of the optic nerve and macula. This
firm posterior adhesion is responsible for the different vitreoretinal traction
syndromes described in subsequent chapters.
4
Figure 3 Diagram showing the arrangement of collagen fibers at the vitreous base.
Note the direct contact between these collagen fibers and the Müller cell layer
ANATOMICAL DISTANCES IN VITRECTOMY

Knowing the distances of the different anatomical structures relative to the
limbus is essential for most vitrectomy procedures.
Crystalline Lens
The crystalline lens, a biconvex structure located in the posterior chamber of the
ocular globe, has a spherical power of 20D in an average adult. Since surgical
access during vitrectomy is often conducted in the presence of the crystalline
lens, it is important for the surgeon to be aware of its diameter. The equatorial
diameter of the crystalline lens is 6.5 mm in newborns and 9–10 mm in adults,
while its anteroposterior diameter is 3 mm at birth, increasing with age from
the third decade of life to around 6 mm in elderly subjects.4,5 The crystalline
lens should be avoided from the time the initial sclerotomies are placed until
the end of surgery, since any slight damage will lead to its complete or partial
opacification.
Extraocular Muscles
The distance between the limbus and the anterior insertion of the four rectus
muscles increases as follows: medial rectus (5.5 mm) → inferior rectus (6.5
mm) → lateral rectus (6.9 mm) → superior rectus (7.7 mm). The “spiral
of Tillaux” is the name given to an imaginary line that passes in this order
through the anterior insertion points of each rectus muscle and this line marks
the position of the ora serrata with respect to the corneal limbus (Fig. 4)5.
5
Figure 4 The spiral of Tillaux marks the position of the anterior insertions of the
rectus muscles and ora serrata with respect to the corneal limbus
Ciliary Body
The ciliary body is 6–7 mm long and is made up of two anatomically and
functionally differentiated parts: pars plicata and pars plana. The pars plicata
occupies some 2.5 mm posterior to its insertion at the scleral spur, is highly
vascularized and formed by some 70 radial folds or ciliary processes, with a
role in the production of aqueous humor and as an attachment structure for
the zonule fibers of the lens. The pars plana extends some 3–4 mm from the
pars plicata to the ora serrata. It is pigmented, completely smooth, relatively
avascular and, as such, is the ideal zone for surgical access at some 3–4 mm
from the corneal limbus6,7 (Figs 5 and 6).
In children, the position of a sclerotomy needs to be corrected due to
the different sizes of the ciliary body during eye development. Several
morphometric studies6,8,9 have shown that the ciliary body grows from birth until
18 years of age. Based on these findings, different authors propose distances
from the limbus for a sclerotomy in pediatric vitrectomy10 which are given in
Table 1.
Blood Vessels
In some surgical procedures, the extraocular muscles need to be manipulated
and other procedures have to do with the blood vessels that supply these
muscles. The muscular branches of the ophthalmic artery supply most of the
extraocular muscles since they give rise to the anterior ciliary arteries. Each
6
Figure 5 Position of the ciliary body in relation to the sclerocorneal limbus.
A B
Figures 6A and B (A) Inserting the microvitreoretinal blade 4 mm from the

limbus; (B) Sclerotomy and its relation to the ora serrata and lens
Table 1
Distances from the limbus for a sclerotomy in pediatric vitrectomy
Age group Distance from limbus

1–6 months 1.5 mm
6–12 months 2 mm
1–2 years 2.5 mm
2–6 years 3 mm
6–18 years 3.5 mm
7
Figure 7 Vortex veins and their anatomical relations
muscle contains 1–3 anterior ciliary arteries. During their journey toward the
anterior pole, these arteries enter the globe’s episclera and irrigate the whole
anterior segment. Maneuvers that compress, segment, or modify the anatomy
of the extraocular muscles and sclera can compromise the arterial blood supply
of the anterior segment.4,5
The venous system that runs parallel to the arterial network merits a special
attention. In general, there are four vortex or vorticose veins located posteriorly
to the equator (at some 14–18 mm from the limbus). These are usually
observed close to the nasal and temporal margins of the inferior and superior
rectus muscles.4,5 Their compression should be especially avoided during the
circumferential placement of episcleral implants (Fig. 7).
REFERENCES
1. Bishop PN. Structural macromolecules and supramolecular organization of the
vitreous gel. Prog Retin Eye Res. 2000;19(3):323-44.
2. Le Goff MM, Bishop PN. Adult vitreous structure and postnatal changes. Eye
(Lond). 2008;22(10):1214-22.
3. Olsen BR. New insights into the function of collagens from genetic analysis. Curr
Opin Cell Biol. 1995;7(5):720-7.
4. Spaide RF, Miller-Rivero NE. Anatomy. In: Spaide RF (Ed). Diseases of the Retina
and Vitreous. Philadelphia: Saunders; 1999.
5. Greve MD. Vitreoretinal surgical anatomy. In: Peyman GA, Meffert S, Conway
M, Chou F (Eds). Vitreoretinal Surgical Techniques. United Kingdom: Martin
Dunitz; 2001. pp. 2-6.
8
6. Bron AJ, Tripathi RC, Tripathi BJ (Eds). Wolff’s Anatomy of the Eye and Orbit,
8th edition. London: Chapman & Hall; 1997.
7. Hairston RJ, Maguire AM, Vitale S, et al. Morphometric analysis of pars plana
development in humans. Retina 1997;17(2):135-8.
8. Streeten BW. Ciliary body. In: Duane TD, Jaeger EA (Eds). Biomedical Foundations
of Ophthalmology. Philadelphia: Lippincott; 1995.
9. Aiello AL, Tran VT, Rao NA. Postnatal development of the ciliary body and pars
plana. A morphometric study in childhood. Arch Ophthalmol. 1992;110(6):802-5.
10. Lemley CA, Han DP. An age-based method for planning sclerotomy placement
during pediatric vitrectomy: a 12-year experience. Retina. 2007:27(7);974-7.
chapter 2
Presurgery Examination
Manolo Baeza Diaz, José Juan Martínez-Toldos
MEDICAL HISTORY
The medical history of the patient should be established, paying particular
attention to the onset of symptoms, previous eye surgery and complications,
current eye or systemic medication, possible allergies, and whether the patient
is taking anticoagulants. The surgeon should clearly inform the patient of the
possible risks and benefits of surgery, and the expected visual outcome of the
procedure. The patient should also be informed about the possibility of needing
more than one operation and the need to adopt a certain head position after
surgery if the use of gas or silicone oil is planned.
VISUAL ACUITY
Best corrected visual acuity should be determined for the patient and if possible
should be confirmed by another clinician. The patient’s light perception and
projection capacity should also be checked using light from the indirect
ophthalmoscope in an opaque medium by asking the patient whether the light
is on or off. Patients unable to perceive light should not undergo intraocular
surgery.
Pupil Reflexes
The patient should show normal pupil reflexes when tested even in the presence
of markedly opaque media or dense vitreous hemorrhage. Loss of the pupil
reflex generally indicates optic nerve damage but can also occur in severe cases
of retinal detachment or a large macular lesion.
10
Color Perception
The results of this test are affected by the presence of blood. A positive result
suggests the macula is not detached but negative results are inconclusive.
Vascular Entoptic Test

A transilluminator light probe is applied to the closed eye with the patient looking
downward. When the light source is removed, a patient with a normal retina
should be able to see a negative image of the retinal blood vessels. A positive
result suggests that posterior retina is not detached in 30°. However, some
patients with a normal retina show a negative response to this test, diminishing
its value.
Slit Lamp Microscopy

This is used to check the transparency of ocular media such as the cornea and
crystalline lens. Patients with cornea guttata and a low endothelial cell count
have an increased risk of postsurgical edema. Epithelial erosions are common
in diabetic patients. The need for crystalline lens surgery should be assessed.
Subcapsular lens opacities interfere most with intraoperative visualization and
are the opacities that most often progress following surgery, especially if gas
is used.
If the patient is phakic, biometry will in any case be needed to calculate the
power of the intraocular lens, whether combined cataract/vitreous surgery is
programmed or not, since the crystalline lens could be damaged and need to be
extracted. In patients who have undergone previous cataract surgery, the type
of intraocular lens present and its stability will need to be assessed especially
if the use of intraocular gas or silicone is anticipated and if opacity of the
posterior capsule or synechiae that could hinder mydriasis exists. In patients
subjected to trabeculectomy, the filtration bleb will have to be avoided during
surgical access for the vitrectomy. During surgery, muscle retroinsertion should
be considered in case a scleral buckle needs to be used.
Rubeosis iridis should be ruled out by examining the patient through
the undilated eye with magnification. Rubeosis in a patient with vitreous
hemorrhage requires an emergency vitrectomy and panretinal photocoagulation.
Tonometry
Indentation tonometry is the most adequate procedure but in the case of an
irregular cornea, it is easier to use the Tonopen (applanation tonometry). A low
intraocular pressure does not cause phthisis bulbi; rather it is the phthisis that
causes hypotony. Erythroclastic and closed-angle glaucoma should be ruled
out (if a scleral buckle is to be used, the need for previous laser treatment will
have to be evaluated).
Chapter 2  Presurgery Examination
11
EXAMINING THE FUNDUS
Indirect Ophthalmoscopy
Compared to direct ophthalmoscopy, indirect ophthalmoscopy provides a
better, more peripheral view of the retina, even when the ocular media is semi
opaque. The procedure may be accompanied by scleral indentation, which
allows the surgeon to reach the ora serrata. The image produced of the retina
is steroscopic, inverted and for the examination a 20D or 28D lens is needed.
The greater diopter this lens has the greater will be its angle of vision but the
lower will be its magnification. These lenses also provide better vision when
looking through small pupils and gas bubbles. The morphology of the retina
is observed in such a way that if the detached retina is concave, this indicates
a traction retinal detachment, while a convex detached retina would suggest
rhegmatogenous retinal detachment. Indirect ophthalmoscopy also serves to
detect a detached macula.
Biomicroscopy of the Retina

Even using a 20D lens, the magnification power offered by the indirect
fundoscope is insufficient to detect subtle retinal changes or vitreous
modifications. This is best done with a retinal slit lamp through a Goldmann
contact lens, Mainster lens, panfundoscopic lens or a noncontact 60D, 78D or
90D lens. These provide a more magnified image of the retina. Newer more
specialized lenses also exist such as the SuperField, and in general lower powers
offer greater magnification, better axial resolution and better stereoscopic
vision accompanied nevertheless by a smaller field of view. Besides its use
for examining the posterior pole, the Goldmann lens allows observation of the
retinal periphery so that we can check for small tears that cannot be seen by
indirect ophthalmoscopy. Retinal biomicroscopy allows the surgeon to check
for epiretinal membranes, macular holes, macular edema, vitreous turbidity and
floaters, traction epicenters of diabetic fibrovascular proliferations, vascular
occlusions, neovascularizations, and the presence of neurosensory detachment.
In summary, this procedure enables us to examine the retina with special
reference to macular disease and the vitreous-retinal interface.
ULTRASONOGRAPHY
The term ultrasound applies to all sound waves with a frequency greater than
20 kHz. When an ultrasound wave crosses a tissue, part of the wave is reflected
back toward the probe. This reflected wave is known as an echo. Echos are
produced by acoustic contact zones that form at the junction between the media,
where different velocities of sound occur; the greater the difference between
two media the greater will be the echo generated. The transducer at the tip of
12
the probe emits ultrasound pulses and receives the reflected echos. The echos
detected are processed in the instrument and represented on the screen in the
form of a scan. The types of scans most frequently used are A-and B-scans.
An A-scan is a unidimensional acoustic representation, in which echos
appear as vertical spikes emerging from a baseline. The space between these
peaks provides information on the measurements of ocular structures and the
height of the peaks indicates the amplitude of the echo.
A B-scan ultrasonography produces a two-dimensional acoustic cross
section, whereby echos appear on the screen as points of different intensity.
The coalescence of multiple points on the screen creates a two-dimensional
cross section of the tissue being examined.
The following characteristics of a tissue can be assessed:
Reflectivity: this is given by the height of the wave peak in mode A.
Depending on this height, brightness will change such that we can
distinguish a more reflective lesion, such as a detached retina, from a
detached posterior vitreous.
The internal structure of a tissue: this gives an idea of the histological
architecture of a lesion. Thus, a homogeneous image will show similar A-mode
echos indicating a regular internal structure such as the structure of a tumor.
The density of a tissue: as the ultrasound beam crosses a tissue the waves
that appear on the A-scan produce less sound. If echos are greatly attenuated,
this means a high tissue density and waves rapidly decrease. If we draw
a line joining the different waves until the isoelectric line, this will give
us an angle called the kappa angle, which is more marked the greater the
attenuation is. In mode B, attenuation corresponds to the acoustic shadow,
a vacuum of echos that occurs when a lesion is highly reflective such as in
the case of a melanoma.
Aftermovement: the patient is asked to move the eye and the echo is then
recorded. This helps distinguish highly mobile lesions, such as detachment
of the posterior vitreous, from those that are static such as a detached retina.
An ultrasound examination would be indicated to detect and diagnose an
ocular disorder in which a direct biomicroscopy examination is not possible or
impaired by the opacity of the ocular media. Ultrasound is also used to diagnose
and measure the size of a tumor.
The ultrasonography should be conducted by the operating surgeon to gain
as much information as possible before surgery. Below we describe the main
findings we would expect in a vitreous, retinal or choroid disorder.
Vitreous Disorder
In a healthy patient, the vitreous is very homogeneous. A B-scan will show an
acoustically black space, and in an A-scan no echos are visible between the
crystalline lens and retina. Possible findings are:
13
Vitreous Hemorrhage
The configuration of the vitreous and its density is revealed by peaks of different
amplitude in the A-mode and spotting or an increase in density in the B mode.
It should be checked if the retina is detached or in place and it will have to be
distinguished from a detached posterior hyaloid.
In a B-scan ultrasonography, posterior vitreous detachment appears as
a fine undulating strand which may be completely separated from the
retina or shows zones of adhesion in the papilla or in areas of retinal
neovascularization. In an A-scan, echos are not usually high. The lesion’s
aftermovement is generally mobile.
Retinal detachment always appears as a more continuous, less mobile
image. Often folds will be seen and when the detachment is total or
extensive the detached retina always inserts in the optic disk and ora
serrata. The subretinal space appears as an empty space. In mode A,
retinal detachment appears as a peak of similar size as the scleral peak
(Table 1). A detachment can be flat, bullous or funnel-shaped. Recent
and bullous detachments may show a marked aftermovement, though
less marked than a detached posterior vitreous. In contrast, long duration
retinal detachments remain highly rigid.
Endophthalmitis
The severity and extension of endophthalmitis can be assessed along with the
presence of a foreign body or a detached retina. We may observe thickening
of the retinochoroid layer and in advanced cases retinal detachment.
Table 1
Differential diagnosis of detachment of the posterior vitreous, retina or choroid
Posterior vitreous Retina Choroid

Topography/ Smooth, open Smooth or folded, Small, domed or
Structure funnel-shaped; with open or closed flat; not inserted in
/Characteristics or without insertion funnel-shaped; papilla; insertion in
in papilla; inserted inserted in papilla ora or ciliary body
in ora and ora
Quantitative Peaks of variable Peaks of 100% Spiky trace with
amplitude < 100% even in ora wide double
in ora peaks; amplitude
100%
Aftermovement Marked/moderate Moderate/null Mild/null
14
Intraocular Foreign Body and Luxated or
Subluxated Intraocular Lenses
Ultrasonography enables us to better locate and quantify intraocular damage.
In B-mode, a brilliant signal is produced with a shadow posterior to the foreign
body. In A mode, high reflectivity peaks appear.
Proliferating Diabetic Retinopathy

This condition produces a great variety of images such as vitreous hemorrhage,
fibrovascular membranes or traction retinal detachment. The latter are usually
located around the papilla or in vascular arcades (Fig. 1). Continuous traction
at a given point leads to a tent-shape detachment; however, if affecting several
points a hammock-shaped detachment is produced. When traction is more
extensive the detachment is a table-top detachment and if there is a massive
contraction of the vitreous a funnel-shaped detachment may occur.
Retinoschisis
This condition generally affects the inferotemporal quadrants. A smooth
membrane that does not affect the optic nerve disk can be seen; it is more focal,
smooth and thinner than a detached retina.
Scleral Buckles
Being dense materials, in mode A, these show a high internal reflectivity that
generates an orbit shadow.
Figure 1 Retina appears as a highly reflective membrane protruding into the

vitreous cavity with vitreous gel at its extreme ends
15
Tumor Masses
Ultrasonography is the most important diagnostic tool for intraocular tumors.
According to the echogenic features of a lesion, we can differentially diagnose
different tumors or other lesions such as neovascular membranes with subretinal
hemorrhage. Through ultrasonography, we can also determine tumor size and
its progression or remission.
Hemorrhagic Choroid Detachment (expulsive hemorrhage)
B-scan: elevated detached choroid of rounded appearance. Note the choroid
space is opaque (coagulated blood).
A-scan: double peak with low peaks in the choroid space (Figs 2 and 3).
Through ultrasonographic imaging we can:
determine the location and extension of a hemorrhage;
examine the state of the retina and detect whether there is retinal detachment;
distinguish between a hemorrhage or choroid effusion; and
monitor the coagulate lysis process to decide upon the best moment for
drainage surgery which is usually from 7 days to 14 days (Fig. 4).
Figure 2 Ultrasound image of hemorrhagic choroid detachment

16
Figure 3 A detached choroid appears as highly echogenic

convex lines in a B-scan
Figure 4 Progressive lysis of the coagulate in choroid hemorrhage
FLUORESCEIN ANGIOGRAPHY
Fluorescein angiography offers information on blood flow through the
retina, structural features of blood vessels and changes in the retinal pigment
epithelium that affects its capacity to block the fluorescence of the dye or to
allow the passage of fluorescein to the deeper layers of the retina. Fluorescein
angiography can be used to diagnose a majority of retinal diseases although
17
with the advent of optical coherence tomography and other more precise
imaging tools, the technique is rapidly being abandoned for the diagnosis and
follow-up of many of these conditions especially at the macular level. For a
surgical vitreoretinal indication, angiography is mostly used today to detect
fibrovascular proliferations and traction retinal detachments produced as a
consequence of vascular ischemia in diseases such as diabetic retinopathy,
vascular occlusions or vasculitis. It is also useful to distinguish an exudative
from a rhegmatogenous retinal detachment in which there is no tear in the
retina or if one or more zones of exudation from the choroids to the subretinal
space exist.
ELECTROPHYSIOLOGY
Electroretinography
This method uses electrodes to measure the response of the retina to stimulation
using a light source of appropriate intensity. It is used to assess the functional
integrity of the retina, specifically of the rods, cones, and both photoreceptor
systems along with Müller and bipolar cells but it is not suitable for detecting
abnormalities in ganglion cells and therefore the optic nerve.
Evoked Visual Potentials

This technique records electric potentials produced in response to a standardized
light stimulus and represents the combined response of the different visual
cortex areas. It is used to assess macular function and the functional integrity
of the visual pathway. It enables us to identify a dysfunction in the visual
pathway and gives an idea of the extent of demyelination if potentials are
delayed (latency increased) or the presence of impaired axon activation in the
pathway (potentials reduced).
Electrophysiological tests are especially useful to diagnose retinal
degenerative diseases or for a differential diagnosis of macular disease, optic
nerve disorders and mimicking symptoms. In diseases that induce opaque
media such as vitreous hemorrhage, these tests serve to assess potential retinal
function or possible optic nerve involvement.
Bibliography
1. American Academy of Ophthalmology. Retina y vítreo 2008-2009. Barcelona:
Elsevier España. 2009. p. 424 (ISBN: 978-84-8086-359-9).
2. Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol. 1999;43(6):
471-86.
3. Friberg TR. Examination of the retina: ophthalmoscopy and fundus
biomicroscopy. In: Albert DM, Miller JW, Azar DT, Blodi BA (Eds). Albert
18
Jackobiec’s Principles and Practice of Ophthalmology, 3rd edition. Philadelphia:
W.B. Saunders. 2008.
4. Kanski J. Oftalmología Clínica, 6th edition. Barcelona: Elsevier España. 2009. p.
907 (ISBN: 978-84-8086-441-1).
5. Mascaró F, Mascaró F, Caminal JM. Atlas de ecografía ocular. Barcelona: Editorial
Glosa SL. 2007. p. 94 (ISBN: 978-84-7429-360-9).
6. Ryan SJ. Retina. Enfermedades hereditarias y retina, 4a edition. Madrid: MARBAN
libros SL. 2009. p. 789 (ISBN: TD: 978-84-7101-616-4).
chapter 3
Vitrectomy and Optical

Coherence Tomography
David Salom, Patricia Udaondo, Manuel Díaz Llopis, José Juan Martínez-Toldos
INTRODUCTION
The optical coherence tomography (OCT) is a diagnostic technique that
generates transversal cuts (tomographies) off the retina with a resolution, which
allows differentiation of the retinal and subretinal histological structures. This
is achieved with an optical measurement technique called “low coherence
interferometry”, similar to that used in B echography but instead of using
ultrasounds this technique uses a beam of light with an 830 nm wavelength,
optimal for visualization of the retina. The first commercially available OCT
machine was the Stratus OCT launched in 1995 by Carl Zeiss Meditec (Dublin,
California). To generate the images of the retina, the Stratus OCT used a
technology called “time domain OCT” (TD-OCT) with an axial resolution of
10 mm and with a speed of 400 A-scans per second. The TD-OCT allowed,
for the first time, the visualization of histological cuts off the retina in vivo.
During the last years a new technology has been developed for obtaining
the retinal images, called “spectral domain OCT” (SD-OCT) that eliminates the
necessity of the reference mirror movement, mandatory in the TD-OCT. The
SD-OCT machines can obtain images of the retina with an axial resolution of 5
mm and a speed of 20,000 A-scans per second. This technology has enabled, for
the first time, not only to better distinguish histological retinal structures but also
to generate tridimensional reconstructions of complete areas of the macula and
the optic nerve. The SD-OCT made possible the reporting of many anatomical
alterations in a great variety of retinal pathologies, the early detection of
glaucomatous damage progression1 and visualization of histological alterations
of everyday more anterior segment pathologies.2 Today, OCT is considered an
essential clinical tool for the diagnosis and evaluation of therapeutic response
in numerous ophthalmological pathologies.
20
More than explaining the role of OCT developed in medical retinal
pathologies; in this chapter we will concentrate on surgical retinal pathologies
in which the OCT is essential in the diagnostic process and surgical planning.
We will also increase our knowledge in the postoperative healing process and
in the everyday nearest possibility of the intraoperative OCT.
OPTICAL COHERENCE TOMOGRAPHY IN MACULAR HOLES

The OCT has become the gold standard for the preoperative identification of
macular holes (MH) and is particularly useful in the differentiation between
complete MH and lamellar or pseudoholes,3 as shown in Figures 1 and 2.
In the postoperative analysis of the MH, the OCT has established parameters
for better prognosis, specifically, those patients with higher retinal thickness at
the borders of the hole had a better visual prognosis after the surgery, indicating
that the MH with thin borders were less likely to close after the surgery.4 Another
predictive factor for the visual restoration and surgical success in the MH was
the distance between the hole margins measured by OCT. The prognosis was
better in those holes with less distance between the margins, it was observed
in the same study that the duration of the visual symptoms did not correlate
with the diameter of the MH, proposing that the time of evolution of the MH
Figure 1 Complete macular hole associated to an epiretinal membrane
Figure 2 Lamellar macular hole associated an epiretinal membrane

Chapter 3  Vitrectomy and Optical Coherence Tomography
21
was not so determinant in the surgical success as it is the distance between
the margins.5 Other authors had combined these two factors, establishing the
macular hole index (MHI) easily calculated from the ratio between the heights
of the MH borders and its diameter, if the MHI is greater than or equal to 0.5
the visual prognosis after the surgery is better.6
In the postoperative convalescence, the OCT has allowed us to monitor the
closing procedure of the MH. It was observed that the MH close during the
first month after the surgery and that the holes persisting for more than one
month were more likely to never close.7 A fundamental parameter for being
able to predict good visual results, in the early postoperative period after MH
surgery, is the visualization at the fovea of normal external limiting membrane,
because this fact can predict an adequate restoration of the photoreceptor layer.8
The OCT has also been able to show that the facedown position after the MH
surgery was only useful in those MH with a diameter greater than 400 mm.9
On the other hand, OCT has allowed establish that the presence of subretinal
fluid at the MH margins is a good predictive factor of successful closing of the
hole after a first surgical failure. The hole dimensions, the type of tamponade,
the duration of MH after the first surgery or the preoperative visual acuity did
not correlate with the anatomic result after the reintervention.10
OPTICAL COHERENCE TOMOGRAPHY IN EPIRETINAL

MEMBRANES
Optical coherence tomography is a diagnostic tool more sensitive than the
clinical evaluation when diagnosing epiretinal membranes (ERM).11 It has also
allowed demonstrate the presence of a thickening of all the retinal layers in
cases with idiopathic ERM; the internal nuclear layer (INL) is the one that has
the highest degree of enlargement. The OCT has demonstrated that the INL is
the retinal layer that contributes the most to changes in visual acuity in patients
with ERM.12 If an INL thickness map is performed in patients with ERM, the
areas with higher thickening correlates with the metamorphopsia areas of
these patients; therefore the OCT could be considered an objective method to
determine the localization of the metamorphopsias.13
In ERM and in vitreomacular traction syndrome (VTS), OCT is characteristic
of the presence of a high reflectivity area between the junction line of the inner
and outer segments (IS/OS) of the photoreceptors, and the line of the external
segment of the cones at the center of the fovea by its round shape, has been
named “cotton ball sign” and reflects the presence of an inward traction over
the fovea. It can also be considered a good predictor of visual disturbances in
the short term.14 In Figure 3, can be seen, an example of the cotton ball sign.
These are clear examples of how the better resolution of SD-OCT is
allowing us to better understand the functional alterations that are suffered
by our patients. The OCT has given the surgeons a possibility to establish
histological correlations with functional alterations, determining new times for
22
Figure 3 Epiretinal membranes with the subfoveal cotton ball sign represented
by a high reflectivity area between the junction line of the internal and external
segments of the photoreceptors and the line of the external segment of the cones
surgery and even contraindicating procedures because of the low possibility of

functional visual restoration after surgery.
The OCT has also been able to establish predictive factors of the possible
difficulty when peeling an ERM. The extension of adhesions and the presence
of fibrillar changes determined by SD-OCT tridimensional reconstructions
are a reliable preoperative assessment for the surgical removal of the ERM.15
In Figure 4, we can observe the spatial distribution of an ERM with a
tridimensional reconstruction. With this general vision of how the ERM is
affecting the retina, it is easier to localize areas of detachment that could be
used to establish a correct surgical removal strategy of the ERM. In Figure 5
we can observe a much attached ERM to the retinal surface, representing a
higher difficulty when performing the surgical procedure.
Other than the preoperative visual acuity, the tomographic findings that
determine better visual results after the surgical removal of an ERM are: the
presence of normal IS/OS line, a smooth internal limiting membrane (ILM)
profile, and the restoration of the normal foveal shape three months before
surgery.16 These findings explain why there are patients with an unsatisfactory
final visual acuity with a complete anatomic recuperation.
OPTICAL COHERENCE TOMOGRAPHY IN VITREORETINAL

TRACTION SYNDROME
Without any doubt, VTS is one of the pathologies in which OCT has become
an indispensable tool for its diagnosis and postoperative evaluation. OCT
is more sensitive than biomicroscopy in the detection of VTS that could
benefit from surgery.17 The posterior hyaloid is represented by a thin line
of middle reflectivity, opposed to ERM that is represented by a thicker,
high reflectivity line with more evident attachments to the retinal surface
as shown in Figure 6.
23
Figure 4 Tridimensional reconstruction of an epiretinal membrane
Figure 5 Epiretinal membrane well attached to the retinal surface
Figure 6 Posterior hyaloid over an epiretinal membrane

24
The OCT is useful in establishing the tridimensional configuration of the
vitreomacular attachments to the posterior pole, playing an important role in
the planning of the best way to access the subhyaloid space during vitrectomy.18
Thanks to the SD-OCT, it has been able to define two distinct patterns of the
vitreous traction over the retina in patients with VTS. The first is represented by
an incomplete posterior vitreous detachment in a “V” shape associated to the
detachment of the fovea (Fig. 7). In these cases the surgical prognosis is favorable.
The second is represented by a partial temporal posterior vitreous detachment
associated to a prominent cystoid macular edema (Fig. 8). In these cases, a greater
incidence of MH or macular atrophies have been observed after the surgery.19
A particular situation is the diffuse diabetic macular edema (DME),
characterized by generalized areas of leakage in the central macula in
which pathogenesis is not that well known. The treatment with grid laser
photocoagulation or with intravitreal drugs administration is the only
temporarily efficacy in many cases.20,21 Ophir et al described an important series
of patients with diffuse DME in which only 24% did not have any associated
signs of vitreomacular traction or ERM.22 A tridimensional reconstruction
showing how the posterior hyaloid is attached to the retinal surface of a patient
with diffuse DME is shown in Figure 9.
Figure 7 Vitreomacular traction syndrome in “V” shape
Figure 8 Temporal vitreomacular traction syndrome associated to a cystoid

macular edema
25
Figure 9 This picture shows, in a tridimensional reconstruction, the attachment

of the posterior hyaloids to the inner surface of the retina in a patient with a diffuse
diabetic macular edema
INTRAOPERATIVE
Without any doubt, OCT has revolutionized the ophthalmology consultation
generating important surgical changes in the patients with macular pathologies.
The logical evolution of the OCT is to get incorporated in the surgical procedure
itself. At this moment it is commercially available as a portable SD-OCT
(Bioptigen, Inc., Research Triangle Park, NC, USA) that obtains images of
the retina with the patient in supine position, as it happens with echography.
The first clinical application of this device was in pediatric patients with good
results.23 There are several publications of its intraoperative use in patients
with MH, ERM and VTS. Images of the retina were obtained before and
immediately after the vitrectomy or ILM, allowing the surgeon the correct result
of the surgery before closing the eye.24,25 The portable Bioptigen OCT has also
been used in complex retinal detachment surgeries, showing the presence of
subfoveal fluid at the end of the surgery which is invisible through the surgical
microscope.26 The weakness of this device is the necessity of stopping the
surgical procedure in order to obtain the images, limiting the intraoperative
applicability of this technology.
Actually there are efforts trying to incorporate the OCT to the surgical
microscope and creating “microscope-mounted OCT” (MM-OCT).27 The
MM-OCT can obtain images of the retina simultaneously with the surgery;
this technology has a clear practical applicability because it can give useful
information to the surgeon in real time. The MM-OCT can obviously
revolutionize the vitreoretinal surgery in the years ahead.
26
REFERENCES
1. Schuman JS, Hee MR, Arya AV, et al. Optical coherence tomography: a new tool
for glaucoma diagnosis. Curr Opin Ophthalmol. 1995;6(2):89-95.
2. Hoerauf H, Gordes RS, Scholz C, et al. First experimental and clinical results
with transscleral optical coherence tomography. Ophthalmic Surg Lasers.
2000;31(3):218-22.
3. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomography of macular
holes. Ophthalmology. 1995;102(5):748-56.
4. Hirneiss C, Neubauer AS, Gass CA, et al. Visual quality of life after macular hole
surgery: outcome and predictive factors. Br J Ophthalmol. 2007;91(4):481-4.
5. Ullrich S, Haritoglou C, Gass CA, et al. Macular hole size as a prognostic factor
in macular hole surgery. Br J Ophthalmol. 2002;86(4):390-3.
6. Kusuhara S, Teraoka Escaño MF, Fujii S, et al. Prediction of postoperative visual
outcome based on hole configuration by optical coherence tomography in eyes
with idiopathic macular holes. Am J Ophthalmol. 2004;138(5):709-16.
7. Jumper JM, Gallemore RP, McCuen BW, et al. Features of macular hole closure
in the early postoperative period using optical coherence tomography. Retina.
2000;20(3):232-7.
8. Wakabayashi T, Fujiwara M, Sakaguchi H, et al. Foveal microstructure and visual
acuity in surgically closed macular holes: spectral-domain optical coherence
tomographic analysis. Ophthalmology. 2010;117(9):1815-24.
9. Solebo AL, Lange CA, Bunce C, et al. Facedown positioning or posturing after
macular hole surgery. Cochrane Database Syst Rev. 2011;12:CD008228.
10. Hillenkamp J, Kraus J, Framme C, et al. Retreatment of fullthickness macular
hole: predictive value of optical coherence tomography. Br J Ophthalmol.
2007;91(11):1445-9.
11. Do DV, Cho M, Nguyen QD, et al. Impact of optical coherence tomography on
surgical decision making for epiretinal membranes and vitreomacular traction.
Retina. 2007;27(5):552-6.
12. Koo HC, Rhim WI, Lee EK. Morphologic and functional association of retinal
layers beneath the epiretinal membrane with spectral-domain optical coherence
tomography in eyes without photoreceptor abnormality. Graefes Arch Clin Exp
Ophthalmol. 2012;250(4):491-8.
13. Watanabe A, Arimoto S, Nishi O. Correlation between metamorphopsia and
epiretinal membrane optical coherence tomography findings. Ophthalmology.
2009;116(9):1788-93.
14. Tsunoda K, Watanabe K, Akiyama K, et al. Highly reflective foveal region in
optical coherence tomography in eyes with vitreomacular traction or epiretinal
membrane. Ophthalmology. 2012;119(3):581-7.
15. Kim JS, Chhablani J, Chan CK, et al. Retinal adherence and fibrillary surface
changes correlate with surgical difficulty of epiretinal membrane removal. Am J
Ophthalmol. 2011;153(4):692-7.
16. Falkner-Radler CI, Glittenberg C, Hagen S, et al. Spectral-domain optical coherence
tomography for monitoring epiretinal membrane surgery. Ophthalmology.
2010;117(4):798-805.
17. Gallemore RP, Jumper JM, McCuen BW, et al. Diagnosis of vitreoretinal adhesions
in macular disease with optical coherence tomography. Retina. 2000;20(2):115-20.
27
18. Chung EJ, Lew YJ, Lee H, et al. OCT-guided hyaloid release for vitreomacular
traction syndrome. Korean J Ophthalmol. 2008;22(3):169-73.
19. Yamada N, Kishi S. Tomographic features and surgical outcomes of vitreomacular
traction syndrome. Am J Ophthalmol. 2005;139(1):112-7.
20. Focal photocoagulation treatment of diabetic macular edema. Relationship of
treatment effect to fluorescein angiographic and other retinal characteristics at
baseline: ETDRS report no. 19. Early Treatment Diabetic Retinopathy Study
Research Group. Arch Ophthalmol. 1995;113(9):1144-55.
21. Shimura M, Nakazawa T, Yasuda K, et al. Comparative therapy evaluation of
intravitreal bevacizumab and triamcinolone acetonide on persistent diffuse diabetic
macular edema. Am J Ophthalmol. 2008;145(5):854-61.
22. Ophir A, Martinez MR, Mosqueda P, et al. Vitreous traction and epiretinal
membranes in diabetic macular oedema using spectral-domain optical coherence
tomography. Eye (Lond). 2010;24(10):1545-53.
23. Muni RH, Kohly RP, Charonis AC, et al. Retinoschisis detected with handheld
spectral-domain optical coherence tomography in neonates with advanced
retinopathy of prematurity. Arch Ophthalmol. 2010;128(1):57-62.
24. Dayani PN, Maldonado R, Farsiu S, et al. Intraoperative use of handheld spectral
domain optical coherence tomography imaging in macular surgery. Retina.
2009;29(10):1457-68.
25. Wykoff CC, Berrocal AM, Schefler AC, et al. Intraoperative OCT of a full-thickness
macular hole before and after internal limiting membrane peeling. Ophthalmic
Surg Lasers Imaging. 2010;41(1):7-11.
26. Lee LB, Srivastava SK. Intraoperative spectral-domain optical coherence
tomography during complex retinal detachment repair. Ophthalmic Surg Lasers
Imaging. 2011;42 Online:e71-4.
27. Ehlers JP, Tao YK, Farsiu S, et al. Integration of a spectral-domain optical coherence
tomography system into a surgical microscope for intraoperative imaging. Invest
Ophthalmol Vis Sci. 2011;52(6):3153-9.
chapter 4
Anesthesia
Manuel Baeza, José Juan Martínez-Toldos
INTRODUCTION
During surgery, handling the iris, ciliary body and sclera can be painful, and
heat stimulation can also be uncomfortable. In addition, cryotherapy is known
to be very painful, more so than the laser or cauterization. Thus, it is important
that the patient is given the most appropriate form of anesthesia.1
The form of anesthesia to use in patients under anticoagulant/antiaggregant
treatment is a controversial topic. For cataract surgery, this type of treatment
need not be suspended. However, the risk of hemorrhage during vitreoretinal
surgery dictates that anticoagulant treatment should be interrupted.
The disease requiring anticoagulation treatment and the patient’s risk
of thromboembolism should be known, since sometimes withdrawing an
antiaggregant puts a patient at great unnecessary risk. Thus, a valve disease or
stroke with arrhythmia and history of embolism is not the same as a stroke or
myocardial infarction without cardiac arrhythmia.
Also, the antiaggregant used should be known since not all show the same
risk of inducing hemorrhage nor require the same duration of replacement
therapy (Table 1).
The reason for surgery is also important; for instance, a technique in which
scleral bands are needed is associated with a greater risk of hemorrhage than
a macular surgery procedure.
The surgeon should assess the least invasive anesthesia method and select
the replacement anticoagulant/antiaggregant with sufficient time before surgery.
Also, a blood test will be needed to determine the international normalized
ratio (INR), which should be within the recommended limits for the disease
under anticoagulation therapy.1,2
The latest published recommendations propose personalized treatment
prescribed by the patient’s internist and anesthetist. The current trend is to try
Chapter 4  Anesthesia
29
Table 1
Characteristics of some of the antiaggregants used for vitreoretinal surgery
Antiaggregant Mechanism Safety margin Risks

for suspension
Aspirin, Adiro, Inhibits thrombox- 7 days -
AAS ane A2 synthesis
Dipyridamole, Inhibits phospho- 24 hours -
Persantine diesterase
Triflusal, Inhibits cyclooxy- 7 days -
Disgren genase
Ticlopidine, Blocks ADP 10 days Severe risk of
Ticlid receptor hemorrhage
Clopidogrel, Blocks ADP 7 days Severe risk of
Iscover, Plavix receptor hemorrhage
Abbreviations: AAS: Acetylsalicylic acid; ADP: Adenosine diphosphate
not to suspend antiaggregant and/or anticoagulant treatment by assessing the

risk/benefits in each case.3,4
A recommended strategy would be:
Patients with low emboligenic risk: suspend antiaggregant treatment
Patients with high emboligenic risk: replace anticoagulants with low-
molecular-weight heparin treatment 3–5 days before surgery
Patients with a very high emboligenic risk: assess the risks of maintaining
treatment or replace antiaggregant with one of lower hemorrhage risk (e.g.
Adiro 100 mg) besides the use of sub-Tenon’s or subconjunctival anesthesia
and an atraumatic surgical technique.
TYPES OF ANESTHESIA
The anesthesia options available are:
General
Topical: not recommended for vitreoretinal surgery
Retrobulbar
Peribulbar
Sub-Tenon’s
Subconjunctival: Introduced through sclerotomies in quick posterior pole
procedures.
General Anesthesia
The benefits of general anesthesia over local anesthesia are: noncooperative
patients can be controlled and intraocular pressure can be reduced if needed;
30
either by reducing CO2 through hyperventilation or reducing arterial pressure.
General anesthesia may also help in controlling intraoperative hemorrhage by
lowering arterial blood pressure.
It is indicated in children, poorly cooperative patients because of phobias,
hyperkinesia or mental impairment, in patients with a neurological disease
(Parkinson’s or cerebral palsy) that prevents them from remaining still during
surgery or subjects with tics or tremors. The use of a general anesthetic is also
recommended in deaf patients, in perforating trauma patients and when surgery
duration of more than 2–3 hours is anticipated.
It should be noted that when a general anesthetic mixture containing nitrous
oxide is used; its administration should be interrupted 10 minutes before
injecting SF6 or C3F8 into the globe, to avoid the gas bubble rapidly expanding
due to the entry of nitrous oxide from adjacent tissues because of the partial
pressure gradient generated. This could cause a considerable intraocular
pressure rise.5-7
With general anesthesia, the risk of oculocardiac reflex (OCR) is increased.
However, OCR is usually transient since repeated stimuli will block the
response. Generally, OCR will spontaneously stop a few seconds after the
stimulus ceases. If OCR occurs, the maneuver triggering the reflex will have
to be interrupted. This is usually muscle traction. In the case of a continued
OCR, 0.5–1 ml of atropine should be given. In children, atropine is sometimes
prophylactically administered.
The medications mostly used for sedation to accompany both, a local and
general anesthetic are:
Anxiolytic agents
–– Diazepam (Valium): has the drawback that active metabolites are
released at the time it is administered.
–– Midazolam: onset: 30–60 seconds; half-life: 3 hours; dose: 0.1–0.2 mg/
kg (anxiolytic of choice, anxiolysis, hypnosis, amnesia)
Opioids
–– Fentanyl: onset: 5 minutes; duration: 30–45 minutes; dose: 0.025–0.05
mg (analgesic of choice)
Hypnotic agents
–– Propofol: onset: 30–45 seconds; half-life: 2.5 minutes; dose: 1–2.5 mg/
kg (immediate hypnotic effect, lowers arterial and intraocular pressure,
antiemetic).
The agents mostly used prior to local anesthesia, to achieve adequate hypnosis
and amnesia at the time of administration, are propofol or midazolam.8-10
Local Anesthesia
The advantage of local anesthesia is that the patient can communicate and
collaborate with the surgeon, along with 4–6 hours of pain relief following
31
Table 2
Most commonly used local anesthetics
Drug Concentra- Onset Duration Vascular

tion effects
Lidocaine 0.5–4 mg/kg Rapid (2–3 minutes) 1–2 hours Vasodila-
tion
Mepivacaine 0.5–2 mg/kg Rapid (2–3 minutes) 1.5–3 No
hours
Bupivacaine 0.5–0.75 Slow (10 minutes) 3–8 hours No
mg/kg
Ropivacaine 1 mg/kg Medium (6–7 min- 3–8 hours Vasocon-
utes) striction
surgery. Moreover, local anesthesia avoids the systemic complications of

general anesthesia as well as coughs or vomiting, which sometimes occur
after extubation. These could provoke hemorrhages or suture dehiscence. In
addition, the use of a local anesthetic will eliminate the risk of OCR, avoiding
hospitalization and the cost this entails.
The most commonly used local anesthetics can be classified into two
categories that are presented in Table 2.
In one category, there are lidocaine and mepivacaine, which are rapidly
acting (2–3 minutes) but have a short-lived effect, approximately 2 hours. In
the other group, bupivacaine and ropivacaine have a slow onset of action; some
10 minutes, but a more prolonged effect of 6–8 hours. The ideal is, thus, to
combine one from each group to achieve the benefits of both.
Local anesthetics are usually given with hyaluronidase, an enzyme that
hydrolyses glucosamine-glucuronic acid bonds, to improve their diffusion,
achieve a more rapid effect, lower intraocular pressure and reduce proptosis. In
contrast to hyaluronidase, adrenaline does not improve the efficacy or prolong
the duration of a local anesthetic. A Honan balloon is also recommended to
increase diffusion and reduce intraocular pressure and chemosis (Fig. 1).
Anatomy Applied to Anesthesia

For the sensory innervation of the eye, signals are transmitted via the first
branch of the trigeminal nerve, the optic nerve, which is in turn divided into
three branches, of which the nasociliary branch comprises the innervation of
the cornea, iris, ciliary body and sclera.
The nasociliary nerve divides into one branch, which passes through the
ciliary ganglion from where the short ciliary nerves emerge and other branches
that accompany the optic nerve, the long ciliary nerves.11,12
In theory, we can divide the orbit into two compartments, intracone and
extracone, bounded by the four rectus muscles that run from the annulus of
32
Figure 1 Patient with a Honan balloon after injection of the anesthetic
Zinn, at the orbit’s apex, to the Tenon’s capsule at the ocular globe. The space
between the rectus muscles contains connective tissue and fat but there is no
defined intermuscular septum to isolate the two compartments (Fig. 2). Thus,
any anesthetic introduced in the extracone space for peribulbar anesthesia can
diffuse to the intracone space.13
We should remind ourselves of some of the measurements between the
structures of the orbit. Thus, the mean distance from the apex to the inferior
margin of the orbit is 48 mm (42–54 mm), the distance to the optic nerve from
the inferior orbital edge is 33 mm and the ciliary ganglion occurs 10 mm from
the apex.14
Figure 2 Orbit anatomy

33
The central retinal artery penetrates the optic nerve close to the ciliary
ganglion. Its long intraorbitary course is susceptible to damage by puncture.
In the inferior half of the orbit are the ophthalmic vein, ciliary ganglion and
cranial nerve pairs, while through the superior and posterior zones run the ciliary
arteries. For this reason, anesthesia at the inferior level is of greatest interest
since this will block sensory-motor nerves and even signals transmitted along
the optic nerve with a lower risk.12
Retrobulbar Block
This mode of anesthesia consists of the intracone injection of the anesthetic
targeted at achieving akinesia through blockage of the cranial nerve pairs and
achieving anesthesia through blockage of the ciliary nerves by actions on the
ciliary ganglion. Sympathetic and parasympathetic stimuli are also blocked,
inducing intraocular pressure lowering and pupil dilation. The technique was
first described by Knapp15 and was then popularized by Atkinson.16
Technique
Patient in a supine position looking straight ahead
Retrobulbar 25 gauge needle, maximum length 35 mm
Transconjunctival or transpalpebral approach
Single point of access
For a transpalpebral approach, the needle is slowly introduced through the
lower eyelid at the junction of the middle third and outer third of the lower
orbital rim (Fig. 3) passing through the orbital septum, and its direction
changed by 25° as the equator of the eye is passed and then advanced into
the muscular cone.
Figure 3 Initiating the transpalpebral retrobulbar injection process at the

junction between the middle and outer thirds of the orbital rim
34
The transconjunctival technique involves:
–– Introducing the needle (30 mm maximum length) with the slanted tip
facing upward
–– Aspiration and injection of 3–5 ml
–– Subdermal injection. Honan balloon
If we wish to achieve complete akinesia, it is sometimes useful to perform
an infiltration at the inner third of the superior orbital rim given the superior
oblique muscle is located in the extracone area.
For akinesia of the orbicular muscle, an inferotemporal subdermal infiltration
may be conducted before withdrawing the needle, or the facial muscle may
be specifically blocked, using the Van Lint technique whereby infiltration is
performed at the outer orbital rim, and extended inferiorly and exteriorly.
Several complications of this technique have been described17,18 such as
retrobulbar hemorrhage,19,20 puncture of the globe,21-23 optic nerve trauma
or puncture, 24 subarachnoid injection causing central nervous system
depression,25,26 ptosis and strabismus.27,28 Each of these complications and the
preventive measures are described below.
Retrobulbar hemorrhage
–– Induces proptosis with or without subconjunctival hemorrhage,
restricted extrinsic ocular motility and increased intraocular pressure.
–– Incidence: 0.1–1.7%
–– It can be resolved by applying pressure with the Honan balloon,
although sometimes surgery needs to be rescheduled and rarely a lateral
canthotomy is needed if central retinal ischemia occurs.
Increased intraocular pressure
–– Secondary to a retrobulbar hemorrhage or excess anesthetic
–– Apply pressure with the Honan balloon
Optic nerve damage
–– It can lead to optical atrophy
–– Needle may cause damage to the optic nerve or arteries or compress
the optic canal
–– Prevention:
-- The patient should adopt a primary viewing position so that the optic
nerve is further from the inferior muscles.29
-- Do not advance the needle more than 31 mm.
Ocular perforation is a serious complication of retrobulbar anesthesia that
needs to be prevented. A useful strategy is to move the needle sideways
before injecting the anesthetic, to make sure this movement is not
accompanied by the globe.
–– It occurs more frequently in an elongated eye in myopic patients or
when scleral bands are used.
–– If the anesthetic is injected inside the globe, an abrupt intraocular
pressure increase may be produced causing irreversible damage. In
this case an anterior chamber paracentesis would have to be performed.
35
–– Puncturing the globe could cause a vitreous hemorrhage or retinal
detachment, which would determine the need for vitrectomy and
endophotocoagulation rather than puncture. Sometimes, retinal
incarcerations dictate the need for a retinotomy.
Subarachnoid diffusion of the anesthetic
–– May lead to convulsions and respiratory arrest
–– Passage of local anesthetic to central nervous system (CNS)
–– A 2–3 hours support treatment is needed with intubation of the patient
Muscular complications
–– Ptosis and strabismus
–– Due to the effects on the inferior rectus and most often the inferior
oblique. Frequently due to toxicity of the anesthetic or trauma to the
muscle. Less commonly due to cranial nerve pair damage.
Peribulbar Anesthesia
Peribulbar anesthesia was described by Davis and Mandel30 and modified by
Bloomberg.31 It consists of injecting the anesthetic into the extracone space
and its diffusion between the intra-and extracone compartments achieving the
anesthetic effect.
Technique
Straight ahead viewing position
Percutaneous delivery
Needle, maximum 25 gauge, 25 mm
Two points of delivery: one at the inferoexternal quadrant (Fig. 4) and the
other at the superointernal quadrant beneath the supraorbital notch; injection
of 8–10 ml of anesthetic.
Figure 4 Peribulbar anesthesia

36
Injection of 1 ml subdermal, inferotemporal
Compression with Honan balloon
Benefits
High safety profile
Less pain during injection
Lowered risk of optic nerve damage
Method of choice in myopes
Avoids facial block due to diffusion of the anesthetic to the eyelids
Drawbacks
Slow diffusion, takes 10 minutes to take effect
Greater volume of anesthetic needed
Greater risk of chemosis and ecchymosis
Hyaluronidase needed
Sub-Tenon’s Anesthesia
Described by Swan in 1956,32 the sub-Tenon’s procedure is gaining popularity
since its efficacy matches that of the aforementioned techniques33,34 and it is
recommended for vitreoretinal surgery.35,36 Its main features are:
Diffusion of the anesthetic in the subtenonian space and its posterior
diffusion from here to block the ciliary nerves
Simple technique
Reduced pain, rapid effect
May be intraoperatively repeated. Useful for peritomy in retinal detachment
Technique
Administered as eye drops
Conjunctival button hole 4 mm from the nasal limbus or inferior-temporal
Blunt dissection of Tenon’s capsule
Introduction of 2–4 ml of anesthetic
A curved Greenbaum 25 mm cannula is used which adapts to the convexity
of the ocular globe (Fig. 5).
Complications
Conjunctival chemosis
Incomplete akinesia
Risk of conjunctival bleeding
Risk of damaging vorticose veins
37
Figure 5 Greenbaum cannula used to deliver a peribulbar anesthetic
Our technique: transconjunctival retrobulbar anesthesia

Given its unquestionable benefits, we prefer to use local anesthesia for routine
vitreoretinal surgery. We use intravenous propofol as an adjuvant (Fig. 6), which
is a short-acting, rapid-recovery hypnotic agent. The half-life of propofol in
the blood system is around 2.5 minutes, after which it is processed in the liver
and is fully eliminated within 55 minutes. Propofol rapidly induces a loss of
consciousness, some 30–45 seconds after administration. The recommended
intravenous dose of propofol is 1–2.5 mg/kg. This dose should be decreased
if propofol is given concomitantly with anxiolytics, opioids or in elderly or
hemodynamically compromised patients. Propofol seems to have a protective
effect against postoperative nausea and vomiting.8-10
Figure 6 Ampoule of the hypnotic agent propofol administered intravenously

along with the local anesthesia
38
The local anesthetic we use is a 50:50 mixture of 2% mepivacaine (of
rapid onset) and 0.75% bupivacaine (of prolonged duration) administered with
hyaluronidase to improve diffusion (Fig. 7).
Patient monitoring: before surgery, the patient’s level of consciousness is
assessed according to his/her verbal capacity and temporal-spatial orientation.
Adequate lung ventilation is ensured using nasal spectacles: oxygenation is
controlled by pulse oximetry (a noninvasive method of monitoring oxygen-
hemoglobin saturation). Blood pressure is also monitored using a digital
pressure gauge (stress causes the release of catecholamines with the subsequent
risk of tachycardia and hypertension) that takes readings every 15 minutes.
Possible arrhythmia and ischemia are also verified in a continuous ECG.
An intracone retrobulbar injection is given through the conjunctiva as follows:
First, a few drops of tetracaine are instilled in the conjunctiva. 1–2 ml of
propofol is then given intravenously followed by a 30–40 seconds waiting
period. The patient is asked to look directly ahead.
A 30 mm long, 25-gauge retrobulbar needle is introduced in the
inferotemporal quadrant through the conjunctiva (Fig. 8).
The needle is slid along the globe wall with the slanted tip facing the wall
to avoid perforations.
The needle is advanced through the septum, which is barely perceivable,
especially in older subjects, until we reach the muscle cone wall between
the inferior and lateral recti, pushing softly (Fig. 9).
The possibility of vessel puncture is ruled out by slight aspiration before
introducing 2–4 ml of anesthetic in the muscle cone. As the syringe is
withdrawn, further anesthetic is injected, checking orbital pressure to avoid
Figure 7 Ampoules containing mepivacaine 2%, bupivacaine 0.75% and

hyaluronidase. A 10 ml syringe and 25 gauge, 30 mm long retrobulbar needle
39
Figure 8 To initiate the transconjunctival injection process, the surgeon pulls the
eyelids apart with the index and thumb
Figure 9 Sliding the needle along the globe wall and introducing it in the
transconjunctival muscle cone
inducing high pressure. In this maneuver we usually introduce around 6–8

ml, which is sufficient for surgery (Fig. 10).
The eye is gently massaged, and intraocular and intraorbital pressures are
manually checked.
This procedure gives rise to a slightly protruding, or exophthalmic, globe
facilitating subsequent surgical access. It also gives direct access to the
muscle cone in a more controlled manner than through the eyelid. So far, we
have not experienced any of the complications associated with Atkinson’s
retrobulbar anesthesia such as intraocular perforation, retrobulbar hemorrhage,
intravascular injection or subarachnoid injection. Surgery is always conducted
40
Figure 10 Transconjunctival retrobulbar anesthesia. First, the needle is slid along
the globe wall to cross the septum. Next, the needle is pointed downwards into
the muscle cone. Overcoming the resistance of the muscle cone, the anesthetic is
introduced after aspiration
slowly, carefully traversing the orbital septum and muscular cone followed by
aspiration.
When operating on young patients who require placement of a scleral graft,
a further injection of the intracone mixture can be given while manipulating
the muscles or the anesthetic can be directly instilled at the insertion points of
the rectus muscles.
REFERENCES
1. Charles S, Fanning GL. Anesthesia considerations for vitreoretinal surgery.
Ophthalmol Clin North Am. 2006;19(2):239-43.
2. Local Anesthesia for Intraocular Surgery. London: Royal College of Anesthetists
and Royal College of Ophthalmologists; 2001.
3. Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal
surgery. Am J Ophthalmol. 2011;151(6):934-9.
4. Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associated
with retrobulbar/peribulbar block: a prospective study in 1383 patients. Br J
Anaesth. 2000;85(5):708-11.
5. Wolf GL, Capuano C, Hartung J. Nitrous oxide increases intraocular pressure after
intravitreal sulfur hexafluoride injection. Anesthesiology. 1983;59(6):547-9.
6. Stinson TW, Donlon JV. Interaction of intraocular air and sulphur hexafluoride
with nitrous oxide: a computer simulation. Anesthesiology. 1982;56(5):385-8.
7. Smith RB, Carl B, Linn JG, et al. Effect of nitrous oxide on air in vitreous. Am J
Ophthalmol. 1974;78(2):314-7.
8. Vann MA, Ogunnaike BO, Joshi GP. Sedation and anesthesia care for
ophthalmologic surgery during local/regional anesthesia. Anesthesiology.
2007;107(3):502-8.
9. Morley HR, Karagiannis A, Schultz DJ, et al. Sedation for vitreoretinal surgery: a
comparison of anesthetist-administered midazolam and patient controlled sedation
with propofol. Anaesth Intensive Care. 2000;28(1):37-42.
41
10. Habib NE, Balmer HG, Hocking G. Efficacy and safety of sedation with propofol
in peribulbar anaesthesia. Eye (Lond). 2002;16(1):60-2.
11. Johnson RW. Anatomy for ophthalmic anesthesia. Br J Anaesth. 1995;75(1):80-7.
12. Dutton JJ, Hasan SA, Edelhauser HF, et al. Anesthesia for intraocular surgery.
Surv Ophthalmol. 2001;46(2):172-84.
13. Ripart J, Lefrant JY, de la Cussaye JE, et al. Peribulbar versus retrobulbar anesthesia
for ophthalmic surgery: an anatomical comparison of extraconal and intraconal
injections. Anesthesiology. 2001;94(1):56-62.
14. Karampatakis V, Natsis K, Gigis P, et al. Orbital depth measurements of human
skulls in relation to retrobulbar anesthesia. Eur J Ophthalmol. 1998;8(2):118-20.
15. Knapp H. On cocaine and its use in ophthalmic surgery. Arch Ophthalmol.
1884;13:402-8.
16. Atkinson WS. The development of ophthalmic anesthesia. Am J Ophthalmol.
1961;51:1-14.
17. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with
retrobulbar injections. Ophthalmology. 1988;95(5):660-5.
18. Hamilton RC, Grizzard WS. Complications. In: Gills JP, Hustead RF, Sanders DR
(Eds). Ophthalmic Anesthesia. New Jersey: Slack Incorporated; 1993. pp. 187-202.
19. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar blocks.
Anesth Analg. 1993;76(5):1019-22.
20. Cionni RJ, Osher RH. Retrobulbar hemorrhage. Ophthalmology. 1991;98(8):1153-5.
21. Schneider ME, Milstein DE, Oyakawa RT. Ocular perforation from a retrobulbar
injection. Am J Ophthalmol. 1988;106(1):35-40.
22. Edge R, Navon S. Scleral perforation during retrobulbar and peribulbar anesthesia:
risk factors and outcome in 50,000 consecutive injections. J Cataract Refract Surg.
1999;25(9):1237-44.
23. Mount AM, Seward HC. Scleral perforations during peribulbar anaesthesia Eye
(Lond). 1993;7(Pt 6):766-7.
24. Pautler SE, Grizzard WS, Thompson LN, et al. Blindness from retrobulbar injection
into the optic nerve. Ophthalmic Surg. 1986;17(6):334-7.
25. Rosenblatt RM, May DR, Barsoumian K. Cardiopulmonary arrest after retrobulbar
block. Am J Ophthalmol. 1980;90(3):425-7.
26. Hamilton RC. Brain-stem anesthesia as a complication of regional anesthesia for
ophthalmic surgery. Can J Ophthalmol. 1992;27(7):323-5.
27. Capó H, Roth E, Johnson T, et al. Vertical strabismus after cataract surgery.
Ophthalmology. 1996;103(6):918-21.
28. Nayak H, Kersey JP, Oystreck DT, et al. Diplopia following cataract surgery: a
review of 150 patients. Eye (Lond). 2008;22(8):1057-64.
29. Liu C, Youl B, Moseley I. Magnetic resonance imaging of the optic nerve in
extremes of gaze. Implications for the positioning of the globe for retrobulbar
anaesthesia. Br J Ophthalmol. 1992;76(12):728-33.
30. Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to
retrobulbar anesthesia. J Cataract Refract Surg. 1986;12(2):182-4.
31. Bloomberg LB. Administration of periocular anesthesia. J Cataract Refract Surg.
1986;12(6):677-9.
32. Swan KC. New drugs and techniques for ocular anesthesia. Trans Am Acad
Ophthalmol Otolaryngol. 1956;60(3):368-75.
33. Stevens JD. A new local anesthesia technique for cataract extraction by one
quadrant sub-Tenon’s infiltration. Br J Ophthalmol. 1992;76(11):670-4.
42
34. Friedman DS, Bass EB, Lubomski LH, et al. Synthesis of the literature on
the effectiveness of regional anesthesia for cataract surgery. Ophthalmology.
2001;108(3):519-29.
35. Li HK, Abouleish A, Grady J, et al. Sub-Tenon’s injection for local anesthesia in
posterior segment surgery. Ophthalmology. 2000;107(1):41-6.
36. Calenda E, Olle P, Muraine M, et al. Peribulbar anesthesia and sub-Tenon injection
for vitreoretinal surgery: 300 cases. Acta Ophthalmol Scand. 2000;78(2):196-9.
Chapter 5
Instrumentation
5.1 OPERATING ROOM
INTRODUCTION
In the operating room, the surgeon seeks maximal independence. This means
having systems that the surgeon and assisting nurses can control without the
need for third parties.1
The personnel needed are: surgeon, nurse, instrument technician, circulating
nurse and anesthetist. Each member of the operating team should know his/
her site of action in the room. The surgeon usually stands nearby the patient
with the technician to his/her right where he/she can control the instrument
tray and ensure the equipment is functioning correctly. The anesthetist usually
stands/sits at the foot of the operating table and controls the monitoring of
electrocardiogram (ECG), arterial blood pressure and partial pressure of oxygen
in the blood. Finally, the nurses provide the equipment needed for each stage
of surgery and ensure the correct functioning of the machines.2
REQUIREMENTS
Ophthalmologic Surgery Table
The operating table or stretcher is used for both transport and surgery so that
the patient does not have to be transferred to another operating bench. It should
be articulated with an adjustable headrest to comfortably change the patient’s
head position. The eye-plane should be parallel to the ceiling as a downward or
upward inclination will impair the surgeon’s vision and hinder the surgery. The
44
upholstery should be comfortable since we are dealing with elderly patients under
local anesthesia. When surgery lasts for more than an hour, common complaints
have more to do with the patient becoming restless and uncomfortable than the
intraocular surgery itself; an uncomfortable patient is less willing to cooperate
(Fig. 1). In addition, the operating table should easily convert into a reclining
chair to help incorporate and position the patient after surgery.
Electrical stretchers also exist with batteries to power the articulation and
movement of the main body and headrest. This means the patient’s position
can be adjusted without physical help required. Before starting the surgery, it
should be checked that the batteries are fully charged to avoid surprises during
an intervention (Fig. 2).
Figure 1 Stryker stretcher for ophthalmology surgery. The table is articulated and
has a hydraulic up/down movement system allowing adjustment of the headrest
so that the patient’s head can be correctly positioned horizontally leaving sufficient
room for the surgeon’s feet and control pedals
Figure 2 Electrical stretcher powered by batteries. Its main articulated body can
be remote-controlled without the need to touch the stretcher
Chapter 5  Instrumentation
45
Instrument Column
There should be a single instrument column to accommodate the vitrectomy
system, endolaser, cryotherapy device, infusion fluids and anything else needed
for the surgery. The column is positioned at the foot of the operating table (Fig. 3).
Integrated Vitrectomy Systems

The improved flow control of the new high-speed vitrectomy systems helps
regulate tissue aspiration towards the vitreotome tip. These systems include their
own lasers, filters, various illumination devices, intraocular pressure-controlling
pumps and dense fluid or gas injection/removal pumps. They do not include a
cryotherapy system since their use is becoming less frequent (Figs 4A and B).
Image Recorder
This allows direct real-time viewing of the microsurgery procedure and has
become indispensable for the members of the operating team, such as the
anesthetist and circulating nurses, who have no access to the microscope. The
monitor should be positioned such that the surgeon can easily center the image
during surgery. The use of a recording system also provides footage of the
different surgery procedures for training medical staff or students. Recordings can
also be used for presentations. Nowadays, available are the new high-definition
digital recording systems. These allow the recordings to be divided into 5, 10
or 15 minutes files. Photographs can also be captured during the intervention.
Figure 3 Instrument column housing the vitreotome equipped with cutter,

aspirator, diathermy system, infusion pump, illumination system, an endolaser,
infusion fluid support system, etc.
46
A B
Figures 4A and B The new high-speed vitrectomy systems are equipped with lasers,
filters, intraocular pressure control pumps, dense fluid injection pumps and tools
for phacoemulsification, phacofragmentation, etc. (A) Constellation; (B) Stellaris PC
Operating Microscope
For vitreous surgery, a multifunctional microscope3 is required equipped with
the following:
X-Y system for movement of the microscope head position with respect
to the eye: X corresponds to nasal-temporal direction of movement and Y
to superoinferior movement. Before the onset of surgery, the X-Y system
should be returned to its central position so that the microscope head can
be moved in any direction4,5
Zoom: Controlled by the surgeon using a foot pedal
Articulated arms: To easily move the microscope
Fine focus: At high magnification, the depth of the field decreases and
focusing becomes more difficult. Thus, sometimes it is best to reduce the
magnification for fine focusing and then gradually increase magnification
to obtain the desired image size
On/off switch: Controlled by the surgeon using the footswitch. This avoids
the need for movement of ancillary staff
Laser filter and an image inverting system when using a wide-field viewing
system
A binocular eyepiece when working with an assistant. The laser filter should
be fitted below the division of the two eyepieces so that both the surgeon
and the assistant are protected
A video camera to transfer the image to the monitor such that the entire
operating team can follow the surgical procedure.
47
The operating microscope (Fig. 5) is ideally attached to the ceiling allowing
more free space in the operating room. If this is not possible, the microscope
can be added to the instrument column. In this last case, the microscope is fixed
to the operating stretcher at the foot of the patient.
Pedal positions (Figs 6A and B) are usually:
Microscope pedal, left
Vitreotome pedal, right
Laser pedal, middle.
Figure 5 Leica microscope with an X-Y sytem, video camera, assistant eyepiece and
surgeon eyepiece. A laser filter placed below the eyepieces protects the surgeon
and the assistant from the laser
A B
Figures 6A and B (A) Left microscope pedal controls X-Y system, microfocus,
zoom, on/off switch; (B) Right vitreotome pedal controls aspiration, cutting, infusion
pressure, backflush and diathermy. The wireless pedal system eliminates cord clutter
48
REFERENCES
1. Charles S, Katz A, Wood B. Vitreous Microsurgery, 3rd edition. Philadelphia:
Lippincott Williams and Wilkins; 2002. pp. 25.
2. Corcóstegui B, Adán A, García-Arumí J, et al. Cirugía vitreoretiniana, indicaciones
y técnicas. Madrid: Tecnimedia editorial; 1999. pp. 20-1.
3. Parel JM, Machemer R, Aumayr W. A new concept for vitreous surgery. An
automated operating microscope. Am J Ophthalmol. 1974;77:161.
4. Charles S, McCarthy C, Eichenbaum D. A chin-operated switch for motorized
three-axis microscopic movement. Am J Ophthalmol. 1975;80(1):150-1.
5. Freeman HM, Tolentino FI. Atlas of Vitreoretinal Surgery. New York: Thieme
Medical Publishers; 1990. pp. 40-3.
49
5.2 VISUALIZATION SYSTEMS
INTRODUCTION
Since the advent of vitreoretinal surgery, contact lenses bearing a ring to fix the
lens to the sclera, 2 mm from the limbus, have been used. Lenses are generally
oriented at 6–12 hours,1,2 although they may also be positioned horizontally or
obliquely if the eye has been subjected to previous surgery preventing good
anchorage (Fig. 1). Currently, there are contact lenses with a silicone self-
retaining ring that do not require suturing to the sclera (Fig. 2).
In 1999, self-stabilizing contact lenses for vitrectomy were developed
(Figs 3A and B) without the need for a suture ring or an assistant. Thus, Volk’s
self-stabilizing vitrectomy lenses let ophthalmologists perform wide-angle
vitreoretinal surgery without a suture-down ring. Currently, a wide-angle high
refractive power self-stabilizing lens is available; the so-called ora-ora lens
provides a visual field of 154° in static mode and of 190° in dynamic mode,
allowing observation of the pars plana and ora serrata.3
Figure 1 Landers lens retaining ring with a wide rim for greater stability even
when used to stabilize wide-angle contact lenses
Figure 2 Dorc silicone retaining ring in which a lens can be inserted avoiding
the need for suturing to the sclera
50
Figures 3A and B (A) The Volk self-stabilizing vitrectomy lens . Vitrectomies can be
performed using wide-angle lenses without the need for scleral suturing or an assistant;
(B) Panoramic view of the ultra-wide-angle “ora-ora” lens (Volk Optical, Mentor)
UPRIGHT IMAGE CONTACT LENSES

Contact lenses offset the high convergent power of the curvature of the cornea,
allowing the operating microscope to focus on the central vitreous or posterior
retina. Although they provide a good quality direct image, (Fig. 4) the few
degrees of visual angle offered means they have to be constantly rotated and
frequently interchanged to work in peripheral areas. For years, vitreous surgery
lenses have been responsible for the success of this type of surgery and in every
vitreoretinal operating room there should be a set of lenses (Fig. 5) comprising:
Landers Biconcave Lens

A 90D lens for viewing the fundus through an air-filled globe in phakic or
aphakic eyes. This lens provides a 25° viewing angle and image magnification
of 0.8x.
51
Figure 4 The Machemer magnifying contact lens provides an upright

28° to 30° image
Figure 5 Conventional vitrectomy lens pack supplied by Dorc including: a

biconcave lens (brown) for visualization of the fundus in an air-filled phakic eye; a
flat (gold) lens for the central vitreous and fundus; a 20° prism lens (green) for the
posterior periphery; a wide-angle lens (blue) for the central posterior fundus and
central vitreous; and a 30° prism lens (purple) for the periphery beyond the equator
Machemer Magnifying Lens

This lens allows observation of retinal surface details. Its viewing angle is 30°
and magnification 1.49x.
52
Figure 6 Disposable silicone lenses marketed by Dorc that do not require a

stabilizing ring
Peyman Wide-angle Lens

The concave anterior surface of this lens provides a viewing angle from 48° to
the equator and a magnification of 0.49x.
Machemer Plano-concave Lens

It provides a viewing angle of 36° and a magnification of 1.02x.
Tolentino Twenty Degree Prism Lens

This lens, for the periphery, offers a viewing angle of 36° and a magnification
of 1.02x.
Tolentino Thirty Degree Prism Lens

It is a lens for the extreme periphery with a viewing angle of 33° and a
magnification of 1.02x.
Woldoff Biconcave Prism Lens

It allows the periphery to be viewed in a gas-filled eye. Its viewing angle is
18° and magnification is 0.40x.
Also available are disposable silicone lenses that do not require a suture
ring (Fig. 6). These may be used for routine vitreoretinal surgery or for specific
procedures when working in a wide field, for instance on the macula.
WIDE-ANGLE-VIEWING SYSTEMS
Indirect contact lens systems were developed for panretinal photocoagulation,
allowing a wide field of visualization of the retina through small pupils.
53
However, these lenses produced an inverted image initially, preventing their
use in surgery.
The problem was overcome in 1987, when Spitznas and Reiver4 developed
the stereoscopic diagonal inverter (SDI) to reinvert the stereoscopic image. This
was followed by the emergence of the binocular indirect ophthalmomicroscope
(BIOM), which provides good quality, noncontact images of the retina, allowing
the surgeon to work with wide-viewing fields within the eye.5 The BIOM procedure
has led to the development of several wide-angle-viewing systems using contact
or noncontact lenses, facilitating many of the maneuvers used in vitreous surgery.6
Wide-angle-viewing systems with an image inverter incorporated in the body
of the microscope include:
The BIOM/SDI noncontact system with or without a miniature, indirect
viewing contact lens (field of view 70°, 90° or 110°) (Figs 7A and B
The Volk reinverting operating lens system used with both standard lenses
and the new self-stabilizing lenses of 58D, 85D or 156D for visualization
up to the vitreous and ora serrata (contact system)
The advanced visual instruments (AVI) inverter with an indirect contact
lens of 68D and 130D (contact system) (Fig. 8)
The iris medical contact wide-angle system (contact system)
Optiflex with a manual or automated system
Optical fiber free intravitreal surgery system (OFFISS) incorporated in
Topcon’s OMS-800 microscope (noncontact system).
These contact and non-contact systems (Table 1) have the common feature
that the image inverting system is mounted in the microscope body separate
from the lenses.
Some wide-angle viewing systems do not require an image inverting system
in the microscope (Table 2), such as:
A B
Figures 7A and B (A) Wide-field BIOM system mounted in the microscope fitted
with a fine focusing wheel. The image-inverting device is incorporated in the
microscope; (B) Working with the BIOM system
54
Figure 8 AVI inverting system used with 68D and 130D lenses.
Note the contact lenses with Landers stabilizing rings
TABLE 1
Contact wide-angle systems (Advanced Visual Instruments, Iris Medical, Volk)
Benefits Drawbacks
• Excellent panoramic view of fundus • Learning curve required
• Wide angle of vision • Trained assistant required
• Work in the periphery possible • Image inverter required
• Air/fluid interchange possible • Indentation difficult
• Presence of blood impairs vision
• Usually several lenses need to be
interchanged
The EIBOS (erect indirect binocular ophthalmic system) is a noncontact

system, with a single component indirect viewing device/image reinverter.
The EIBOS provides a visual field of 100° with 90D lenses and 125° With
XL lens of 132 D (Figs 9A and B).
The Peyman-Wessels-Landers 132D upright vitrectomy lens has an internal
prism system that gives an upright wide-angle image. The image is focused
using the pedal.
In the past, we have worked with classic contact lenses, Landers suture
rings, and the contact wide-angle AVI system and noncontact EIBOS system,
which give us at least a 100° panoramic image (Fig. 10). Presently, we use
the noncontact EIBOS method. This procedure allows us to work more
independently without the need for an assistant or lens interchange. The problem
of limited peripheral vision is well resolved by two strategies: tilting the eye,
making small microscope movements in the desired direction and reaching the
ora serrata with peripheral indentation. This last maneuver is achieved with the
55
TABLE 2
Noncontact wide-angle systems (BIOM, EIBOS, OFFISS, Peyman)
BIOM-OFFISS EIBOS-Peyman-Leica
Benefits: Benefits:
• Wide field of panoramic vision • Direct panoramic image seen
• Easy handling of globe upright
• Indentation possible • X-Y movements in correct direc-
• No assistant needed tion, subtle
• Work with narrow pupils and some • Easy handling of globe
corneal opacity possible • Indentation, work with small pupils,
• Good air/fluid exchange visualiza- fluid/air exchange possible
tion • Easy focusing
• No assistant needed
• No inverter needed
Drawbacks: Drawbacks:
• Inverter needed • 120° of maximum vision
• X-Y movements in opposite direc- • Short learning curve needed
tion • Indentation needed to see ora ser-
• Learning curve required rata and pars plana
Abbreviations: BIOM: Binocular indirect ophthalmomicroscope; OFFISS: Optical fiber free
intravitreal surgery system; EIBOS: Erect indirect binocular ophthalmic system
A B
Figures 9A and B (A) Noncontact EIBOS system supplied by Möller-Wedel. This

system has its own image reinverting system to produce an upright image avoiding
the need for a microscope-mounted inverter; (B) Upright 100° image provided using
a 90D lens
cryotherapy probe, providing excellent indentation. Recently, a similar system

to EIBOS has been introduced by Leica that can, nevertheless, only be used
with the company’s own RUV800 microscope (Fig. 11).
56
Figure 10 Panoramic view achieved with a wide-angle-viewing

system of 100° to 135°
Figure 11 Leica RUV800 noncontact retinal viewing system. A new system
similar to EIBOS has been introduced by Leica
Use of the Erect Indirect Binocular Ophthalmic System

