Converting to MIVS

Pravin U. Dugel MD
Managing Partner
Retinal Consultants of Arizona
Phoenix Arizona
Advantages of microincision surgery

• Less trauma, less post-operative pain

• Suture-less incisions
• Highly controlled fluidics
• Rapid post-operative recovery
• Faster visual recovery
• Less astigmatism
• Increased OR efficiency
PAT Survey

66.26%
Microincision Surgery

• UBM studies have shown sclerotomies

may remain open and require a vitreous
plug or later scarring to seal
• Lack of sutures might lead to:
• Leakage
• Hypotony
• Shorter tamponade time of long acting
gases or silicone oil leakage
• Endophthalmitis
Wound construction

• Displace conjunctiva
ARS...

37th Annual ARDS

Do you angle your incisions?

A. Never
B. Always
C. Only for 23g
D. Other
 Wound construction

• Flatten sclera on insertion to make longer

wound (chord length)

As described by Carl Awh, MD

 Wound construction

• Flatten sclera on insertion to make longer

wound (chord length)

As described by Carl Awh, MD

 Angled incisions critical

• 12 left eyes with • 12 right eyes with

angled incisions straight incisions
 23g
Straight Angled
15 / 18 open
83.3%
P = 0.017

7 / 18 open
Round opened 38.9% Chevron closed
(0.216 mm2) (0.055 mm2)
25g
Straight Angled
11 / 19 open 0.2 mm

55.6%
P = 0.04

4 / 17 open
Round opened 27.8% Chevron closed
(0.186 mm2) (0.038 mm2)
(Chi-square test)
Histopathology
25g
Straight Angled
0.2 mm 0.2 mm

High magnification
Histopathology
23g
Straight Angled
0.2 mm 0.2 mm

High magnification
 Kupperman 25g pressure study

• 10 freshly enucleated New Zealand white rabbit

eyes with conjunctiva excised
• Standard 25g infusion inserted at 6 o’clock
• Two superior 25g incisions performed

Angled vs straight
Kupperman 25g pressure study

• After PPV and cannula removal, infusion

pressure of ICG stained BSS raised until
leakage observed

25g Straight incision 25g Angled incision

 Kupperman 25g pressure study
mmHg
8 of 9 tolerated maximum infusion
140
120
100
Mean IOP [mmHg] Angled
80 Straight
Angled = 110 (30-120)
60 Straight = 12.8 (5-20) p<0.001

40
20
0
0 1 2 3 4 5 6 7 8 9 10 11
Rabbit #
Eye number 2 excluded due to damage during testing
 Dynamic wound study

• 8 fresh cadaver rabbit heads (New Zealand

white) 16 eyes
• Eyes enucleated with overlying
conjunctiva intact
• Placed in globe holder

Taban et al. Ophthmol 2008;115:2221–2228

Dynamic wound study

• Bioptigen
spectral domain
anterior
segment OCT
• Evaluate wound
integrity
• Variable IOP
 Dynamic wound study

• Obvious wound gap and leakage with

straight incisions
• Wound not visible with angled incisions

23g 23g

23g Straight incision 23g Angled incision

Straight Incisions
25g Low IOP 25g High IOP
• x

23g Low IOP 23g High IOP

Angled Incisions
25g Low IOP 25g High IOP
• x

23g Low IOP 23g High IOP

 Results
Straight Angled

23g

25g
Dynamic wound study

• Evaluate potential ingress of surface

fluid into the sclerotomy wounds
• India ink
• Applied to ocular surface following
removal of the 2 cannulas except the
infusion cannula
• IOP was varied while ink was applied
onto a supersaturated cellulose
sponge, lightly held in place against
the wound sites
Straight Incisions

• x 25g 23g

23g
Angled Incisions
25g
• x

23g
 Amount of angle important

Incision Angle of 45° Incision Angle of 30°

Reducing angle by 15° lengthens tunnel by 30%

30° angle

No gap

Stanislao Rizzo, MD
Wound construction surgical tips

• Leave trocar in place when inserting 3rd

cannula (if pseudophakic)
• Avoids need for plug
• Raise pressure momentarily to make
entry easier
PAT Survey
 Endophthalmitis rates
Study Incision Endophthalmitis
20-g sutured 1/5,498  0.018%
Kunimato1
25-g straight 7/3,103  0.23% straight
20-g sutured 2/6,375  0.03%
Scott2 25-g straight 8/1,307  0.61% straight
25-g angled 3/1,307  0.23% angled
20-g sutured 2/2,642  0.076%
Mason3
25-g angled 1/1,906  0.053%
20-g sutured 1/3,046  0.03%
Chen4
25-g straight 1/431  0.2% straight

