International multi-center study of iatrogenic retinal tears in pars plana vitrectomy

AIM: To study and compare the effect of different surgical settings on the development of iatrogenic retinal tears(IRT) in conventional(20-gauge) and microincisional vitrectomy.METHODS: An international retrospective comparative study of 394 patients who had simple vitrectomy at three tertiary centers. Surgeries were performed by four retina surgeons using different viewing systems. Two groups of eyes were compared: microincisional vitrectomy(327 eyes) and conventional(67 eyes) vitrectomy. An iatrogenic tear was defined as the occurrence of one or more peripheral retinal tears during surgery or at any visit in the first 6 wk postoperatively.RESULTS: Mean age was 67±12 y and 55% were female. Iatrogenic tears occurred in 11/394(2.8%) of eyes. The rate of tears was similar among different surgeons and viewing systems(P=0.93 and P=0.76, respectively). Surgical indication, preexisting pseudophakia/aphakia, induction of posterior vitreous detachment(PVD) during surgery, and the use triamcinolone acetonide didn’t significantly affect the rate of tears(P>0.1 for all factors). A higher rate of tears was found in the conventional group compared to the microincisional group(respectively, 7.5%, 1.8%, P=0.02).CONCLUSION: The rate of IRT in vitrectomy is not significantly affected by surgical indication, preexisting PVD or pseudophakia, or use of triamcinolone or different viewing systems but is significantly higher in conventional vitrectomy. Microincisional platforms improve the safety of vitrectomy regardless of the viewing system used.

Outcomes after combined excisional goniotomy and manual small incision cataract surgery

AIM: To report the long-term outcomes of combined excisional goniotomy and manual small incision cataract surgery(MSICS).METHODS: This is a retrospective case series of patients with open angle glaucoma and visually significant cataracts that underwent combined excisional goniotomy and MSICS with one-year follow-up. The medical history, demographic information, and clinical characteristics of each case were recorded. Data regarding changes in vision, intraocular pressure(IOP), the number of glaucoma medications, and the evolution of the disease after surgery were reported. RESULTS: Three patients, with open angle glaucoma and cataracts underwent combined excisional goniotomy and MSICS without adverse events. All patients had improvement in vision compared to baseline measurements. The range of IOP at baseline was from 14 to 18 mm Hg and decrease to a range of 10 to 14 mm Hg after one year of follow-up. Additionally, two patients also decreased their dependence on IOP-lowering medications at the last follow up visit with one patient maintaining baseline level of medication use.CONCLUSION: A combination of excisional goniotomy and MSICS illustrates both the safety and efficacy to treat patients with visually significant cataract and glaucoma. This procedure allows for a more cost-effective surgical approach that matches the needs of resource strained territories around the globe.

Outcomes of 1.8-3.0 mm incision phacoemulsification combined with trabeculectomy for primary angle-closure glaucoma with cataract

●AIM:To compare efficacy of coaxial microincisions(1.8 mm,2.2 mm)and small incisions(3.0 mm)on phacoemulsification combined with trabeculectomy for primary angle-closure glaucoma(PACG)with cataract.●METHODS:Ninety-six patients(96 eyes)with PACG and cataract were recruited and randomly divided into three groups between January 2015 and June 2017.Group A(3.0 mm incision),B(2.2 mm incision),and C(1.8 mm incision)comprised 30,34 and 32 eyes respectively.All cases were treated with clear corneal incision phacoemulsification combined with trabeculectomy.Data including best corrected visual acuity(BCVA),corneal astigmatism,corneal endothelial cell counts(CECC),intraocular pressure(IOP),and complications were collected before the operation,and at postoperative 1 d,1 and 3 mo.●RESULTS:All the patients were successfully treated with surgery.The BCVA of groups B and C were significantly improved as compared to group A at postoperative 1 d,1 and 3 mo(all P<0.05),but there was no difference between groups B and C at each time interval(all P>0.05).The corneal astigmatism of group A was statistically higher than that of group B(P=0.026);corneal astigmatism of group B was statistically higher than that of group C at postoperative 1 d(P=0.006).The corneal astigmatism of group A at postoperative 3 mo was significantly higher than that before operation(P=0.003).At postoperative 1 and 3 mo,corneal astigmatism of groups B and C were significantly lower than that of group A(all P<0.05).The CECC in group B was significantly higher than that of group A(P=0.020),and CECC in group C was significantly higher than that of group B(P=0.034)at postoperative 1 d.At postoperative 1 and 3 mo,CECC of groups B and C were significantly higher than that of group A(all P<0.05).In each group,postoperative mean IOP at each time interval was significantly lower than preoperative IOP(all P<0.05).●CONCLUSION:Coaxial microincision phacoemulsification combined with trabeculectomy for PACG with cataract has better curative efficacy in reducing postoperative corneal astigmatism and corneal endothelial cell injury than traditional small incision combined surgery,and the 1.8 mm microincision has better curative efficacy than 2.2 mm microincision in the early postoperative period.

