Evolutionary and Revolutionary Trends in Vitreoretinal Surgery
BHATNAGAR, MD, HOWARD F. FINE, MD, MHSc, & I-VAN HO, MBBS
Figure 1. Intraoperative
photographs of technique to stain theinternal
limiting membrane while protecting the macular hole with a bubble of perfluorocarbon
liquid. This prevents the ICG from reaching the RPE or subretinal space during staining.
the 35 years that have elapsed since Machemer first reported successful closed vitreoretinal
surgery, the field has seen tremendous growth.1
The advent of vitreoretinal surgery has allowed for the management of previously
incurable conditions and has expanded the treatment options in others. Herein, we
describe the revolutionary and evolutionary trends in vitreoretinal surgery that
have and will continue to define the face of the field in the coming years. Revolutions
are defined as advances that are major steps forward that brought or will bring
widespread change in surgical practice, while evolutions are those that reflect
the continued refinement of surgical patient care. As innovations in technology
and equipment often pave the way for progress in surgical techniques, we will begin
our discussion with the changes in surgical equipment that have and will continue
to redefine vitreoretinal surgery.
The introduction of perfluorocarbon liquids into the surgical
arena has spurred a new era in retinal surgery.2
Beyond having revolutionized the treatment of retinal detachments with giant tears
by obviating the need for the surgeon to operate in the supine position, it has
also affected great change in the management of many other conditions. New evolutionary
applications of this compound have been devised to harness perfluorocarbon liquid
as a "third instrument." These approaches include its use in aiding the management
of dislocated lenses, in the removal of intraocular foreign bodies, and for stabilization
of bullous retinal detachments during vitreous base shaving. In subretinal or suprachoroidal
hemorrhages, perfluorocarbon liquids are used to displace hemorrhage through retinotomies
or sclerotomies for evacuation.3,4
Others have used perfluorocarbons in macular hole surgery for safer application
of indocyanine green (ICG) to stain the inner limiting membrane (ILM) while minimizing
the risk of retinal pigment epithelium (RPE) exposure with good results (Figure
1). Its use as a short-term tamponade of inferior retinal pathologies is also an
area of continued investigation.5
A natural evolutionary focus includes the search
for perfluorocarbon-related liquids with safer profiles for longer-term postoperative
tamponade of inferior retinal breaks.5
Though the search for an ideal compound continues, some progress has been made.
The recent introduction of heavy oil mixtures as inferior tamponade agents has shown
initial promise in the management of cases with proliferative vitreoretinopathy
as well as those with inferior retinal breaks.6-8
Although attractive as a tamponade agent, the long-term effects of heavy silicone
oil are unknown and its subsequent removal from the eye is a very challenging maneuver,
particularly in the setting of an underlying re-detached retina.
Figure 2. This patient presented with an idiopathic
epiretinal membrane and preoperative visual acuity of 20/100. A. Placement of
the first microcannula. The microcannula is being held by its collar to stabilize
it while the trocar is withdrawn. B. An infusion cannula has been placed in the
infe-rotemporal quadrant. No suture is required to hold it in place, because it
fits tightly into the microcannula. In the same frame, a second microcannula is
being placed. The insertion of the microcannula is transconjunctival, and no previous
dissection is required. C. After insertion of the second microcannula, its orifice
was temporarily closed with a plug (black arrow), and a third microcannula was inserted
(white arrow). D. After vitrectomy and membrane peel, all the microcannulae were
simply removed. No suture was required at any conjunctival and scleral opening site.
In this frame, the superonasal microcannula is being removed.E. Last, the inferotemporal
microcannula is being removed in conjunction with the infusion cannula held by its
collar.F. The eye immediately after the removal of all microcannulae. This sutureless
and self-sealing system allowed for minimal postoperative discomfort and hastened
the recovery by minimizing the surgically induced trauma. Intraocular pressure at
first postoperative visit was 12 mm Hg. Visual acuity was measured at 1 week in
this case and improved to 20/40.
recent revolutionary trend in vitreoretinal surgery was the introduction of the
transconjunctival sutureless25-gauge vitrectomy system (Figure 2).9
This technique has allowed for reduced surgical trauma, duration of surgery, and
postoperative healing time. The success of 25-g vitrectomy has been well described,
but its application for more complex vitreoretinal diseases, such as complex retinal
detachment with proliferative vitreoretinopathy, has been limited. The main limiting
factors with the 25-gsystem are the relative lack of instrument rigidity, slower
vitreous cutting ability, and suboptimal fluidics inherent to the reduced caliber
of the instrumentation. The risk of postoperative hypotony from leaking wounds that
persist despite partial fluid-air exchange has been reported as well.