Eifrig5,6 20-g sutured 0.03-0.05%

20-g sutured 6/17,561  0.034%

Total 25-g straight 7/3,103  0.23%
25-g angled 1/1,906  0.053%
1. Kunimato DY, et al. Ophthalmology 2007. 2. Scott IU, et al. Retina 2008.
3. Mason III JO, et al. Retina in press. 4. Chen JK, et al. Eye 2008.
5. Eifrig CW, et al, AJO 2004.
 Incidence of Acute-Onset
Endophthalmitis After 20-Gauge PPV
 Predisposing Factors for
Endophthalmitis After 23 or 25
Gauge PPV
1. Leaking sclerotomies / early postoperative hypotony
2. Patient-induced wound distortion (e.g. eye rubbing)
3. Vitreous wick in sclerotomies
4. Any bacterial innoculum into the vitreous cavity in
patients with relative immune compromise
5. Non-use of subconjunctival antibiotics
6. Increasing use of intravitreal adjuvants (IVK)
Vitreous wick ? = endophthalmitis

Vitreous wick

?increase risk of
endophthalmitis

20g = 0.07%
25g = 0.14%
Wound closure

• Remove cannulas with solid instrument to

prevent vitreous wick
Preventing vitreous wick
Preventing vitreous wick
Preventing vitreous wick
Preventing vitreous wick
Preventing vitreous wick
Surgical Pearls

• Increase IOP (40 to 60) while pressing with

cotton tipped applicator to close internal
lip of wound
 Surgical Pearls

IOP = 40 mm Hg

IOP = 14 mm Hg
B

IOP = 5 mm Hg
C

Taban et al Ophthalmology 2004

Surgical Pearls

• Endophthalmitis prevention
• Subconjuctival antibiotics, all cases
• I never use aminoglycosides
Surgical Pearls

• Small air bubble at end of every case

• Careful removal of lid speculum
23g Microincisional Vitrectomy
Study
• Purpose: To describe the short term
safety and efficacy of a 23g Microincision
Vitrectomy System

• Design: Multi-center, multi-surgeon (7),

consecutive surgical case series of 128
patients
23g Microincisional Vitrectomy
Study - IOP

4.6% hypotony
ARS...

37th Annual ARDS

Current Trocar Blade

• Current trocar blade is a significant

improvement over earlier hypodermic
needle trocars – reduced penetration forces
• However, does not make a linear incision
 New Trocar Blade

Ridge pulls tissue into Trail edge cuts tissue

trail edge – widening pulled to edge by ridge
the incision – widening the incision

Trailing edge

Lead edge –
stab cut

• New trocar blades generate a linear incision

while maintaining reasonable penetration
forces
New Trocar Blade

Incisions made in pigment coated silicone rubber

Current Trocar Blade – New Trocar Blade -

Bi-planar incision Linear incision
 New 25g Infusion Cannula

High Flow Luer fitting High Flow Silicone Tubing

Inner Diameter: Inner Diameter:

1.93 mm 1.57 mm
New

Old Inner Diameter: Inner Diameter:

1.19 mm 1.02 mm
New 25g Infusion Cannula
Improved 25g cutter
Moved cutting port closer and increased lumen size

Old New

.009”
.013”
 25+ Performance Summary

Probe Old New

Feature 25g Cutter 25+ Cutter

Cut Rate 1500 cpm 2500 cpm

Flow Rate 3.5cc/min @ 6.8cc/min @
(BSS) 600mmHg 1500cpm 600mmHg 2500cpm

27 mm
Needle Length 32 mm
w/needle stiffener

Port to Tip .013” .009”

Duty Cycle 37% @ 1500 cpm 51% @ 2500 cpm

 Stiffness Comparison
Increased Needle Stiffness

3.75
4.05
x
2.5 3.17
x

1.25 1.77
1.45 x
x
0
Port Entrance Mid Vitreous Macular Surface Far Periphery
 Conclusions

• Wound construction critical

• Angled incisions better
• Careful removal of cannulas
• Allow time for wound to close
• Future improvements will make system even
better
What’s next?!
Thank you