The nonsterile block (optical system with inverter) is placed in the microscope.
Once fixed, the sterile silicone cover and manual focusing device are positioned
by the surgeon. The working sterile lens is also put in place. This lens will be
of 90D if we need to work in the macular region, while an XL lens is used
when treating a detached retina, vitreoretinal proliferation or when working
more in the periphery. We then set the microscope focus at “0” and center the
X-Y movement motor. The microscope is lowered or raised until we can see
the anterior pole well without altering the focus.
57
At this stage in the procedure, we can see the anterior pole well and the
EIBOS still has its sterile cover and is retracted behind the microscope’s optics.
We then introduce the endo-ocular light source, place the EIBOS under the
microscope’s optics and switch off the microscope light. Next, we observe the
light in the vitreous, focus the probe using the manual focus of the EIBOS and
increase the zoom. We then lower the EIBOS a little to increase the field of
view and do not touch the microscope’s focus again. Fine focusing is achieved
using the manual device of the EIBOS (Figs 12A and B).
To avoid the need to constantly irrigate the cornea and avoid epithelial
edema or having to remove the epithelium, at the start of the surgery we place
a viscoelastic substance on the cornea and then with a few drops of saline we
can create a smooth surface allowing good visualization of the fundus.
When we have difficulty in viewing the posterior segment, we use a
magnifying contact lens with a silicone ring to work at the level of the macula.
In some cases, we use a biconcave lens for fluid/air exchange, especially in
phakic patients with considerable myopia. We can undertake fluid/air exchange
placing the biconcave lens in the EIBOS and thus have a panoramic view for
the maneuver in difficult eyes.
Figures 12A and B (A) The surgeon achieves fine focus using the index finger; (B)
Use of the EIBOS system showing the working distance and sterile silicone drape
covering the instrument
58
OTHER VISUALIZATION SYSTEMS
In 2003, Peyman and Landers7 launched a new wide-angle-viewing system
(Peyman-Wessels-Landers) fitted to an inverter such that this component does
not have to be placed in the body of the microscope. The system is similar to
the EIBOS in that there is no need for a microscope-mounted image inverter
(Figs 13A and B). Recently, a new holding device has been introduced that
consists of a rotating bar and lens holder.8
In 2004, Topcon started marketing the OFFISS that can be fitted to the new
OMS-800 microscope with its lens stabilizing system. The OFFISS provides
an inverted image and therefore requires a microscope-mounted inverter.
The microscope is fitted with its own illumination system that condenses
the light through the lenses to visualize the fundus and work in the eye without
really needing endoillumination fiber optics. Since the light emitted is diffuse,
it illuminates the entire ocular globe well. To improve light focusing on tissues,
it also has an incorporated slit lamp. The lenses currently available are 40D
and 87D, giving 60° and 120° viewing angles.
The great advantage of OFFISS is that most vitrectomy procedures can
be undertaken with two ports for infusion and instrumentation. Also, in the
Figures 13A and B (A) Wide-angle noncontact system designed by Peyman, Wessels
and Landers for ocular instruments. This system incorporates an image reinverter so
there is no need for a microscope-mounted inverter; (B) Rotating bar (arrow) and
lens holder (asterisk)
59
case of bimanual surgery, three ports can be used (one for infusion and two
for sclerotomy) along with the normal instrumentation without the need for
an optic fiber light. Among its drawbacks, we could mention the need for a
microscope-mounted inverter and for some amount of training to be able to
work comfortably (Figs 14A to C).
Some ophthalmologists prefer to view the vitreous in retinal surgery by
angling the light from the microscope’s slit lamp by 5°. Using this technique,
it is possible to work in the macular region using a Machemer lens and only
two ports for infusion and instrumentation. The method, especially used by
the French school, provides a good view of the posterior pole when removing
epiretinal membranes, internal limiting membrane, subretinal membranes, etc.
B
Figures 14A and B
60
C
Figure 14C
Figures 14A to C (A) Topcon’s OFFISS system with the lens fixed to the microscope;
(B) Bimanual surgery performed only with light from the microscope; (C) Slit lamp view
To work in the periphery, the Goldmann three mirror lens needs to be used;
requiring constant rotation. Several microscopes currently have an incorporated
slit lamp including Zeiss’ OPMI VISU and the new Möeller model, which
allows the surgeon to work with light from the microscope and a contact lens
on the cornea (Figs 15A and B; Fig. 16).
A
Figure 15A
61
B
Figure 15B
Figures 15A and B (A) Working with the microscope’s slit lamp and using only
two ports for infusion and instrumentation; (B) Machemer contact lens
Figure 16 Zeiss microscope with slit lamp
COMBINED PROCEDURES
We can combine slit lamp illumination with the use of wide-angle contact
lenses to give a panoramic view allowing the detailed observation of the retinal
periphery9 (Figs 17A and B). The main shortcoming of this method is that glare
is produced with slit lamp-illuminated contact lenses. To avoid this, multicoated
62
Figures 17A and B (A) View of the posterior pole using a slit lamp and wide-angle
contact lens; (B) View of the periphery with indentation
Source: Reproduced with permission from Ohji M, Tano Y. Vitreoretinal surgery
with slit-lamp illumination combined with a wide-angle-viewing contact lens. Am
J Ophthalmol. 2004;137(5):955-6
antireflective contact lenses are used that provide a clear image of the retina
without glare10 (Figs 18A and B).
To avoid the cornea drying during vitrectomy, we can use the new antidrying
corneal contact lens for a noncontact wide-angle-viewing system. The
viscoelastic is placed on the cornea and over this, the lens is positioned using a
63
Figures 18A and B (A) Retina viewed with the slit lamp and a multicoated contact
lens; (B) Bimanual surgery performed using the same combination
Source: Reproduced with permission from Kadonosono K, Kamezawa H, Uchio E, et
al. Bimanual vitreous surgery with slit-beam illumination and multicoated contact
lens. Retina. 2006;26(6):708-9
sutureless stabilizing ring. This technique offers clear panoramic visualization

of the retina throughout the entire surgical procedure11 (Fig. 19).
Finally, it is possible to fit an ocular coherence tomography system to the
microscope’s beam splitter. This allows tomographic monitoring during surgery,
aiding decision making both during and following surgery.12
64
Figure 19 Quartz lens with a refractive power of zero placed on the cornea
Source: Reproduced with permission from Ohno H, Inoue K. An antidrying corneal
contact lens for a noncontact wide-angle viewing system. Retina. 2011;31(7):1435-6
REFERENCES
1. Freeman HM, Tolentino FI. Atlas of Vitreoretinal Surgery. New York: Thieme
Medical Publishers; 1990. pp. 11-2.
Lippincott Willians and Wilkins; 2002. pp. 37.
3. Murthy R, Brar V, Chalam K. Evaluation of ultra wide angle “ora-ora” high
refractive index self-stabilizing contact lens for vitreous surgery. Retina. 2010;
30(9):1551-3.
4. Spitznas M, Reiner J. A stereoscopic diagonal inverter (SDI) for wide-angle vitreous
surgery. Graefes Arch Clin Exp Ophthalmol. 1987;225(1):9-12.
5. Spitznas M. A binocular indirect ophthalmomicroscope (BIOM) for non-contact
wide-angle vitreous surgery. Graefes Arch Clin Exp Ophthalmol. 1987;225(1):13-5.
6. Lesnoni G, Billi B, Rossi T, et al. The use of panoramic viewing system in relaxing
retinotomy and retinectomy. Retina. 1997;17(3):186-90.
7. Landers MB, Peyman GA, Wessels IF, et al. A new, non-contact wide field viewing
system for vitreous surgery. Am J Ophthalmol. 2003;136(1):199-201.
8. Kakinoki M, Hirakata A, Landers MB, et al. The new lens holder for Peyman-
Wessels-Landers 132D upright vitrectomy lens. Retina. 2010;30(8):1316-7.
9. Ohji M, Tano Y. Vitreoretinal surgery with slit-lamp illumination combined with
a wide-angle-viewing contact lens. Am J Ophthalmol. 2004;137(5):955-6.
10. Kadonosono K, Kamezawa H, Uchio E, et al. Bimanual vitreous surgery with
slit-beam illumination and multicoated contact lens. Retina. 2006;26(6):708-9.
11. Ohno H, Inoue K. An antidrying corneal contact lens for a noncontact wide-angle-
viewing system. Retina. 2011;31(7):1435-6.
12. Binder S, Falkner-Radler C, Hauger C, et al. Feasibility of intrasurgical spectral-
domain optical coherence tomography. Retina. 2011;31(7):1332-6.
65
5.3 ENDOILLUMINATION SYSTEMS
INTRODUCTION
A good source of light is needed to illuminate the intraocular tissue that is to
be removed. The source can be an external light that crosses the transparent
media of the globe and lights its inner structures. Alternatively, fiber optic light
pipes can be introduced through sclerotomies to directly illuminate the tissues.
EXTERNAL SYSTEMS
As an external light source, we can use the light from the slit lamp attached
to the microscope, which with the help of corneal contact lenses, allows the
surgeon to work on the retina. The new optic fiber free intravitreal surgical
system also uses light emitted from the microscope.
INTERNAL SYSTEMS
The most common illumination method is the use of a direct endo-ocular light
that can be introduced into the eye through probes, the infusion port or fitted
to the instruments used.
The endoillumination probe is the most frequently used and is the light
source we generally use. The tips of 20- or 25-gauge probes are perpendicularly
cut to provide concentrated light in a given area and a certain slit lamp effect,
offering good vision of the peripheral vitreous. Depending on the distance from
the tissue, we will obtain a greater or smaller illuminated field. As we approach
the retina, we will have more light yet a smaller illuminated field and vice versa
as we move away from the retina. These probes can be fitted with picks and
spatulas to facilitate surgical maneuvers (Figs 1A and B).
Bullet type fibers provide wide-angle illumination, diffusely lighting the
surgical field, and are thus useful when working with wide-angle viewing
systems and for exchange maneuvers, but are inappropriate for working on
the retina since they cannot be used to focus light on a given spot. These
optical fibers are usually introduced through the infusion port and are used as
an additional light source for bimanual surgery procedures. When a fiber optic
is used in the infusion system, the irrigation pressure should be increased and
aspiration needs to be more carefully controlled.
Forceps and scissors are the instruments generally fitted with a fiber optic
light (Fig. 2) but these instrument have to be turned inwards, towards the tissue,
to avoid generating glare. In addition, shadows may be produced. Currently,
we have instruments available with an incorporated fiber optics such that they
do not have to be mounted during surgery. These ready to use instruments may
even be disposable.
66
A B
Figures 1A and B (A) Straight 20-gauge endoillumination probe. Probe with

membrane pick and bullet type probe; (B) Panoramic illumination probe
Figure 2 Segmenting/delaminating scissors with an incorporated light source
We can introduce a supplementary optic fiber through a 0.5 mm incision for

several bimanual maneuvers, suturing the fiber to the sclera. When removing
the optic fiber there is no need to close the wound since it is sufficiently small.
Light incorporated in the laser probe is very useful, since it frees up one
of the surgeon’s hands for indentation during photocoagulation. Retractile
curved probes also exist that facilitate photocoagulation in the superior zone.
There are also optic fibers combined with an irrigation cannula such that some
vitrectomies can be performed with only two-port openings or bimanual surgery
can be conducted with illumination in the infusion zone.
Another device, the tissue manipulator with its functions of illumination,
diathermy and aspiration, 1 was designed to treat retinal fibrovascular
proliferations as in diabetic retinopathy, but may also be used to manipulate
tissues in other circumstances (Fig. 3).
More complex endoillumination systems exist such as the multiport
illumination system (MIS). This instrument, with two trocars that need to be
67
Figure 3 Tissue manipulator for: (1) Illumination, (2) Diathermy, and (3) Aspiration
inserted through a cross-shaped incision, provides illumination controlled by

20-gauge instruments introduced via the trocars, which remain fixed to the
sclera throughout the operation.2-4 The MIS can be used for bimanual surgery
without the need for illuminating instruments. Its main shortcoming is that a
scleral incision larger than 0.9 mm is needed (Figs 4A and B) and it has not
been too widely adopted.
Yet another illumination system is the Tornambe mini-light system that
can be introduced through a 25-gauge incision and does not require sutures to
close the incision wound once removed. Four mini-lights can be used at a time
to avoid shadowing by the instruments. This system is used for wide-field and
bimanual surgery (Figs 5A and B). Today, individual 25-gauge Tornambe lights
can be purchased that provide good illumination of the top zone.
CHANDELIER SYSTEM
A recent appearance in the market that can be used for bimanual surgery
without illuminated instruments is the 25 gauge Awh Microfiber™ Sutureless
Chandelier which illuminates the entire posterior segment. Surgery with
25-gauge instruments can be comfortably conducted and membranes can
be removed bimanually. Due to its small caliber it does not require suturing
and has a stabilizing system. Although a fourth side-port opening is required
to introduce the light source, permanent light is provided during the entire
operation (Figs 6A to C).
Modifications to the system have included the incorporation of 27 and 29
gauges and a new mercury vapor light source (Photon II), which reduces retinal
phototoxicity and allows for the use of laser fiber optics. The light emitted is
yellowish green5 (Figs 7A to C).
68
A B
Figures 4A and B (A) The multiport illumination system avoids the need for
illuminated instruments in bimanual surgery; (B) Light providing trocar through
which instruments are introduced; currently unused
A B
Figures 5A and B (A) System comprised of small torpedoes that illuminate the eye
without producing shadows. The 0.5 mm incisions needed can be transconjunctival;
(B) Tornambe mini-light system from Insight Instruments is very little used at present
A B C
Figures 6A to C (A) Synergetics light source; (B) Image of the chandelier showing
its 25-gauge optic fiber; (C) Chandelier in a pars plana position without sutures
A B C
Figures 7A to C (A) Photon I and Photon II; (B) Photon II screen, exit for mercury
vapor light and for laser; (C) Yellowish green appearance of the retina
69
Endoillumination systems have been improved to avoid the need for suturing
in place. The new 27-gauge twin probe is an example. It provides panoramic
illumination avoiding shadows. To help introduce a twin probe, we used the
edge of a 27-gauge needle to perforate the sclera6 (Figs 8A and B).
Illuminated vitrectomy probes are now available that allow the surgeon to
conduct an efficient peripheral vitrectomy with the help of indentation, since this
system frees the hand that normally held the endoillumination probe (Fig. 9).
A new illumination system, the ocuLED, is based on light emitting diode
technology. This device provides brilliant light that is scarcely toxic since its
emission spectrum is far from that of blue light.7
Any type of light (especially short wavelength, or blue/violet light)8-10 close
to the retina can cause phototoxic retinal lesions. To avoid this, the macula
should be illuminated for just the necessary amount of time using the minimum
intensity of light. Any preretinal bleeding should be dealt with at the end of the
surgical procedure since this acts as an excellent protective filter for the retina.
A B
Figures 8A and B (A) 27-gauge twinlight Chandelier illumination system; (B)

Maneuver to introduce the probe
Source: Reproduced with permission from Eckardt C, Eckert T, Eckardt U. 27-gauge
twinlight chandelier illumination system for bimanual trans conjunctival vitrectomy.
Retina. 2008;28(3):518-9
Figure 9 Illuminated 20-gauge vitrectomy probe from Dorc

70
REFERENCES
1. McCuen BW, Hickingbotham D. A fiberoptic diathermy tissue manipulator for
use in vitreous surgery. Am J ophthalmol. 1984;98(6):803-4.
2. Koch FH, Pawlowski D, Spitznas M. A multiport illumination system for
panoramic bi-manual vitreous surgery. Graefes Arch Clin Exp Ophthalmol. 1991;
229(5):425-9.
3. Boker T, Augustin AJ, Schmidt H, et al. Larger sclerotomies for use of the multiport
illumination system do not increase the complication risk of vitrectomy. Klin Monbl
Augenheilkd. 1995;206(2):78-82.
4. Steinmetz RL, Grizzard WS, Hammer ME. Vitrectomy for diabetic traction
retinal detachment using the multiport illumination system. Ophthalmology.
2002;109(12):2303-7.
5. Oshima Y, Chow DR, Awh CC, et al. Novel mercury vapor illuminator
combined with a 27/29-gauge chandelier light fiber for vitreous surgery. Retina.
2008;28(1):171-3.
6. Eckardt C, Eckert T, Eckardt U. 27-gauge Twinlight chandelier illumination system
for bimanual transconjunctival vitrectomy. Retina. 2008;28(3):518-9.
7. Dithmar S, Hoeh AE, Amberger R, et al. Light-emitting diode technology in
vitreoretinal surgery. Retina. 2011;31(5):924-7.
8. Fuller D, Machemer R, Knighton RW. Retinal damage produced by intraocular
fiber optic light. Am J Ophthalmol. 1978;85(4):519-37.
9. Khun F, Morris R, Massey M. Photic retinal injury from endoillumination during
vitrectomy. Am J Ophthalmol. 1991;111(1):42-6.
10. Michels M, Lewis H, Abrams GW, et al. Macular phototoxicity caused by
fiberoptic endoillumination during pars plana vitrectomy. Am J Ophthalmol.
1992;114(3):287-96.
71
5.4 INFUSION PRESSURE SYSTEM
INTRODUCTION
To work inside the globe, intraocular pressure (IOP) can be kept constant using
two methods: (1) the height of the physiological saline bottle can be adjusted
to create hydrostatic pressure or (2) we can use an air pump to constantly
pressurize the fluid infusion system.
HYDROSTATIC PRESSURE
The difference in height between the bottle (Fig. 1) containing the infusion
liquid and the eye being operated on generates a pressure gradient that is
transmitted to the inner eye. As we are dealing with a closed circuit, if we raise
the bottle 35–40 cm from the level of the eye, we will obtain an IOP between
25 mm Hg and 30 mm Hg. This is the pressure we normally work with to avoid
significant collapse of the eye globe during aspiration.1
If bleeding commences during surgery, the bottle should be lifted to 125
cm to control the bleeding episode and then gradually lowered to the working
height without removing the intraocular instruments. This last precaution avoids
leakage and reduces the risk of tissue incarceration at the sclerotomy sites due
to high IOP. It is important to check that the infusion bottle is never without
liquid, since this would produce a sudden drop in IOP, accompanied by a risk of
bleeding or retinal tears if we are working with the vitreotome, through intense
traction on the vitreous caused by the abrupt fall in IOP.
Figure 1 Infusion bottle. When using a positive pressure pump, the bottle is placed
at the level of the patient’s head to avoid adding hydrostatic pressure to the infusion
pressure provided by the pump
72
The IOP in mm Hg can be calculated by multiplying the height of the
infusion fluid bottle in centimeters by 0.74 (Table 1).
IOP = Height of infusion bottle in cm × 0.74
INFUSION PUMP OR GAS FORCED INFUSION

In current clinical practice, the height of the infusion bottle is unimportant,
since positive pressure pumps are used that continuously pressurize the
irrigation system. Thus, the infusion fluid bottle should be at the same level
as the patient’s head so that no hydrostatic pressure is added to the pressure
achieved by the pump. The pump can be independent from or integrated in
the vitrectomy system.
The first pumps for pressure control worked by introducing air into the
fluid at the bottom of the infusion bottle and this meant that IOP could not be
rapidly recovered.2,3
Vented gas forced infusion systems have a trocar that reaches the air
chamber in the infusion bottle, so that IOP can be more precisely controlled
(Fig. 2) and as air pump pressure falls, so does the pressure in the ocular globe.
This is the system we prefer since it allows us to rapidly achieve any IOP
changes needed during surgery.4,5
Pressure pumps (Figs 3A and B; Fig. 4) are useful for fluid/air or air/fluid
exchange. Using a pump, the surgeon can directly control the filling of the eye
with air and thus keep the retina in position when applying the laser or installing
some type of tamponade. We can also direct blood toward the posterior pole
following intense bleeding by replacing fluid with air.
In this way, the infusion and intraocular pressure can be defined as:
Infusion pressure = Pump positive pressure + hydrostatic pressure
Intraocular pressure = Infusion pressure – aspiration pressure – losses through
sclerotomies
The Constellation vitrectomy incorporates a new IOP control system. The
system consists of a cartridge with fluid movement-measuring sensors. This
TABLE 1
Intraocular pressure according to the position of the irrigation bottle
Height of bottle above the eye Intraocular pressure

15 cm 11 mm Hg
25 cm 18.5 mm Hg
50 cm 37 mm Hg
75 cm 55 mm Hg
100 cm 74 mm Hg
125 cm 92 mm Hg
73
Figure 2 Vented gas forced infusion system. The air filter is connected by pressure
to the air outflow port and the three-way valve allows the system to be used with
irrigation of fluid/air or to close the system off such that nothing enters the eye
A B
Figures 3A and B (A) Positive pressure pump that injects air into the infusion fluid
bottle via a vented gas forced infusion trocar reaching the air chamber. The fluid,
pushed by the pressure, enters and pressurizes the ocular globe. If we close off the
passage of irrigation fluid using the three-way valve, this will allow the entry of air
at a given pressure (generally 25 mm Hg) into the globe. To fill the globe with air,
intraocular fluid has to be simultaneously aspirated; (B) Accurus pressure pump.
The pump blows air through the vented gas forced infusion tubes, pressurizing the
bottle, which in turn introduces fluid into the eye when intraocular pressure drops
74
Figure 4 Grieshaber pressure pump. The picture shows the air outflow tube with
filter, the pressure display and the infusion pipe through which we introduce the
system in the globe. This pump is independent of the vitrectomy system
enables the device to offset any pressure differences produced in the infusion
line so that a constant IOP is maintained during surgery.
This infusion system automatically adjusts the amount of infused saline in
response to pressure reductions in the line and infusion cannula. Pressure is
maintained at +/– 2 mm Hg with respect to the value indicated by the system
(Fig. 5).
Figure 5 The infusion line from the saline bottle directly enters the cartridge from
which the eye infusion line emerges. This allows for an immediate response to any
change in pressure
75
The benefits of the Constellation system include the possibility of increasing
IOP using the pedal in cases of bleeding. The instrument’s display panel
indicates the precise time of high IOP and incorporates an alarm and voice
confirmation system.
PRESSURE CONTROL
Adequate pressure control is important throughout surgery since any rise or
drop in IOP could give rise to problems.
Low Intraocular Pressure

Low IOP may lead to:
Tendency for retinal bleeding
Risk of pupil miosis
Striate keratopathy.
High Intraocular Pressure

High IOP may lead to:
Optic nerve ischemia and visual field defects
Jabbing ocular tissue when removing instruments
Corneal edema resulting in poor visualization of the retina.
REFERENCES
1. Parel JM, Parrish RK, Nose I. An intraoperative intraocular pressure monitor.
Ophthalmic Surg. 1987;18(5):371-4.
2. Witherspoon CD, Morris RE, Goggans WE. Automated regulation of fluid infusion
pressure during vitrectomy. Arch Ophthalmol. 1986;104(10):1551.
3. Moorehead LC, Armeniades CD. The pressure-controlled infusion system: a new
instrument for closed-system surgery. Ophthalmic Surg. 1988;19(4):282-8.
Lippincott Williams and Wilkins; 2002. pp. 28-9.
5. Corcóstegui B, Adán A, García-Arumí, et al. Cirugía vitreoretiniana, indicaciones
y técnicas. Madrid. Tecnimedia editorial; 1999. pp. 50-2.
76
5.5 INFUSION DEVICES SYSTEMS
TWENTY-GAUGE INCISIONS
Opening the Conjunctiva
Infusion cannulas are connected to the infusion line. They are used to introduce
physiological saline, air and sometimes silicone oil into the globe.1 The lengths
available are: 2.5 mm, 4 mm and 6 mm; the 4 mm cannula being the most
widely used (Fig. 1). The 6 mm cannula is used when we know there is dense
or fibrous tissue in the periphery of the retina, to make sure we have reached
the eye interior. The cannula is then used to instill fluid in the vitreous space.
We routinely use the 4 mm probe, making sure the beveled tip faces upwards
to avoid touching the crystalline lens in a phakic eye.
It should always be checked that the infusion cannula has been effectively
introduced in the vitreous space otherwise opening the infusion line could
provoke detachment of the choroid, precluding surgery. Also available are
infusion cannulas fitted with fiber optics (Fig. 2) for supplementary illumination
when performing bimanual surgery.2
To avoid extrusion of the infusion cannula during surgery, the tube is sutured
to the sclera, allowing the surgeon to work with indentation. If small bubbles
enter through the sclerotomy during surgery, this means the cannula has not been
properly fixed and requires resuturing. There are several self-retaining cannulas
that do not need to be sutured3-5 yet allow good perfusion control (Fig. 3).
When instruments do not need to be introduced into the globe, such as when
reviewing the periphery or tightening a scleral buckle at the end of surgery,
we use 20-gauge plugs to close the sclerotomies and avoid intraocular tissue
incarceration in the case of a high intraocular pressure (IOP) provoked by
the surgical maneuvers (Fig. 4A). When using valved trocars, indentation is
possible without the need for plugs (Fig. 4B).
Figure 1 Infusion cannulas of lengths 2.5 mm, 4 mm and 6 mm. The 4 mm

cannula sutured to the sclera is used most often
77
Figure 2 Dorc’s illuminating infusion cannula. This cannula allows the control of
intraocular pressure while diffusely illuminating the fundus
Figure 3 Dorc’s sutureless infusion cannula. The retainer at the base of the
cannula keeps it in place during surgery
A B
Figures 4A and B (A) Scleral plugs and plug forceps supplied by Alcon; (B) Valved
trocars maintain the stability of the globe by preventing the leakage of saline
78
Figure 5 A counter incision creates a self-sealing valve against intraocular pressure

Source: Reproduced with permission from Theelen T, Verbeek AM, Tilanus MA, et
al. A novel technique for self-sealing, wedge-shaped pars plana sclerotomies and
its features in ultrasound biomicroscopy and clinical outcome. Am J Ophthalmol.
2003;136(6):1085-92
TWENTY-GAUGE TRANSCONJUNCTIVAL VITRECTOMY

It is currently possible to perform a 20° transconjunctival vitrectomy6,7 by
introducing the massive vitreous retractor blade perpendicularly to the limbus with
a 15° orientation to the sclera. Penetration should be conducted at right angles to
the sclera; introducing the infusion cannula first and leaving it without sutures.
At the end of surgery, the eye should remain filled with air to avoid a large
drop in IOP. If after checking the incisions, there is continued air leakage,
a counter incision creates a self-sealing valve for a nonleaking sutureless
sclerotomy8 (Fig. 5).
Many of the trocars available are valved, so we do not need plugs for
indentation. Twenty-three, 25- and 27-gauge transconjunctival vitrectomies
are dealt within the chapter on microincisions.
REFERENCES
Lippincott Williams and Wilkins; 2002. pp. 26.
2. Zinn KM, Grinblat A, Katzin HM, et al. A new endoillumination infusion cannula
for pars plana vitrectomy. Ophthalmic Surg. 1980;11(12):850-5.
3. Mason G, Sullivan JM, Olk RJ. A sutureless self-retaining infusion cannula for
pars plana vitrectomy. Am J Ophthalmol. 1990;110(5):577-8.
4. Hilton GF. A sutureless self-retaining infusion cannula for pars plana vitrectomy.
Am J Ophthalmol. 1985;99(5):612.
5. Rahman R, Rosen PH, Riddell C, et al. Self-sealing sclerotomies for sutureless
pars plana vitrectomy. Ophthalmic Surg Lasers. 2000;31(6):462-6.
6. Stanescu-Segall D, Sebag M, Jackson T, et al. Modified 20-gauge transconjunctival
pars plana vitrectomy. Retina. 2011;31(5):982-7.
7. Lafetá AP, Claes C. Twenty-gauge transconjunctival sutureless vitrectomy trocar
system. Retina. 2007;27(8):1136-41.
8. Theelen T, Verbeek AM, Tilanus MA, et al. A novel technique for self-sealing,
wedge-shaped pars plana sclerotomies and its features in ultrasound biomicroscopy
and clinical outcome. Am J Ophthalmol. 2003;136(6):1085-92.
79
5.6 SUCTION AND CUTTER SYSTEMS
INTRODUCTION
In the early days of vitreoretinal surgery, probes capable of cutting, aspiration,
infusion and even endoillumination were used.1,2 These multipurpose instruments
required incisions as large as 3.5 mm, which led to the development of smaller
instruments carrying out the functions of aspiration and cutting separate from
infusion and illumination3-5 that could be introduced through 0.9 mm incisions.
These new instruments greatly facilitated globe rotation, bimanual surgery
maneuvers and have made three-port vitrectomy the procedure of choice.
Intraocular aspiration can be achieved either actively through the use of
aspiration pumps—traditionally a Venturi effect pump and more recently
peristaltic pumps—or passively, using instruments in which suction is generated
through the difference in intra and extraocular pressure.
ACTIVE ASPIRATION
The basic functions of the vitrectomy probe are aspiration and cutting. These
functions are performed with the help of the vitrectomy machine, which
incorporates an aspiration pump and a pneumatic or electric cutting device.
Today, vitrectomy machines incorporate both Venturi and peristaltic pumps,
which the surgeon can easily select during surgery using the foot pedal. The
Venturi pump creates a vacuum in a closed, rigid chamber. In this system, a
compressed gas passes through a conduit of increasing diameter connected to
a chamber, which in turn, is linked to the aspiration tube. This flow through the
conduit generates a vacuum in the chamber and the vacuum exerts a negative
or suction pressure in the aspiration tube (Fig. 1).
The vacuum is regulated by varying the amount of compressed gas
producing the vacuum in the chamber. This system has a quick response time
for starting and stopping suction such that the vitreous can be easily extracted.
Peristaltic pumps produce a vacuum as the roller rotates on the aspiration
tubes, which therefore need to have some degree of elasticity (Fig. 2). The
flow rate or aspiration speed is provided in ml/min and is directly proportional
to the pump rotation speed; the greater the speed the higher the flow rate. The
main feature of the peristaltic pump is that we can separate flow (aspiration
speed) from vacuum (level of aspiration or negative suction pressure produced
when the aspiration system is occluded). For a peripheral vitrectomy, we use
a flow rate under 10 ml/min and a high vacuum to approach the periphery of
the retina and selectively eliminate the vitreous without the risk of damaging
the retina. This is possible because as we occlude the aspirator, the vacuum is
very slowly generated such that the vitreous alone, and not the retina, is pulled,
allowing selective cutting of the vitreous.
80
Figure 1 Venturi pump. Flow rate and vacuum power cannot be separated,
providing a rapid response time while aspirating
Figure 2 Peristaltic pumps with independent flow and vacuum functions so that
we can work with low flow rates close to the retina
Most surgeons use both types of pump: the Venturi for central vitrectomy
and the peristaltic pump for peripheral vitrectomy or when working close to the
retina. Both pumps are also used in combined phacoemulsification-vitrectomy
procedures (Figs 3A and B).
With the traditional vitreotome, the surgeons controlled aspiration and
cutting devices through the use of foot pedals. By depressing the pedal to a
greater or lesser extent (linear control), the intensity of aspiration could be
81
A B
Figures 3A and B Dorc vitreotome supplied with both Venturi and peristaltic
pumps for use at the anterior and posterior poles
instantly adjusted, although the same could not be done for the cutting function,
since once the cutter was connected it worked at the same speed. In today’s
vitreotomes, both these functions can be linearly controlled.
We use the Accurus vitreotome, which does not have a peristaltic pump,
but has a dual system that allows some flow control (Fig. 4). This machine has
three vitrectomy systems for the following purposes:
Linear vitrectomy such that we can linearly control aspiration but the cutting
speed is preset. Thus, if using high cutting speeds and low aspiration, the
suction is low. As we lower the cutting speed, suction power increases
especially if we increase the aspiration intensity. Cutting speeds of 600–800
cuts per minute and maximum vacuum pressures of 125–150 mm Hg can
Figure 4 Diagram showing the flow control provided by the Accurus vitreotome
using the dual vitrectomy mode. As the pedal is lowered, vacuum power increases
and cutting rate diminishes such that the suction power of the probe increases. As
the foot pedal is released, the vacuum decreases and cutting rate increases providing
less flow and suction power for use, particularly, in the retinal periphery
82
be applied. If we use high-speed probes, the vacuum pressure has to be
increased
Momentary vitrectomy (linear vacuum and cutting speed on demand),
whereby aspiration is linearly controlled and when needed, we can introduce
a preset cutting rate from 1 cut per minute
Dual vitrectomy (dual dynamic drive) allows simultaneous regulation of
cutting speed and vacuum pressure using the pedal within independent
limits.
Flow control using the Accurus vitreotome is managed as follows:
Flow increased by pressing the pedal
–– Vacuum increases and cutting rate diminishes
Flow reduced by releasing the pedal
–– Vacuum decreases and cutting rate increases.
We normally use the dual system since it is highly responsive: when we
need more suction power, we press the pedal and when we do not want suction,
we lift the foot off the pedal (Fig. 5). To segment the fibrous membranes in
proliferative retinopathies, we use the vitrectomy probe in the momentary mode
(Fig. 6) to attract tissue to the vitrectomy port, and then introduce the cutting
function using the pedal to remove slightly raised membranes.
A further active aspiration method is the extrusion cannula system, which
is independent of the machine’s aspiration system.6 Hence, we can connect
a silicone-tipped cannula for linear foot-controlled suction to lift a hyaloid
membrane, aspirate subretinal fluid or for fluid/air exchange (Fig. 7).
Figure 5 3D or dual system in which the vacuum needs to be preprogrammed

for treadle start, full treadle and cuts per minute. In this way, the start of the pedal
trajectory provides a low vacuum intensity and high cutting rate for low suction and
greater safety, while the end of the pedal push will give us high vacuum and a lower
cutting speed for greater efficiency
83
Figure 6 Momentary vitrectomy system in which the aspiration threshold and

number of cuts per minute are programmed. Vacuum power is linear, while the
cutting rate is fixed and activated when required using the pedal
Figure 7 Extrusion system independent of the vitrectomy probe. Using this system
a silicone tipped cannula can be connected for linear suction power until a preset
maximum
PASSIVE ASPIRATION
Passive aspiration, involving the use of a silicone-tipped cannula to sweep
the retina without damaging it, is based on the intra and extraocular pressure
difference.7 Since the intraocular pressure (IOP) is greater than the pressure
outside the eye, any fluid or blood will travel up the cannula. The higher the
IOP, the greater will be the cannula’s power of suction (Fig. 8). This type of
probe is used to clean away blood remnants on the retina, identify membranes
or their remains when we have finished dissecting and to aspirate subretinal
84
Figure 8 The exit of perflurocarbon liquid is the result of the difference between
intraocular pressure and the lower atmospheric pressure outside the eye. The higher
the intraocular pressure, the greater the suction power
Figure 9 Dorc’s backflush probe allowing passive aspiration and reflux. The tip
is made of silicone and has cuts to avoid tissue incarceration. This device can be
connected to the equipment’s active aspiration drive
fluid. Backflush systems can be used for passive aspiration. These probes allow
fingertip-controlled backflush (Fig. 9).
VITRECTOMY PROBES
Cutting can be achieved by a guillotine pneumatic mechanism that can
be activated by air or liquid nitrogen. Alternatively, the use of an electric
mechanism provides a rotary cutting action reaching cutting speeds of 2,500
cuts per minute, requiring an increase in aspiration power.
The vitreotome should have a backflush system in the aspiration line.
Current pneumatic vitreotomes offer high cutting speeds of up to 2,500 cuts per
85
minute, which together with appropriate suction levels serve to safely sweep
the anterior vitreous. High-speed vitreotomes exert less traction on the vitreous
and are safer to use. Using the linear vitrectomy system with a preset cutting
speed, the suction pressures and cutting rates successfully used by us are:
Central vitreous: Aspiration 150–200 mm Hg and cutting speed of 600
cuts per minute
Peripheral vitreous: aspiration 100 mm Hg and cutting rate of 800–1,200
cuts per minute. Cutting can be undertaken without suction.
If we need to cut a fibrous posterior capsule, the cutting speed is reduced and
aspiration power is increased, with care taken to avoid traction on the retina.
The probe we prefer is the Accurus 2500, which is very ergonomic. This vertical
guillotine has a distal aspiration tip and a 32 mm probe and works well in long
eyes. Cutting is controlled by a microprocessor (Figs 10A and B).
We always work following the configuration of the vitreous. This means
making circular movements around the globe’s 360°, trying to avoid traction
to prevent tears. Below we describe two new high-speed cutting vitrectomy
machines.
Constellation Vision System

This machine incorporates new Ultravit© probe for a high cutting rate and good
control of the duty cycle by modifying the probe opening time irrespective
of cutting or vacuum functions, thus controlling flow. It also has a new IOP
control system with a vented gas forced infusion device integrated in the cassette
offering immediate response to pressure changes.
A B
Figures 10A and B (A) Detailed image of the Accurus 2500 vitrectomy probe
showing the guillotine and its closeness to the probe tip; (B) Its concave shape is
designed for grasping between the index finger and thumb
86
Its two xenon light sources comprise 20-, 23- and 25-gauge optic fibers,
featuring a new probe for retractable illuminated laser functions. The
Constellation system also incorporates a new 532 nm green-emitting laser.
For combined phacovitrectomy procedures, it also features OZil Intelligent
Phaco, a phacofragmentation handpiece, and pneumatic forceps and scissors,
which can be adjusted with the foot pedal to work in simple or multicut mode.
Its injection/extraction pump works with 20- and 23-gauge cannulas. The
diathermy module with fixed and linear functions allows for selective controlled
diathermy. Another of the Consellation’s features is that from the main menu
C3F8 and SF6 gas bottles can be refilled at the desired concentration. In addition,
an automatic fluid/air exchange valve, controlled using the foot pedal, obviates
the need for a three-way valve. The new vitrectomy probes and duty cycle
control merit further attention.
Ultravit© probes are pneumatically driven. They are available in calibers
of 20-, 23- and 25-gauge, and all attain cutting speeds of up to 5,000 cuts per
minute, reducing traction on the ocular tissue. The open position of the probe
is optimized in the most distal zone so that the surgeon can work close to the
retina using the vitrectomy modes: 3D, linear or momentary.
With the traditional pneumatic vitrectomy probes, the guillotine is advanced
via air pulses. The return path of the guillotine is passively achieved by means
of a spring. The new probes are fitted with two pneumatic lines that provide air
pulses, actively controlled by the machine’s microprocessor. This means the
guillotine may be advanced and retracted offering the surgeon effective duty
cycle control (Figs 11A and B).
Figures 11A and B (A) Traditional pneumatic vitrectomy probe;

(B) New probe Ultravit©
87
Duty Cycle Control
Till now, the surgeon could only control the vacuum and cutting frequency.
The new technology introduces a new variable, the duty cycle, which indicates
the proportion of time the vitrectomy port is open or closed.8 This function is
independent of the desired cutting speed or preselected vacuum. Three duty
cycles are available: core, 50/50 and shave (Fig. 12).
Core: this indicates maximum opening time of the vitrectomy port and is
used when seeking greater efficiency and flow rates
50/50: the port remains open half of the time and closed the remaining half
of the time
Shave: port opening is minimized for the gentle extraction of tissues,
generally at the periphery where lower flow rates are preferred to minimize
pull.
For a good vitrectomy, we should try not to pull the vitreous with the probe,
cutting it into small pieces while maintaining flow as low as possible. Using
the new probes, we can cut the vitreous into small fragments and select the
appropriate duty cycle to carefully control the flow. It should be remembered
that electric probes work at a constant duty cycle, thus the open/close port time
proportion is the same such that flow will be constant when we work at high
or low cutting speed; the only factor that varies is fragment size, which will
be smaller for higher cutting speeds9 (Table 1).
Our experience with the Constellation system and new Ultravit© probe is that
the system allows for a better controlled vitrectomy with improved adjustment
of flow, or traction on tissue. The instrument is especially effective when
working at the periphery since using the shave mode we can almost “caress”
the retina without harming it.
Figure 12 Constellation vision system. Duty cycle control:

Core, 50/50, Shave
88
TABLE 1
Benefits and drawbacks of the different vitrectomy modes
Small vitreous fragment Large vitreous fragment

Benefits Low force and tissue defor- Force exerted over a large surface
mation area
Drawbacks Force spread across a small High force and tissue deformation
surface area
Stellaris PC Vision Enhancement System

This new platform introduces new illumination sources with the choice of
several filters when we use the xenon light. This equipment is also good for
small incision (1.8 mm) combined phacovitrectomy.10
Its pneumatic probes with optimized duty cycles determine an open port at
least 50% of the time even at a cutting speed of 5,000 cuts per minute. These
probes can thus work at ultra-rapid cutting speeds yet at a duty cycle that
enables the effective elimination of vitreous. Because of the high cutting rate,
vitreous pieces are smaller and behave more like a liquid, facilitating their
removal without traction.
We would highlight the following features: a new programmable wireless
foot pedal, and two independent double xenon and mercury lamps with three
color filters for the xenon light—yellow, green and amber—which the surgeon
intercalates using the foot pedal. The green filter is absorbed by red pigment and
provides a darker view of the fundus. This filter is considered best for peeling
membranes. The yellow filter is absorbed by the xanthophyll pigments of the
macula providing a warm color when we use a blue dye. Amber is considered
the safest color filter for unstained eye tissues; it is absorbed by blue dye and
is defined as the best filter to visualize the peripheral retina. The mercury vapor
lamp generates brilliant light for prolonged procedures. The angle of vision has
been improved with the new wide-field illumination probes.
REFERENCES
1. Machemer R, Parel JM, Buettner H. A new concept for vitreous surgery. I.
Instrumentation. Am J Ophthalmol. 1972;73(1):1-7.
2. O’Malley C, Heintz RM. Vitrectomy via the pars plana—a new instrument system.
Trans Pac Coast Otoophthalmol Soc Annu Meet. 1972;53:121-37.
3. Peyman GA. Miniaturization of the vitrophage: vitrectomy instrument. Can J
Ophthalmol. 1980;15(1):49-50.
4. Zinn KM, Grinblat A, Katzin HM, et al. An improved endoillumination probe for
pars plana vitrectomy. Ophthalmic Surg. 1980;11(10):698-700.
5. Rappazzo JA, Michels RG. New system of intraocular instruments. I. Guillotine
intraocular forceps. Arch Ophthalmol. 1983;101(5):814-5.
89
Lippincott Williams and Wilkins; 2002. pp. 94-5.
7. Peyman GA, Diamond J. A new variable suction system with finger-tip control.
Can J Ophthalmol. 1986;21(6):225-6.
8. Kirk H, Packo MD. High speed cutting and duty cycle control. Retina Today
Supplement. 2009;3-6.
9. Magalhães O, Maia M, Rodriques EB, et al. Perspective on fluid and solid dynamics
in different pars plana vitrectomy systems. Am J Ophthamol. 2011;151(3):401-5.
10. Awh C, Tadayoni R. Stellaris PC: improved illumination and visualization for
retina surgery. Retina Today Supplement. 2011;3-6.
90
5.7 DIATHERMY
INTRODUCTION
The control of bleeding is essential during vitreoretinal surgery. This problem is
most common in eyes with proliferative diabetic retinopathy or after penetrating
eye wounds. Bleeding is usually controlled during the dissection and removal of
abnormal tissue by increasing the height of the irrigation bottle or the positive
pressure pump to raise intraocular pressure (IOP).1,2 However, entire bleeding
should cease before the end of the surgery and this is verified by decreasing
the IOP to check if bleeding reappears. Focal points of hemorrhage are treated
with diathermy or photocoagulation.
In vitreoretinal surgery, an efficient hemostasis system is required, since
bleeding in the vitreous cavity will darken the viewing field and may induce
postoperative preretinal cell proliferation. In effect, all modern vitrectomy
machines have an integrated diathermy system.
Diathermy is used to control bleeding, to constrict fibrovascular tissue
or create a drainage retinotomy, marking the retinotomy zone with the
endodiathermy device.3
Diathermy may be applied using a unipolar or bipolar system. The bipolar
method is preferable since it minimizes the diverted current. If unipolar
diathermy is used to close to the optic nerve, the energy could be transmitted
to the nerve causing optical atrophy and permanent blindness.4,5
Some years ago, bipolar bimanual diathermy was used whereby electrodes
were connected to the instruments whose tips worked as electrodes to coagulate
fibrovascular tissue. With this system, it is not necessary to withdraw the
instruments to coagulate blood vessels although the method is at present
hardly used.
The method mostly used is the bipolar unimanual system, in which
diathermy is applied with a single probe that has two electrodes with adequate
insulation (coaxial bipolar diathermy). These are the classic scleral erasers and
fine point endodiathermy pencils. Forceps type diathermy tips are excellent for
control of bleeding on the sclera, conjunctiva and Tenon’s capsule (Fig. 1).
Diathermy is now done using 23 gauge instruments (Fig. 2).
Bipolar coagulation instruments with aspiration and backflush functions
enable the surgeon to aspirate blood and identify the bleeding vessel with the
possibility of backflush if incarceration occurs (Fig. 3).
Another useful instrument is the handpiece for illuminated, unimanual,
bipolar diathermy that can be used with the vitreotome as an aspirating line
(Fig. 4).
As already mentioned, some tissue manipulators are equipped with
aspiration, diathermy and endoillumination systems.6 These are especially
useful to remove fibrovascular proliferations, mainly in diabetic retinopathy
(Fig. 5).
91
Figure 1 Diathermy forceps and erasers
Figure 2 Dorc’s 23-gauge diathermy instrument
Figure 3 Medtronic’s cannulas for bipolar diathermy with active/passive

aspiration, backflush and extrusion functions
Figure 4 Illuminating diathermy probe for selective coagulation of a bleeding point

92
Figure 5 Tissue manipulator incorporating three functions (illumination,

aspiration and coagulation) in a single instrument
REFERENCES
1. Klein RM. Hemorrhage of major branch retinal artery during vitrectomy. Retina.
1986;6(2):123-4.
2. de Bustros S. Intraoperative control of hemorrhage in penetrating ocular injuries.
Retina. 1990;10 Suppl 1:S55-8.
3. Fisher YL, Sorenson JA. Retinal tear localization following fluid-gas exchange
during pars plana vitreoretinal surgery. Am J Ophthalmol. 1984;97(3):390.
4. Parel JM, Machemer R, O`Grady GE, et al. Intraocular diathermy coagulation.
Graefes Arch Clin Exp Ophthalmol. 1983;221(1):31-4.
5. Machemer R. Transvitreal radiofrequency diathermy. Am J Ophthalmol. 1977;
83(2):282.
6. Awh CC, Rader RS, Walsh AC, et al. A fiberoptic pick-manipulator for vitreoretinal
surgery. Arch Ophthalmol. 1994;112(6):853-4.
93
5.8 RETINOPEXY
INTRODUCTION
All retinal tears should be treated with some form of retinopexy, since it is
impossible to predict when a tear will lead to retinal detachment and also
because of the relative safety of retinopexy. For cryocoagulation, a probe
is applied to the scleral wall to freeze the endo-ocular tissues and induce
chorioretinal scars. On the down side, we know that cryotherapy causes
migration of pigment epithelium cells promoting their proliferation, such that
it is best to limit its use to cases where it is strictly necessary.
The cryotherapy probe is an excellent tool for indenting the globe and
we use it to revise the retinal periphery at the end of surgery. If we find any
small tears, these can be sealed with cryotherapy directly controlled under the
microscope. We never apply cryotherapy without control at the end of surgery
in a zone posterior to the sclerotomy (Fig. 1).
Another situation in which we could use cryotherapy would be to complete
panretinal coagulation in the peripheral retina in cases of active proliferative
diabetic retinopathy, particularly at sclerotomy sites, reducing the risk of
proliferation, which sometimes gives rise to recurrent hemorrhage. In this case,
we always undertake cryotherapy after completing the vitrectomy with the
retina attached and with direct control under the microscope. The use of endo-
ocular cryoprobes is reserved for cases of atrophy of the pigment epithelium
or albino patients.1,2
Our method of choice for retinopexy is endophotocoagulation in the
periphery with the cryotherapy probe, which achieves excellent indentation
and provides good vision of the retinal periphery. To do this, we often indent
with one hand and use the laser probe with illumination on the other hand to
treat zones anterior to the retina with relative comfort (Figs 2A and B).
LASER ENDOPHOTOCOAGULATION
Endophotocoagulation is performed using a probe introduced through a
sclerotomy. The first endocoagulator was a portable xenon arc.3 The endoprobe
Figure 1 This is the cryoprobe we use for small holes as a method of pexis and
especially to indent the retinal periphery
94
A B
Figures 2A and B (A) Peripheral indentation using the cryoprobe; (B)

Endophotocoagulation with an illuminated laser probe
had to be positioned 0.5 mm from the retina; the light emitted was multicolored
and was absorbed by all retinal pigments, which is why this type of laser is
not used nowadays.
The light from the laser is unidirectional and is transmitted through an
optical fiber4 allowing photocoagulation some distance from the retina. The
size of the laser spot is 600–1000 μm depending on the distance from the probe
tip to the retinal surface. If we want to cause a small burn, we should bring the
probe closer to the retina and reduce the power selected. Conversely for more
extensive impacts, we need to move away from the retina.
The type of impact produced also depends on the position of the probe with
respect to the retina. Thus, if we place the probe perpendicular to the retina
we will achieve a rounded impact, but if the orientation is oblique, the impact
will be oval, especially at the periphery where the probe makes a tangent with
the retinal surface. This slanted approach can be avoided using curved probes,
which are better at reaching peripheral zones (Fig. 3).
The endolaser is used to treat retinal tears, for panretinal photocoagulation
in patients with diabetic retinopathy, occlusive venous disease, hemoglobin
disorder or retinal telangiectasia.5 We can also use the endolaser with light to
treat a bleeding vessel6 (Fig. 4). For extensive bleeding, we will need to use
an aspiration probe or the vitrectomy probe to aspirate the blood followed by
accurate coagulation. This will enable us to keep one hand free for aspirating
and observing where the blood is coming from or for peripheral indentation
as indicated previously. We can also endophotocoagulate ciliary processes in
cases of glaucoma of difficult control, aided by scleral indentation.7,8 Some
laser probes have an aspiration port to remove residual fluids and completely
dry the retina before photocoagulation (Fig. 5).
The lasers, we use to achieve photocoagulation in an eye, are filled with
infusion fluid, air or gas, liquid perfluorocarbon or silicone oil. In eyes filled
with air or gas, the effect of the laser is intensified and the risk of provoking
95
Figure 3 Synergetic laser probe allowing a straight or curved approach
Figure 4 This illuminating probe allows laser treatment with one hand and
indentation with the other
Figure 5 Laser probe capable of aspiration to dry the retina before

photocoagulation
hemorrhage or tears is increased. Intense laser treatment applied under any

type of gas or fluid can cause retinal tearing, but this is most likely to occur in
eyes filled with air or gas. In general, it is best to use lower power impacts for
a longer exposure time to avoid explosive effects on the retina. Currently, the
lasers used are argon, infrared diode, green diode and yellow lasers.
96
Argon Laser
This laser emits blue-green light (440–550 nm) or green light alone. The light
is absorbed well by hemoglobin and melanin. The wound produced is cone-
shaped with its apex in the blood vessels and base in the choriocapillaris.9,10
Its drawbacks are:
It is absorbed by hemoglobin and will thus destroy the retina in hemorrhagic
retinopathy
Poor transmission arises when there are opacities in the media along with
absorption by the vitreous and crystalline lens of some of the radiation.
Diode Laser
This laser uses gallium, aluminum and arsenic semiconductor crystals which
upon excitation produce radiation close to the infrared range 790–950 nm
(peak at 810 nm). This solid state laser has the following advantages: it is
small, does not require water refrigeration since it has no tube, needs no special
electrical installation and can be fitted to a slit lamp, binocular ophthalmoscope,
endo-ocular probe or scleral probe (Fig. 6). This laser can coagulate through
hemorrhage. It produces occlusion of choriocapillaris and large vessels. It has
a red guiding light. Diode lasers emit at wavelengths close to the infrared range
and produce deeper burns.
Green Diode Laser

This is the most recently developed laser. It has the same applications and
acts similar to the argon laser with the advantages of the diode. The radiations
it emits are better absorbed by the pigment epithelium and hemoglobin than
argon (Fig. 7). Despite emitting green light, it produces a guiding red 670
nm beam.
Figure 6 The 810 nm diode laser achieves high penetration

endophotocoagulation and has a red guiding light
97
Figure 7 The 532 nm diode laser emits in the green spectrum but has a red
guide light and shows optimal hemoglobin and oxyhemoglobin absorption
Yellow Laser
Recently a yellow 577 nm laser has been introduced, which causes less energy
dispersion to adjacent tissues. It is a solid state laser of power 2,000 mW. Probe
is available for endo-ocular laser treatment (Fig. 8).
This laser also has a micropulse mode for photocoagulation in the macular
zone, where it is not absorbed by xanthophyll and the wound is limited to the
pigmentary epithelium alone11 (Fig. 9).
This wavelength has been incorporated into the Pascal laser for routine
retinal treatment using the different grids available. All these lasers require a
filter to avoid glare and possible retinal damage to the surgeon and assistants.
This filter should be positioned under the eyepieces for protection during
photocoagulation.
Figure 8 Yellow 577 nm solid states, high reliability laser with a power of 2,000
mW for endophotocoagulation, featuring a micropulse mode
98
Figure 9 Absorption at different wavelengths
REFERENCES
1. Shea M. A microprobe for intraocular cryosurgery. Can J Ophthalmol. 1967;
2(3):163-8.
2. Bradbury MJ, Fung WE. A new 20-gauge intravitreal cryoprobe. Am J Ophthalmol.
1980;90(3):424-5.
3. O´Malley P. Portable xenon arc light coagulator. Br J Ophthalmol. 1973;
57(12):935-44.
4. Landers MB, Trese MT, Stefansson E, et al. Argon laser intraocular photocoagulation.
Ophthalmology. 1982;89(7):785-8.
5. Charles S. Endophotocoagulation. Retina. 1981;1(2):117-20.
6. Awh CC, Schallen EH, de Juan E. An illuminating laser probe for vitreoretinal
7. Lim JI, Lynn M, Capone A, et al. Ciliary body endophotocoagulation during pars
plana vitrectomy in eyes with vitreoretinal disorders and concomitant uncontrolled
glaucoma. Ophthalmology. 1996;103(7):1041-6.
8. Sears JE, Capone A, Aaberg TM, et al. Ciliary body endophotocoagulation during
pars plana vitrectomy for pediatric patients with vitreoretinal disorders and
glaucoma. Am J Ophthalmol. 1998;126(5):723-5.
9. Acheson RW, Capon M, Cooling RJ, et al. Intraocular argon laser photocoagulation.
Eye (Lond). 1987;1(Pt 1):97-105.
10. Karlin DB. Intravitreal argon and carbon dioxide laser, and xenon arc photo
coagulation in vitreoretinal surgery. Graefes Arch Clin Exp Ophthalmol. 1986;
224(3):221-5.
11. Ohkoshi K, Yamaguchi T. Subthreshold micropulse diode laser photocoagulation for
diabetic macular edema in Japanese patients. Am J Ophthalmol. 2010;149(1):133-9.
99
5.9 PHACOEMULSIFICATION
INTRODUCTION
Phacoemulsification is the current technique of choice for cataract surgery. It
may also be used when a candidate, for vitreoretinal surgery, has an opacity
preventing good visualization of the posterior pole. In such cases, combined
cataract/vitreoretinal surgery is recommended.1-12 It is not recommended
to perform two separate surgeries, since besides increasing costs, more
inflammation is produced.
All vitrectomy machines are equipped with an ultrasound system for
cataract removal through a clear corneal incision. Surgery can be performed by
a vitreoretinal surgeon trained for this procedure or an anterior pole surgeon.
The use of phacoemulsification to extract the cataract, means the intraocular
lens (IOL) haptics can be placed in the capsular bag, reducing contact between
the IOL and the uveal tissue thus preventing rupture of the blood-aqueous
barrier, which in turn, diminishes the inflammatory response.13 Implanting
the IOL inside the bag improves centering of the lens and reduces pigment
dispersion induced by mechanical rubbing of the haptics against the posterior
pigment epithelium of the iris if the intraocular pressure has to be implanted
in the sulcus.14
We routinely undertake combined phacoemulsification/vitrectomy surgery.
Surgery is started by placing the infusion port 3.5 mm from the limbus, using
the normal clear cornea approach. The crystalline lens nucleus is bimanually
fractured to reduce the ultrasonography time and we always undertake IOL
placement at the end of the vitreoretinal surgery procedure. This allows us good
access to the posterior pole and periphery, permitting better management of
any complications that could arise during surgery such as tears, deinsertions,
bleeding, etc. The surgeon can even decide not to implant the IOL and remove
the capsule at the end of the surgery.
When scleral indentation is indicated, the scleral buckle is fixed before
positioning the port for cataract surgery. This maneuver would otherwise be
difficult and carries the risk of intraocular complications due to handling of
the muscles.
Our indications for combined phacovitrectomy surgery are cataracts of
hardness grade II or more while in the case of a clear crystalline lens or hardness
grade I cataract, the patient is subjected to a pars plana lensectomy. Combined
surgery is always preferred to separate surgeries.
We can also use the phacoemulsifier hand piece without irrigation to extract
a crystalline lens luxated to the vitreous with grade III or IV cataract (Figs 1A
and B). The following are the prerequisites for this procedure:
There should be no corneal edema from previous surgery as edema prevents
good visualization of the posterior retina, particularly of the periphery,
100
A B
Figures 1A and B (A) Phaco tip used to retrieve a crystalline lens luxated to
the vitreous; (B) Lifting the middle of the vitreous cavity to proceed with the
emulsification process
increasing the risk of complications. Moreover, if there is corneal edema,

surgery could be cut short by the appearance of striate keratopathy. It is
therefore always advisable to wait for any corneal edema to resolve
The vitrectomy should be carefully undertaken to remove as much
peripheral vitreous as possible, thus avoiding interference with the phacoe
mulsification tip
If not already detached, removal of the posterior hyaloid should be done. To
do this, it helps if we observe how the remains of the crystalline lens move:
if it seems they are attached, this indicates the hyaloid is still connected but if
the remnants move freely, this will tell us the hyaloid membrane is detached
Fluid dynamics should be slow, increasing the infusion pressure to avoid
prolapses at the start of aspiration
We recommend the pulse mode to keep the crystalline lens adhered to the tip
Always keep an eye on the phacoemulsification probe tip
Bear in mind that phaco tips are short and it is difficult to reach the posterior
pole
Finally, we should remember that the phacoemulsifier is very efficient inside
the globe but can be very dangerous if not adequately used.
For hard nuclei, we use Alcon’s Legacy/Infinity system, which incorporates
a peristaltic pump, with a microtip needle angled at 0–15° without irrigation
in pulse mode, varying the power and vacuum as required, starting with low
levels and gradually increasing these until they become efficient.
REFERENCES
1. Nawrocki J, Cisiecki S. Combined surgery, phacoemulsification, implantation of
intraocular lens and pars plana vitrectomy. Klin Oczna. 2004;106(4-5):596-604.
2. Lahey JM, Francis RR, Kearney JJ, et al. Combining phacoemulsification
and vitrectomy in patients with proliferative diabetic retinopathy. Curr Opin
Ophthalmol. 2004;15(3):192-6.
101
3. Pollack A, Landa G, Kleinman G, et al. Results of combined surgery by
phacoemulsification and vitrectomy. Isr Med Assoc J. 2004;6(3):143-6.
4. Lahey JM, Francis RR, Kearney JJ. Combining phacoemulsification with pars
plana vitrectomy in patients with proliferative diabetic retinopathy: a series of 223
cases. Ophthalmology. 2003;110(7):1335-9.
5. Heiligenhaus A, Holtkamp A, Koch J, et al. Combined phacoemulsification and pars
plana vitrectomy: clear corneal versus scleral incisions: prospective randomized
multicenter study. J Cataract Refract Surg. 2003;29(6):1106-12.
6. Lam DS, Young AL, Rao SK, et al. Combined phacoemulsification, pars plana
vitrectomy, and foldable intraocular lens implantation. J Cataract Refract Surg.
2003;29(6):1064-9.
7. Demetriades AM, Gottsch JD, Thomsen R, et al. Combined phacoemulsification,
intraocular lens implantation, and vitrectomy for eyes with coexisting cataract and
vitreoretinal pathology. Am J Ophthalmol. 2003;135(3):291-6.
8. Lahey JM, Francis RR, Fong DS, et al. Combining phacoemulsification with
vitrectomy for treatment of macular holes. Br J Ophthalmol. 2002;86(8):876-8.
9. Lam DS, Rao SK, Chan WM, et al. Combined phacoemulsification and pars plana
vitrectomy. J Cataract Refract Surg. 1999;25(10):1309-11.
10. Scharwey K, Pavlovic S, Jacobi KW. Combined clear corneal phacoemulsification,
vitreoretinal surgery, and intraocular lens implantation. J Cataract Refract Surg.
1999;25(5):693-8.
11. Senn P, Schipper I, Perren B. Combined pars plana vitrectomy, phacoemulsification,
and intraocular lens implantation in the capsular bag: a comparison to vitrectomy
and subsequent cataract surgery as a two-step procedure. Ophthalmic Surg Lasers.
1995;26(5):420-8.
12. Koenig SB, Mieler WF, Han DP, et al. Combined phacoemulsification, pars plana
vitrectomy and posterior chamber intraocular lens insertion. Arch Ophthalmol.
1992;110(8):1101-4.
13. Kokame GT, Flynn HW, Blankenship GW. Posterior chamber intraocular lens
implantation during diabetic pars plana vitrectomy. Ophthalmology. 1989;
96(5):603-10.
14. Mamalis N, Teske MP, Kreisler KR, et al. Phacoemulsification combined with pars
plana vitrectomy. Ophthalmic Surg. 1991;22(4):194-8.
102
5.10 ULTRASONIC FRAGMENTATION
INTRODUCTION
Girard was amongst the first to propose the use of ultrasound in vitrectomy
surgery and developed an instrument with a 0.9 mm diameter cannula capable
of undergoing between 20,000 vibrations per second and 40,000 vibrations per
second as well as aspirating.1 Infusion was conducted independently through
another sclerotomy. This system serves to emulsify the crystalline lens2 through
the pars plana introducing a second infusion cannula in the crystalline, and
through ultrasound and aspiration, the lens can be removed, preserving the
anterior capsule intact until the end of surgery. We can also use this device to
emulsify fragments of crystalline lens in the vitreous.3 This requires a good
central and peripheral vitrectomy before we can introduce the phacofragmenter
hand piece without irrigation. While aspirating we approach the nucleus, trap
it, lift it so that it reaches the center of the vitreous cavity and emulsify it at
this site in 3D mode, which allows the simultaneous control of the vacuum and
ultrasound power. The nucleus can be refloated using perfluorocarbon liquid
to protect the macula from possible damage.4
Compared to phacoemulsification instruments, fragmentation tips are longer
for easy reach of the posterior pole but are less efficient when dealing with
hard nuclei, lengthening the removal time and therefore increasing the risk of
complications (Fig. 1).
We use a fragmentation hand piece for vitreous-luxated nuclei of hardness
grade II and III or to perform a pars plana lensectomy with the same degree of
hardness. When the crystalline lens is soft, we use the vitrectomy probe. Its 0.9
mm diameter means it can be easily introduced through a 20-gauge sclerotomy
and its greater length allows the surgeon to work comfortably in the posterior
pole without forcing incisions, and thus avoiding folds forming in the cornea,
impairing visualization of the posterior pole.
Figure 1 Fragmentation hand piece by Accurus. Four different fragmentation

modes exist: linear, momentary, 3D frag and fixed frag. The new 3D fragmentation
mode allows simultaneous control of ultrasound power and vacuum power
103
Pars plana torsional phacoemulsification (Ozyl ) is possible for removal
of retained lens material during pars plana vitrectomy.The major advantage of
the Ozil is that it cuts sideways, which functionally shaves the lens, so the lens
fragments are not repulsed as they are in traditional phacoemulsification, which
uses a back and forth motion. This facilitates the lens fragments staying at the
instrument tip and decreases the tendency for the pieces to be pushed away from
the tip as happens with the fragmatome. It also reduces the need to go back
towards the retina, re-engage the fragment and begin phacoemulsification again.5
The new high-speed vitrectomy machines are equipped with 23-gauge
phacoemulsification probes for microincisional transconjunctival procedures.
REFERENCES
1. Girard LJ, Nieves R, Hawkins RS. Ultrasonic fragmentation for vitrectomy and
associated surgical procedures. Trans Sect Ophthalmol Am Acad Ophthalmol
Otolaryngol. 1976;81(3 Pt 1):432-50.
2. Meredith TA. Pars plana lensectomy by ultrasonic fragmentation. II. A poor
procedure for routine cataract extraction. Surv Ophthalmol. 1982;27(2):96, 101-4.
3. Girard LJ. Pars plana lensectomy for subluxated and dislocated lenses. Ophthalmic
Surg. 1981;12(7):491-5.
4. Shapiro MJ, Resnick KI, Kim SH, et al. Management of the dislocated crystalline
lens with a perfluorocarbon liquid. Am J Ophthalmol. 1991;112(4):401-5.
5. Garg SJ, Lane RG. Pars plana torsional phacoemulsification for removal of retained
lens material during pars plana vitrectomy. Retina. 2011;31(4):804-5.
104
5.11 FORCEPS AND SCISSORS
INTRODUCTION
Scissors are used to cut membrane junctions on the retina especially in
detachments due to traction. There are two types of scissors:
Horizontal (cutting parallel to the retina) for delamination (Fig. 1)
Vertical (cutting perpendicular to the retina) used for segmentation (Fig. 2).
Both can be manual or automatic. Automatic scissors avoid movement as
the surgeon squeezes on them. Recent developments include curved scissors
that can be used both for delamination and segmentation. These manual scissors
have two springs, although scissors with one spring are preferable for controlled
hand movements.
Figure 1 Horizontal scissors by Dorc for delamination by cutting the attachment

zones of proliferative tissue to the retina
Figure 2 Vertical scissors of the Accurus system that allows tissue segmentation by
grasping the tissue and then cutting. These scissors are pneumatic and their cutting
speed can be controlled with the foot pedal
105
We use vertical pneumatic microscissors controlled by the surgeon with the
foot pedal. It is possible to vary the cutting mode and number of cuts. These
scissors are excellent for segmentation.1,2 For delamination, we prefer curved
manual scissors (Figs 3A and B). This maneuver can be performed bimanually:
with one hand the tissue is secured using forceps and the other hand can be
used for cutting the attachment zones.
There are several forceps type and design. Forceps are used to remove
preretinal, subretinal and neovascular membranes and the internal limiting
membrane. We prefer the positive action membrane forceps, which is the
movement we are accustomed to. These forceps have diamond powder coated
tips to help grasp the membranes. For preretinal membranes, we use fine tipped,
diamond-coated forceps, always with positive action (Fig. 4).
For subretinal proliferation strands, we use the same type of forceps as for
preretinal membranes with positive action. Once the subretinal strand has been
grasped, the forceps are rotated to wrap the membrane around the forceps without
it breaking. For subretinal membranes it is best to use curved forceps that can
easily be introduced under the retina. For the internal limiting membrane, blunt
forceps or forceps with a serrated jaw (Figs 5 and 6) are used to directly grasp
the membrane or lift up an edge of the membrane and then dissect it.
A B
Figures 3A and B Curved scissors we normally use for delamination. (A) View
under the microscope; (B) Side view of the same scissors
Figure 4 Grieshaber positive action diamond-coated forceps

106
Figure 5 Blunt-tipped, positive-action forceps used for fine epiretinal

membranes and internal limiting membrane
A B
Figures 6A and B Blunt-tipped forceps with a serrated platform that close perfectly
at the tips. (A) View under the microscope, forceps open; (B) Same forceps, closed
Among the new forceps appearing in the market, we should mention

the Corcóstegui design. These are direct action forceps, with straight edges
designed to remove the internal limiting membrane. They are manufactured in
23-, 25- and 27-gauge measurements and in our experience offer an excellent
grasp of the membrane, along with its complete dissection. Currently, these
are the forceps of choice (Figs 7A and B). We can also use disposable forceps
for the internal limiting membrane (Fig. 8).
We can also use a pick to dissect or lift membranes. As a pick, we use a
sclerotomy blade, which we fold under the microscope at an angle of 90–110°
to lift the membrane or create a border (Figs 9A to C).
We should always have available foreign body forceps. These are larger
than the forceps used for tissues: 19, 18 or 17 gauge. Diamond powdered
models are preferable since they provide a good grasp on the foreign body
preventing it from falling onto the retina. Tripod-shaped forceps with three
hooks to firmly secure the foreign body is another good option (Figs 10A and
B). For a large foreign body, the incision may need to be enlarged. Magnetic
forceps are sometimes useful.
107
A B
Figures 7A and B Corcóstegui’s direct action forceps designed to remove the

internal limiting membrane
Figure 8 Disposable forceps can also be used to remove the

internal limiting membrane
A B C
Figures 9A to C Folded MVR blade used as a

pick for lifting membranes
A B
Figures 10A and B (A) Diamond-coated foreign body forceps by Synergetics;

(B) Tripod-shaped forceps
108
REFERENCES
1. Charles S, Wang C. Pneumatic intraocular microscissors. Arch Ophthalmol.
1981;99(7):1251.
2. Machemer R, Parel JM, Hickingbotham D, et al. Membrane peeler cutter. Automated
vitreous scissors and hooked needle. Arch Ophthalmol. 1981;99(1):152-3.
109
5.12 VITREOUS SUBSTITUTES: MANIPULATORS
OF TISSUES
INTRODUCTION
Vitreous substitutes are introduced into the vitreous cavity to help maneuver
or manipulate tissues during surgery.
HYALURONIC ACID
Hyaluronic acid is very viscous and slightly heavier than the infusion fluid. It
is hydrosoluble and lacks surface tension thus is ineffective for sealing retinal
tears. Hyaluronic acid is used by some surgeons for a procedure known as
viscodelamination of membranes:1 the membrane is lifted a little and the
viscoelastic is introduced to slightly tense the membrane, which facilitates its
dissection or segmentation.
Hyaluronate is also used to help refloat the nucleus in the vitreous cavity, when
trying to keep a luxated crystalline lens in the central zone avoiding its displacement
to the periphery because of the convex meniscus formed by perfluorocarbon.
Interest in viscodelamination has been rekindled due to the introduction
of trypan blue staining of the viscoelastic. The stained viscoelastic is placed
under the membranes making it easy to work while avoiding damage to the
retina and specific instruments are currently being developed for this purpose.2
Hyaluronate is mainly used as the viscoelastic in anterior pole surgery.
In vitreoretinal surgery, it is used to preserve space in the anterior chamber,
improve mydriasis, displace blood and to regularize the endothelium in air-
filled eyes in aphakic patients with striate keratopathy. This strategy helps
successfully complete the air-fluid exchange maneuver.
We personally use hyaluronate in two situations:
To regularize the corneal epithelium and avoid desiccation during surgery
using a noncontact viewing system. The viscoelastic is placed on the cornea
such that a physiological saline bubble is then sufficient to work in most
cases without the need for constant irrigation of the cornea, which could
induce epithelial edema and subsequent de-epithelialization (Figs 1A and B)
After combined cataract/vitrectomy surgery, hyaluronate serves to maintain
good mydriasis and also avoids the loss of anterior chamber space during
indentation maneuvers.
PERFLUOROCARBON LIQUIDS
The specific weight of perfluorocarbon liquids (PFCL) is double that of water
so that they can press down on the retina and displace any subretinal fluid.
110
A B
Figures 1A and B (A) Placing viscoelastic on the cornea; (B) The surface is regularized
with a drop of saline avoiding corneal drying and offering a good image of the fundus
These liquids are therefore often used in maneuvers performed on the retina
in many retinal diseases.3-6
Perfluorocarbon liquids have a high surface tension and therefore tend to
form a single bubble such that they cannot pass through retinal tears. When
there is retinal traction, however, as the PFCL is injected, the retina lifts up
in the shape of a tent and the PFCL bubble eventually penetrates behind the
retina since the traction prevents the bubble flattening the retina. To avoid this,
we should relieve any traction even if this means undertaking a retinotomy.
Because of their low viscosity, PFCL can be easily injected and removed
through the cannula. The use of a Chang double cannula is recommended to
eliminate liquid from the globe while injecting PFCL, avoiding intraocular
pressure peaks and vitreous blocking the infusion cannula (Fig. 2).
Perfluorocarbon liquids are optically clear, yet their refractive index is
different from that of physiological saline such that they can be easily visualized
during surgery (Table 1). The refractive power of the eye is unaffected by
the use of PFCL and they can be used when dissecting membranes using
conventional or wide-angle lenses. Perfluorocarbons do not absorb laser
radiation allowing endophotocoagulation under the PFCL bubble.
The refractive index of perfluoro-n-octane is 1.27 and it is easily visible in
saline solution. Its interface is therefore easy to see during exchanges and it is
the liquid we use in routine practice (Figs 3A to C).
Figure 2 A Chang double cannula is used to introduce perfluorocarbon while

allowing the exit of fluid
111
TABLE 1
Properties of perfluorocarbon liquids
Perfluoroctano Perfluorodecalin Perfluoro-hydro

phenanthrene
Chemical formula C8F18 C10F18 C14F24
Molecular weight 438 462 624
Specific gravity 1.76 1.94 2.03
Refractive index 1.27 1.31 1.33
Viscosity 0.69 2.7 7.80
Vapor pressure 105 177 215
Surface tension 17 16 23.9
Tamponade 3.65 4.55 5.0
Trade name F-octane DK-line Vitreon
A B C
Figures 3A to C Perfluoro-n-octane introduced using a Chang cannula; its two

channels allow liquid to exit the eye as the perfluorocarbon liquid is introduced
avoiding intraocular pressure peaks. (A) Starting the maneuver; (B) Reattaching the
retina; (C) Large perfluorocarbon bubble with the retina reattached
Perfluorodecalin has also been used by many surgeons with good results,
yet it is more viscous and its interface is less easily observed than perfluoro-
n-octane.
Perfluoro hydrophenanthrene is very viscous and thus more difficult to work
with during exchanges. Moreover, the aqueous-perfluoro hydrophenanthrene
interface is difficult to see and sometimes the physiological saline has to be
replaced with air in order to localize it. Visualization depends on the difference
between the refractive index of water (1.33) and that of the perfluorocarbon.
Thus, the similar refractive index of perfluoro hydrophenanthrene and water
means it is impossible to observe the bubble-saline interface.7
Perfluoro hydrophenanthrene is used for tamponade of inferior tears, but
in all cases contact time should be short, some 15 days, since there have been
descriptions of its dispersion, retinal damage owing to its weight, cataracts in
phakic patients and increased intraocular pressure.8
112
REFERENCES
1. McLeod D, James CR. Viscodelamination at the vitreoretinal juncture in severe
diabetic eye disease. Br J Ophthalmol. 1988;72(6):413-9.
2. Fortun JA, Hubbard GB. New viscodissection instrument for use with micro—
incisional vitrectomy in the treatment of diabetic tractional retinal detachments.
Arch Ophthalmol. 2011;129(3):352-5.
3. Chang S. Low viscosity liquid fluorochemicals in vitreous surgery. Am J Ophthalmol.
1987;103(1):38-43.
4. Chang S, Ozmert E, Zimmerman NJ. Intraoperative perfluorocarbon liquids in
the management of proliferative vitreoretinopathy. Am J Ophthalmol. 1988;
106(6):668-74.
5. Mathis A, Pagot V, Idder A, et al. Use the perfluorodecalin during vitrectomy in
diabetics. J Fr Ophthalmol. 1993;16(11):584-90.
6. Comaratta MR, Chang S. Perfluorocarbon liquids in the management of
complicated retinal detachments. Curr Opin Ophthalmol. 1991;2(3):291-8.
7. Meffert S, Peyman GA. Intraoperative complications of perfluoroperhydro
phenanthrene: subretinal perfluorocarbon, retinal slippage and residual
perfluorocarbon. Vitreon Study Group. Can J Ophthalmol. 1999;34(5):272-80.
8. Bottoni F, Bailo G, Arpa P, et al. Management of giant retinal tears using
perfluorodecalin as a postoperative short-term vitreoretinal tamponade: a long-term
follow-up study. Ophthalmic Surg. 1994;25(6):365-73.
113
5.13 VITREOUS SUBSTITUTES: TAMPONADES
INTRODUCTION
Tamponade agents are introduced in the globe at the end of surgery to seal
retinal tears and avoid liquid seeping into the subretinal space. Tamponades
also provide time for scarring to occur after retinopexy is performed during
the surgery. Gases or air are generally used as temporary tamponades, while
silicone oil is used for prolonged tamponade.
INTRAOCULAR GASES
Ohm was the first to reattach the retina by air injection in 1911.1 Rosengren
subsequently described the concepts of internal tamponade in terms of the site
of tearing and an adequate head position.2 However, scleral buckles were soon to
replace the use of gas to treat the detached retina and the tamponade method was
subsequently revived by a series of studies performed by Norton.3 Following
the advent of vitreoretinal surgery, the effectiveness of gas, especially sulfur
hexafluoride (SF6), was again recognized. Lincoff 4,5 examined the properties of
perfluorocarbon gases, particularly their capacity to expand and persist in the
globe. Dominguez6 and later on Hilton described the procedure of pneumatic
retinopexy, using gas to seal the tear and then retinopexy in selected cases
without the need to indent and on an ambulatory basis. Today, air is routinely
used for many types of exchanges in intraocular surgery and several gases are
used for tamponade.
Air and other gases injected into the vitreous show no toxicity towards
ocular tissues. The noxious effects of gases are mainly related to their physical
properties such as volume expansion, which produces an increase in intraocular
pressure (IOP). However, prolonged contact of a gas with the endothelium or
posterior crystalline lens surface can lead to endothelial damage or cataract,
respectively.
The beneficial effects of a gas bubble for the treatment of a detached retina
is the tamponade produced by the functional sealing of a retinal tear and
flotation pressure, which presses the retina up against the globe wall. When
the patient’s head position is such that the bubble touches an open retinal tear,
the tamponade effect prevents any fluid from the vitreous cavity to seep via the
tear into the subretinal space. When all retinal tears are sealed by the bubble,
the retinal pigment epithelium absorbs any subretinal fluid and the retina is
flattened against the back wall of the globe.
It is unlikely for a gas bubble to pass through the tear into the subretinal
space, but this could occur if the tear is larger than the bubble or if existing
membranes prevent the flattening of the retina against the globe wall.
Gases used for intraocular surgery are of high molecular weight and
114
elements from the blood pass into the gas in three different stages: bubble
expansion, equilibrium and dissolution. In the expansion stage, nitrogen and
other gases enter the bubble and expand it. This usually occurs 6–8 hours after
gas injection.7
The equilibrium stage starts at the point of maximal expansion and continues
until the partial pressure of nitrogen in the gas bubble and in the blood capillaries
reach equilibrium. When this happens, the bubble stops expanding and slowly
starts to be reabsorbed.
The last stage starts when the nitrogen pressure in the bubble is greater or
is in equilibrium with the pressure in the capillaries. This leads to diffusion
of elements outside the bubble with the consequent reduction in bubble size
(Table 1).
The surgeon should be familiar with the properties of the gas and choose
the gas according to the condition to be treated (Table 2):
Superior tears with retinal detachment (RD) without proliferation can be
treated with air
Inferior tears with RD can be treated with 20% SF6
TABLE 1
Angle of contact the bubble makes in the vitreous cavity according to the
percentage bubble and the volume of gas needed in the phakic eye
Contact with the retina Percentage of gas bubble and vol-
ume needed in phakic eyes
120° 25%, 0.50 ml
180° 50%, 1.95 ml
240° 75%, 3.10 ml
360° 100%, 3.91 ml
TABLE 2
Properties of gases used for tamponade
Expan- Expan- Longevity Slightly Nonex-
sion rate sion delay (Days) expansive pansive
(Days) concen- concen-
tration tration
(%) (%)
Air 0 0 5–7 0 0
Sulfur hexafluoride 2 1 15 20–25 20
(SF6)
Perfluoroethane 4 1.5 30 17–20 16
(C2F6)
Perfluoropropane 3.3 3 60 14–17 12
(C3F8)
115
Complex RD with proliferative vitreoretinopathy or giant tears can be
treated with 10–15% C3F8
Macular holes, if recent, can be treated with C3F8 or SF6.
A face-down head position should be maintained until the bubble decreases
by 20% to avoid contact with the crystalline lens in an upright position. It should
be remembered that a laser-induced chorioretinal scar could appear during the
first few days. With cryotherapy, adhesion of the choroid to the retina occurs
as early as the 6th or 7th day after surgery. The active proliferation stage can
last around 50 days.
The use of nitrous oxide in general anesthesia is contraindicated if a gas has
been introduced during surgery, since any nitrous oxide inhaled by the patient
can pass from the blood to the eye and give rise to a high IOP, eventually
occluding the central retinal artery. Conversely, if the patient inhales nitrous
oxide after air-gas exchange, the gas will pass to the vitreous cavity, and at
the end of the surgery will return to the blood flow, substantially diminishing
the effective gas volume. Nitrous oxide is eliminated from the blood in 10–12
minutes, which is the time we would have to wait before using intraocular gas
after gas inhalation.
Variations in atmospheric pressure affect the total volume of the gas bubble.
Thus, if there is an abrupt change in outside pressure, the gas volume tends to
expand and this occurs when we travel by air or rapidly climb to a high altitude.
At altitudes higher than 1,000–1,500 meters above the height at which the
gas bubble was injected, the increase in volume can be considerable and even
dangerous. Thus, a patient travelling to a place of high altitude should do so
slowly, to allow the gradual expansion of the gas.
SILICONE OIL
This oil is lighter than water and tends to float upwards achieving good
tamponade of the superior retina. An inferior iridectomy is needed to allow
circulation of the aqueous humor such that it does not build up posteriorly
and displace the bubble towards the front of the globe. Silicone oil is usually
introduced through an injection pump after reattaching the retina and keeping
it in position with air. The direct exchange of perfluorocarbon-silicone oil is
also possible.
The oil is available in 1,000 and 5,000 centistokes. Both show similar
behavior in terms of maintaining the retina in position. Silicone oil of 5,000
centistokes can be left in the eye for longer, but the vitreotome used for its
removal has to have a liquid extraction pump (Box 1).
Silicones are inert hydrophobic compounds of the siloxane polymer family
whose viscosity is determined by polymer length. Silicone oil has a refractive
index of 1.4035, which is slightly higher than that of vitreous gel at 1.33.8,9
When used it produces hyperopia in the phakic or pseudophakic patients
because of the concave surface of the silicone bubble. Conversely, in the aphakic
116
Box 1: Main properties of silicone oil for its use in vitreoretinal surgery
• Transparent, nonvolatile and immiscible in water
• Exerts pressure on the superior retina
• This tamponade agent is physically weaker than gas (floating power and
interfacial tension lower than gas)
• Occupies the vitreous cavity in a permanent manner
patient, the convex curvature of the silicone bubble increases dioptic power,
reducing hyperopia and tending towards myopia. In these patients, as the head
is moved, the silicone bubble changes its curvature, varying its refractive state.
Hence, it is difficult to determine refraction in aphakic subjects with silicone
oil, especially if the globe is incompletely filled allowing the silicone to move
more freely.
In 1958, Stone was the first person to describe the use of silicone10 as a
vitreous substitute that can remain indefinitely in the globe. Its density of
0.97 g/cm3 is lower than that of water such that it floats over the fluid in the
vitreous cavity. The surface tension of silicone oil is far less than that of gas,
which along with its reduced floating capacity makes it a much less resistant
tamponade agent than gas. Silicone oil is particularly suited for the repair of a
superior retinal tear, but proliferations often appear in the inferior retina, such
that indentation should be placed inferiorly to contact the ball of silicone,
especially if there are tears or inferior membranes.11
Silicone Solvent
When silicone oil has been used in a patient with retinal problems, who has
undergone prior cataract surgery with the implant of a silicone intraocular
lens (IOL) (as the oil interacts with the IOL) blurred, distorted or even double
vision is produced. To resolve this problem, research efforts have led to the
use of semifluorinated alkanes as a silicone solvent. In Europe, the use of
perfluorohexyloctane (F6H8) was approved for this purpose in 1998. Silicone
is extracted from the lens using a syringe.
Subsequent to this, semifluorinated alkanes have been used to dissolve
drops of intraocular silicone oil. This use has proved to be efficient and
recommendable. Compared to perfluorocarbons (density 1.8–2.0 g/cm3), F6H8
has a lower density (1.36 g/cm3) and could be less damaging to the retina while
preserving some of the benefits of perfluorocarbon liquid such as surface tension
(Fig. 1). This has led to suggestions of the use of F6H8 as temporary tamponade
in cases of inferior proliferations or tears. Several authors have assessed its use
and some have reported significant problems such as redetachments, high IOP,
cataract, emulsification, etc.12-16
We employ perfluorohexyloctane as a solvent to remove all the drops of
silicone oil and, as such, its use is extremely easy and efficient. In few cases
117
Figure 1 Silicone solvent can also be used as a tamponade in inferior

retinal detachments
we have used it as a tamponade for recurrent inferior detachments, we have

always managed to reattach the retina but have noted emulsification in each
case and sometimes, intraocular hypertension. We therefore consider F6H8
as a therapeutic tool for use in very selected cases and always with caution.
We do not recommend mixing it with silicone oil for inferior and superior
tamponade since it forms an opalescent mixture that is difficult to manipulate.
Nevertheless, there is currently a compound available that contains 69.5%
ultrapure polydimethylsiloxane and 30.5% perfluorohexyloctane (Densiron
68), which is immiscible in water, with a density of 1.06 g/cm3 and viscosity
1400 mPas. This compound has been recommended as a short-term tamponade,
but has also been described to induce complications such as glaucoma and
cataract.17
Heavy Silicone Oil

