Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

23-Gauge Vitrectomy for Retained Lens Material

Ramanath Bhandari, MD; Benjamin J. Ernst, MD; Ksenia Stafeeva, MD; Naresh Mandava, MD; Hugo Quiroz-Mercado, MD

Abstract

A technique for removal of retained lens material is described with a three-port 23-gauge vitrectomy system. Removal of the core vitreous is first performed, followed by removal of the cortical vitreous. All vitreous adhesions to the lens are cleared. The cut rate is then decreased to 1,500 cuts per minute, and vacuum increased to 600 mm Hg. The cortical lens material is cleared first, and then the nuclear material is taken with the same vitrectomy probe using the light pipe to assist in crushing the nuclear fragments. With this technique, even large dense nuclear and cortical retained lens material can be removed from the vitreous chamber without the need for a fragmatome.

Abstract

A technique for removal of retained lens material is described with a three-port 23-gauge vitrectomy system. Removal of the core vitreous is first performed, followed by removal of the cortical vitreous. All vitreous adhesions to the lens are cleared. The cut rate is then decreased to 1,500 cuts per minute, and vacuum increased to 600 mm Hg. The cortical lens material is cleared first, and then the nuclear material is taken with the same vitrectomy probe using the light pipe to assist in crushing the nuclear fragments. With this technique, even large dense nuclear and cortical retained lens material can be removed from the vitreous chamber without the need for a fragmatome.

From the Department of Ophthalmology (RB, BJE, KS, NM), University of Colorado Health Science Center, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, Colorado; and the Department of Ophthalmology (HQ-M), Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Ramanath Bhandari, MD, Rocky Mountain Lions Eye Institute, University of Colorado, Department of Ophthalmology, 1675 Aurora Court, F731, Aurora, CO 80045. E-mail: ramanath.bhandari@gmail.com

Received: September 01, 2011
Accepted: April 30, 2012
Posted Online: June 07, 2012

Introduction

As phacoemulsification has been increasingly adopted, complications related to this surgery have also increased. There is a 0.2% to 1.1% risk of crystalline lens dislocation,1 and complications associated with significant retained lens material (greater than 2 disc diameters) include glaucoma, inflammation, cystoid macular edema, and retinal detachment.2 Pars plana vitrectomy is recognized as standard treatment.3 A 20-gauge vitrectomy has been recommended for use of the 20-gauge fragmatome and other large-gauge instruments to facilitate removal of the retained lens material. However, 23- and even 25-gauge vitrectomy have gained popularity among retinal surgeons given decreased postoperative inflammation, sutureless vitrectomy, and reduced time to recuperation from these surgeries.4 Unfortunately, the 23-gauge fragmatomes are in their infancy and this has led some to advocate use of hybrid systems with two 23-gauge cannulae and a 20-gauge sclerotomy to tackle the problem of retained lens material.5 The difficulty with a hybrid system is the infusion may be inadequate for the larger gauge fragmatome sclerotomy site, leading to transient hypotony. We propose using the conventional 23-gauge vitrectomy probe to remove even large pieces of retained lens material, bypassing the need for a 20-gauge or hybrid vitrectomy.

Technique

All corneal wounds are checked and ensured to be adequately closed prior to starting the vitrectomy. Three 23-gauge transconjunctival sclerotomy ports are created for infusion, illumination, and the conventional vitrectomy probe (Alcon Laboratories, Inc., Fort Worth, TX). The 23-gauge trocar cannula system is inserted 3.5 mm posterior to the limbus with the infusion placed in the conventional inferotemporal position. A complete vitrectomy is performed with the core vitreous removed first, followed by induction of a posterior vitreous detachment and removal of the cortical vitreous. The retained lens material is then inspected for vitreous adhesions. It is vital to remove all adhesions to the lens prior to attempting to remove the lens with the vitrectomy probe. The cut rate is then reduced to 1,500 cuts per minute and the vacuum increased to 600 mm Hg. Perfluoron heavy liquid (Alcon Laboratories, Inc.) can be placed on the surface of the macula for protection. The lens is then lifted from the surface and the cortical lens material is removed (Fig. 1). The light pipe is then used to help crush the nuclear material against the vitrectomy probe for removal (Fig. 2). The peripheral retina is then inspected for breaks and a partial fluid–air exchange is performed. The 23-gauge cannulae are removed with inspection to ensure the sclerotomies are airtight.

The 23-gauge vitrectomy probe is used to engage the cortical lens material after completing the vitrectomy.

Figure 1. The 23-gauge vitrectomy probe is used to engage the cortical lens material after completing the vitrectomy.

The light pipe is used to crush nuclear material against the 23-gauge vitrectomy probe to facilitate its removal.

Figure 2. The light pipe is used to crush nuclear material against the 23-gauge vitrectomy probe to facilitate its removal.