Some retinal surgeons have described the technique of 20-g sutureless
vitrectomy to overcome some of the limitations of 25-g systems, but inconsistencies
in the application of this technique have limited its widespread use. This has led
to the evolutionary compromise between these two techniques: 23-g transconjunctival
This system combines the advantages of decreased surgical trauma and recovery time
enjoyed with 25-g sutureless vitrectomy with the sturdier instrumentation and improved
fluidics of the 20-g vitrectomy systems. These characteristics make 23-g vitrectomy
a promising approach to efficiently and safely tackle the complete range of vitreoretinal
surgical procedures with a single system (Figure 3).
Optimal visualization is the starting point of any successful
retinal surgery; as such, the development of wide-angle viewing systems has greatly
expanded the scope and safety of vitreoretinal surgery. Today, the 2 types of wide-angle
systems include both contact and noncontact lenses.11
Both deliver a large field (up to 150Þ) of view during vitreoretinal surgery,
leading to a safer and more complete vitrectomy. Modern contact lenses include those
that are more compact, allowing the surgeon to visualize the scleral ports at all
times, hence facilitating the insertion and removal of instruments without removal
of the lens (Figure 4).12
Newer lenses also ease indented examination of the peripheral retina, providing
better access to peripheral fundus pathologies. Increasingly complex vitreoretinal
maneuvers are also made possible by the smaller diameter contact lenses, allowing
for further instrument mobility. These developments combine to improve the efficiency
of vitrectomy surgery.
evolution of endoillumination systems was driven by the need for a brighter, wider,
and more even field of illumination to utilize the wider fields newer lenses have
provided. Evolution to modern xenon arc lighting has brought vivid and uniform illumination,
while reducing the reflections and scattering glare encountered in air-filled eyes.
This is particularly important in the current trend toward smaller-gauge (23- and
25-g) sutureless vitrectomy techniques, which have inherently lowered illumination
compared with 20-g systems. Other advances have included the addition of bullet
probes to enhance wide-field endo-illumination, shielded bullet probes to provide
up to 180Þ of illumination while controlling glare (Figure 5),13
and more recently, chandelier lighting systems (Figure 6).14
Lighted instruments likewise have been introduced to the surgical armamentarium
to further ease complex tissue manipulations by aiding bimanual surgery. Potential
improvements on current systems include the use of slit-lamp illumination combined
with a wide-angle contact lens during vitrectomy to provide a wide field of view
and sufficient illumination. This approach obviates the need for light pipe illumination,
thereby enhancing the use of bimanual surgical techniques (Figure 7).15
NOVEL SURGICAL DEVICES
The ability to address more complex retinal pathologies as outlined
above, including those with retinal neovascularization and preretinal fibrous proliferation,
has also brought greater attention to the intraoperative difficulties some of these
cases pose. In addition to bleeding, the dissection of epiretinal tissue is often
fraught with the creation of iatrogenic retinal breaks. Investigations have aimed
to equip surgeons with intraocular tools with multiple functions to better meet
these challenges and ease bimanual surgery. Ideally they would also minimize the
need for frequent introduction and removal of instruments from the eye. Progress
is reflected in the creation of lighted vitrectomy instruments and multifunction
tissue manipulators with diathermy and aspiration.
Figure 3. Technique
for tunnel incision and insertion of the microcannulae. A. 23-g stiletto blade is
inserted transconjunctivally into the sclera at a 30° to 45° angle. B.
The inserter is introduced into the tunnel incision. C. To insert the microcannulae
into the tunnel, the inserter is moved from its original tangential position into
a position perpendicular to the scleral surface, where it exerts the necessary pressure
on the globe. D. Microcannula in place within the tunnel incision after removal
of the inserter.
that retinal traction created by epiretinal tissue dissections predispose to bleeding
and breaks, the pulsed electron avalanche knife (PEAK-fc) was designed to eliminate
these surgically created forces. This novel electrosurgical knife has, in initial
reports, been capable of precisely dissecting tissue without the use of traction.
By harnessing pulsed plasma-mediated discharges, it has allowed for accurate and
controlled retinal incisions and tissue dissections. Furthermore, its design has
incorporated both illumination and coagulation capabilities to optimize its functionality
as a surgical tool (Figure 8).16
Continued experience with, and greater availability of, this tool will help identify
its safety profile for intraocular use and its range of application. (Currently
it is not available commercially.)
