ABSTRACT.Purpose: Four-port bimanual vitrectomy is a surgical technique that facilitates removal of epiretinal membranes in severe proliferative diabetic retinopathy (PDR). As the illumination is held by the assistant through the fourth scleral incision, fibrovascular membranes are removed by bimanual manipulation techniques. The objective of this study was to evaluate the safety and efficacy of four-port bimanual 23-gauge vitrectomy for patients with tractional retinal detachment (TRD) in severe PDR. Methods: Retrospective, comparative, consecutive, interventional case series. Sixty-six eyes of 58 consecutive patients who underwent primary vitrectomy for severe diabetic TRD. Thirty-six eyes of 31 cases that were treated with four-port 23-gauge vitrectomy were compared with 30 eyes of 27 cases that were treated with 23-gauge pars plana vitrectomy (PPV). Main outcome measures were bestcorrected visual acuity (BCVA), retinal status, intraocular pressure, and incidence of intraoperative and postoperative complications with at least 6 months of follow-up. Results: The primary and ultimate anatomic success rates (94.4% versus 93.3%, and 100% in both groups, respectively) and the mean BCVA changes did not differ significantly between groups. The whole surgical time and the membrane removal time were significantly (p < 0.001, respectively) shorter in the four-port 23-gauge group than in the 23-gauge group. There was no difference in the incidence of intraoperative and postoperative complications in both groups. Conclusions: Four-port bimanual 23-gauge vitrectomy offers comparable anatomic success and shortens the surgical time compared with conventional 23-gauge PPV in patients with TRD resulting from severe PDR.
D espite continuing improvements in machines and surgical techniques for phacoemulsification, dislocation of crystalline lens fragments into the vitreous cavity is an uncommon but has potentially serious complications. The rate of retained lens fragments during phacoemulsification is estimated to be 0.3% to 1.1%. 1,2 Retained lens fragments can lead to intraocular inflammation, cystoid macular edema, epiretinal membrane formation, phacoanaphylaxis, increased intraocular pressure (IOP), and corneal edema and may be associated with retinal detachment. 3 Pars plana vitrectomy (PPV) for posteriorly dislocated lens fragments has been reported to be associated with visual acuity improvement and control of inflammation and IOP in most patients. Although the best time at which vitrectomy should be performed after cataract surgery is under debate, immediate or early vitrectomy theoretically should reduce the severity of uveitis, the incidence of cystoid macular edema, and glaucoma, 4,5 and these findings have been reported in some series. 6-9 However, immediate PPV can be difficult for cataract surgeons who have not been trained in the technique. 10 As a general rule, cataract surgeons who have experience with retinal surgery can remove dislocated nuclear fragments during cataract surgery if the appropriate basal vitreal instruments are available.More recently, Nakasato et al 11 reported a new surgical technique of removing dislocated nuclear fragments with fragmatome with 27-gauge chandelier endoilluminator fiber through the sclerocorneal incision made for cataract surgery. The limitations of this method were a relatively large sclerocorneal incision and been used in the dislocated nuclear fragments smaller than one fourth of the size of the lens nucleus. Furthermore, some additional kinds of equipment or instruments are needed. 12 In this study, we report our experience in immediately removing dropped lens fragments that are smaller than one half of the size of the lens nucleus during complicated cataract surgery. The technique is simple and useful because posterior core vitrectomy and lens removal can be performed through three corneal ports without additional equipment and instruments. Patients and MethodsThe medical records of all consecutive patients were identified by searching the Department of Ophthalmology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, from April 2007 through December 2011. All surgeries were performed by the same experienced surgeon (P.-Q.Z.) using the Accurus 800 CS Phaco-Vitrectomy System (Alcon Laboratories, Fort Worth, TX). Pre-, intra-, and postoperative medical record data were retrospectively collected. Demographic information, preexisting eye diseases, previous eye surgical procedures, pre-and postoperative ocular medications, and details of the initial and final examinations including best-corrected visual acuity, IOP, PPV surgery details, and postoperative complications were noted. All patients were examined for posterior vitreous detachment by B-scan ultrasonograp...
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