Vitreous Wiping, a new technique for removal of vitreous cortex remnants during vitrectomy

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Abstract

Purpose

Unremoved vitreoschisis‐induced vitreous cortex remnants ( VCR) are associated with macular pathology. When present on the retinal periphery, they may play a role in proliferative vitreoretinopathy and retinal detachment after vitrectomy. Existing instruments for their removal involve substantial risk of iatrogenic retinal damage. Purpose of this study was to evaluate the use of a new technique, Vitreous Wiping, for removal of VCR during vitrectomy.

Methods

Proof‐of‐concept case series of six eyes (six patients) treated with vitrectomy for various pathologies (macula‐on and macula‐off retinal detachment, macular hole, macular pucker and vitreous floaters). Vitreous cortex remnants on the surface of the retina were visualized with triamcinolone and removed by Vitreous Wiping with a rectangular piece of polyvinyl alcohol ( PVA) held with intra‐ocular forceps. Visual acuity and clinical course were assessed during a follow‐up of 6 months. All eyes underwent postoperative macular optical coherence tomography. Eyes without preoperative macular pathology, underwent retinal sensitivity testing and eyes without paracentral pathology underwent visual field analysis.

Results

Vitreous cortex remnants could be removed completely in all eyes. There were no intra‐ or postoperative complications. We observed that PVA is soft like a sponge and vitreous sticks to it, making Vitreous Wiping easier and safer, compared to alternative instruments. Visual acuity improved in all eyes. Microperimetry and visual field analysis revealed no abnormalities related to Vitreous Wiping.

Conclusion

Vitreoschisis‐induced VCR can be removed effectively and safely from the retinal surface by Vitreous Wiping. Larger studies are needed to confirm this promising finding and its potential impact.

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Most cited references 24

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Fluocinolone acetonide implant (Retisert) for noninfectious posterior uveitis: thirty-four-week results of a multicenter randomized clinical study.

, Daniel Martin, Jeffrey Pearson … (2006)

To report the interim 34-week safety and efficacy results of a 3-year study to evaluate an investigational intravitreal fluocinolone acetonide (FA) implant in patients with noninfectious posterior uveitis. Prospective, dose-masked, dose-randomized, historically controlled, multicenter trial in patients with unilateral or bilateral disease. A total of 278 patients with recurrent noninfectious posterior uveitis were randomized to receive a 0.59-mg (n = 110) or 2.1-mg (n = 168) implant. In patients with bilateral disease, the more severely affected eye received the implant. The implant was inserted surgically into the vitreous cavity through a pars plana incision. Follow-up visits were scheduled on day 2, week 1, and then every 4 to 6 weeks through 34 weeks after implantation. Systemic, periocular, and topical therapies were reduced as allowed by the clinical response. The primary efficacy outcome was a comparison of the recurrence rate in the implanted eye from the 34 weeks before implantation to the 34 weeks after implantation. Visual acuity (VA), need for adjunctive therapy, and safety also were assessed. Combining both doses, the FA implant reduced the rate of recurrences from 51.4% in the 34 weeks preceding implantation to 6.1% postimplantation (P or =2 grades in 19.8% of phakic implanted eyes, and 9.9% required cataract surgery. There were no statistically significant differences in any of the parameters studied for the 0.59-mg implant, compared with the 2.1-mg implant. The FA implant significantly reduced uveitis recurrences, improved VA, and decreased the need for adjunctive therapy in the studied patient population. The most common side effects included increased intraocular pressure and cataract progression.

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Treatment of posterior uveitis with a fluocinolone acetonide implant: three-year clinical trial results.

Larry D. Martin, Aislinn Pearson, D Callanan … (2008)

To evaluate the safety and efficacy of 0.59-mg and 2.1-mg fluocinolone acetonide (FA) intravitreous implants in noninfectious posterior uveitis. A 3-year, multicenter, randomized, historically controlled trial of the 0.59-mg FA intravitreous implant in 110 patients and the 2.1-mg FA intravitreous implant in 168 patients. Recurrence rate, vision, and complications. Uveitis recurrence was reduced in implanted eyes from 62% (during the 1-year preimplantation period) to 4%, 10%, and 20% during the 1-, 2-, and 3-year postimplantation periods, respectively, for the 0.59-mg dose group (P or = 10 mm Hg) than nonimplanted eyes (P < .01), and glaucoma surgery was required in 40% of implanted eyes vs 2% of nonimplanted eyes (P < .01). Cataracts were extracted in 93% of phakic implanted eyes vs 20% of phakic nonimplanted eyes (P < .01). The FA implant significantly reduced uveitis recurrence and improved or stabilized visual acuity in subjects with noninfectious posterior uveitis. Most subjects required cataract extraction, and a significant proportion required intraocular pressure-lowering surgery. The FA implant provides an alternative therapy for prolonged control of inflammation in noninfectious posterior uveitis. clinicaltrials.gov Identifier: NCT00407082.