NEW SURGICAL TECHNIQUES
As the tools needed to perform vitreoretinal surgery have become
increasingly more ergonomic, efficient, and reliable, the spectrum of surgical indications
and techniques has expanded. Perhaps the best and most successful example of this
principle has been the description of vitrectomy and subsequent gas tamponade for
the closure of macular holes.17
This revolutionary procedure has allowed for the successful visual rehabilitation
of countless patients who previously had incurable conditions.18
While the initial report achieved a then-astounding 58% closure rate, successful
application of vitrectomy for macular holes has seen an increase to greater than
90% success. This increased closure rate reflects the continuing evolution of the
surgical technique. Though not endorsed by all surgeons, ILM peeling is a radical
modification introduced to the management of macular holes. The choice of tamponade
agent has also varied by authors. The continued improvement of macular hole surgery
includes shorter positioning times after surgery to ease patient recovery; some
authors advocate only 4 days of face-down positioning while others have attempted,
with some success, no positioning at all.19,20
Increased experience will lead to the further evolution of this already successful
surgery with increasing closure rates and decreasing patient recovery times.
Improved vision after successful macular hole closure reflects
the relative preservation of the retinal photoreceptors and the underlying RPE.
It is, however, the lack of a healthy underlying RPE in age-related macular degeneration
(AMD) that led to the pioneering surgical technique of macular translocation.21
This revolutionary concept, though used less commonly today due to improved pharmacologic
treatments for choroidal neovascularization, represented a major paradigm shift
in vitreoretinal surgery. Another revolutionary technique proposed for the management
of AMD was that of submacular surgery. At the time of its initial description in
1988, there were essentially no effective treatments for submacular hemorrhage.22
The novel concept of intentionally creating posterior macular incisions to gain
access to the submacular space mandated innovation in technique and instrumentation.
Though revolutionary at the time of their initial descriptions, the importance of
macular translocation and submacular surgery as techniques may still have even greater
import in future experimental treatments, such as stem-cell transplantation or in
the placement of artificial visual implants.
Figure 4. New wide-angle viewing lens, ClariVIT
(left) and the section of ClariVIT (right). ClariVIT is partially truncated, and
the diameter is greatly reduced. This section of ClariVIT shows the relationship
of two bonded parts: PMMA and glass.
Current trends in vitreoretinal surgery, as in other surgical
specialties, revolve around the minimization of surgical trauma. This minimally
invasive shift in vitreoretinal practice has led to decreased patient recovery times
and less postoperative discomfort. Current efforts to further diminish iatrogenic
injury include the experimental use of enzymes or chemically active substances to
create and/or facilitate vitrectomy. The use of plasmin prior to vitrectomy has
been shown to create a posterior vitreous detachment in a substantial percentage
of cases.23,24 These agents
are being evaluated as adjuncts to vitrectomy to ease the vitreoretinal traction
induced during intraoperative posterior hyaloid separation. Even less invasive is
the concept of pars plana injection of these agents as monotherapy for conditions
such as vitreous hemorrhage.25
The importance of pars plana delivered anti-vascular endothelial
growth factor (VEGF) therapy in retinal and choroidal neovascular processes, as
well as in certain venous occlusive states,26
has recently gained attention for non-surgical conditions. The ability of these
agents to induce regression of new vessels has been increasingly documented in the
it is an attractive concept to inject anti-VEGF agents prior to surgery in an effort
to minimize intraoperative bleeding in eyes with retinal proliferative diseases.
Future studies will hopefully determine the safety and efficacy of these medications
for this indication.
5. The wide-angle endoilluminator. Note almost 180° spread of the light from
the tip of the probe.
The revolutionary off-label use of intravitreal triamcinolone
acetonide (IVTA) injection in many ways has paved the way for our clinical use of
pharmacologic agents. The evolution of IVTA use has affected surgical practice as
well. As an adjunct during surgery, IVTA has proved to be an effective marker to
highlight residual vitreous on the retinal surface. In the same manner, substances
such as ICG and trypan blue, though initially meant for other ocular uses, have
become integral tools to successful vitreoretinal surgery in off-label capacities.