Oxane HD
The low density of silicone oil induces fluid deposition in inferior quadrants
and increases the percentage of inferior reproliferations. This has prompted the
development of new vitreous substitutes with greater density than water which
allows the repair of retinal tears in inferior quadrants (Fig. 2).
Heavy silicone oil is a new vitreous substitute with a high specific
gravity. It is a mixture of silicone oil of 5,000 centistokes and fluorinated and
hydrocarbonated olefin (RMN3). The mixture is homogeneous and stable in the
presence of water, air or perfluorocarbon.18
Heavy silicone oil has been used to treat retinal detachments complicated
with vitreoretinal proliferation grade C2 or higher, retinal detachment due to
118
Figure 2 Oxane HD is used in complicated cases for inferior and

posterior tamponade
Figure 3 High density silicone for temporary tamponade
eye trauma and giant or inferior retinal tears. The mean period recommended
for its placement is 3 months after which time it has to be surgically removed.
An 18% rate of increased IOP has been described.19,20
In our experience, heavy silicone oil is a good tamponade for inferior and
posterior problems but is not very good for tamponade of the superior zone.
The patient should be strictly followed to check for complications so that, if
necessary, the oil can be rapidly removed with the help of a fluid extraction
pump.
119
Densiron
This product is a stable mixture of silicone solvent (F6H8) and Siluron 5000.
Its density of up to 1.06 g/cm3 makes it an efficient tamponade and it is easy
to use and shows little tendency for dispersion. Its use should be limited to
complex cases; at most it may be left for 3 months before its removal (Fig. 3).
For complicated cases, it is currently our product of choice. It should be
noted, however, that it is not possible to achieve a total tamponade effect across
the whole retinal surface.
REFERENCES
1. Ohm J. Uber die Behandlung der Netzhautablösung durch operative entleerung
der subretinalen flüssigkeit und einzpirtzung von luft in den glassköpen. Albrecht
Von Graefes Arch Ophthalmol. 1911;79:442-65.
2. Rosengren B. Über die behandlung der netzhautablosung mittelst diatherme und
luftinjektion in den glasköper. Arch Ophthalmol. 1938;16:3-42.
3. Norton EW, Aaberg T, Fung W, et al. Giant retinal tears. I Clinical management
with intravitreal air. Am J Ophthalmol. 1969;68(6):1011-21.
4. Lincoff H, Mardirossian J, Lincoff A, et al. Intravitreal longevity of three
perfluorocarbon gases. Arch Ophthalmol. 1980;98(9):1610-1.
5. Lincoff A, Haft D, Liggett P, et al. Intravitreal expansion of perfluorocarbon
bubbles. Arch Ophthalmol. 1980;98(9):1646.
6. Dominguez A. Cirugía precoz y ambulatoria del desprendimiento de retina. Arch
Soc Esp Oftal. 1985;48:47-54.
7. Chang S. Intraocular gases. In: Ryan SJ, Wilkinson CP (Eds). Retina, 3rd edition.
St Louis: Mosby; 2001. pp. 2147-61.
8. Crisp A, De Juan E, Tiedeman J. Effect of silicone oil viscosity on emulsification.
Arch Ophthalmol. 1987;105(4):546-50.
9. Gabel VP, Kampik A, Burkhardt J. Analysis of intraocularly applied silicone oils
of various origins. Graefes Arch Clin Exp Ophthalmol. 1987;225(3):160-2.
10. Stone W. Alloplasty in surgery of the eye. N Engl J Med. 1958;258(10):486-90.
11. Vitrectomy with silicone oil or sulfur hexafluoride gas in eyes with severe
proliferative vitreoretinopathy: results of a randomized clinical trial. Silicone Study
Report 1. Arch Ophthalmol. 1992;110(6):770-9.
12. Kirchhof B, Wong D, Van Meurs J, et al. Use of perfluorohexyloctane as a long-
term internal tamponade agent in complicated retinal detachment surgery. Am J
Ophthalmol. 2002;133(1):95-101.
13. Zeana D, Becker J, Kuckelkorn R, et al. Perfluorohexyloctane as a long-term
vitreous tamponade in the experimental animal. Experimental perfluorohexyloctane
substitution. Int Ophthalmol. 1999;23(1):17-24.
14. Roider J, Hoerauf H, Kobuch K, et al. Clinical findings on the use of long-
term heavy tamponades (semifluorinated alkanes and their oligomers) in
complicated retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol.
2002;240(12):965-71.
15. Stefaniotou MI, Aspiotis MV, Kitsos GD, et al. Our experience with per
fluorohexyloctane (F6H8) as a temporary endotamponade in vitreoretinal surgery.
Eur J Ophthalmol. 2002;12(6):518-22.
120
16. Gerding H, Kolck A. Perfluorohexyloctane as internal tamponade in patients
with complicated retinal detachment. Results after 6 months. Ophthalmologe.
2004;101(3):255-62.
17. Schatz B, El-Shabrawi Y, Haas A, et al. Adverse side effects with perfluorohexyloctane
as a long-term tamponade agent in complicated vitreoretinal surgery. Retina.
2004;24(4):567-73.
18. Mathis A, Grosmaire V, Garcia P, et al. Etude expérimentale de la tolérancia
intraoculaire d´un nouveaux produit de tamponnement interne en chirurgie
vitréorétinienne: résultats préliminaires. In: Societe Francaise d´Ophtalmologie.
Paris; 1999. p. 92.
19. Wolf S, Schön V, Meier P, et al. Silicone oil-RMN3 mixture (“heavy silicone oil”) as
internal tamponade for complicated retinal detachment. Retina. 2003;23(3):335-42.
20. Avitabile T, Bonfiglio V, Buccoliero D, et al. Heavy versus standard silicone oil in
the management of retinal detachment with macular hole in myopic eyes. Retina.
2011;31(3):540-6.
Chapter 6
Basic Vitrectomy
CHECK LIST
Before embarking on a vitrectomy, it is the task of the surgical team to make sure
that all the equipment are working properly, and all the drugs and instruments
we may need are at hand. Making a checklist is recommended including all
the items that need to be checked before the patient lies down. This checklist
should be drawn up by each surgery team since there could be variations in the
instruments, adjuvants or other systems regardless of the surgical procedure
scheduled. Table 1 lists the essential points that should be checked before
starting a vitreoretinal surgery:
TABLE 1
Points to check before a vitreoretinal surgery
Items Essential points to be checked

Operating table Comfortable, head parallel to ceiling, eye well-centered
Surgeon’s chair Positioned such that the surgeon is at the height of the
patient’s head
Foot pedals Easily accessed
Microscope X-Y drive centered, focus on “0”
Visualization Lenses available, good condition
Laser filter Laser in rest position
Infusion line Purged, bottle at level of patient’s head
Vitreotome Check aspiration and cutting functions using saline
Illumination Check probes
Instruments Forceps and other instruments, availability, sterile
Adjuvants Availability, good condition
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POSITIONING THE PATIENT
We should dedicate a few minutes to the correct position of our patient: the
head, resting on a silicone or gel donut, should be parallel to the ceiling such
that the chin is in line with the chest and it must be checked that the eye
appears in the microscope’s center of vision. The operating table should be
comfortable, otherwise after the 1st hour of surgery the patient will become
restless and any movement will hinder the surgery. Some patients even request
that surgery be detained. The surgeon usually sits at the 12 o’clock position but
may adopt a temporal position in certain situations (scleral problems, certain
membranectomies, etc.).
It is best to have an oxygen supply close to the patient’s airway in case
local or regional anesthesia is needed. We recommend that the surgeon set the
position of all nonsterile items (stretcher, patient, surgeon’s chair, armrests,
pedals, etc.) before scrubbing in to avoid the risk of infringing conditions of
sterility. If during surgery any nonsterile item needs to be repositioned, this
would be best accomplished by someone outside the surgery team under the
instructions of the surgeon.
VISUALIZATION SYSTEMS
There are two main types of visualization systems: (1) contact systems and (2)
noncontact systems.
Contact Systems
These are lenses that need to be placed in contact with the corneal surface
to visualize the eye fundus. Many of these systems require a lens retaining
ring fixed to the sclera to give the lens stability and prevent its movement or
decentring. The most widely used device (the one we also use) is the Landers
metal ring, which is placed close to the limbus and sutured to the sclera at 12–6
o’clock position using 6-0 vicryl sutures. Alternatively it may be obliquely
positioned at 3–9 o’clock if the sclera is affected by previous surgery (Fig. 1).
Lenses with stabilizing systems that do not require a retaining ring may also
be used.
Noncontact Systems
These lenses do not need to make direct contact with the globe to allow good
visualization of the fundus. They are incorporated in the microscope at the end
of an articulated arm so that they can be easily placed or withdrawn during
surgery. Although they do not need a retaining ring, the quality of visualization
can be affected by corneal desiccation. To avoid this, we recommend abundant
rinsing with balanced saline solution (BSS) followed by evenly coating the
Chapter 6  Basic Vitrectomy
123
Figure 1 The Landers lens retaining ring gives stability to the wide-field
lens used in surgery
entire corneal surface with a viscoelastic/methylcellulose. This provides stable

corneal transparency without the need to constantly irrigate the corneal surface.
CONJUNCTIVAL INCISIONS
The generalized use of microincisional vitrectomy has substantially reduced
the need for conjunctival incisions in a large number of cases. However, the
conjunctiva will need to be accessed in the following situations:
For sclerotomies when 20-gauge caliber instruments are to be used
For openings designed to remove a tumor or an intraocular foreign body
For implanting scleral indentation devices, whether segmental or circular.
If we wish to place a scleral buckle, a 360° conjunctival peritomy is
first undertaken. The conjunctiva and Tenon’s capsule are dissected 2.5 mm
from the limbus to expose the underlying sclera, leaving a 2.5 mm margin of
perilimbal conjunctiva to promote tissue regeneration after surgery. Points
of bleeding are coagulated with bipolar diathermy. Following this, the rectus
muscles are captured using a hook and a silk 4-0 suture is thread around
the insertion point to mobilize the eye, passing the scleral buckle under the
muscles. It is helpful, if forceps are fixed to the suture to traction the muscles
and help access the globe.
If a scleral buckle is not used, we make three transconjunctival incisions:
(1) a temporal superior one (3.5 mm from the limbus) to perform the temporal
sclerotomy in order to introduce the vitreotome handpiece, (2) a temporal
inferior for the infusion cannula (Fig. 2) and (3) one more sclerotomy in the
nasal superior zone for endoillumination.
124
Figure 2 Conjunctival opening for superior temporal and inferior temporal

scleral incisions for the infusion port
SCLEROTOMY
Scleral incisions are made with a double cutting edge triangular scalpel, or
microvitreal (MVR) blade, whose size varies according to the incision size
selected by the surgeon (Box 1). Sclerotomies should be placed close to the
horizontal meridians so that access to the inferior and superior periphery
is possible.1 Sclerotomies are directly scleral in 20-gauge procedures and
transconjunctival with the use of trocars for 23-, 25-, and 27-gauge vitrectomy.
The scleral tunnel access technique for suture-free microincisional vitrectomy
(23-, 25-, 27-gauge) has been the subject of numerous studies, since on this—in
large measure depends the final sealing of the sclera. Most recommendations
are based on the individual surgeon’s experience. We conduct an approximation
mostly in an oblique direction and then with a gentle turn of the hand we adjust
this direction toward one perpendicular to the globe and leave the trocar in
place. This achieves an oblique tunnel in the scleral thickness comprised of two
Box 1: Sclerotomy equivalents in mm of the different

microvitreoretinal gauges
19 gauge = 1 mm
20 gauge = 0.9 mm
21 gauge = 0.8 mm
22 gauge = 0.7 mm
23 gauge = 0.6 mm
25 gauge = 0.5 mm
27 gauge = 0.4 mm
30 gauge = 0.3 mm
125
lips which at the end of surgery will tend to apposite themselves one over the
other, thus producing a tight seal without the need for sutures (Figs 3A to D).
As mentioned in the first chapter, sclerotomies should be placed on the pars
plana as far away as possible from the crystalline lens (3–3.5 mm from the
limbus in aphakic or pseudoaphakic eyes and 3.5–4 mm in phakic eyes). Three
sclerotomies are usually placed: an initial inferior-temporal to insert the infusion
cannula and two superior incisions close to the horizontal globe axis (between
2 o’clock and 3 o’clock, and 9 o’clock and 10 o’clock) to allow for bimanual
surgery. Once the infusion line (previously purged) has been introduced, it is
important to check that it is correctly positioned in the vitreous chamber before
initiating infusion. This can be done by pressing on the tube and illuminating
from outside using the optics fiber (Figs 4A and B). The infusion cannula we
normally use is 3.5–4 mm with the slant aimed toward the crystalline lens
to avoid jabbing the lens if the tube bends. There are also 2.5 mm cannulas,
which we use in children and 6 mm cannulas, which we use in cases of anterior
proliferations, choroid detachments, anterior trauma, and any time we anticipate
difficulty in reaching the vitreous cavity with the cannula. In these cases, we can
start surgery placing the cannula in the anterior chamber and it is even possible
to conduct a three-port transcorneal vitrectomy.2 At the onset of vitrectomy, it is
recommended that the vitreotome be used to eliminate the vitreous that could
impede infusion flow through the cannula (Figs 5A and B).
Similarly, after marking the nasal and temporal sclerotomies aiming for a
separation of 160°, we introduce the MVR blade in the same way toward the
center of the eye. We start off with the nasal sclerotomy for endoillumination
and finish with the temporal sclerotomy for the vitreotome. Next we introduce
Figures 3A to D Constructing a scleral tunnel. (A) Direction of the sclerotomy.

(B) Placement of the trans-scleral trocar to introduce and withdraw the instruments.
(C) Tunnel anatomy after removing the trocar and the actions of positive intraocular
pressure. (D) Scleral lips in apposition seal the sclera
126
A B
Figures 4A and B (A) Checking the infusion cannula is in the vitreous space; (B)
View of the infusion cannula with its slanted tip facing upward
A B
Figures 5A and B (A) Freeing the infusion cannula from tissue impeding its entry
into the vitreous chamber; (B) We can watch the procedure as we push in the cannula
and free it from surrounding tissue using the vitreotome, leaving it in the vitreous
cavity before starting infusion
the instruments: first the endoillumination probe and then the vitreotome
directed toward the eye center. The vitreotome is introduced active to start
creating the vitreous tunnel. If during the insertion maneuver we notice
vitreous traction, we should remove the instruments and reintroduce the
MVR blade (Fig. 6).
Figure 6 Conditions needed to start vitreous surgery: an open infusion line, a

switched on light pipe, an active vitreotome and good visualization provided by
the wide-field system
127
PUPIL MANAGEMENT
In this section, we will pay special attention to an essential feature of
vitreoretinal surgery, pupil mydriasis. Although the new wide-field visualization
instruments provide an excellent view of the eye fundus without the need for
intense mydriasis, this is still an important aspect of the preoperative preparation
of the patient as a good mydriasis allows the surgeon to better visualize the
retina as well as provide easier access to the retinal periphery and vitreous
base. Generally, an adequate pupil aperture is achieved with a preoperative
regimen which starts at least 1 hour before surgery based on anticholinergic
eye drops, such as tropicamide 1% and/or cyclopentolate 1%, instilled every
15–20 minutes in the eye to be operated on. Upon arrival of the patient, a
member of the surgery team should check the extent of mydriasis and, if
necessary, reinforce this with the same eye drops or by adding an adrenergic
such as phenylephrine at 10%.
Achieving effective pupil mydriasis may be difficult at the surgery time
point’s pre and intraoperative. Preoperatively, this could occur in cases of
synechiae, atrophic iris or traumatic iris associated with floppy iris syndrome
due to prolonged use of alpha adrenergic agonists. In these situations, we can
use mechanical methods of pupil dilation. Eckardt was the first to describe the
use of iris sutures for temporal dilation during vitreous surgery.3 Currently,
the most widely employed method to achieve mechanical mydriasis is the use
of iris hooks. Four of these hooks are placed through the limbus, although,
if needed, more than four may be used (Figs 7A and B). We place these
hooks at 12–6 o’clock and 3–9 o’clock positions after having introduced a
cohesive viscoelastic in the anterior chamber. If the eye is phakic, we perform
a paracentesis from the perilimbal sclera to the anterior chamber or load a 25
gauge needle with the hook and introduce it at the level of the limbus. As the
needle is withdrawn, the hook stays in the anterior chamber and can then be
hooked in the pupil (Domínguez method). When the hooks are well positioned,
we can achieve wide, stable mydriasis. However, it is possible that the sphincter
may be ruptured causing paralytic mydriasis after surgery.
A B
Figures 7A and B (A) De Juan hooks from Grieshaber used for mechanical dilation
of the pupil. These hooks are easy to place and remove; (B) De Juan hook placed 1
mm behind the limbus
128
Another possible scenario is intraoperative pupil block. Generally this is
caused by an abrupt drop in intraocular pressure (IOP) but may also be due to
small intraoperative iris traumatism or to an insufficient preoperative mydriasis.
If pupil block occurs, an epinephrine solution of 1:10,000 can be injected in
the anterior chamber.
PHACOEMULSIFICATION
Today, combined cataract-vitrectomy surgery is evermore frequent, given the
high prevalence of retinal disease in patients with established cataract. With
the exception of the indications for lensectomy already mentioned, the cataract
is approached via the anterior. We use the usual technique for extracting a
cataract by the temporal route through a 2.2–2.75 mm clear corneal incision. It
is important to remember that ocular tone will vary after phacoemulsification
so that if we are going to be using a scleral buckle this should be done before
starting cataract surgery to avoid the lack of tone being a source of error and
hinder its placement. For the same reason, the infusion port should be set up
before phacoemulsification and kept closed until the end of the procedure.
Below we describe the technique used for phacoemulsification:
Surgical Technique
Temporal clear corneal 2.2 mm or 2.75 mm incision
Anterior chamber filled with a mixture of chondroitin sulfate and hyaluronic
acid while expelling the aqueous humor
Paracentesis 90° to the incision
Capsulorhexis undertaken with a cystotome using both hands: one to fix
the eye, always looking for the reflection of the fundus and the other hand
to handle the cystotome
Nucleus hydrodissected and delaminated with BSS
Nucleus fractured using two hooks in a bimanual maneuver: one hook is
used to grasp the nucleus and the other one to fracture it. This maneuver
shortens surgery, helps remove fragments and reduces the ultrasound energy
required
Emulsification, optimizing fluid flow to decrease the amount of ultrasound.
Many grade II–III cataracts can be aspirated directly after manual fracture
Surgery should be as rapid and less aggressive as possible to minimize
trauma to the cornea. The cortex is aspirated leaving the capsule clean for
subsequent vitreous surgery
Once the surgery is over, the anterior chamber is filled with a viscoelastic
trying to avoid the entry of bubbles. If this occurs the viscoelastic has to
be removed
A cross stitch is made to avoid leakage from the chamber during vitreous
surgery or indentation.
129
Placement of the intraocular lens (IOL) should be left to the end of surgery,
since pseudophakia permits good visualization of the posterior pole and
periphery. The only drawback is that the capsule is difficult to identify during
vitrectomy and could be accidentally ruptured with the vitreotome. If this
happens, the viscoelastic escapes to the vitreous chamber creating waves in
the field of view. This situation normalizes quickly. After the vitreous surgery
procedure, the IOL will have to be placed in the sulcus with the lens optics
retained by the capsulorhexis.
During lens implantation, we should try to avoid high pressure in the
vitreous chamber by closing the infusion port. If there is insufficient tone to
introduce the injector, the lens cartridge is placed at the incision and the infusion
port is opened momentarily while we introduce the cartridge and is then quickly
closed after this operation.
Special Cases
Vitreous Hemorrhage
In these cases there is insufficient visibility for efficient phacoemulsification.
In some cases, the eye can be moved with forceps to seek out sufficient
backlighting to undertake the capsulorhexis. However, if this is not possible, we
can use trypan blue to stain the anterior capsule and perform the capsulorhexis,
and a light probe can be introduced through one of the sclerotomies to provide
us with sufficient light to remove the cortex. Placement of a Chandelier light
probe via a fourth port before the start of phacoemulsification will enable all
these steps to be carried out. By turning the microscope light off and using
backlighting, we can satisfactorily complete the technique.4,5
REMOVING THE VITREOUS HUMOR: BASIC CONCEPTS

The instruments are held with the thumb and index finger of both hands to
adequately stabilize them for movements in an anteroposterior and lateral
direction. Hand movements always need to be in synchrony with movements
induced by manipulations of the globe and the microscope’s position and its
adequate focusing.
First, the light probe (switched on) is inserted perpendicularly to the scleral
wall and slowly, with oscillating motions, is pushed toward the center of the
eye. The vitrectomy probe is also introduced until we can see both instruments
through the microscope. Before any cutting, the infusion tube should be open
and the eye should have the appropriate tone otherwise the eye could collapse
and the traction generated could produce tears (Fig. 8).
The main objective of vitrectomy is to extract the vitreous and the main
objective of the surgeon is to do this in the safest way possible. One of the
main risks encountered during vitrectomy is the generation of traction on the
130
Figure 8 Endoillumination probe and vitreotome in position ready to initiate a

core vitrectomy to treat a vitreous hemorrhage
retina, which could later lead to tears or detachments. The principle solution to
traction we have is the cutting function, and the greatest generator of traction
is the probe’s aspiration function. However, the vitreous cannot be eliminated
without its aspiration so we need to be capable of handling our tools with
the necessary dexterity. To do this, we should avoid the zones of greatest
vitreoretinal adherence by placing the probe in the most central zone of the
vitreous and then start to work at high cutting frequencies while approaching
the vitreous we want to cut; because if we wait for the vitreous to come to the
probe tip, this will generate more pull. As we make circular movements of
increasing diameter cutting and aspirating the central vitreous, we will slowly
move toward the equator and periphery. As we seek to cut the vitreous, it is
essential that the light pipe is well positioned, as perpendicular as possible
to the vitreous for its optimal visualization. As we approach the periphery,
the vacuum pressure should be reduced at the expense of slowing down the
procedure. The position of the posterior hyaloid varies in each patient. In some
individuals, it is detached while in others it is completely adhered to the retina.
Once the central and peripheral vitrectomy has been completed, we pass the
functioning vitreotome probe over the posterior retinal surface; the observation
of waves on the surface is a definitive sign of an attached posterior hyaloid.
Injected triamcinolone is of great help in identifying the hyaloid since it gets
deposited on the hyaloid. Several ways of removing the posterior hyaloid have
been described,6,7 but perhaps the simplest is the use of an active aspiration
system with a cannula whose distal end consists of a silicone tube to avoid
trapping or damaging the retina (Fig. 9).
With a linear vacuum of 400 mm Hg we position the probe close to the
optic disk. Suction is slowly started. If the silicone tip bends when occluded,
this is known as the fish strike sign. Once the hyaloid has been hooked, we
look for the wave sign. To do this, we increase the suction power and slowly
lift the probe, watching how the hyaloid detaches as the pull produces a wave
on the retinal surface. It is not always possible to observe this wave, especially
in myopic patients (Fig. 10).
Whenever we perform this maneuver, we should revise the retinal periphery
perhaps even with the help of indentation, since as we lift the hyaloid, it is
possible to provoke tears in the retina which will need to be treated.
131
Figure 9 Silicone-tipped cannula used to remove the hyaloid connected to the

active aspiration system in an “extrude” mode
Figure 10 Fish strike sign observed while removing the posterior hyaloid: the
silicone tip arches as it hooks the hyaloid. After this maneuver, the hyaloid is
eliminated up to the periphery using the vitreotome
ASPIRATION SYSTEMS
We cannot overstress the importance of good control of suction power in
vitrectomy. In summary, aspiration can be conducted in two different ways:
in an active manner through the use of pumps incorporated in the vitrectomy
machine and in a passive manner, using the pressure difference between the
inside and outside of the eye. Both systems have their given uses and should
be adequately dominated by the surgeon.
Active Aspiration
This is achieved through the vitrectomy probe to extract the central and
peripheral vitreous by combining the vacuum power with the cutting rate to
obtain greater or lesser suction as described above.
Alcon’s Accurus and Constellation systems have a mode for active aspiration
with no cutting, denoted as momentary vitrectomy. In this mode, the vitreotome
132
aspirates until the level indicated to trap, at the vitreotome mouth, solid or high
density structures such as blood clots or remnants of crystalline lens, iris or
proliferative membranes. Other vitrectomy platforms like Stellaris PC could also
offer this kind of parameters to the surgeon. Once engaged, we can introduce
the cutting function for their fragmentation and aspiration (Fig. 11).
We also have available active aspiration systems that are independent of
the vitrectomy probe, such as the silicone tip (extrusion), which allows us to
approach the retina in a safer way and even gently touch its surface without
damaging it. This device is especially useful when inducing detachment of the
posterior vitreous during surgery or to aspirate blood or subretinal fluid and
for fluid/gas exchange.
In cases of uveitis or intraocular infections, samples of vitreous humor may
need to be obtained for diagnostic purposes. For this we usually use the active
aspiration pump, connecting the probe to a final collector from which we can
then obtain the sample (Fig. 12).
Passive Aspiration
This is achieved through a cannula connected to a flute-like handle with an
inner conduct and side opening. With this side opening closed (by the surgeon’s
finger) the pressure gradient toward the exterior of the eye is maximal and this
promotes the exit of liquid or blood, provided its density is sufficiently low to
permit good flow toward the exterior. The aspiration speed can be increased
or lowered as the IOP changes (Figs 13A and B). Currently, these passive
aspiration systems include a reflux mechanism via the compression of a soft
tube in the handle. These are known as backflush systems.
PEELING MEMBRANES IN VITRECTOMY

One of the retinal disorders the posterior pole surgeon is most often faced with
is the appearance of macular epiretinal membranes. In their most advanced
form, these membranes produce radial folds in the macular area causing a loss
Figure 11 Active aspiration generated by the vitreotome pump. Note the vitrectomy
probe lifting a blood clot, which can be completely removed by activating the
vitreotome’s cutting function
133
Figure 12 Sample collection by active aspiration. Using a syringe connected to

the vitreotome’s aspiration line, the required volume of vitreous is obtained and the
aspiration line then reconnected
A B
Figures 13A and B Passive aspiration is produced by the difference in intra-and

extraocular pressure. (A) The intensity of aspiration will depend on this difference
in pressure—the greater the intraocular pressure, the greater the aspiration power;
(B) Aspiration cannula capable of manual backflush
of visual acuity and metamorphopsias. These membranes can be removed by

their dissection using specially designed forceps following their prior staining.
For this purpose, we prefer a dye such as trypan blue under physiological
saline and using a magnifying contact lens to visualize the macula in detail,
we directly dissect with the forceps searching out the most intensely stained
zone of most prominent folding, from which we create an initial flap of tissue
to initiate the peeling process. The maneuver should be conducted with utmost
care since the risk of iatrogenic trauma to the macula is high. The light probe
should be correctly positioned to avoid reflections from the forceps handle,
avoid phototoxicity and also achieve adequate illumination of the zone. We
recommend keeping the endolight at an equatorial point of the globe and
avoiding its movement during peeling. Once the first flap has been created,
we continue tractioning from the margin furthest away from the fovea in a
circular motion with respect to the surgeon and tangential to each point of the
retina. The idea is to obtain an ever-larger flap as the peeling process ensues,
134
but unfortunately this is not always possible and the initial flap tears. In this
case, we start the procedure again not necessarily at the same point although
it is true that the contrast between the already peeled and still adhered stained
tissue really helps construct a new flap. We should always try to leave for the
end the peeling of the perifoveal area, since excessive traction on adhered tissue
at the fovea could lead to the formation of a hole over the fovea. It is therefore
recommended that peeling is achieved from the most external and furthest away
part of the flap with respect to the fovea. Once peeling has been done over 360°
around the fovea, we can then proceed with the definitive separation of the
membranes by means of a gentle anteroposterior movement (Figs 14A to C).
For scarcely stained and discrete membranes, an option is to create the initial
flap using a more or less sharp dissector known as a pick, which facilitates the
initial dissection of the membrane. If we do not have such an instrument, we
can use a 20/23-gauge needle and bend over its tip with a needle holder some
90–100° under the microscope.
Sometimes the membranes we are faced with are the consequences of other
serious diseases of the eye such as detached retina or proliferative diabetic
retinopathy (PDR). In these cases, epiretinal membranes have greater traction
capacity and they use the posterior hyaloid as a support to extend from one
point to another of the retina, creating bridges that cause traction and can detach
the retina. The strong anchoring of such membranes and the poor state of the
retina makes their peeling especially risky. It is easy to cause iatrogenic tears
and consequently we should undertake a bimanual procedure of segmentation
and delamination to remove them. In some cases, we recommend the use of
liquid perfluorocarbon to stabilize the retina and aid these maneuvers (Figs
15A and B).
Segmenting Membranes
Parallel arm scissors (manually or pneumatically controlled) are used to cut
the bridges of proliferation tissue and fragment these membranes into separate
islets, and thus minimize traction on adhesion zones. The lower blade of the
scissors can be used as a pick to identify the adequate plane and also to lift the
A B C
Figures 14A to C (A) Macular pucker generating traction on the macula; (B) Starting
the dissecting procedure on the clear separation border; (C) Tangential movements
used to remove the membrane
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A B
Figures 15A and B (A) Dissecting the membrane under perfluorocarbon. Note
the traction folds; (B) Freeing the macula, observing the separation and freeing of
the membrane
tissue for its dissection prior to cutting.8-10 It is common that the edges of the
epiretinal tissue widely separate after they are cut indicating that the membrane
was generating considerable traction (Figs 16A and B). Membranes can also
be segmented using curved scissors, by passing one of the blades under the
membrane, producing slight traction upward and then sectioning.
The design of current vitreotomes with the mouth so close to the tip permits
a safe approach to the retina, and in many cases, the rapid and safe segmentation
of the membranes.
Delaminating Membranes
This consists of dissection with horizontal scissors, cutting the fixation points
between the proliferation and the retina without first dividing epicenters of
traction. This technique allows a more complete elimination of proliferative
tissue (Figs 17A and B). Curved or right angled scissors may be introduced in the
junction epicenters, slightly raising the scissors before cutting to avoid damage
to the retina and its vessels. Delamination is generally performed bimanually.
Forceps are used to lift the tissue, and with the other hand, the scissors used to
A B
Figures 16A and B (A and B) Segmenting membranes. With the help of vertical
scissors, the junction bridges that are raised slightly above the retinal tissue are cut
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A B
Figures 17A and B (A and B) Bimanual membrane delamination procedure: lifting

the proliferative tissue with one hand, and using the other hand to cut the junctions
with horizontal scissors
cut the junction sites are held. A light source independent of the instruments is
needed, such as a light fitted to the infusion cannula, or light can be provided
by one of the instruments. Instruments with a light source have the drawback
that they create shadows. We use the Chandelier light through the fourth port.
The membrane manipulator has also been used for this procedure, which has
endoillumination, aspiration to retain the membrane and diathermy in case of
bleeding. The noncontact visualization system optical fiber free intravitreal
surgery system provides endo-ocular illumination through the microscope such
that bimanual delamination can be performed without lit instruments. In most
cases of PDR, segmentation and delamination are combined.11-13
Staining Membranes
The good visualization of epiretinal membranes and their discrimination from
the adjacent or underlying retina is a decisive factor for their adequate removal.
To aid this tissue discrimination, several dyes exist which we have described
in detail below:
Indocyanine Green
It is widely used in the photography and textile industries; cyanines share the
features that they are organic dyes of great staining capacity for all types of
tissue. Indocyanine green (ICG), approved in the late 1950s by the Food and
Drug Administration (FDA) for its medical diagnostic use, is an anionic dye
of molecular weight 775 Da used in vitrectomy to stain the internal limiting
membrane (ILM) despite not having been explicitly indicated for surgical
use14,15 (Figs 18A to C). The mechanism whereby ICG stains the ILM is
unclear, but most authors propose that it has something to do with collagen
IV, fibronectin and the laminin present in the extracellular matrix comprising
the ILM. One of the arguments in favor of its use as a stain is that it greatly
facilitates membrane peeling. This was confirmed in an experimental model in
the pig, in which ICG staining and subsequent exposure to light increased the
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A B C
Figures 18A to C (A) Epiretinal membrane of difficult visualization; (B) Staining

with indocyanine green perfectly outlines the edges of the membrane facilitating
its removal; (C) Rapidly removing the membrane with forceps
stiffness of the ILM.16 Thus, numerous authors have defended and continue to
advocate the use of ICG as a safe, nonexpensive dye for peeling.17,18 Various
preparations exist in the market: 5, 25 or 50 mg vials such as Indocianina Verde
(Ophthalmos), ICG-Pulsion (Pulsion Medical Systems), among others. The
powder is reconstituted first with distilled water and then with physiological
saline to obtain a solution containing 0.05–0.5% of ICG.
Notwithstanding, the use of ICG has been questioned as a consequence
of studies indicating toxic changes produced in the pigment epithelium after
30 seconds of contact with ICG. Visual field defects and optic nerve atrophy
have also been described with serious consequences on the patient’s visual
prognosis.19-24 Currently, this stain is still used by many posterior pole surgeons.
In effect, we used it over a few years diluted in glucose at concentrations of
0.05%25,26 but currently we avoid its use.
As an alternative, some authors have assessed the use of the dye infracyanine
green. Results so far indicate that this stain is somewhat less toxic for ganglion
and pigment epithelium cells.27
Trypan Blue
This is a synthetic azo dye containing nitrogen in its formula, of molecular
weight 960 Da and stains the tissues intense blue. Trypan blue is routinely
used to examine the endothelial layer of the donor button before a cornea
transplant and has been used in cataract surgery to stain the anterior capsule
of the crystalline lens.28 In vitrectomy it is used due to its special affinity for
epiretinal membranes and membranes in proliferative vitreoretinopathy (PVR)
because of their high contents in glial cells. Despite not being recommended to
stain the ILM, in a comparative study with ICG used to peel the ILM in cases
of macular hole, it was shown that the percentage of anatomic closure achieved
was similar but that the visual outcome was significantly better in the eyes
stained with trypan blue.29 Two commercial preparations exist: (1) Membrane
Blue [Dutch Ophthalmic Research Center (DORC) International] at a 0.15%
concentration and (2) Vision Blue (DORC International) at a concentration
of 0.06%. For vitreous surgery, we use the higher concentration preparation
138
since, once injected in the vitreous chamber, the dye becomes diluted with
the irrigation saline. In contrast, for cataract surgery, a low concentration is
sufficient to stain the anterior capsule. The product is supplied in a vial in
physiological saline with an osmolarity of 257–314 mOsm/kg and pH 7.3–7.6.
Its combination with glucosated saline at 5% or 10% increases its density and
improves its penetration when the vitreous chamber is filled with infusion
saline. However, the osmolarity of this combination is greater such that it may
be toxic if used at higher concentrations. Most studies examining the possible
retinal toxicity of trypan blue have concluded that there is no evidence for such
toxicity, although one report exists of a case of possible pigmentary epithelium
toxicity in which the dye migrated to the subretinal space.30
We use trypan blue to stain epiretinal membranes and in some cases to
stain the ILM. We found, it stains epiretinal membranes and PVR membranes
facilitating their removal (Figs 19A and B).
Brilliant Blue
It is an anionic dye with a molecular weight of 854 Da. Also known as acid blue
or Coomassie blue, it has been used in the textile, paint and food industries.
Since its approval in 2007 for marketing in Europe, its use has been described
to stain the ILM as an alternative to ICG with no descriptions of any toxic effect
on the retina.31 Marketed as Brilliant Peel (Fluoron, Geuder, Germany) as an
iso-osmolar solution of concentration 0.25 mg/ml, it is the stain of choice for
many surgeons including the authors. It is a useful tool for visualizing the ILM
with high biocompatibility. It is recommended that the eye should be filled with
air and then the air and dye removed after use. However, if we dilute brilliant
blue in heavy water or glucose solution at 5%, it will be heavier than water and
will not need to be exchanged by air prior to its introduction.32
Dye Combinations
A combination of trypan blue and brilliant blue (trypan blue 0.15%, brilliant
blue G 0.025%) in an aqueous solution, heavier than saline (4% PEG), has
recently appeared in the market and this product can be used to stain epiretinal
A B
Figures 19A and B (A) Epiretinal membrane; (B) Trypan blue staining
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membranes and the ILM. We find it extremely efficient and easy to deposit on
the retinal surface en bloc without dispersion. It stains the tissues well and is
easy to remove. This combination is a good option especially for surgeons still
at an early stage in the learning curve.
Refrigerated Dyes
A way of improving contact between the dye and the retina is to store the
dyes refrigerated at 4ºC and using them directly from the fridge. Because
of their density, cold liquids sink to the bottom when injected, facilitating
contact between the dye and epiretinal tissue. Before injection, we close the
infusion line to avoid turbulence and slowly introduce the dye. In addition,
the hypothermal effect, albeit limited, protects the retina from the possible
toxicity of the dye.33,34
Triamcinolone Acetonide
It is a synthetic powerful corticosteroid, which is insoluble in water and has
a molecular weight of 434 Da. Triamcinolone acetonide was used for the first
time by Kimura et al35,36 to peel the ILM, who argued that the deposition of its
crystals on the ILM helped them identify and peel the membrane. No adverse
effects were recorded in the postoperative course. Currently, it is mostly used to
improve the visualization of the posterior hyaloid membrane during vitrectomy,
especially in cases in which the joining or incomplete separation of the posterior
hyaloid can be a source of traction (e.g. in macular hole, vitreomacular
traction syndrome, proliferative and fibrovascular vitreoretinopathy, diabetic
retinopathy). Several preparations of triamcinolone acetonide exist such as
Triesence (Alcon Labs, Fort Worth, TX, 40 mg/ml), Kenalog (Bristol-Myers-
Squibb, Peapack, NJ, 40 mg/ml), Trivaris (Allergan, Irvine, CA, 80 mg/ml) or
Trigon Depot (Squibbs, 40 mg/ml).
Several adverse effects have been related to the use of intravitreal
triamcinolone especially when used to treat diabetic macular edema, such as
glaucoma, cataract and aseptic endophthalmitis. Studies also exist that have
shown that its intravitreal injection is not toxic for retinal cells.37 However,
the alcoholic component of the solvent has indeed been described as toxic.
Accordingly, several methods have been devised to avoid introducing the
solvent in the vitreous including decanting, leaving the ampoule for 24 hours
in a vertical position and centrifuging for 3 minutes at 3,000 rpm. Once the
solid has been separated from the liquid, the latter is replaced with BSS.
Thus, if we dilute the solid in 1 ml of BSS, by injecting 0.1 ml we will be
introducing 4 mg of triamcinolone; if we dilute it in 0.5 ml of BSS, 0.1 ml
will contain 8 mg.
We undertake double washing of the solvent using a three-way stopcock
and a 5 µm Millipore filter (triamcinolone molecules will not pass through the
filter) taking the following steps:
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The filter is positioned
The triamcinolone is filtered by pushing the solution through the filter to
eliminate the solvent and retain the solid in the filter
The solid is reconstituted in 2 ml BSS
Washing is repeated
The liquid is replaced with 1 ml BSS, so that 0.1 ml will give us 4 mg of
triamcinolone.
After double washing the triamcinolone, we inject several drops through
a sclerotomy and observe that the vitreous becomes impregnated with the
corticosteroid facilitating the dissection of the posterior hyaloid. If we wish
to remove the ILM, we introduce a little more triamcinolone watching how it
impregnates the retinal surface. We should take care not to introduce too much
triamcinolone, since an excess of the corticosteroid will make the thickness
and plane of the membrane less obvious during peeling (Figs 20A and B).
A useful strategy to avoid flooding the field with particles is to pump the
triamcinolone through a silicone cannula connected to a silicone lengthener.
As the silicone is pressured, the particles are slowly scattered on the tissue
surfaces sufficiently to trace the membrane.
PERFLUOROCARBON LIQUIDS
Curiously, the use of perfluorocarbon liquids (PFCL) was investigated
in medicine as a substitute for human blood due to their high capacity to
transport oxygen and good biocompatibility. In ophthalmology, their use
as vitreous substitutes was first assessed in experimental animals in which
inferior detachment of the retina was induced. Chang et al38 were the first to
use PFCL on the human retina in retinal detachment surgery. Perfluorocarbon
liquids are colorless, odorless, immiscible in water and have a high density
and low viscosity. These properties make them ideal to help the surgeon
handle and stabilize the detached retina, as they induce the exit of subretinal
fluid through peripheral tears. Their low surface tension makes PFCL arrange
A B
Figures 20A and B (A and B) Removing the posterior hyaloid with forceps and
the vitrectomy probe. Note the membrane is impregnated with particles
141
themselves as a single large bubble, thus reducing the risk of migration to the
subretinal space. Moreover, their low viscosity makes their aspiration very
simple facilitating fluid-, oil- or air-exchange. Several perfluorocarbons have
been assessed for their use in vitrectomy. Thus, perfluoro-n-octane has been
approved by the FDA for intraocular use owing to its high stability and purity
compared to other compounds. The most common indications for the use of
PFCL in vitrectomy are the treatment of complex detachments, PVR and giant
tears. Further indications are detailed in Box 2.
The use of a PFCL requires a prior three-port pars plana core and peripheral
vitrectomy. It should first be checked whether the posterior hyaloid is detached
and if not, we should lift it with a silicone-tipped vitrectomy probe using active
aspiration. A wide-field-viewing system has to be used for constant control of
the surgical maneuvers.
Uses of Perfluorocarbon Liquids

Giant Retinal Tear
Surgery for a giant retinal tear has been substantially simplified and nowadays
the retina is unrolled and reattached with the patient in a decubitus supine
position in a single maneuver. The successful reattachment rate can be up
to 90%. In addition, membranes can be removed, the edge of the tear can be
treated with endolaser, and surgery can be completed with exchange for air
and subsequently for gas or silicone oil. Once the retina is reattached, we can
also perform direct perfluorocarbon-silicone oil exchange to avoid the retina
becoming subsequently displaced.
Vitreoretinal Proliferation
In cases of vitreoretinal proliferation the use of PFCL has improved anatomic
and visual outcomes with a success rate between 84% and 96%. The duration
of surgery is shortened and as the retina is stabilized, membranes can be easily
dissected. As the PFCL is injected, the retina contracted by the membranes
opens up facilitating their exposure and visualization. Initially a small amount
Box 2: Indications for the use of perfluorocarbon liquids

• Retinal detachment with giant tear
• Retinal detachment with vitreoretinal proliferation
• Retinal detachment in proliferative diabetic retinopathy
• Refloating a luxated crystalline lens
• Refloating a luxated intraocular lens
• Membrane dissection
• Bleeding control during vitrectomy
• Any complex retinal detachment
• Choroid hemorrhage
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is introduced but as we start to remove the membranes and the retina starts to
reattach, the volume of PFCL is increased. When the level of the bubble reaches
the height of the scleral band, this also helps identify anterior proliferative
membranes. Once we have completed the dissection of membranes if the retina
is still rigid and will not reattach due to residual tractions, and if these cannot
be eliminated, the level of the bubble is lowered and a relief retinotomy is
performed until we observe the retina has adequately reattached. At this point
in time, we go beyond the level of the retinotomy and seal the retina using the
laser. The procedure is then completed by exchanging the PFCL, first for air
and then for gas or silicone oil.
Luxated Natural or Intraocular Lenses

In cases of a luxated lens, the use of perfluorocarbon is mandatory. If the retina
is detached, this will allow for its reattachment and refloating the lens to the
anterior chamber to adequately handle it. If the crystalline lens is luxated,
PFCL protects the macula from possible damage during its fragmentation in
the vitreous chamber. If very hard, the natural lens can also be refloated to the
anterior chamber for its anterior removal.
Further Uses
Perfluorocarbon liquids can also be used in proliferative retinopathy with
rhegmatogenous retinal detachment, bleeding control during vitrectomy,
evacuating choroid hemorrhagic detachments or the management of traumatic
injuries.
Intraoperative Management of Perfluorocarbon Liquids

Injection of PFCL under Physiological Saline
To inject the PFCL, we prefer to use a silicone tipped cannula connected to
the PFCL syringe. It is best to first lower the IOP by adjusting the infusion
rate to avoid IOP peaks with the risk of occluding the central retinal artery
and also reducing the risk that infusion fluid turbulence prevents the cohesion
of the PFCL into a single large bubble. When working through 20 gauges we
usually use the Chang cannula to extract the intraocular fluid as we slowly
introduce the PFCL (Fig. 21). As mentioned earlier, the high density of PFCL
determines that it attaches the detached retina while displacing the subretinal
fluid toward tear zones achieving its drainage. It is important to be aware of
the possibility that the perfluorocarbon bubble surpasses the tear zone without
all the subretinal liquid having emerged, leaving an anterior ridge of fluid that
cannot leave because the tear is tamponaded by the PFCL (Figs 22A and B).
If we do not avoid this raised ridge as we replace the subretinal fluid with
air it will again move toward the posterior pole. To avoid this situation, we
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Figure 21 Chang cannula with a double lumen allowing the simultaneous
injection of perfluorocarbon and the exit of physiological saline
A B
Figures 22A and B (A) Injecting a perfluorocarbon liquid in a case of retinal

detachment.The perfluorocarbon liquid bubble weighs more than physiological saline
and displaces the subretinal fluid, which in turn, emerges from the retinal tear and
reattaches the retina. As we introduce the perfluorocarbon liquid through a Chang
cannula, the saline emerges from the globe such that the exchange maneuver does
not provoke an increase in intraocular pressure; (B) Retinal detachment anterior ridge
produced as the perfluorocarbon liquid displaces the subretinal fluid upward. If this
occurs, the fluid can be subsequently displaced by perfluorocarbon liquid-air exchange
can position the perfluorocarbon bubble close to the tear zone and exchange
saline for air, which in this case will displace the fluid anteriorly toward the
tear as an upward-downward force, draining and flattening the more anterior
retina (Figs 23A and B). Once the retina is reattached, we can proceed with
endophotocoagulation, IOL implantation, cryotherapy, scleral buckle placement
or buckle readjustment.
Perfluorocarbon Liquids Removal and Air Introduction

This is a crucial step during surgery for a detached retina. Before injecting
the air, it is important to achieve good subretinal fluid drainage avoiding
that the PFCL bubble surpasses the retinal tears. The next step has a dual
function: first it strives to remove the saline on top of the PFCL to avoid
it repenetrating the tears and second it seeks to drain out any possible
subretinal fluid that exists in the more anterior retina. Before initiating the
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A B
Figures 23A and B (A) Using perfluorocarbon liquid, a retina with donuts of
subretinal fluid is reattached as the fluid is displaced anteriorly; (B) This situation can
be avoided by performing a double exchange with perfluorocarbon liquid up to the
level of the tear and air in the anterior zone which will displace the subretinal fluid
forcing its exit through the tear and completely reattaching the retina
exchange procedure, an aspiration probe should be placed at the tear opening

(preferably with a silicone tip so as not to jab the retina) to avoid saline
entering the subretinal space during the exchange maneuver. Aspiration is
started as close to the tear as possible simultaneous to the introduction of air.
As the air rises, it will move toward the most anterior zone of the vitreous
chamber. This will greatly impair our visualization due to the presence of
three substances of varying refractive index (posterior to anterior, PFCL-
saline-air) (Fig. 24). We should keep calm and not move the aspiration
cannula. As we continue to inject air and aspirate saline, the refractive
interface will be gradually lost and we will start to see even more clearly.
Gradually, the new PFCL-air interface will be appreciable. We should not
be in a hurry to remove the aspiration tube from the mouth of the tear, since
small amounts of fluid may remain, pushed by the air from the anterior
subretinal space (Figs 25 A and B). Once the anterior retina has been
reattached and the saline has been completely eliminated, the aspiration
cannula can be placed beneath the PFCL pointing toward the optic disk
for its removal, leaving the vitreous cavity filled with air. Despite having
carefully followed each step, it is still possible that a small amount of saline
escapes through the tear during the exchange process and is subsequently
displaced as the air bubble retreats. If the amount of saline is small, by
the next day it will have been reabsorbed by the pigmentary epithelium.
However, if a large volume of saline seeps behind the tear, the retina will
be redetached and the exchange maneuver will have to be repeated, filling
the vitreous cavity again with perfluorocarbon.
145
Figure 24 Removing perfluorocarbon (blue arrow) and introducing air (green
arrow). As the perfluorocarbon is extracted, air is introduced by the infusion pump
A B
Figures 25A and B (A) Extrusion system positioned at the level of the tear to
aspirate the meniscus between the air and perfluorocarbon liquid to avoid it seeping
through the tear; (B) Diagram showing this maneuver at the stage when the bubble
of air surpasses the tear. The aspiration probe is positioned in the center of the eye
on the perfluorocarbon liquid bubble until its complete removal
Perfluorocarbon Liquids Removal without Air Introduction

In situations in which the retina is attached, such as in cases of a luxated natural
or artificial lens, the vitreous cavity contains saline in the upper zone while
the perfluorocarbon occupies the lower area. The aspiration cannula should be
positioned over the optic disk and it should be made sure that this is the eye’s
lowest point. Then once we have removed the perfluorocarbon, we should allow
a few drops of saline to fall on the retinal surface, to wash away any remnants
adhered to the retina and then reaspirate the retinal surface.
146
Direct Exchange for Silicone Oil
The direct exchange of perfluorocarbon for silicone oil can be performed in
cases of giant retinal tear with a tendency for displacement of the retina when
we exchange for air. In this case, the silicone oil is introduced via the infusion
cannula helped by the fluid injection pump. As it is injected, the perfluorocarbon
is aspirated with an extrusion cannula until the cavity is completely filled with
silicone oil.
Potential Problems during the Use of Perfluorocarbon

Although PFCLs are stable and safe compounds, their use is not exempted
of certain possible complications. First, a PFCL cannot be left for long in the
vitreous cavity since it has a toxic effect on the retina and may also break up
into small bubbles that affect optical transparency. However, cases have been
described in which a few drops of PFCL remained in the vitreous cavity with
no adverse effects noted. Another possible complication in aphakic patients
is the alteration of the corneal endothelium as it contacts the PFCL. This may
be avoided by the placement of a dispersive viscoelastic over the bubble to
protect the corneal endothelium. In patients with a crystalline lens, interaction
of the lens with air could result in a small layer of saline becoming trapped
between the air and the crystalline lens, hindering visualization during the
extraction maneuver. To improve vision, a biconcave contact lens can be
added to the wide-field noncontact viewing system. With these measures,
visualization can be improved to complete the exchange process in complex
cases.
FLUID-AIR EXCHANGE
The exchange of fluid for air has the objective of filling the eye cavity with
air for purposes such as the adequate tamponade of a sutureless sclerotomy,
avoiding ocular hypotony in the postoperative course or for the subsequent
injection of a gas or silicone oil. The maneuver is performed with an active
or passive aspiration cannula at the upper level of the eye. Air is introduced
through the infusion port with the help of the infusion pump 39,40 of the
vitreotome set at a pressure of 25–35 mm Hg. We then watch the upper portion
of the vitreous chamber filling with air, position the aspiration cannula at the
liquid-air interface and start aspirating at a vacuum between 100–150 mm Hg
until we reach the area above the disk where we will see that, as we aspirate
all the liquid, a different intense reflection or shine appears on the retina (Figs
26A to D).
After a complete exchange, fluid will again accumulate at the posterior
pole and on the retina and optic disk. This is due to the gradual drainage of
the peripheral vitreous and the constant production of aqueous humor. After
waiting a few minutes, we can aspirate this residual liquid.
147
A B
C D
Figures 26A to D (A) Perfluorocarbon-air exchange. Using the extrusion system, we

aspirate the perfluorocarbon at the same time as we introduce the air; (B) Appearance
of the interface as we touch the bubble surface; (C) Aspiration is continued until
beyond the level of the optic disk; (D) Reflection of the air on the retina. Aspirating
remaining fluid
Air offers certain benefits when managing an intraocular hemorrhage since

it displaces blood toward the posterior retina and facilitates its visualization
as it avoids its dilution with the saline such that it can then be more easily
aspirated.41
If we are dealing with a detached retina with a tear that is so posterior that
PFCL would be ineffective at achieving drainage of the subretinal fluid, we
can use air simultaneously to aspirate fluid from the mouth of the tear with a
silicone-tipped cannula.
Air remains in the vitreous chamber for 5–7 days and is therefore not
adequate for good tamponade of tears until chorioretinal adhesion occurs.
However, air can be useful for localized primary retinal detachments without
vitreoretinal proliferations, especially superior detachments, and is also useful
for treating small tears observed while revising the periphery.
USE OF GAS IN VITRECTOMY

Two types of gases exist: (1) nonexpanding gas and (2) expanding gas.
Nonexpanding Gas
With a nonexpanding gas, the size of the bubble does not increase after its
injection. The most widely used gas of this type is atmospheric air. Xenon is
another example although it is currently in disuse.
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Expanding Gas
When the gas used is an expanding gas, the size of the bubble increases during
the hours after its injection due to the interchange and/or incorporation of other
gases dissolved in blood. The most widely used expanding gases are sulfur
hexafluoride (SF6) and perfluoropropane (C3F8). Both are odorless and colorless,
inflammable and nontoxic. Sulfur hexafluoride, is five times heavier than air
while C3F8 is six times heavier.
All gases show inert intraocular behavior, avoiding the accumulation of
proinflammatory factors, growth factors, etc. and their deposition on the retina
thus prevents the development of proliferative membranes. The force exerted
by the gas on the retina flattens it and seals tears, avoiding the passage of saline
and its consequent redetachment. The floatability of the gas contributes to this
action since its specific weight is less than that of water. This property can be
used to promote contact between the gas and retinal tear, solely by modifying
the position of the patient’s head.
Clinical Indications of Gases

Gases are used to achieve adequate tamponade of filtering tears and/or holes
over sufficient time for new chorioretinal adhesion bridges to form (promoted
by laser impacts) around these tears. This determines that the choice of gas is
made according to the condition being treated and the tamponade time deemed
necessary. Our general indications are as follows:
Primary superior tears with retinal detachment (RD) without proliferation
can be treated with air or SF6 20%
Inferior tears with RD can be treated with SF6 20%
Complex RD with PVR A, B, C1–2 (Retina Society) can be treated with
SF6 20%
Complex RD with PVR C3, D (Retina Society) or giant tears can be treated
with C3F8 10–15%
For macular hole it is usually sufficient to use SF6. For recent or small holes,
air could be sufficient.
Air-Gas Exchange
This is done at the end of surgery when we are about to close the last
sclerotomy, which is left presutured. To do this, we use a 60 ml syringe and
for a 20% mixture we add 12 ml of pure gas and make up the rest with air
to give a nonexpansive mixture. It is important to know that gas aspiration
should be conducted through two 0.22 μm Millipore filters: one connected to
the pump and the other connected to the syringe. This avoids the introduction
of contaminants in the mixture and ensures that the atmospheric air is sterilized
as it passes through the Millipore filter. The mixture should be injected as
149
quickly as possible to avoid the gas diffusing through the plastic comprising
the syringe. Using a three-way stopcock, the injection is introduced into the
infusion line.
The gas is slowly injected in the eye and the air spontaneously escapes
through one of the sclerotomies. If the sclerotomy becomes occluded with
vitreous remains, a cannula or 25-gauge syringe can be inserted through it to
facilitate the exchange. Once 30 ml of the gas mixture has been injected (about
8 times the volume of the vitreous chamber), we know that all the air has been
replaced with the air/gas mixture. We should keep a small amount of mixture
in the syringe to replace any gas lost when retrieving the infusion line, leaving
the globe with an IOP of approximately 20 mm Hg.
Postoperative Management of Patients Receiving Intraocular Gas

The safest position for the patient while the gas remains in the eye is the
decubitus prone position. This favors contact of the gas with the retina while
distancing it from the crystalline lens in phakic eyes, IOL in pseudophakic
eyes or the corneal endothelium in aphakic eyes. It also avoids pupil block.
This position should be maintained until only a small amount of gas remains
in the ocular globe. During the first 12 hours of the postoperative course, at
least two doses of oral acetazolamide should be given as prophylaxis. If pupil
block occurs, intraocular gas may be removed at the slit lamp by pars plana
insertion of a 30-gauge needle connected to a 2 ml syringe and aspiration of
approximately 0.7 ml of gas.
SILICONE OIL IN VITRECTOMY

Injection of Silicone Oil
This is generally done when the retina has been reattached and after fluid/air
exchange when the globe is full of air. The silicone is injected with the help of
the infusion pump for viscous liquids up to the level of the iris, trying to leave
the eye with a normal pressure of some 20 mm Hg. If the eye is left hypertensive,
the bubble will be displaced to the anterior chamber as the sclera recovers its
shape after being distended by the hypertension, pushing the bubble forward. A
PFCL can also be directly exchanged for silicone oil by connecting the silicone-
containing syringe to the infusion line and removing the perfluorocarbon at the
same time with another instrument, as the eye is filled with silicone. Current
vitreotomes have a system that simultaneously achieves this exchange under
control by the surgeon’s foot pedal. The advantage of this technique is that it
avoids the backward displacement of the retina that could occur in other types
of exchanges when we are dealing with large tears or detachments with giant
tears (Figs 27A and B).
150
A B
Figures 27A and B (A) Direct perfluorocarbon-silicone oil exchange. This always
generates a layer of saline that has to be aspirated (yellow arrow). To do this, the
probe is positioned at the meniscus formed at the perfluorocarbon liquid-silicone
interface; (B) Once the saline meniscus has been removed, the silicone fills the entire
eye cavity as the perfluorocarbon is removed
Emulsification of the Silicone Oil

An emulsion of oil in water is produced by a fall in the surface tension of
the bubble of oil. This decrease in surface tension is usually the result of the
deterioration of the chemical properties of the oil over time. However, other
factors such as viscoelastic agents or blood remains, fibrin or new hemorrhages,
can contribute to an early drop in surface tension. Emulsification is dangerous
because the small drops or micelles of oil can penetrate the subretinal space,
obstruct the trabeculae and alter the corneal equilibrium. In normal conditions,
this phenomenon usually occurs 3–6 months after the oil has been implanted in
the vitreous cavity. As already outlined, there is a nonlinear direct correlation
between the molecular weight, density, surface tension and stability of the oil.
Oils of 5,000 cSt are more stable and show a greater durability than oils of up
to 4,000 cSt. However, no evidence exists for this correlation in oils of viscosity
greater than 5,000 cSt. Accordingly, for short-term tamponade we use oils of
1,000 cSt because they are easy to inject and extract, while for longer periods
of tamponade, we use oils of 5,000 cSt.
Indications of Silicone Oil Tamponade

RD with PVR C3-D
Severe PDR
RD due to macular hole
Giant tears
Chronic uveitis with marked hypotony
151
Infectious retinitis
Endophthalmitis
Ocular trauma
Inferior Peripheral Iridectomy

An inferior iridectomy may be performed for prophylactic purposes if it is
anticipated that the silicone oil could cause pupil block. This will allow the
aqueous humor to flow from the ciliary processes to the anterior chamber
unimpeded by the silicone, which will always remain in the most superior
zone (given its lower density than water). An inferior iridectomy is especially
indicated in aphakic eyes, in which the silicone bubble itself can impair the
circulation of aqueous humor to the anterior chamber, and pseudophakic eyes
due to the closeness between the iris and the IOL with the risk of their positioning
one in apposition to the other. There is also a risk of pupil block in patients with
an IOL implanted in the posterior chamber, with scarce capsular support, in
which resistance to the push of the oil is much lower. The inferior iridectomy
can hinder the entry of oil in the anterior chamber and its toxic effect on the
corneal endothelium. Also for this reason we prefer to perform an iridectomy
in eyes that show deteriorated physical barriers to the passage of silicone oil to
the anterior chamber. For instance, when during vitrectomy or exchanges the
bubbles of air or gas are capable of penetrating the anterior chamber from the
vitreous space, this suggests that the silicone oil could also do so.
For an inferior iridectomy, we recommend the use of the vitreotome at high
aspiration and low cutting speed. With the eye filled with physiological saline
(if filled with air this would pass to the anterior chamber after the iridectomy),
we approach the mouth of the vitreotome to the lower base of the iris, a gentle
suction and once the iris is trapped at the vitreotome mouth, we introduce the
cutting function. Iridectomies should be large otherwise they tend to reclose.
Removal of Silicone Oil

Silicone is a temporary tamponade agent and should therefore be removed
before any complications arise such as those mentioned earlier. For many
years, the 20-gauge approach has been our method of choice to extract silicone
oil, but as mentioned in this chapter, the improvements introduced in the new
vitrectomy platforms allow for excellent removal of silicone oil through a
23-gauge port. First we place a temporal infusion line and further two superior
ports for the extrusion cannula and endolight. The infusion line is opened at
some 20 mm Hg, the dense fluid extraction pump is started, and we then watch
how the silicone is drawn to the extrusion pipe. The cannula is always kept
in the silicone bubble, otherwise the syringe would fill with saline and we
would have to empty it to continue extracting the silicone (Fig. 28). We then
152
Figure 28 Syringe with a 20-gauge needle used for injecting/extracting fluids. The
syringe is connected to the vitreotome’s infusion pump. To extract fluid, make sure
the plunger is initially pushed in
observe the bubble diminishing in size until it disappears from the pupillary
area and then rotate the eye such that the force of the saline expels the small
remains of silicone through one of the sclerotomies. Surgery is completed by
revising the retina and checking if it is flat. If we have any doubts as to whether
it will remain in place, laser treatment can be applied to any suspected zones
using an illuminating laser probe. If the patient is aphakic, we can extract the
silicone through the anterior chamber by placing a 25-gauge infusion line and
by making an incision in the sclerocorneal limbus; we can observe how the
silicone emerges pushed by the saline (Fig. 29).
CLOSURE AFTER SURGERY

When surgery is complete, the entire retinal periphery should be revised for
tears, which should be appropriately treated. This is undertaken by placing a
scleral plug in one of the sclerotomies and reducing the IOP to avoid the risk
of incarceration of the vitreous. Using the wide-field system and with the help
of scleral indentation, we carefully revise the entire peripheral retina and treat
any tear detected directly with the laser probe. Treatment can be followed by
Figure 29 Extracting silicone through a limbal incision in an aphakic patient.