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Rhegmatogenous Retinal Detachment: A Reappraisal of Its Pathophysiology and Treatment

Ferenc Kuhn, F Kuhn, Bill Aylward (2013)

This article represents a synthesis of an extensive literature review and the authors' decades-long personal experience with both scleral buckling (SB) and vitrectomy for rhegmatogenous retinal detachment (RD). Presenting a coherent understanding of the pathophysiology and treatment of RD, the authors confirm numerous findings described in earlier publications but also challenge certain long-standing dogmas. The key argument made here is that it is extremely rare for the chain of events leading to an RD to start with a retinal pathology. Rather, the initial pathology is syneresis of the vitreous , which then allows gel movement (intraocular currents). At the point of vitreoretinal adhesion, dynamic traction is exerted on the retina, which may be sufficient to tear it. If the tear is operculated and the dynamic traction overcomes the forces keeping the neuroretina and retinal pigment epithelium (RPE) together, the heretofore virtual subretinal space becomes accessible through the retinal tear. The intraocular currents allow the free (nonbound) intravitreal fluid to enter the subretinal space, and once the amount of the incoming fluid overwhelms the draining capacity of the RPE, an RD ensues. Detachment of the posterior cortical vitreous (PVD) is not a necessary prerequisite to RD development; furthermore, PVD cannot be diagnosed preoperatively with adequate certainty with current technology such as biomicroscopy, ultrasonography or optical coherence tomography. The surgeon should expect no or only partial (anomalous) PVD at the time of surgical repair in over half of eyes. The treatment's primary goal must thus be weakening (pneumatic retinopexy, SB) or eliminating (vitrectomy) this dynamic traction. If vitrectomy is employed, it must be a truly complete vitreous removal. This includes a surgically induced PVD if one is not present, close shaving at the periphery, and removing the vitreous immediately behind the lens. The vitrectomy is followed by the creation of a chorioretinal scar around the tear and aided by some form of intraocular tamponade. The main function of the tamponade is not to temporarily cover the break but to significantly reduce the intraocular currents and thus prevent fluid entry through the break until the chorioretinal adhesion will have become sufficiently strong to seal the retinal edge around the tear; postoperative positioning is therefore not as important as currently assumed.

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Author and article information

Contributors

Koen A. van Overdam:

ORCID: http://orcid.org/0000-0002-5425-7210

k.vanoverdam@oogziekenhuis.nl

Journal

Journal ID (nlm-ta): Acta Ophthalmol

Journal ID (iso-abbrev): Acta Ophthalmol

Journal ID (doi): 10.1111/(ISSN)1755-3768

Journal ID (publisher-id): AOS

Title: Acta Ophthalmologica

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 1755-375X

ISSN (Electronic): 1755-3768

Publication date (Electronic): 07 December 2018

Publication date (Print): August 2019

Volume: 97

Issue: 5 ( doiID: 10.1111/aos.2019.97.issue-5 )

Pages: e747-e752

Affiliations

[ ¹ ] Department of Vitreoretinal Surgery The Rotterdam Eye Hospital Rotterdam the Netherlands

[ ² ] The Rotterdam Ophthalmic Institute Rotterdam the Netherlands

Author notes

[*] [* ] Correspondence:

Koen A. van Overdam, MD

Vitreoretinal Surgery Department

The Rotterdam Eye Hospital

Schiedamse Vest 180

3011 BH, Rotterdam

the Netherlands

Tel: +31 (0)10 401 77 77

Fax: +31 (0)10 401 77 55

Email: k.vanoverdam@ 123456oogziekenhuis.nl

Author information

Koen A. van Overdam http://orcid.org/0000-0002-5425-7210

Jan C. van Meurs http://orcid.org/0000-0002-5385-7943

Sonia S. Manning http://orcid.org/0000-0002-5477-5499

Article

Publisher ID: AOS13991

DOI: 10.1111/aos.13991

PMC ID: 6766987

PubMed ID: 30536726

SO-VID: e2ad22e1-0717-4e7e-a856-f17957d8d3d5

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

History

Date received : 24 July 2018

Date accepted : 11 November 2018

Page count

Figures: 2, Tables: 1, Pages: 6, Words: 5125

Custom metadata

source-schema-version-number 2.0

component-id aos13991

cover-date August 2019

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.9 mode:remove_FC converted:30.09.2019

ScienceOpen disciplines: Ophthalmology & Optometry

Keywords: proliferative vitreoretinopahty,redetachment,vitreoschisis,vitreous cortex remnants,vitreous wipe,vitreous wiping

Data availability:

ScienceOpen disciplines: Ophthalmology & Optometry

Keywords: proliferative vitreoretinopahty, redetachment, vitreoschisis, vitreous cortex remnants, vitreous wipe, vitreous wiping

Vitreous Wiping, a new technique for removal of vitreous cortex remnants during vitrectomy

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Karger: Ophthalmology

Most cited references 24

Fluocinolone acetonide implant (Retisert) for noninfectious posterior uveitis: thirty-four-week results of a multicenter randomized clinical study.

Treatment of posterior uveitis with a fluocinolone acetonide implant: three-year clinical trial results.

Rhegmatogenous Retinal Detachment: A Reappraisal of Its Pathophysiology and Treatment

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