Discussion

A posteriorly dislocated lens is a relatively rare event, but, when it does occur, it requires urgent attention to ensure the best possible outcome. The goal of the retinal surgeon is to remove the retained lens material in a safe manner to avoid complications. This can be accomplished using 20-gauge vitrectomy. However, 20-gauge vitrectomy often requires large sclerotomies, suture closure of wounds, and longer postoperative healing.6 The modern 25-gauge vitrectomy system was first described in 2002, and Eckardt first introduced the 23-gauge system in 2003.7,8 Since that time, the 23- and 25-gauge systems have been adopted for a multitude of indications. The 23-gauge vitrectomy for lensectomy is an emerging concept and two recent studies have explored its use.9,10 In those studies, anywhere between 40% and 60% of cases required conversion to a hybrid vitrectomy system with removal of a cannula and enlargement of a sclerotomy. The high rate of conversion in the studies may be secondary to the learning curve with any new technique in addition to the multiple surgeons and their level of comfort with 23-gauge vitrectomy. The crush-aspiration technique of lensectomy is not new and was described previously in the context of larger gauge vitrectomy as early as 1977; however, this is the first report to describe in detail the crush-aspiration technique in the context of a 23-gauge vitrectomy.11 Given the ever-increasing expectations of our patients, small-gauge surgery has gained popularity among our colleagues and patients. In our experience, a 23-gauge vitrectomy probe has been adequate for removal of dense large nuclear material, and has resulted in equivalent patient outcomes to larger gauge surgeries, although operative times may be longer with a dense nucleus.

References

  1. Pande M, Dabbs TR. Incidence of lens matter dislocation during phacoemulsification. J Cataract Refract Surg. 1996;22:737–742.
  2. Kapusta M, Chen JC, Lam WC. Outcomes of dropped nucleus during phacoemulsification. Ophthalmology. 1996;103:1184–1187.
  3. Kageyama T, Ayaki M, Ogasawara M, Asahiro C, Yaguchi S. Results of vitrectomy performed at the time of phacoemulsification complicated by intravitreal lens fragments. Br J Ophthalmol. 2001;85:1038–1040. doi:10.1136/bjo.85.9.1038 [CrossRef]
  4. Nagpal M, Wartikar S, Nagpal K. Comparison of clinical outcomes and wound dynamics of scleretomy ports of 20, 25, and 23 gauge vitrectomy. Retina. 2009;29:225–231. doi:10.1097/IAE.0b013e3181934908 [CrossRef]
  5. Kongsap P. Combined 20-gauge and 23-gauge pars plana vitrectomy for the management of posteriorly dislocated lens: a case series. Clinical Ophthalmology. 2010;4:625–628. doi:10.2147/OPTH.S11837 [CrossRef]
  6. Chang CJ, Chang YH, Chiang SY, Lin LT. Comparison of clear corneal phacoemulsification combined with 25-gauge transconjunctival sutureless vitrectomy and standard 20 gauge vitrectomy for patients with cataract and vitreoretinal disease. J Cataract Refract Surg. 2005;31:1198–1207. doi:10.1016/j.jcrs.2004.11.041 [CrossRef]
  7. Au Eong KG, Fujii GY, de Juan E Jr, et al. A new three-port cannular system for closed pars plana vitrectomy. Retina. 2002;22:130–132. doi:10.1097/00006982-200202000-00032 [CrossRef]
  8. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;25:208–211. doi:10.1097/00006982-200502000-00015 [CrossRef]
  9. Cho M, Chan RVP. 23-gauge pars plana vitrectomy for management of posteriorly dislocated crystalline lens. Clin Ophthalmol. 2011;5:1737–1743. doi:10.2147/OPTH.S22331 [CrossRef]
  10. Baker PS, Spirn MJ, Chiang A, et al. 23-gauge transconjunctival pars plana vitrectomy for removal of retained lens fragments. Am J Ophthalmol. 2011;152:624–627. doi:10.1016/j.ajo.2011.04.003 [CrossRef]
  11. Michels RG, Shacklett DE. Vitrectomy technique for removal of retained lens material. Arch Ophthalmol. 1977;95:1767–1773. doi:10.1001/archopht.1977.04450100069004 [CrossRef]
Authors

From the Department of Ophthalmology (RB, BJE, KS, NM), University of Colorado Health Science Center, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, Colorado; and the Department of Ophthalmology (HQ-M), Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Ramanath Bhandari, MD, Rocky Mountain Lions Eye Institute, University of Colorado, Department of Ophthalmology, 1675 Aurora Court, F731, Aurora, CO 80045. E-mail: ramanath.bhandari@gmail.com

Received: September 01, 2011
Accepted: April 30, 2012
Posted Online: June 07, 2012

10.3928/15428877-20120531-04

Sign up to receive

Journal E-contents