Clear Corneal Vitrectomy Combined with Pha

coemulsification and

Foldable Intraocular Lens Implantation.

Takeshi Iwase, Tsuyoshi Yoshita and Kazuhisa Sugiyama2

1) Toyama Prefectural Central Hospital, Toyama, Japan2) Kanazawa University Graduate School of Medical Science, Kanazawa, Japan

None of the authors have a financial or proprietary interest in any product mentioned.

PurposeRecently, modification in vitrectomy instruments have led to a decreas

e in size of the instruments and consequently in smaller incisions. It ha

s been introduced a 25-gauge transconjunctival sutureless vitrectomy s

ystem (TSV25) and found it to be a safe surgical procedure in a variety

of vitreoretinal pathologies. However, sclerostomy is still necessary in

the TSV25 and this may induce complications associated with retinal d

isease. On the other hand, in cataract surgery alone, it is possible to red

uce postoperative inflammation with a clear corneal incision rather tha

n a corneoscleral incision. Herein, we have invented a vitrectomy in w

hich all wounds could be closed without suture in simultaneous catarac

t surgery and vitrectomy from clear corneal incision.

PatientsSurgery was carried out based on the approval of the institutional revie

w board and the ethical standard established by the Declaration of Hels

inki. After an explanation of the purpose of the study, informed consent was obtained from all patients. A total of consecutive seven patients who had cataract and epi-retinal membrane (ERM) underwent phacoemulsification, intra-ocular lens (IOL) implantation and vitrectomy. They were followed up over 3 months after surgery.

• History of intraocular surgery

• Uveitis

• Retinitis pigmentosa

• Pseudoexfoliation syndrome

• Retinal tear, retinal detachment

• Lattice degeneration

Excluded criteria

Methods• Performing combined cataract surgery with vitrectomy

（ see surgical technique ）• Visual acuity

• Intraocular pressure (IOP)

• Corneal endothelial cell were collected for each patient.

(Snellen visual acuity was converted to their logarithm of the minimum angle of resolution (Log MAR) units to create a linear scale of visual acuity.)

Surgical technique

• Retrobulbar anesthesia (2% Xylocaine).

• Corneal side ports (0.5 mm in width, at 2, 4, 10 o’clock ((and 8 o’clock in right eye)).

• CCC (5.0 to 5.5 mm diameter, from the 10 o’clock port).

• clear corneal tunnel of 3.0 mm in width.

• Hydrodissection.

• PEA(a phaco-chop hook was inserted from the 4 o’clock port ） (Fig. 1A).

• I/A.

• Posterior CCC (25-gauge ILM forceps through the 10 o’clock port ) (Fig. 1B).

• Infusion cannula (23-gauge) was inserted from the infero-temporal por

t (Fig. 1C).

• 30°contact lens (the brim was partially cut ） (Fig. 1D).

• 25-G vitrectomy(vitreous cutter and a light guide were inserted from t

he 2 or 10 o’clock ports) (Fig. 1E).

• Replacement to a contact lens for observation of the post pole.

• Peeling of ILM （ ILM forceps) (Fig. 1F).

• Confirmation of the periphery of the vitreoretina (Fig. 1G).

• SA60AT (Alcon) was implanted into the capsular bag (Fig. 1H).

• The viscoelastic substance was aspirated using a Simcoe needle.

• Hydration (all corneal incision wounds).

Results1. Two patients required sutures to close the 10 o’clock port ．

2. There was no leakage of aqueous humor from the corneal wounds

and no fibrin formation.

3. The number of inflammatory cells in the anterior chamber seemed

to be similar to the one after cataract surgery ．（ Fig 2) ．

4. The cornea showed neither edema nor wrinkles in the Descemet's

membrane

5. Corneal endothelial cell loss was 8.9 % at the 2 weeks after surger

y.

6. There was neither any residual pre-macular membrane nor retinal

detachment or hemorrhage ．

7. The condition of the IOL fixed in the capsule was satisfactory ．

8. A paired t test revealed a statistically significant improvement in vis

ual acuity at 1 week (P = 0.011) and 3 months (P = 0.002) postopera

tively.

9. There were no significant differences in IOP throughout the follow-u

p (paired t test).

DiscussionIn the present system, postoperative inflammation was less probably be

cause only corneal incision was performed without conjunctiva and scle

ra disturbance. Only small sutureless clear corneal incision even in vitre

ctomy is of great advantage to both patients and surgeons. For patients,

it causes less postoperative foreign-body sensation, allows a shorter rec

overy time, and absence of incision in the conjunctiva and sclera results

in better appearance of the operated eye after the surgery due to the abs

ence of conjunctival hemorrhage or congestion. For surgeons, it simplif

ies operative procedures, not required peritomy, infusion line fixation a

nd suturing the incisions. In the TSV25, high force is required for incisi

on, because of the needle-like design of the trocar and the stepped-up di

ameter at the transitional area from the trocar to the cannula. In contras

t, high force for incision is not needed

in the present system. Therefore, the set-up in the system is easier than

TSV25.

Sclerostomy is necessary and the wounds are closed by incarcerating th

e vitreous body into the scleral incision ports in the TSV25. Retinal tear

s may also develop due to traction force on the retina accompanying po

stoperative contraction of the vitreous fibers, which are incarcerated int

o the sclerostomy incision. The present system is more advantageous th

an TSV25 from the aspect of preventing postoperative complications as

sociated with retinal disease.

Conclusions

Clear corneal incision vitrectomy caused shorter operating time and les

s postoperative ocular irritation than combined surgery with 25-gauge tr

ansconjuntival vitrectomy. Therefore, this procedure would be a good o

ption for selected cased with cataract and vitreoretinal diseases.