In advanced stages of pediatric ischemic vitreoretinopathies, total or subtotal tractional retinal detachment (TRD) usually ensues, often with multiple retinal folds and retrolental plaque. The retrolental plaque usually obscures the view to the fundus, and in such cases, the retina is drawn anteriorly at very close proximity to the plaque. To address this safely, vitrectomy with limbal or iris root approach is required. Wong and Capone elegantly described illumination techniques that allow better visualization during plaque dissection.1 The utilization of chandelier illumination systems has been a monumental advancement in adult vitreoretinal surgery.2,3 However, its use in pediatric ischemic vitreoretinopathies has not been reported. Herein, we report a safe illumination technique utilizing a non-trocar chandelier illumination system in stage 5 retinopathy of prematurity (ROP).
The surgical technique is as follows. Three keratotomies are performed at the 10-o'clock, 2-o'clock, and 7-o'clock meridians. Posterior synechiae, if present, are released with the use of viscoelastic. Four iris hooks are inserted to maintain pupil dilatation. Lensectomy and total capsulectomy are then performed with the vitreous cutter. The retrolental plaque is then carefully opened using a 23-gauge needle with help of retroillumination to identify and avoid retinal tissue. A 25-gauge needle is then inserted transcon junctivally, 0.3 mm from the limbus, through the iris root toward the intended area and directed horizontally just behind the iris plane and away from retinal tissue. The light fiber (Combined Eckardt Multi-Fiber Endoillumination Probe / Chandelier; DORC, Zuidland, The Netherlands) is then inserted (Figure 1). The light fiber is placed at 12-o'clock behind the iris plane to avoid glare and possible limitation of the surgeon's view. In this setting, the chandelier light can be easily moved and manipulated to achieve the best illumination of the surgical field. Membrane dissection is then performed with bimanual technique until maximal removal of the fibrous tissue (See supplemental video below).
Intraoperative photos showing the insertion technique of chandelier light at the level of the iris root. (A) A 25-gauge needle used to create a track for light insertion. (B) Chandelier light inserted through the track. (C) Chandelier light in position shielded by the iris.
A premature infant born at 29 weeks gestational age with 900 grams birth weight presented at 50 weeks postmenstrual age with bilateral stage 5 ROP. The surgery was performed by one of the authors (MM) in both eyes starting with the right eye. A limbal 25-gauge vitrectomy system was used. A 25-gauge trocar's blade was used to create three limbal incisions. An infusion line was placed in the anterior chamber through the inferotemporal incision. Posterior synechiae were released using viscoelastic material. Iris hooks were inserted to dilate the pupil. Lensectomy was performed with a vitreous cutter. The residual capsule was removed using serrated forceps and the cutter, with scleral depression. Retroillumination was achieved using an intracameral endoilluminator to identify a safe plane for starting the dissection. An opening was made into the retrolental plaque using a 23-guage needle. Subsequently, a non-trocar chandelier was inserted superiorly about 0.3 mm posterior to the limbus in an area where there was no anterior dragging of the retina using a 25-guage needle. No bleeding was noted with the insertion of the chandelier light. A combination of bimanual delamination and blunt dissection was then carried out using the curved horizontal scissors, forceps, and the vitreous cutter. Bimanual dissection was then completed posteriorly. Fluid-viscoelastic exchange was then performed. No subconjunctival bleb formation was noted after removing the chandelier light. At 1 month postoperatively, the retina was attached with dry folds.
The surgical repair of advanced pediatric ischemic vitreoretinopathies such as ROP or familial exudative vitreoretinopathy is technically challenging and often requires special instrumentation. We described the use of a non-trocar chandelier light technique that is safe and provides adequate illumination for bimanual dissection. However, the surgeon must be cognizant of the following points. The intended area of insertion should be freed from any traction. The insertion should be parallel to the back surface of the iris and the light fiber should be under iris tissue to avoid glare. In cases where surgical iridectomy is advisable, we prefer to perform it at the end of surgery, and we opt for intraoperative iris hooks to allow shielding of the chandelier light from the overlying iris tissue.
In our view, the non-trocar chandelier system offers several advantages over the trocar system. Firstly, the insertion does not require the introduction of the entire length of the trocar blade to get the microcannula into the eye, reducing the chances of potential retinal damage, especially in small eyes with a dragged retina. In addition, the length of the light fiber inside the eye can be adjusted as needed, without any limitations from metallic or polyamide trocars creating shadowing on the underlying tissue. This single light fiber is also malleable and could be directed to illuminate the area of interest.
In conclusion, we described a safe non-trocar chandelier light technique that allowed bimanual dissection in advanced pediatric ischemic vitreoretinopathies.
- Wong SC, Capone A Jr., Illumination techniques for complex pediatric anterior retinal detachment and associated retrolental plaque. Retina. 2015;35(9):1905–1907. doi:10.1097/IAE.0000000000000708 [CrossRef]
- Eckardt C. Twin lights: A new chandelier illumination for bimanual surgery. Retina. 2003;23(6):893–894. doi:10.1097/00006982-200312000-00039 [CrossRef]
- Oshima Y, Awh CC, Tano Y. Self-retaining 27-gauge transconjunctival chandelier endoillumination for panoramic viewing during vitreous surgery. Am J Ophthalmol. 2007;143(1):166–167. doi:10.1016/j.ajo.2006.07.051 [CrossRef]