In summary, vitreoretinal surgery is a specialty that has rapidly
progressed and that continues to incorporate new technologies and techniques. Revolutionary
changes have allowed for the successful management of previously inoperable states,
and they have served as the impetus for continued evolution. The spectrum of vitreoretinal
surgical indications has grown because of a wider array of instrumentation with
improved safety profiles. These improved abilities have allowed for the attempted
repair of more severe conditions that have necessitated, out of their complexity,
further surgical innovation to optimize patient outcomes. The future may bring robotic-assisted
vitreoretinal surgery for fine manipulations not currently achievable by humans;
artificial vision with retinal, choroidal, or cortical implants; advances in pharmacotherapy-assisted
surgical techniques, including inhibitors of proliferative vitreoretinopathy and
gene therapy; and other techniques that we have yet to imagine. It is clear that
current trends will continue to redefine vitreoretinal surgical procedures and that
an exciting era of minimally invasive, yet maximally effective, surgical approaches
is on the horizon.
Figure 6. Schematic
of Awh Chandelier, providing wide-field illumination to allow for bimanual surgery
with a low risk of macular phototoxicity due to the significant distance between
the light source and the posterior pole.
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7. (Left) Fundus view illuminated by a light pipe through a wide angle viewing contact
lens. (Right) Fundus viewing illuminated by a slit lamp through a wide angle viewing
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("heavy silicone oil") as internal tamponade for complicated retinal detachment.
9. Fujii GY, De Juan E Jr, Humayun MS, et al. Initial experience
using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery.
10. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy.
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viewing of the fundus during vitrectomy. Arch Ophthalmol. 1995;113:1572-1573.
12. Nakata K, Ohji M, Ikuno Y, et al. Wide-angle viewing lens
for vitrectomy. Am J Ophthalmol. 2004;137:760-762.
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16. Priglinger SG, Haritoglou C, Mueller A, et al. Pulsed electron
avalanche knife in vitreoretinal surgery. Retina. 2005;25:889-896.
Figure 8. Drainage retinotomy on attached retina.
Patient had minor subretinal bleeding with age-related macular degeneration. Extrafoveolar
retinotomy on attached retina was performed, and subretinal bleeding and choroidalneovascularizations
were removed successfully. Pulsedelectron avalanche knife parameters (determined
for safe dissection of the neurosensory retina 15): voltage, 350 V; pulse repetition
rate, 30 Hz; pulse duration, 100 microseconds; and 30 minipulses per pulse.
17. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular
holes. Results of a pilot study. Arch Ophthalmol. 1991;109:654-659.
18. Williams GA. Macular holes: the latest in current management.
Retina. 2006;26(6 Suppl):S9-S12.
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hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology.
20. Tornambe PE, Poliner LS, Cohen RG. Definition of macular hole
surgery end points: elevated/open, flat/open, flat/closed. Retina. 1998;18:286-287.
21. Machemer R, Steinhorst UH. Retinal separation, retinotomy,
and macular relocation: II. A surgical approach for age-related macular degeneration?
Graefes Arch Clin Exp Ophthalmol. 1993;231:635-641.
22. de Juan E Jr, Machemer R. Vitreous surgery for hemorrhagic
and fibrous complications of age-related macular degeneration. Am J Ophthalmol.
23. Rizzo S, Pellegrini G, Benocci F, Belting C, Baicchi U, Vispi
M. Autologous plasmin for pharmacologic vitreolysis prepared 1 hour before surgery.
24. Williams JG, Trese MT, Williams GA, Hartzer MK. Autologous
plasmin enzyme in the surgical management of diabetic retinopathy. Ophthalmology.
25. Hermel M, Mahgoub M, Youssef T, et al. Safety profile of the
intravitreal streptokinase-plasmin complex as an adjunct to vitrectomy in the rabbit.
Graefes Arch Clin Exp Ophthalmol. 2006;244:996-1002.
26. Iturralde D, Spaide RF, Meyerle CB,et al. Intravitreal bevacizumab
(Avastin) treatment of macular edema in central retinal vein occlusion: a short-term
study. Retina. 2006;26:279-284.
27. Spaide RF, Fisher YL. Intravitreal bevacizumab (Avastin) treatment
of proliferative diabetic retinopathy complicated by vitreous hemorrhage. Retina.
MD, Howard F. Fine, MD, MHSc, and I-Van Ho, MBBS, practice ophthalmology at Vitreous
Retina Macula Consultants of New York. Dr. Fine is also a postdoctoral clinical
fellow with the Harkness Eye Institute of the Columbia University College of Physicians
and Surgeons in New York. None of the authors has any financial interest in any
of the information contained in this article. They can be contacted at (212) 861-9797.
Retinal Physician, Issue: November 2006