Through a 25-gauge port, pressure is infused pushing the silicone through the corneal
incision, which has been half-opened with the help of a cannula
153
fluid/air exchange and the air left in the eye as a preventive measure. If we
find no tears in the retina, we then move onto revising the sclerotomies to
check for incarcerated vitreous using the active vitreotome and ensuring there
is no remaining vitreous. When working with 23-gauge, incomplete fluid/
air exchange is possible making use of the floatability of air in water and its
pushing power to better seal the sclerotomy avoiding the need for sutures.
However, if the trocars have been manipulated extensively during surgery
or if we suspect that the sclerotomies will not self-heal, we recommend their
transconjunctival suture. When working with 20 gauge, the sclerotomies are
sutured by planes using 8-0 vicryl for the sclera and bipolar cautery or vicryl
8-0 for the conjunctiva.
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y técnicas. Madrid: Tecnimedia; 1999. pp. 47-8.
2. Matsumoto M, Suzuma K, Miyamura N, et al. Transcorneal three-port vitrectomy
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1985;5(4):235-8.
4. Oshima Y, Shima C, Maeda N, et al. Chandelier retroillumination-assisted torsional
oscillation for cataract surgery in patients with severe corneal opacity. J Cataract
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Williams and Wilkins; 2002. pp. 74-5.
7. Peyman GA, Meffert SA, Conway MD, Chou (Eds). Vitreoretinal Surgical
Techniques. London: Martin Dunitz; 2001. pp. 132-5.
8. Meredith TA, Kaplan HJ, Aaberg TM. Pars plana vitrectomy techniques for relief of
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10. Charles S, Wang C. Pneumatic intraocular microscissors. Arch Ophthalmol.
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11. Michels RG. Proliferative diabetic retinopathy: pathophysiology of extraretinal
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12. Abrams GW, Williams GA. “En bloc” excision of diabetic membranes. Am J
Ophthalmol. 1987;103(3 Pt 1):302-8.
13. Charles S, Katz A, Word B. Vitreous Microsurgery, 3rd edition. Philadelphia:
Williams and Wilkins; 2002. pp. 76-82.
14. Kadonosono K, Itoh N, Uchio E, et al. Staining of internal limiting membrane in
macular hole surgery. Arch Ophthalmol. 2000;118(8):1116-8.
15. Da Mata AP, Burk SE, Riemann CD, et al. Indocyanine green-assisted peeling of
the retinal internal limiting membrane during vitrectomy surgery for macular hole
repair. Ophthalmology. 2001;108(7):1187-92.
16. Rodrigues EB, Meyer CH. Meta-analysis of chromovitrectomy with indocyanine
green in macular hole surgery. Ophthalmologica. 2008;222(2):123-9.
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17. Farah ME, Maia M, Rodrigues EB. Dyes in ocular surgery: principles for use in
chromovitrectomy. Am J Ophthalmol. 2009;148(3):332-40.
18. Rodrigues EB, Maia M, Meyer CH, et al. Vital dyes for chromovitrectomy. Curr
Opin Ophthalmol. 2007;18(3):179-87.
19. Engelbrecht NE, Freeman J, Sternberg P, et al. Retinal pigment epithelial changes
after macular hole surgery with indocyanine green-assisted internal limiting
membrane peeling. Am J Ophthalmol. 2002;133(1):89-94.
20. Gandorfer A, Haritoglou C, Gass CA, et al. Indocyanine green-assisted peeling
of the internal limiting membrane may cause retinal damage. Am J Ophthalmol.
2001;132(3):431-3.
21. Rodrigues EB, Meyer CH, Mennel S, et al. Mechanisms of intravitreal
toxicity of indocyanine green dye: implications for chromovitrectomy. Retina.
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22. Gandorfer A, Haritoglou C, Kampik A, et al. Retinal damage from indocyanine green
in experimental macular surgery. Invest Ophthalmol Vis Sci. 2003;44(1):316-23.
23. Lee JE, Yoon TJ, Oum BS. Toxicity of indocyanine green injectect into the subretinal
space: subretinal toxicity of indocyanine green. Retina. 2003;23(5):675-81.
24. Da Mata AP, Burk SE, Foster RE, et al. Long-term follow-up of indocyanine
green-assisted peeling of the retinal internal limiting membrane during vitrectomy
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25. Haritoglou C, Gandorfer A, Schaumberger M, et al. Light-absorbing properties and
osmolarity of indocyanine-green depending on concentration and solvent medium.
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26. Haritoglou C, Gandorfer A, Gass CA, et al. Histology of vitreoretinal interface after
staining of the internal limiting membrane using glucose 5% diluted indocyanine
and infracyanine green. Am J Ophthalmol. 2004;137(2):345-8.
27. Balaiya S, Brar VS, Murthy RK, et al. Comparative in vitro safety analysis of dyes
for chomovitrectomy: indocyanine green, brilliant blue green, bromophenol blue,
and infracyanine green. Retina. 2011;31(6):1128-36.
28. Melles GR, de Waard PW, Pameyer JH, et al. Trypan blue capsule staining
to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg.
1999;25(1):7-9.
29. Stalmans P, Van Aken EH, Melles G, et al. Trypan blue not toxic for retinal pigment
epithelium in vitro. Am J Ophthalmol. 2003;135(2):234-6.
30. Farah ME, Maia M, Furlani B, et al. Current concepts of trypan blue in
chromovitrectomy. Dev Ophthalmol. 2008;42:91-100.
31. Enaida H, Hisatomi T, Goto Y, et al. Preclinical investigation of internal limiting
membrane staining and peeling using intravitreal brilliant blue G. Retina.
2006;26(6):623-30.
32. Haritoglou C, Schumann RG, Kampik A, et al. Heavy Brilliant Blue G for internal
limiting membrane staining. Retina. 2011;31(2):405-7.
33. Schmid MK. A new method to improve dye application to the retinal surface during
vitrectomy. Retina. 2011;31(4):801-3.
34. Kunikata H, Abe T, Murata H, et al. Hypothermia of 8 degrees C protects cultured
retinal pigment epithelial cells and retinal ganglion cells against trypan blue
toxicity. Am J Ophthalmol. 2006;141(4):754-6.
35. Peyman GA, Cheema R, Conway MD, et al. Triamcinolone acetonide as an aid to
visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy.
Retina. 2000;20(5):554-5.
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36. Kimura H, Kuroda S, Nagata M. Triamcinolone acetonide-assisted peeling of the
internal limiting membrane. Am J Ophthalmol. 2004;137(1):172-3.
37. McCuen BW, Bessler M, Tano Y, et al. The lack of toxicity of intravitreally
administered triamcinolone acetonide. Am J Ophthalmol. 1981;91(6):785-8.
38. Chang S. Low viscosity liquid fluorochemicals in vitreous surgery. Am J
Ophthalmol. 1987;103(1):38-43.
39. Charles S, Wang C. A motorized gas injector for vitreous surgery. Arch Ophthalmol.
1981;99(8):1398.
40. Brucker AJ, Hoffmam ME, Nevyas HJ, et al. New instrumentation for fluid-air
exchange. Retina. 1983;3(2):135-6.
41. Charles S. Vitrectomy Microsurgery. Philadelphia: Williams and Wilkins; 2002.
pp. 89.
chapter 7
Pars Plana Lensectomy
Carlos Mateo, Anniken Burés
INTRODUCTION
Pars plana lensectomy (PPL) is a surgical technique employed to extract the
lens using the same entry sites as used for vitrectomy. It is not the first choice
technique when dealing with a cataract surgery or combined surgery (lens
extraction and vitrectomy) in those cases in which the anterior vitreous or
anterior hyaloid does not have a significant pathologic role. However, PPL is
an excellent technique in all those cases that require a thorough management
of the anterior vitreous.
SURGICAL TECHNIQUE
Since PPL is practically always used in combination with pars plana vitrectomy,
the first step would be to place the infusion cannula in the pars plana. After this,
some surgeons prefer to perform a central vitrectomy to avoid interference of
the anterior vitreous with the phacofragmenter in case of premature rupture of
the posterior capsule. However, we prefer to start with the lensectomy before
proceeding with the vitrectomy, since this provides greater stability to the lens
during lensectomy.
To perform the PPL, two sclerotomies are performed, located at 10
o’clock and 2 o’clock positions. The right hand is usually employed to use the
phacofragmenter whereas the left hand holds an intralenticular infusion cannula
at the same pressure as the previously placed and opened infusion cannula (after
confirming its correct placement into the vitreous cavity). The intralenticular
infusion maintains the lens bag open during the surgery, avoiding the collapse
of the bag and therefore minimizing the risk of damaging the capsules with
the phacofragmenter (Fig. 1).
Chapter 7  Pars Plana Lensectomy
157
Figure 1 The intralenticular infusion maintains an open lens bag during the
surgery, which avoids the collapse of the bag and minimizes damage to the
capsules
It should be mentioned that, in spite of being a personal preference, some

surgeons do not use this kind of infusion because of the risk of inadvertent
damage to the posterior capsule, which is clearly less resistant than the anterior
capsule. Also, in the cases of traumatic cataract, due to intraocular foreign body,
it is better not to use the intralenticular infusion since the fluid turbulences could
tear further, the already damaged capsules.
The two sclerotomies are performed at 3–3.5 mm distance from the
sclerocorneal limbus directing the microvitreal blade toward the center of
the lens nucleus. The phacofragmenter is introduced following the same
track and after it the intralenticular infusion is performed (Figs 2A to D).
The first maneuver is to place the tip of the infusion cannula in front of the
phacofragmenter and to perform an initial aspiration with or without ultrasound
(depending on the hardness of the lens). This is done in order to unblock the
tip of the phacofragmenter, since lens material enters the tip when introducing
the phacofragmenter into the lens (Fig. 2A).
Once we observe that the infusion cannula is permeable (the capsular bag
remains open and a certain degree of hydrodissection of the lens is observed),
fragmentation and aspiration of the central and harder lens material are
performed. The “miner” technique (St Charles) consists of introducing and
extracting the tip of the phacofragmenter in different directions to fragment
the nucleus and then aspirate it (Fig. 2B).
If some whitish material appears around the tip of the phacofragmenter, the
procedure must be interrupted immediately (Fig. 3). This material is a sign of
heating of the phacofragmenter and secondary lens protein coagulation. The
heating of the phacofragmenter occurs when the tip is blocked and thus cannot be
refrigerated. Simultaneously, we may observe a burn at the sclerotomy site, not
only exteriorly, but also on the inside. When this occurs, the instrument is pulled
out and cleaned, to remove the lens material blocking the tip. The peripheral part
of the lens can be removed safely with the vitreous cutter (Fig. 2C).
On many occasions we may observe that once the lens nucleus is extracted,
the posterior capsule is torn and vitreous fibers flow into the anterior chamber.
At this point, the vitreous cutter is cutting lens material as well as vitreous
158
A B
C D
Figures 2A to D (A) To ensure that the tip of the phacofragmenter is unblocked, an

initial aspiration is performed by placing the tip of the infusion cannula in front of
the phacofragmenter; (B) Consecutive introduction and extraction of the tip of the
phacofragmenter fragments the nucleus of the lens, making it easier to aspirate; (C)
Cortical lens material can be managed with the vitreous cutter, which is also used to
remove the anterior vitreous gel, once the posterior capsule is open; (D) The anterior
capsule is polished using the vitreous cutter at a low aspiration rate and performing
fast polishing movements
and anterior hyaloid, minimizing peripheral vitreoretinal traction. From this

moment onward, the intralenticular infusion is no longer necessary and can be
pulled out. The remains of the posterior capsule are cut up to the pre-equatorial
area placing the port of the vitreous cutter downward. After this, the anterior
capsule is polished using the vitreous cutter with the cutting turned off and with
a low aspiration rate (100–150 mmHg) performing fast polishing movements
(Fig. 2D). Lens material that falls into the vitreous cavity is easily removed
during vitrectomy.
ADVANTAGES OF PARS PLANA LENSECTOMY

Compared to standard phacoemulsification by the anterior approach, the main
advantages of pars plana lensectomy combined with vitrectomy are:
The anterior chamber remains sealed throughout the entire procedure,
therefore no corneal alterations or changes in the pupil size occur (in those
cases where the anterior capsule remains undamaged)
It allows full access to the anterior vitreous and anterior hyaloid
Despite pressure fluctuations during the surgical procedure, it is neither
necessary to introduce viscoelastic material nor to suture the cornea since
the anterior chamber remains sealed during the surgery.
159
Figure 3 A rapid and whitish opacification of the lens during pars plana lensectomy
is a sign of protein coagulation due to the high temperature of the phacofragmenter
tip. This means that the tip of the phacofragmenter is blocked and is not aspirating
efficiently, making it impossible for the tip to cool down
PARS PLANA LENSECTOMY INDICATIONS

Vitreoretinal Proliferation
Vitreoretinal proliferation (VRP) after retinal detachment surgery, particularly
when the anterior vitreous is clearly involved, is a major indication for PPL,
since it is almost impossible to treat the contracted anterior vitreous and
membranes without damaging the lens (Fig. 4). On the other hand, many
of these patients show variable degrees of lens opacities due to the previous
surgeries and tamponading elements used.
When maintaining the anterior capsule intact throughout the surgery,
PPL minimizes the risk of intraoperative myosis and allows an excellent
visualization and accessibility, facilitating a thorough removal of the anterior
vitreous and anterior hyaloid which, if left untreated, can promote secondary
postoperative hypotony.
At the end of the surgery, the surgeon must choose between leaving the
anterior capsule intact or removing it. Whereas some surgeons prefer to remove
the capsule to prevent a hypothetical contraction of the latter that could cause
traction of the ciliary processes and thus postoperative hypotony, others prefer
to leave the capsule in order to keep a separation between anterior and posterior
compartments and thus avoiding any damage of the anterior segment structures
due to the tamponading elements.
If one chooses to remove the anterior capsule, it is important to perform
a peripheral iridotomy that should be superior when employing a gas or low
160
Figure 4 Due to the convexity of the lens, damage to the posterior capsule is
almost constant when dealing with anterior vitreoretinal proliferation
density silicone oil and inferior when using high density silicone oil. If the
anterior capsule is not removed, the capsule will be progressively opacified
due to the fibrin deposition secondary to the rupture of the blood-retinal barrier
present in VRP (Fig. 5).
Perforating Ocular Trauma with or without

Intraocular Foreign Body
Depending on how the lens penetrates the eye, an intraocular foreign body may
or may not damage the lens. When the lens is damaged, because of a penetrating
foreign body or due to an open globe injury, the hydration of the lens material
makes it almost impossible to ascertain whether the posterior capsule is torn.
Figure 5 At the end of the surgery, the surgeon chooses whether to remove all the
capsular remnants or leaving the anterior capsule, which will facilitate a secondary
intraocular lens implant
161
For this reason, phacoemulsification by the anterior approach is usually not
recommended due to the high risk of complications. If the posterior capsule is
torn, vitreous gel may appear between the lens material and this vitreous should
under no circumstance be managed with phaco tip, since the risk of placing
traction over the peripheral retina and thus producing retinal tears and retinal
detachment is high (Figs 6A to F). In these particular cases, lensectomy is, in
our opinion, the safest and most rational way of managing the cataract as well
as the vitreoretinal tractions, allowing the extraction of the intraocular foreign
body (if present) by the anterior approach. There are some technical differences
in these cases compared to other lensectomy indications:
The use of an intralenticular infusion cannula may be detrimental, since the
fluid currents could tear even more the already damaged capsules
Whenever possible, it is important to keep as much of the anterior capsule
as possible, since it will serve as a support for an intraocular lens. It is quite
useful to inject viscoelastic material into the anterior chamber in those
cases with corneal laceration that is still not sealed in spite of the sutures.
With this, we avoid damaging the residual capsular support due to the fluid
currents (Fig. 7A).
A B C
D E F
Figures 6A to F (A) Traumatic cataract due to penetrating ocular trauma with an

iron wire. In these cases, it is almost impossible to ascertain whether the posterior
capsule is torn or not; (B) Manual aspiration of the cortical masses; (C) Rupture of the
posterior capsule and vitreous material inside the lens; (D) Pars plana lensectomy
using the vitreous cutter allows complete removal of both the vitreous gel and the
lens material; (E) Polishing of the anterior capsule; (F) Intraocular lens implantation
in the posterior chamber
162
The vitreous cutter is usually enough to perform lensectomy in these cases,
both because of the previous hydration of the lens, which makes it softer,
and because the patients tend to be younger (Fig. 7B). Using the vitreous
cutter will also avoid unnecessary vitreoretinal traction in those cases where
there are residual vitreous fibers mixed with the lens material. It is also
important to perform a careful polishing of the anterior capsule avoiding
extending any possible tears (Fig. 7C).
It is preferable to extract any intraocular foreign body through the limbus
instead of the sclerotomy. The risk of producing an uncontrolled retinal tear
is much higher when extracting the intraocular foreign body through the
pars plana (Fig. 7D). After extracting the intraocular foreign body through
the limbus, the same incision can be used to implant an intraocular lens
whenever there is enough capsular support.
Proliferative Diabetic Retinopathy

It is widely known that cataract is more common and develops earlier in diabetic
patients. In most cases, phacoemulsification and intraocular lens implantation in
the capsular bag is the first choice technique when performing combined surgery
in proliferative diabetic retinopathy (PDR). However, phacoemulsification can
show some difficulties when performed right before the vitrectomy:
A B
C D
Figures 7A to D (A) Viscoelastic material is injected into the anterior chamber to

avoid fluid currents through the corneal laceration, which would tear even more a
previously damaged anterior capsule; (B) Lensectomy is performed with the vitreous
cutter to avoid peripheral retinal tractions; (C) Polishing of the posterior side of the
anterior capsule; (D) The intraocular foreign body is extracted by an anterior approach,
before implanting an intraocular lens
163
Phacoemulsification and the capsulorrhexis, in particular, are more difficult
in those cases with vitreous hemorrhage due to the poor fundus reflex
Myosis during surgery is more common in diabetic patients as is bleeding
from small vessels into the anterior chamber, which may reduce visualization
When dealing with retinal vascular proliferations, intraocular pressure needs
to be raised to avoid bleeding. This requires a completely sealed anterior
chamber, thus corneal sutures are usually necessary, which can cause
residual astigmatism and corneal striae that reduce visualization
The intraocular lens can interfere in the correct visualization of the retinal
periphery. This is especially important when dealing with peripheral
preretinal neovessels
Posterior synechiae from the iris to the capsulorhexis and fibrin in the
anterior chamber are more frequent in diabetic patients.
Pars plana lensectomy offers some advantages in severe cases of PDR:
The anterior chamber remains sealed throughout the entire surgical
procedure, which reduces the risk of myosis and thus reduces the risk of
bleeding into the anterior chamber
Both central and peripheral visualization are excellent since there is no
interference of an intraocular lens
When implanting the intraocular lens into the sulcus, the risk of synechiae
formation is less since there is no contact between the iris and the capsule.
In spite of its potential advantages, pars plana lensectomy in diabetic
retinopathy is only considered in severe cases with peripheral retinal neovessels
that need to be treated and which require excellent visualization of the periphery
throughout the surgical procedure.
Chapter 8
Basic Endoscopic Vitrectomy
Vicente J Chaqués-Alepuz, Enrique V López-Sánchez
BASIC EQUIPMENT FOR ENDOSCOPY

The equipment we need for endoscopic surgery of the ocular globe can be
divided into two main groups (Fig. 1):
The endoscope itself (hand piece and probe) (Fig. 2)
The illumination system, the video system and the laser source.
Essentially, the video system for endoscopy comprises (Fig. 3):
–– a video camera,
–– a monitor or screen and
–– a light source.
The images “captured” by the endoscope are transmitted to the charge
coupled device (CCD) chips of the video camera and then to the monitor. These
recorders can have one or three analog or digital chips. Usually they have three
digital CCD chips. The captured images are stored in an image-capturing device
such as a video recorder, DVD or hard disk (Fig. 4). Currently, hard drives are
the preferred storage devices. The best and most used light source is the xenon
Figure 1 Diagram showing the components of an endoscope system

used in ophthalmology
Chapter 8  Basic Endoscopic Vitrectomy
165
Figure 2 Ophthalmologic endoscope. Hand piece and intraocular straight piece
Figure 3 Integrated module for ocular endoscopy with image and illumination
Figure 4 Video recorder and monitor module
light. As a laser source, any optic fiber laser used in ophthalmology can be
combined with endoscopy for intraocular treatment. In practice, semiconductor
diode lasers emitting wavelengths of 532 nm (green) and 810 nm (close to
infrared) are the standard sources used.
166
TECHNICAL ASPECTS: VISUALIZATION
Most endoscopy “systems” are essentially a “pack” containing these individual
components (image capturer, video camera, video monitor, image storing
device, illumination and laser source) (Figs 5 and 6).
To protect the surgeon and assistants from the detrimental effects of the
laser, we usually place a filter that blocks the laser’s specific wavelength (532
or 810 nm) in the microscope’s optical path. Although obvious, we should
mention that if the laser beam is only observed on the monitor screen and not
through the microscope then a laser filter is not needed.
Figure 5 Complete set-up for endoscopy including a monitor, video recorder,

light and image source, and 810 nm laser diode
Figure 6 Probe with three functions (imaging, illumination and laser)

167
Fiber optic endoscopes are indisputably the most widely used in
ophthalmology practice. In these, the image guide is comprised of a beam
of thousands of quartz fibers. Each individual quartz fiber provides a tiny
fraction of the overall image called a pixel. The first marketed ophthalmologic
endoscope used an image guide of 3000 pixels while the current standard is
10,000 pixels and models exist of 17,000 pixels.
This fiber optic system of image capture and transfer produces a
“honeycomb” effect on the monitor when the image is focused. Although
annoying at first, the surgeon eventually gets used to this effect, which indicates
maximum focus and resolution.
It should be noted that the number of pixels is not the only determinant of
the quality of the image. This depends on other factors such as:
the viewing field (currently 110°)
the field depth, or the distance across which the image is focused: from
0.75 to 40 mm
the illumination angle: ideally 110°
Another important feature is the lack of stereopsis. This is because only
a single image is captured. However, there are a few tricks to obtain some
degree of pseudostereopsis. Wide-field endoscopes of 110° can offset this
deficiency by exchanging stereopsis for a panoramic view. The surgeon can
also guide himself/herself using certain visual details such as the locations of
the instruments within the globe or the effects of such instruments on adjacent
ocular structures.
Image Rotation
The image guide occupies a specific position within the endoscope structure.
The orientation of the image is determined by the relative position of the distal
and proximal ends of the image guide. According to the relative position of
these extremes, we will perceive a well-orientated upright image or an obliquely
orientated or even inverted image.
At many points during the surgery, it is not excessively important to have
real information about the position of the image since we can equally see the
intraocular structure of interest or apply laser treatment to a structure without
worrying about its orientation. However, in practice it is best that the image
orientation matches the real anatomy since this is reassuring and simplifies
the surgical maneuvers. In other words, in intraocular endoscopically guided
surgery it is of great help if we can maintain the correct position of the superior
and inferior part of the image.
Changing the orientation of the image is simple: the surgeon only has to
rotate the endoscope’s hand piece between the fingers. This rotation can be
conducted before the endoscope is introduced in the eye or after it has been
introduced in the surgical space (Figs 7A and B).
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A B
Figures 7A and B (A) Real view of ora serrata (OS), ciliary processes (PC), ciliary
sulcus (SU) and (B) Vision with rotation 90º
Thus, the first step before introducing the endoscope in the eye is to orientate
the endoscope image on the monitor. This is done by focusing the endoscope on
any object or point of the surgical field and swivelling the probe with the fingers.
Image Artifacts
If we consider the large number of optical interfaces existing along the
endoscopic path, it becomes obvious that there is every chance that the final
image with which the surgeon needs to work will be altered.
The build-up of deposits at the tip of the endoscope can lead to a blurred
image or to black spots of different sizes. Just a small amount of blood or
particles can markedly compromise vision. To resolve this problem it is usually
sufficient to clean the endoscope tip with a dry sponge or cotton bud.
The proximal end of the probe can similarly be affected by the build-up of
remnants creating a diffuse haze or black spots. The most common cause of
this problem is the powder from the gloves of the surgery team. The remedy
is the same as described above.
Less frequently dust or other deposits that accumulate at the distal or
proximal end of the magnifying, focusing complex or the filter that connects
the endoscope to the camera’s CCD chips, may also give rise to a degraded
image. This problem may be resolved by using a lens cleaning solution or a
stream of compressed air.
Fiber optic endoscopes contain bundles of up to 17,000 small glass tubes.
Any physical damage along their length has the consequence of a “broken”
pixel, which appears as a large irregular area of well-defined image loss. This
artifact cannot be eliminated without reconstructing the endoscope’s imaging
system and it is more expensive to repair this defect than to buy a new probe.
Hence, if the scotoma created by a loss of pixels does not impair the surgeon’s
vision, the endoscope can still be used.
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The surgeon should control the intensity of illumination to obtain the best
image possible. The closer the tip of the endoscope to the tissue, the less light is
needed. Conversely, the further away the tip the greater will be the field of view
and more light is needed. If the intensity of light is too high, the video image
will be washed out or faded while insufficient light will generate a dark image.
With some ophthalmologic endoscopes, the surgeon controls the intensity of
light with a pedal to avoid this problem.
A further problem that has not yet been resolved is glare produced on the
video screen caused by the light reflected off the metal surface of the vitreotome
hand piece.
Technical Tips for the Beginners

Since the endoscope image is produced at the distal tip of the instrument, this
part of the instrument cannot be seen. Thus, the instrument should be advanced
within the eye according to what the endoscope “sees”. The surgeon should
learn to recognize the endoscopic features of the eye, which may look different
to when viewed by conventional means. Certain visual cues can be obtained
from the surrounding anatomy so that the endoscope and other instruments can
be manipulated in the eye.
This brings us to the second technical tip, which is to watch the operation
in progress on the video screen rather than through the operating microscope.
For some people, this transition can be difficult (Fig. 8).
Beginners should try to avoid surgery on phakic eyes to prevent the risk
of damaging the crystalline lens generating a traumatic cataract. A relatively
simple case should be selected such as chronic vitreous hemorrhage.
Early in the learning curve, it is useful to simultaneously work with double
illumination from both the microscope and endoscope. To do this, we use the
light provided by the endoscope for endoillumination and then simultaneously
Figure 8 Relative positions of the operating surgeons and surgical equipment. The
surgeons are watching the video on the screen rather than through the microscope
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watch out for visual cues through the operating microscope. This tactic can
speed up the learning process.
ENDOSCOPIC POSTERIOR VITRECTOMY: BASIC CONCEPTS

AND INDICATIONS
There are two basic benefits of endoscopic guidance during intraocular surgery:
visualization through opaque media and access to anatomical structures that
could not otherwise be seen.
The first of these refers to visualization of the posterior segment when the
conditions of the anterior pole prevent this, as occurs when there is corneal
opacification, a flat anterior chamber, the presence of blood in the anterior
chamber, a miotic pupil, opacification of the crystalline lens or the posterior
capsule, or the presence of a cyclitic membrane. The image obtained by the
endoscope assisted by the video monitor avoids these obstacles by definition since
the endoscope tip is introduced through the pars plana. In cases of opaque corneas,
there is no need for penetrating keratoplasty or a temporary keratoprosthesis.
The second benefit conferred by the endoscope has to do with its capacity to
provide images of structures that are inaccessible using other techniques. Thus,
posterior iris, sulcus and ciliary body cannot be viewed using the operating
microscope, and structures such as the pars plana and retinal periphery cannot
often been clearly observed, which can sometimes preclude certain surgical
procedures. It is in these circumstances, when the endoscope can be of most help.
In addition, the endoscope can inform us of the state of the posterior pole as
well as of the presence of optic nerve disk atrophy, which will limit the patient’s
vision and visual outcome despite conducting flawless surgery.
Also, before finishing surgery we can inspect the peripheral retina and the
sclerotomies, especially in aphakic or pseudophakic eyes.
The use or not of the endoscope and its combination with the operating
microscope is the surgeon’s decision since it has to be recognized that its
resolution is still not comparable to that of the operating microscope and we
lack stereopsis. Depending on the eye condition and the point during surgery,
the use of one or other visualization system will be best since at certain times
during an operation we will need to use both hands and let go the endoscope
hand piece, for instance, while looking through the microscope.
Surgeon’s Position
When performing endoscopic eye surgery, the surgeon is usually positioned at
the head of the operating table. The endoscope system’s video screen should
be approximately 1 metre from the surgeon for good visualization, although
its position depends on the preference of the surgeon and that of the rest of the
surgical equipment. If the screen is too far away, it may be difficult to see the
details of the image (Fig. 8).
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Image Size and Lighting
Magnification, visual field and illumination vary with the distance between the
tip of the endoscope and the target tissue.
For intraocular endoscopy, it is important to know how image and visual
field size change. As the endoscope tip approaches the zone to be treated, the
size of the image will increase and the visual field will be diminished, and vice
versa as we move away from the zone, the image will get smaller but we will
see across a wider field. Illumination requirements are such that we will need
less light as we approach the treatment zone and more light as we move away
from this zone.
Blurred Image
During the course of endoscopic surgery, a blurred image can be quickly
produced but this is nevertheless easy to remedy. This is a frequent problem
even when using an endoscope at other body sites.
In intraocular surgery, “fog” appears mostly during fluid/air exchange, when
the warm balanced saline solution is replaced with cold air or gas owing to
condensation on the tip of the endoscope, as occurs on the posterior side of an
intraocular lens in similar circumstances. Fog can also occur when an active
hemorrhage is produced and when dense deposits exist such as in infectious
ophthalmitis.
When a foggy image occurs, the most useful measure is to withdraw the
tip of the endoscope towards the entrance sclerotomy. Usually, a film of liquid
sticks to the endoscope rod and this will dissipate and spread to the tip lens
clarifying the image. This maneuver can be repeated as many times as needed.
If this does not work, another option is to advance the tip of the endoscope until
it makes contact with any residual intraocular fluid—we will see the fog quickly
vanish although it often quickly reappears as the endoscope tip is withdrawn
from the fluid meniscus.
Another option is to use an instrument with a soft tip, such as a brush or
extrusion cannula, to help us remove the remains from the endoscope tip without
the need to withdraw it from the globe.
Finally, if all else fails, the instrument is removed from the eye and carefully
cleaned with a dry cloth, cotton bud or sponge.
COMPLICATIONS OF VITREORETINAL SURGERY THAT CAN

BE AVOIDED BY ENDOSCOPY
Vitreous Incarceration
Many surgeons understand the importance of examining the inner aspect of
a sclerotomy before finalizing the surgical procedure. However, using the
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operating microscope, this cannot usually be well visualized. Many articles
exist in the literature describing possible problems caused by sclerotomies. One
of the main advantages of endoscopic surgery is the possibility of examining
in great detail the state of both prior and current sclerotomies, and resolving
the problems caused by these.
In most sclerotomies, incarcerated vitreous is easily observable (Fig. 9).
Although many surgeons think that cutting the collapsed vitreous through
the sclerotomy incision may be sufficient to resolve the problem, endoscopy
has shown that this strategy is not the solution. Thus, the vitreous incarcerated
on the internal lip of the sclerotomy cannot be detached by cutting the vitreous
herniated towards the outside of the incision.
The only way to resolve this problem is to use a mechanical vitreous cutter
to cut and suction the vitreous adhered to the inner side of the incision in the
ocular wall. It is, however, true that this maneuver is difficult or impossible to
complete. The vitreous base can be very dense and sticky such that the vitrector
is unable to cut it.
Most often this situation does not affect the outcome of surgery and
vitrectomy has a high success rate.
Controlling Intraoperative Bleeding

Occasionally, bleeding can occur from the inner aspect of the sclerotomy and
may even persist during the entire procedure.
Sometimes cautery or an increase in intraocular pressure is insufficient to
resolve this problem. Bleeding areas can be easily detected using the endoscope
and direct cautery, or pressure exerted by the tip of the instrument on the point
of bleeding added to increase the intraocular pressure are often sufficient to
control the situation.
Figure 9 Vitreous incarceration is a complication of vitreoretinal surgery that

can be easily seen using an endoscope
173
TECHNIQUES AND MANEUVERS OF VITRECTOMY AND
ENDOSCOPY
All the maneuvers conventionally performed under visualization through the
microscope can be completed with lesser or greater difficulty using endoscopic
visualization. Here, we will only comment on the strategies that are best
performed by endoscopy.
Vitrectomy
The endoscope is introduced through the sclera maintaining a panoramic
view. Through the opposite sclerotomy, the vitreotome is introduced. With
the endoscope still, the vitrector is manipulated until it appears in the middle
vitreous. The cutting and aspiration mechanism is started. We should avoid
moving the endoscope to maintain the field of view. The vitreous looks like an
opaque white cloud and this appearance gradually disappears as we eliminate it.
As the vitrectomy proceeds, the vitreotome gets closer to the endoscope; this
results in magnification of the vitrectomy hand piece rod (Figs 10A and B). The
surgeon is provided with some degree of 3 dimensional orientation such that,
with this movement, inadvertent damage to ocular structures can be avoided.
This procedure is conducted until the remaining vitreous has been removed;
the endoscope and vitreotome can be exchanged hands to aid visualization of
all the residual vitreous.
To enable working closer to the retina, we move the endoscope towards the
retina followed by the vitreotome through a small approximation movement.
This maneuver is repeated until the surface of the retina has been reached.
The principles of vitrectomy are similar to those of vitrectomy under the
microscope; as we approach the retina we should increase the cutting speed
and lower the aspiration power to control flow and traction on the retinal tissue.
Figures 10A and B Relation between the endoscope tip and the vitreotome. A
panoramic view is maintained using the endoscope while the vitrector is advanced
towards the endoscope. (A) At first the vitrector is far away and appears small; (B) As
the vitrector approaches the endoscope it appears larger
174
At any point during the surgery, the surgeon can check the adequate progress
of surgery by visualization under the microscope, controlling the appropriate
positions of the instruments. Only when microscope observation is impaired by
the opacity of the media does the endoscopy technique reach its full potential,
allowing the surgeon to calmly continue with the procedure. To dominate the
technique, the endoscope should be regularly used alongside the microscope,
such that this mode of working can be selected when the situation demands.
Membranectomy
The removal of membranes is by far the most challenging endoscopic surgery
procedure and requires stereoscopic vision. Despite this, a 2 dimensional
image may be sufficient for a good membranectomy except in cases of fine
dissection, such as the presence of a premacular membrane, since the risk of
inadvertent damage may be high. It is not the same to remove a membrane
from the optic nerve surface or a more peripheral membrane as in proliferative
diabetic retinopathy.
Fluid-Air Exchange
It is relatively frequent that the microscope image is poor in complicated cases
at the end of the surgery because of corneal opacity, miosis or condensation of
drops behind an intraocular lens. This situation can be particularly frustrating
for the surgeon. The exchange maneuver can be performed under endoscopic
guidance avoiding the problems just mentioned.
For the exchange, we introduce a soft silicone-tipped extrusion cannula
through one of the sclerotomy incisions and through the other sclerotomy we
insert the endoscope maintaining a panoramic view with good illumination.
The hand piece should be well orientated with respect to the ocular anatomy.
The bubbles of air will enter the eye and it will be possible to visualize the air/
fluid meniscus.
Endophotocoagulation
Endophotocoagulation is certainly one of the most common procedures in
vitreoretinal surgery. When performed under the operating microscope we need
two hands; one for the laser probe and one for endoillumination. With these
instruments, endolaser treatment can be well applied especially in posterior
zones, but as we work more anteriorly, it becomes difficult or even impossible
to reach the ciliary body.
With the endoscope in only one hand we have available an image,
endoillumination and laser probe, and can simultaneously use these three
functions for effective photocoagulation throughout the entire globe even in
circumstances of media opacity (Fig. 11).
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Figure 11 Endoscopic photocoagulation
Pars Plana Lensectomy

The course of a lensectomy can be followed through the anterior segment with
the microscope. The posterior localization of nuclear or cortical fragments
along with capsule remains can be surveilled using the endoscope. In this way
it is easy not to miss any crystalline lens remains that could be left in the eye,
as may occur if we only use the microscope.
Moreover, after removing the crystalline lens fragments the endoscope
enables any iatrogenic peripheral retinal tears to be detected and if these appear,
we can immediately photocoagulate them.
Capsulectomy
Depending on the underlying disease, the surgeon may choose to extract the
capsule remains. Although this procedure can be partially or fully conducted
using the vitrector, the ideal is to use forceps to lift the edges of the capsule
under endoscopic guidance. Endoscopically-guided capsulectomy is easy to
perform and serves to eliminate all capsule remains without leaving behind any
tissue that could act as a substrate for a potential proliferation.
Introducing Silicone Oil

Under endoscopic visualization, the injection of silicone oil is an easy
procedure. Normally, the endoscope is used with a wide visual field in an air-
filled eye. The silicone cannula can be visualized within the eye when we start
the injection process and we can watch the oil falling on the optic nerve and
macula gradually filling the globe.
This technique offers two advantages over injection guided by the
microscope. The first is that we can visualize the procedure until the end of
the filling process with the endoscope but not with the operating microscope.
When the oil goes beyond the globe equator, microscopy vision of the extreme
176
periphery is poor. In contrast, the endoscope allows revision of the periphery
and the posterior iris without the need for indentation or other maneuvers,
offering precise monitoring of the air/silicone interface and the desired filling.
The second advantage is the immediate detection of the eventual passage
of silicone oil to the subretinal space, facilitating its resolution at the moment
of injection.
Silicone oil does not degrade the endoscope image yet attenuates the impacts
from the laser. Thus, the maneuvers we can carry out in an air-filled eye can
also be undertaken in an eye filled with silicone oil.
Introducing Perfluorocarbon Liquid

Generally the injection of a perfluorocarbon liquid is conducted with the eye
filled with fluid and since it is heavier, it sinks towards the posterior pole
creating a clear boundary between the perfluorocarbon and the balanced
salt solution (Fig. 12). As more perfluorocarbon liquid is gradually injected,
the subretinal fluid is displaced peripherally through the tear and the retina
is flattened if there is no traction. However, if significant traction persists,
the retina will not respond and will not flatten. One of the advantages of the
endoscope is that the retinal flattening process can be visualized and any zones
of persistent traction or gliosis can be detected.
The endoscope may also be useful for the removal of perfluorocarbon
liquid from the eye. Sometimes, small bubbles of perfluorocarbon liquid may
be trapped in zones that are invisible to the microscope or visualization through
the cornea and/or crystalline lens may have become blurred. In this situation
the endoscope is of great help since it allows visualization and extraction of
every last bubble of perfluorocarbon liquid.
Diabetic Retinopathy and Endoscopic Vitrectomy

As proliferative diabetic retinopathy progresses, ocular proliferation gives rise
to numerous problems which in turn lead to surgical indications, such as vitreous
Figure 12 Endoscopic visualization of the injection

of perfluorocarbon liquid
177
hemorrhage, premacular hemorrhage, severe diabetic retinopathy not responding
to photocoagulation, tractional macular detachment, rhegmatogenous and
tractional retinal detachment, anterior hyaloid fibrovascular proliferation,
rubeosis iridis, etc. These diseases may be associated with opacity of the media.
Vitreous Hemorrhage
The vitrectomy maneuvers, active or passive extrusion, fluid/air exchange
and endophotocoagulation are those most commonly used to treat vitreous
hemorrhage; all these procedures can be better performed under endoscopy
making the removal of vitreous and blood more complete.
Cleaning the anterior vitreous at the base of the vitreous is easier under
endoscopic visualization. Similarly, in cases of recurrent hemorrhage, we can
detect the presence of anterior proliferations, which we can approach or treat
with the vitrector or forceps. It is also possible to more efficiently complete
anterior panretinal photocoagulation.
Neovascularization of the Iris with Opacity of the Media

If the patient has a dense cataract, corneal opacity, hyphema, or any other media
opacity problem, the best treatment option is endoscopic photocoagulation.
Substantial anterior pole opacity makes photocoagulation impossible with
the visualization offered by the operating microscope. Further, the endoscope
enables extensive photocoagulation.
Finally, if neovascular glaucoma is already present after posterior retinal
treatment, endoscopic cyclophotocoagulation can be conducted, irrespective
of crystalline lens transparency.
Combined endoscopic cyclophotocoagulation and panretinal photocoagulation
is, in this situation, the safest and most efficient treatment option, avoiding
aggressive procedures such as retinal cryotherapy or cyclocryotherapy.
Retinal Detachment Surgery

Endoscopy facilitates vitrectomy when treating rhegmatogenous retinal
detachment in several ways. First of all, the elimination of vitreous with blood,
deposits and opacities can give rise to improved vision for the patient, assuming
the retina flattens and attains good functionality. In second place, it simplifies the
search for retinal tears avoiding the need for indirect ophthalmoscopy. This can
be of particular help when faced with an opacified posterior capsule that impairs
proper visualization of the peripheral retina. The endoscope can even easily
detect retinal holes in the extreme periphery and these can be photocoagulated
at the exact moment of their visualization (Fig. 13). Thirdly, fluid/gas exchange
with internal drainage of subretinal fluid can be easily and quickly performed
under endoscopic guidance, thus flattening the retina (Fig. 14). This maneuver
178
Figure 13 Peripheral retinal tear associated with a sclerotomy incision
Figure 14 Endoscopic visualization of fluid/air exchange
is evidently safer, more controlled and more complete than external drainage.
Fourthly, endoscopic endophotocoagulation in an air-filled eye with an attached
retina is very simple and efficient. Moreover, it is less aggressive than trans-
scleral cryopexy (Fig. 15) and may reduce the risk of inducing proliferative
vitroretinopathy (PVR). It can also be performed without changing instruments.
In fifth place, postoperative discomfort is minimal for the patient compared to
extrascleral surgery, especially if a scleral buckle is used. Finally, reoperations
for retinal detachment are simplified with less aggression to the ocular globe
than repeat scleral surgery (Fig 16).
Proliferative Vitreoretinopathy
Scleral Indentation
The endoscope can be of great help for the complete removal of the anterior
vitreous and its anterior and posterior adhesions. This feature can thus minimize
the need for scleral indentation, at least for those surgeons who use a scleral
buckle to better access the base of the vitreous.
179
Figure 15 Endoscopic visualization of transscleral cryopexy
Figure 16 Retinal detachment. Tear bridged by a vessel and vitrectomy of the
vitreous adhesion-traction to the flap
180
Dissecting the Vitreous Base
Independent of when, during the course of vitrectomy, the surgeon acts in this
zone, the complete elimination of the base of the vitreous and the membrane
at the posterior iris and ciliary body is essential for the successful treatment
of PVR.
In this region, the endoscope may be of great use given its difficult access
even in the best of circumstances. For surgeons with early experience in
PVR surgery with scleral indentation and lensectomy, visualization using
the operating microscope can be extremely poor during this stage of surgery.
The endoscope can clearly delineate the altered anatomy and its effect on
neighbouring structures. Scleral depression is often used to approach areas of
interest to the microscope’s visual field. With the endoscope this is unnecessary.
In effect, scleral depression could relax points of vitreous adhesion to the
peripheral retina, pars plana, ciliary body, crystalline lens or posterior iris, thus
masking their presence while endoscopic visualization clearly identifies their
existence (Fig. 17).
Endoscopic Vitrectomy for Crystalline Lens Fragments

Luxated in the Vitreous Cavity
The operating endoscope can be useful to remove fragments from the
posterior pole but is mainly used to localize and remove remnants of the
lens nucleus and cortex that are not visible with the operating microscope
because of their location and that could cause glaucoma and intraocular
inflammation (Figs 18 and 19).
It is surprising how much crystalline lens material can become trapped
at the posterior iris, sulcus and vitreous that we cannot visualize using the
operating microscope. Generally, this persisting material has no important
consequences and disappears without leaving sequelae but sometimes it could
cause considerable damage.
Figure 17 Endoscopic peripheral retinectomy in a case of anterior PVR

181
Figure 18 Endoscopic visualization of fragments of crystalline lens luxated in the

vitreous in an eye with intense corneal edema. With the operating microscope, good
visualization is not possible
Figure 19 Exploring the posterior zone of the iris and ciliary body with the help of
the endoscope. Note the abundance of crystalline lens remains, which if not removed
could cause chronic intraocular inflammation
Endoscopic Vitrectomy in Endophthalmitis

In many cases of endophthalmitis, visualization conditions are insufficiently
good for vitrectomy due to corneal edema and miosis.
When endophthalmitis is detected early, especially as a consequence of
cataract surgery, most inflammation occurs at the site of intraocular lens implant
and the anterior vitreous. However, the focus of infection can be detected in
the sulcus region (Figs 20A and B). Conventional visualization techniques do
not allow these areas to be seen, particularly if the cornea is edematous or the
pupil is miotic.
182
A B
Figures 20A and B (A) Inflammatory and infectious deposits on ciliary processes.
View of the posterior aspect of the iris and pupil, and endoillumination probe
entering through the pars plana; (B) Higher magnification image of the inflammatory
masses appearing in the image on the left
One of the reasons why eyes with endophthalmitis that have been
successfully vitrectomized require such a long time period until the infection
resolves after surgery, is perhaps that infectious and inflammatory remains
persist in inaccessible areas of the eye. Endoscopic vitrectomy offers the
surgeon the opportunity to detect and eliminate most of this material.
In addition, when vitrectomy is needed, most eyes with endophthalmitis
find themselves in the postoperative course of the surgery that provoked the
infection and thus have unhealed surgical incisions. In this situation scleral
indentation is not recommended. In contrast, the endoscope can provide a view
of the periphery at great magnification and good resolution, and any break
detected can be rapidly sealed by photocoagulation.
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22. Uram M. Endoscopic Surgery in Ophthalmology. Philadelphia: Lippincott Williams
& Wilkins; 2003.
23. Uram M. Laser endoscope in the management of proliferative vitreoretinopathy.
Ophthalmology. 1994;101(8):1404-8.
24. Uram M. Ophthalmic laser microendoscope endophotocoagulation. Ophthalmology.
1992;99(12):1829-32.
25. Uram M. Ophthalmic laser microendoscope ciliary process ablation in the
management of neovascular glaucoma. Ophthalmology. 1992;99(12):1823-8.
26. Volkov VV, Danilov AV, Vassin LN, et al. Flexible endoscope for intraocular
27. Volkov VV, Danilov AV, Vassin LN, et al. Flexible endoscopes. Ophthalmoendoscopic
techniques and case reports. Arch Ophthalmol. 1990;108(7):956-7.
28. Sabti KA, Raizada S, Kandari JA, et al. Williams GA. Applications of endoscopy
in vitreoretinal surgery. Retina. 2008;28 (1):159-66.
chapter 9
Minimal Incision Vitrectomy
Surgery: Twenty-Three,
Twenty-Five and
Twenty-Seven Gauge
José Juan Martínez-Toldos, Javier A Montero-Moreno, José M Ruiz-Moreno,
Armadá Maresca Félix, Natalia Pastora-Salvador, Anna Grabowoska, María
9.1 TWENTY-THREE GAUGE VITRECTOMY

José Juan Martínez-Toldos
INTRODUCTION
The year 2002 saw the introduction of new smaller caliber instruments designed
for conjunctival and scleral incisions of 0.6, 0.5 or 0.4 mm, which did not
require sutures. In principle, the benefits of smaller caliber instruments include
less damage to ocular tissues, diminished circulation of fluid in the ocular globe
and because of the small surgical wounds created, more rapid recovery for the
patient and a reduced amount of induced astigmatism.1,2
In 2004, Eckardt3 developed a 23-gauge system that is used in complex
cases of proliferative diabetic retinopathy (PDR) or vitreoretinal proliferation.
Given the similar strength of the instruments to those used in conventional 20
gauge surgery, there is no limit to the surgical procedures the new instruments
can be used for; it is easier to control the position of the eye and to manipulate
the instruments, as this often depends on the force they produce.
The 23-gauge system also allows for suture-free incisions. Such incisions
are achieved using a 23-gauge stiletto blade angled at 45° to create a valved
incision through which metal trocars are introduced with the help of a pressure
plate. Constant pressure is applied to the pressure plate while the incision is
made and during withdrawal of the stiletto blade to prevent slippage of the
conjunctiva against the sclera (Figs 1A to C). The illumination system provides
sufficient light, and forceps, scissors, endolaser and endodiathermy probes,
backflush aspiration systems have been developed in 23 gauge. The vitrector
Chapter 9  Minimal Incision Vitrectomy Surgery: Twenty-Three ...
185
A B C
Figures 1A to C (A) Twenty-three gauge metal trocars with sealing plugs and
infusion cannula; (B) The incision is made with the help of a pressure plate; (C)
Inserting the stiletto blade with the trocar
has a cutting speed of 1,200 cuts per minute and aspiration power above 500
mm Hg.
With small variations, this vitrectomy system has been widely developed
and all the commercial firms offer a system of this caliber. Also, among
surgeons, the system has become so popular that 72.5% of vitreoretinal surgeons
routinely conduct 23-gauge vitrectomy.4
When starting on this type of surgery following 20-gauge vitrectomy, it
is important to select cases that are not too complex until a certain comfort
level has been attained in each step of the procedure. The treatment of vitreous
hemorrhage and epiretinal membranes are good procedures to start with before
moving on to cases of retinal detachment, macular hole and PDR.
It should be stressed that instrument rigidity is similar to that of 20-gauge
instruments and that it does not take long to adjust to the new technique. Fluid
dynamics and control are good, especially with the new high-speed vitrectomy
machines that offer working with duty cycles.
INCISION CONSTRUCTION
Good wound construction is important to avoid cannulas becoming dislodged
during surgery and ensure that the incision self seals so that there are no leaks
that could provoke hypotension or increase the risk of endophthalmitis. In
addition, we should seek to avoid the need for sutures.
Today’s hollow trocars enable the incision to be placed and the trocar
inserted in a single maneuver. Basically this consists of displacing the
conjunctiva and then introducing the trocar and stiletto blade at an angle of
25–30° through the sclera in a slightly oblique direction to make a small tunnel,
and then pointing toward the eye center to create an incision involving two
planes, which will always be more airtight and safe.
Valved cannulas exist which permit a tightly sealed surgical procedure
with less turbulence within the eye. These cannulas are preferable to the more
simple plugged cannulas.
As in 20-gauge surgery, it is important to check that the infusion cannula
is well positioned in the ocular cavity to avoid choroid detachment. We
186
should start with the inferior temporal incision to position the infusion line
and then introduce the instrument ports with a separation of 160–170° (Figs
2 and 3).
VITRECTOMY
When working with a high-speed vitrectome, the duty cycle can be adjusted.
We use the 50/50 cycle in the central vitreous and as we approach the retina,
we switch to the shaving mode, which gives us the security that we will not
damage the retina.
Since the probes are longer and the cutting mouth is more toward the tip,
we can get closer to the retina. In cases of PDR, the vitrector can be used as
scissors by placing it under the membrane and cutting at high speed and low
suction. This maneuver can be made easier if we use viscodissection to remove
zones of traction without the need to introduce new instruments or the need
for bimanual surgery.
Figure 2 New Edge Plus system by Alcon comprising a single-step trocar for a
linear incision, metal 23- and 25- gauge cannulas with integrated silicone valves and
vitrector with a 3.3–4 mm scleral marker
A B
Figures 3A and B Disposable 23G forceps ILM

187
We can also use the vitrectome probe with active aspiration to lift
membranes and detach the hyaloid. Using backflush we can displace blood
and then by reducing the cutting speed eliminate pieces of tissue, clots or small
crystalline lens fragments.
CLOSING THE INCISION

To close the wound, we should lower the infusion pressure to around 20 mm Hg,
to avoid losses through the cannulas. An instrument is attached to the cannula
such as the illumination probe, the cannula is withdrawn retaining the probe
and finally we can remove the probe and apply a gentle massage to the sclera
so that the scleral fibers recover their memory.
We can also use a 23-gauge needle to introduce a little air through the cannula
before its removal to avoid or minimize losses and vitreous incarceration. If we
have worked for a long time and the incision has been excessively manipulated, it
is best to fill the globe completely with air. This will facilitate closing the incisions.
Notwithstanding, if there is leakage and the eye shows a tendency toward
hypotony, we should not hesitate to place a stitch using reabsorbable 8-0 sutures.
If the incision is visible beneath the conjunctiva this can be done directly; if
there is blood or we cannot see the incision well, it is best to place a linear cut
in the conjunctiva to expose the wound and then close it well. The conjunctival
incision does not require suturing. If silicone oil has been left in the eye, it is
best to suture the incisions to avoid leakage. The main problems caused by
a poorly closed wound are hypotony and endophthalmitis. An incision in a
hypotonic eye has a siphon effect for the entry of microorganisms.
BENEFITS OF TWENTY-THREE GAUGE SURGERY

Instruments are similar to those of 20 gauge in terms of rigidity and fluidics.
Other than this, the advantages of twenty-three gauge surgery are:
Incisions are usually airtight without sutures
Less surgery time
Since there are no sutures, there is usually no induced astigmatism
It may be used in nearly all procedures except in very complex cases or
foreign bodies although 20/23 gauge may be combined
Faster recovery
Reduced inflammation
Owing to these benefits, 23-gauge vitrectomy is currently the preferred system
and is used in over 90% of procedures.
COMPLICATIONS
Several complications have been described for the use of 23-gauge vitrectomy:
retinal detachment, cataract progression, persistent or recurrent vitreous
188
hemorrhage, cystoid macular edema, conjunctival chemosis on the day
following surgery, hypotony, endophthalmitis, intraoperative choroidal
detachment and even hemorrhagic choroidal detachment.5
The appearance of endophthalmitis is directly related to incision closure
and the practice of introducing gas in the eye has reduced the incidence of
endophthalmitis from the initial 0.18% described in the literature to 0.04%,
suggesting the possible benefit of fluid/air exchange at the end of surgery.6
Retracting the cannula during surgery has been proposed as an explanation
for choroidal detachment as a complication. To avoid this problem, more
pronounced 30–45° incisions are recommended so that the cannula can be
introduced several millimeters in the vitreous chamber (a 15° incision would
mean the cannula is scarcely introduced in the ocular cavity such that any slight
retraction would make the cannula occupy the choroidal space and induce
choroidal detachment). We should check that at least 2 mm of cannula have
been introduced in the eye and then align the cannula at 90° to the sclera with
the help of a Steri-strip.7
REFERENCES
1. Fujii GY, De Juan E, Humayun MS, et al. Initial experience using the
transconjunctival sutureless vitrectomy system for vitreoretinal surgery.
Ophthalmology. 2002;109(10):1814-20.
2. Fujii 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.
3. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina.
2005;25(2):208-11.
4. American Society of Retina Specialist Annual Preferences and Trends Survey;
2010.
5. Lott MN, Manning MH, Singh J, et al. 23-gauge vitrectomy in 100 eyes: short-term
visual outcomes and complications. Retina. 2008;28(9):1193-200.
6. Chiang A, Kaiser RS, Avery RL, et al. Endophthalmitis in microincision vitrectomy:
outcomes of gas-filled eyes. Retina. 2011;31(8):1513-7.
7. Tarantola RM, Folk JC, Shah SS, et al. Intraoperative choroidal detachment during
23-gauge vitrectomy. Retina. 2011;31(5):893-901.
189
9.2 TWENTY-FIVE GAUGE VITRECTOMY
Javier A Montero-Moreno, José M Ruiz-Moreno
INTRODUCTION
Since 1974, three-port, 20-gauge caliber surgery has been the gold standard
for vitrectomy. However, during the past few years, interest has been mounting
in the use of ever smaller caliber operating instruments to perform sutureless
minimally invasive microincision surgery. Chen was the first to describe
sutureless vitrectomy in 1996.1 In earlier work, Peyman had developed
the 23-gauge caliber system, which was used mostly in pediatric surgery.2
According to a questionnaire about preferences and trends administered to
the members of the American Society of Retina Specialists, 48% of those
who completed the questionnaire in 2004 had never employed a small caliber
system; in 2007, 75% admitted to using such a system at least once and in
2008, this figure was 80%.3
Among the benefits of sutureless transconjunctival vitrectomy we find,
reduced surgical trauma, faster postoperative and visual recovery, and greater
patient satisfaction.4-8 Moreover, transconjunctival access avoids the need to
dissect and suture the conjunctiva and sclera, shortening surgery time thus
increasing efficiency in the operating room, besides reducing surgical trauma,
and the foreign body sensation produced by the increased manipulation that
sutures entail and by possible reactions induced by the sutures themselves.
The use of microcannulas facilitates the exchange of instruments from one
entry port to another and protects the vitreous base from mechanical traction.
Not least important, is the almost complete lack of scarring of the conjunctiva,
which enables further operations if necessary.
Among its drawbacks we could mention, suction and flow speed in the
25-gauge system are significantly lower than with 20 gauge as a consequence of
the smaller caliber, which could make the removal of vitreous strands difficult.
Further, 25-gauge instruments may seem more flexible. In effect, this was the
reason for the initial restrictions of this gauge to cases not requiring extensive
vitrectomy or to membrane dissections (such as epiretinal membranes, macular
holes or vitreomacular traction syndromes).
For these reasons, the popularity of transconjunctival sutureless
vitrectomy with small caliber instruments has exponentially grown among
ophthalmologists. However, parallel to its increased use have also grown the
number of doubts about the airtightness of such self-healing incisions. Thus,
a series of published reports has described a greater risk of postoperative
hypotony and endophthalmitis compared to conventional vitrectomy.9-11
Over recent years, both the quality and variety of instruments for this type
of surgery have increased and we today have available sets of instruments from
the different companies (Dorc, Grieshaber, Millenium, Synergetics, among
others) designed to undertake any vitreoretinal surgical procedure.
190
Among these newly developed tools, we find single-step trocars that
are easier to insert or two-step trocars that provide greater stability. Valved
trocars exist that avoid the use of plugs, although they hinder the introduction
of silicone-tipped cannulas. There is a large variety of light probes for each
instance during surgery: stiff, flexible, with a pick, focal, intermediate or
wide-field, as well as auxiliary light probes such as the Chandelier or Torpedo.
There are also several types of laser probes: straight or curved, with or without
illumination or the multidirectional retractile laser probe which is useful for
endophotocoagulation in zones of difficult access. Similarly, we also have
available a growing number of forceps and manual or pneumatically-driven
scissors (Figs 1 and 2).
Inserting the trocars is a key maneuver to prevent complications. Thus,
the conjunctiva has to be sufficiently displaced such that the conjunctival
incisions do not coincide with the sclerotomies (Fig. 3). Sclerotomies should
be performed at an angle of 20–30° on the plane of the pars plana, parallel to
the limbus. Their position should be at 2 o’clock and 5 o’clock for maneuvers
and in the inferior temporal zone for infusion, all three at a distance of 3.5 mm
from the limbus.
To avoid suturing the lens retaining ring to the limbus, silicone rings (these
require more assistant cooperation) or noncontact systems such as binocular
indirect ophthalmomicroscope, Oculus or optical fiber free intravitreal surgery
system, Topcon may be used.
The vitrectomy itself does not vary from the 20-gauge technique, except that
the smaller caliber infusion cannula determines a higher infusion pressure in
the console (35–40 mm Hg) and a longer vitrectomy duration (Fig. 4). It is best
to reduce the intraocular infusion pressure to 10–15 mm Hg as the operation
is finalized and before removing the cannulas, to avoid the risk of excessive
pressure forcing the incisions causing the passage of saline solution or gas to
the subconjunctival space. The cannulas are removed one by one, in the same
direction to their introduction while cutting the vitreous to avoid peripheral
Figure 1 Peeling an unstained epiretinal membrane using Eckardt pincers

191
Figure 2 Stripping the internal limiting membrane after brilliant blue staining in
a case of macular hole
Figure 3 Inserting the transconjunctival trocars
Figure 4 25-gauge vitrectomy

192
vitreous hernias. Massaging the sclerotomies helps wound closure. This can be
done using a microsponge to detect the presence of a vitreous wick.
BENEFITS OF MICROINCISION VITRECTOMY

Surgery time is reduced since there is no need for conjunctival opening
or closing, or closing sclerotomies—between 10 minutes and 16 minutes
depending on the series
There is less postsurgery inflammation reducing the need for topical
postoperative treatment and visual recovery is faster for the patient
improving postsurgery comfort
The ocular surface is better preserved along with limbus stem cells leading
to reduced conjunctival scarring. In turn, this leads to the diminished
appearance of postoperative ulcers or epithelial alterations, which is of
special interest in diabetic patients and contact lens wearers
A fourth port can be easily added so that the use of the ports and infusion can
be easily exchanged reducing peripheral vitreous traction and the production
of retinal tears. This benefit facilitates the introduction of lights such as
the chandelier and torpedo, as additional support or for bimanual surgery
As scleral sutures are avoided, this reduces the risk of corneal topographic
changes and associated astigmatism.
DRAWBACKS OF MICROINCISION VITRECTOMY

Maneuvering capacity is lessened due to the reduced rigidity of the
instrument ends. This makes it difficult to work in the retinal periphery
and increases the risk of damaging the natural lens in phakic patients. The
newer instruments have improved this feature of the 25-gauge system by
providing more rigid ends
Fluid dynamics is reduced compared to 20 gauge and 23 gauge, both for
aspiration and infusion. Vitreous aspiration and cutting is slower for 25
gauge although in the new models, the cutter mouth is closer to the vitrector
tip, which increases efficiency and enables more precise shaving of the
peripheral vitreous
A lower intensity of light is produced because of the caliber of the fiber.
This shortcoming has been resolved in part by the more powerful xenon
light source and lights with additional fibers (Chandelier)
There is a risk of trocar dislodgement especially during prolonged surgery.
This produces immediate intraoperative chemosis hindering surgery with
a need to replace the trocar
Instruments are more expensive than 20-gauge instruments although the
trend is that they are becoming comparable in price
193
COMPLICATIONS
The most frequent complications of 25-gauge vitrectomy are related to
sutureless sclerotomies.9-11 Postoperative hypotony is common but transient and
is associated with a conjunctival chemosis that reabsorbs spontaneously but
that may provoke ciliochoroidal detachments and macular folds. Postoperative
vitreous hemorrhages can occur due to bleeding of the sclerotomies toward
the vitreous cavity, especially in patients on anticoagulants. This complication
seems to be related to the lack of diathermy in the sclerotomy zone and may
be promoted by postoperative hypotony. Subconjunctival hemorrhages are
frequent but insignificant.
The most revealing study has reported a 0.018% incidence of endophthalmitis
following 20-gauge surgery compared to 0.23% for sutureless 25-gauge surgery.9
Collectively, reported results suggest a cumulative incidence of 0.025% for 20
gauge versus 0.45% for 25-gauge.9,12,13 In a survey performed in 2007, 14.7%
of responders admitted to having had at least one case of endophthalmitis
following sutureless 25-gauge or 23-gauge surgery, so it seems evident that the
rate of endophthalmitis is higher in these cases than for 20-gauge vitrectomy.
This difference has been attributed by some authors to incision construction,
since it seems that the risk of both postoperative infections, leakage and
hypotony, and even of postoperative vitreous hemorrhage, was higher in the
studies in which straight incisions were used compared to those placing angled
incisions. Thus, it seems the wound architecture can be an essential factor.
Similarly, it has been observed that the penetration, throughout the incision,
of India ink applied to the conjunctiva, immediately after the intervention is
greater in cases of straight incisions rather than angled incisions.14 Even when
the sclerotomy has been initially well constructed, excessive manipulation
and traction during surgery may induce changes in incision structure. In
addition, other complications common to 20-gauge surgery, such as cataract,
phototoxicity, etc. can be produced.
FUTURE PERSPECTIVES
The considerable technical advances made in the field of microincisional
surgery in recent years are likely to continue into the coming years. Areas in
which there is still room for improvement include improving illumination,
and resolving the issue of the excessive flexibility of instruments along with
the efficiency of vitrectomes. Ideally these will permit up to 5,000 cuts per
minute and adjustable cutting/aspiration cycles. This will also help shorten
core vitrectomy times and improve the control of vitreous cutting in peripheral
zones or close to a detached retina (Box 1).
Apart from adequate incision construction, developments in sclerotomy closure
techniques include the use of reabsorbable sutures and biological adhesives that
help reduce losses, which occasionally occur despite making angled incisions.
194
Box 1: Keys to microincisional surgery
• Incision shape: angled sclerotomies (in two planes) are preferable to
straight sclerotomies as the risk of an incision remaining half open is
reduced and this is accompanied by a diminished risk of leakage and
endophthalmitis
• Instilling povidone iodine 5%: in the conjunctival fornices and over the bul-
bar conjunctiva to reduce the risk of microbes entering the vitreous cavity
• Incision:
–– Measure the distance to the limbus and displace the conjunctiva at the
entry point
–– Flatten the sclera to obtain the longest possible intrascleral path, which
will allow for better apposition of the wound edges
• At the end of the surgery:
–– Undertake partial air/fluid exchange
–– Withdraw the cannula with a solid instrument such as the light pipe to
avoid vitreous wicks
–– Massage the incision wound with a microsponge or cotton bud
–– Wait for the wound to close
–– Use a reabsorbable suture or adhesive if leakage persists
–– Straight incisions need to be sutured.
These methods can be used in selected cases in which the surgeon has reason
to suspect the incision may not be airtight.15
REFERENCES
1. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch
Ophthalmol. 1996;114(10):1273-5.
2. Peyman GA. A miniaturized vitrectomy system for vitreous and retinal biopsy.
Can J Ophthalmol. 1990;25(6):285-6.
3. Mehran Taban, Peter K. Kaiser. (2009). Microincisional vitrectomy: techniques,
tips and the future.[online] Available from www.retinaspecialistsorg/services/
pat_survey/. [Accessed March, 2008].
4. Ibarra MS, Hermel M, Prenner JL, et al. Longer-term outcomes of transconjunctival
sutureless 25-gauge vitrectomy. Am J Ophthalmol. 2005;139(5):831-6.
5. Lakhanpal RR, Humayun MS, de Juan E, et al. Outcomes of 140 consecutive
cases of 25-gauge transconjunctival surgery for posterior segment disease.
Ophthalmology. 2005;112(5):817-24.
6. Okamoto F, Okamoto C, Sakata N, et al. Changes in corneal topography after
25-gauge transconjunctival sutureless vitrectomy versus after 20-gauge standard
vitrectomy. Ophthalmology. 2007;114(12):2138-41.
7. Rizzo S, Genovesi-Ebert F, Murri S, et al. 25-gauge, sutureless vitrectomy and
standard 20-gauge pars plana vitrectomy in idiopathic epiretinal membrane surgery:
a comparative pilot study. Graefes Arch Clin Exp Ophthalmol. 2006;244(4):472-9.
8. Yanyali A, Celik E, Horozoglu F, et al. 25-Gauge transconjunctival sutureless pars
plana vitrectomy. Eur J Ophthalmol. 2006;16(1):141-7.
9. Kunimoto DY, Kaiser RS, Wills Eye Retina Service. Incidence of endophthalmitis
195
after 20- and 25-gauge vitrectomy. Ophthalmology. 2007;114(12):2133-7.
10. Scott IU, Flynn HW, Acar N, et al. Incidence of endophthalmitis after 20-gauge vs
23-gauge vs 25-gauge pars plana vitrectomy. Graefes Arch Clin Exp Ophthalmol.
2011;249(3):377-80.
11. Scott IU, Flynn HW, Dev S, et al. Endophthalmitis after 25-gauge and 20-gauge
pars plana vitrectomy: incidence and outcomes. Retina. 2008;28(1):138-42.
12. Aaberg TM, Flynn HW, Schiffman J, et al. Nosocomial acute-onset postoperative
endophthalmitis survey. A 10-year review of incidence and outcomes.
Ophthalmology. 1998;105(6):1004-10.
13. Eifrig CW, Flynn HW, Scott IU, et al. Acute-onset postoperative endophthalmitis:
review of incidence and visual outcomes (1995-2001). Ophthalmic Surg Lasers.
2002;33(5):373-8.
14. Singh A, Chen JA, Stewart JM. Ocular surface fluid contamination of sutureless
25-gauge vitrectomy incisions. Retina. 2008;28(4):553-7.
15. www.retinalphysician.com/articleviewer.aspx?articleID=102833.
196
9.3 TWENTY-SEVEN GAUGE VITRECTOMY
Armadá Maresca Félix, Natalia Pastora-Salvador, Anna Grabowoska, María
INTRODUCTION
Currently, 27-gauge instruments are being used to directly remove epiretinal
membranes and for 27-gauge caliber vitrectomy.1,2 Thus, complete three-port
vitrectomy with 27-gauge instruments are today being performed using the
vitrectomes [Alcon Accurus (ALCON Fort Worth, Texas) and Dorc Associate
(DORC 3214 VN Zuidland, The Netherlands)] with the Dorc vitrector probe
(Fig. 1).
Extracting epiretinal membranes directly without vitrectomy is a treatment
mode designed to preserve the crystalline lens in patients susceptible to cataract
because of their age.1,2
The use of ever smaller caliber instruments for vitrectomy or other surgical
procedures seeks to improve recovery, induces less postoperative trauma,
diminishes conjunctival scleral scarring, avoids suture-induced astigmatism
and to achieve more rapid visual recovery and comfort for the patient.3,4
However, small-caliber surgical approaches are not free from several
complications such as insufficient sclerotomy closure, the need for sutures in
some cases and postoperative hypotony with the consequence of choroidal
detachments. Although rare, the risks of bacterial contamination and
postsurgical endophthalmitis need to be considered when performing a small-
caliber technique.
Reducing the caliber of vitrectomy to 27 gauge may help diminish these
complications, as induced risks are minimized.3,4
INSTRUMENTATION
The instruments used so far for 27-gauge procedures are manufactured by Dorc
and consist of a 27-gauge vitrector and valved, disposable metal 27-gauge
microcannula mounted on a 27-gauge stiletto blade with a handle whose
proximal end has scleral markings. The infusion line, also by Dorc, has a jawed
tip to help connect it to the microcannula (Figs 1, 2, 3 and 4).
The vitrectome with which these instruments are used is the Dorc Associate
machine (DORC 3214 VN Zuidland, The Netherlands), but it is also possible
to work with the Alcon Accurus (ALCON Fort Worth, Texas). As light pipes,
a Dorc or Synergetics design can be employed with the Alcon Accurus, Dorc
BrightStar or Synergetics Photon light sources (Figs 5 and 6).
Twenty-seven gauge caliber laser probes are manufactured by Dorc and
Synergetics, and with an adapter can be used with the Alcon laser system.
The surgical instrument manufacturers Synergetics (Synergetics Inc., St
Charles, MO, USA) and Asico (26 Plaza Drive Westmont, IL 60559, USA)
197
Figure 1 Dorc’s 27-gauge vitrector
Figure 2 Cutting mouth of Dorc’s 27-gauge vitrector
Figure 3 Metallic valved trocar for 27-gauge vitrectomy

198
Figure 4 Tip of Dorc’s 27-gauge infusion cannula
Figure 5 Self-puncturing 27-gauge light probe by Synergetics
Figure 6 Dorc’s 27-gauge light fiber

199
already offer in their catalogues a sufficient number of forceps, scissors,
diathermy probes, spatulas and picks to conduct most current procedures,
especially at the level of the macula. The firm Hurricane offers a 27-gauge
cannula that is useful for aspiration of fluid/gas exchange maneuvers.
Owing to a study by Oshima,5 we have available data to compare with the
25-gauge Total Plus system by Alcon. Thus, for the 25-gauge system versus the
27-gauge system, respectively: vitrector dimensions are inner diameter 0.347
mm versus 0.275 mm, outer diameter 0.515 mm versus 0.409 mm; distance
from cutter mouth to its tip 0.33 mm versus 0.211 mm; cutter mouth area 0.066
mm2 versus 0.079 mm2; vitrector length 32 mm versus 25 mm; and vitrector
tip displacement in response to a 0.5 N force (i.e. rigidity) 3.3 mm versus 5.8
mm.5 These data are provided in Table 1.
The optimal duty cycle for the 27-gauge Dorc vitrectome is 1,000–1,500
cuts per minute and an aspiration capacity of 0.05–0.07 ml/second and power
of 600 mm Hg.5 Optimal infusion pressures using a Dorc 27-gauge infusion
system with an Alcon Accurus vitrectome are in our opinion 25–35 mm Hg.
Using these pressures, maximum aspiration without cutting will not induce
ocular prolapse due to the vacuum generated.
INDICATIONS
The indications we propose for this caliber span from macular surgery in its
entirety, with the exception of eyes with myopia magna, including macular hole,
macular pucker, etc., to simple hemovitreous, vitreous opacities, vitreomacular
traction, noncomplex proliferative diabetic retinopathy, vitreous biopsy,
endophthalmitis and macular edema of different origins.6
Our first impression with the use of this equipment (with the Alcon Accurus
vitrectome) has been the extraordinary cutting and suction capacity for this small
caliber. The rigidity of the vitrector shaft enables working comfortably in the
periphery and even entering the anterior chamber without the vitrector bending.
Its shorter length than probes of higher caliber confer it this rigidity yet it is not
Table 1
Comparing the new 27-gauge instruments with the 25-gauge Total Plus
system by Alcon
25 gauge 27 gauge
Inner diameter 0.347 mm 0.275 mm
Outer diameter 0.515 mm 0.409 mm
Cutter mouth-to-tip distance 0.33 mm 0.211 mm
Guillotine area (vitrector mouth area) 0.066 mm 0.079 mm
Length 32 mm 25 mm
Rigidity (displacement in response to a 3.3 mm 5.8 mm
0.5 N force)
200
recommended for long eyes such as those with myopia magna. The 27-gauge
infusion system generates the necessary intraocular pressure to undertake any
type of maneuver such as achieving hyperpressure in cases of retinal bleeding or
fluid/air exchange. For such exchanges, the Hurricane 27-gauge cannula needs
to be used with the vitrectome’s active aspiration system.6
For illumination, the PHOTON I light source by Synergetics has proved
sufficient for most vitrectomies. However, each light probe has its peculiar
features. Thus, the 27-gauge Dorc system provides diffuse light, which is
inadequate for macular surgery (comprising most vitrectomies for which it is
used). The Synergetics probe is more useful for this purpose, since it gives more
focal light. Nevertheless, both probes are excessively short and the macula is
not properly reached by the light beam. This is perhaps the most significant
drawback of the 27-gauge caliber system.
In our experience, the forceps marketed by Asico are world apart from the
remaining 27-gauge forceps available. Thus, their Corcostegui pick forceps are
extremely good at grasping and their rigidity makes the surgeons forget that they
are working with a caliber of 27-gauge. The remaining designs are a step behind
these supplied by Asico.6 Both Synergetics and Dorc 27-gauge laser probes
have proved their efficacy for photocoagulating even the peripheral retina.
In our initial 10 surgeries using this caliber we have treated cases of epiretinal
membranes, hemovitreous secondary to retinal central vein obstruction and to
diabetic retinopathy, myopic foveoschisis, macular hole and combined cataract/
macular pucker. The mean surgery duration was 27.3 minutes. In no case was it
necessary to suture the sclerotomies and mean intraocular pressure was slightly
lower, 24 hours after surgery than the presurgery value—13.1 mm Hg compared
to 15 mm Hg. At 1 week postsurgery, the mean was 16.1 mm Hg. Conversion
to a larger caliber (23-gauge or 25-gauge) was not necessary in any case and
there were no perioperative complications.
CONCLUSION
In conclusion, we would say that the 27-gauge vitrector has a similar rigidity
to the 25-gauge Alcon design, albeit shorter in length, and shows sufficient
cutting and aspiration capacity.
Optimal duty cycles are obtained from 1,000–1,500 cuts per minute for
aspiration power ranges of up to 600 mm Hg. However, above a speed of 2,000
cuts per minute it is inefficient.
Using a vented gas forced infusion pressure system, a range of 25–35
mm Hg is sufficient to maintain a flow rate of 0.05–0.07 ml/second, which is
optimal for vitrectomy.
The light pipe is clearly too short such that a focal light source is better
than a more diffuse one.
Our surgery times are slightly longer than those needed for 25-gauge
procedures but this is because we are still at an early stage in the learning
201
curve. As the caliber is reduced, so too are the risks of complications inherent
to Micro-incision vitrectomy system, although there is still a need for new
instruments and materials to improve the quality of surgery.
REFERENCES
1. Saito Y, Lewis JM, Park I, et al. Nonvitrectomizing vitreous surgery: a strategy to
prevent postoperative nuclear sclerosis. Ophthalmology. 1999;106(8):1541-5.
2. Sawa M, Saito Y, Hayashi A, et al. Assessment of nuclear sclerosis after
nonvitrectomizing vitreous surgery. Am J Ophthalmol. 2001;132(3):356-62.
3. Sawa M, Ohji M, Kusaka S, et al. Nonvitrectomizing vitreous surgery for epiretinal
membrane long-term follow-up. Ophthalmology. 2005;112(8):1402-8.
4. Sakaguchi H, Oshima Y, Tano Y. 27-gauge transconjunctival nonvitrectomizing
vitreous surgery for epiretinal membrane removal. Retina. 2007;27(8):1131-2.
5. 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.
6. Armadá Maresca, Félix, et al. Técnicas 27 gauge poderaoserutels? Libro: 25
Perguntas and Respostas Membranas Epirretinianas. GER Grupo de Estudios Da
Retina: 2011. pp. 54-9.
chapter 10
Vitrectomy in Anterior
Segment Surgery
Complications
José Juan Martínez-Toldos, Juan Carlos Elvira-Cruañes
INTRODUCTION
Cataract surgery is one of the most frequently performed surgical procedures
worldwide. Over the last few years, the technique has advanced tremendously
especially since the use of phacoemulsification was proposed by Kelman.1,2
Today, there is no argument that the surgical treatment of choice for cataract
is phacoemulsification, as a safe procedure offering rapid visual recovery.
Phacoemulsification surgery has been completed with the use of topical
anesthesia and sutureless corneal incisions.
This type of surgery provides excellent results in the vast majority of cases.
However, although infrequent, when complications do occur, these can lead to
a significant loss in vision. It is, therefore, important that the surgeon knows
how to manage these complications to minimize vision loss in these patients.
OCULAR PERFORATION IN RETROBULBAR ANESTHESIA

As already pointed out, topical anesthesia is even more used by anterior pole
surgeons, since it avoids the risk of perforation during retro-or peribulbar
injection. Notwithstanding, in vitreoretinal surgery the use of retrobulbar
anesthesia represents an advancement from the days when surgery was
performed under general anesthesia. We have already mentioned that our
anesthesia of choice is transconjunctival retrobulbar, which has provided
excellent results.
Although we generally use topical anesthesia, there are still cases in which
the retrobulbar approach is preferred, such as in patients who do not cooperate,
patients with neurological or psychic disorders; or in combined cataract/
glaucoma, cataract/vitrectomy surgery and when an intraocular lens (IOL) is
fixed to the iris in aphakic patients with no capsule support.
Chapter 10  Vitrectomy in Anterior Segment Surgery Complications
203
Globe perforation while administering local anesthesia can be a rare yet
serious complication occurring in 0.075–0.1% of the cases.3 Among the risk
factors for this complication are axial myopia, posterior staphyloma and
previous scleral surgery. The risk increases when axial myopia is associated
with a small orbit impairing the control of the needle and following the needle
as it crosses the tissue planes. It is also known that an eye size larger than 26
mm, staphyloma or the presence of a scleral buckle will also increase the risk of
perforation. Duker et al4 estimated an incidence of 1 in 140 cases in these eyes.
In such cases, the use of sub-Tenon’s peribulbar anesthesia may be considered,
which consists of introducing anesthesia, avoiding its injection, via an incision
in the anterior conjunctiva using a blunt metal needle into the sub-Tenon’s
space. A variation of this is Fukasaku’s pinpoint anesthesia, whereby a long,
curved, blunt-tipped cannula is inserted in the sub-Tenon’s space until close to
the optic nerve.5,6 To avoid complications during the injection process, the “up
and in” viewing position popularized by Atkinson should be avoided since in
this position, the macula and optic nerve are more exposed and therefore more
susceptible to damage. Mild sedation with propofol is thus recommended for
anesthesia injection in the primary viewing position.
Transconjunctival Sub-Tenon’s Anesthesia

The conjunctival incision is placed 10 mm from the limbus (usually in the
inferior nasal quadrant, between the middle and inferior rectus muscles) until
some 1.2 mm length of sclera can be observed. Next the sub-Tenon’s space is
dissected and opened to help introduce the cannula, which should preferably be
a blunt curved metal or plastic design of 20 gauge. The cannula is introduced
and advanced through the sub-Tenon’s space until the retrobulbar zone is
reached where a mixture of adequate anesthetic is injected (some 2–3 ml). A
few minutes should be waited gently massaging the area to obtain the full effect.
This form of anesthesia achieves good analgesia and akinesia. It is also a good
rescue technique for incomplete/failed peri-or retrobulbar anesthesia or when
surgery is complicated or prolonged in patients undergoing cataract extraction
under topical anesthesia (in such cases it is best to suture the incision). Although
some surgeons/anesthesiologists use a needle for sub-tenonian injection, a blunt
cannula introduced through a conjunctival incision is safer in terms of avoiding
ocular perforation and retrobulbar hemorrhage. The greatest shortcoming of this
procedure is a higher incidence of conjunctival chemosis, which increases the risk
of extrusion of current vitrectomy trocar systems. Chemosis may be drained by
massage or even a conjunctival and Tenon incision to avoid this small problem.7
Ocular Perforation
Ocular perforation may occur without previous warning. High intraocular
pressure (IOP) can be induced when anesthetic is injected in the globe.
Intraocular hypotension can also occur if the eye is perforated before the
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anesthetic is injected. Intraoperatively, a diminished or absent fundus reflex
may be observed.
After ocular perforation, vitreous hemorrhage or retinal detachments or
tears are produced in most cases although these may not be detected until the
first postoperative visit. Most intraocular anesthetics, especially lidocaine,
are not toxic for the retina and vision is recovered in the patient after the
accidental injection of anesthetic in about 16 hours. The most serious outcome
of inadvertent anesthetic injection is central retinal artery obstruction due to
the increased intraocular volume.8
Treatment
Treatment requires that the problem is first identified. If suspected, cataract
surgery should be delayed until the problem stabilizes and can be correctly
identified. In cases of intraocular injection, the increased pressure can lead
to occlusion of the central retinal artery. If this occurs, the patient will
immediately go into amaurosis such that the elevated ocular tone can be felt,
often accompanied by an immediate, progressive, intense corneal edema. In
such cases, IOP should be reduced by an anterior chamber paracentesis and
removal of the aqueous humor.
We should also visualize using the indirect ophthalmoscope the state of the
retina in peri/retrobulbar cases that show signs of: hemorrhage at the angle or
anterior chamber, severe hypotony or hypertony or loss of previous fundus reflex
in an early cataract. This could help the surgeon make the appropriate decision.
Following anesthesia injection, if the ocular media is transparent and the
retina is reattached and there is extramacular perforation, photocoagulation of
the retina is performed at the site of needle entry.
If vitreous hemorrhage exists, combined phacovitrectomy surgery is
undertaken in which it is especially important to eliminate all the vitreous
traction at the portal of entry by photocoagulating around the lesion.
If there is a previous retinal detachment observed by ophthalmoscopy
or ultrasound because of accompanying vitreous hemorrhage, we can also
undertake phacovitrectomy. A scleral buckle is usually not necessary if vitreous
traction has been adequately removed but should never be ruled out depending
on the size of the tear or other factors indicating a poor prognosis. An auxiliary
light can be used for this purpose, which will allow, with self-indentation, a
more exhaustive peripheral vitrectomy. Linear tears can be seen at the needle
entry point and these could subsequently detach the retina.
Occasionally, retinal incarceration can occur, in which case we perform
a phacovitrectomy with retinotomy to remove the traction caused by the
incarceration and then undertake endophotocoagulation with posterior
tamponade, usually with gas or air.
When the macular area is affected by subretinal hemorrhage, phacovitrectomy
can be carried out with retinotomy to remove the blood with the help of tissue
plasminogen activator (tPA). If choroid hemorrhage is not too extensive, it could
205
resolve on its own. If not, 14 days later scleral drainage will help liquefy the
blood and then surgery with transscleral drainage and intraocular injection of
perfluorocarbon liquid can be performed.
RETROBULBAR HEMORRHAGE
Retrobulbar hemorrhage occurs in approximately 0.3–0.44% cases of
retrobulbar anesthesia.9,10
Predisposing factors for this complication are medication with anticoagulants,
corticosteroids or nonsteroidal anti-inflammatory drugs. Systemic diseases such
as thrombocytopenia and poorly controlled high blood pressure can also be
risk factors, as can excessive handling of the needle during its insertion and
the injection procedure.
Several studies have revealed a significant flow reduction in posterior ocular
vessels following a retrobulbar injection (even in the absence of hemorrhage).11
Retrobulbar hemorrhage causes rapid filling of the orbit with significant
chemosis, proptosis and immobilization of the globe. The abrupt increase in
IOP can compromise the intraocular vasculature.12,13
In most cases, compression of the globe with a finger can be enough to
control bleeding. If the pressure is very high, we can perform a canthotomy to
decompress the globe and avoid vascular effects. Surgery should be undertaken
after a period of 15 days.
If the lateral canthotomy fails to reduce the pressure on the ocular globe,
an emergency orbitotomy can be performed. After opening the external canthal
tendon and freeing its superior and inferior fibers, we access the retrobulbar
space in the inferior temporal quadrant reaching the septum. The septum is
dissected using blunt scissors and opened between the lateral and inferior recti.
If there is hematoma associated with the high pressure, retrobulbar pressure may
be reduced through this septal opening by means of the drainage described.14
There are three sites in the anterior orbit that are relatively avascular: (1) the
inferotemporal quadrant (where the lateral third joins the medial two-thirds);
(2) the superotemporal quadrant in the sagittal plane of the lateral limbus; and
(3) the nasal component of the middle rectus. The superonasal quadrant should
be avoided because of the presence of terminal vessels of the ophthalmic artery
and the trochlea of the superior oblique muscle.15
ANTERIOR VITRECTOMY
An anterior vitrectomy can be defined as the removal of vitreous from the
anterior chamber, or the anterior third of the vitreous cavity. The approach
can be anterior via the clear cornea, or sclerocorneal limbus, or posterior via
the pars plana.
Most common indications for an anterior vitrectomy are capsular rupture
during cataract surgery or in cases of surgery for anterior segment trauma. Other
206
indications are the removal of vitreal fibers bound to the iris or to the surgical
wound, as a measure of avoiding complications related to vitreous adhesions
such as cystoid macular edema or vitreocorneal touch syndrome, which could
provoke corneal edema.
Vitrectomy Following Vitreous Loss

The incidence of vitreous loss has been estimated at 0.8–1.25%16-19 and is most
common in elderly patients with hard cataracts and with pseudoexfoliation
syndrome owing to zonular weakness and poor dilation.
Vitreous is lost when the posterior capsule is torn during surgery. The
surgeon should be well aware of the signs that indicate capsular rupture such
as deepening of the anterior chamber and difficult displacement of crystalline
lens material. Often rupture occurs beneath the nucleus and passes undetected
by the surgeon. When a posterior capsular rupture is detected, the surgeon
should act quickly, yet calmly, first by withdrawing all instruments from the
anterior chamber (Fig. 1) following the steps:
Stop phaco tip aspiration
Keep all instruments in the eye; do not remove them
Maintain irrigation; pedal at position 1
Withdraw the paracentesis instrument
Generously fill the anterior chamber with viscoelastic
Once the anterior chamber has been filled with viscoelastic, the phaco tip
can be removed and the situation assessed. Often the buttonhole widens
as the pressure in the anterior chamber falls because of flow cessation
without having adequately filled the anterior chamber with viscoelastic.
Nevertheless, the chamber should be filled with viscoelastic for the
remaining maneuvers.
These maneuvers serve to keep the vitreous in place preventing its escape
through the incisions. It is important to stop aspiration since the entire vitreous
sac could be suctioned. The viscoelastic maintains the IOP and keeps the
vitreous in a posterior position.
Figure 1 Capsular rupture. Aspiration through the phaco tip should be stopped
and a constant intraocular pressure maintained, first with infusion fluid and then
with viscoelastic
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Traditionally vitrectomy was performed using the vitrectome with coaxial
irrigation, which was inserted through the phaco incision lowering the height
of the infusion bottle. However, this method has the consequence of enlarging
the capsular tear and hydrating the vitreous, provoking its escape toward the
anterior chamber and incisions. The use of the vitrectome with coaxial infusion
is therefore not recommended (Figs 2A and B).
We prefer to perform a vitrectomy using both hands;19 one for the irrigation
cannula and the other for the vitrectome. If we place the vitrector at the phaco
incision, infusion will cause the vitreous to escape through the incision and
the vitreous fibers will become trapped in the postoperative course. To avoid
this, we should:
Make a new 1 mm incision close to the phaco incision making use of the
pressure provided by the viscoelastic
Introduce the irrigation tube through the paracentesis, lowering the infusion
bottle height to 15 cm above the patient’s head; direct irrigation toward
the iris and aspirate most of the saline with the vitrector to avoid hydrating
the vitreous
Introduce the vitrectome with no irrigation through the new incision (not
the phaco incision)
Place the vitrectomy probe just under the tear with the vitrector opening
facing upward to extract the vitreous above the point of rupture
The remains of the cortex can be removed by vitrectome aspiration. The
normal irrigation/aspiration momentary cutting modes are useful to suction
the cortex at the periphery (with no cutting function to avoid breaking
capsule remains) and then cutting more in the center to minimize traction
on small vitreous fibers that could be trapped.
If the anterior capsule is intact, an IOL can be implanted by trapping its
optics in the capsulorhexis; this creates a stable plane to complete the
anterior chamber flushing procedure.
These maneuvers are generally conducted with vitrectomy systems fitted
A B
Figures 2A and B (A) Anterior vitrectomy following capsular rupture; (B) The
image shows the irrigation line and vitrector introduced through accessory incisions
avoiding the main temporal incision
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to the normal phacoemulsifier. However, with the necessary experience and
equipment, 23-gauge or even 25-gauge instruments (depending on the size and
density or cortex remains) may be employed. A 23-gauge irrigation cannula
may be adapted to the vitrectome infusion line and, through another corneal
incision, the 23-gauge vitrector is introduced without the need for trocars.20,21
An infusion pressure of 20 mm Hg is set and we conduct a bimanual vitrectomy.
Following a central vitrectomy in the pupil area, we proceed with the peripheral
cortex. Depending on its density, the cutting speed can be dropped to 500–600
cuts per minute for its aspiration (Figs 3A and B).
These maneuvers will enable us to pressurize the eye while controlling the
vitreous. The pressure provided by the viscoelastic and the infusion cannula
keeps the phaco incision closed. If not, the incision can be closed with a cross
stitch.
Figures 3A and B (Chalam et al) (A) After capsular rupture, the corneal wound can
be sutured and 25 gauge trocars introduced for the anterior vitrectomy just beneath
the capsule tear. The infusion cannula may be placed at the pars plana or the anterior
chamber through the cornea; (B) Once the tear and anterior chamber have been freed
of vitreous, the intraocular lens is placed in the sulcus with the help of viscoelastic
209
Vitrectomy can be undertaken without irrigation relying only on the
viscoelastic pressure with the vitrectomy probe’s open side facing upward. As
pressure is lost, more viscoelastic is introduced. This maneuver allows us to
remove the vitreous that tends to escape without the need for irrigation.
If a large amount of nucleus remains during anterior capsule rupture, the
eye is pressurized using a dispersive viscoelastic placed under the nucleus
(viscoelastic is also placed in the anterior chamber), displacing the vitreous.
The irrigation bottle is then lowered, the nucleus is transferred to the anterior
chamber and phacoemulsification undertaken in the anterior chamber, trying
to avoid aspirating the vitreous. This is done by alternatively stopping to plug
the phaco tip and continuing emulsification, then stopping to plug the tip again
and emulsifying, etc. This process is repeated until the complete removal of
the nucleus. We can then go on to perform a bimanual vitrectomy, as described
above. A guide may be placed under the nucleus for the emulsification procedure
with the help of viscoelastic as described by Michelson.22
If the nucleus is lost in the vitreous cavity, then the vitrectomy is performed
as indicated; if the capsule exists, the IOL can be implanted and the patient
referred to a posterior pole surgeon for standard vitreoretinal surgery. If the
surgeon is an experienced anterior/posterior pole surgeon, then, in the same
operation, vitreous surgery can be conducted and a sulcusor iris-fixated IOL is
implanted. We prefer this last option.
RETAINED LENS FRAGMENTS

The clinical situation that most frequently leads to the presence of crystalline
lens or portions of the lens in the vitreous cavity, is capsular rupture during
phacoemulsification (Figs 4A and B). This complication is more common in
elderly patients with a hard nucleus and in cases of pseudoexfoliation. It is
also more likely to occur in patients who have undergone previous vitreous
surgery and also frequently occurs at the start of the learning curve for
phacoemulsification. Its incidence is 0.3%.23 Sometimes, zonular weakness will
lead to posterior dislocation of the lens without subsequent capsular rupture.
Also posterior polar cataracts or traumatic cataract can induce the nucleus to fall.
Several techniques have been described to treat a dislocated crystalline
lens. These mostly include a three-port pars plana vitrectomy and the use of a
perfluorocarbon liquid to refloat the crystalline lens to an anterior position.24-26
Other surgeons have described maneuvers performed during surgery that
involve refloating the nucleus using large volumes of balanced saline solution
(BSS)27 or applying the vitrectome with coaxial irrigation through the phaco
incision and Machemer lens. 28 All these maneuvers and techniques are
potentially dangerous, and have been linked to the possibility of giant retinal
tears29 such that we do not recommend them. In these situations, the vitreous
should be removed from the anterior chamber without excessive handling to
avoid inflammation, and the IOL implanted. This is made possible because
210
of the presence of capsular remnants or an intact anterior capsulorhexis; the
luxated crystalline lens can then be approached. If the crystalline lens is very
hard, it is best not to implant a lens in case it has to be removed anteriorly
(Box 1).
The most common clinical manifestation of a dislocated crystalline
lens is diminished vision in the postoperative course. Poor visual acuity is
a consequence of intraocular inflammation, which is directly related to the
amount of crystalline remains and the extent of surgical manipulation. This
inflammation increases during the 1st week and may then start to decrease.
In a high proportion of cases, IOP increases. This is due to obstruction of
the trabeculum by inflammatory cells or lens particles.
Corneal edema is another constant sign of this problem and is related to
surgical manipulation, mass remains in the anterior chamber and a high IOP.
The occurrence of vitreous hemorrhage in the postoperative course is related
to inadequate pressure changes or trauma to tissue due to posterior dislocation
of the lens or part of the lens.
Retinal detachment is not a consequence of the presence of crystalline
material in the eye rather it is produced by the manipulation needed during
cataract surgery or posterior vitreous surgery to extract the lens. Hence, traction
of the vitreous gel will subsequently provoke retinal tears and detachment. The
appearance of this problem markedly worsens the visual prognosis.
A B
Figures 4A and B (A) Soft nucleus located in the anterior vitreous; (B) An almost
complete nucleus in the posterior vitreous. Note the initial cuts made for the “divide
and conquer” maneuver
Box 1: Managing a dislocated crystalline lens

• Avoid panicking; do not undertake any unplanned maneuvers
• Perform an anterior vitrectomy without leaving vitreous in the wound
• If there are capsular remnants implant an intraocular lens
• If the cataract is very hard avoid intraocular lens placement
• Apply ocular anti-inflammatory and hypotensive agents.
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Surgical Indications
It is clear that large fragments of crystalline lens will not be well tolerated by
the eye and that vitreous surgery should be pursued as soon as possible after
the corneal edema resolves, which is the limiting factor for surgery.
When crystalline remnants are small and soft, that is, when fewer than
25% are less than 2 mm in size,30 the patient should be monitored. However,
we should always be prepared, since if the inflammation does not resolve, we
will have to undergo surgery because lens remnants could exist in the anterior
vitreous or beneath the iris that could go undetected.
In our experience, any hard crystalline lens fragment should be removed.
If we wait too long, we run the risk of substantial inflammation with vascular
effects such that we prefer to pursue surgery in these cases. Soft lens remains
are simply monitored, and vitreous surgery undertaken if we are unable to
control the inflammation.
Sometimes a patient may have soft lens remnants in the bag, which
become displaced in the postoperative course to the papillary area inducing a
pseudocataract. In these cases, we also pursue early surgery.
The time from dislocation to surgery should always be as short as possible
and never exceed a month (Box 2).
Associating Surgery at the Time of Lens Dislocation

If the surgeon performing cataract surgery is also (as often occurs) a vitreoretinal
specialist, conversion to standard vitreous surgery may be conducted at the
time of lens dislocation.
Each day there are more machines available with Venturi and peristaltic
pumps so that phacoemulsification and vitrectomy can be performed with the
same equipment. In effect, we conduct vitreous surgery at the time of lens
dislocation. The corneal incision should be sutured before proceeding with
the vitrectomy. The advantages of performing vitreous surgery at the time of
lens dislocation are:
No complex maneuvers are needed
The eye is not excessively manipulated
The cornea is kept free from edema
No inflammation has been produced at this stage
An IOL can be placed on capsule remnants
Box 2: Surgical indications for a dislocated crystalline lens

• Large lens fragments
• Hard lens fragments, irrespective of size
• High intraocular pressure
• Noncontrollable uveitis
• Pseudocataract due to cortical remains
• Early surgery: 10–15 days, maximum 30 days
212
If we lack capsular support, an Artisan lens can be fixed to the iris in the
anterior chamber or behind the iris.
The drawbacks of immediate vitrectomy are usually associated problems: a
greater risk of choroidal hemorrhage due to prior manipulation of the anterior
pole and the presence of an adhered posterior hyaloid. This will need to be lifted
to adequately remove the crystalline lens fragments and avoid postoperative
complications such as retinal detachment and macular pucker or macular edema.
Thus, in a single surgery, the problem can be resolved avoiding the need for
a second operation allowing for faster recovery of vision. Moreover, surgery
is ambulatory so the patient can go home.31
For conversion to vitreous surgery, we first have to close the corneal incision
with a cross stitch, pressurizing the eye with viscoelastic, and then administer
anesthesia, preferably sub-Tenon’s peribulbar, as described at the beginning
of this chapter.
Surgical Technique
Our current preference is the use of 23-gauge transconjunctival trocar systems.
After introducing the trocar for the infusion line a superior trocar is introduced.
A conjunctival incision is made and the sclerotomy widened to 20-gauge if the
phacofragmentor will need to be used and we lack a 23-gauge phacofragmentor
or phacoemulsifier. Infusion via 23-gauge avoids hypotony (even with the
20-gauge phacofragmentor) if we set a pressure of 30 mm Hg or more, especially
if we can control intraocular pressure as with the latest vitrectomy machines.
However, 25-gauge systems could be dangerous due to imbalance between
infusion and aspiration. With the 23-gauge trocars we try to eliminate as much
of the vitreous possible, producing posterior detachment of the hyaloid, along
with all the crystalline lens fragments possible. The phacofragmentor needs only
be used for the harder fragments that cannot be eliminated with the vitrectome
even at high aspiration power and low cutting speed (300–400 cuts per minute).
It is very useful to have an auxiliary torpedo or chandelier-type light source.
First, we perform a central and peripheral vitrectomy as exhaustively as
possible to avoid aspirating further vitreous in the aspiration or emulsification
maneuvers with the retinal traction this would produce. It is known that vitreous
cannot be emulsified. We should especially insist on the sclerotomy through
which we will later introduce the phacofragmentor, since due to its larger mouth
and aspiration without cutting it is easier to inflict retinal damage.
The hardness of the crystalline lens is graded 1–4 (1-soft, 2-semisoft,
3-semihard and 4-hard). The following situations can be encountered:
Soft remnants (grade 1) at the anterior and posterior poles
Medium hardness remains (grade 2–3) at the posterior pole
Hard crystalline lens remains (grade 4)
Remains of any grade with retinal detachment
Hard lens remnants with retinal detachment
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When lens fragments are soft, they can be easily removed with the vitrector
both from the anterior and posterior pole. The anterior pole is cleaned by
freeing the vitreous and conducting an anterior vitrectomy with indentation to
remove vitreous as much as possible. We then continue by aspirating the cortical
remnants that remain in the capsular bag with the vitrector, always trying to
preserve sufficient remnants for IOL placement or to avoid the displacement of
an already implanted IOL (Figs 5A and B). The momentary mode of vitrectomy
is very useful to remove these cortical remains. First, we suction cortical masses
in the periphery (to avoid breaking capsule remains) and then switch to cutting
mode in the center. We then check whether the hyaloid is attached and remove
it with aspiration to the periphery.
Surgery is completed by conscientiously revising the retinal periphery
to check for tears or holes. Any small retinal breaks are treated with
laser or cryotherapy, and fluid/air exchange is undertaken as a preventive
measure.
In the case of a harder crystalline lens (grade 2–3), we will have to use
the phacofragmentor. The first step is to free the crystalline lens from the
vitreous with the vitrector, ensuring it falls to the posterior pole. We should
then continue to eliminate all possible remains with the vitrector, which is
always safer than the phacofragmentor. Once the crystalline lens has fallen
to the posterior pole, the state of the posterior hyaloid can be verified. If
it cannot be observed, the use of triamcinolone will help. A sign that the
hyaloid membrane is attached is that the fragments do not freely move and
often they spring back toward the retina as the hyaloid also incarcerates at
the mouth of our probe.
Once the hyaloid has been eliminated, we can introduce a little
perfluorocarbon to protect the retinal posterior pole. If we introduce too much,
because of the convex surface of the perfluorocarbon bubble, the lens will move
to the periphery impairing its visualization and approach.
A B
Figures 5A and B (A) Soft crystalline lens remnants that fully occlude the pupil
impeding visualization of the fundus; (B) These cortical remnants are removed under
aspiration using the vitrectome with no cutting function
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In most cases it is sufficient to partially refloat the crystalline lens to roughly
the distal third of the vitreous cavity. For very hard lenses, it is recommended they
should be refloated to a plane behind the iris before their phacofragmentation.
With the phaco tip we approach the crystalline lens fragment and aspirate
to trap it and lift it to the center of the eye where, with the help of the
endoillumination probe, we continue with its emulsification. Usually the lens
will break up into pieces that fall to the posterior pole and these need to be
repeatedly retrieved and lifted until only small fragments remain. At this point,
we again use the vitrectome to eliminate them and to aspirate any cortical
remains that may persist. The phacofragmentor settings should be pulsed
(maximum number of pulses possible) linear-mode ultrasound and medium
vacuum (80 mm Hg, always with the crystalline lens at the phaco tip). Special
attention has to be paid at the times the point becomes exposed because this
is when most aspiration is exerted on the vitreous cavity, such that we need to
lower aspiration at these moments.
To keep the crystalline lens stuck to the phacofragmentor tip, we should use
low ultrasound power. This will avoid the lens fragments shooting out from
the phaco tip (Figs 6 A and B). The anterior pole phacoemulsifier may also be
used, though with the drawback of its shorter tip (yet sufficient in most cases).
If we use the Ozil system, fragments are more easily retained on the phaco tip
and thus more easily eliminated.
Surgery is completed by revising the periphery.
If the crystalline lens is hard (grade 3–4), it will be difficult to remove and
many aspiration/lifting maneuvers will be needed (Fig. 7). Ultrasound
power may be increased and it is recommended that the lens be luxated to a
retroiridal plane. The anterior pole phacoemulsifier may also be used, which
we introduce with a microtip without irrigation through the sclerotomy. The
drawback is that it is shorter than the phaco tip and it is more difficult to
reach the posterior pole. As a benefit, however, it is extremely efficient and
much quicker. Low powers are used to avoid repelling the lens fragments
A B
Figures 6A and B (A) Freeing the posterior hyaloid with triamcinolone and
the vitrectome active; (B) Phacofragmentation of the nucleus with the aid of the
endoillumination probe
215
and a little perfluorocarbon is introduced over the macular area to protect it
from the fallout of lens fragments.
We have been using the phacoemulsifier for more than 10 years and have
never had any problems of burns at the corneal incision. This instrument is
tremendously efficient if it is used with low flow rates (10–15 ml/minute) and
low ultrasound power in pulsed mode to keep the crystalline lens fragments
stuck to the tip.
A type of smoke is produced upon emulsification that fills the vitreous
cavity, and this has to be aspirated to restore good visualization (Figs 8A and B).
It is also best to previously protect the corneal endothelium with viscoelastic.
Figure 7 In the case of hard remnants, we can use viscoelastic alongside

perfluorocarbon to keep the crystalline lens fragments in the central zone and
avoid their displacement to the periphery promoted by the convex surface of the
perfluorocarbon bubble. If the perfluorocarbon bubble is small, viscoelastic is not
needed
A B
Figures 8A and B (A) As we emulsify the nucleus in the vitreous cavity, smoke is
produced at the start of the maneuver; (B) Lifting the nucleus to the middle portion
of the vitreous to start emulsification. The tip of the phaco has been plugged but
aspiration is maintained providing good retaining power
216
During phacofragmentation or phacoemulsification, small drops of saline can
splash both wide-field contact lenses or noncontact visualization systems, which
will consequently need to be cleaned.
The small particles remaining on the retina can be removed with the
vitrectome and we can get closer to the retina with sufficient safety.
If the patient presents retinal detachment besides a dislocated natural lens,
we first emplace a scleral buckle and then revise the anterior chamber since
there are often remnants of masses that hide in the anterior angle. Special
attention should be paid to eliminating vitreous remains on any retinal tears; we
might find to avoid the introduction of perfluorooctane as the lens is refloated
and the entry of subretinal fragments. We then perform anterior and posterior
vitrectomy and introduce the perfluorocarbon liquid to reattach the retina and
refloat the fragments to an anterior position, where with the vitrector they can
be removed if soft. If harder, we can use the phacoemulsifier or fragmentor,
setting the parameters mentioned above. In this case, if we place the probe in
the pupillary area close to the level of the iris, we can use a spatula to keep the
fragments on the tip; we use the microscope light as if we were undertaking
anterior pole surgery without the need for endoillumination at this stage.
Following emulsification, we apply the endolaser, implant an IOL if not
already placed on capsular remnants, or even better, trapped in the anterior
capsulorhexis if intact. If there is no capsular support, we can fix the IOL to
the iris, having previously revised the periphery. This surgery procedure is
completed with perfluorocarbon/air and air/gas exchange, maintaining the
habitual tamponade proportional to the case.
In the uncommon event of a retinal detachment and a dislocated very hard
crystalline lens, the procedure is as follows:
Placement of a scleral buckle
Anterior and posterior vitrectomy
Perfluorocarbon to reattach the retina and refloat the nucleus to the most
anterior plane possible
Phacoemulsification with the help of a Sinskey hook and light from the
microscope
If we think that too many maneuvers will be needed, the lens fragment may
be displaced to the anterior chamber and then removed via a corneal incision
Revision of periphery with indentation
Endolaser therapy for tears
Implant of an iris-fixated IOL in the anterior chamber or behind the iris
Perfluorocarbon/air/gas or if necessary silicone oil exchange. In the latter
case, an additional inferior iridectomy would be needed.
INTRAOCULAR LENS DISLOCATION

The decentration of a posterior chamber IOL occurs in 0.2–1.2% of the cases
and does not usually require treatment.32,33 Less common but more complicated
217
is an IOL luxated to the vitreous chamber. A feature shared by all cases is a lack
of sufficient capsular support (Figs 9A and B). The general course of events is
capsular rupture, IOL placement and a few days or weeks later, its subluxation
or complete dislocation. Other causes are dislocation following anterior segment
trauma, or spontaneous dislocation including the capsular bag due to a zonular
defect34 as in pseudoexfoliation syndrome. Other described cases have been
dislocations in patients of an advanced age with high myopia, previous vitrectomy
and some connective tissue disorders.35 Also certain silicone plate lenses can be
dislocated as the result of capsule contraction following YAG laser treatment.36
Recently, the dislocation of a silicone lens implanted in the posterior chamber
above the crystalline lens (phakic refractive lens) has been described. This type
of lens is implanted in patients with high myopia who suffer dislocation to
the vitreous chamber due to probable zonular damage and who, being phakic,
require a vitrectomy with lens removal via the pars plana37 (Fig. 10).
A B
Figures 9A and B (A) Complete dislocation of a polymethylmethacrylate lens with

an intact capsular bag in a patient with high myopia; (B) Dislocated lens in a patient
undergoing cataract surgery 2 years previously
Figure 10 Dislocated posterior chamber phakic refractive lens with risk of
passage to the vitreous chamber
218
A dislocated lens may be explanted and replaced or repositioned.
Repositioning the lens in the sulcus by means of today’s vitreoretinal surgery
seems a good option to achieve good vision. Thus, many techniques have been
described to resolve this problem, which may be managed in a variety of ways:
Repositioning the lens via an internal approach:
–– The most simple option is to reposition the lens on the anterior or
posterior capsular remnants without the need for suturing. However,
the lens could again become displaced in which case its removal or
placement in the sulcus would be recommended
–– After removing the posterior chamber lens, it may be implanted in the
anterior chamber.37,38 This option is sometimes used in elderly patients
since it barely requires manipulation, although the patient has to have
a good endothelial cell count since 30% endothelial loss is produced.39
Accordingly, we do not recommend this technique
–– We can also fix the lens to the iris. This involves placing the lens in
the anterior chamber and luxating its haptics behind the iris. When in
position, the haptics are sutured to the iris and the lens optics can be
introduced into the posterior chamber.40-42 This position of the lens is
more physiological although it will have to be established whether it
induces pigment dispersion with the risk of secondary glaucoma
–– The lens can be repositioned in the sulcus with scleral fixing sutures.
To do this, we can refloat the IOL with perfluorocarbon liquid and
transiently externalize the haptics to place the suture.43-48 This method
has been widely used and its related problems are well known and
include: external erosion of the suture, endophthalmitis, decentration,
tilt, dislocation, vitreous and choroidal hemorrhage, and cystoid macular
edema.
–– In 2007 a new suture-free scleral fixation technique via a scleral tunnel
was introduced.49,50
Repositioning the lens via an external approach:
–– In this way we can remove the IOL, place the sutures and implant it in
the sulcus fixing it with the suture. In this case, we can use the same
lens that has become dislocated, or implant a type of lens designed for
this purpose with holes for sutures.51-55 The implant of the lens through
a small self-sealing corneal incision has also been described
–– The IOL may be fixed to the sclera without sutures through a scleral
tunnel
–– Another possibility is to remove the IOL and if there is no capsular
support implant a new IOL in the anterior chamber fixed to the iris.
The lens designed for this purpose is the Artisan “iris-claw” lens,
which has iris-fixating haptics. Currently, Eckardt implants this type
of lens behind the iris after hooking the haptics on the posterior iris
surface.56,57
219
Surgical Technique
In all cases, we perform an anterior and posterior vitrectomy and check if the
hyaloid is detached or attached to the retina.
The IOL is usually stuck in the vitreous in the inferior globe, so we should
undertake vitrectomy to free the lens and deposit it at the posterior pole. The
lens should not be first manipulated since this could traction the vitreous causing
retinal tears, which could provoke its detachment and compromise the visual
outcome. Once the vitrectomy is finished and the lens freed, we can proceed
to lift the lens using the following maneuvers:
Use of Perfluorocarbon Liquid

To refloat the lens, we have to place the perfluorocarbon bubble under the IOL
and as the bubble enlarges, the lens is displaced to an anterior position. To
avoid the perfluorocarbon bubble settling on the lens and squashing it against
the retina, it should be lifted and positioned vertically with the help of forceps
or the light pipe and injection system. Once the lens has been grasped, we can
fill the eye with perfluorocarbon until the lens adopts an anterior position behind
the mydriatic pupil (Fig 11).
Lifting the Lens with Forceps

When we lift the IOL using forceps by the anterior haptic, as we reach a superior
position we will need another instrument such as a spatula to retain the lens and
place it in the anterior chamber. This maneuver is therefore bimanual.
According to Ducorneau, we can lift the lens in a single maneuver. To do this,
we grasp the posterior haptic, lift the lens, turn the forceps 180° and lift until the
anterior haptic reaches the anterior chamber angle. Next, the posterior haptic held
with the forceps can be placed in the lower half of the angle. For this maneuver,
Figure 11 Refloating a lens with perfluorocarbon: the lens is grasped using a
light probe with pick and a Chang cannula until it reaches an anterior position
220
Figure 12 Refloating using the vitrector
the haptics have to be able to keep the entire lens in an upright vertical position.
With polypropylene haptics this is difficult, although these have practically
disappeared from the market. As we enter the anterior chamber, the wide-field
visualization system should be withdrawn and we can then switch to direct
viewing through the microscope. It is also possible to refloat the lens inserted in
the bag and dislocated, using the suction handpiece vitreotome (Fig. 12)
Once the lens is in position we can perform the following maneuvers:
Implant the lens in the sulcus if there is sufficient anterior and posterior capsular
support. If the anterior capsulorhexis is intact, we pass the IOL through it to
implant it in the sulcus trapping its optics in the capsulorhexis; this provides
a stable fixation plane with little risk of decentration. If an IOL reimplanted
in the sulcus is again dislocated by rotation or the contraction of capsular
remains, it is best to remove the lens and undertake another form of implant
The posterior chamber IOL can be reimplanted in the anterior chamber.
This could be a good option for elderly patients or patients with a high
endothelial cell count. However, we do not recommend this strategy due
to the high endothelial loss induced
Implant the lens in the posterior chamber sutured to the iris. The lens is first
placed in the anterior chamber with the haptics displaced to the posterior. In
this position, the haptics are sutured to the iris and the entire lens finishes
up behind the iris. The risk of pigment dispersion inducing glaucoma will
later have to be checked
Suturing the lens to the sulcus. For this we prefer to externalize the haptics
to place the suture and thus avoid dangerous intraocular maneuvers
Implant the aphakic Artisan lens in the anterior chamber, anchoring the
haptics on the anterior iris surface or as described by Eckardt jabbing the
haptics behind the iris, leaving the lens in the posterior chamber
Our technique of choice is an aphakic Artisan lens implanted in the anterior
chamber although recently we have been placing this lens in the posterior
chamber.
221
Implanting an Aphakic Artisan Lens
This is the lens of choice when there is no capsule support. We have been
implanting the Artisan lens in aphakic patients for several years. Its use provides
good chamber depth, allows for good visualization of the retina, and if required,
vitreoretinal surgery can be performed.56,57
Surgery is performed in a single procedure in cases of traumatic dislocation,
crystalline fragments persisting after cataract extraction, complete dislocation
of the lens and capsular bag and dislocation due to insufficient capsular support.
Undertaking surgery after vitrectomy has the drawback that we lack
vitreous support and the globe has a tendency to collapse as we try to work in
the anterior chamber.
This problem can be resolved by: Working with an open infusion line:
this will give us ocular tone but will induce protrusion of the iris as we
manipulate the anterior chamber with the risk of bleeding and rupture of
the iris
Filling the globe with perfluorocarbon: sufficient tone for lens implant can
be achieved by introducing viscoelastic in the anterior chamber, but after
this we should undertake perfluorocarbon/fluid exchange with the pupil
closed. Surgery can be done using a wide-field visualization system since
not much mydriasis is needed
Positioning a Flieringa ring to avoid the globe collapsing: sutured to the
sclera, this ring provides sufficient stability in the anterior chamber, which
will have to be filled with viscoelastic (Figs 13A to C).
To implant the IOL in the anterior chamber, a 5 mm corneal incision is
made and acetylcholine is introduced to close the pupil, and viscoelastic, to
give tone and protect the endothelium. The lens is slightly curved and should
be placed concave downward on the iris. Then with the help of forceps and a
hook, the lens is fixed to the iris (Figs 14A and B).
If we wish to implant the IOL behind the iris, we can also apply acetylcholine
and viscoelastic and introduce the lens concave upward so that the haptics hook
onto the iris and there is no tent effect. The lens is introduced into the anterior
A B C
Figures 13A to C (A) Anchoring the Artisan “iris-claw” lens in the anterior chamber.
Note the Flieringa ring and lens placed concave side downward; (B) Fixation is
achieved with the help of retaining forceps and an anchoring hook; (C) Fixation
maneuver on the opposite side using the same instruments
222
A B
Figures 14A and B (A) Lens with slight curvature. The concave side faces upward
as the lens is placed behind the iris to avoid tenting; (B) With the concave side facing
downward, the lens is positioned on the iris in the anterior chamber
chamber, the lens optics is grasped with T-forceps in the center of its diameter
and the lens is displaced through the pupil. In this position, the haptics are
marked behind the iris to create an imprint on the iris so that, with the help of
a spatula, the lens can be anchored to the posterior side of the iris (Figs 14,
15 and 16).
Late Intraocular Lens Dislocation with the Capsular Bag

The standard of care for cataract surgery is phacoemulsification with the
implant of an IOL in the capsular bag. However, an optimal surgical result
does not guarantee a postoperative course without complications. Anterior and
posterior capsular opacification, capsular contraction and closure, and cystoid
macular edema are some of the well-known complications of the state-of-the-
art cataract surgery.
Following cataract surgery, the complication of IOL decentering or
dislocation to the posterior chamber occurs at a reported incidence between
0.2% and 3%. The causes are loss of zonular or capsular integrity during surgery
or the asymmetric placement of the lens haptics.
A B
Figures 15A and B (A) Lens newly implanted behind the iris; (B) Appearance of
the lens on the day after surgery in another patient
223
A B C
Figures 16A to C (A) Implanting the lens behind the iris: the lens is grasped with
T-shaped forceps by the middle portion of the optics; (B) Lens positioned behind the
iris. An imprint is made behind the iris and using a spatula the haptics are fixated; (C)
Fixation is repeated on the opposite side
Dislocation of an IOL with the capsular bag is a late complication described

with increasing frequency as a result of progressive zonular dehiscence. Its real
incidence is unknown but 20% of the surgeons admit they have encountered
this complication and cases have been described to arise from 4.5 months to
16 years. The incidence reported in 2009 in a 10-year study including 810
cataracts was 1%.58
Mechanisms
Predisposing conditions are pseudoexfoliation in 50% of the cases followed
by other circumstances such as uveitis, trauma, vitrectomy and a long axial
length.59,60 Associated factors are preoperative zonular weakness, surgical
trauma to the zonules, capsular contraction syndrome and postoperative
trauma.
Zonular weakness has been well described in pseudoexfoliation
syndrome, high myopia, as an outcome of vitreoretinal surgery and in
some connective tissue disorders (Marfan syndrome, homocystinuria,
hyperlysinemia, scleroderma, Ehlers-Danlos syndrome and Weill-
Marchesani syndrome).
Prevention
Small continuous curvilinear capsulorhexis increases fibrosis and contraction,
thus if these signs are detected the use of the YAG laser to create relaxing cuts
is recommended. During phaco, efforts should be made to preserve zonular
integrity with chopping techniques being the safest.
Tangentially aspirating the cortex more or less perpendicular to the
zonule may minimize zonular dehiscence. The use of a capsular tension ring
is indicated in cases of pseudoexfoliation, although this may reduce but not
prevent capsule contraction. In eyes with significant zonular weakness, the
use of tension rings could diminish the incidence of luxation by increasing
resistance to capsular contraction.
224
In cases of advanced pseudoexfoliation, lens placement at the sulcus with its
optics captured in the capsulorhexis has been described to avoid displacement
though this induces inflammation. In eyes undergoing vitrectomy, sparing of
the anterior hyaloid membrane has been proposed.
Treatment
Some cases of a subluxated IOL may be followed by observation only. However,
a loss of visual acuity, monocular diplopia or halos are indications for surgery.
Oshika described a simple technique in which the subluxated bag was fixed
using a double-armed 9-0 polypropylene (Prolene) suture to the sulcus through
a clear cornea stab incision (Fig. 17).61 One needle goes over the haptic and
capsular bag under the iris and out through the ciliary sulcus; the other needle
penetrates the capsular bag under the haptic and exits through the ciliary sulcus.
Alternatively, the subluxated IOL containing bag can be sutured to the
iris with the help of a second instrument using 10-0 Prolene suture (Figs 18A
and B). The IOL should be stabilized and there should be good ocular tone to
Figure 17 Sulcus fixation of an intraocular lens in the bag using a

double-armed suture
A B
Figures 18A and B (A) Stabilizing an intraocular lens using a straight 10-0 suture
needle; (B) Fixating the fibrous capsule to the sulcus
225
manipulate the sutures well. We use 23–25 gauge vitrectomy instruments for
this technique.
An ingenious technique uses viscoelastic introduced through the pars plana
to lift and retain the lens in the center, and then a spatula is introduced through
the pars plana to help pass the suture to the iris and the bag-IOL complex.
Also described, has been the use of a straight needle passed through the ring
of capsular fibrosis with the help of anterior chamber infusion.
In cases of complete dislocation requiring IOL explant, a good option is
an Artisan lens fixated to the anterior iris surface or eventually in the posterior
chamber.
ENDOPHTHALMITIS
Endophthalmitis is a serious intraocular inflammation caused by infection.
The incidence of endophthalmitis after cataract extraction and IOL implant is
around 0.1%.62,63 This incidence rises by around fourfold in the case of posterior
capsule rupture and anterior vitrectomy.
The most common preventive measures currently adopted are:
Wide-spectrum topical antibiotics (commonly a quinolone) a few days
preoperatively and cleaning with pure povidone iodine of the skin and
eyelids, and diluted 50% in the conjunctival sac a few minutes before
surgery to reduce counts of conjunctival flora.
Isolating the eyelids and lashes with tape
Intracameral antibiotic: Cefuroxime has been found to cut the risk of
endophthalmitis by fivefold but is ineffective against methicillin-resistant
staphylococci, enterococci and pseudomonas. It also has to be reconstituted
in a vial with the consequent risk of endophthalmitis. Moxifloxacin
(Vigamox R, 0.1 ml) may also be used. In Europe, intracameral cefuroxime
is most commonly used.
Endophthalmitis symptoms are: considerable loss of vision, ocular pain
(although 25% present without pain) and photophobia.
The most common signs are:
Conjunctival hyperemia
Eyelid edema
Anterior chamber turbidity with corneal edema and keratic precipitates
Anterior chamber hypopion
Absence of the red reflex due to substantial vitritis classifying postsurgery
endophthalmitis:
Hyperacute: fulminating infection whose onset is earlier than 24 hours,
usually caused by Gram-negative bacteria (Pseudomonas aeruginosa) or
pneumococcus. Prognosis is poor even after receiving adequate treatment.
Fortunately its incidence is very low (Figs 19A and B).
Acute: this is the most common form. It manifests between days 1 and 5
after surgery. Gram-positive organisms account for 80% (Staphylococcus
226
A B
Figures 19A and B (A) Severe hyperacute endophthalmitis in a patient with cataract
and vitreous hemorrhage. Caused by Streptococcus pneumoniae. Conducting an
anterior approach vitrectomy due to poor visualization. Outcome poor despite
complete treatment including three flushing attempts; (B) Endophthalmitis
presenting 48 hours after surgery caused by Staphylococcus epidermidis. Note the
hypopyon, corneal edema and vitreous infiltration behind the lens
epidermidis, Staphylococcus aureus). This form of endophthalmitis

responds well to adequate diagnosis and treatment.
Subacute: occurs after days 5–6 and before day 20 postsurgery. Symptoms
are milder and it may respond well to treatment.
Late onset: this form of endophthalmitis develops after a month and
before a year has passed after surgery. The course of infection includes
persistent red eye and uveitis responding to steroid treatment. The causative
microorganism is usually Propionibacterium acnes.
Etiology
Most infections secondary to cataract surgery are caused by Gram-positive
bacteria. According to the US Endophthalmitis Vitrectomy Study,64 94.2%
are caused by Gram-positive microorganisms, of which 70% are produced
by S. epidermidis, 9.9% by S. aureus and 14.3% by other Gram-positive
organisms. It should be noted that 100% of these causative agents are sensitive
to vancomycin. Gram-negative microorganisms account for 6.5% of the cases,
of which 89% respond to amikacin and ceftazidime.
When a diagnosis of endophthalmitis is suspected according to the signs
and symptoms described above, the first step is to obtain samples for microbial
culture. Swabs taken from the conjunctiva, eyelids or cornea are of little use
because of their variability. In contrast, a vitreous humor sample will return a
positive result in close to 70% of the cases of infection. Aqueous humor provides
a positive culture result in only 50% of the cases.65,66 Vitreous or aqueous
humor samples will first inform the surgeons of whether the microorganism is
Gram-positive or negative. If available, polymerase chain reaction is the most
sensitive method for diagnosing endophthalmitis. If the bacteriological results
are negative, then standard treatment is given and maintained according to
227
the signs and symptoms. In general, if the condition does not worsen, initial
treatment is continued.
Samples of vitreous humor may be obtained during surgery or on an
outpatient basis. Topical or retrobulbar anesthesia is induced followed by the
instillation of 5% povidone. A 22-gauge needle fitted to an insulin syringe is
inserted 3.5–4 mm from the limbus penetrating 5–10 mm toward the eye center
and 0.4 ml of vitreous humor are aspirated. In this operation, the first dose of
wide-spectrum antibiotic is usually given.
Treatment
In the clinical trial designed to evaluate treatment strategies in the
Endophthalmitis Vitrectomy Study,67 no differences were detected in final
visual acuity and ocular media transparency according to the use or not of
systemic antibiotics (amikacin, ceftazidime). In patients with an initial visual
acuity of light perception only, better results were obtained when a pars plana
vitrectomy was immediately performed compared to intracameral antibiotics.
Results indicated a threefold higher chance of a final visual acuity greater
or equal to 0.5, a twofold chance of a visual acuity greater or equal to 0.05,
and a halved risk of severe vision loss. In the case of a visual acuity of hand
motion or better no differences were detected between immediate pars plana
vitrectomy and tap biopsy.
Intravitreal antibiotic injection is the best way to achieve high concentrations
of antibiotic in the eye. The following doses of antibiotic should be administered
in every endophthalmitis process:
Intravitreal doses
–– Vancomycin: 1 mg in 0.1 ml
–– Ceftazidime: 2.25 mg in 0.1 ml
–– If the patient is allergic to beta-lactams, amikacin can be given at 0.4
mg in 0.1 ml. Dexamethasone (0.4 mg in 0.1 ml) can be added.
Other routes of administration may be added to the intravitreal injection.
Subconjunctival
–– Vancomycin: 25 mg in 0.5 ml
–– Ceftazidime: 100 mg in 0.5 ml
–– Dexamethasone: 6 mg
Topical
–– Vancomycin: 50 mg in 1ml
–– Ceftazidime 100 mg in 1ml
–– Amikacin 20 mg in 1ml
–– Prednisolone acetate 1% every 2 hours
General
These agents penetrate inflamed eyes and attain potentially efficient doses
after their intravenous administration.
–– Vancomycin: 1 g every 12 hours
228
–– Ciprofloxacin (750 mg every 12 hours); high concentrations of this
antibiotic are achieved in the vitreous after its oral administration
–– Ceftazidime (1 g every 12 hours).
Infusion Drip
If a vitrectomy is undertaken, the following antibiotics are added to the
infusion saline.
–– Gentamicin: 8 μ/ml (4 mg in 500 ml BSS)
–– Vancomycin: 10 μ/ml (5 mg in 500 ml BSS) or clindamycin 9 μ/ml (4.5
mg in 500 ml BSS)
–– Dexamethasone 64 μ/ml (32 mg in 500 ml BSS).
Vitrectomy
The idea of conducting a vitrectomy is that it eliminates the microorganisms
causing infection along with their toxins from the globe, improving the
penetration of antibiotics and clearing the path of vision. Nevertheless,
vitrectomy carries several risks, especially in cases of corneal opacity, presence
of an IOL and substantial vitritis, apart from the risk of suffering retinal tears
in surgery due to the inflammation and friability of the retina. The presence of
retinal detachment considerably worsens the prognosis. A rate of 5% retinal
detachments was detected in the Endophthalmitis Vitrectomy Study.
Some surgeons recommend an anterior approach to vitrectomy to avoid
vitreous traction at the pars plana.68 However, with the introduction of trocars
(23/25 gauge systems), especially valved designs, less traction is generated
on the peripheral retina making the pars plana vitrectomy a more suitable
option. In addition, the posterior capsule can be spared (not all current IOLs are
suitable for sulcus placement). Notwithstanding, in cases of poor visualization
an anterior vitrectomy approach is practically mandatory.
Anterior Approach
For an anterior approach, we use the incision made previously for cataract
surgery and place another incision at the limbus separated by an angle of 170°
to introduce 23/25-gauge instruments. First, a sample is taken from the anterior
chamber and membranes on the iris and IOL is removed. Next, the posterior
capsule is opened at the central level using the vitrector with irrigation and
introducing the light pipe. This means we can perform the vitrectomy with only
two port openings. A core vitrectomy is undertaken avoiding traction on the
vitreous, and at the end of surgery, the antibiotics are introduced. If possible, the
IOL is luxated to the sulcus in front of the capsulorhexis, to avoid its subsequent
dislocation. In the case of a three-piece IOL we can try to trap the optics in the
capsulorhexis, either leaving the haptics in the bag or simultaneously luxating
them to the sulcus. If owing to the capsulotomy (normally the IOL does not
adhere to the capsular remains) the lens is too unstable; for in the bag or sulcus
229
placement it is best to explant the lens and replace it, if not immediately in a
subsequent operation.
Posterior Approach
The possibility of placing a 6 mm infusion cannula or an infusion tube in
the anterior chamber should be evaluated. We always include the antibiotics
mentioned previously in the infusion fluid. Before opening the infusion line,
we should ensure the fluid will not pass to the choroids, since some uveal
effusion and hypotony or the presence of a peripheral dense exudate is relatively
common in these cases. If the exit point of the infusion line cannot be seen,
the introduction through the 23-gauge trocar of a 25/27 gauge needle to free
the line is a helpful strategy.
First, the fibrin membranes formed on the iris and lens are removed using
intraocular membrane forceps. Once this has been done, greater dilation of
the iris can be achieved or iris hooks can be used for good visualization of all
maneuvers (Figs 20A and B).
The vitreous sample can be obtained with the infusion line closed or
preferably introducing air. Using a 5 ml syringe, the assistant collects a 0.3–0.5
ml sample of vitreous gel free of infusion fluid by manual aspiration for Gram
staining and culture (Figs 21A and B). To do this, the syringe is connected
to the vitrectome’s aspiration line and the sample is obtained as we cut the
vitreous with vitrector.
A core vitrectomy is performed behind the lens and we work backward at a
high cutting rate and low aspiration power to avoid tractions and tears of the retina
since it is highly friable. No traction should be exerted on the hyaloid for the same
reason. As we approach the end of surgery, the doses of intravitreal antibiotics
can be introduced. In all cases, good visualization is needed for the maneuvers.
Late-Onset Endophthalmitis
This may occur from the first month postsurgery up until 1 year. Following a
YAG capsulotomy, endophthalmitis can even appear later than a year. Mutton-
fat keratic precipitates in uveitis are a classic granulomatous presentation
accompanied by a Tyndall effect and anterior vitreous cellularity. The
appearance of typical saccular whitish plaques reminiscent of cortical remnants
is more characteristic of Propionibacterium acnes infection.
Besides frequent topical treatment with corticosteroids, wide-spectrum
antibiotics and mydriatics, some authors have described the successful use in
30–50% of the cases of oral clarithromycin 500 mg/12 hours for 14 days (Fig. 22).69
A further therapeutic option described in the literature is Nd-YAG
capsulotomy followed by intravitreal antibiotic injection.70 For cases refractory
to treatment, we would proceed with intravitreal vancomycin. If ineffective,
the course to follow would be a pars plana vitrectomy with flushing of the
230
A B
Figures 20A and B (A) Removing inflammatory membranes from the anterior
chamber affecting the iris and angle; (B) Appearance of the anterior chamber after
freeing from membranes
A B
Figures 21A and B (A) Obtaining a sample of infiltrated vitreous for culture: the
vitreotome is active and a 5 ml syringe is connected to the aspiration line; (B) Pressure
is maintained by instilling air
Figure 22 Late-onset endophthalmitis. Note the deposits on the anterior lens
surface
231
capsular bag with the aforementioned antibiotics, though in these resistant
cases it is necessary to replace the IOL by means of a full capsulectomy and
sacculectomy followed by IOL implant in the sulcus or anterior chamber. Our
choice for this purpose would be an iris-fixated IOL.
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21. Shah VA, Gupta SK, Chalam KV. Management of vitreous loss during cataract
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30. Kim JE, Flynn HW, Smiddy WE. Retained lens fragments after phacoemulsification.
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32. Stark WJ, Worthen DM, Holladay JT, et al. The FDA report on intraocular lenses.
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34. Gross JG, Kokame GT, Weinberg DV, et al. In-the-bag intraocular lens dislocation.
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implants. Ophthalmol Clin North Am. 2001;14(4):681-93.
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37. Mittra RA, Connor TB, Han DP, et al. Removal of dislocated intraocular lenses
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38. Allara RD, Weinstein GW. A new surgical technique for managing sunset syndrome.
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39. Hara T, Hara T. Ten-year results of anterior chamber fixation of the posterior
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40. Zeh WG, Price FW. Iris fixation of posterior chamber intraocular lens. J Cataract
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43. Friedberg MA, Pilkerton AR. A new technique for repositioning and fixating a
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dislocated intraocular lenses using pars plana vitrectomy instrumentation. J
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47. Chang S, Coll GE. Surgical techniques for repositioning a dislocated intraocular
lens, repair of iridodialysis, and secondary intraocular lens implantation using
innovative 25-gauge forceps. Am J Ophthalmol. 1995;119(2):165-74.
48. Chan CK. An improved technique for management of dislocated posterior chamber
implants. Ophthalmology. 1992;99(1):51-7.
49. Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens
fixation. J Cataract Refract Surg. 2007;33(11):1851-4.
50. Scharioth GB, Prasad S, Georgalas I, et al. Intermediate results of sutureless
intrascleral chamber intraocular lens fixation. J Cataract Refract Surg.
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51. Lindquist TD, Agapitos PJ, Lindstrom RL, et al. Transscleral fixation of posterior
chamber intraocular lenses in the absence of capsular support. Ophthalmic Surg.
1989;20(11):769-75.
52. Ramocki JM, Shin DH, Glover BK, et al. Foldable posterior chamber intraocular
lens implantation in the absence of capsular and zonular support. Am J Ophthalmol.
1999;127(2):213-6.
53. Oshima Y, Oida H, Emi K. Transscleral fixation of acrylic intraocular lenses
in the absence of capsular support through 3.5 mm self-sealing incisions.
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54. Lane SS, Schwartz GS. Techniques of primary and secondary transscleral fixation
of posterior chamber intraocular lenses. In: Fishkind WJ. Complications in
Phacoemulsification. New York: Thieme; 2002. pp. 155-65.
55. van der Meulen IJ, Gunning FP, Vermeulen MG, et al. Artisan lens implantation
to correct aphakia after vitrectomy for retained nuclear lens fragments. J Cataract
Refract Surg. 2004;30(12):2585-9.
56. Mohr A, Hengerer F, Eckardt C. Retropupillary fixation of the iris claw lens
in aphakia. 1 year outcome of a new implantation techniques. Ophthalmologe.
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57. Baykara M, Ozcetin H, Yilmaz S, et al. Posterior iris fixation of the iris-claw
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2007;144(4):586-91.
234
58. Mönestam EI. Incidence of dislocation of intraocular lenses and pseudophakodonesis
10 years after cataract surgery. Ophthalmology. 2009;116(12):2315-20.
59. Davis D, Brubaker J, Espandar L, et al. Late in-the-bag spontaneous intraocular lens
dislocation: evaluation of 86 consecutive cases. Ophthalmology. 2009;116(4):664-
70.
60. Hayashi K, Hirata A, Hayashi H. Possible predisposing factors for in-the-bag
and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens
exchange surgery. Ophthalmology. 2007;114(5):969-75.
61. Gimbel HV, Condon GP, Kohnen T, et al. Late in-the-bag intraocular lens
dislocation: incidence, prevention and management. J Cataract Refract Surg.
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62. Peyman GA, Bassili SS. A practical guideline for management of endophthalmitis.
Ophthalmic Surg. 1995;26(4):294-303.
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endophthalmitis survey. A 10-year review of incidence and outcomes.
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application. Ophthalmology. 1978;85(4):374-85.
67. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate
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70. Rojo A. Ferrer E, Torrón C, et al. Nd-YAG capsulotomy and intravitreal antibiotics
as treatment of chronic endophthalmitis. Arch Soc Esp Oftalmol. 2000;75(2):109-16.
chapter 11
Eye Trauma Vitrectomy
Joséfina Bañuelos Bañuelos, Patricia Martínez-García, Javier Orduña-Azcona,

Ana Orive-Bañuelos, Alfonso Arias Puente
INTRODUCTION
The ocular trauma may affect all globe structures and represents an important
cause of blindness. There is no preference with respect to laterality and it
affects more the young men. Vitrectomy is frequently required1 and the timing
of surgery depends on the integrity of the eye wall.
An open ocular trauma implies a rupture of the globe walls.2,3 Lesions
can be multiple and in most cases they affect anterior and posterior chamber.
Furthermore, they lead to an exposure of the ocular content to a septic
environment with a high risk of endophthalmitis.
In the case of blunt trauma, vitrectomy is directed to treat the complications:
vitreous hemorrhage, glaucoma, retinal detachment (RD), alterations of the
lens and macular involvement.
VITRECTOMY IN OPEN TRAUMATISMS

Clinical History and Initial Examination
In addition to recording the personal history and comorbidities which may
interfere with the treatment, it is essential to ask when, where, how and
with which object, the injury occurred. In cases of extensive wounds any
manipulation that could provoke massive intraocular hemorrhage needs to be
avoided.4
In addition to assessing the situation of the ocular media, it is essential to
exclude the existence of endophthalmitis and the presence of an intraocular
foreign body (IOFB). Orbital radiology is the most accessible method if a
metallic foreign body is suspected. Once it has been confirmed, a CT should be
236
carried out in order to localize the IOFB. If it is not metallic, nuclear magnetic
resonance is indicated. Ultrasound should not be performed in an open eye
injury.
Presurgical Considerations
Once the eyeball has been evaluated, the following surgical questions need to
be addressed:
Assess whether the preparation and the available appliances are adequate
to tackle the surgery and possible complications that may occur. If surgery
can’t be delivered, the patient should be referred to another health provider4
Avoid the manipulation of the eyeball, the removal of protruding IOFB or
forced opening of the lids. Occlude the eyeball and administer the first dose
of systemic antibiotic.
Whenever possible a hospital admission should be done as that encourages
treatment compliance and a better relation with the patient. Generally
patients are young people and anxious due to the high visual risk. They
perceive a lower injury severity if they are sent home.
General anesthesia is the preferred technique. It favors the wound closure
and treatment of complications. Local anesthesia can be used to close small
wounds if the patient is cooperative and later peribulbar anesthesia can be
performed for vitrectomy.
Treatment options:
– Perform complete surgery in the initial intervention: close the ocular
wound and perform vitrectomy. It has the advantage of reducing the
risk of endophthalmitis, a better situation of the transparent media and
lower costs. However, it increases the risk of intraoperative bleeding
especially of posterior scleral wounds and the ciliary body. Generally,
a skilled team will not be available to execute the surgery in 24 hours.
– Perform the urgent ocular wound closure and later a vitrectomy. Then
we will generally have better technical resources, a better eye evaluation
and a lower risk of bleeding. However, we may have more opaque media
due to a corneal edema or a progression of the crystalline opacity. The
vitrectomy should be done as soon as possible, better within 4 days, to
reduce the activation of vitreoretinal proliferation (VRP) factors and
of endophthalmitis if there is an IOFB. But it can be delayed by up to
2 weeks if there is no risk of infection and depending on the nature of
the trauma. It is preferable to postpone the surgery and wait for having
qualified personnel and resources.4
The lack of light perception does not contraindicate surgery and it should
not delay an initial reconstruction of the eyeball. Primary enucleation is only
indicated if there is significant lack of tissue. The secondary enucleation is
indicated in case of a painful blind eye unresponsive to treatment. Sympathetic
ophthalmia is very rare and can occur days or decades after the trauma, but that
Chapter 11  Eye Trauma Vitrectomy
237
is very unlikely. The threat of sympathetic ophthalmia is not an indication for
enucleation of an eye with no light perception.4
Informed consent: you must specify the previous findings, treatment options,
likely intraoperative complications, the need to modify the technique to new
findings during the surgery, postoperative complications and the possibility
of needing several interventions. The patient must know the purpose of
the surgery: the need to close the eyeball, to remove the IOFB, to restore
ocular anatomy, to prevent infection and to control inflammation. Functional
recovery is secondary and often subject to intraoperative findings. It is
important that the professional who informs the patient is familiar with
the procedure to be able to answer the questions. Frequently, these patients
claim medicolegal implications during or at the end of the process.
Surgical Technique
Vitrectomy can be realized with 20, 23 or 25 gauge provided that you have
these equipments at your disposal and accepting that it might be necessary to
revert to a 20 gauge or even expand the incision further in case of an IFOB.
In some cases accessory light might be required in order to exert the surgery
bimanually. The infusion must be visualized before opening due to the risks
of a detachment of the choroid or the retina. If required use a 6 mm infusion.
However, if the opacity of the media persists, an infusion in the anterior chamber
should be initially installed and once structures can be visualized, an infusion
in the posterior segment can be installed. Avoid incisions close to traumatic
scleral wounds.
In these procedures wide-field systems are preferably used, like the
binocular indirect ophthalmomicroscope system, in order not to be in contact
with the eyes.5
If there is a corneal wound it is best to perform corneal suturing because
it decreases the stromal edema and facilitates the visualization.4 If the edema
is epithelial it can de-epithelialize (Not in diabetes or a history of recurrent
erosion). In cases of severe corneal edema, corneal infiltration or hematocornea,
temporary keratoprosthesis may be required,6,7 or if donor cornea is available
the best technique is penetrating keratoplasty.8,9
In case of anterior lacerations, it can be frequently found blood in the
anterior chamber, a hernia of the iris, miosis and fibrin if some hours have
already elapsed. It is fundamental to wash the hyphema, to remove the
membranes and to achieve pupil dilatation with epinephrine or iris retractors.
Viscoelastic material is often required in order to keep the anterior chamber
transparent and allow the surgery to continue.
If there is no cataract or the opacity is small and thus we can perform
a surgery, the extraction of the crystalline is not indicated. In case of an
opacification or a rupture that prevents us from visualizing the posterior pole,
the cataract needs to be removed. The morphology of traumatic cataracts plays
238
an important role in determining the appropriate surgical technique and the
final visual outcome.10-12
The phacoemulsification may only be performed in an anterior way if there
is no risk of vitreous in the anterior chamber, subluxation by a zonular rupture
or a posterior rupture causing tractions of the vitreous during the aspiration.
This technique allows to avoid that residuals fall into the posterior chamber
and to put an intraocular lens (IOL) into the capsular bag.
In case of a soft lens with a rupture of both capsules, lensectomy of the
crystalline can also be performed by vitrectomy via the anterior chamber. But
it is preferable to perform it via pars plana, leaving a maximum of the anterior
capsule in order to place a lens into the sulcus (Fig. 1).
In case of a senile cataract and a firmer nucleus it is sometimes necessary
to dislocate it to the posterior pole and to perform a lensectomy in the posterior
chamber fragmenting the nucleus manually or with a phacofragmenter. If
mechanical phacofragmentation is performed it is paramount to perform a
complete vitrectomy in advance, in order to prevent tractions provoking new
iatrogenic retinal lesions. In some cases, the lens must be removed during the
intervention due to an increased opacity, an intraoperative lesion or in order
to better complete the surgery. The patient must always be informed on this
eventuality before starting the intervention.
If the retina is severely affected and there is a high risk of anterior
proliferative vitreoretinopathy (PVR), it is required to completely remove the
lens, although it might be transparent or not bruised. Furthermore, executing
a complete capsulectomy reduces the risk of anterior PVR and the evolution
of phthisis.
The placement of an IOL is not a priority in the surgery of ocular trauma.
In case of severe traumas with significant affection of the retina, if the lens is
not placed we will have less inflammation and a better visualization. The IOL
needs to be acrylic due to the possibility of retinal complications. Generally
Figure 1 Posterior lensectomy

239
we cannot carry out biometry in a perforated eye. Deferring the placement of
the IOL to a second intervention will facilitate a more precise correction. After
trauma, a zonular affection preceding the surgery is frequent and this risk is
increased by the vitrectomy. There are an increased number of incidences of
subluxation or of posterior luxation of the IOL and the capsular bag13 (Figs 2
and 3).
When a perforating trauma exists (anterior and posterior laceration) and the
posterior wound is not accessible, suture only the anterior perforation and defer
the surgery. After 24 hours there may be a spontaneous sealing of the posterior
laceration that may contain normal pressure during the vitrectomy (Fig. 4).
Figure 2 Intraocular silicone oil in ocular severe trauma
Figure 3 Oil extraction and insertion of intraocular lens

240
Figure 4 Healed posterior laceration
The risk of reopening is higher in case of large wounds, elderly patients

and high pressure during the vitrectomy.
Cerclage placement is not paramount in urgent treatments because of the
risks associated with ocular manipulation. There is no consensus on whether
it should be used in all perforating traumas or posterior vitrectomies in
particular, in case of media opacity. It can be beneficial to use a prophylactic
laser. Cryotherapy on scleral or intraoperational lesions must be avoided as it
increases the risk for PVR.14
SPECIAL SITUATIONS
Trauma and Dense Vitreous Hemorrhage
When we have an open trauma with a dense hemorrhage and high risk of retinal
rupture, early vitrectomy needs to be executed in order to prevent the starting
of PVR factors. It is important to avoid intraoperative hypotony because it
increases the risk of rebleeding. If there is a risk of rebleeding or choroidal
detachments, postoperative intraocular silicone may repress hemorrhage and
prevent hypotony.
In the absence of ocular laceration, the presence of post-traumatic
intraocular hemorrhage does not imply emergency vitrectomy. It is of utmost
importance to carry out ultrasound to rule out RD. If it starts to be reabsorbed
and can be visualized, it is not necessary to operate the retina. If the retina
cannot be visualized and the vitreous begins to organize, early vitrectomy is
indicated due to the risk of PVR and RD.
241
Trauma and Retinal Detachment
The detachment of the retina associated with a perforating trauma represents
a high risk factor for visual loss. As in any open injury, the question arises
whether to do a complete surgical intervention or delay the vitrectomy in order
to repair the RD. In addition, the detachment may be very different depending
on if it is associated with a perforation, an IOFB or a burst of the eyeball, and
if the lesions are unique or multiple and older or more recent. Performing an
emergency surgery, including the closing of the ocular wound and to repair the
detachment, has the advantage of reducing the incidence of endophthalmitis
and the risk of PVR. If the vitrectomy is delayed there is a higher likelihood of
a detachment of the posterior vitreous, especially significant in case of young
patients. The recommendable delay should not be more than 1 week and it must
not surpass 2 weeks. The PVR factor risks are: traumatic injury to the retina,
presence and size of the IOFB, traumatic cataract, vitreous hemorrhage and
preoperative visual acuity (AV).15
The use of intraocular silicone as the first choice reduces the early
redetachment and limits the PVR, supports the positioning, and reduces
rebleeding and the development of postoperative endophthalmitis16,17 (Fig. 5).
In the complex post-traumatic detachments of the retina, partial retinectomy
should be performed, or including 360° when there are severe previous PVR
and subretinal fibrosis, large tears with contraction of the edges, and retinal
incarceration of the scleral wound.18 It should be assessed if circular indentation
is needed in order to fully secure the retinal detachment surgery. Risk of
redetachment in these complex RD cases is 17–39%.17,18
Trauma and Intraocular Foreign Body

About 40% of open eye injuries involve an IOFB. Most of the foreign bodies
(FBs) are metallic (90%) and of these, 55–80% are magnetic. Also, more than
half (65%) remain lodged in the vitreous cavity.19,20
Figure 5 Post-traumatic detachment and reparation with intraocular silicone oil

242
Plain radiography has low sensitivity for IOFB. CT scan is the diagnostic
technique of choice to locate metallic IOFB; it is fast, accessible and highly
sensitive. You can spot sizes from 0.5 mm onwards, and the size gives
information on the location and the condition of the eye wall. However, it does
not detect fresh wood, ceramic or plastic. Ultrasound can detect any intraocular
alteration, but this technique involves manipulating the eye and should be
performed when the walls of the eyeball are already closed.
In the presence of an ocular laceration with retention of IOFBs the Gold
Standard technique is to intervene as soon as possible with closing of the wound
and extraction of the FB applying vitrectomy. However, the criteria may vary
depending on the risk of endophthalmitis. In case of no risk, the closure of
the wound can be done first, followed by protection with systemic antibiotics
and posterior vitrectomy with IOFB extraction. However, if the risk is high a
complete urgency treatment is indicated with only one intervention. The risk
is determined by the composition of the FB, the origin, the place where the
trauma has occurred, the size and delay of the diagnosis.21-24
In addition to the risk of endophthalmitis there are other indications of
delayed IOFB removal which are listed below:
When human and technical resources are not available to perform the
vitrectomy
When there has not been the possibility of a prior workup to know the
location of the IOFB
When we have extensive wounds at the level of the ciliary body and no
risk of endophthalmitis
In perforating trauma with no accessible exit and FB in orbit. Wait for
closure through cicatrization of the posterior wound before conducting the
vitrectomy. It is not necessary to remove the orbit FB.
The delay of vitrectomy also favors the detachment of the posterior vitreous,
which allows better alimentation of the vitreous
We must always maintain a correct and comprehensive coverage with
antibiotics or conduct intravitreal antibiotic, respectively.
For extraction of IOFB you must have an intraocular magnet and intraocular
forceps that can adapt to different IOFB (Fig. 6).
If the foreign body is on the retina or difficult to access, once freed
from the vitreous it should be captured with the magnet and extracted with
intraocular forceps. This bimanual technique is performed using the accessory
light. Alternatively, the central vitreous can be illuminated with a microscope
and the IOFB can be captured and extracted with the bimanual forceps (Fig.
7). However, the intraocular magnet does not have enough pull to allow the
extraction through the aperture of the sclera and the IOFB could again fall on
the retina.
In case of retinal injuries caused by the impact of a FB, the retinectomy with
choroidectomy on the edges of impact and complete removal of the vitreous
significantly decreases the risk of retraction and PVR25 (Fig. 8).
243
Figure 6 Magnet and intraocular forceps
Figure 7 Intraocular foreign body extraction with magnet and forceps
Figure 8 Macular impact. Intraocular oil

244
If the foreign body is stuck in the sclera, it is likely that the perforation is
complete. It is also likely that while capturing the IOFB a decompression of the
globe will happen and the infusion has to be lowered. Generally, these wounds
are not accessible to the suture. If you require a vitreous tamponade, better use
silicone. It is important to assess the CT of the injured globe for the presence
of a double perforation. This injury usually has a bad prognosis.
About 14–26% of IOFB are associated with RD for traumatic retinal breaks,
peripheral tears in the extraction, iatrogenic retinal ruptures and PVR. Factors
associated with final AV are: preoperative visual acuity, size of the foreign
body, posterior localization of the IOFB and presence of preoperative RD
endophthalmitis, and timing of surgery.19,26, 27
Trauma and Endophthalmitis

In an open eye trauma you have to be alert about the infection risk. The
incidence of endophthalmitis in the diverse reports varies considerably
(Table 1).
The presence of corneal affection does not relate to the trauma, inflammation
in the anterior chamber or hypopyon, vitreous involvement and endophthalmic
retinopathy (perivascular infiltrates, hemorrhages and retinal edema), but it
confirms the beginning or the existence of bacterial endophthalmitis.28 In the
case of a clinical fungal infection, the clinical picture is more chronic, the
infiltrated vitreous is more characteristic and it is generally associated with
organic foreign bodies (Fig. 9).
The most important risk factors are: the place where the trauma occurred
(contamination), rural environment, delayed closure of the wound, age greater
than 50 years, presence of IOFB, a lens rupture, and a filtering and dirty wound.
The onset of endophthalmitis may be masked by injuries from the trauma
and pain is not a paramount symptom except for Bacillus hyperacute disease
pattern.29,30
TABLE 1
Incidence of endophthalmitis
Yang et al Ophthalmo- (1981–2002) 41 years 12% endophthalmitis

logica 2010
Andreoli Am J Ophthal- 675 patients 40 years 0.9% endophthalmitis
et al mol 2009
Colyer Ophthalmology 2003–2005 27 years 0% endophthalmitis
et al 2007 (Iraq)
Allen B Ophthalmology 2003–2004 26.6 years 0% endophthalmitis
2005 (Iraq)
Mansouri Retina 2009 1998–2003 22.5 years 5.1% endophthalmitis
et al (Iran)
245
Antibiotic prophylaxis of endophthalmitis should be performed from the
moment of the diagnosis whenever there is an open trauma in the absence of
aseptic conditions. Extensive coverage with systemic and topical antibiotics
should be conducted, adding clindamycin depending on the risk of anaerobic
contamination. The use of intravitreal antibiotic is based on an individual
decision (Box 1).
Treatment of post-traumatic endophthalmitis is always surgical and
vitrectomy is the treatment of choice. It must be assumed that the degree
of difficulty of the intervention is greater and less predictable than in the
postoperative endophthalmitis, the germs are usually more aggressive and the
prognosis is worse.30,31
The media should be clarified, reducing corneal edema. If the cornea is
strongly affected, temporary keratoprosthesis or a penetrating keratoplasty
may be required. If the lens is integrated, it must be removed. An extensive
capsulotomy needs to be conducted if there exists an IOL. The vitrectomy must
be performed very carefully and slowly due to the risk of predamaged structures.
Remove the FBs if any, remove all the affected vitreous and the maximum
of pus. Do not induce posterior vitreous detachment if the vitreous is much
attached and if the retina is necrotic. The internal limiting membrane (ILM)
needs to be left for a second intervention. Intraocular silicone is used if there
Figure 9 Early endophthalmitis
Box 1: Antibiotic prophylaxis of endophthalmitis

Vancomycin 1 g/12 (Anaerobic Gram-positive and Gram-positive) + (Clin-
damycin 600 mg/8 hour) (Anaerobic Gram-positive and Gram-negative) +
Ceftazidime 1 g/12 (Gram-negative)
or
Fluoroquinolones: Levofloxacin or Moxifloxacin 400 mg/24 hour
Systemic steroids
Topical: Antibiotics (Moxifloxacin) + steroids + mydriatics
246
has been a complete vitrectomy and there are associated lesions of the retina.
It has the advantage of promoting infection control, keep the media clear and
maintain the retina fixed. If you apply intravitreal antibiotics, use one quarter
of the dose (Table 2).4
VITRECTOMY AND COMPLIACTIONS OF THE OCULAR

TRAUMA
Macular Hole
The incidence is higher in young males and more frequent in blunt traumas
with small objects and ocular contusion. The etiopathology of the traumatic
macular hole is not known. It could be caused by a shock wave (this would
explain its elliptic form) or by a sudden DVP (only 15% of the patients present
associated DVP), traumatic necrosis of the fovea (edema and hemorrhage) or
simply traction of the ILM at the moment of the impact. Though they may
close spontaneously and it is recommended to wait for at least 3 months, the
early surgery improves the visual acuity even in the presence of traumatic
maculopathy.32,33
TABLE 2
Treatment for bacterial traumatic endophthalmitis
Mode of injection Name of the antibiotic Dosage

Intravitreal Ceftazidime 2.2 mg/0.1 ml
Vancomycin 1–2 mg/0.1 ml
Dexamethaxone 0.4 mg/0.1 ml
Liquids Ceftazidime 2.2–25 mg/100 ml
infusion Vancomycin 25 mg/100ml
Dexamethasone 0.4–25 mg/100 ml
Subconjunctival Ceftazidime 100 mg/0.5 ml
(not tested) Vancomycin 25 mg/0.5 ml
Dexamethasone 15 mg/1 ml
Topical Fortified topical Hourly
Prednisolone acetate 1%
Moxifloxacin
Oral Moxifloxacin 400 mg/day
Intravenous Ceftazidime 1 g/12 h
Vancomycin 1 g/12 h
Dexamethaxone 1–2 mg/kg/wt
(Source: Reproduced with permission from Kuhn F. Ocular Traumatology. Berlin:
Springer, 2008)
247
Ocular Hypotony and Bulb Phthisis
This is the most severe complication because it implies a loss of the ocular
anatomy. It can be caused by open traumas or by blunt traumas. It involves a
loss of the function of the ciliary body with a decreased production of aqueous
may be due to serous or chronic hemorrhagic detachment with or without
RD, chronic inflammation or traction due to previous VRP. The vitrectomy
is indicated to reapply the retina, extract the membrane structure, completely
remove the lens and try to normalize the ocular anatomy. If the eye has functional
viability, intraocular silicone should be placed into the posterior chamber. If
you just want to keep the anatomy you must completely fill the eyeball. If
there exists hypotony only, which does not improve with the treatment, and
the vision deteriorates with the edema of the disk and chorioretinal folds
(Fig. 11), the vitrectomy with the extraction of the ILM and intraocular gas
may be sufficient to reverse the situation.34
Figure 10 Post-traumatic macular hole
Figure 11 Disk and macula edema

248
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of intraocular foreign bodies and their complications. Br J Ophthalmol.
1980;64(7):476-82.
2. Kuhn F, Maisiak R, Mann L, et al. The Ocular Trauma Score (OTS). Ophthalmol
Clin North Am. 2002;15(2):163-5.
3. Kuhn F, Morris R, Witherspoon CD, et al. The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10.
4. Kuhn F. Ocular Traumatology. Berlin: Springer, 2008.
5. Kuhn F. Visualization issues in ocular trauma surgery. Retina Today. 2011:66-9.
6. Harissi-Dagher M, Dohlman CH. The Boston Keratoprosthesis in severe ocular
trauma. Can J Ophthalmol. 2008;43(2):165-9.
7. Dong X, Wang W, Xie L, et al. Long-term outcome of combined penetrating
keratoplasty and vitreoretinal surgery using temporary keratoprosthesis. Eye
(Lond). 2006;20(1):59-63.
8. Yan H, Cui J, Zhang J, et al. Penetrating keratoplasty combined with vitreoretinal
surgery for severe ocular injury with bloodstained cornea and no light perception.
Ophthalmologica. 2006;220(3):186-9.
9. Roters S, Szurman P, Hermes S, et al. Outcome of combined penetrating
keratoplasty with vitreoretinal surgery for management of severe ocular injuries.
Retina. 2003;23(1):48-56.
10. Shah MA, Shah SM, Shah SB, et al. Effect of interval between time of injury and
timing of intervention on final visual outcome in cases of traumatic cataract. Eur
J Ophthalmol. 2011;21(6):760-5.
11. Pieramici DJ, Capone A Jr, Rubsamen PE, et al. Lens preservation after intraocular
foreign body injuries. Ophthalmology. 1996;103(10):1563-7.
12. Kuhn F. Traumatic cataract: what, when, how. Graefes Arch Clin Exp Ophthalmol.
2010;248(9):1221-3.
13. Shah MA, Shah SM, Shah SB, et al. Comparative study of final visual outcome
between open- and closed-globe injuries following surgical treatment of traumatic
cataract. Graefes Arch Clin Exp Ophthalmol. 2011;249(12):1775-81.
14. Stone TW, Siddiqui N, Arroyo JG, et al. Primary scleral buckling in open-globe
injury involving the posterior segment. Ophthalmology. 2000;107(10):1923-6.
15. El-Asrar AM, Al-Amro SA, Khan NM, et al. Retinal detachment after posterior
segment intraocular foreign body injuries. Int Ophthalmol. 1998;22(6):369-75.
16. Nashed A, Saikia P, Herrmann WA, et al. The outcome of early surgical repair with
vitrectomy and silicone oil in open-globe injuries with retinal detachment. Am J
Ophthalmol. 2011, 151(3):522-8.
17. Azen SP, Scott IU, Flynn HW, et al. Silicone oil in the repair of complex retinal
detachments. A prospective observational multicenter study. Ophthalmology.
1998;105(9):1587-97.
18. Kolomeyer AM, Grigorian RA, Mostafavi D, et al. 360º retinectomy for the
treatment of complex retinal detachment. Retina. 2011;31(2):266-74.
19. Greven CM, Engelbrecht NE, Slusher MM, et al. Intraocular foreign bodies:
management, prognostic factors, and visual outcomes. Ophthalmology.
2000;107(3):608-12.
249
20. Williams DF, Mieler WF, Abrams GW, et al. Results and prognostic factors in
penetrating ocular injuries with retained intraocular foreign bodies. Ophthalmology.
1988;95(7):911-6.
21. Colyer MH, Weber ED, Weichel ED, et al. Delayed intraocular foreign body
removal without endophthalmitis during Operations Iraqi Freedom and Enduring
Freedom. Ophthalmology. 2007;114(8):1439-47.
22. Thach AB, Ward TP, Dick JS, et al. Intraocular foreign body injuries during
Operation Iraqi Freedom. Ophthalmology. 2005;112(10):1829-33.
23. Wani VB, Al-Ajmi M, Thalib L, et al. Vitrectomy for posterior segment intraocular
foreign bodies: visual results and prognostic factors. Retina. 2003; 23(5):654-60.
24. Ahmadieh H, Soheilian M, Sajjadi H, et al. Vitrectomy in ocular trauma. Factors
influencing final visual outcome. Retina. 1993;13(2):107-13.
25. Weichel ED, Bower KS, Colyer MH. Chorioretinectomy for perforating or
severe intraocular foreign body injuries. Graefes Arch Clin Exp Ophthalmol.
2010;248(3):319-30.
26. Bai HQ, Yao L, Meng XX, et al. Visual outcome following intraocular foreign
bodies: a retrospective review of 5-year clinical experience. Eur J Ophthalmol.
2011;21(1):98-103.
27. Jonas JB, Knorr HL, Budde WM, et al. Prognostic factors in ocular injuries caused
by intraocular or retrobulbar foreign bodies. Ophthalmology. 2000;107(5):823-8.
28. Zhang Y, Zhang MN, Jiang CH, et al. Endophthalmitis following open globe injury.
Br J Ophthalmol. 2010;94(1):111-4.
29. Alfaro DV, Roth D, Liggett PE. Posttraumatic endophthalmitis. Causative
organisms, treatment, and prevention. Retina. 1994;14(3):206-11.
30. Chaudhry IA, Shamsi FA, Al-Harthi E, et al. Incidence and visual outcome of
endophthalmitis associated with intraocular foreign bodies. Graefes Arch Clin
Exp Ophthalmol. 2008;246(2):181-6.
31. Lieb DF, Scott IU, Flynn HW, et al. Open globe injuries with positive intraocular
cultures: factors influencing final visual acuity outcomes. Ophthalmology. 2003;
110(8):1560-6.
32. García-Arumí J Corcostegui B, Cavero L, et al. The role of vitreoretinal surgery
in the treatment of posttraumatic macular hole. Retina. 1997;17(5):372-7.
33. Yanagiya N, Akiba J, Takahashi M, et al. Clinical characteristics of traumatic
macular holes. Jpn J Ophthalmol. 1996;40(4):544-7.
34. Ishida Y, Minamoto A, Takamatsu M, et al. Pars plana vitrectomy for traumatic
cyclodialysis with persistent hypotony. Eye (Lond). 2004;18(9):952-4.
chapter 12
Basic Vitrectomy in
Diabetic Retinopathy
Jose Garcia-Arumi, Anna Boixadera, Laura Distefano,

Vicente Martínez-Castillo, Miguel Angel Zapata
INTRODUCTION
Diabetic retinopathy is the leading cause of blindness among working-age
individuals in developed countries.1 Thirty-three percent of patients with type
1 diabetes and 17% with type 2 will develop proliferative retinopathy within
15 years of diabetes diagnosis,2 and 20% of patients with type 1 diabetes and
40% with type 2 will develop macular edema over a period of 10 years.3
Several complications of diabetic retinopathy require surgical man
agement. Pars plana vitrectomy (PPV) has a number of established indications
in diabetic patients yet others are still under discussion. Vitrectomy offers
relief from retinal traction, clearing of media opacities, and stabilization
of the proliferative process. Classic indications for PPV are vitreous
hemorrhage, severe fibrovascular proliferation with tractional retinal
detachment (TRD) affecting or threatening the macula, dense premacular
hemorrhage and tractional-rhegmatogenous retinal detachment, whereas
diffuse macular edema is a nonstandard indication for this procedure.4-6
However, diabetic macular edema (DME) associated with posterior hyaloid
traction has been recently added as an indication for vitrectomy. 7 In
addition, in patients with macular edema without a taut posterior hyaloid,
vitrectomy surgery with or without internal limiting membrane (ILM)
peeling has been reported.8
In general, improvements in surgical techniques instrumentation, and skills,
have shortened the timing threshold for surgery and newly discovered benefits
of early treatment continue to be described.9
Chapter 12  Basic Vitrectomy in Diabetic Retinopathy
251
Surgical Approach
First, a core three-port PPV is performed. A 6 mm cannula can be used in cases
of extensive peripheral fibrosis or anterior retinal displacement that may obscure
the cannula tip. Lensectomy can be added if lens opacity prevents adequate
visualization or surgical access to the vitreous base. In eyes with complete
vitreous separation, the usual indication is nonclearing vitreous hemorrhage;
the vitreous is removed and this is followed by panretinal photocoagulation.
If there is incomplete posterior hyaloid detachment, surgery is targeted
at separating the posterior hyaloid. Several surgical techniques have been
developed for membrane removal, such as segmentation, in which traction
forces are eliminated by removing the posterior hyaloid and fibrovascular
tissue connections to adjacent traction areas and isolating these independent
segments (Figs 1A and B).7 Another technique is delamination, which involves
cutting connections between the posterior hyaloid and/or fibrovascular tissue
and the ILM (Figs 2A and B). In en bloc dissection, the vitreous and associated
vitreoretinal membranes are removed as a single unit. The current technique
A B
Figures 1A and B Diagram showing the segmentation procedure: traction forces

are eliminated by removing the posterior hyaloid and/or fibrovascular tissue
connections to adjacent traction areas to isolate these independent segments
A B
Figures 2A and B Diagram showing how delamination is achieved: the connections

are cut between the posterior hyaloid and/or fibrovascular tissue and the internal
limiting membrane
252
combines delamination and segmentation using a bimanual approach. For all
these maneuvers, an accessory light may be needed, such as a 25-gauge xenon
endoillumination probe through a fourth sclerotomy port.
In eyes with incomplete posterior vitreous detachment and one or more
focal adhesions, the cortical vitreous is identified, with or without the use of
intravitreal triamcinolone, for a core vitrectomy.10 If there is wide separation
between the vitreous and retina, the vitreous probe can be used to incise
the posterior hyaloid in this region to gain access to the subhyaloid space.
When a smaller separation exists, an opening can be made with a barbed
microvitreoretinal (MVR) blade. Once the subhyaloid space is accessed,
the opening is extended circumferentially 360° or minimally, depending
on the degree of vitreous separation. This maneuver releases the peripheral
vitreous from its posterior attachments, thus reducing the risk of iatrogenic
retinal tears. Next, vitreoretinal proliferations and epiretinal membranes are
addressed. Their dissection, which is usually initiated in the peripapillary
region, can be conducted with the vitreous probe if there is adequate space
between the vitreous and retina. If the separation cannot accommodate the
probe, more detailed dissection using scissors, picks and/or forceps is required
through a bimanual approach. Several radial cuts are made in the posterior
hyaloid between focal areas of fibrovascular adhesion to extend the separation
anteriorly.
An additional surgical technique is viscodissection, which is used to increase
the separation between the hyaloid or proliferative tissue. In this technique,
small amount of hyaluronic acid is injected through a 40-gauge subretinal
cannula (Fig. 3). A limitation of viscodissection is that one of the sclerotomies
must be enlarged to 20-gauge if 23-gauge transconjunctival sutureless
vitrectomy (TSV) is being done. We have designed a 23-gauge cannula for
Figure 3 Intraoperative fundus photograph showing the process of viscodissection:

small amounts of hyaluronic acid is injected through a 40-gauge subretinal cannula
to increase the separation between the hyaloid or proliferative tissue
253
viscodissection of 33-gauge caliber that will soon be available. Once focal
adhesions are isolated, they are usually excised parallel to the retinal surface.
If epiretinal membranes also exist, they are usually peeled toward the vascular
epicenter and removed. After separation and removal of all posterior hyaloid
and fibrovascular adhesions, the dissection is continued anteriorly.
Broad vitreoretinal adhesions are more difficult to remove, particularly
if they underlie retinal folds. In this case, the edge of the adhesion must be
elevated, and each individual adhesion excised using membrane peeler cutter
scissors.
In eyes with no posterior vitreous separation, core vitrectomy is performed,
but the subhyaloid space in the mid-periphery cannot be accessed using the
vitreous cutter. This can be done in the peripapillary region using a barbed
MVR blade. After making radial cuts, the hyaloid is stripped to the periphery
in all quadrants. Blood beneath the posterior hyaloid can be aspirated using a
soft-tipped cannula, the vitreous cutter, or if clotted, peeled with forceps. In
some cases in which the retina is not completely reattached despite vitreoretinal
dissection, a relaxing retinectomy may be required. The fibrovascular tissue
over the optic disk is carefully removed with forceps (Fig. 4).
After completing the vitrectomy, panretinal photocoagulation with or
without cryotherapy of the sclerotomies is performed (Fig. 5). The peripheral
fundus is then examined under scleral depression to search for possible
iatrogenic retinal breaks before fluid-air exchange, when needed. Depending
on the state of the retina after surgery, an extended tamponade of nonexpansible
gas or silicone oil is left in the vitreous cavity. It should be noted that with
23-gauge TSV, injection of silicone oil is feasible. If silicone oil is used, all
sclerotomies should be sutured (Figs 6 to 8).
A recent variation of vitrectomy for proliferative diabetic retinopathy (PDR)
is the use of intravitreally injected anti-VEGF medication as an adjuvant. One
Figure 4 Removal of a fibrovascular proliferation over the optic nerve using

intraocular forceps
254
Figure 5 Panphotocoagulation performed at the end of the vitrectomy
A B
Figures 6A and B (A) A 65-year-old man with severe tractional retinal detachment
affecting the macula. Preoperative visual acuity was 20/400; (B) One month after
23-gauge transconjunctival sutureless vitrectomy with bimanual dissection and
silicone oil tamponade, visual acuity was 20/100
A B
Figures 7A and B (A) A 25-year-old woman with traction-rhegmatogenous retinal

detachment. Preoperative fundus photograph. Visual acuity was 20/200; (B) Three
months after 23-gauge transconjunctival sutureless vitrectomy with bimanual
dissection and gas tamponade, visual acuity was 20/60
255
A B
Figures 8A and B (A) Tractional retinal detachment affecting the macula.

Preoperative visual acuity was 20/400; (B) After 23-gauge transconjunctival sutureless
vitrectomy with bimanual dissection, visual acuity was 20/100
such agent, bevacizumab 1.25 milligram, or ranibizumab 0.05 milligram, is

injected into the vitreous cavity 2–5 days before PPV. This monoclonal antibody
decreases bleeding during surgical dissection of fibrovascular membranes
and inhibits the growth of new vessels. Its use also decreases surgical time
and the incidence of postoperative recurrent vitreous hemorrhage, as well as
improving final visual acuity.11 Certain complications can occur, as described
by Arevalo et al.12 These authors reported a risk of TRD or its progression soon
after intravitreal bevacizumab in patients with severe PDR. In our experience,
the optimal effect of intravitreal anti-VEGF is achieved when vitrectomy is
performed 2 days after the injection.
Among the descriptions of 23-gauge TSV for diabetic retinopathy, Eckardt’s
first article13 reports the outcome in 41 patients treated with 23-gauge TSV
using the Dutch Ophthalmic Research Center system; of these patients, 11 had
diabetic retinopathy. The author reported that the instruments are less flexible
than in 25-gauge TSV, and noted that vitrectomy was still somewhat slower
than for 20-gauge vitrectomy. In two cases of PDR, slight bleeding into the
vitreous cavity occurred in the first few days after the operation. No case of
postoperative hypotony was observed and Eckardt concluded that 23-gauge
TSV seems to offer all the advantages of the minimally invasive TSV system
developed by Fujii et al14 plus the benefits of larger, sturdier instrumentation.
The characteristics of the vitreous probe, particularly the fact that the cutting
tip is closer to the edge, facilitate dissection of the fibrovascular proliferations
occurring in diabetic retinopathy. All the classic surgical maneuvers can be
carried out with 23-gauge TSV. In addition, an accessory, the 25-gauge wide-
field endoillumination probe, can be placed on a fourth sclerotomy, permitting
bimanual dissection. After the initial experience of Eckardt with 23-gauge
TSV, Kim et al15 described a pilot study in 22 diabetic retinopathy patients.
Among the indications, 11 were vitreous hemorrhage, 10 DME, and one TRD.
Intraoperative suture placement was necessary in 7.5% and the authors reported
no serious postoperative complications. This publication was followed by several
reports of further pilot studies.16-19 Thus, Oshima et al17 compared a group of 33
256
patients treated with 20-gauge PPV and 38 patients treated with 23-gauge TSV:
significant differences were detected only in the operating time and need for
sutures on the sclerotomies. A larger number of iatrogenic tears were produced
at the entry sites with 23-gauge TSV, although the difference was not significant.
In addition, better intraoperative fluid control was observed with 23-gauge TSV.
In a prospective, randomized study of diabetic TRD comparing 34 patients
treated with 20-gauge PPV and 47 patients with 23-gauge TSV, we noted that
membrane dissection was possible using the vitreous probe in 82% of the
patients in the 23-gauge group compared to only 25% undergoing 20-gauge
PPV (p < 0.05). Sutures were required in 22% of the 23-gauge TSV patients
versus 100% of the 20-gauge PPV patients (p < 0.05). No differences were
recorded in postoperative visual acuity, operating time (although there was
a trend toward shorter surgery duration with 23-gauge TSV), postoperative
cataract, iatrogenic tears, or postoperative vitreous hemorrhage.
Outcomes of 25-gauge PPV for the treatment of PDR also appear to be
similar to those reported for 20-gauge vitrectomy in terms of effectiveness
and safety.20,21 According to the Diabetic Retinopathy Vitrectomy Study,22 the
timing of vitrectomy for severe vitreous hemorrhage should be within 3 months
in patients with Type 1 diabetes and within 6 months in those with Type 2.
Moreover, this study reported that 15% of eyes with TRD suffered severe visual
loss (< 5/200) when surgery was not performed within 1 year (Figs 9A to D).
Despite the indication based on the results of classic studies of up to 3 months
and 6 months respectively for Type 1 and 2 diabetes, in our experience, prompt
surgery avoids worsening functional results in severe cases.
Postoperative complications include vitreous hemorrhage, which occurs
in 29–75% of patients, depending on the series;23 the use of intravitreal gas is
ineffective at decreasing the risk of this event.24 Other complications include a
A B
Figures 9A to D (A) Macular tractional retinal detachment in a patient with a

preoperative visual acuity of 20/60 and; (B) Optical coherence tomography scan
showing subfoveal fluid; (C) After 23-gauge transconjunctival sutureless vitrectomy
with bimanual dissection, visual acuity was 20/30 and; (D) Optical coherence
tomography revealed a normal foveal contour
257
rise in postoperative intraocular pressure to over 30 mm Hg, occurring in 35%
of the patients in the first 48 postoperative hours,25 growth of new iris vessels,
which takes place in 8–26% of phakic patients and 31–55% of pseudophakic
patients,26 and the severe complication, anterior fibrovascular proliferation,
which is seen in 13% of the patients.27 Intravitreal bevacizumab at the end
of surgery may help decrease the rate of these postoperative complications,
although the benefits of this measure remain to be proven. Ahn et al noted a
significant decrease in early vitreous hemorrhage and a shorter vitreous clearing
time in patients receiving intravitreal bevacizumab at the end of PPV compared
to patients not given this intravitreal injection.28
VITRECTOMY FOR DIABETIC MACULAR EDEMA

Vitreous changes leading to increased vascular permeability have been proposed
as a cause of macular edema, such as destabilization by abnormal glycation
and cross-linking of vitreous collagen, deposition of vascular factors in the
premacular gel, and cell migration to the posterior hyaloid with subsequent
contraction and macular traction. The observation that relieving mechanical
traction on the macula reduces DME supports the indication for vitrectomy
in such patients. Further, improved retinal oxygenation with an associated
reduction in macular thickness suggests a potential benefit of surgery.29
In cases of diffuse macular edema, vitrectomy is only indicated when this
edema is refractory to focal laser treatment and several intravitreal injections
of triamcinolone or anti-VEGF. In cases of an attached posterior hyaloid
without a thickened vitreous membrane, some authors have described benefits
of vitrectomy with or without ILM peeling,8,30-34 although these patients show
anatomic but not visual improvement35-38 and this indication for vitrectomy
remains uncertain. Anti-VEGF or triamcinolone treatment can be left until
after the completion of surgery. A good alternative to treat macular edema may
be the use of sustained-release dexamethasone implants (OzurdexÒ), because
of their longer-lived effect and the fact that the clearance time of the drug is
unaffected by the vitrectomy as occurs with intravitreal injections.
In cases of diffuse macular edema with a taut posterior hyaloid observed
by ophthalmoscopy and optical coherence tomography, the benefits of surgery
include opening, elevating, and removing the posterior hyaloid.7 The Diabetic
Retinopathy Clinical Research Group has recently published the results of a
trial conducted in 87 patients with clinical vitreomacular traction, moderate
visual loss and a thickened macula. At the 6-month follow-up visit, 38% of
the patients gained greater than or equal to 10 letters from baseline, while 22%
lost greater than or equal to 10 letters compared to initial visual acuity. In most
patients, a 50% reduction in central retinal thickness from baseline was achieved
at the 12th month visit, but only in about half of the patients was central retinal
thickness less than 250 microns.29 Although vitrectomy may lead to visual and
anatomic improvements in patients with macular edema, further work is needed
to address the benefits of this procedure.
258
REFERENCES
1. Moss SE, Klein R, Klein BE. The 14-year incidence of visual loss in a diabetic
population. Ophthalmology. 1998;105(6):998-1003.
2. Klein R, Klein BE, Moss SE, et al. The Wisconsin epidemiologic study of diabetic
retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis
is less than 30 years. Arch Ophthalmol. 1984;102(4):520-6.
3. Klein R, Klein BE, Moss SE, et al. The Wisconsin epidemiologic study of diabetic
retinopathy. XV. The long-term incidence of macular edema. Ophthalmology.
1995;102(1):7-16.
4. Mason JO, Colagross CT, Haleman T, et al. Visual outcome and risk factors for light
perception and no light perception vision after vitrectomy for diabetic retinopathy.
Am J Ophthalmol. 2005;140(2):231-5.
5. Helbig H, Sutter FK. Surgical treatment of diabetic retinopathy. Graefes Arch Clin
Exp Ophthalmol. 2004;242(8):704-9.
6. Mason JO, Colagross CT, Vail R. Diabetic vitrectomy: risks, prognosis, future
trends. Curr Opin Ophthalmol. 2006;17(3):281-5.
7. Lewis H, Abrams GW, Blumenkranz MS, et al. Vitrectomy for diabetic macular
traction and edema associated with posterior hyaloidal traction. Ophthalmology.
1992;99(5):753-9.
8. Rosenblatt BJ, Shah GK, Sharma S, et al. Pars plana vitrectomy with internal
limiting membranectomy for refractory diabetic macular edema without a taut
posterior hyaloid. Graefes Arch Clin Exp Ophthalmol. 2005;243(1):20-5.
9. Sullu Y, Hamidova R, Beden U, et al. Effects of pars plana vitrectomy on
retrobulbar haemodynamics in diabetic retinopathy. Clin Experiment Ophthalmol.
2005;33(3):246-51.
10. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinolone-assisted pars plana
vitrectomy improves the surgical procedures and decreases the postoperative blood-
ocular barrier breakdown. Graefes Arch Clin Exp Ophthalmol. 2002;240(6):423-9.
11. Zhao LQ, Zhu H, Zhao PQ, et al. A systematic review and meta-analysis of clinical
outcomes of vitrectomy with or without intravitreal bevacizumab pretreatment for
severe diabetic retinopathy. Br J Ophthalmol. 2011;95(9):1216-22.
12. Arevalo JF, Maia M, Flynn HW, et al. Tractional retinal detachment following
intravitreal bevacizumab (Avastin) in patients with severe proliferative diabetic
retinopathy. Br J Ophthalmol. 2008;92(2):213-6.
13. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;
25(2):208-11.
14. Fujii 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.
15. Kim MJ, Park KH, Hwang JM, et al. The safety and efficacy of transconjunctival
sutureless 23-gauge vitrectomy. Korean J Ophthalmol. 2007;21(4):201-7.
16. Arumí JG, Boixadera A, Martínez-Castillo V, et al. Transconjunctival sutureless
23-gauge vitrectomy for diabetic retinopathy. Review. Curr Diabetes Rev.
2009;5(1):63-6.
17. Oshima Y, Shima C, Wakabayashi T, et al. Microincision vitrectomy surgery and
intravitreal bevacizumab as a surgical adjunct to treat diabetic traction retinal
detachment. Ophthalmology. 2009;116(5):927-38.
259
18. da R Lucena D, Ribeiro JA, Costa RA, et al. Intraoperative bleeding during
vitrectomy for diabetic tractional retinal detachment with versus without
preoperative intravitreal bevacizumab (IBeTra study). Br J Ophthalmol. 2009;
93(5):688-91.
19. Yang SJ, Yoon SY, Kim JG, et al. Transconjunctival sutureless vitrectomy for
the treatment of vitreoretinal complications in patients with diabetes mellitus.
Ophthalmic Surg Lasers Imaging. 2009;40(5):461-6.
20. Schoenberger SD, Miller DM, Riemann CD, et al. Outcomes of 25-gauge pars
plana vitrectomy in the surgical management of proliferative diabetic retinopathy.
Ophthalmic Surg Lasers Imaging. 2011;42(6):474-80.
21. Farouk MM, Naito T, Sayed KM, et al. Outcomes of 25-gauge vitrectomy
for proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol.
2011;249(3):369-76.
22. Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Two-year
results of a randomized trial. Diabetic Retinopathy Vitrectomy Study report 2.
The Diabetic Retinopathy Vitrectomy Study Research Group. Arch Ophthalmol.
1985;103(11):1644-52.
23. Tolentino FI, Cajita VN, Gancayco T, et al. Vitreous hemorrhage after
closed vitrectomy for proliferative diabetic retinopathy. Ophthalmology.
1989;96(10):1495-500.
24. Joondeph BC, Blankenship GW. Hemostatic effects of air versus fluid in diabetic
vitrectomy. Ophthalmology. 1989;96(12):1701-6.
25. Han DP, Lewis H, Lambrou FH, et al. Mechanisms of intraocular pressure elevation
after pars plana vitrectomy. Ophthalmology. 1989;96(9):1357-62.
26. Rice TA, Michels RG, Maguire MG, et al. The effect of lensectomy on the incidence
of iris neovascularization and neovascular glaucoma after vitrectomy for diabetic
retinopathy. Am J Ophthalmol. 1983;95(1):1-11.
27. Lewis H, Abrams GW, Foos RY. Clinicopathologic findings in anterior hyaloidal
fibrovascular proliferation after diabetic vitrectomy. Am J Ophthalmol.
1987;104(6):614-8.
28. Ahn J, Woo SJ, Chung H, et al. The effect of adjunctive intravitreal bevacizumab
for preventing postvitrectomy hemorrhage in proliferative diabetic retinopathy.
Ophthalmology. 2011;118(11):2218-26.
29. Diabetic Retinopathy Clinical Research Network Writing Committee, Haller
JA, Qin H, et al. Vitrectomy outcomes in eyes with diabetic macular edema and
vitreomacular traction. Ophthalmology. 2010;117(6):1087-93.e3.
30. Dillinger P, Mester U. Vitrectomy with removal of the internal limiting membrane
in chronic diabetic macular oedema. Graefes Arch Clin Exp Ophthalmol.
2004;242(8):630-7.
31. Ikeda T, Sato K, Katano T, et al. Vitrectomy for cystoid macular oedema with
attached posterior hyaloid membrane in patients with diabetes. Br J Ophthalmol.
1999;83(1):12-4.
32. La Heij EC, Hendrikse F, Kessels AG, et al. Vitrectomy results in diabetic macular
oedema without evident vitreomacular traction. Graefes Arch Clin Exp Ophthalmol.
2001;239(4):264-70.
33. Tachi N, Ogino N. Vitrectomy for diffuse macular edema in cases of diabetic
retinopathy. Am J Ophthalmol. 1996;122(2):258-60.
260
34. Yamamoto T, Hitani K, Tsukahara I, et al. Early postoperative retinal thickness
changes and complications after vitrectomy for diabetic macular edema. Am J
Ophthalmol. 2003;135(1):14-9.
35. Figueroa MS, Contreras I, Noval S. Surgical and anatomical outcomes of pars
plana vitrectomy for diffuse nontractional diabetic macular edema. Retina.
2008;28(3):420-6.
36. Mochizuki Y, Hata Y, Enaida H, et al. Evaluating adjunctive surgical procedures
during vitrectomy for diabetic macular edema. Retina. 2006;26(2):143-8.
37. Patel JI, Hykin PG, Schadt M, et al. Pars plana vitrectomy with and without peeling
of the inner limiting membrane for diabetic macular edema. Retina. 2006;26(1):5-13.
38. Hoerauf H, Brüggemann A, Muecke M, et al. Pars plana vitrectomy for diabetic
macular edema. Internal limiting membrane delamination vs posterior hyaloid
removal. A prospective randomized trial. Graefes Arch Clin Exp Ophthalmol.
2011;249(7):997-1008.
chapter 13
Macular Surgery
Amparo Navea, Elena Palacios, Carmen Desco, Jorge Mataix
SURGERY ON THE SURFACE OF THE MACULA

This surgery is performed to treat several diseases: epiretinal membranes
(ERM), vitreomacular traction syndrome, macular edema of a vascular origin
(diabetic, vein occlusion), inflammatory macular edema (Irvine-Gass, uveitic),
and macular hole (MH).
PRELIMINARY CONSIDERATIONS
The clinical case should be studied attempting to determine the pathology
requiring surgery. A good clinical history makes it possible to distinguish the
primary retinal causes of the ERM, for example, vascular causes and cystoid
macular edema following cataract surgery, vitreous interface diseases like
MH and vitreomacular traction syndrome. The former conditions may have a
poor visual prognosis due to the underlying retinal disease, while in the latter
the membranes may be more closely adhered, thinner, and difficult to remove.
Determination of the factors will help us to explain the prognosis to the patient
and have an idea of what we will find during surgery.
The retina should be carefully studied in order to examine the macula and
observe the extent of the puckers; the edges of the ERM should be studied if
they are visible, as should the contraction centers, the condition of the vitreous,
and the cystic or noncystic appearance of the fovea. It is important not to forget
to examine the peripheral retina: an open or treated tear can have generated
an ERM which would contain cells from the retinal pigment epithelium and
supposedly the surgery would be easier.
An optical coherence tomography will show the points of adhesion of the
membrane as well as the state of the retina, the degree of edema or atrophy
262
which could contraindicate surgery if it is severe, as can be found in some forms
of dry macular degeneration, since no visual improvement would be obtained.1
The crystalline lens should be evaluated. This lens can be preserved in the
case of phakic patients so long as there is clear visualization of the macula
during biomicroscopic stereoscopic examination. If there are central opacities
or nuclear sclerosis that distort vision of the posterior pole, cataract surgery
will have to be associated; this could be performed during the same operation
or beforehand. If cataract surgery is not performed, the patient will have to be
informed that he/she will probably need the operation some months afterward.
Combined phakovitrectomy surgery has the advantage of saving the
patient I operation. However, it does have some disadvantages. Although it is
taken for granted that cataract surgery is a well mastered technique, awkward
problems can arise during posterior vitrectomy (corneal edema, a pupil tending
to contract, incisions that are not wholly sealed with flattening of the chamber)
which will make the vitrectomy more tricky than if the two operations were
performed separately. A possibly higher degree of postoperative inflammation
should be expected and the appearance of pupillary synechiae should be
watched out for as they are more frequent when the operations are associated.
Separating the operations has the obvious disadvantage of making the
patient go through surgery twice. Another point to be taken into account is
that performing phacoemulsification on a vitrectomized eye is usually more
difficult than on an eye with an integral vitreous.
INTERVIEW WITH THE PATIENT

As in all medical activity, it is important to talk to the patient and explain what
he/she may expect from the surgery. Macula surgery can lead to unwelcome
postoperative surprises. The patient should know that the possibilities of visual
recovery are generally uncertain and are related to the length of time their
disease has been developing and the visual loss he/she has already undergone;
the greater both of these are, the worse the visual prognosis. Nonetheless, they
are not processes that tend to resolve spontaneously; therefore surgical treatment
should be indicated promptly after diagnosis.2
The explanation should cover several aspects:
Visual recovery associated with primary disease, time elapsed, and extent
of visual loss
Decrease in symptomatology: metamorphopsia or central scotoma
depending on the postoperative retinal recovery. A certain degree of residual
metamorphopsia may remain for some time or indefinitely
Recovery period: retinal remodeling processes take their time and recovery
of vision can be seen after months and years if long-term follow-up is
performed. Nonetheless, a relative improvement is usually observed 1
month after surgery in the best cases
Chapter 13  Macular Surgery
263
Crystalline lens treatment in phakic patients: simultaneity of crystalline
lens surgery or its probable necessity in the months after vitrectomy will
have to be explained
The patient should be told about the need of postoperative postural rest, if
it should be applied.
SURGERY PREPARATION
A vitrectomy is programmed or not with cataract surgery. The size of the ports
can be chosen in accordance with the surgeon’s preference. We find 23-gauge
surgery very balanced and is what we usually use.
Technical Requirements
A vitrectomy system, a wide field visualization device and visualization of the
macula with high definition, such as the Mackemer magnifying macular contact
lens or the high-resolution contact or noncontact lens, microforceps, dyes.
Human Requirements
An experienced retinal surgeon is required. The work on the surface of the
retina requires skill and training. It is difficult.
Patient Preparation
The usual premedication for retina surgery will include pupillary dilation,
sedation, and local anesthesia. The patient should be as comfortable as possible
on the operating table so that he/she can keep still during surgery. The area
should be cleansed with povidone and the areas should be sterile with an
adhesive dressing holding eyelashes.
Surgeon Preparation
The surgeon should be sitting properly in the surgeon’s seat. Macula surgery
requires precision and a steady hand which is impossible if the surgeon is not
sitting properly or if his/her arms are not supported, therefore the points that
support the arms must be checked. The eyepieces, the height of the table, the
microscope, and the surgeon’s seat should be suitably positioned. Check the
position of the patient’s head. The plane of the patient’s face should be parallel
with the floor so that the cornea is centered in the palpebral fissure and it should
be possible to tilt the eyeball in order to have access to the upper and lower
retinal periphery. Likewise, the sterile cloths and drapes should be correctly
positioned. Work with little light during the vitrectomy requires that each drape
be appropriately positioned and that there be no folds which could inadvertently
264
limit the movements of the instruments, particularly at the inner and outer edges
where the active terminals of the surgeon’s intraocular work move.
VITRECTOMY
Position the microcannulas and the infusion line or perform the
sclerotomies if the former is not used, try to separate the incisions
sufficiently for the instruments so that there is good intraocular mobility.
Placement slightly above the horizontal meridians (some 150° of
separation) is a comfortable position. Put on the wide field visualization
system and start the vitrectomy
Perform a mid-and peripheral vitrectomy. The length of time to be devoted
to this part of the surgery is debatable: in the case in which there is no
disease at the base of the vitreous body, it will probably not be necessary
to eliminate the vitreous wholly. It is, however, advisable to eliminate it
from the entry canal of the instruments to avoid subsequent incarcerations.
At this point, the whole peripheral retina can be examined to detect any
conditions that could need treatment
Detach the hyaloid membrane if it was not already detached. Once the
central vitreous has been removed, go deeper into the papilla to reduce the
amount of vitreous cortex. Deactivate the vitrectomy blade and position the
head on the edge of the papilla, preferably the nasal area, perform suction
to try to grasp the posterior hyaloid membrane, swing the vitreotome
horizontally to induce detachment. Repeat several times until achieved.
Once it is detached, complete the vitrectomy halfway down or to the
vitreous base
Observe the macula: Decide whether to use dye and, if so, which to use
Decide whether visualization is good or if macular lenses should be used
Dye: There are different types; the one we use most is bright blue. It is
loaded into a 2 cc syringe connected to a silicone tipped cannula which
is injected directing the flow toward the posterior pole. When using
microcannulas incorporating valves, it is not absolutely necessary to close
up the infusion line as turbulence decreases considerably. After 1 minute
we remove the coloring with a silicone tipped cannula connected to the
extrusion needle or with the vitreotome
Replace the lens if necessary. If we use a magnifying contact lens, the
microscope head should be moved to a lower setting (as it will be focused for
wide-field lenses). Start by focusing it approximately and, after introducing
the microforceps and being able to see them through the pupil, adjust the fine
focus and magnify the image. Unless you are very used to this procedure,
care should be taken because of the drastic reduction in field produced by
these lenses. To avoid involuntary intraocular contact, it is advisable to
keep the ends of the two active instruments visible at all times through the
pupil from the time they are introduced into the eye
265
Peel away the membrane. Finding the edge or peeling plane of the membrane
is the most difficult maneuver in this operation; the second most difficult
is not letting it go. If the edge of the membrane can be seen, which not the
usual case is, it can be peeled back and removed entirely. When the edge
is not visible, which is the usual case; there are several ways to proceed.
Although there are reports of Tano’s brush for “scraping” the surface of
the retina, it is difficult to find a plane without knocking it and causing
bleeding. It may be a question of pinching the membrane and peeling it
back until it tears which would give us a flap, going about it in the same way
as one would to perform a capsulorhexis directly with forceps in cataract
surgery. For this maneuver, try to choose an area where the membrane is
thicker, for example where there are more puckers or a contraction center,
or near or over one of the macular vessels. With the hand well-supported,
open the forceps slightly and touch the surface of the membrane, depress it
slightly, close the forceps without making a vertical movement and then pull
gently upward once the membrane has been grasped. It usually tears thus
providing a flap that can be dissected. It seldom comes away in one piece
so it is dissected from the whole macula or part of it. If the dye has worked
well, it is easier to find an edge as the membrane will be more “visible”. A
membrane flap can also be created by using a vitrectomy surgical blade to
make a linear incision and then using the forceps to remove it
Once the membrane plane has been found, it should be dissected with the
forceps. This maneuver should be performed by pulling the membrane
tangentially over the retina centripetally. At this point in surgery, we should
observe both the point of the membrane we are peeling and also the head
of the forceps simultaneously. The head of the forceps should be situated
in front of the point the membrane is being peeled away from; care must
be taken or the retina could be knocked and torn. One of the most delicate
steps is separating the membrane from the fovea. Care should be taken in
performing this centripetally and very gently to avoid tearing the retina,
especially if it is a cystic fovea. In some cases, there are friable membranes
that tear and shred during dissection. They usually stay joined to the fovea
and can be dissected from the perifoveal retina and, at the end, cut where
they are joined to the fovea with the vitreotome
Once the central membrane has been dissected, further dissection around
the macula should be carried out
To complete the operation, replace the wide-field system to check the
peripheral retina, make a small final central vitrectomy and a partial or
total air exchange.
SPECIFIC TECHNICAL POINTS IN MACULAR HOLE

The technique is same, although special care should be taken in examining the
peripheral retina as a greater incidence of detached retina after MH surgery
266
has been reported than in ERM surgery.3 The inner limiting membrane (ILM)
should be removed, using the same technique as for ERM, up to the edges of
the hole. Further dissection of ILM beyond the vascular arches, or even inside
them with a distance of 1 disk around the anatomic macula, is not necessary.
Peeling the ILM is probably the most difficult part of macula surgery. At
the end of the surgery a more complete air exchange should be done and the
appropriate tamponade should be chosen. If the patient is not going to keep
a facedown position, the C3F8 provides a longer-lasting, effective tamponade
so long as the posture of the head is upright. If the patient can tolerate being
facedown for some days, SF6 may be better. In cases of macular atrophy, silicone
oil may be more useful.
267
SURGERY IN THE SUBRETINAL MACULAR SPACE
This type of surgery in the 90s was indicated for extracting subretinal
neovascular membranes. Currently it has few, but necessary indications: serious
submacular hemorrhage and foveal perfluorocarbon (PFC) liquid bubbles.
An option for a relatively easy treatment of submacular hemorrhage consists
of using combined recombinant tissue plasminogen activator (r-TPA) 25–50
µg/0.1 ml with gas.4
Recombinant tissue plasminogen activator injection of 0.1 cc followed by
0.3 cc of pure SF6 into the vitreous cavity, with the patient lying on his/her
back for the first 6–8 hours so that the r-TPA can spread toward the clot and
liquefy it, then the patient should lie facedown so that the gas can move the
blood away from the macula.
Perform a central vitrectomy and inject 0.1 ml of r-TPA solution under the
retina using 38 or 40-gauge microcannulas needles. You can either wait 45–60
minutes for clot lysis and remove it by suction once it has liquefied, or you can
inject pure SF6 and position the patient facedown, some hours after surgery.
We have little and bad experience with these procedures. There is no large
series that compares the injection of r-TPA and gas as opposed to vitrectomy
although some short series give a better visual result with surgery in cases
associated with age-related macular degeneration (AMD), which can also be
used to remove the neovascular membrane that may be present.5
Regarding the surgical removal of these hemorrhages, the general points of
macular surgery described above can also be applied to submacular surgery. It
is indicated in circumstances in which the collection of subretinal substances
can compromise vision. Natural evolution of big submacular hemorrhages leads
to a very poor visual acuity because of both, the toxic effect of blood and also
the subsequent fibrosis associated with exudative-AMD cases (Figs 1 to 4).
Different situations may be encountered:
SEVERE SUBMACULAR HEMORRHAGE LOCATED INTO

THE MACULAR AREA
It should not extend to the periphery: perform a vitrectomy, use a fine-tipped
cannula (38–40 gauge) connected to an injection system, perforate the retina and
detach it injecting balanced salt solution (BSS). Then introduce the subretinal
angled forceps through the retinotomy and extract the clot with care. It is enough
just to free the fovea, it is not necessary to clean the whole subretinal space.
If signs of new hemorrhaging are observed, intraocular pressure should be
increased. To finish, perform an air exchange and use this or gas as a tamponade.
It is not necessary to treat the posterior retinotomies with laser. An anti-VEGF
injection can be added when finishing in the case in which hemorrhaging has
occurred in AMD in order to help the lesion to heal up, unless it is due to tearing
of a pigment epithelium detachment which is, in fact, quite usual in these cases.
268
Figure 1 Patient I: submacular hemorrhage, observe the blood collecting under

the macula before the surgery
Figure 2 Patient I: month after surgery
It is important to make a careful choice of the site for performing the

retinotomy. This should be above and to the right of the fovea (as we look at the
eye in the operating theater through the microscope, it will be upper temporal
in the right eye and upper nasal in the left eye for right-handed surgeons), at
a point at which the macula is damaged as little as possible, but which lets us
reach under the fovea with the forceps. If we are very close we will run the
risk of inducing macular scotomas and tears, on the other hand if we are not
close enough the retina could be ripped by the forceps when trying to grasp
the subfoveal clot.
269
Figure 3 Patient II: another case of unilateral submacular hemorrhage
Figure 4 Patient II: spontaneous evolution 6 months of follow-up. Patient

rejected the treatment
MASSIVE SUBRETINAL HEMORRHAGE THAT ALSO

AFFECTS THE MACULA
In these cases, the crystalline lens should be removed in phakic patients,
a complete vitrectomy should be performed, a wide 100–180° temporal
peripheral retinotomy along with the extraction of the clots with forceps
and a vitreotome, application of the retina and laser and tamponade with
silicone oil.
270
SUBFOVEAL PERFLUOROCARBON BUBBLES
Subretinal PFC bubbles do not require treatment, except those situated
subfoveally or on the macula and which are very symptomatic.
If they are not subfoveal, they can be extracted by piercing the retina with
a thin cannula and suctioning, or using a vitrectomy blade and making a small
incision in the direction of the retinal fibers and suctioning.6
If the bubbles are below the fovea, they cannot be extracted by using the
technique described above without damaging it. In these cases, a detachment
of the retina reaching the macula should be induced and a partial exchange of
liquid-air should be performed leaving half the eye full of air; the patient should
adopt a sitting position for a couple of days to move the bubbles downward.
This technique can also be used for the treatment of postoperative retinal folds
that affect the fovea.
It is not easy to induce a voluntary retinal detachment, but it can be achieved
in several ways. The one we use is as follows: connect a cannula with a 40-gauge
tip to a silicone injection system with a syringe filled with BSS. This procedure
makes it possible to direct a fine jet of liquid hard against the surface of the
retina. The cannula is introduced into the eye and the point is placed in contact
with the retina without pressing the point chosen. Maintaining the position,
the liquid is injected; a blister usually forms and the retina detaches little by
little. The tip of the cannula should be maintained into the created retinotomy
without enlarging it, otherwise the liquid injected will reflow to the vitreous
cavity and a large enough detachment would not be obtained.
More than one separate injection often has to be applied. The first should
be near the macular area outside the macular vessels, so that the macula can
be detached but does not tear.
We will keep injecting BSS till no further detachment can be induced. At
this point, the macula can or cannot be detached. If not still detached, we will
change tools and proceed to perform several air-fluid exchanges which will push
the subretinal liquid toward the posterior pole (exactly what we do not want to
happen when we operate on a detachment with adhered macula).
The subfoveal bubble should not be attempted to be removed with
instruments, as they are difficult to visualize once the retina is detached.
Moreover, the fovea may tear if the subretinal space is suctioned.
There are more situations besides those we have described in which macular
surgery is indicated; detailing them all does not fall within the scope of this
practical manual. However, the techniques described here cover the great
majority of the cases we treat at present. In the future, there will probably be
other possibilities available. On the other hand, we observe that old techniques,
like removing subretinal membranes, are still useful in a few complex present
day cases.
271
REFERENCES
1. Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use
in evaluation of the vitreoretinal interface: a review. Surv Ophthalmol.
2007;52(4):397-421.
2. Suh MH, Seo JM, Park KH, et al. Associations between macular findings by optical
coherence tomography and visual outcomes after epiretinal membrane removal.
Am J Ophthalmol. 2009;147(3):473-80.
3. Le Rouic JF, Becquet F, Ducournau D. Does 23-gauge sutureless vitrectomy modify
the risk of postoperative retinal detachment after macular surgery? A comparison
with 20-gauge vitrectomy. Retina. 2011;31(5):902-8.
4. Arias L, Monés J. Transconjunctival sutureless vitrectomy with tissue plasminogen
activator, gas and intravitreal bevacizumab in the management of predominantly
hemorrhagic age-related macular degeneration. Clin Ophthalmol. 2010;18:67-72.
5. Thompson JT, Sjaarda RN. Vitrectomy for the treatment of submacular hemorrhages
from macular degeneration: a comparison of submacular hemorrhage/membrane
removal and submacular tissue plasminogen activator-assisted pneumatic
displacement. Trans Am Ophthalmol Soc. 2005;103:98-107.
6. García-Arumí J, Castillo P, López M, et al. Removal of retained subretinal
perfluorocarbon liquid. Br J Ophthalmol. 2008;92(12):1693-4.
Chapter 14
Vitrectomy for Retinal

Detachment with and without
J Fernando Arevalo, Reinaldo A Garcia, Veronica Oria
INTRODUCTION
Repair of primary rhegmatogenous retinal detachment (RRD) was usually
unsuccessful before Gonin1 demonstrated the importance of localizing and
sealing retinal breaks. Scleral buckling introduced by Custodis,2 intraocular
gases introduced by Norton,3 and the development of vitreous surgery
by Machemer4 profoundly changed the history of RRD repair. Pars plana
vitrectomy (PPV), a method originally reserved for complicated cases, is now
used increasingly for primary repair of uncomplicated RRD.5 Vitrectomy may
be selected to diminish complications associated with scleral buckling, to help
relieve vitreoretinal traction and/or to create a large empty vitreous cavity in
which a tamponade can be introduced. Even though vitrectomy is the most
invasive of all techniques described for RRD repair, primary vitrectomy seems
to be useful in complicated cases, which has an unfavorable prognosis with
simpler procedures.6
The selection of alternative techniques for different types of retinal
detachment (RD) is a matter of surgeon preference. However, a variety of
relatively complicated RRD are currently best managed with vitrectomy
techniques with or without associated scleral buckling: (a) RRD with
proliferative vitreoretinopathy (PVR), (b) RRD associated with giant retinal
tears (GRTs), (c) RD associated with proliferative retinal vascular disease, (d)
RRD due to posterior breaks, (e) RD associated with viral and other forms of
retinitis, (f) RD associated with posterior vitreoretinal traction, and (g) RD
associated with significant vitreous opacification.7
The objective of this chapter is to discuss the different vitrectomy techniques
available to repair RD with and without PVR in a step-by-step approach.
Chapter 14  Vitrectomy for Retinal Detachment with and without Proliferative. . .
273
COMBINED VITRECTOMY AND SCLERAL BUCKLING
Scleral Buckling Technique
Preparation of the Surgical Field
Under peribulbar anesthesia, a 360° conjunctival peritomy at the limbus is
performed, this maneuver can be facilitated by spreading Wescott scissors
beneath Tenon’s capsule just posterior to the limbus, thereby avoiding the
fusion of conjunctiva and Tenon’s capsule at the limbus. Taking into account
the considerable manipulation the conjunctiva undergoes during scleral
buckling, two radial relaxing incisions should be made to prevent tearing of
the conjunctiva (Fig. 1). After peritomy, the space between Tenon’s capsule
and sclera is entered in the four quadrants between the rectus muscles with
closed blunt scissors. Opening the scissors at each quadrant lyses the episcleral
fascial connections between Tenon’s capsule and sclera. The insertion of each
rectus muscle is then engaged with a muscle hook. Once the muscle insertion
is engaged, the connections to Tenon’s capsule can be identified and separated
from the muscle. The septum is then cut between the forceps and the tip of the
muscle hook with the scissors. This maneuver will expose the tip of the muscle
hook from behind the muscle and septum. It is then verified that the entire
muscle is engaged on the muscle hook (Fig. 2A). To expose the posterior part
of the eye, the conjunctiva and Tenon’s capsule is pushed back with a cotton
tip applicator (Fig. 2B). After isolation of the muscle is complete, a traction
suture is placed around the muscle using either a fenestrated muscle hook or a
reversed needle (Figs 3A and B); 2-0 or 4-0 black silk is an effective traction
suture. All four rectus muscles can be isolated in this manner.8
Figure 1 (Arevalo et al) Limbal peritomy and relaxing incisions. Limbal peritomy is
begun by grasping both Tenon’s capsule and the conjunctiva as close to the limbus
as possible. A radial relaxing incision approximately 8 mm long is made through
the conjunctiva and Tenon‘s capsule in oblique meridians to prevent tearing of the
conjunctiva during exposure of the globe
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A B
Figures 2A and B (Arevalo et al) Isolation of muscle’s tendons. (A) The insertion
of the rectus muscles is isolated using a muscle hook; (B) Tenon’s capsule and
conjunctiva are retracted
A B
Figures 3A and B (Arevalo et al) Muscle engaging. (A) With the first muscle hook
in place, a needle of a 4-0 black silk suture is passed through the holder’s tip of the
second hook, and then it is passed under the muscle; (B) With the second hook in
place, the first hook is retracted to engage one arm of the black silk suture. This
procedure is repeated at the four rectus’ muscles
Accurate Placement of the Buckle on the Sclera

This is one of the most important steps in the procedure. After ophthalmoscopic
localization of retinal breaks, the surgeon should make temporary marks on the
sclera with a scleral marker such as an O’Connor’s or Gass’ marker. The scleral
mark is then enhanced with a sterile pen, superficial cautery or both (Fig. 4).
For small flap tears or atrophic holes, a single mark on the posterior edge of the
break is sufficient. Some surgeons prefer a single mark after a scleral burn with
diathermy placed in the center of their anterior edge because the anterior edge
is the usual site of persistent vitreoretinal traction. In lattice degeneration, both
275
Figrue 4 (Arevalo et al) Localizing the retinal breaks. The black dots show the proper
location of the external scleral marks, which are made to denote the boundaries of
each break through indirect ophthalmoscopic visualization
ends of the degeneration are marked on the sclera. The boundaries of a dialysis
are noted by marking both ends and the posterior extent to which the retina
will likely fall. In large horseshoe tears, the posterior edge and the ends of the
anterior flaps are marked externally on the sclera. Both anterior and posterior
extent of the tear is important to note because not all the time the horseshoe
tear is radially oriented.6 If the retina is bullously detached, elevated breaks
appear to lie more posteriorly than their true location because of parallax.8
Rarely it may be necessary to drain subretinal fluid to flatten the retina before
localization. If no specific pathologic factor is to be supported, the encircling
element should support the posterior margin of the vitreous base.
Encircling Exoplants
Although radial exoplants are preferred with large horseshoe tears and relatively
posterior tears without the presence of other retinal pathology, specifically
other areas of vitreoretinal traction away from the segmental element are not
supported, which may result in formation of new retinal breaks. Traditionally
an encircling exoplant is chosen for RD with multiple breaks, aphakic or
pseudophakic eyes, high myopia, extensive areas of lattice degeneration, PVR
grade B or greater, giant tears, and eyes with very thin sclera.8 We prefer an
encircling #41 silicone band alone or a #240 silicone band alone or with a piece
of grooved soft silicone tire (#506 gauge) placed beneath the encircling band
in areas needing support of retinal breaks or vitreoretinal traction. The addition
of the encircling band ensures a permanent buckling effect and provides some
degree of support in areas where it is necessary, even though it is not intended
to be of a significant height. The band is passed around the circumference of
the globe and beneath the rectus muscles (Fig. 5), and then it is anchored with
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Figure 5 (Arevalo et al) Encircling procedure. An encircling #240 solid silicone band
is passed under the four rectus muscles. If there are small tears, the band is positioned
just over them. In large posterior horseshoe tears, the band can be combined with
a grooved 5 mm sponge (#506 gauge). When there are no pathologic areas, the
encircling exoplants can be fixed 12 mm posterior to the limbus. The two ends of the
band are joined together by pulling in opposite direction through a silicone slip (#70)
a single mattress suture with posterior bites located 12 mm away and parallel
to the limbus placed at the center of each quadrant (Fig. 6). When a piece of
grooved silicone tire is added beneath an encircling band, suture bites are always
placed posterior to the location overlying the responsible retinal break(s).
Figure 6 (Arevalo et al) After the ends of the encircling element have been
trimmed, it is anchored in each quadrant along the greatest circumference of the
globe using a 5-0 nonabsorbable suture (such as polyester, nylon or polypropylene)
with a spatulated needle
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SCLERAL SUTURE TECHNIQUE
A spatulated needle with a 5-0 nonabsorbable suture such as polyester, nylon
or polypropylene is used. When suturing, the surgeon must firmly fixate the
globe by grasping a muscle insertion with a toothed forceps. The suture is
passed through the sclera at one-half to three-fourths depth over a distance of
3–5 mm, usually in a horizontal mattress fashion. The #240 encircling band is
sutured with the posterior border 12 mm posterior to the limbus (Fig. 6). The
#41 encircling band is sutured at the vitreous base just posterior to the rectus
muscle insertions. Usually sutures are placed a minimum of 2 mm farther apart
than the width of scleral contact for a given silicone element. To ensure that
the most posterior edge of the retinal break is supported, the surgeon places the
posterior suture a minimum of a 2–3 mm posterior to the scleral localization
mark.8 The ends of the band should be secured with a silicone sleeve (#70)
because it allows easy adjustment of the band throughout surgery.
PRIMARY VITRECTOMY
As we usually combine vitrectomy with an encircling scleral buckling, a 360°
peritomy with isolation of the rectus muscles has to be done. Light bipolar
diathermy is applied to the episcleral vessels in preparation for sclerotomies.
Sclerotomies are made 2.5–3 mm posterior to the limbus in pseudophakic or
aphakic eyes or in eyes in which a lensectomy is planned. Sclerotomies are made
3.5–4 mm posterior to the limbus in phakic eyes. The sclerotomy sites must be
placed more anteriorly in infant eyes and in eyes in which the retina is pulled
anteriorly over the pars plana by anterior fibrous traction (e.g. PVR). The infusion
port should be located just inferior to the meridian of the lateral rectus insertion,
while the instrument sclerotomies should be just superior to the meridians of the
horizontal rectus insertions.9 The sclerotomies are made with a microvitreoretinal
(MVR) blade with the flat portion parallel to the limbus. The knife is directed
toward the center of the phakic eye, though it can be directed slightly more
anteriorly in the aphakic eye (Fig. 7). The clamped infusion cannula is then
placed into the vitreous cavity through the inferotemporal sclerotomy. Its position
in the vitreous cavity is ascertained by directly visualizing the cannula before
being opened for infusion. The nasal sclerotomy for the fiber optic light source
is usually made next (Fig. 8). The sclerotomy is made with a 20-gauge MVR
blade, and then the light probe is placed into the eye. With the eye stabilized
by the nasal instrument, a temporal sclerotomy is made, and the vitrectomy
instrument is placed in the eye and the infusion is turned on.
Basic Operative Steps in Primary Vitrectomy

Although not all must be met in every case, there are seven goals of primary
vitreous surgery: 10
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Figure 7 (Arevalo et al) Placement of the irrigation port. Previous to anchoring the
infusion cannula at the inferotemporal quadrant, a deep and short 6-0 vicryl suture
bite parallel to the surface of the sclera and in opposite directions is passed around
the sclerotomy measured point. The MVR knife is carefully passed through the pars
plana at 2.5 mm posterior to the limbus in aphakic or pseudophakic eyes, and at 3.5
mm in phakic eyes
Figure 8 (Arevalo et al) One suture loop is placed on the shoulder of the cannula
while the opposite loop is pulled up. Then the other loop is tied with a slip knot over
the opposite shoulder. The infusion line is opened (after tip visualization) and finally
the other two sclerotomies are made in the superior quadrants
1. Removal of vitreous opacities preventing adequate visualization: After

making sure that the infusion is on, cutting is tested in the central anterior
vitreous. Moderate suction usually between 100 mm Hg and 250 mm Hg
and a rapid cutting rate of 1,000–2,500 cycles/second are generally used.
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New vitrectomy systems allow for a cutting rate of 5,000 cycles/second.
The procedure should begin in the anterior one-third of the vitreous, in an
area in which visualization is relatively good and away from the lens. As
visualization improves and the anterior vitreous is removed, the vitrectomy
probe may be moved more posteriorly in the eye to clear the media (Fig.
9). If the posterior hyaloid is collapsed and thin, it may curl around the
vitrectomy instrument tip into the cutting port even if the port is not directed
toward the hyaloid. If the hyaloid is thickened, it is necessary to direct
the port toward the hyaloid (see removal of posterior cortical vitreous).
The hyaloid is engaged and cut in a centrifugal manner, enlarging the
opening in progressively larger concentric circles toward the periphery. In
most instances, it is only necessary to excise enough vitreous to enable an
adequate view of the peripheral retina. It is usually not necessary to depress
the vitreous in the uncomplicated case. If a peripheral retinal break is present
or suspected or if focal peripheral vitreoretinal adhesions are present, it is
necessary to remove peripheral vitreous more completely (Fig. 10).
2. Removal of perpendicular traction: Vitrectomy is begun, as described
earlier, to remove the anterior and middle gel of the vitreous cavity. The
goal here is to remove perpendicular traction forces leading to open breaks,
particularly in RD associated with posterior breaks or in tractional RDs
associated with vitreomacular traction or diabetic retinopathy. In cases
with a posterior cortical vitreous partially detached, a vitrectomy can be
performed in 360° to relieve perpendicular traction that keeps the retinal
break(s) open. In diabetic patients where fibrous proliferation can grow onto
the surface of the posterior cortical vitreous, an en bloc or a modified en
bloc approach can be utilized. Vitreomacular traction can be divided into
tangential, anteroposterior and combined traction. Anteroposterior traction
Figure 9 (Arevalo et al) Once a central cavity has been created in the opaque
vitreous, visibility may improve so that vitrectomy of retrolental opacities can be
done more safely. As soon as the retrolental region has been cleared of opacities,
removal of opaque vitreous proceeds posteriorly
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Figure 10 (Arevalo et al) When vitrectomy is directed to the vitreous base, the
assistant applies a scleral depressor or a cotton swab in the area of the opaque
vitreous base, pushing it toward the axial region and making it more safely accessible
to vitrectomy. The cutting frequency of the probe is increased, and suction is set at
a low level to minimize traction to the peripheral retina
is released with careful “core” vitrectomy. If vitreous is firmly adherent only

to the macula or if there is traction over the macula, it is advisable to cut
these adhesions with scissors before the vitrectomy is completed to reduce
the risk of creating an intraoperative macular hole (MH).
3. Removal of posterior cortical vitreous (tangential traction): Tangential
traction may arise from the posterior cortical vitreous layer as well as from
underlying preretinal membranes or the internal limiting membrane (ILM).
After removal of the central vitreous, the posterior cortical vitreous must
be identified and separated from the retinal surface. The posterior cortical
vitreous is most easily identified with the use of a soft-tipped silicone suction
cannula. When active suction is lightly applied, the orifice of the cannula
becomes occluded by the cortical vitreous, and as the cannula is swept
close to the retinal surface, the cannula flexes. Because of the analogous
movement, this has been called the “fish strike” sign11 or the “diving rod”
sign.12 The cortical vitreous is then separated from the inner retinal surface,
creating a posterior vitreous detachment (PVD). This is performed by
engaging the cortical vitreous in the area adjacent to the optic disk with the
suction/cutting instrument or cannula using active suction (100–300 mm Hg)
and elevating it in a posteroanterior direction. With the creation of a PVD,
the surgeon usually can visualize a floating Weiss’ ring. Once detached to the
equator or just posterior to it, the infusion bottle is elevated and the suction
function of the vitrectomy probe is switched to cutting and aspiration to
remove the vitreous layer. Generally, the cortical vitreous only needs to be
removed from the posterior pole and arcades or from the area of interest.
4. Membrane surgery approach: Membrane peeling: If an edge of the
membrane is not apparent, then a pick or a bent 20-gauge needle, or a bent
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MVR blade, or a diamond-dusted silicone tipped cannula (Tano’s scraper)
can be used to create an edge. When a well-defined edge of a preretinal
membrane can be visualized, the edge of the membrane is explored with a
membrane pick, until the edge is elevated; it is usually then possible to grasp
it with a membrane forceps. This tissue is then gently stripped away from
the retina. If the membrane is tightly adherent to the retina, regrasping the
membrane and gently stripping from several points will help in membrane
removal. These multiple “regraspings” should take place as close to the
membrane-retina interface as possible. Sometimes a surgeon notes that
the retina is becoming elevated away from the retinal pigment epithelium
(RPE). At this point, the membrane should be re-engaged at another site and
a different directional vector force used to strip the membrane. If the retina
is pulled up and the membrane cannot be removed, then the membrane can
sometimes be truncated with horizontal scissors to relieve traction or cut it
from its adherence to the retina.
Membrane sectioning: The membranes are often widespread and involve
the posterior cortical vitreous. The vitreous and membranes may or may
not be separated from the retina surrounding the epicenters. Sectioning the
membranes between the epicenters will often adequately relieve traction.
The area of the vascular epicenters is identified, and the distal blade of the
vertically cutting scissors is placed into the space between the membrane
and the underlying retina between the adjacent epicenters. At this point the
membrane is cut to relieve tangential traction. If the vitreous is not separated
surrounding the epicenters, it is necessary to lift the posterior hyaloid with
the tip of the scissors or a membrane pick to separate the hyaloid from
the retina, so the scissors can enter the space between the retina and the
membrane prior to cutting. If the membrane is vascularized, it may be
advantageous to apply endodiathermy to large vessels prior to cutting and
to residual bleeding vessels after the cut.9
Membrane delamination: Vascular membranes can be removed from the
retina by dissecting the membrane free at the vascular epicenters. First,
the vitreous near the membrane is excised, then the membrane is lifted
unimanually with the scissors or bimanually with an illuminated pick. The
membrane is lifted with closed scissors to separate attachments to the retina
surrounding the epicenter, and then the epicenter is cut parallel and flushed
with the retina to separate the membrane. After all the vascular epicenters
are dissected free from the retina, the membranes and vitreous are removed
with the vitreous cutter.9
5. Flattening the retina with perfluorocarbon fluid-air exchange/perfluorocarbon-
air exchange: Perfluorocarbon liquid: Perfluorocarbon liquids (PFCL) can
help identify the location of occult break(s) by exerting a posterior flattening
force that displaces the subretinal fluid through the peripheral break;
exhibiting “Schlieren”, seen when two liquids of differing refractive index
are mixed. The retinal break(s) can be located by observing the direction
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of Schlieren flow. Perfluorocarbon liquids can also reveal areas of the
retina previously obscured by a bullous detachment, potentially exposing
occult retinal breaks. Once the retinal break(s) have been identified, PFCL
is added until the bubble meniscus is located at the posterior edge of the
most anterior retinal break. Laser endophotocoagulation can be applied to
posterior breaks at this time or deferred until after the fluid-air exchange. A
PFCL/air exchange is then performed with drainage of sub-retinal fluid to the
most anterior break. Perfluorocarbon liquid is then removed at the anterior
interface. Once all PFCL has been removed, further endophotocoagulation
to the peripheral anterior break(s) is applied, and an appropriate intraocular
gas tamponade is exchanged for air.
Fluid or perfluorocarbon-air exchange: Once the vitreous has been
removed, the break has been identified, and preretinal membranes have
been stripped; a fluid-air exchange or perfluorocarbon (PFC)-air exchange
is performed to flatten the retina, fill the eye with air and, provide internal
tamponade of a retinal break. It may be also performed to remove subretinal
fluid. During fluid-air exchange or PFC-air exchange subretinal fluid can be
drained through a posterior break. Depending on case severity, air is then
exchanged for a long-acting gas or silicone oil.
With the air pump pressure to approximately 35–45 mm Hg, we turn on
the air, which is insufflated through the infusion port. The stopcock is turned
“on” to air and “off” to infusion. Air is insufflated to replace the volume of
fluid removed. As the air enters the eye the fluid is removed from the anterior
vitreous cavity with a back-flush needle held over the retinal break to aspirate
subretinal fluid. Sometimes air over the break may limit aspiration of viscous
subretinal fluid. Therefore, it is helpful to begin aspirating the subretinal
fluid before the air seals the break opening. Subretinal fluid appears as a
viscous stream compared with balanced salt solution within the vitreous
cavity. We then remove progressively more posterior fluid until all the
fluid or PFCL is removed. The posterior meniscus of the fluid and PFCL is
easily identified by observing the light reflex at its surface. The light reflex
that is prominently seen tends to dull or disappear as the needle tip touches
the posterior meniscus. Once the posterior fluid or PFCL is entered with
the needle tip, the needle is held in place and suction is applied. When the
fluid level passes below the needle tip, the light reflex from the meniscus
reappears once more. This technique is continued over the optic nerve until
all the fluid is gone. If the retina is still detached and no posterior retinal
break is present, a posterior drainage retinotomy using endodiathermy can
be created, usually in the superonasal quadrant, one and half disk diameters
from the optic disk.9 After initial fluid-air exchange, sequestered intraocular
fluid from the anterior walls of the eye can be removed from the posterior
pole with the back-flush needle after waiting for 1 minute.
6. Tamponade with gas or silicone oil: Air-gas exchange: In order to prevent
the expanding gas bubble from increasing the intraocular pressure (IOP), it
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is safer to instill a nonexpansile concentration of gas. Mixtures of 20% SF6
with 80% air and 14% C3F8 with 86% air are clinically nonexpansile.9 Pure
gas is mixed with air to the desired concentration in a 60 ml syringe. The ports
are sutured first. The gas mixture then is injected by the assistant through
the infusion cannula while the surgeon holds a 30 gauge syringe without its
plunger, and connected to a needle in the vitreous cavity. The surgeon monitors
IOP tactilely and notes as the gas mixture is injected into the vitreous cavity,
replacing the air. We usually flush with 60 ml or more of the gas mixture.
Gas should be injected through a millipore filter to ensure sterility.
Air-silicone oil exchange: If silicone oil is used, it is injected slowly into
the vitreous cavity through a short, large-bore needle. Air escaping from the
sclerotomies prevents IOP from rising too high during this maneuver. Air
infusion pressure can also be progressively reduced or the tubing clamped.
A small inferior iridectomy should be performed in aphakic or pseudophakic
eyes with a ruptured posterior capsule to permit aqueous flow into the
anterior chamber postoperatively to maintain an open angle and silicone
oil behind the iris.
7. Creating chorioretinal adhesion with endolaser: Low power and long
duration (0.2–0.5 seconds) applications are used when treating with
endophotocoagulation. Short duration burns of higher power increase the
risk of rupturing Bruch’s membrane. Endolaser energy is delivered under
fluid, air, PFCL (our preferred method) or silicone oil. The laser probe is
held near the retina until the aiming beam is clearly seen, and then laser
is applied. The power is increased and/or the probe is held closer to the
retina until there is whitening (coagulation) of the tissue. Higher power
is necessary if there is reduced pigmentation of the fundus or if there is
residual subretinal fluid; conversely less power is necessary in the presence
of a darkly pigmented fundus and attached retina.9
INTRAOCULAR TAMPONADE
For the forms of RD surgery requiring vitreous surgery, sulfur hexafluoride
(SF6) and perfluoropropane (C3F8) gases are used more frequently to provide
extended internal tamponade. In GRTs or highly myopic eyes with RD from
MH, a large volume of gas is desirable until the chorioretinal adhesion resulting
from photocoagulation or cryotherapy is established. Perfluoropropane is a
good choice selection for these conditions (for silicone tamponade see internal
tamponade in PVR).13
SMALL-GAUGE PARS PLANA VITRECTOMY

Small-gauge vitrectomy (25-gauge and 23-gauge) is becoming increasingly
popular and is replacing standard 20-gauge vitrectomy for many surgical
indications. According to the Preferences and Trends survey conducted of
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its memberships annually by the American Society of Retina Specialist, 48%
of respondents in 2004 had never tried small-gauge PPV; by 2007, 80% of
respondents used it for most of their cases.14 Small-gauge vitrectomy systems
have become available from multiple manufacturers, and many vitreoretinal
surgeons have begun transition to small-gauge vitrectomy based on the
theoretical advantages of small-gauge PPV including reduction in inflammation,
patient discomfort, recovery time, surgery induced astigmatism and changes in
corneal topography and for some cases, operative time. However, because of
the increased flexibility associated with the smaller instrumentation, surgical
indications most conducive to small-gauge PPV initially were limited to those
not requiring extensive vitrectomy or membrane dissection. Over the last few
years, advances in technology and instrumentation, such as the development of
second generation small-gauge instruments, ultra high cutting machines, and
brighter xenon light sources; modifications in surgical technique, and surgeons’
increasing confidence and experience with the system have promoted an
expansion of surgical indications including primary RD and even to complicated
cases, such as recurrent RD, complicated RDs, tractional RDs in patients
suffering from proliferative diabetic retinopathy (PDR), PVR, neovascular
glaucoma, GRTs, pathologic myopia and cases in which silicone oil injection is
obligatory. The choice of instrument gauge is definitively evolving, as surgeons
decide according to their personal experience and expertise which cases are
preferable for small-gauge vitrectomy versus the ones performed more easily
with 20-gauge instrumentation.15-18
Sclerotomies with 23-Gauge Vitrectomy

The conjunctiva is displaced using a cotton tip applicator, forceps or pressure
plates, taking care not to tear it. In general the more oblique (longer) the path
through the sclera, the better the edges reappose when the cannulas are removed.
However, endoscopic evaluations of the sclerotomies have shown vitreous
plugging the wounds in both 23 and 25 gauge cases.19 Therefore, the majority
of surgeons favor a biplanar scleral incision, with a more oblique initial and
more perpendicular final entry into the vitreous to create a two-step incision
in cross section (Fig. 11), although this is difficult to achieve consistently.
Ultrasound biomicroscopy has not shown any statistical difference in wound
size between a single plane and 23-gauge biplanar incisions.20
Sclerotomies with 25-Gauge Vitrectomy

In the original 25-gauge vitrectomy, after the displacement of the conjunctiva,
trocars were placed perpendicular to the sclera (similar to 20-gauge technique),
but many surgeons now advocate oblique incisions to promote watertight
wound closure. It has been postulated that oblique sclerotomies may become
lax and deformed because of pivoting motions of the instruments during
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Figure 11 (Arevalo et al) Schematic surgical steps for oblique 23-gauge sclerotomy.
After conjunctival displacement, the eyes are penetrated as tangentially as possible
(10–30°) parallel to the corneal limbus with the bevel up; once past the trocar sleeve,
the angle is changed to 90° (perpendicular to surface)
peripheral vitrectomy. The degree of scleral rigidity also may play a role,
because the more flexible sclera in younger patients may result in incomplete
closure of the sclerotomy sites. Trocar wound construction may be important
for avoiding gas leakage in some cases. Although, a possible mechanism for
25-gauge wound closure is the plug created by vitreous incarceration into the
scleral wound,21,22 in most RRD cases, meticulous anterior vitreous removal is
necessary. Therefore, a well-constructed oblique sclerotomy may leak because
of a lack of vitreous prolapse. In addition, the increased flexibility of the smaller
25-gauge instruments limits the ability to use long, oblique incisions due to
deformation of the shaft when the oblique entry is brought into the perpendicular
position that is most convenient when performing the vitrectomy.
NEW CONSIDERATIONS IN FLUID DYNAMICS DURING

SMALL-GAUGE VITRECTOMY
The evolution of smaller cutters was accompanied by a number of drawbacks,
one of which was the occurrence of a decrease in flow rate that can take place
during the vitrectomy, a fact that can lead to undesirable extension of operation
time. The flow rate through the cutter is influenced by several factors, such
as the diameter of the cutter’s opening, the duty cycle, the vacuum strength,
the viscosity of the aspirated vitreous, the mechanism upon which the cutter
is based (pneumatic or electrical), the movement of the blade and the internal
diameter of the cutter’s lumen.23 According to Poiseuille’s equation, flow is
related to the fourth power of the internal diameter of the vitrectomy probe
and is inversely related to the length of the 25-gauge vitrector and associated
tubing. This explains the marked and moderated decrease in flow with 25 and
23-gauge probes respectively compared to 20-gauge. Most 20-gauge vitrectomy
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are performed at IOPs between 30 mm Hg and 40 mm Hg, vitrectomy with
23-gauge instrumentation can be performed at these infusion pressures, but
25-gauge vitrectomy is more efficient at higher infusion pressures, in the
range of 40–50 mm Hg, because of the smaller diameter of the instrument.
Increasing the infusion pressure improves flow to make the vitreous removal
somewhat faster than, but still not as rapid as with a 20-gauge system. The
aspiration pressure is another factor that influences how long it takes to remove
the vitreous. Small-gauge vitrectomy instruments require higher aspiration
pressures to achieve a reasonable rate of vitreous removal. The maximun suction
setting is typically about 150 mm Hg for 20-gauge vitrectomy, 400 mm Hg for
23-gauge, and 600 mm Hg for 25-gauge. Finally the duty cycle (the length of
time the vitrector port is open compared to the time it is closed) results in higher
flow rates, and this can partially compensate for the decreased flow inherent
in smaller diameter 23 and 25-gauge instruments. The commercially available
small-gauge vitrectomy machines differ in their abilities to control duty cycles.24
Increasing Safety
In vitreoretinal surgery safety often depends on two main factors: fluidics
stability and tissue separation. Fluidics stability and the risk of vitreous traction
depend on the flow rate, lumen area and cut rate. If the flow rate is increased,
the length of pull of collagen fibril is increased so, vitreous traction is increased,
decreasing safety. Conversely, increasing the cut rate decreases the length of
pull of collagen fibril, decreasing vitreous traction, and increasing safety. So,
maximum safety requires low flow with ultra-high cutting. At a fixed distance,
the amount of flow required for tissue attraction is less for the 25-gauge probe
than both 23 and 20-gauge. Then, the chance of inadvertently incarcerating
the normal retina would be lower with smaller gauge. Duty cycle in new
vitrectomy systems allows the surgeon to switch the duty cycle to “shave” in
which the cutter is closed the majority of the time, reducing the risk of retinal
incarceration. In addition, then surgeons do not need for instrument exchange as
often as the cutter acts as vertical scissors. Finally new technology has created
new vitrectors with the probe opening closer to tip that allow surgeons to remove
scar tissue in more proximity to the retina without touching it with the probe.
Wound Closure
In order to decrease the vitreous plugging in the wounds some surgeons
suggest removing firstly the trocars over the cannulas to finally remove the
cannulas (Fig. 12). Cannulas should be removed at roughly the same flat
angle of insertion and the sclerotomy tunnel compressed with a cotton tip
swab to collapse and close the tunnel. We usually increase the IOP to 60 mm
Hg, while compressing the sclerotomy tunnel with a cotton tip swab, when an
immediate sclerotomy leak does not cease with cotton tip swab compression
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Figure 12 (Arevalo et al.) Removing first the trocars over the cannulas to finally
remove the cannulas (A), Cannulas should be removed at roughly the same flat
angle of insertion, (B) The sclerotomy tunnel compressed with a cotton tip swab to
collapse and close the tunnel (C)
alone. However, if the surgeon is unsure if the wound is leaking or not, then it
is probably best to suture. In cases with gas tamponade, suturing of sclerotomies
in leaking trocar insertion sites should be performed based on the presence of
subconjunctival gas bubbles associated with hypotony during sequential trocar
extraction. After scleral suturing, additional nonexpansible gas mixture should
be injected into the vitreous cavity through the maintainer port, or through the
sclera with a 30-gauge needle when leakage is evident from the last removed
trocar entry wound.
More common complications associated with the small-gauge PPV:
Retinal Tears
It is generally agreed that less peripheral vitreous is removed during a standard
small-gauge vitrectomy than during a standard 20-gauge vitrectomy. Thus,
a theoretical concern exists that contraction of this more prominent residual
vitreous skirt could cause significant anterior vitreoretinal traction and
subsequent retinal tears. The rate of retinal tears discovered during surgery
for MH and epiretinal membrane has been reported to be between 0% and
24%, with most series reporting an incidence of less than 5%.25 In the largest
retrospective series of 177 consecutive 25-gauge PPV cases, the incidence
of intraoperative retinal breaks was 15.8%, with roughly two-thirds of these
occurring away from the superior sclerotomies.26 According to recent reports
the rates of iatrogenic retinal breaks in small-gauge vitrectomy are comparable
(if not smaller) to previously published series of modern 20-gauge surgery.
Furthermore, in one comparative series of 25-gauge and 20-gauge cases, no
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statistically significant difference in the incidence of intraoperative retinal
breaks was found (3.1% of the 25-gauge cases compared with 6.4% of the
20-gauge cases).27
Hypotony
There are numerous reports of hypotony following sutureless small-gauge
vitrectomy. The hypotony is usually transient, lasts up to a few days following
surgery, and improves spontaneously once the sclerotomies heal adequately.
Localized choroidal detachments were found in 69% of eyes using anterior
segment optical coherence tomography in one study.28 In some eyes the
hypotony can be more severe, causing large choroidal detachments or escape
of gas with inadequate tamponade in eyes with retinal breaks or detachments.
Improved trocar/cannula placement using beveled rather than perpendicular
incisions and treatment of any leaking sclerotomies at the end of the case have
decreased, but not eliminated this complication.24
Endophthalmitis
Intraocular infection is another complication that was initially suspected to
occur more frequently after sutureless vitrectomies. The explanation for the
increased incidence of endophthalmitis following sutureless vitrectomy was that
bacteria on the ocular surface entered the eye through defects in the conjunctiva
and sclera, then some surgeons advocated aggressive removal of the vitreous
around the cannulas to prevent vitreous prolapse into the wounds. However, the
currently available data from the recently published large retrospective studies
does not indicate that sutureless small-gauge vitrectomy is associated with
higher rates of endophthalmitis than in 20-gauge vitrectomy. Noteworthy, the
surgeons in those studies used an oblique penetrating angle to the eye wall.29-31
VITRECTOMY FOR RETINAL DETACHMENT WITH

PROLIFERATIVE VITREORETINOPATHY
Proliferative vitreoretinopathy is an intraocular wound healing disorder
characterized by a breakdown of the blood-retinal barrier, proliferation of
RPE cells, glial cells, inflammatory cells, and extracellular matrix production
on the retinal surface, subretinal space, and in the vitreous cavity, that lead
to the formation of subretinal and epiretinal membranes. The cell mediated
contraction of these membranes causes tangential retinal traction and fixed
retinal folds.32,33 The cells in the vitreous are often seen by slit-lamp examination
and appear as pigmented dots. The cells on the surface of the retina usually go
unrecognized until the retina detaches; even then, the fixed folds resulting from
cellular traction, rather than the cells themselves, are most often seen. Initially
the detachment may be purely tractional, but almost always the traction results
289
in reopening of a pre-existent break(s) or occurrence of new breaks, causing
combined tractional-rhegmatogenous RD.33 Proliferative vitreoretinopathy
most frequently develops in the inferior retina or is at least most severe in the
inferior retina. The predisposition for the inferior retina is believed to be the
result of gravity, whereby the RPE and inflammatory cells liberated into the
vitreous cavity via retinal tears settle in the inferior vitreous.34
RISK FACTORS FOR THE DEVELOPMENT OF

PROLIFERATIVE VITREORETINOPATHY
Because it is now possible to treat subjects at high risk for developing
PVR, it is important to identify and target those subjects to avoid costly
and complex vitreoretinal surgery. In addition, to improve the prognosis
of RD surgery recent research has focused on the use of intravitreal
pharmacological agents to prevent the occurrence of PVR, although none
of these agents is used routinely in clinical practice owing to concerns about
retinal toxicity. However, if risk factors for the development of PVR could
be identified, these potentially toxic intravitreal treatments could only be
targeted at those patients at greatest risk.35 Many studies have investigated
and identified a number of clinical risk factors for PVR including (a) Long
RD duration; with long duration defined as greater than 3 months.36 Tseng
et al32 have hypothesized that the long detachment duration allows more
time for RPE cells to be in contact with vitreous to migrate, proliferate,
and produce extracellular matrix, ultimately causing contraction of epi-
and subretinal membranes, fixed retinal folds, and retinal traction, (b)
Eyes with large retinal breaks; RDs larger than two quadrants or GRTs at
increased risk of developing PVR,37 with large retinal breaks more cells can
be induced to migrate and proliferate and thereby contribute to the wound-
healing response characteristic of PVR,1 (c) Horseshoe tears;32,37,38 a lower
rate of PVR among eyes with atrophic holes compared with those with
horseshoe tears has been previously reported.38 Tseng et al32 speculated that
traction exerted on the hole margin in eyes with horseshoe tears may allow
greater vitreous fluid movement through the hole to contact RPE cells, (d)
Vitreous hemorrhage;32,37 it is likely that serum released into the vitreous
as a component of vitreous hemorrhage may further elevate the vitreous
serum concentration above that induced by blood-ocular barrier breakdown
alone,32 (e) Patients with uveitis or increased inflammation from trauma are at
increased risk for PVR, especially if the eye has a retinal break,39 (f) Prior RD
repair is the most common factor that predisposes an eye to PVR, although
some of these eyes may have developed PVR regardless of the technique
used for repair of the initial RRD. The RD surgery itself appears to hasten
PVR in eyes predisposed to this problem by releasing proliferating cells
into the vitreous and causing breakdown of the blood-ocular barrier, which
creates an environment promoting cellular proliferation,40 (g) Excessive
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cryopexy releases viable RPE cells and creates breakdown of the blood-
ocular barrier, which creates an environment conductive to the development
of PVR.41 Laser appears to cause less breakdown of the blood-ocular barrier
than cryopexy,42 (h) Postoperative choroidal detachment; may predispose
eyes to develop PVR,43 (i) The existence of preoperative PVR suggests that
the cellular, extracellular, and chemical elements required for wound healing
are present. It is therefore not unreasonable to expect preoperative PVR to
be a risk factor for the development of postoperative PVR. Girard et al.43
in a retrospective study of preoperative PVR grades B and C1 found only
grade B but not grade C1 preoperative PVR to be a significant risk factor.
They concluded that grade B PVR might represent an immature form of
PVR with a definitive potential for progression, whereas grade C1 PVR
may represent a spontaneously arrested, nonevolutive form of the disease.
However, other studies have found grade C PVR to be a significant risk
factor,35 (j) Although controversial, the pathological mechanism by which
aphakia could be related to the development of PVR is unclear. However
the breakdown of blood-ocular barrier may be significant.37 Miyake et al44
suggested that the posterior lens capsule might protect the anterior uvea
(site of active transport) from mechanical and physical irritation by vitreous
gel. It is also possible that the intact lens provides a physical barrier for
transmission of inflammatory cytokines from the anterior chamber to the
vitreous cavity. The disruption of blood-retinal barrier would, in theory,
allow serum factors such as fibronectin, to enter and remain in the vitreous
and may enhance the development of PVR.
Asaria et al45 determined prospectively the accuracy of a predictive risk
formula for the development of postoperative PVR when applied in a clinical
setting; this prospective study has shown that with the use of a clinical risk
formula it is possible to identify individuals at greater risk for PVR after
primary vitrectomy.
DIAGNOSIS OF PROLIFERATIVE VITREORETINOPATHY

Epiretinal proliferation causing traction on the retina in an eye with a RRD is
the most common presentation of PVR.41 The finding of a triangular RD by
B-scan ultrasonography and retinal stiffness on kinetic ultrasonography in
eyes with opaque media is diagnostic of advanced PVR. The ultrasonographic
triangular configuration is created by a proliferative membrane that attach
detached retina anteriorly.46
CLASSIFICATION OF PROLIFERATIVE VITREORETINOPATHY

In the past 30 years the classification of PVR has evolved as a result of increased
understanding of the pathophysiologic processes in this disorder. The most
popular and universal classification system is the updated version of the Retina
291
Society classification. This refined classification system by Machemer and co-
authors was an improvement over the original classification, since it provides
more detailed information about the location, extent, and severity of PVR in
an individual eye.47 This system divides PVR into three major grades: Grade
A, vitreous haze, vitreous pigment clumps and pigment clusters on inferior
retina (Fig. 13); Grade B, wrinkling of inner retinal surface, retinal stiffness,
vessel tortuosity, rolled and irregular edge of retinal break(s) and decrease
mobility of vitreous (Fig. 14); and Grade C, focal, diffuse or circumferential
full-thickness folds and/or subretinal strands and/or anterior displacement
and condensed vitreous strands. It is important to note how many hours of the
clock are affected by PVR and their anteroposterior localization, Grade CA
1–12 or Grade CP 1–12 respectively. Finally they subclassified PVR grade C
into five subcategories:
Type 1
Focal contraction: Is caused by an epicenter or multiple isolated epicenters of
contraction in the posterior zone of the retina. Because there is a focal point
toward which the resulting traction is directed, folds radiate away from each
epicenter in a characteristic starfold configuration (Fig. 15).
Figure 13 (Arevalo et al) Proliferative vitreoretinopathy Grade A represents the

earliest recognizable manifestation of intraocular proliferation. It is characterized
by uncomplicated rhegmatogenous retinal detachment (R), presence of pigment
clumps (A) in the vitreous matrix, and decreased mobility of the posterior vitreous
surface (P), retinal tear (T)
Source: Reprinted with permission from Lewis H. Proliferative vitreoretinopathy
(PVR). In: Boyd BF, Boyd S, Drews RC (Eds). Retinal and Vitreoretinal Surgery:
Mastering the Latest Techniques, 1st edition. Panama: Highlights of Ophthalmology;
2002. pp. 459-84.
292
Figure 14 (Arevalo et al) Proliferative vitreoretinopathy Grade B is defined by the

presence of wrinkling of the inner retinal surface (W), retinal breaks with irregular edges
(B), and tortuous retinal vessels (V) from not yet visible periretinal membranes. The
retina frequently appears slightly rigid and the vitreous may have decreased mobility
2002. pp. 459-84.
Figure 15 (Arevalo et al) Proliferative vitreoretinopathy Grade C Type 1 has focal
posterior contraction as a single star fold (S) or multiple isolated single star folds. This
type only occur posterior to the posterior border of the vitreous base (B)
2002. pp. 459-84.
293
Type 2
Diffuse contraction: Is caused by linked adjacent epicenters of contraction that
produce a diffuse area of irregular retinal folds in the posterior portion of the
retina. Contraction in an anterior-posterior direction tends to flatten the normally
bullous contours of the more anterior retina. Contraction in the circumferential
direction creates a funneled configuration of the posterior retina, with folds
radiating anteriorly toward the ora (Fig. 16).
Type 3
Subretinal proliferation: It can appear as an annular fold of the retina in the
area of the optic nerve and also manifest as a subretinal band which can be
single or branching (Fig. 17).
Type 4
Circumferential contraction: Is caused by diffuse preretinal membrane
contraction within or immediately behind the insertion of the posterior hyaloid,
which produces an area of irregular folds in this region of the retina. The retina
is contracted in a circumferential direction and therefore a series of radial folds
tends to form in the redundant retina on either side of the area of irregular folds
that extend posteriorly (Fig. 18).
Figure 16 (Arevalo et al) Proliferative vitreoretinopathy Grade C Type 2 is a diffuse

posterior contraction. It is marked by areas of irregular full-thickness retinal folding
(F). This type only occur posterior to the posterior border of the vitreous base (B)
2002. pp. 459-84.
294
Figure 17 (Arevalo et al) Proliferative vitreoretinopathy (PVR) Grade C Type 3 is

basically PVR with subretinal proliferation. It can appear as an annular fold (A) of
the retina in the area of the optic nerve. It may also manifest as a subretinal linear
band (S), which can be single or branching. This type of contraction may be found
anteriorly and posteriorly
2002. pp. 459-84.
Figure 18 (Arevalo et.) Proliferative vitreoretinopathy Grade C Type 4 is a

circumferential contraction (C) along the posterior edge of the vitreous base (B)
with central displacement of the retina (R). The peripheral retina is stretched and
radial retinal folds (F) can be seen extending posteriorly from the posterior border
of the vitreous base
2002. pp. 459-84.
295
Type 5
Anterior displacement: Occurs most commonly in eyes that have either
undergone a previous PPV or incurred penetrating trauma. Proliferative
membranes, which are variably opacified, are present on the remnants of the
posterior hyaloid, the anterior hyaloid, and the surface of the residual vitreous
base. Their contraction at the vitreous base pull peripheral retina anteriorly
to the pars plana, pars plicata, or even to the posterior iris. This may lead to
anterior RD, or to ciliary body detachment and hypotony (Fig. 19).
Most eyes requiring vitreoretinal surgery for this indication have PVR
Grade C.
SURGERY FOR PROLIFERATIVE VITREORETINOPATHY

Timing of Surgery
The goal of surgery for PVR is to reattach the retina as soon as possible but to
avoid recurrent RD resulting from reproliferation. In most eyes with PVR, the
epiretinal proliferation becomes mature within 6–12 weeks of the onset of the
disease. If the macula has previously been detached and there is little hope of
achieving a visual acuity better than 20/200, it is often advisable to wait several
Figure 19 (Arevalo et al) Proliferative vitreoretinopathy Grade C Type 5 Contraction

is an anterior displacement of the vitreous base (1-arrow). The posterior border of
the vitreous base is pulled anteriorly by proliferative tissue (P) and attaches to the
pars plicata of the ciliary body, posterior surface of the iris, or even to the pupillary
margin. This creates a circumferential fold (F) of the retina with a trough (T) anterior
to this fold
2002. pp. 459-84.
296
weeks for the proliferation to mature, even though the macula remains detached
for additional time. If the macula was never previously detached and it is still
attached or has become detached within the past few days, then it is usually
best to operate promptly to try to preserve macular function even though the
risk of recurrent proliferation is greater.40
Scleral Buckling in Proliferative Vitreoretinopathy

Although some authors48,49 have reported in PVR classified as grade C3
or worse that vitrectomy with vitreous shaving without scleral buckling
achieved approximately the same rate of anatomic success as vitrectomy
with scleral buckling, traditionally scleral buckling is indicated in PVR. The
scleral buckle is important for several reasons. The scleral buckle relieves
peripheral anteroposterior retinal traction, this is very important, since it is
not possible to remove 100% of epiretinal proliferation in many eyes with
PVR. The buckle helps to relieve circumferential retinal traction by reducing
the circumference of the equatorial and anterior sclera. The buckle provides
support to the peripheral retina, which may prevent recurrent RD when there is
reproliferation after surgery. Finally, the buckle helps to isolate the peripheral
retina from the posterior retina, forming a new, more posterior “ora serrata”
on the crest of the buckle. This allows the posterior retina to remain attached
in some eyes in which there is peripheral RD because of peripheral epiretinal
proliferation.40
Because of the limited support offered by segmental buckles, we prefer
encircling procedures when possible. Encircling procedures are particularly
indicated in PVR of grade B or greater. We prefer solid silicon elements for
encircling procedures because of their compressibility, encircling sponges tend
to result in a variable undulating contour to the buckle unless multiple sutures
are placed in each quadrant.
Lensectomy and Intraocular Lens

In cases with primarily posterior PVR, lensectomy can frequently be avoided
and subsequent postoperative inflammation reduced. A lensectomy is performed
if the lens is too opaque to allow adequate visualization of the retina or if the
lens is impending the ability to perform anterior dissection of epiretinal tissue.
To prevent traction on the retina, removal of the anterior vitreous should be
performed before lensectomy if the latter is going to be done by/via pars
plana. The crystalline lens is removed via pars plana by phacofragmentation if
necessary, and the capsule is removed by grasping the peripheral capsule with
the end opening of a diamond coated forceps or using the vitrectomy probe
to cut and aspirate the capsule, which is facilitated by indenting the anterior
sclera. An intraocular lens (IOL) is generally not inserted at this time, since
the presence of the IOL can impair visualization of the retina and the posterior
297
IOL surface can act as a scaffold for reproliferation. An IOL may be implanted
4–6 months later for visual rehabilitation.40 It has been suggested that only
polymethylmethacrylate lenses, with a 6.5 mm optical zone, be implanted in
diabetic patients to facilitate postoperative examination and treatment of the
posterior segment. If we choose to implant an IOL at the time of the vitrectomy
surgery a convex-plano optical design may offer certain optical advantages, such
as less refractive change in eyes which require fluid-gas exchange or silicone
oil tamponade. If a foldable IOL is to be used, acrylic IOLs are preferred to
silicone IOLs. Water condenses on the posterior face of the silicone IOL after
fluid-gas exchange in eyes with a posterior capsulotomy, and visualization of the
retina is very poor as a result of this condensation phenomenon. For this reason
silicone lens should be avoided. Sometimes it may be necessary to explant a
silicone IOL to improve visualization of the retina during PVR surgery. Clinical
judgment must guide the determination of which IOL must be removed. If the
PVR is primarily posterior, one could opt to leave the lens in place. The presence
of the lens does not usually impair posterior dissection techniques, but during
fluid-gas exchange, visibility can occasionally be reduced owing to any number
of reasons. Air or silicone oil can gain access into the anterior chamber, making
adequate optical correction difficult. Condensation on the posterior lens surface
can impair the view of the posterior pole, necessitating wiping of the lens with
a soft-tipped silicone tube or coating the lens with a viscoelastic substance. It is
more common need to remove anterior chamber lenses than posterior chamber
lenses. Posterior chamber IOLs may have to be removed in eyes in which
extensive anterior dissection must be performed to mobilize the peripheral
retina. Furthermore, in eyes receiving both silicone oil and relaxing retinotomy,
higher IOP and lower proportion of hypotony were found where a native lens
or intraocular implant is absent. So, removal of the lens or intraocular implant
may be considered for those eyes at greatest risk of hypotony.50
VITRECTOMY FOR PROLIFERATIVE VITREORETINOPATHY

The main surgical goals in managing PVR include closing the retinal breaks,
sealing the retinal breaks, and completely releasing all periretinal traction.
Although, almost all eyes with PVR have a PVD, after removing the central
and posterior vitreous, the surgeon needs to debulk as much of the anterior
basal gel as possible. Taking care to avoid creating any peripheral retinal breaks
the peripheral vitreous is removed aggressively, since the residual vitreous
base may serve as a scaffold for reproliferation and can lead to anterior RD
postoperatively. The vitreous base proliferation is best removed by indenting
the peripheral sclera with a cotton tipped applicator or scleral depressor
and removing the vitreous under direct visualization through the operating
microscope with a wide-angle viewing systems.51 It is essential that sufficient
vitreous base traction be removed to allow the peripheral retina to remain
reapposed to the RPE.
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Removal of Posterior Epiretinal Proliferation
The epiretinal proliferation is removed by using a pick, forceps, or both. Most
membranes can be elevated and removed with a vitreoretinal pick. The pick
is used to check within the valley of the retinal folds to look for epiretinal
membranes. Bimanual dissection using lighted picks and lighted forceps are
helpful, since they allow counter traction to be placed on the retina to aid in
separating membranes from the retina.40
Removal of Anterior Epiretinal Proliferation

Two different approaches can be done to manage anterior PVR. The best
anatomic and visual results are obtained by directly releasing the anterior
traction with anterior membrane dissection. Perfluorocarbon liquid is used to
fill one-third to one-half of the vitreous cavity. The PFC pushes the posterior
retina against the posterior eye wall, which stretches the peripheral retina. This
helps to stabilize the peripheral retina during dissection and helps to demonstrate
where the epiretinal proliferation is located.52 It is often helpful to perform the
anterior dissection under direct illumination of the operating microscope, with
the surgeon indenting and rotating the peripheral sclera. The light pipe may be
held adjacent to the external limbus by the assistant and directed toward the
peripheral retina to improve illumination of the anterior retina/ciliary body. The
surgeon may then use one hand to hold a pick and the other to hold forceps to
allow bimanual dissection. Panoramic (wide-angle) viewing systems are very
useful in performing the anterior dissection, since these systems allow a better
view of the peripheral retina.40 In severe anterior PVR, the peripheral retina is
pulled toward the ciliary body, making a circular trough. The membrane that
forms a bridge between the folded retina and the ciliary body or the iris, is cut
with curved or angled scissors.
The second approach, by retinotomies and retinectomies, is used in some
eyes that have very adherent peripheral vitreous base proliferation that cannot
be separated from the retina with any technique and must be considered if the
surgeon is convinced that the scleral buckle will not adequately support the
residual retinal traction.40,53
Removal of Subretinal Proliferation

Subretinal dissection should be left to the end of the removal of epiretinal
membrane because in most cases it is not necessary to remove a subretinal
membrane in order to reattach the retina; so then, bands may be left in the
eye if they are distant from retinal breaks and are not causing any traction.
Subretinal fibrosis will sometimes relax enough to allow retinal reattachment,
so in most cases an attempt to flatten the retina with PFCL or air may be
warranted to determine if removal of the membranes is necessary. In general,
299
there are two surgical approaches depending on the type of subretinal
membrane: (1) In single, multiple, or branching subretinal bands, if they
are localized near a retinal break subretinal fibrosis can be removed via the
retinal break(s), however a retinotomy as far away from the posterior pole and
adjacent as possible to the membrane must be created to remove subretinal
fibrosis if it cannot be removed via any existing retinal break. Subretinal
fibrosis is rarely adherent to the retina, so grasping the subretinal band with
a pick and bringing it to the retinotomy usually allows easy removal with
an intraocular forceps, and (2) Subretinal bands may form an annular ring
around the optic nerve or be a diffuse sheet in eyes with chronic RD with or
without PVR. With a large sheet of membrane sometimes a larger anterior
circumferential retinectomy should be created. It may be necessary to fold
the retina over to gain access to the subretinal space so that the membrane
can be removed with a bimanual technique. Scissors can be used to cut a
subretinal membrane in the form of an annular band. Then forceps are used
to remove the annular band from the eye.54
Relaxing Retinotomies and Retinectomies

As a general rule, a relaxing retinotomy (in which the retina is cut but not
excised) is made if the retina remains shortened after complete membrane
removal; retinectomy (to excise membranes and involved retina) is done
if membranes remain and a scleral buckle cannot relieve traction. Retinal
shortening in PVR is divided into seven categories: 55
1. Focal contraction: Because it is localized, focal contraction has little effect
on the overall configuration of the RD.
2. Diffuse posterior contraction: It is rarely necessary to cut the retina in
focal or diffuse contraction. Occasionally when the retina is atrophic, the
membranes will not strip from the retina without extensive retinal tearing.
Diathermy is applied to the retina surrounding the area to be excised,
particularly to the retinal vessels. The retina is most safely excised with
scissors.
3. Circumferential contraction: A ridge of equatorial retina may sometimes
remain in a circular contracted state even after excision of the posterior
hyaloid and sectioning of circumferential membranes. The first two steps
in relief of circumferential contraction are placement of a scleral buckle
and extensive membrane dissection. With the vitrectomy instrument the
vitreous should be cut to the retinal surface anteriorly to the posterior
edge of the vitreous base. Any stripping anteriorly beyond this margin can
result in retinal break. Remaining circumferential membranes should be
sectioned with multiple radial cuts, being careful not to cut into elevated
ridge of retina. Radial cuts, which may or may not be complete, are made
at the posterior border of the vitreous base. Incomplete cuts that do not
extend along the entire vitreous base will still relieve the circumferential
300
traction and allow for retinal reattachment. The vitreous base should be
excised during scleral depression. Perfluorocarbon liquids can show if
we need a relaxing retinotomy at the posterior aspect of the vitreous base.
With the posterior retina held in place by the PFCL and after a double
row of endodiathermy, the retinotomy is extended circumferentially into
normal appearing retina on each end of the retinotomy and then extended
anteriorly to the ora serrata or the ciliary body if the pars plana is involved
with traction. The retinectomy needs to be extended at the point that allows
the retina to flatten. The anterior flap of the retina and membranes upon
it are usually excised to reduce the risk of postoperative proliferation and
contraction.
4. Anterior retinal displacement: Certain techniques may be useful, such as
placing the infusion cannula as anteriorly as necessary to avoid subretinal
infusion (1.5 mm behind the limbus). Scleral depression and bimanual
techniques are also required. It is necessary to remove the lens with the
capsule to perform an adequate peripheral dissection. Anterior peripheral
vitreous is removed with the vitreous cutter using scleral depression and
coaxial illumination. If the retina is displaced anteriorly, it may be possible
to release traction by incising the forward displaced posterior hyaloid with
a sharp MVR blade or with the vitreous cutting instrument, but most often
it is necessary to section the membranes that form on the surface of the
vitreous base with vitreoretinal scissors, that may or may not be followed
by radial cuts in the remaining membrane to further release circumferential
traction (Fig. 20).56 If excessive traction persists, an anterior retinotomy is
performed after all posterior membranes have been removed just posterior
to the anterior retinal traction. Lewis et al.57 performed initial vitreoretinal
surgery on 81 eyes with RRD complicated by severe PVR. They performed
vitreous base dissection on all 18 eyes that had anterior PVR. With one
vitreoretinal operation, 66 of 81 eyes (81%) remained totally reattached.
The main cause of initial anatomic failure and reoperation was either new
or recurrent proliferation at the vitreous base. With additional vitreoretinal
surgery 90% were totally reattached. The final causes of anatomic failure
were anterior PVR and proliferation from relaxing retinotomies.
5. Intrinsic retinal contraction: Is often recognized only after injection of
PFCL or insufflation of air. If the area of intrinsic retinal contraction is in
the peripheral retina, the retinotomy should be extended circumferentially
posterior to the area of contraction into normal retina at each end and
anteriorly to the ora serrata (Fig. 21). When the intrinsic retinal contraction
is localized in the posterior retina, we can get loss of visual field secondary
to a circumferential retinotomy. Radial retinotomies can adequately relieve
the traction; but these may extend too far posteriorly toward the optic nerve.
Finally, excision of a section of nasal retina may adequately relieve traction
on the more visually significant temporal retina.
301
Figure 20 (Arevalo et al) Releasing tractional forces of proliferative vitreoretinopathy:

relieving anterior displacement of the vitreous base. Anterior displacement of the
vitreous base is relieved by incising the forward displaced posterior hyaloid (H) with
a sharp myringotomy blade (M). Relaxing this posterior surface opens up the vitreous
space collagenous tissue which is then debulked with a vitreous cutter (not shown).
Endoilluminator (E) and infusion terminal (I)
2002. pp. 459-84.
Figure 21 (Arevalo et al) When the area of intrinsic retinal contraction is in the
peripheral retina, the retinotomy should be extended circumferentially posterior
to the area of contraction into normal retina at each end and anteriorly to the
ora serrata. The anterior flap of retina needs to be excised (retinectomy), and laser
photocoagulation applied. Cryotherapy may be used to create a chorioretinal
adhesion anteriorly to the ora serrata
302
6. Extensive periretinal fibrous proliferation: Usually occurs after trauma,
retinal contusion or necrosis. The retina becomes replaced by fibrous tissue
on both anterior or often the posterior sides of the retina. Membrane removal
can result very difficult because in these areas, the retina may become
very thin, contracted and shortened. The retina in these areas usually is
nonfunctional and should be excised with the vitreous cutting instrument
if it prevents retinal reattachment.
7. Contraction and fibrosis of the flap of a giant retinal tear: A GRT is often
accompanied by the inward curling of the anterior retinal edge. The intrinsic
elasticity of the retina initiates the curling process, with migration of the
RPE cells over the edge to the ILM facilitating proliferation and contraction,
which results in PVR. Even after removal on both the anterior and posterior
membranes surface of the inward curling posterior flap of most GRTs, the
edge may remain folded, requiring a retinotomy or retinectomy to allow
complete flattening of the flap. Alternatively, a series of radial retinotomies
may be placed approximately every 30° along the margin of the flap to
allow unfolding.58 However, the irregular edge created by this series of
retinotomies is more difficult to manage, and excision of the edge with the
vitreous cutting instrument is the preferred approach.
Creating a Chorioretinal Adhesion

We prefer to use laser photocoagulation over cryopexy in eyes with PVR
because cryopexy causes greater breakdown of the blood-ocular barrier and
may predispose for reproliferation and recurrent RD. It is important to remove
all subretinal fluid via pre-existing posterior retinal breaks or creating with
endodiathermy a drainage retinotomy distant from any potential source of
traction, so that the retina will be completely flat against the RPE allowing
laser photocoagulation to create a good adhesion. Laser photocoagulation
should be applied utilizing an intravitreal fiberoptic laser probe. Some surgeons
prefer to place a tight-scatter laser pattern in the entire peripheral retina to try
to prevent recurrent RD. The advantage of extensive laser photocoagulation
of the periphery is the creation of a chorioretinal burn that causes adherence
of the retina to the RPE in the entire retinal periphery, which is prone to
reproliferation and retinal breaks, but the disadvantage is that extensive laser
photocoagulation causes greater breakdown of the blood-ocular barrier and
creates thin retina over the laser burns, and this is more prone to tearing if there
is recurrent proliferation.
Intraocular Tamponade
The Silicone Study confirmed the superiority of silicone oil compared with
sulfur hexafluoride (SF6) gas as an intraocular tamponade for the management
of RD complicated by advanced grades of PVR.59 Eyes randomized to silicone
303
oil were more likely to be successfully reattached, to achieve a visual acuity
of 5/200 or better, and to have fewer postoperative complications than eyes
randomized to SF6 gas. In contrast, the semipermanent tamponade of silicone oil
offered little or no advantage compared with the prolonged but comparatively
short-term tamponade with perfluoropropane (C3F8) gas.60 The Silicone Study
has also shown that for the cohort of C3F8 gas- and silicone oil-treated eyes, there
were similar outcomes between eyes that underwent a primary vitrectomy for
PVR and eyes that had already undergone at least one unsuccessful vitrectomy
with gas tamponade before enrollment into the study.61 In conclusion, there are
two choices for intraocular tamponade in eyes with PVR. In general gas should
be used for intraocular tamponade for several weeks if deemed adequate to
reattach the retina. Silicone oil is used when tamponade for more than 4 weeks
is necessary and depending on the severity of the case. Although the Silicone
Study did not provide clear guidelines for when to use silicone oil and when to
use gas, the physical properties of the two tamponade modalities make silicone
oil preferable in some situations and gas preferable in others. Silicone oil may
be preferred for patients who need to fly in an airplane postoperatively; some
patients are unable to lie in a prone position as required for treatment with gas,
and eyes at risk for hypotony. Conversely, gas may be preferred for eyes at
risk for corneal touch by silicone oil, eyes with retinal breaks posterior to high
scleral buckles (gas better conforms to the shape of the eye and scleral buckle),
and eyes with intraoperative retinal or choroidal hemorrhages.62
Removal of Silicone Oil

Some eyes require removal of silicone oil because of complications arising from
the oil, such as glaucoma, emulsification of the silicone oil, band keratopathy,
possible retinal toxicity and cataract. The timing of silicone oil removal
remains controversial in different reports in the literature;63-65 however, we
favor removal of silicone oil at 3–6 months to avoid complications. In Bassett
et al66 series, there was no correlation between the silicone oil duration and the
incidence of redetachment or other complications, as previously reported.64,67
They could not identify any significant risk factor for redetachment when the
eyes with redetachment were compared to the eyes that remained attached.66
Recurrent RD occurs in 9–33% of eyes after removal of silicone oil in most
series reported in the literature.60,63 However, the advent of wide-angle viewing
systems, the introduction of the PFCL and sophisticated intraocular instruments
and the actual capacity of the surgeon to manage the complexities of anterior
PVR in recent years has shown that the rate of redetachment after oil removal
is significantly lower than reported in previous series and the silicone study.
In pseudophakic eyes, the silicone removal is carried out through a pars plana
sclerotomy. In aphakic eyes, the oil is removed in the majority of cases through
a small limbal paracentesis. In phakic eyes that did not have combined cataract
extraction, the oil is removed via the pars plana, and finally in phakic eyes that
304
underwent silicone oil removal combined with cataract extraction, a small
posterior capsulotomy is performed with the vitrectomy probe or with capsular
forceps, and the oil is removed through this opening. With this last technique,
Bassett et al66 reported redetachment in 8.8% of all eyes and in 9.3% of the PVR
eyes. With this technique the operating time is shorter than when silicone oil is
removed via the pars plana, as new sclerotomies are not required. In addition,
avoiding new sclerotomies may be associated with lesser risk for peripheral
retinal break formation and postoperative vitreous hemorrhage. The central
posterior capsulotomy eliminates the need for postoperative YAG capsulotomy.
Reoperations for Recurrent Retinal Detachment from

The timing or repeated surgery in eyes with recurrent RD from PVR is critical;
early surgery may be associated with recurrent epiretinal proliferation, and
late surgery is associated with poorer visual outcome if the retina is allowed to
remain detached for 2–3 months while the surgeon waits for the proliferation to
mature. The surgeon must determine which factor led to the recurrent RD and
plan further surgery on the basis of this assessment. If the cause is reproliferation
of epiretinal membranes, management consist of waiting until the proliferation
is mature and then removing the recurrent proliferation. Any recurrent retinal
breaks or new retinal breaks must be treated to create a stable chorioretinal
adhesion. Recurrent RD within 1 week of initial surgery strongly suggests
inadequate relief of traction at the time of initial surgery. Surgery in this setting
may be performed promptly. Inadequate or misplaced scleral buckles are treated
by replacing or revising the scleral buckle. Finally, insufficient chorioretinal
adhesion may be treated by supplemental laser photocoagulation in the office
as long as there is no subretinal fluid around the retinal break(s). In some cases,
reoperations involving membrane surgery can be performed with silicone oil in
situ68 whereas in others, it involves removal of silicone oil, membrane surgery,
and internal tamponade with silicone oil or gas or just scleral buckling without
revision of vitrectomy.
ADJUNCTIVE TREATMENT IN PROLIFERATIVE

VITREORETINOPATHY
There are a number of studies showing a potential benefit of a variety of
pharmacological interventions, including retinoic acid,69 dexamethasone,70
colchicine,71 paclitaxel (Taxol),72 and daunorubicin.73 However, none of these
regimens are in routine clinical use. Recently, there has been increasing interest
in the use of a combination of 5-fluorouracil (5-FU) and low-molecular-weight
heparin (LMWH) in the prevention of PVR and in established PVR. Because
5-FU and LMWH are effective in different aspects in the PVR process, it
is believed that a synergistic approach to the prevention of PVR would be
305
advantageous. Asaria et al74 reported a significant reduction in the incidence
of postoperative PVR in patients receiving 5-FU and LMWH therapy and
in the reoperation rate resulting from PVR. However Charteris et al75 found
that a perioperative infusion of this combined adjunctive treatment does not
significantly increase the success rate of vitreoretinal surgery for established
PVR. A recent review done by Sundaram et al76 concluded that when only
randomized controlled trials are compared the evidence is inconsistent. Due
to the anti-inflammatory properties and the proved improvement visualization
of the vitreous, delineation of posterior hyaloid and epiretinal membranes,
triamcinolone acetonide has been used to allow a more complete and safer
ERM removal during vitrectomy for PVR.77 However it is controversial if its
use could improve the outcome of the surgery.78 Recently Ahmadieh et al in a
randomized clinical trial reported that the outcomes of vitreoretinal surgery for
established PVR are not improved significantly by adjunctive triamcinolone
acetonide injection in silicone-filled eyes.79
GIANT RETINAL TEARS

In an eye with a fresh GRT, a lens sparing vitrectomy with a scleral buckle
may be performed. However, when there is a highly elevated anterior flap
or PVR and the lens interferes with necessary vitreous base dissection and
removal, a lensectomy must be performed. We place the scleral buckle before
vitrectomy if the final posterior flap position can be accurately estimated
before reattachment. Meticulous vitrectomy over the vitreous base is critical
to release all anterior traction. Attention to the anterior flap is essential. If it is
pulled anteriorly toward the pars plana or lens, attempts to release it are first
made by removing vitreous gel. The release of the anterior flap should not be
possible if the vitreous and anterior flaps are excised together. Perfluorocarbon
liquids facilitate the unfolding of the flap of the tear while minimizing retinal
trauma resulting from the use of microsurgical tools. Additionally, the need for
a posterior retinotomy to remove subretinal fluid is obviated, since the weight of
the PFCL forces the fluid anteriorly. If necessary, residual preretinal membranes
are dissected under PFCL. As the PFC meniscus approaches the edge of the
tear, inspection may reveal star folds and/or circumferential shortening of the
tear from PVR. Additionally, the edge may assume a scrolled appearance from
epiretinal membranes proliferation on the inner surface of the retina. Removal
of the epiretinal membranes using bimanual dissection is easier, since the
retinal flap is immobilized by PFCL. At this point, the meniscus of PFCL is
kept just posterior to the margin of the tear. The basal vitreous gel is trimmed
with the vitreous cutter for 360°, paying careful attention to the margin of the
tear. Meticulous removal of the peripheral vitreous gel permits a more complete
replacement of the vitreous volume if silicone oil tamponade is used, decreases
the likelihood for new breaks along the posterior insertion of the vitreous base,
and diminishes the occurrence of anterior PVR. With the use of PFCLs proper
306
repositioning of the torn retina is achieved while endophotocoagulation or
trans-scleral cryotherapy is applied to the posterior edge of the tear through
the liquid. Cryotherapy application is more precise, excessive treatment can be
avoided, and intravitreal dispersion of RPE cells during cryotherapy may even
be reduced, since the PFC liquid presses the edge of the giant break against the
RPE. Endophotocoagulation is the preferred method of retinopexy, but when
the margin of the tear is too peripheral and cannot be visualized, cryopexy or
indirect laser photocoagulation is used.
POSTOPERATIVE COMPLICATIONS
It is well-recognized that the use of scleral explants combined with PPV repair
of RD is associated with several risks including hypotony during placement
of the buckle with associated choroidal hemorrhage,80-82 and longer duration
of surgery.81 Postoperative complications include refractive change, 83,84
diplopia, 85,86 exoplant erosion or infection, 85,87 and a risk of decreased
retinal blood flow88 and anterior segment ischemia.89,90 Early postoperative
complications in PVR surgery are elevated IOP, excessive inflammation,
infection, endophthalmitis and others. Late postoperative complications
are recurrent epiretinal proliferation leading to RD, keratopathy, hypotony,
rubeosis iridis, cataract, and cystoid macular edema. Finally, retinotomies and
retinectomies are associated with intraoperative and postoperative hemorrhage,
hypotony and recurrent RD.
SUMMARY
In summary, this chapter has discussed the different vitrectomy techniques
available to repair RD with and without PVR in a step-by-step approach.
Pars plana vitrectomy, a method originally reserved for complicated cases, is
now used increasingly for primary repair of uncomplicated RRD. Vitrectomy
may be selected to diminish complications associated with scleral buckling,
to help relieve vitreoretinal traction and/or to create a large empty vitreous
cavity in which a tamponade can be introduced. Primary vitrectomy with
and without a scleral buckling seems to be useful in complicated cases
that have an unfavorable prognosis with simpler procedures. The selection
of alternative techniques for different types of RD is a matter of surgeon
preference. However, a variety of relatively complicated RRD are currently
best managed with vitrectomy techniques with or without associated scleral
buckling including RRD with PVR (Figs 22A and B), RRD associated with
GRTs, RD associated with proliferative retinal vascular disease, RRD due
to posterior breaks, RD associated with viral and other forms of retinitis,
RD associated with posterior vitreoretinal traction, and RD associated with
significant vitreous opacification.
307
Figures 22A and B (Arevalo et al) (A) Retinal detachment with proliferative
vitreoretinopathy before and (B) after pars plana vitrectomy with silicone oil injection
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segmental scleral buckling. Br J Ophthalmol. 1994;78(5):409-10.
chapter 15
Current Indications of
Antiangiogenics in Vitrectomy
Mauricio Maia, Fernando M Penha, J Fernando Arevalo
antiangiogenics: overview
Introduction: Vascular Endothelium Growth Factor
The vascular endothelium growth factor (VEGF) is a joint of proteins including
the platelet growth factor, VEGF-A, VEGF-B, VEGF-C, VEGF-D and the
VEGF-E.1 The well-known VEGF-A is a dimeric protein of nine different
isoforms synthesized by RNAm. Four of the isoforms are: VEGF-121,
VEGF-165, VEGF-179, VEGF-206.1 The subtypes VEGF-A are related to
cellular migration and proliferation as well as the synthesis of the VEGF tube
throughout variety of different pathways which is the common final event in
the activation of the protein kinases using three VEGF receptors: VEGF-R1,
VEGF-R2, VEGF-R3. It is known that VEGF-A results in increasing of the
vascular permeability as well as neovascularization due to specific portions of
the plasmatic membrane from endothelial cells that are highly permeable for
macromolecules named vesicular/vacuolar.1 The cytokines from VEGF are
related to the upregulation and downregulation of the physiological activities
during the embryogenesis in human eyes.1
This chapter will discuss causes, management and prevention of
intraoperative bleeding during pars plana vitrectomy (PPV), emphasizing the
state-of-the-art regarding the use of antiangiogenics before PPV in proliferative
diabetic retinopathy (PDR) in order to minimize the intraoperative bleeding.
Role of Bevacizumab and Ranibizumab in the

Angiogenesis Process
It is known that PPV is generally indicated when the tractional retinal
detachment (TRD) is involving the macular area or there is a macular-
314
threatening condition.2 However, sometimes the postoperative functional
result may not be as good as the anatomical outcome.1-4 The surgical technique
includes removal of the fibrovascular membranes and relief of vitreoretinal
traction.1-3 Particular attention is focused on minimizing intraoperative
bleeding and avoiding iatrogenic retinal breaks.4-6 Intraoperative bleeding is
one of the main complications associated with PPV in PDR and may hinder
the surgical outcome or even be uncontrollable. In addition, intraoperative
bleeding during PPV increases the risk of vitreous hemorrhage in the early
postoperative period, further emphasizing the need for careful hemostasis
during surgery.1-6
The intravitreal injection of bevacizumab 1.25 mg in eyes with PDR
reduces the neovascularization when used 3–5 days prior to PPV; this
facilitates the vitreoretinal surgical procedure and decreases the risks of
intraoperative hemorrhage.7-10 However, surgeons must be aware about the
possibility to induce worsening of TRD in 5.4% of young patients with
previous initial TRD.11 Additionally, eyes with PDR and initial vitreous
hemorrhage may have a faster blood reabsorption rate than natural history.
This may also be used as an adjuvant therapy at the end of the PPV in
complex cases in order to decrease the possibility of iris neovascularization
in complicated cases of PDR.12-14
The prospective Comparison of Age-Related Macular Degeneration
Treatments Trials study (CATT), a large National Institute of Health
(NIH) sponsored trial, reported similar risks of thromboembolic events
in eyes submitted to intravitreal bevacizumab injection versus intravitreal
ranibizumab injection in eyes with age-related macular degeneration
(AMD).15 Similar safety profile was observed by a retrospective study of the
Pan-American Collaborative Retina Study Group (PACORES) in 4,303 eyes
with different vitreoretinal diseases such as PDR, DMR, cystoid macular
edema in pseudophakic eyes, central retinal vein occlusion, AMRD and
branch retinal vein occlusion.16
Ranibizumab has been widely used for the treatment of several choroidal
and retinal vascular diseases as well as in patients with TRD and PDR
undergoing PPV to avoid bleeding after the surgery. 17 The intravitreal
injection of 0.5 mg of ranibizumab is associated with regression of persistent
neovascularization in eyes with PDR when used 3–5 days preoperative for
the management of patients with TRD in PDR eyes; this also minimizes
intraoperative bleeding, thus facilitating the surgery and contributing to
a better outcome due to a decrease in the surgical duration, similar to the
observations of the intravitreal effects of bevacizumab injection 3–5 days
prior to PPV in PDR eyes.17
Chapter 15  Current Indications of Antiangiogenics in Vitrectomy
315
INTRAOPERATIVE BLEEDING DURING PARS
PLANA VITRECTOMY IN PROLIFERATIVE DIABETIC
RETINOPATHY
Introduction
Intraoperative bleeding during PPV is a challenge for the surgeon and has been
a matter of debate regarding techniques for controlling these hemorrhages.
Massive intraoperative bleeding is correlated to histological damage due
to high degree of hemosiderin deposit into the retina.18,19 High volumes of
blood clot retraction can produce secondary TRD, retinal holes and subretinal
accumulation of blood.19
Bleeding during the surgical procedure may impair surgical field, thus
yielding poor postoperative results including low vision, proliferative
vitreoretinopathy (PVR) and secondary retinal detachment. Prevention as well
as the correct management of intraoperative bleeding is important to achieve
good surgical results. Meticulous surgical technique is essential to prevent
intraocular hemorrhage; however, when bleeding occurs, it must be promptly
controlled.
Vitreoretinal Bleeding
Vitreous hemorrhage may occur during dissection, segmentation and
delamination of fibrovascular membranes from PDR. Particularly, focal
fibrovascular adhesions have less chance of persistent bleeding as compared to
plaques. However, it may be controlled using many techniques such as: rising
of intraocular pressure (IOP), utilization of backflush device, endodiathermy,
perfluorocarbon liquid (PFCL) and fluid-air exchange.
Unimanual or bimanual bipolar diathermy is routinely applied to sites of
persistent bleeding other than the optic nerve. Avoiding segmentation of highly
vascularized membranes and ensuring that the patient’s blood pressure is normal
can reduce the incidence of hemorrhage. Elevation of IOP is used to minimize
bleeding during the dissection of vascular tissue. Adjusting IOP to a level above
systolic blood pressure for 1–2 minutes will frequently stop persistent bleeding
in patients with normal values of blood pressure.20-22
It is important to emphasize that any blood on the retina should be removed
immediately, before clot formation. Clotted blood should be cautiously stripped
from the retina, as it may be tightly adhered. In some circumstances, scissors,
forceps or vitrectomy tip may be necessary to excise a clot.20-22
Recently, prevention of intraoperative bleeding may be performed by
intravitreal injection of anti-VEGF (ranibizumab 0.5 mg or bevacizumab 1.25
mg) applied 3–5 days before the vitrectomy (see session below). This is a
common technique performed preoperatively in vitreoretinal surgery for PDR;
adequate preoperative blood pressure control as well as a normal systemic blood
316
coagulation status is also very important to avoid intraoperative bleeding during
vitreoretinal surgeries from many etiologies.
Blood into the vitreous cavity may also occur during dissection of PVR
starfold membrane. Care must be taken when performing peeling close to major
vessels or near to the optic disk. Large vein rupture may cause intense bleeding
at the posterior pole, followed by difficulty to remove big clots, mainly in the
macula region that may aggravate low vision and PVR in the postoperative
period.20-22
The backflush system connected to a vitrectomy probe is an important
surgical maneuver in order to remove blood from the fovea; in this technique,
a reverse flow from the vitreous probe is achieved and using the mechanical
flow of balanced salt solution (BSS), the clot is “washed” nicely from the
posterior pole.23-25
Some surgeons do prefer to perform posterior retinotomy at the nasal
retina in order to make subretinal fluid drainage during fluid-air exchange. An
adequate retinotomy away from large vessels, endodiathermy of microvessels
and deviation of vitrectomy aperture from large vessels may preclude bleeding
either into the vitreous cavity or into the subretinal space.23-25
Subretinal clot may be disastrous to the postoperative visual and anatomic
prognosis, leading to PVR formation and retinal redetachment. Slow and careful
aspiration of bleeding with or without further rising of IOP may prevent its
migration and the size of the clot. After controlling the hemorrhagic process,
mechanical removal of blood may be difficult and it may result in severe outer
retina atrophy.20-22
Intraoperative control of hemorrhage in penetrating ocular injuries may
be a challenge to the surgeon. Some techniques (such as IOP rising, fluid-air
exchange, endodiathermy, endophotocoagulation) must be known to be part
of the surgical arsenal to avoid such complication.20
Preoperative procedures to minimize the

possibility of intraoperative bLeeding
Blood Pressure Control
Preoperative blood pressure control could aid to prevent intraoperative bleeding
during vitrectomy.
Antiplatelet and Anticoagulants—Is It Necessary to

Discontinue Them before Surgery?
Warfarin, the most commonly used anticoagulant, inhibits vitamin K dependent
clotting factors (II, VII, IX and X) and need the International Normalized
Ratio between 2–3 to maintain optimal anticoagulation (e.g. atrial fibrillation,
valvular heart disease and thromboembolic diseases).26 There are two main
317
platelet aggregation pathways to be inhibited.26 Clopidogrel inhibits adenosine
diphosphate-produced platelet aggregation. Aspirin works through the inhibition
of the cyclooxygenase pathway and frequently has been used in combination
with warfarin, although with less therapeutic efficacy than clopidogrel.26 The
most common indication for antiplatelet therapy in vitrectomy candidates is
cardiac stent, coronary artery bypass grafting and history of transient ischemic
attack.27-30 Use of antiplatelet agents has increased in patients undergoing
vitreoretinal surgery.27-30 However, there is no unified consensus regarding the
risks of systemic anticoagulation or platelet inhibition during ocular surgery
and whether continuation of such medication is appropriate.27-32 Warfarin use
should be avoided if the patient’s thromboembolic risk is low because of high
possibilities of either intraoperative and/or postoperative bleeding.27,28
Particularly, if a PDR patient with highly active neovascularization and TRD
has a high risk of thromboembolic event, anticoagulation may be continued.
Preoperative use of anti-VEGF and a fast as well as good quality small gauge
surgery may contribute to induce lower rates of hemorrhagic events.
Intravitreal Injection of Anti-VEGF Inhibitors in Proliferative

Diabetic Retinopathy
Important evidences have shown the benefits of intravitreal anti-VEGF therapy
3–5 days before vitrectomy for PDR and this is an important preoperative
adjuvant therapy performed worldwide in order to facilitate the PPV and
minimize the bleeding during the surgical procedure.
INTRAVITREAL INJECTION OF ANTI-VEGF BEFORE

SURGERY IN PROLIFERATIVE DIABETIC RETINOPATHY
Rationale
Regression of neovascularization before surgery results in less intraoperative
bleeding and contributes to an easier PPV procedure in PDR.
Intravitreal Bevacizumab Before Pars Plana Vitrectomy In

Intravitreal bevacizumab administration 3–5 days prior to PPV results in a
decrease of intraoperative bleeding during PPV in patients with advanced
PDR 8-14,33,34 (Figs 1A to F). A recent update review of 698 intravitreal
injections of bevacizumab from the PACORES group has detected an incidence
of progression of TRD in 3.5% of the cases.34 The time period between
bevacizumab administration and PPV should be less than 7 days in order to
reduce the risk of increased vitreoretinal traction due to excessive contraction
of fibrotic tissue induced by the abrupt decrease of VEGF levels in patients
318
A B C
D E F
Figures 1A to F Infrared, autofluorescence and fluorescein angiography performed

at the 30th postoperative day of right eye submitted to vitrectomy in proliferative
diabetic retinopathy. Best corrected visual acuity improved from hand movements
to 20/25. (A) Infrared image showing normal macula. The anatomy of optic disk is
abnormal due to chronic glaucoma; (B) Autofluorescence showing no abnormalities
at the fovea; (C) Fluorescein angiogram from the macula showing no edema or
leakage; (D) Fluorescein angiogram showing no active neovascularization and two
big scars temporal superiorly/inferiorly to the macula due to diathermy; (E) Late phase
of fluorescein angiogram showing similar findings; (F) Fluorescein angiogram at the
nasal retina showing no active neovessels
with advanced PDR submitted to intravitreal injection of VEGF inhibitors.11

This leads to regression of neovascularization and less bleeding during the
PPV—usually performed 3 days after the intravitreal anti-VEFG injection; it
results in a fast vitreoretinal surgery which is especially useful in eyes with
glaucoma associated with PDR8-14,33,34(Figs 1A to F).
As the theoretical risk factors for this complication is the abrupt inhibition
of VEGF, it is recommended that only 1.25 mg of bevacizumab (instead of 2.5
mg) be used in order to avoid excessive fibrotic contraction.11 The possible risk
factors for progression of TRD in PDR are: uncontrolled systemic diabetes,
previous TRD, type I diabetes and the attached hyaloid to the retina11 (Figs
1E and F).
Decrease of intraoperative bleeding was observed in around 85% of eyes
compared to sham group following 1.25 mg of bevacizumab injection into
the vitreous cavity 1 week prior to PPV. Lowest dose of bevacizumab (0.16
mg) was as effective as the standard dose (1.25 mg) in reducing intraoperative
319
hemorrhage when administered 3 days before surgery.9 A recent meta-analysis
showed that the incidence of intraoperative bleeding and frequency of
endodiathermy were significantly lower following intravitreal bevacizumab
injection before the surgery in PDR compared to surgery without previous
anti-VEGF injection.14 Nowadays it is suggested that 1.25 mg of intravitreal
bevacizumab injection be performed 3 days before the vitrectomy in PDR
(Figs 1A and B). This preoperative technique allows that PPV be performed
even in complex surgical cases with minimal ocular trauma (Figs 1E and F).
However, the surgeon must be aware about the possibility of worsening the
previous TRD; the estimated risk evaluated by retrospective study is around
5.4%.9,34
Intravitreal Ranibizumab before Pars Plana Vitrectomy in

Differences regarding the intraoperative bleeding were also observed following
intravitreal injection of ranibizumab (0.5 mg) 7 days before vitrectomy for
TRD management.17 Incidence of intraoperative hemorrhage was decreased
by 65% when compared to sham group.17 However, no data regarding the
risk of inducing TRD is available due to low number of cases reported in the
literature. In summary, intravitreal injection of 0.5 mg of ranibizumab is a useful
tool in order to decrease the amount of intraoperative bleeding in PDR but is
also recommended that PPV be performed around 3–5 days after intravitreal
injection.
Technique of Preoperative Intravitreal Anti-VEGF Injection

The surgical technique of intravitreal anti-VEGF injections 3–5 days before
PPV in PDR must be performed similarly to the technique used for the
management of choroidal neovascularization in AMD (Box 1).
All eyes with PDR due to TRD and/or vitreous hemorrhage that will be
submitted to PPV should be treated by intravitreal antiangiogenic injection
Box 1: Key points for successful anti-VEGF injections before pars plana
vitrectomy in proliferative diabetic retinopathy
1. Perform the intravitreal injection under sterile conditions
2. Prophylaxis for endophthalmitis using 5% topical Povidone Iodine
3. Use either 1.25 mg of bevacizumab or 0.5 mg of ranibizumab
4. Be aware that progression of previous tractional retinal detachment or
development of tractional retinal detachment may occur after intravitreal
anti-VEGF injection in proliferative diabetic retinopathy. For this reason,
the pars plana vitrectomy must be performed 3 to 5 days after intravitreal
anti-VEGF injection in proliferative diabetic retinopathy eyes.
320
(either 1.25 mg of bevacizumab or 0.5 mg of ranibizumab) 3–5 days before
the PPV.
The procedure should be performed in the operating room, under sterile
conditions using the sterile drape and topical anesthesia. After the eye speculum
is inserted, the eye should be submitted to topical instillation of Povidone Iodine
5% and the surgeon should wait for a minimum of 15–45 seconds; so, the eye
should be washed by BSS irrigation.. Paracentesis is not necessary but it may
be used in glaucomatous eyes.
The surgeon must give an intravitreal injection at 2.5 mm posterior to the
limbus in pseudophakic eyes and 3.5–4.0 mm posterior to the limbus in phakic
eyes. Intravitreal injection of 1.25 mg of bevacizumab (0.05 ml of bevacizumab
25 mg/ml) or 0.5 mg of ranibizumab (0.05 ml of ranibizumab 10 mg/ml) must be
performed after the half of the 29-gauge needle been inserted into the vitreous
cavity with the needle positioned towards the optic disk.
The surgeon should wait around 5 seconds before the needle removal. As
soon as the needle is removed from the eye, the surgeon holds the wound using
the cotton tip against the scleral wound during 5–10 seconds.
Care During Preoperative Intravitreal Anti-VEGF Injection

Before Pars Plana Vitrectomy in Proliferative Diabetic
Retinopathy
Conclusion of Intravitreal Injection of Anti-VEGF Before

The anti-VEGF therapy before PPV for management of PDR is a procedure
performed worldwide and a very helpful adjuvant technique which minimizes
bleeding during PPV in PDR eyes. Surgeons should use either 1.25 mg of
bevacizumab or 0.5 mg of ranibizumab as well as plan the PPV procedure
around 3 days after anti-VEGF procedure due to the possibility of worsening
or development of TRD in PDR eyes.
techniques OF INTRAOPerative posterior segment

bleeding control
There are several ways to control intraocular hemorrhage and all of them follow
three basic principles:
1. Compressive effect over the vessels by fluids and/or increasing IOP that leads
to vasoconstriction and clot formation; these maneuvers do not require a
direct contact of instruments with the bleeding vessels and are especially
useful for hemorrhage in the macular area and optic disk.20-22
2. Induction of pharmacological vasoconstriction reducing the vascular
permeability;35-37 these maneuvers do not also require a direct contact
321
of instruments with the bleeding vessels and are especially useful for
hemorrhage in the macular area and optic disk; however they are not often
used by vitreoretinal surgeons.
3. Direct thermal effect over the blood, leading to local coagulation of the
blood and resulting in a clot formation; these maneuvers require a direct
contact of instruments with the bleeding vessels and are especially useful
for hemorrhage outside of the macular area and/or optic disk.23-25
Based on these principles, the management of intraoperative hemorrhage
may be organized in a following didactic way:
Rising the Intraocular Pressure

It is a rapid and common technique for controlling the intraoperative hemorrhage.
Thrombosis and hemostasis occur with difficulty under fluid-filled medium.
Thus, increasing of IOP is a useful maneuver to compress bleeding vessels
and helps to decrease blood flow, resulting in clot formation and hemostasis
which facilitates that key surgical steps such as posterior hyaloid detachment
to be nicely performed, resulting in minimal hemorrhage20-22 (Figs 2A and
B). In hypotonic eyes, the hemorrhage process tends to be a more frequent
and complex event. Rising of IOP is achieved by lifting the infusion bottle or
preferentially by increasing the pressure in the infusion system using a controlled
mechanism.20-22 Estimated infusion pressure from the first method is not known.
Nowadays, vitrectomy systems have enough resources to induce elevation of
IOP in a controlled way, resulting in better outcomes of vitreoretinal surgeries.
Intraocular pressure must be increased until optic disk pulsation is observed.
Care must be taken in order to avoid the pale retina as well as pale optic nerve;
this clinical feature indicates decrease of optic disk perfusion and it may result in
postoperative irreversible visual loss due to iatrogenic ischemic optic neuropathy,
especially if the increased IOP is continuously high for more than 5 minutes.
Normally, the raised IOP must persist until the decrease of bleeding process and
the observation of clot formation. In case residual active bleeding is observed,
diathermy and/or endolaser may be used to control bleeding (Fig. 2C). Intraocular
pressure elevation may range between 1 minute and 3 minutes, depending on case
and variables such as size and number of bleeding sites, vessel caliber, the systemic
status of blood coagulation as well as the blood pressure maintenance of remained
closed system is important to keep the high and controlled levels of IOP. To achieve
this goal, plugged sclerotomies, avoidance of frequent removal of instruments
away from the eye or the preferred valved trocars systems (Fig. 2D) may help
maintain a steady IOP during the surgery and a reasonable fluidic dynamics. The
high IOP technique is especially useful for management of neovascularization at
the anterior chamber in order to avoid bleeding; high IOP values must be used
with care to avoid atrophic changes at the optic disk after surgery.
Increased IOP may damage intraocular structures sensitive to ischemia.
Particularly, care must be taken in eyes with glaucoma, ischemic optic
322
A B
C D
Figures 2A to D Surgical techniques for intraoperative bleeding control. (A)

Initial stage of posterior hyaloid detachment in proliferative diabetic retinopathy
submitted to 1.25 mg of intravitreal bevacizumab injection 3 days before the surgical
procedure; (B) Advanced stage of posterior hyaloid detachment in the same case;
(C) Endodiathermy at bleeding sites; (D) Use of valved trocars to avoid sudden
intraocular pressure changes
neuropathy or diabetic retinopathy; in these eyes, the “safe duration of high

IOP” is unknown and should be the lowest one enough to control the bleeding
process.
Fluid-Air Exchange
Increasing of IOP values can also be achieved by intraocular air/gas application.
The surface tension of air bubble is higher than that exerted by fluid. Therefore,
an intraocular air/gas bubble frequently stops the blood flow and facilitates
thrombus formation.20-22 It is a worldwide surgical technique during extensive
hemorrhage because this maneuver is able to maintain the blood “packed”
posteriorly to the fluid-air surface, especially at the posterior pole because the
surface tension of air is higher than fluid. This is a useful maneuver during
extensive bleeding from many causes.20-22 It is also useful during epiretinal
membrane and internal limiting membrane peeling, especially in patients unable
to stop the systemic anticoagulation therapy due to systemic diseases; in these
eyes, bleeding in the macular area is very common and must be treated by
indirect compression of the clot using high IOP levels instead of endodiathermy
to avoid thermal damage to the macula area. Additionally, in these patients,
323
bleeding from the iris/ciliary body may occur and should be treated by fluid-air
exchange and increasing of the IOP.
Vitrectomy systems have an air-pump device for controlled fluid-air
exchange. It is suggested that flute, backflush or especially the soft-tipped
cannula be used and connected into the vitrectomy aspiration line or
preferentially into an accessory extrusion line. The vitrectomy tip can be also
used particularly when progression of hemorrhage is too big and results in
difficulties for changing the instruments. During the fluid-air exchange, the
recently formed little soft clots can be simultaneously removed by aspiration
under fluid while the air is injected.
Fluid-air exchange may be a good alternative to improve the visualization of
the periphery of retina and shows up the bleeding site. It is worthy particularly
in cases where vitreous hemorrhage persisted despite adequate blood aspiration.
Once bleeding is controlled, reversal from air to fluid state may be done at any
moment.
Perfluorocarbon Liquids
The properties of transparency, molecular weight higher than water and high
surface tension have made PFCLs an adjunctive for management of complicated
cases in vitreoretinal surgery.38 Their property of immiscibility with blood and
water and its liquid transparency allow surgeons to identify and stop bleeding
sites when injected above the retina. This facilitates the hemostasis of bleeding
sources. Intraocular perfluorooctane significantly reduced the time to achieve
hemostasis.2,38
Injection is performed using a syringe-threaded soft-tipped cannula over
the optic disk. To prevent liquid dispersion, the tip must be positioned into the
bubble, in order to produce only a big one.
Technique for “en bloc” PFCL dissection of fibrovascular membranes in
PDR and TRD showed good results in preventing intraoperative bleeding.2
Separation of epiretinal tissues is performed injecting PFCL between retina
and posterior hyaloids.2 Additional to iatrogenic retinal breaks that may be
observed in 7% of the patients, care must be taken to avoid PFCL injection
into subretinal space.2 Moreover, during PFCL injection into the vitreous
cavity, the fluid inside the vitreous cavity must go outside of the eye and the
valved trocar systems may avoid this fluid migration. For this reason, it is very
important to turn off the infusion or insert a needle throughout the trocars;
these maneuvers allow the migration of fluid that was displaced by the PFCL
through the valved trocars.
Endodiathermy and Cauterization

Protein denaturation and hemostasis occur when resistance of tissues to electric
currents are applied by diathermy; it is different than cauterization in which an
324
electric current heat up the probe tip and results in tissue; both techniques—
endodiathermy and cauterization—require the touch of the tip of the probe at
the target tissue.20-22
Endodiathermy is the preferable technique for many surgeons to manage
bleeding during PPV, because it minimizes the epiretinal blood side effects
(Figs 3A to D). Unimanual coaxial bipolar endodiathermy probes are
available for 20-, 23- and 25-gauge systems. They can be used to coagulate
active bleeding retinal neovascularization (Figs 3A to C), which results in an
easy dissection of fibrovascular tissue with minimal bleeding and no need to
use intraocular forceps/scissors to remove fibrovascular membranes before
its segmentation (Figs 3A to C). This procedure is normally followed by
endophotocoagulation20-22 (Fig. 3D).
It is also useful to assist retinotomies for subretinal fluid drainage. For
better control of hemostasis, this technique should be performed using a pedal
that contains a progressive control of the intensity. It avoids iatrogenic heating,
especially if the bleeding site is close to the fovea or optic disk. In case of
inadvertent avulsion of retinal vessel or iatrogenic retinal tears, complementary
techniques (e.g. IOP increasing, PFCL, air-fluid exchange) should be used to
re-establish visualization and control of bleeding.
A B
C D
Figures 3A to D Surgical techniques of endodiathermy for management of

intraoperative bleeding. (A) Dissection/segmentation of proliferative tissue in
proliferative diabetic retinopathy using 23-gauge vitrectomy probe, 5,000 cuts/
minute, aspiration of 200 mm Hg and 30 mm Hg of infusion pressure; (B) Initial
stage of endodiathermy in bleeding sites of proliferative diabetic retinopathy
using the diathermy device and the vitreous cutter probe for aspiration; (C) Final
stage of endodiathermy in bleeding sites of proliferative diabetic retinopathy using
the diathermy device and the vitreous cutter probe for aspiration; (D) Panretinal
endophotocoagulation at the final step of proliferative diabetic retinopathy using
a flexible/extendable laser probe to avoid the lens touch
325
Endodiathermy should be avoided at the fovea as well as over the optic
nerve and papilomacular bundle (Figs 4A to D). Caution about excessive
endodiathermy is very important because it can also result in retinal tears
or shortening; in eyes with previous intravitreal anti-VEGF injection, the
necessity of excessive endodiathermy is low (Figs 4A to C). At the end of the
surgical procedure, fluid-air exchange and intravitreal air or gas injection may
be performed to avoid bleeding (Fig. 4D). Elevated disk neovascularization
must be treated very carefully with low energy and maximum distance from
optic nerve surface to prevent damage to nerve fiber layer and vascular supply.
Laser Photocoagulation
Laser energy absorbed by the hemoglobin in the bleeding vessel can induce
thermal denaturation of proteins followed by hemostasis, which may be
performed under air following a fluid-air exchange to aid in the bleeding
A B
C D
Figures 4A to D Intraoperative bleeding control in proliferative diabetic

retinopathy using high intraocular pressure and no endodiathermy 3 days following
1.25 mg of intravitreal bevacizumab injection. (A) Initial phase of posterior hyaloid
detachment using the vitrectomy probe. The hyaloid is extremely thick and adherent
and no bleeding is observed. No additional endodiathermy was necessary; (B)
Advanced phase of posterior hyaloid detachment in the same case. No bleeding
was detected and no additional endodiathermy was needed; (C) Final surgical step
of vitreous base removal to avoid anterior proliferation of proliferative diabetic
retinopathy in the same case. Minimal bleeding is observed which was controlled by
raising the intraocular pressure for 1–3 minutes. No endodiathermy was necessary;
(D) Final aspect of eye at the end of the surgical procedure in the same case after
intravitreal air injection
326
control.23-25 This may have similar effect to intraocular diathermy. Laser could
be initiated using power of 200 mW and exposure time at 200 milliseconds.
Delivery should be applied to flat areas and not under direct contact. Laser
photocoagulation may be also useful for minimal amount of active bleeding
around the attached retina (Figs 5A to D).23-25
Combination of Techniques
Alternative instruments with coupled aspiration could be useful in cases
of active bleeding. Those aspirating laser probes have practical ability to
improve visualization and make local hemostasis without the need to exchange
instruments.
Nowadays, the combination of techniques for bleeding control and
especially the preoperative injection of VEGF inhibitors 3 days before the
PPV allows the vitreoretinal surgeon to deal with complex cases (Figs 5 to 7).
A B
C D
Figures 5A to D Intraoperative bleeding control in proliferative diabetic retinopathy

using several surgical techniques 3 days following 1.25 mg of intravitreal bevacizumab
injection and the use of combination of techniques for hemostasis. (A) Complex
tractional retinal detachment in a 26-year-old patient; (B) Bimanual dissection and
segmentation of proliferative membranes in proliferative diabetic retinopathy following
the phacoemulsification/intraocular lens implantation under high intraocular pressure
values. Minimal bleeding is observed following previous bevacizumab injection; (C)
Fluid-air exchange to reattach the retina and to minimize the bleeding; (D) Panretinal
endophotocoagulation after vitreous base removal to avoid anterior proliferation of
proliferative diabetic retinopathy followed by silicone oil injection
327
A B
C D
Figures 6A to D Preoperative and postoperative images from eye submitted to

intravitreal injection of 1.25 mg of bevacizumab 3 days before the vitrectomy in
diabetic tractional retinal detachment. (A) Fluorescein angiogram showing leakage
of vessels in macula; (B) Fluorescein angiogram showing leakage in mid-periphery;
(C) Infrared image at the 7th postoperative day showing no residual blood at the
vitreous cavity. Best corrected visual acuity improved from count fingers at 1 meter
to 20/40; (D) Fluorescein angiogram at the 7th postoperative day showing no vitreous
bleeding and minimal residual leakage nasal to the optic disk/arcades
A B C
Figures 7A to C Postoperative images from eye submitted to intravitreal injection of

1.25 mg of bevacizumab followed by phacovitrectomy in the left eye. Best corrected
visual acuity improved from hand motion to 20/30. (A) Postoperative infrared image
of the left eye at the 30th postoperative day. No residual blood/vitreous is observed;
(B) Postoperative composite infrared image showing similar findings; (C) Fluorescein
angiogram showing no leakage and no active neovascularization
328
Conclusion
Intraoperative hemorrhage is frequently observed during PPV in PDR.
Vitreoretinal surgeons may be aware regarding the need of preoperative control
of systemic disease or risk conditions of intraocular bleeding as well as the
choice of surgical tools and techniques that can prevent/treat the intraoperative
bleeding during PPV in PDR.
The intravitreal injection of 1.25 mg of bevacizumab or 0.5 mg of
ranibizumab should be performed around 3 days before all PPV in PDR; this
technique decreases the intraoperative bleeding in PDR, optimizing the surgical
results. Surgeons must be aware regarding the possibility of worsening previous
TRD in complex cases of PDR.
References
1. de Oliveira Dias JR, Rodrigues EB, Maia M, et al. Cytokines in neovascular age-
related macular degeneration: fundamentals of targeted combination therapy. Br
J Ophthalmol. 2011;95(12):1631-7.
2. Arevalo JF. En bloc perfluorodissection for tractional retinal detachment in
proliferative diabetic retinopathy. Ophthalmology. 2008;115(6):e21-5.
3. Rice TA, Michels RG, Rice EF. Vitrectomy for diabetic traction retinal detachment
involving the macula. Am J Ophthalmol. 1983;95(1):22-33.
4. Fong DS, Ferris FL, Davis MD, et al. Causes of severe visual loss in the early
treatment diabetic retinopathy study: ETDRS report no. 24. Early Treatment Diabetic
Retinopathy Study Research Group. Am J Ophthalmol. 1999;127(2):137-41.
5. Ho T, Smiddy WE, Flynn HW. Vitrectomy in the management of diabetic eye
disease. Surv Ophthalmol. 1992;37(3):190-202.
6. Aaberg TM, Abrams GW. Changing indications and techniques for vitrectomy
in management of complications of diabetic retinopathy. Ophthalmology.
1987;94(7):775-9.
7. Avery RL, Pearlman J, Pieramici DJ, et al. Intravitreal bevacizumab (Avastin) in the
treatment of proliferative diabetic retinopathy. Ophthalmology. 2006;113(10):1695.
e1-15.
8. Chen E, Park CH. Use of intravitreal bevacizumab as a preoperative adjunct for
tractional retinal detachment repair in severe proliferative diabetic retinopathy.
Retina. 2006;26(6):699-700.
9. da R Lucena, Ribeiro JA, Costa RA, et al. Intraoperative bleeding during vitrectomy
for diabetic tractional retinal detachment with versus without preoperative
intravitreal bevacizumab (IBeTra Study). Br J Ophthalmol. 2009;93(5):688-91.
10. Ishikawa K, Honda S, Tsukahara Y, et al. Preferable use of intravitreal bevacizumab
as a pretreatment of vitrectomy for severe proliferative diabetic retinopathy. Eye
(Lond). 2009;23(1):108-11.
11. Arevalo JF, Maia M, Flynn HW, et al. Tractional retinal detachment following
intravitreal bevacizumab (Avastin) in patients with severe proliferative diabetic
retinopathy. Br J Ophthalmol. 2008;92(2), 213-6.
329
12. Abdelhakim MA, Macky TA, Mansour KA, et al. Bevacizumab (Avastin) as
an adjunct to vitrectomy in the management of severe proliferative diabetic
retinopathy: a prospective case series. Ophthalmic Res. 2011;45(1):23-30.
13. Hattori T, Shimada H, Nakashizuka H, et al. Dose of intravitreal bevacizumab
(Avastin) used as preoperative adjunct therapy for proliferative diabetic retinopathy.
Retina. 2010;30(5):761-4.
14. Zhao LQ, Zhu H, Zhao PQ, et al. A systematic review and meta-analysis of clinical
outcomes of vitrectomy with or without intravitreal bevacizumab pretreatment for
severe diabetic retinopathy. Br J Ophthalmol. 2011;95(9):1216-22.
15. CATT Research Group, Martin DF, Maguire MG, et al. Ranibizumab and
bevacizumab for neovascular age-related macular degeneration. N Engl J
Med. 2011;364(20):1897-908.
16. Wu L, Martínez-Castellanos MA, Quiroz-Mercado H, et al. Twelve-month
safety of intravitreal injections of bevacizumab (Avastin): results of the Pan-
American Collaborative Retina Study Group (PACORES). Graefes Arch Clin
Exp Ophthalmol. 2008;246(1):81-7.
17. Ribeiro JA, Messias A, de Almeida FP, et al. The effect of intravitreal ranibizumab
on intraoperative bleeding during pars plana vitrectomy for diabetic traction retinal
detachment. Br J Ophthalmol. 2011;95(9):1337-9.
18. Sanders D, Peyman GA, Fishman G, et al. The toxicity of intravitreal whole
blood and hemoglobin. Albrecht Von Graefes Arch Klin Exp Ophthalmol.
1975;197(3):255-67.
19. Ehrenberg M, Thresher RJ, Machemer R. Vitreous hemorrhage nontoxic to retina
as a stimulator of glial and fibrous proliferation. Am J Ophthalmol. 1984;97(5):611-
26.
20. de Bustros S. Intraoperative control of hemorrhage in penetrating ocular injuries.
Retina. 1990;10 Suppl 1:S55-8.
21. Ambler JS, Meyers SM. Management of intraretinal metallic foreign bodies without
retinopexy in the absence of retinal detachment. Ophthalmology. 1991;98(3):391-4.
22. Chou F, Kertes PJ. Chapter 23: Control of intraocular hemorrhage during
vitrectomy. In: Peyman GA, Meffert SA, Conway MD (Eds). Vitreoretinal Surgical
Techniques, 2nd edition. Informa Healthcare; 2007. p. 213.
23. Peyman GA, D’Amico DJ, Alturki WA. An endolaser probe with aspiration
capability. Arch Ophthalmol. 1992;110(5):718.
24. Chang S. Multifunction endolaser probe. Am J Ophthalmol. 1992;114(5):648-9.
25. Charles S, Chang S, McCuen BW. New techniques for hemostasis during diabetic
vitrectomy. Retina. 2003;23(1):120-2.
26. Mason JO, Gupta SR, Compton CJ, et al. Comparison of hemorrhagic complications
of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group.
Ophthalmology. 2011;118(3):543-7.
27. Narendran N, Williamson TH. The effects of aspirin and warfarin therapy on
haemorrhage in vitreoretinal surgery. Acta Ophthalmol Scand. 2003;81(1):38-40.
28. Chandra A, Jazayeri F, Williamson TH. Warfarin in vitreoretinal surgery: a case
controlled series. Br J Ophthalmol. 2011;95(7):976-8.
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29. Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal
30. Fu AD, McDonald HR, Williams DF, et al. Anticoagulation with warfarin in
vitreoretinal surgery. Retina. 2007;27(3):290-5.
31. Dayani PN, Grand MG. Maintenance of warfarin anticoagulation for patients
undergoing vitreoretinal surgery. Arch Ophthalmol. 2006;124(11):1558-65.
32. Brown JS, Mahmoud TH. Anticoagulation and clinically significant postoperative
vitreous hemorrhage in diabetic vitrectomy. Retina. 2011;31(10):1983-7.
33. Ishikawa K, Honda S, Tsukahara Y, et al. Preferable use of intravitreal bevacizumab
as a pretreatment of vitrectomy for severe proliferative diabetic retinopathy. Eye
(Lond). 2009;23(1):108-11.
34. Arevalo JF, Sanchez JG, Saldarriaga L, et al. Retinal detachment after bevacizumab.
Ophthalmology. 2011;118(11):2304.e3-7.
35. Heyworth P, Bourke R, Moore C, et al. The systemic absorption of adrenaline from
posterior segment infusion during vitreoretinal surgery. Eye (Lond). 1998;12(Pt
6):949-52.
36. O’Brien DM, Farmer SG, Kalina RE, et al. Acute macular neuroretinopathy
following intravenous sympathomimetics. Retina.1989;9(4):281-6.
37. Desai UR, Sudhamathi K, Natarajan S. Intravenous epinephrine and acute macular
neuroretinopathy. Arch Ophthalmol. 1993;111:1026-7.
38. Moreira Júnior CA, Uscocovich CE, Moreira AT. Experimental studies
with perfluoro-octane for hemostasis during vitreoretinal surgery. Retina.
1997;17(6):530-4.
chapter 16
Use of Sustained Drug Release

Implants in Vitrectomized Eyes
Jose Maria Ruiz-Moreno, Javier A Montero
INTRODUCTION
When faced with a patient with macular edema, the first choice therapeutic
option is the intravitreal injection of an antiangiogenic or steroid drug. However,
in a vitrectomized patient, the practical lack of vitreous gel and its replacement
with aqueous humor means a loss of the reservoir capacity of the vitreous
cavity. In turn, this will condition the efficacy of such drugs by modifying
their pharmacokinetics.
This situation normally arises in diabetic patients with diabetic macular
edema (DME) who have undergone prior vitrectomy due to proliferative
diabetic retinopathy (PDR), although it may also occur in patients with cystoid
macular edema following pars plana vitrectomy (PPV) due to a cause other
than diabetic retinopathy. Patients with retinal central vein or branch occlusion,
as a result of radial optic neurotomy surgery in the former case or dissection
of the adventitia in the latter, may also present macular edema. In addition,
patients who have undergone PPV for another retinal disease and then develop
the neovascular form of age-related macular degeneration (AMD) may also be
candidates for intravitreal antiangiogenic treatment.
Notwithstanding, as mentioned earlier the most common situation we are
likely to find are individuals with PDR who have undergone PPV for persistent
vitreous hemorrhage and later present DME requiring intravitreal treatment,
as in the clinical case described at the end of this chapter.
To date, all double-blind, controlled multicenter trials on the intravitreal use
of antivascular endothelial growth factor (VEGF) agents have been conducted
in nonvitrectomized eyes.1-5 Accordingly, the real efficacy of these drugs in
vitrectomized eyes remains unknown. These eyes show both structural and
332
anatomical differences along with varying drug kinetics due to the lack of
vitreous gel.
What has been established, however, is that surgery in the vitrectomized eye
carries a higher risk of complications than in nonvitrectomized eyes.6 However,
no study has addressed the issue of possible iatrogenic tears induced in the
peripheral retina of vitrectomized eyes by intravitreal injections, so its incidence
is so far unknown. Since the anterior chamber is deeper, displacements of the
natural lens occur and there is greater zonule weakness. This occurs because of
the lack of vitreous support and leads to an increased risk of retinal detachment.6
In addition, in an eye without vitreous support, intravitreal injection could
induce possible modifications to the zonula or crystalline lens.
In second place, we should consider the changes in the pharmacokinetics of
intravitreally administered drugs induced by PPV. The removal of the vitreous
gel and its replacement with aqueous humor is beneficial during the course of
diabetic retinopathy, since the oxygen supply to the retina is improved and toxic
products are more rapidly eliminated. This improvement in vitreous clearance
reduces macular edema and neovascularization.7 The improved vitreous
clearance in eyes undergoing PPV has also been linked to the elimination
of VEGF.8 The authors of this last study, Lee et al observed that following
intravitreal VEGF165 injections in rabbits, the half-life of VEGF was tenfold
greater in vitrectomized eyes compared to nonvitrectomized eyes.8
In an experimental study performed in macaque monkeys, it was shown
that the half-life of intravitreally-injected bevacizumab was reduced by 60%
in eyes subjected to PPV compared to nonvitrectomized eyes. Similarly,
the reduction in the aqueous humor concentration of VEGF induced by the
intravitreal injection of bevacizumab lasted less time in vitrectomized versus
nonvitrectomized eyes.9
In human clinical practice, the efficacy of anti-VEGF drugs has been
examined in eyes subjected to PPV although results have been contradictory
and have depended on the disease treated. Thus, Metha et al10 retrospectively
analyzed 60 eyes in which DME was treated by intravitreal bevacizumab and
noted worse visual acuity and a diminished reduction in macular thickness in
PPV-eyes than nonvitrectomized eyes (P = 0.002 and P = 0.028, respectively).
In another retrospective, noncomparative intervention study, visual acuity
and foveal thickness were examined in 11 eyes of 10 patients with persistent
DME following PPV who were treated with three monthly intravitreal
bevacizumab injections of 1.25 mg/0.05 ml. Central foveal thickness was
408±77 mm at baseline, 453±97 mm 3 months after treatment and 454±101
mm at 6 months (P = 0.172). Mean visual acuity was 59±15 (20/80). Early
Treatment Diabetic Retinopathy Study (ETDRS) letters at baseline, 59±16
(20/80) at 3 months and 57±15 (20/80) at 6 months (P = 0.398). The authors
concluded that no changes were produced in visual acuity or foveal thickness
in the short-term attributable to intravitreal bevacizumab in eyes undergoing
PPV and removal of the internal limiting membrane.11
Chapter 16  Use of Sustained Drug Release Implants in Vitrectomized Eyes
333
In yet another study, Connor found that intravitreal ranibizumab was
effective in PPV eyes for the treatment of exudative AMD. In this small
noncomparative retrospective study, 10 patients undergoing PPV for different
reasons developed exudative AMD at a mean of 5.8 years after vitreous surgery.
Mean visual acuity improved from 20/182 to 20/74 following a mean number
of 5.6 intravitreal ranibizumab injections.12
These contrasting results should be interpreted with caution since they
were obtained in retrospective studies with a limited number of patients. The
drugs employed were different (bevacizumab versus ranibizumab), as were the
conditions treated (DME versus exudative AMD). It remains unclear whether
the increased clearance from the vitreous cavity of anti-VEGF drugs would
determine a need for shorter treatment intervals and if this would mean the
greater systemic absorption of these drugs with possible repercussions at the
general level.13
From a theoretical standpoint, the greater rate of elimination of the
anti-VEGF drug from the vitreous cavity would mean a lowered efficacy.
This problem could be resolved by the use of a sustained release implant to
achieve longer-lasting concentrations of the drug. The Ozurdex implant by
Allergan for the treatment of macular edema in vein occlusions14 achieves
the sustained release of dexamethasone and may therefore be useful in
vitrectomized eyes.
In the Champlain study,15 the authors assessed the safety and efficacy of
the dexamethasone implant for the treatment of DME in PPV eyes. In this
multicenter, prospective trial of 26 weeks’ duration, 55 patients received a
single injection of the 0.7 mg dexamethasone implant (Ozurdex, Allergan).
The main outcome measure was the change in OCT-determined central foveal
thickness produced at 26 weeks. Mean patient age was 62 years and mean
DME duration was 43 months. The mean central foveal reduction produced
was –156 μm (–190 to 122 μm) at 8 weeks (P < 0.001) and –39 μm (–65 to
13 μm) at 26 weeks (P = 0.004). Mean visual acuity was improved from 54.6
ETDRS letters, by 6 letters (3.9–8.1) at 8 weeks (P < 0.001) and by 3.0 letters
(0.1–6.0) at 26 weeks (P = 0.046). The main adverse effect was an increase in
intraocular pressure. The authors concluded that the sustained release implants
led to significantly improved vision and DME in vitrectomized eyes, with an
acceptable safety profile.15
According to the available information, the first choice for the treatment of
macular edema in eyes previously subjected to PPV would be the intravitreal
injection of a sustained release implant containing steroids. For PPV eyes
with exudative AMD, the real efficiency of intravitreal treatment with
antiangiogenics is yet to be determined. Future studies need to address the
possibility of treatment with antiangiogenic drugs alone or in combination with
the intravitreal injection of a sustained steroid releasing device.
334
CLINICAL CASE
A 58-year-old man with a history of diabetic retinopathy treated with panretinal
photocoagulation in both eyes presented with bilateral traction retinal
detachment and PPV was performed in both eyes. Two years later he underwent
cataract surgery and showed a best corrected visual acuity of 20/32 in the right
eye and 20/25 in the left eye. At 17 months postcataract surgery, the patient
suffered a loss of vision in the RE (20/160) due to the development of DME
(Figs 1A and B). Given his prior PPV, an intravitreal Ozurdex® implant was
used. One month later, normal foveal anatomy was recovered and the DME
had resolved (Figs 2A and B). At 3 months, visual acuity had improved to
20/40 and there was no DME (Fig. 3); the intravitreal implant was visible in
the inferior zone of the vitreous cavity (Fig. 4).
A B
Figures 1A and B (A) 58-year-old man, who had undergone prior vitrectomy and
cataract surgery, presenting with diabetic macular edema; (B) Appearance of the
fundus in the same patient
A B
Figures 2A and B (A) Normal foveal anatomy observed 1 month after

placement of the Ozurdex® implant; (B) Appearance of the fundus post-treatment
Chapter 16  Use of Sustained Drug Release Implants in Vitrectomized Eyes
335
Figure 3 Visual acuity was 20/40 at 3 months post-treatment. Note the absence
of macular edema
Figure 4 Vitreous implant visible in the inferior zone of the vitreous cavity
REFERENCES
1. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related
macular degeneration. N Engl J Med. 2006;355(14):1419-31.
2. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for
neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1432-44.
3. Elman MJ, Bressler NM, Qin H, et al. Expanded 2-year follow-up of ranibizumab
plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic
macular edema. Ophthalmology. 2011;118(4):609-14.
4. Brown DM, Campochiaro PA, Singh RP, et al. Ranibizumab for macular edema
following central retinal vein occlusion: six-month primary end point results of a
phase III study. Ophthalmology. 2010;117(6):1124-33.
5. Campochiaro PA, Heier JS, Feiner L, et al. Ranibizumab for macular edema
following branch retinal vein occlusion: six-month primary end point results of a
phase III study. Ophthalmology. 2010;117(6):1102-12.
6. Shousha MA, Yoo SH. Cataract surgery after pars plana vitrectomy. Curr Opin
Ophthalmol. 2010;21(1):45-9.
7. Stefánsson E. Physiology of vitreous surgery. Graefes Arch Clin Exp Ophthalmol.
2009;247(2):147-63.
8. Lee SS, Ghosn C, Yu Z, et al. Vitreous VEGF clearance is increased after
vitrectomy. Invest Ophthalmol Vis Sci. 2010;51(4):2135-8.
336
9. Kakinoki M, Miyake T, Sawada O, et al. The clearance of intravitreal bevacizumab
in vitrectomized macaque eyes. Poster presented at: Annual meeting of the
Association for Research in Vision and Ophthalmology; Fort Lauderdale, FL;May
5,2011.
10. Mehta S, Blinder KJ, Shah GK, et al. Intravitreal bevacizumab for the treatment
of refractory diabetic macular edema. Ophthalmic Surg Lasers Imaging.
2010;41(3):323-9.
11. Yanyali A, Aytug B, Horozoglu F, et al. Bevacizumab (Avastin) for diabetic macular
edema in previously vitrectomized eyes. Am J Ophthalmol. 2007;144(1):124-6.
12. Helzner J. Lucentis in vitrectomized eyes. Retinal Physician. 2010;7:8.
13. Waisbourd M, Loewestein A. Anti-VEGF therapy in vitrectomized eyes. Retinal
Physician. 2011;8:40-1.
14. Haller JA, Bandello F, Belfort R, et al. Randomized, sham-controlled trial of
dexamethasone intravitreal implant in patients with macular edema due to retinal
vein occlusion. Ophthalmology. 2010;117(6):1134-46.
15. Boyer DS, Faber D, Gupta S, et al. Dexamethasone intravitreal implant for treatment
of diabetic macular edema in vitrectomized patients. Retina. 2011;31(5):915-23.
chapter 17
Enzymatic Vitrectomy
Patricia Udaondo, David Salom, Salvador Garcia-Delpech, Manuel Díaz-Llopis
INTRODUCTION
The vitreous is an extracellular matrix of a spherical shape that fills the center
of the eye with a transparent gel that maintains clarity and protects the internal
structures from the eye, head and body movements.
In terms of the molecular components, 99% of the composition of the
vitreous is water and its main structure is formed by a matrix of hyaluronic
acid surrounded by collagen fibrils and little content cell that makes it ideal
for handling pharmacological manipulation.1
The relationship and ratio of its main components (water/collagen-
hyaluronic acid) is conferred to the vitreous structure; the central vitreous is
less dense than the cortex by presenting less collagen and hyaluronic acid and
more water. This difference becomes more apparent with age because of the
progression of the liquefaction of the central vitreous with time.2 The problem
is that these changes are not symmetric in the vitreous cavity which leads to a
liquefaction and an abnormal separation of the posterior vitreous. This process
is believed to be associated with the pathogenesis of various vitreoretinal
pathologies (concept of asynchronous aging by Sebag).3
In recent years, the importance of the vitreous and the vitreoretinal interface
in the pathogenesis of many diseases of the posterior pole has increased and
the treatment thereof, mainly with surgical modalities.
The side effects of the persistence of a strong adherence of the vitreous to
the retina (pathology of the vitreoretinal interface) and, on the other hand, the
benefits of its slow and controlled detachment from the retina are already well
known. Among the side effects we find:
Recurrence of retinal detachment with or without vitreoretinal proliferation
and appearance of retinal tears
Persistency, chronicity and exacerbation of macular edema (diabetic , vein
occlusion, uveitis, pseudophakic) (Fig. 1)
338
Vitreoretinal traction syndrome: macular holes or epiretinal membranes
among others (Figs 2 and 3)
Progression of retinal neovascularization, mainly in diabetic retinopathy
Higher risk of development or appearance of wet age-related macular
degeneration.
Figure 1 Optical coherence tomography image showing a large macular edema

refractory to intravitreal treatment. Note the epiretinal membrane associated and the
posterior hyaloid attached. Both are considered the cause of this diabetic macular edema
Figure 2 Optical coherence tomography showing an epiretinal membrane with

the posterior hyaloid detached
Figure 3 Vitreoretinal traction syndrome in optical coherence tomography

Chapter 17  Enzymatic Vitrectomy
339
CONCEPT OF ENZYMATIC VITRECTOMY
The enzymatic or pharmacological vitreolysis/vitrectomy is the therapy that
tries to break the vitreous structure in small particles and get its liquefaction to
weaken its retinal adhesion and finally obtain a subsequent complete and safe
detachment of the vitreous.4 It includes all the mechanical and biochemical
changes resulting from the pharmacological manipulation of the vitreous.
Over time and through various studies, it has been demonstrated that
the vitreous detachment is a dynamic process that involves many enzymatic
reactions; Trese encompasses all of these chemical and molecular changes in
the term vitreodynamics.5
METHODS AND MECHANISM OF ACTION

Although the concept of pharmacological vitrectomy is resuming force at
present it is not a new concept. A good example of this is the work done by
Professor Alió in the 1980s with the intravitreal injection of hyaluronidase.6
many substances have been tested with variable degrees of success, to
handle pharmacologically the vitreous. Among them we highlight:
Hyaluronidase: It is an enzyme which digests the proteoglycans. The
last commercial hyaluronidase that has been tested is the purified ovine
hyaluronidase (Vitrase®) that has demonstrated its effectiveness in the
management of vitreous hemorrhages by liquefying the vitreous but does
not detach the vitreous
Collagenases: They are a group of enzymes that degrade the collagen. There
are up to 18 types being the most important the collagenase II (C1764
Sigma, St. Louis, missouri) but its function is still unclear
microplasmin [Ocriplasmin ® (Thrombogenics Ltd, Dublin)]: It is a
recombinant human plasmin. The results of the trials in phase III related
to the treatment of macular holes already have been published and it has
demonstrated its effectiveness in the detachment of the vitreous7
Autologous plasmin purified or in its simplified form: It is a serum human
protease.
The main action of plasmin and microplasmin is to act or trigger the
fibrinolysis. Inside the eye it has a proteolytic activity against laminin and
fibronectin that are responsible for maintaining the adherence of the vitreous
to the surface of the retina; this is the reason why it is considered an inducing
agent of the posterior detachment of the vitreous.8 As mentioned previously, the
vitreous detachment also causes an increase of retinal oxygenation as well as the
modification of some molecules like cytokines and growth factors in the vitreous
cavity which could explain the anti-inflammatory and antiangiogenic action of
autologous plasmin and so its many indications among which we highlight:
Adjuvant of surgery: his best known indication. Radically reduces surgical
time in macular holes, retinopathy of prematurity and diabetic retinopathy9,10
(Fig. 4)
340
Vitreoretinal traction syndrome:11 Including epiretinal membranes and
macular holes (Figs 5 to 7)
Macular edema: diabetes, vein occlusion, uveitis, pseudophakic12-14 (Fig. 8).
Regarding the security profile of both autologous plasmin and microplasmin
is good, being less frequent the side effects associated with autologous
plasmin compared to microplasmin. It has been described, associated with
microplasmin, some cases of peripheral retinal tear and vitreous hemorrhage;
it is believed that those effects are dose dependent.7
Figure 4 Image of a patient with an epiretinal membrane. This patient was

treated with a single injection of autologous plasmin and pars plana vitrectomy.
The relevance of the case is that the membrane was not peeled but it was aspirated
during vitrectomy (Membrane lysis)
Figure 5 Optical coherence tomography image of a patient with an epiretinal

membrane before and after the treatment with three intravitreal injections of
autologous plasmin separated by 1 month. The only place where the membrane is
still attached is the optic nerve and the macula appears free
Chapter 17  Enzymatic Vitrectomy
341
Figures 6A and B (A) Another patient with an epiretinal membrane treated with
three injections of autologous plasmin; (B) The membrane has disappeared after
the therapy
Figure 7 Optical coherence tomography image corresponding to a patient with

vitreomacular traction treated with intravitreal autologous plasmin
Figure 8 Patient showing a refractory diabetic macular edema treated with

autologous plasmin. We can observe how the maximum edema is where the posterior
hyaloid is attached to the retina and how the edema improves when the hyaloid is
detached after the treatment
342
REFERENCES
1. Sebag J, Balazs EA. Morphology and ultrastructure of human vitreous fibers. Invest
Ophthalmol Vis Sci. 1989;30(8):1867-71.
2. Sebag J. Structure, function and age-related changes of the human vitreous. In:
Schepens CL, Neetens A. The vitreous and vitreoretinal interface. New York:
Springer-Verlag; 1987:20. p. 17.
3. Sebag J. Macromolecular structure of vitreous. Progr Polym Sci. 1998;23:415-46.
4. Gandorfer A. Pharmacologic vitreolysis. Dev Ophthalmol. 2007;39:149-56.
5. Quiram PA, Leverenz VR, Baker RM, et al. Microplasmin-induced posterior
vitreous detachment affects vitreous oxygen levels. Retina. 2007;27(8):1090-6.
6. Alió J, Sanchez A, Ludeña MD, et al. Vitreolisis enzimática: Estudio experimental de
un nuevo método no mecánico de vitrectomia. Arch Soc Esp Oftal. 1987;53:349-60.
7. de Smet MD, Gandorfer A, Stalmans P, et al. Microplasmin intravitreal
administration in patients with vitreomacular traction scheduled for vitrectomy:
the MIVI I trial. Ophthalmology. 2009;116(7):1349-55.
8. Li X, Shi X, Fan J. Posterior vitreous detachment with plasmin in the isolated
human eye. Graefes Arch Clin Exp Ophthalmol. 2002;240(1):56-62.
9. Sakuma T, Takana M, Inoue J, et al. Efficacy of autologous plasmin for idiopathic
macular hole surgery. Eur J Ophthalmol. 2005;15(6):787-94.
10. Williams JG, Trese MT, Williams GA, et al. Autologous plasmin enzyme in the
surgical management of diabetic retinopathy. Ophthalmology. 2001;108(10):1902-5.
11. díaz-Llopis m, Udaondo P, Cervera E, et al. Enzymatic vitrectomy by intravitreal
autologous plasmin injection as initial treatment for macular epiretinal membranes
and vitreomacular traction syndrome. Arch Soc Esp Oftalmol. 2009;84(2):91-100.
12. díaz-Llopis m, Udaondo P, García-delpech S, et al. Enzymatic vitrectomy by
intravitreal autologous plasmin injection, as initial treatment for diffuse diabetic
macular edema. Arch Soc Esp Oftalmol. 2008;83(2):77-84.
13. Diaz-Llopis M, Udaondo P, Arevalo F, et al. Intravitreal plasmin without associated
vitrectomy as a treatment for refractory diabetic macular edema. J Ocul Pharmacol
Ther. 2009;25(4):379-84.
14. Udaondo P, diaz-Llopis m, Garcia-delpech S, et al. Intravitreal plasmin without
vitrectomy for macular edema secondary to branch retinal vein occlusion. Arch
Ophthalmol. 2011;129(3):283-7.
chapter 18
Posterior Vitrectomy
Complications
Carme Guardia, Jaume Catalá, Jairo Hoyos-Chacón
INTRODUCTION
The advancement of surgical techniques has improved the outcome of surgery
in the treatment of vitreoretinal pathologies. Surgical results depend on multiple
factors and one of them is the ability of the surgeon to reach the objectives of
the surgery whether or not intraoperative and/or postoperative complications
exist. In this chapter we will focus on the description, and treatment of different
complications if they occur, and the analysis of how to avoid them.
INTRAOPERATIVE COMPLICATIONS
Sclerotomy Complications
Sclerotomies must be placed in the pars plana before the ora serrata. The
election of the correct placement of the sclerotomy at 3–3.5 mm in aphakic/
pseudophakic eyes and at 4 mm in phakic eyes, with a distance of about 160°
between the light probe and the vitreotome is fundamental to work easily
along different areas of the retina during vitrectomy and to have access to the
peripheral retina without crossing the instruments behind the crystalline lens.1 If
the sclerotomy is at 3 mm, we can access up to 6.5 mm from the opposite side
of the ora serrata without touching the crystalline lens. While, if the sclerotomy
is placed at 4 mm we can reach up to 3.1 mm. If the sclerotomies are placed
at 3 mm, we can move the instrument for 2.8 hours and reach the ora serrata
without touching the periphery of the crystalline lens, while if the sclerotomy
is at 4 mm from the limbus, the time span stretches to 3.8 hours.2
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Placement of the Infusion Cannula
The sclerotomy corresponding to the infusion cannula, is the first that must
be performed and we must take into account that in eyes with anterior
proliferative vitreoretinopathy (PVR), choroidal detachments, anterior
traumas or dense vitreous hemorrhage, the infusion cannula may be
incorrectly placed, and in the case of opening the passage of fluid without
having correctly checked that the cannula of infusion was inside the vitreous
cavity, can cause serious complications. To avoid them it is best to make sure
it is on vitreous chamber by direct observation illuminating it from outside
the eye with an intraocular light:
Uveal infusion: This happens when the infusion cannula does not get
through all the pigmented pars plana epithelium. While the vitrectomy is in
progress, the infusion in the suprachoroidal space increases, flattening of the
anterior chamber due to a forward shift of the vitreous and the ciliary body.
Early diagnosis and closing the infusion immediately are very important.
The main goals of the treatment are to restore the vitreous volume and try
to drain the suprachoroidal fluid. Remove the infusion cannula and connect
it to a 30-gauge needle that is introduced through the pars plana (if there
is enough room), through the limbus (in aphakics) or through the anterior
chamber even in phakics.3
Subretinal infusion: This can happen in eyes with retinal detachment
(RD) associated with the pars plana when the infusion cannula does not
get through completely. This complication must be suspected when RD
increases at a fast rate during the course of the vitrectomy.3 When this
situation arises, the infusion must be closed immediately, and we must try
to restore the vitreous volume with the infusion line connected to a needle,
as in the former case. After this, try again to pierce completely the pars
plana with a 6 mm cannula, or try to place the infusion through another
sclerotomy in a new position.
These two complications should be prevented by making sure the infusion
cannula extremity is always in the vitreous cavity before opening the passage
of fluid (Fig. 1). When in doubt, if we see some tissue on the extremity of
the cannula, we can enter through a sclerotomy with a 20-gauge needle with
infusion while the assistant lights with a light pipe through the pupil. Indenting
the cannula, we can cut the tissue that obstructs the extremity avoiding a
crystalline lens injury in phakic patients.4 Another option is to use a longer
(6 mm) infusion cannula from the beginning in those cases where complications
in reaching the vitreous cavity are foreseen. In these cases, we must take care
not to produce an anterior deflexion, which could cause a touch to the crystalline
lens, or a posterior deflexion, which could cause a peripheric iatrogenic break
in the infusion meridian, especially if we have placed a circumferential band
and we are working with an air-filled eye.
Chapter 18  Posterior Vitrectomy Complications
345
Vitreous or Retinal Incarceration
Vitreous incarceration in sclerotomy is inevitable and is a frequent cause of
peripheric iatrogenic breaks. In diabetic patients the incarcerated vitreous can
offer support to neovascular proliferation which gives rise to repetitive vitreous
hemorrhages in the late postsurgical period. We must try to minimize this
complication by separating the vitreous from the entry sclerotomies, attempting
not to remove the instruments while we are working at high pressure and
extracting the incarcerated vitreous with the vitreotome.
The retinal incarceration at the sclerotomy level is a serious complication
which follows vitreous incarceration in eyes with very bullous RDs. Treatment
must try to decrease retinal prolapse estimating the performance of air
exchange.5
If the prolapse does not decrease, we must try with a blunt instrument, or an
injection of viscoelastic agents while injecting perfluorocarbon liquid (PFCL)
into the posterior pole. This complication can be avoided by introducing and
removing the instruments carefully, slowing or even closing the passage of
infusion before exiting the eye and stabilizing the retina with PFCL if there is
significantly bullous RD.3
Hemorrhage
Sclerotomies can cause bleeding not only during surgery but also during the
postoperative period. In order to avoid this, it is very important to perform a
correct diathermy of the superficial blood vessels and to prevent hypotony
through the end of the surgical procedure. If bleeding occurs, a diathermy with
conic tip can help us to stop it.
The introduction of a sharp instrument must be done carefully so as to
avoid enlarging the sclerotomy and the possibility of a secondary hemorrhage
(Fig. 2).
Figure 1 Maneuver to check that the infusion cannula is inside the vitreous cavity:
with the microscope light off, indent the infusion while placing the light probe in
limbus until the metallic shine of the cannula tip can be seen
346
Figure 2 Sclerotomy enlargement introducing a barbed microvitreoretinal blade

used as a pick
Retinal Tears
This subject will be covered in part 3, which covers anterior iatrogenic retinal
tears.
VISUALIZATION PROBLEMS
Visualization problems are very frequent and the prevention and proper
treatment can avoid more complications associated with bad visualization.
Corneal Complications
The most frequent intraoperative corneal complications are epithelial defects,
epithelial corneal edema and Descemet membrane-endothelium folds. They
can appear in any patient but are more common in diabetics, who can often
have fewer adherences between the corneal epithelium and the Bowman’s
membrane. For this reason, diabetic patient’s cornea is very vulnerable to trauma
and moisturization changes (Figs 3A and B). In these patients, prevention is
possible with the use of topical autologous serum 1 week before vitrectomy.6
The corneal epithelium must be protected from desiccation and trauma
during the course of the entire surgical procedure as well as during preparation
with 2% methylcellulose.
Epithelial defects can be caused by small traumas as well as by extended
traumas such as contact lens use. In some rare occasions they are so great as
to impair fundus visualization.
Epithelial corneal edema appears when ocular pressure remains elevated
and is related to surgery length. A polished phacoemulsification and lensectomy
technique is important, reducing the time and duration of ultrasounds. We
must try to improve corneal conditions by diminishing infusion pressure and
using corneal dehydration maneuvers with absorbent sponges (Fig. 4). The last
resource is corneal de-epithelialization.
347
A B
Figures 3A and B (A) Epithelial bullae during phacoemulsification prior to

posterior vitrectomy in a diabetic patient with vitreous hemorrhage; (B) Acceptable
visualization is maintained during surgery
Figure 4 Corneal dehydration maneuver with absorbent sponges to improve

visualization through the edematous epithelium
Descemet membrane-endothelium folds occur in aphakic patients when the

air exchange is performed or when there are variations in ocular tension and
excessive intraocular maneuvers. Descemet membrane folds will disappear
if methylcellulose is injected via pars plana into the anterior chamber while
working in an air-filled eye.
Myosis
Wide-angle viewing systems have decreased the need to work with large pupils.
In cases where it is necessary to work comfortably on the vitreous base we will
use the systems described in chapter 5.
To maintain mydriasis during surgery it may be diluted with adrenaline
1:1,000 in the infusion serum. Myosis can occur intraoperatively as a
consequence of long surgical procedures, manipulations of the iris during
combined anterior segment surgeries, and during situations that generate
episodes of hypotony. If the myosis persists and makes surgical procedure
difficult we can resort to different pupil dilatation techniques according to the
patient being phakic, aphakic or pseudophakic (Table 1).
348
TABLE 1
Pupil dilatation techniques
Phakic • Viscoelastics
• Translimbal iris hooks (6 a)
Aphakic • Iris hooks
• Iris sutures (6 b)
• Sphincterotomies and iridectomies
Pseudophakic • Viscoelastics
• Iris hooks
• Iris sutures
A B
Figures 5A and B Mydriasis obtained by retractors and iris sutures
In current practice, if sodium hyaluronate is not enough to achieve an

adequate mydriasis, we should resort to iris hooks, and only in the case that
these hooks are unavailable, we should consider other options (Figs 5A and B).
The use of iris hooks can cause tears in the sphincter resulting in permanent
mydriasis and small hemorrhages. Hooks can become loose if they have been
reused and some infusion may leak through the paracentesis.
Cataract
Cataracts can cause visualization problems which affect the safety of the
surgical procedure. Although wide visualization field systems help to improve
visualization, when a patient who needs vitreoretinal surgery has a cataract, it
is currently preferred to perform a combined surgical procedure to reduce the
number of surgeries and accelerate visual rehabilitation. On the other hand, it
is well known that posterior vitrectomy favors the progression of pre-existent
opacities.
Various options are currently available when a combined cataract and
posterior vitrectomy surgery is required:
Lensectomy
Phacoemulsification and intraocular lens (IOL) in the capsular bag
Lensectomy preserving the anterior capsule +/- IOL in the sulcus.
349
In our opinion, the preferred technique is phacoemulsification previous to
posterior vitrectomy using the technique described in chapter 5, pointing out
that, in order to avoid complications, a good surgical technique is critical to
prevent iris manipulations which favor myosis and corneal alterations. This
technique also offers the advantage of being able to decide when to implant
the lens, having the lens inside the sac and preserving the integrity of the
zonulocapsular barrier.
If lensectomy via pars plana is indicated, we will have an advantage in
visualization, but visual rehabilitation will be more difficult, and there is the
potential risk of luxation of crystalline lens fragments into the vitreous cavity.
Lensectomy preserving the anterior capsule or Blankenship technique7,8
can be used in complex vitreoretinal pathologies and offers the advantages of
preventing gas or silicone oil related intra- and postoperative complications,
allowing to decide whether or not the lens should be implanted, and maintaining
the normal appearance of the iris. It must be considered that there is also a
risk of luxation of crystalline lens fragments and the IOL must be implanted
in sulcus. This surgical technique consists of fragmenting the crystalline lens
via pars plana and polishing the posterior surface epithelium of the anterior
capsule. After this, continue with the vitrectomy and peripheral retina work. At
the end of the surgery it must be decided whether or not the lens is implanted
in sulcus. If we are interested in preserving the integrity of the zonulocapsular
barrier, we can postpone the capsulotomy; otherwise, perform a capsulotomy
via pars plana with the vitreotome.
In rare occasions, a very hard cataract must be extracted through a limbic
incision performing an extracapsular surgery. In these cases, we must try not
to manipulate the iris, check that the surgical incision is tight by increasing
infusion pressure, and thereby avoid leaks and complications during the
vitrectomy. It will also be useful to avoid the use of rings sutured either by
noncontact visualization techniques or with silicone rings.
Injury to the crystalline lens during vitrectomy generally occurs during
maneuvers to separate the peripheric vitreous from the opposite side. To avoid
this injury, it is fundamental to choose correctly the distance of the sclerotomies
from the limbus and the sclerotomy meridian (2–10 hours) 160° apart2 and to
use peripheral indentation. Changing hands of the vitreotome enable access to
the vitreous base without having to cross the instruments behind the crystalline
lens. Curved instruments, such as laser probes and vitreotomes, allow access to
the peripheral retina with a lesser chance than straight instruments of injuring
the crystalline lens.9
If major injury is produced during the vitrectomy, normally a cataract
is rapidly developed which opacifies the entire crystalline lens within a few
days. In these cases, the best option is to implant the IOL in the same surgical
intervention, performing a Blankenship lensectomy. If there is a slight touch and
the posterior crystalline capsule has not been torn, we can see the evolution of
the opacity (Fig. 6). Crystalline lenses in young people present a great recovery
capacity, but in older patients, the cataract will tend to progress.
350
Figure 6 Vitreotome cutter lens injury that develops cataract in the

postoperative period
Intraocular Lens Complications

The most common complication associated with IOLs during vitrectomy
is difficult visualization, especially when working in an air-filled eye. The
desiccation produced in the posterior capsule reduces visibility and improves
by injecting a small amount of methylcellulose through the pars plana.
For deposits of various materials (anti-inflammatories, hematics, and fibrin)
or air bubbles that limit vision, we should attempt cleansing and suction through
a limbic paracentesis, or injecting viscoelastic.
When silicone oil comes into contact with a silicone IOL, the silicone oil
irreversibly coats the lens and obscures both the view in and the view out. The
silicone coating is very adherent and cannot be dislodged by instruments or
viscoelastics. When the use of silicone oil is contemplated in an eye with a
silicone IOL and posterior capsulotomy, we must either consider removing the
lens or using a long-acting gas instead.
Intraocular lens can get shifted or dislocated if there is insufficient support
during manipulations of the eye while implanting a scleral procedure, especially
if the eye is filled with air or is hypotonic. If the IOL cannot be repositioned,
it is important to complete the peripheral vitrectomy before manipulating it
so as to minimize traction over the vitreous gel which could cause peripheral
tears. Then, it should be assessed, in each case, whether it is better to explant
the lens or to anchor it with a fixation suture.
Hemorrhage
The intraoperative bleeding is a common problem during vitreoretinal
surgery, but fortunately, in most cases it is solved with simple maneuvers.10
Hemorrhages are especially frequent during proliferative diabetic retinopathy
(PDR) vitrectomies and depend on the degree of the proliferation’s activity
extension as well as the presence of neovessels in the iris (Fig. 7). Other factors
that have an influence on bleeding and that must be previously assessed are the
patient’s vascular state, the presence of arterial hypertension, nephropathy and
351
Figure 7 Bleeding of iris neovessels can form a thin hematic layer which makes
visualization difficult
the diabetes mellitus control. Patients with previous panphotocoagulation will

tend to bleed less. The use of anti-VEGF injections before vitrectomy reduces
the bleed, although the risk of tractional RD increases.11
Hemorrhage can occur as a result of retinal tears and vascular avulsions,
which can be prevented with careful surgical technique.
Choroidal hemorrhage is a rare but particularly serious complication, and
some of the risk factors associated with it are: elderly patients, increase of
preoperative eye pressure, RD, aphakia or pseudophakia, and the association of
a scleral procedure.12 It can be said that there are no untreatable hemorrhages.
We must try to block blood from going under the retina.
The initial treatment consists of increasing infusion pressure until the
bleeding stops. We must take into account that this strategy will only be effective
if the system is well sealed either by the instruments or with plugs. Removing
the instruments while eye pressure is high will result in vitreous incarceration,
possible retinal tears and even retinal incarceration if the retina is detached.
Another possibility is to raise the level of the infusion ampoule, but we must
know how to calculate the pressure we are putting the eye under (see chapter 4).
After a few minutes, the eye pressure must be lowered, and if bleeding
resumes, we can try to treat the point of bleeding (generally neovessels) by
using a conic tip diathermy, backflush diathermy systems or tissue manipulator.
There are illuminating laser probes that can be used to coagulate precisely a
bleeding point while blood is vacuumed with a suction line or vitreotome.13
Laser probes with aspiration capability are useful in cases of active bleeding.14
If bleeding persists, direct pressure on the bleeding point should be
attempted with a silicone tip suction cannula or other instruments designed to
stop the hemorrhage of the injured vessel and achieve clot formation.15
If the vitreous cavity is filled with blood, performing air exchange will
concentrate all the blood in the posterior pole, allowing its suction and
improving visualization of the bleeding point, and enabling work on the same.
When hemostasis is reached, infusion pressure is gradually diminished and the
passage of fluid is opened.
352
Bovine thrombin, a powerful hemostatic agent, combined with the infusion
fluid, accelerates the process of clotting. Its use is limited by the inflammation
it produces, but can be prescribed in cases of profuse and difficult control
bleeding.16,17
Viscodelamination is a useful surgical technique to ease dissection of very
vascularized proliferations in the treatment of diabetic retinopathy.18
Preoperative hemorrhage prophylaxis begins by assessing not only local
situations (such as iris neovessels, fibrovascular proliferations, etc.) but also
systemic ones, which can favor the hemorrhage, and by trying to improve them,
if it is possible. These norms are useful to follow during surgical procedure:
Avoid situations of prolonged eye hypotony which favor bleeding
In potentially bleeding situations, such as when segmenting very vascular
proliferations, increase eye pressure or treat prophylactically with diathermy
Use careful surgical technique to avoid iatrogeny, which can cause tears or
vascular avulsions that generate bleeding
Careful scleral surgery to avoid iatrogeny (scleral perforation during suture
placing). Adjust the band at the end of surgery
Correct diathermy of sclerotomies, at times a conic tip diathermy can be
useful.
Retinal Tears
Iatrogenic retinal tears19 are a frequent and serious complication of vitreoretinal
surgery, varying in incidence from 4–30%, depending on the type of indication.
If they are not diagnosed and treated correctly, they can result in RD with severe
diminution of visual acuity and require additional surgery.
Anterior Retinal Iatrogenic Tears

These are caused by the entry, and especially, the removal of instruments
from the eye. Any instrument can produce them, but in most cases, they are
generated by those with edges where the vitreous can get caught, such as
scissors (especially right-angle vertically cutting scissors) which generate a
pushing movement when entering, or a traction movement when withdrawn
on the posterior edge of the vitreous base that causes the tear. We will look for
these tears on the sclerectomy meridians and, most frequently, in the sclerotomy
of the dominant hand.19
Other less common mechanisms which can generate these kinds of tears
are: (a) external traction of the incarcerated vitreous in the sclerotomy with
tweezers, for example, when removing the sclerotomy plug; (b) direct injury or
cut with the vitreotome or other instruments; (c) hyaloid separation maneuvers
with peripheral vitreous traction; (d) internal traction of the peripheral vitreous
during, for example, the dissection of an adhered posterior hyaloid; (e) scleral
perforation during fixation sutures in case of combined scleral surgery.
353
Prevention is essential in order to avoid these kinds of tears:
Gently introduce the instrument through the sclerotomy and minimize
entries and removals
Visualize the entry of instruments, and in case of vitreous traction, proceed
to change the direction of entry
Clean the incarcerated vitreous with the vitreotome in sclerotomies. Avoid
tractions of the vitreous
Try not to work with eye pressures higher than 25–30 mm Hg which favor
vitreous incarceration
Always revise the entire peripheral retina with indentation before performing
air exchange and at the end of surgery in order to do an early diagnosis.
Treatment consists, first, of releasing vitreous tractions on the tear and
cleaning the vitreous incarcerated in sclerotomy, if present. Then perform
a retinopexy procedure, leaving a short-acting gas or air inside the eye, and
positioning the patient in the correct manner (Fig. 8). In case there is pathology
of the vitreous base, the association of a scleral indentation buckle would be
indicated.
Posterior Retinal Iatrogenic Tears

These can be produced by direct injury caused by the instruments or by
traction of the vitreous or membranes. They are frequent in delamination and
segmentation maneuvers on diabetic patients.20 They can also occur on the edge
of laser impacts and in areas of atrophic retina.
Prevention is performed by controlling the position of the instruments
during the entire procedure and avoiding traction over proliferations and
epicenters.
Figure 8 Anterior iatrogenic retinal tear during proliferative diabetic retinopathy

vitrectomy. We must specially take care to relieve all vitreous tractions arrow the tear
and isolate fibrovascular proliferations
354
In case of tears in diabetic patients, a total extraction of proliferative
tissue is required, followed by an exchange of liquid by air to accomplish the
reapplication of the retina, and finally laser application around the tear and
substitution for long-acting gas.
Retinopexy Complications
Endolaser
The endolaser is used to treat retinal tears and to perform panretinal
photocoagulations, and in certain occasions, to coagulate bleeding vessels.
Complications are related to very intensive treatments or direct trauma to the
retina by the probe. The risk of hemorrhage with injury to the Bruch’s membrane
(which produces a “popping” sound) diminishes using low power and long
exposure burns. We must employ the least intensity which can accomplish
the appropriate effect, changing parameters according to the degree of eye
pigmentation, especially if laser is performed in an air-or gas-filled eye, since
in these media the effects of the laser intensify. Avoid treating areas with retinal
hemorrhage, which absorb the laser’s energy.
Cryotherapy
This is the preferred method to treat small holes and to finish peripheral retina
ablation. The cryoprobe can be used as indentator during periphery revision
at the end of surgery.
Cryotherapy generates inflammation and dispersion of viable retinal pigment
epithelium (RPE) cells when there are retinal tears.21 These two elements
combined, if administered in excess, favor PVR not only in predisposed eyes
but also in those where no risk factors are present.
As a system of retinopexy, endophotocoagulation is generally preferred, but
in case of needing cryotherapy, we must know how to use it well: (a) limit to a
minimum the number and time of the applications, (b) avoid treating exposed
RPE areas, (c) avoid refreezing areas already treated, (d) avoid prophylactic
or diagnostic cryotherapy, and (e) wash postcryotherapy RPE dispersed cells
by performing an air-fluid exchange.
POSTOPERATIVE COMPLICATIONS
Corneal Complications
Epithelial defects are seldom very painful and heal quickly except in diabetic
patients and in previous corneal diseases22 (Fig. 9). While epithelial defects
heal, folds in the Descemet membrane or corneal edema can arise, which will
make fundus visualization difficult.
355
Figure 9 Postvitrectomy epithelial defect in a diabetic patient
Prevention starts using topic autologous serum in risk patients; in the

operation room, protecting the corneal epithelium from dehydration and from
trauma before and during the surgical procedure. Long surgeries and procedures
where much manipulation is performed will favor inflammation and will affect
corneal transparency. They are less frequent in noncontact lens viewing systems.
Epithelial defects heal with ocular occlusion and emollients. Some will
require the use of therapeutic contact lenses. If epithelialization of the defect
is delayed, the superficial layers of the stroma can infiltrate producing opacity.
Diffuse opacities such as bullous keratopathy or band keratopathy result from
damage to the corneal endothelium.
Ocular Hypertension and Glaucoma

An increase in eye pressure is relatively common after vitrectomy23 and numbers
greater than 30 mm Hg happen in 35% of cases in the 48 hours following a
vitrectomy via pars plana.24 Previous or intraoperative scleral buckle surgery,
panendophotocoagulation, the association of lensectomy and postoperative
development of fibrin membranes have been described as risk factors of
postoperative ocular hypertension.
Eyes with previous glaucoma have a greater tendency to elevate pressure,
since their drainage systems are compromised and their resistance to pressure
increase is lessened. For this reason, they must be treated more aggressively.
At evaluation time it is important to determine the state of the camerular
angle. If open-angle glaucoma is present, the causes can be: inflammation, the
presence of blood, silicone oil or gas in the anterior chamber, viscoelastics,
incorrect mixtures of gas and its expansion, or the presence of neovessels in
the angle.
Treatment involves aqueous humor and carbonic anhydrase production
inhibitors (by mouth or intramuscular) and anti-inflammatories. If the
intraocular pressure (IOP) is very high, an anterior chamber paracentesis may
be necessary or even a punctuation via pars plana with a 30-gauge needle to
extract some gas when there is bulging in the anterior iris or crystalline lens.
356
If the angle or the pupil is blocked by fibrin, an injection of 10–12 micrograms
of recombinant tissue plasminogen activator (r-TPA) in the anterior chamber
will dissolve the fibrin and improve ocular tension.
A late increment in IOP can be secondary to the administration of topic or
systemic corticosteroids, chronic inflammation or by ghost cells.
If the iridocorneal angle is closed, we will consider the gas or silicone oil
of the vitreous cavity as possible causes, or the mechanical effect of a very
indented scleral band. If tension is very elevated, we will resort to hyperosmotic
agents, topic corticosteroids and cycloplegics. We will insist on the correct
prone position, evaluate iridectomy permeability and if it is necessary, evacuate
some gas or oil to resolve the complication.
If the above-mentioned problems are not present, aggressive treatment with
topic or oral hypotensors and anti-inflammatories will decrease tension quickly.
Iris neovascularization and camerular angle in diabetics or patients
with retinal vascular occlusions can exist before vitreous surgery. Previous
intraoperative photocoagulation and intraoperative endophotocoagulation
reduce the incidence of neovessels in the iris. Nevertheless, sudden neovascular
glaucoma can be present, and the degree of retinal ablation must be revised
along with the assessment of the peripheral cryotherapy treatment. The presence
of a rhegmatogenous RD in the vitrectomy postsurgical period in a patient with
PDR usually evolves in neovascularization of the iris and the phthisis bulbi, if
reattachment of the retina is not accomplished.
When the neovascular process is stabilized and there is a secondary
glaucoma, the options for treatment must be evaluated.
It is important to warn patients who carry intraocular gas that atmospheric
pressure variations will have an influence on the size of the gas bubble.
If they fly or rapidly rise by more than 1,000 or 1,500 meters of altitude
from the place where the gas was injected, the increment in volume can cause
a pressure increase and severe eye pain. It is recommended to avoid flying
until the gas bubble reduces to 10% its size and in case of necessary traveling
to high altitude places, the ascent must be gradual to allow the eye to adapt to
the increment in size of the gas bubble.25,26
The hyperbaric pressure condition produced during scuba diving practice
or during hyperbaric oxygen treatments brings about a diminution of gas
volume and ocular hypotony.27 The eye tries to compensate by producing
aqueous humor, and the return to normal atmospheric pressure will generate
an expansion of the gas bubble, causing important increments in eye
pressure.
Postvitrectomy glaucoma mechanisms are:
Hemorrhage
Inflammation (fibrinoid reaction)
Choroidal edema
Pupillary block
357
Intraocular gases
Viscoelastics in the anterior chamber
Silicone oil
Neovascular glaucoma
Vitreous Hemorrhage
This is the most common postoperative complication in PDR patients. Many
patients present blood in the vitreous cavity in some degree after surgery, and
in most cases, it clears up spontaneously.
Early (First Month)

These are usually mild and bleeding is caused by remains of red blood cells
left over in the peripheral vitreous. When they originate in bleeding points
treated during vitrectomy (neovessel proliferations in the retina or optic disk)
blood is usually denser.
If the hemorrhage does not clear up, we must check eye pressure to rule out
ghost cell glaucoma, and perform echographies to rule out RD.
Late (After the First Month)

These are more serious and can cause repetitive hemovitreous hemorrhages.
They are usually produced by anterior neovessel proliferation at sclerotomy
level. If they do not improve, pars plana vitrectomy (PPV) must be performed
within a month.
We must suspect RD or anterior hyaloidal fibrovascular proliferation
(AHFVP) if a dense vitreous hemorrhage with neovessels in the iris and
hypotonia are present.
Anterior hyaloidal fibrovascular proliferation28,29 is a serious complication
which may appear from the 3rd week to the 3rd month after surgery. It is caused
by a proliferation of highly vascularized fibrous tissue, clinically manifested
by retrolental vitreous hemorrhage associated with retinal and ciliary body
detachment, which cause the hypotonia also associated with the profile
(Fig. 10). Young diabetic patients badly controlled or photocoagulated later
than they should have been, as well as adults with aggressive diabetes, are more
likely to suffer with this complication. Retinal detachment presence, multiple
surgeries and the need for cerclage can also favor it.
In general terms, treatment would consist of vitrectomy, lensectomy,
RD treatment (PFCL), retinotomy if needed, treatment of anterior hyaloid
proliferation with diathermia or cryotherapy, scleral procedure and silicone
oil according to the case (Fig. 11).
358
Figure 10 Anterior hyaliod fibrovascular proliferation: note the retrolental

vitreous hemorrhage and the ectropion uveae
Figure 11 Anterior hyaloids fibrovascular proliferation after surgery
Retinal Detachment
Retinal Detachment Exudative
It is not uncommon in extensive and confluent panphotocoagulation in patients
with neither previous nor surgical tears. It typically appears in the inferior area.
Retinal Detachment Due to Posterior Break

It is produced when a previously treated posterior break reopens due epiretinal
membrane traction.
Surgery must not be delayed in order not to develop PVR. A new three-port
PPV is necessary to extract epiretinal membranes and reapply the retina. The
break is treated again and long-acting gas is left.
Retinal Detachment Due to Anterior Break

The presence of RD in vitreoretinal surgery postoperatively can happen in easy
surgeries as well as in difficult ones. It is caused by undiagnosed peripheral
tears or by the contraction of the vitreous base.
359
Treatment must be assessed in each case based on tear size and position.
Small and superior ones can be treated injecting gas or air followed by a
pexia system, if the retina is reattached. In larger or inferior breaks, a scleral
procedure with or without gas injection would be indicated according to the
requirements of the case.
The postoperative development of a RD with associated PVR is a serious
complication which, in its most severe extremes, can cause serious vision loss.
It can occur after any vitrectomy but it is more frequent when large and multiple
tears are present, as well as in cases of long evolution of the detachment,
association of choroidal detachment and especially, after excessive cryotherapy
treatment or with retinal incarceration.30
Proliferative vitreoretinopathy can appear as a complication in the evolution
of rhegmatogenous RD, but more frequently, it arises as a surgical complication,
and in large part, it is an iatrogenic disease.
There are some risk factors, some of which are surgical PPV complications,
which favor it:
Clinical Factors
Characteristics of RD:
– Evolution time
– Size and number of tears
– Multiple and large horseshoe tears
– Giant tear
– Preoperative PVR
– Old patient
– Biologic typology
Hemovitreous
Choroidal detachments: intraocular inflammation
Ocular trauma
Surgical Factors
Failed previous surgeries
Surgical complications
– Retinal incarceration
Surgical manipulations
– Retinopexy (especially excessive cryotherapy)
– Tamponades
360
Intraocular Inflammation and Fibrinoid Reaction
After vitrectomy a certain degree of intraocular inflammation is common,
especially when it is associated with a lensectomy, intraocular gas, laser
therapy, and in particular, cryotherapy. In most situations, treatment with topic
corticosteroids is sufficient to improve the process.
A fibrinoid reaction in the anterior chamber can occur in vitrectomies
performed to repair a RD with PVR in diabetic patients with severe PDR,
particularly poorly controlled young patients or young patients with kidney
failure. Therefore mentioned complication is more habitual if it is associated
with anterior segment surgery. As prevention, a treatment with frequent use
of topical corticosteroids is indicated. In case of moderate or severe fibrinoid
reaction, inject 10–12 μg of r-TPA with a 30-gauge needle into the anterior
chamber31 (Figs 12A and B). Never use this substance in the immediate
postoperative, to avoid bleeding, or 72 hours after the fibrin has been
established, because it has very little effect. Mild fibrinoid reactions are often
treated with hourly topical corticosteroids.
Massive fibrin formation in the vitreous cavity is another severe
complication that may occur after a vitrectomy for PDR. The use via pars plana
not more than 25 μg of r-TPA can help to control massive fibrin response but
generally is best managed with a repeated vitrectomy with fibrin removal.32,33
Tamponade and Manipulator Agents Complications

Intraocular Gas
Some of the complications associated with the use of gas as a tamponade agent
include an elevation of IOP, the occlusion of the central artery of the retina,
injury to the optic nerve (Fig. 13) and the flattening of the anterior chamber
(Table 2).
A B
Figures 12A and B (A) Severe fibrinoid reaction; (B) The same case few minutes
after recombinant tissue plasminogen activator treatment
361
Figure 13 Nerve atrophy, secondary to ischemic optic neuropathy in a retinal

detachment surgery with vitrectomy. In a vitrectomy, it is very important to
maintain a right intraocular pressure control. In cases of high intraocular pressure
maintained you could have a vascular occlusion
TABLE 2
Most common gases
Expansion Nonexpansive Length
concentration
Air x 1 - 1–2 days
SF6 x 2 20% 2–3 weeks
C3F8 x 4 15% 6–8 weeks
During vitrectomy, the selected gas is mixed with a certain amount of

filtered air to achieve a nonexpansible mixture which remains in the eye for
as long as it is required. It is essential to avoid gas mixing errors to prevent
complications. If there is too much gas in the mixture, the gas will expand and
cause ocular hypertension problems and even, shallowing of the chamber.34 If
the proportion of air is greater, the air-gas bubble will reabsorb too quickly.
If the vitrectomy has been incomplete or much subretinal fluid has been
left, the bubble will be very small at the end of the surgery. Gas can leak
spontaneously through the sclerotomy (a poorly sutured sclerectomy) or
forcibly, if something (i.e. choroidal detachment) increments eye pressure.
Nitrous oxide anesthesia must be avoided during retinal surgery when an
intraocular gas bubble is placed in the eye. If nitrous oxide anesthesia is used
it should be discontinued about half an hour before the gas is instilled into the
eye (see chapter 4).
A subretinal migration of the gas is rare but can arise when there are
large tears or the retina is too tight or when gas is injected in the subretinal
area. Gas can move into the anterior chamber through wide capsulotomies
362
or through zonular dehiscence, but will not cause major problems as long
as a prone position is maintained which prevents gas from touching the
endothelium.
Silicone Oil
Silicone oil is a long-term tamponade which must be used in complex cases or
when the patient cannot follow the postural treatment properly.
The main intraoperative complication during silicone oil instillation is that
of overfill. If the IOP is not controlled and we try to overfill the eye with silicone
oil, then zonular rupture generally ensues and a silicone oil bubble gains access
to the anterior chamber. We must prevent this complication lowering air infusion
pressure and stop injecting once silicone can be seen refluxing back up the air
infusion line. Another problem arises when silicone gains access to subretinal
space through a pre-existing retinal tear. This complication may be avoided
removing all tractions around retinal breaks and performing a fluid-air exchange.
If silicone oil is left inside the eye, it will generally produce secondary
complications after a few months.35,36 Thus, we must attempt its removal in
3–6 months, unless the risk of RD recurrence is very high.
Whenever silicone oil is injected in aphakic patients, an inferior iridotomy
with vitreotome must be performed.37 Pupillary and iridotomy blocking can arise
in the immediate and also late postoperative period due to a fibrin deposit. The
silicone oil then moves into the anterior chamber causing ocular hypertension.
An iridotomy with laser YAG will be necessary to revert the blockage.
The tamponade effect of silicone oil of 1,000 centistokes and 5,000 centistokes
(cSt) is similar. The tendency to emulsificate is lesser in the second, and for this
reason, it should be the choice in cases where oil removal is not anticipated.
When silicone oil moves into the anterior chamber, it is toxic for the corneal
endothelium and for the trabecular meshwork, often causing glaucoma. If the
patient is phakic, a cataract will very likely develop within a few months,
in which case a combined procedure of gas removal and cataract surgery is
indicated (Fig. 14).
Silicone oil postoperative complications are:
Emulsification (Fig. 15)
Cataract
Pain: Subconjunctival oil (Fig. 15)
Corneal edema and band keratopathy
Closure of inferior iridectomy
Glaucoma
Iritis
Rubeosis iris
Postoperative RD
– After oil removal
– With oil present
Persilicone oil fibrous proliferation
363
Figure 14 Secondary cataract produced by silicone oil tamponade
Figure 15 Emulsified silicone oil in the anterior chamber and

subconjunctival oil infiltration
Perfluorocarbon Liquids
The use of PFCL has few complications. The main complication is postoperative
intraocular retention, which may cause toxicity in the tissues by persistent
contact. Perfluorocarbon remnants may enter the anterior chamber through
zonulocapsular barrier defects and cause visual acuity fluctuations and
endothelial toxicity. If these symptoms are serious, perfluorocarbon (PFC)
remnants must be all removed (Fig. 16). Subretinal retention of PFC bubbles
can be originated in surgeries where large peripheral retinotomies are required,
and if they are located outside the macular area, they do not seem to cause any
anatomic or visual acuity alterations.38
364
Figure 16 Perfluorocarbon liquid remnants in the anterior chamber
Endophthalmitis
This is a rare postvitreous surgery complication which manifests itself in intense
pain, hypopyon and visual acuity diminution 36–48 hours after surgery. Its proper
diagnose may be delayed because its symptoms are common in a vitreous surgery.
In cases where the ocular fundus can be evaluated, the existence of intraretinal
hemorrhages and periphlebitis may be an early sign of endophthalmitis.39 When
this condition is suspected, a sample of aqueous and vitreous humor must be
taken for culture, followed by intravitreous administration of antibiotics. Topic
and systemic antibiotics should be also prescribed, which can be modified
according to culture and antibiogram results. Topic and systemic corticosteroids
are prescribed to control intraocular inflammation.
Cataract
The progressive opacification of the crystalline lenses or the progression of a
previous cataract is common after vitrectomy. Up to 80% of patients show nuclear
sclerosis progression 2 years after vitreous surgery, especially if it is associated
with gas or silicone oil use.40,41 A posterior subcapsular opacity, in the form of
vacuoles, related to the use of gas as an intraocular tamponade,42 can arise during
the immediate postoperative period. It is critical to position the patient correctly
while the intraocular bubble is large. These subcapsular vacuoles tend to disappear
within a few days, but if they are numerous in 40–50-year-old patients, they can
evolve into permanent posterior subcapsular opacities (Fig. 17).
Young patients (younger than 50 years old) show a lesser tendency to
develop cataract after vitrectomy, with an incidence of 7% after 2 years,43
although their evolution may be strongly influenced by the requirement of a
complex surgical procedure.44
365
Figure 17 Permanent subcapsular opacities related with long-acting gas use
TO PREVENT VITRORETINAL SURGERY COMPLICATIONS

All surgical team members (assistants and nurses included) must be
acquainted with posterior vitrectomy surgical techniques
The surgeon must be comfortably positioned and instruments must be
inspected and tested prior to their introduction into the eye
Always work with a systematic plan and well-established surgical
objectives
Do not open the passage of fluid of the infusion cannula until making sure
it is in the interior of the vitreous cavity
Use a careful surgical technique to avoid iatrogeny (hemorrhages, tears,
scleral perforations during buckling surgery, phototoxicity, etc.)
Try to anticipate risk situations and factors. Prevent and treat them
prophylactically if it is possible
Avoid hypo-and hypertonic situations which promote bleeding
and visualization problems. Try to work with infusion pressures of
20–30 mm Hg
Minimize the number of entries and exits into and out from the eye
Clean the incarcerated vitreous with the vitreotome in sclerotomies. Avoid
tractions of the vitreous
Revise the peripheral retina with indentation before proceeding to air
exchange and at the end of the surgery. Treat tears adequately
Correct use of retinopexy systems. Avoid excessive or deficient treatments
Suture sclerectomies and conjunctiva very carefully
Give the patient and their family adequate instructions of postoperative
treatment and reasons for urgent consultation.
366
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Index
A sub-Tenon’s 36
transconjunctival retrobulbar 37
Anterior epiretinal proliferation
Absorption
removal of 298
different wavelengths 98
Antiplatelet and anticoagulants 316
optimal hemoglobin and
Aphakic or pseudophakic eyes 170, 275,
oxyhemoglobin 97
278, 283
Accurus pressure pump 73
Applanation tonometry 10
Accurus vitreotome, using the dual
Argon laser 96
vitrectomy mode 368
drawbacks, absorbed
Age-related macular degeneration 267
hemoglobin 96
better visual result with surgery in
melanin 96
cases associated with 267
intravitreal ranibizumab injection in
eyes with 314 B
treatments trials study 368
Air-filled phakic eye 51
Backflush and
Air-gas exchange 148
extrusion functions 91
close the last sclerotomy 148 Berger’s space 2
end of surgery 148 Biconcave lens 51
Ampoule of the hypnotic agent, use of Landers 50
local anesthesia 37 use for fluid/air exchange 57
Anesthesia Bimanual
anatomy applied to 31 dissection 255, 256, 326
types of 29 surgery 60, 63, 68
general 29 Biomicroscopy of
local 30 the retina 11
peribulbar 35 Bipolar diathermy 91
370
Blunt-tipped 106 Crystalline lens
Buckle on the sclera abundance of 181
accurate placement of 274 fragments 180
surgery 10
Cystoid macular edema 24
C
Capsular rupture 206 D

Capsule to the sulcus 224
Capsulectomy 175 De Juan hook 127
Cataract surgery 99, 128, 138, 202, 217 Delaminating membranes 135
Central displacement of the retina (R) Densiron 119
294 Detachment of the posterior vitreous,
Central posterior fundus 51 differential diagnosis 13
Diabetic macular edema 24, 25
Central vitreous 51
Diabetic retinopathy 14, 162, 320,
Chandelier in a pars plana position 68
324, 326
Chang cannula 143, 219, 368 Diabetic retinopathy and
Chorioretinal adhesion 301, 302 endoscopic vitrectomy 176
Choroid hemorrhagic detachment, Diamond-coated foreign body forceps
ultrasound image of 15 107
Choroid highly echogenic convex lines Diathermy
in a B-scan 16 device 324, 324
Chronic intraocular inflammation 181 forceps and erasers 91
Ciliary Diffuse posterior contraction 293
body 5, 6, 28, 181 Diode laser 96
Direct exchange for silicone oil 146
processes 168
Diseases
sulcus 168
corneal 354
Cloquet’s canal 2 diabetic eye 112, 328, 367
Coagulate in choroid hemorrhage 16 hyperacute 244
Conjunctiva, opening of 76 iatrogenic 359
Conjunctival macular 11, 17, 26
displacement 285 neurological 30
incisions 123 occlusive venous 94
opening 124 primary disease 262
Constellation vision system 85, 87 retinal vascular disease 272, 307, 314
segment 194
Corcóstegui’s direct action forceps 107
thromboembolic 316
Cornea and crystalline lens 10
valve disease 28
Corneal dehydration maneuver 347
vascular ischemia in diseases 17
Corneal vitreoretinal 1, 314
edema 181, 226 vitreous interface 261
incision 152 Disk and macula edema 247
limbus 4, 5 Dislocated lens 217
lens material 158 Dislocated posterior chamber phakic
Cryotherapy 354 refractive lens 217
Index
371
DoRC silicone retaining ring 49 Focal posterior contraction 292
DoRC’s Fragments of crystalline lens 181
backflush probe 84
illuminating infusion cannula 77
sutureless infusion cannula 77 G
23-gauge diathermy instrument 91
27-gauge light fiber 198 Giant retinal tear 141, 305
27-gauge vitrector 197 Goldmann lens 11
Double lumen 143 Goldmann three mirror lens 60
Green diode laser 96
Greenbaum cannula 37
E Grieshaber pressure pump 74
Ectropion uveae 358

Edematous epithelium 347 H
Emulsification of the silicone oil 150
Encircling exoplants 275
Healed posterior laceration 240
Encircling procedure 276
Heavy silicone oil 117
Endodiathermy Hemorrhagic choroid detachment
final stage of 324 ultrasound image of 15
initial stage of 324 High intraocular pressure 75, 326
Endoillumination probe 130 Hyaliod fibrovascular proliferation 358
Endoillumination systems 65 Hyaluronic acid 109
Endoilluminator 301 Hydrostatic pressure 71
Endolaser 354 Hypotony 288
Endophotocoagulation 93, 94, 174
Endophthalmitis, early 245
Epiretinal membranes I
attached to the retinal surface 23
complete macular hole associated 20 Iatrogenic retinal tear 353
subfoveal cotton ball sign 22 Illuminated 20-gauge vitrectomy probe
tridimensional reconstruction of 23 from DoRC 69
Epithelial erosions 10 Illuminated laser probe 94
Erect indirect binocular ophthalmic Implanting an aphakic artisan lens 221
system, use of 56
Indirect ophthalmoscopic visualization
External segment of the cones 22
275
Extraction of the tip of the
Indocyanine green 136
phacofragmenter fragments 158
Inferior and posterior tamponade 118
Extraocular muscles 4
Inferior peripheral iridectomy 151
Extrusion system 83
Inferior temporal scleral incisions 124
Inferotemporal quadrants 14
F Infusion devices systems 71, 76
Infusion pump or gas forced infusion 72
Fibrovascular tissue connections 251 Infusion terminal 301
Fluorescein angiogram 318, 327 Inner and outer segments 21
Fluorescein angiography 16 Instrumentation 196
372
Integrated vitrectomy systems 45 autologous plasmin 341
Internal and external segments of the bevacizumab injection of
photoreceptors 22 anti-VEGF 317, 320
Internal limiting membrane 106, 251 autologous plasmin 340
Internal nuclear layer 21 ranibizumab 319
Internal systems 65 Iris neovessels, bleeding of 351
Intraocular foreign body 14
Irregular full-thickness retinal folding
extraction with magnet and
293
forceps 243
Isolate fibrovascular proliferations 353
Intraocular
gas 113, 360
inflammation and fibrinoid L
reaction 360
lens complications 350 Lamellar macular hole, associated an
lens dislocation 216 epiretinal membrane 20
lens implantation 161, 326 Landers biconcave lens 50
pressure 72, 77, 78, 322, 325 Landers lens retaining 49
silicone oil in ocular severe Laser
trauma 239 endophotocoagulation 93
tamponade 283, 302 photocoagulation 301, 325
Intraoperative Leica microscope 47
bleeding Lens
controlling of 172 convexity of 160
during vitreoretinal surgeries from dislocation 211
many etiologies 315-319 Lensectomy and intraocular lens 296
choroidal detachment 188, 303 Limbal incision 152
complications 237, 343 Limbal peritomy and
fundus photograph 252 relaxing incisions 273
Linear suction power 83
hemorrhage 30
Luxated
hemosis 192
natural or intraocular lenses 142
hypotony 268
subluxated intraocular lenses 14
lesion 238
macular hole 268
management of perfluorocarbon M
liquids 142
myosis 159 Machemer
oCT 368 contact lens 61
posterior segment bleeding control, magnifying lens 51
techniques of 320 plano-concave lens 52
pupil block 128 Macular hole
retinal breaks 288 complete 20
suture placement 255 index 21
visualization 10 Magnet and intraocular forceps 243
Intravitreal Manual backflush, aspiration cannula
air injection 325 capable of 133
Index
373
Medtronic’s cannulas 91 optic nerve using intraocular forceps
Membranectomy 174 253
Meshwork of collagen fibers 2 optical coherence tomography 19-22,
Metallic valved trocar for 27-gauge 256, 338, 340, 341
vitrectomy 197 ora serrata, real view of 168
Microincision vitrectomy orbit anatomy 32
drawbacks of 192 oxane HD 117, 118
Microvitreoretinal blade 6
Minimal residual leakage nasal 327
Müller cell layer 4 P
Multifunctional microscope 46
Multiple isolated single star folds 292 Panoramic illumination probe 66
Myosis 347 Panphotocoagulation 254
Myringotomy blade 301 Panretinal endophotocoagulation 324,
326
Panretinal photocoagulation 10
N
Pars plana lensectomy 161, 159, 175
Pars plana lensectomy
Neovascularization of the iris with opacity
advantages of 158
of the media 177
indications of 368
Nerve atrophy 361
surgical technique 156
Noncontact systems 122
Nonexpanding gas 147 with silicone oil injection 307
Nucleus of the lens 158 Pars plicata of the ciliary body 295
Peeling membranes in vitrectomy 132
Perfluorocarbon liquids
O properties of 111
using a Chang cannula 111
ocular Peribulbar anesthesia 35, 37
endoscopy with image and Periphery beyond the equator 51
illumination 165 Periphery using the vitreotome 131
hypertension and glaucoma 355 Periretinal membranes 292
hypotony and bulb phthisis 247 Peristaltic pumps 80
media 10 Peyman wide-angle lens 52
perforation in retrobulbar
Phacoemulsification 99, 128, 326
anesthesia 202
Phacofragmentation of the nucleus with
trauma with or without intraocular
the aid of the endoillumination
foreign body 160
probe 214
oil extraction and insertion of
intraocular lens 239 Phthisis bulbi 10
opacification of the lens 159 Polishing of the anterior capsule 161
opaque vitreous proceeds posteriorly, Posterior hyaloid detachment
removal of 279 advanced phase of 325
ophthalmologic Posterior hyaloid over an epiretinal
endoscope 165 membrane 23
surgery table 43 Posterior retinal iatrogenic tears 353
optic nerve disk 14 Posterior surface of the iris 295
374
Post-traumatic detachment and Retrobulbar hemorrhage 205
reparation with intraocular silicone Retrobulbar needle 38
oil 241 Retrolental vitreous hemorrhage 358
Post-traumatic macular hole 247 Rhegmatogenous retinal detachment
Postvitrectomy epithelial defect in a 291
diabetic patient 355 Rubeosis iridis 10
Potential problems during the use of Rupture of the posterior capsule 161
perfluorocarbon 146
Preoperative intravitreal anti-VEGF
injection, technique of 319 S
Proliferative diabetic retinopathy
anterior proliferation of 325 Scleral buckle 10, 14
Proliferative diabetic retinopathy Scleral buckling in proliferative
vitrectomy 353 vitreoretinopathy 296
Proliferative vitreoretinopathy Scleral buckling technique 273
adjunctive treatment 304 Scleral indentation 178
classification of 290 Scleral peak 13
diagnosis of 290 Scleral suture technique 277
surgery of 295 Sclerocorneal limbus 6
Pupil management 127 Sclerotomies with
Pupil reflexes 9 23-gauge vitrectomy 284
Pupillary margin 295 25-gauge vitrectomy 284
Sclerotomy
complications 343
Q enlargement 346
pediatric vitrectomy 6
Quartz lens 64 tunnel 287
Segmentation of proliferative
membranes 326
R Segmenting membranes 134, 135
Sign of
Radial retinal folds 294 an attached posterior hyaloid 130
Rectus endophthalmitis, early 364
inferior 4 heating of the phacofragmenter 157
lateral 4 protein coagulation 159
superior 4 vitreomacular traction 24
Retina or choroid 13 Silicone oil
Retinal detachment removal of 151, 303
due to anterior break 358 solvent 116
exudative 358 tamponade, indications of 150
surgery 177 tip arches 131
with proliferative vitreoretinopathy 307 tipped cannula 83, 131
Retinal iatrogenic tears 352 Slit lamp microscopy 10
Retinal tears 287, 291, 346, 352 Spiral of Tillaux marks 5
Retinopexy, complications 354 Staining membranes 136
Retinoschisis 14 Staphylococcus epidermidis 226
Retrobulbar block 33 Stellaris PC 46
Index
375
Stellaris PC vision enhancement Trauma and dense vitreous hemorrhage
system 88 240
Stryker Stretcher for ophthalmology Trauma and endophthalmitis 244
surgery 44 Trauma and intraocular foreign body
Subconjunctival oil infiltration 363 241
Subfoveal cotton ball sign 22 Trauma and retinal detachment 241
Subfoveal fluid 256 Triamcinolone acetonide 139
Subfoveal perfluorocarbon bubbles 270 Tridimensional reconstruction of an
Submacular hemorrhage located into the epiretinal membrane 23
macular area 267 Tripod-shaped forceps 107
Subretinal macular space, surgery of 267 Trypan blue 137
Subretinal proliferation, removal of 298 Tumors
Sulcus fixation of an intraocular lens 224 intraocular 15
Syndromes masses 15
capsular contraction 223 size of 12
Ehlers-Danlos 223 structure of 12
fibrinoid 367
Floppy iris 127
managing sunset 232 U
Marchesani 223
Marfan syndrome 223 Ultrasonic fragmentation 102
pseudoexfoliation 206, 217, 223 Ultrasonography 11
vitreocorneal touch 206 Unilateral submacular hemorrhage 269
vitreomacular traction 3, 22, 24, 27,
139, 189, 261, 342, 340
Synergetic laser probe allowing a straight V
or curved approach 95
Valved trocars
preventing the leakage of saline 78
T use of 76, 322
Vascular
Tamponade and manipulator agents arcades 14
complications 360 endothelium growth factor 313
Temporal vitreomacular traction entoptic test 10
syndrome 24 ischemia 17
Tenon’s capsule 274 Vented gas forced infusion system 73
Tolentino
Venturi pump 80
thirty degree prism lens 52
Vertical scissors of the ACCURUS system
twenty degree prism lens 52
104
Tortuous retinal vessels 292
Vision with rotation 90° 168
Traction forces 251
Transconjunctival Visual acuity 9, 255, 256, 327
injection process 39 Vitrectomy
retrobulbar anesthesia 37 anatomical distances 4
sub-tenon’s anesthesia 203 basic operative steps in primary 277
Transilluminator light 10 benefits of microincision 192
Transscleral cryopexy 179 compliactions of the ocular trauma 246
376
diabetic macular edema 257 implant visible in the inferior zone of
endoscopic 180, 181 the vitreous cavity 335
following vitreous loss 206 incarceration 171, 172
open traumatisms 235 infiltration 226
probe 83, 140 material inside the lens 161
proliferative vitreoretinopathy 297 space collagenous tissue 301
retinal detachment with proliferative substitutes
vitreoretinopathy 288 manipulators of tissues 109
surgery tamponade 113
after combined cataract 109, 128 tractions 353
Vitroretinal surgery
combined phacoemulsification 99
complications of 365
twenty five gauge 193
Volk self-stabilizing
twenty gauge caliber surgery 189
vitrectomy lens 50
twenty three gauge 184, 187
Vortex veins and their
use of gas in 147
anatomical relations 7
use of ultrasound 102
Vitreomacular traction syndrome 21,
24, 324 W
Vitreoretinal
bleeding 315 Warfarin 368
proliferation 141, 159 Wide-angle-viewing systems 52, 53
anterior 160 Wide-field BIoM system 53
surgery 172 Wieger’s hyaloidocapsular ligament 2
characteristics of some of the Woldoff biconcave prism lens 52
antiaggregants used for 29 Wound closure
complications of 171 remove the cannulas 286
traction syndrome 22 vitreous plugging 286
traction syndrome in optical coherence
tomography 338
Vitreotome cutter lens injury that X
develops cataract in the
postoperative period 350 Xanthophyll pigments of the macula 88
Vitreotome in position 130
Vitreous
anatomy of 1, 3 Y
anterior displacement of 295, 301
base and vitreoretinal interface 2 Yellow laser 97
cavity 180, 327, 345 absorption at different wavelengths 98
chamber 217 endo-ocular laser treatment 97
cutter 158, 161, 324 endophotocoagulation 97
disorder 12
gel and the lens material 161
anterior 158 Z
hemorrhage 10, 13, 129, 130,
177, 357 Zeiss microscope with slit lamp 61
humor anatomy of 3 Zone of the iris 181

Step by Step VITRECTOMY PDF

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Step by Step

José J Martinez-Toldos md phd

Jairo E Hoyos md phd

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd

© 2013, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Step By Step Vitrectomy

Amparo Navea Tejerina MD PhD Carme Guardia MD

Anna Grabowoska MD Cristian Fernández-Martínez MD

Fernando M penha MD Jorge Mataix MD

Félix Armadá Maresca MD PhD Josefina Bañuelos Bañuelos MD PhD

Javier Montero Moreno MD Laura Distefano MD

Once again, José Juan Martinez-Toldos provides us with a book on vitreoretinal

Borja Corcóstegui md phD

The topic of vitrectomy includes both diagnostic and therapeutic approaches

Vitrectomy is a wide subject that includes diagnostic and therapeutic

3. Vitrectomy and Optical Coherence Tomography 19

5.1. Operating Room 43

5.2. Visualization Systems 49

5.4. Infusion pressure Systems 71

5.5. Infusion Devices Systems 76

5.6. Suction and Cutter Systems 79

5.11 Forceps and Scissors 104

5.12 Vitreous Substitutes: Manipulators of Tissues 109

5.13 Vitreous Substitutes: Tamponades 113

6. Basic Vitrectomy 121

9. Minimal Incision Vitrectomy Surgery: Twenty-Three,

9.1 Twenty-Three Gauge Vitrectomy 184

10. Vitrectomy in Anterior Segment Surgery Complications 202

11. Eye Trauma Vitrectomy 235

12. Basic Vitrectomy in Diabetic Retinopathy 250

13. Macular Surgery 261

15. Current Indications of Antiangiogenics in Vitrectomy 313

16. Use of Sustained Drug Release Implants in Vitrectomized Eyes 331

17. Enzymatic Vitrectomy 337

18. posterior Vitrectomy Complications 343

Cristian Fernández-Martínez, José Juan Martínez-Toldos

ANATOMY OF THE VITREOUS

Vitreous Base and Vitreoretinal Interface

Figure 1 Meshwork of collagen fibers or filaments interspersed with large

Figure 2 Anatomy of the vitreous humor

ANATOMICAL DISTANCES IN VITRECTOMY

Figure 5 Position of the ciliary body in relation to the sclerocorneal limbus.

Figures 6A and B (A) Inserting the microvitreoretinal blade 4 mm from the

Age group Distance from limbus

Figure 7 Vortex veins and their anatomical relations

Manolo Baeza Diaz, José Juan Martínez-Toldos

Vascular Entoptic Test

Slit Lamp Microscopy

Biomicroscopy of the Retina

Posterior vitreous Retina Choroid

Proliferating Diabetic Retinopathy

Figure 1 Retina appears as a highly reflective membrane protruding into the

Figure 2 Ultrasound image of hemorrhagic choroid detachment

Figure 3 A detached choroid appears as highly echogenic

Figure 4 Progressive lysis of the coagulate in choroid hemorrhage

Evoked Visual Potentials

Vitrectomy and Optical

OPTICAL COHERENCE TOMOGRAPHY IN MACULAR HOLES

Figure 1 Complete macular hole associated to an epiretinal membrane

Figure 2 Lamellar macular hole associated an epiretinal membrane

OPTICAL COHERENCE TOMOGRAPHY IN EPIRETINAL

The EIBOS (erect indirect binocular ophthalmic system) is a noncontact