Corneal biomechanical properties changes after coaxial 2,2-mm microincision and standard 3,0-mm phacoemulsification

AIM： To compare the changes in corneal biomechanics measured by ocular response analyzer （ORA） after 2.2-ram microincision cataract surgery and 3.0-mm standard coaxial phacoemulsification. METHODS： The prospective nonrandomized study comprised eyes with cataract that had 2.2-mm coaxial microincision or 3.0 -mm standard incision phacoemulsification. The corneal hysteresis （CH）, corneal resistance factor （CRF）, corneal-compensated intraocular pressure （IOPcc） and Goldmann-correlated intraocular pressure （IOPg） were measured by ORA preoperatively and at ld, 1-, 2-, 3- and 4-week postoperatively. Results were analyzed and compared between groups. RESULTS： In both groups, CH decreased in the immediate postoperative period （P〈0.05）, returned to the preoperative level at one week （P =0.249） in the 2.2-mm group, and at two weeks in the 3.0-mm group （P --0.264）; there was no significant change in CRF values. In 2.2-mm group, mean IOPcc and IOPg increased at ld postoperatively （both ,P〈0.05）, and returned to preoperative level at one week （,0 =0.491 and P =0.923, respectively）. In 3.0-mm group, mean IOPcc and IOPg increased at ld and lwk postoperatively （P =0.005 and ,P =0.029, respectively）, and returned to preoperative level at 2wk （P =0.347 and P =0.887, respectively）. CONCLUSION： Significant differences between preoperative and postoperative corneal biomechanical values were found for CH, IOPcc and IOPg. But the recovery time courses were different between the two groups. The 2.2-mm coaxial microincision cataract surgery group seemed recovery faster compared to the 3.0-mm standard coaxial phacoemulsification group.

A comparison of surgical efficacy between a 1.8-mm microincision and 3.2-mm and 5.5-mm incisions for phacoemulsification

Phacoemulsification is a commonly used surgical method in cataract surgery. This paper observes and compares the surgical efficacy of three incisions of different length for phacoemulsification to identify the optimal method for cataract surgery. Ninety patients were enrolled in the present study and divided into three groups. The 1.8-mm group received Bausch ＆ Lomb MI60 foldable intraocular lens （IOL） implantation （n=30）, 3.2-mm group received Bausch ＆ Lomb Akreos AO foldable lens implantation （n=30）, and 5.5-mm group received Alcon TYPE 05 rigid IOL implantation （n=30）. Visual acuity, Oculyzer-based anterior segment analysis, and corneal endothelial cell count before surgery, and 3, 7, 30, and 90d after surgery were recorded and compared. Pseudophakic accommodation three days, one week, one month, and three months after surgery was determined. Intraoperative ultrasound time and ultrasonic energy were recorded. It was finally concluded that for phacoemulsification with the same phaco tip, a 1.8-mm microincision can lead to quicker recovery of visual acuity, more stable astigmatism, and higher pseudophakic accommodation than conventional incision.

Bimanual microincision cataract surgery with implantation of the new Incise~? MJ14 intraocular lens through a 1.4 mm incision

AIM：To analyze the visual outcomes and the posterior capsule opacification（PCO）with the new Incise？MJ14intraocular lens（IOL）implanted through a 1.4 mm clear corneal incision（CCI）in patients who underwent bimanual microincision cataract surgery（B-MICS）.METHODS：Eighty eyes which underwent cataract surgery using B-MICS technique performed by the same experienced surgeon were included in the study：40 eyes were implanted with an Incise？MJ14 IOL through a 1.4 mm CCI（group A）without enlargement of the main CCI,while 40 eyes were implanted with an Akreos？MI60 IOL with enlargement of the main CCI to 1.8 mm（group B）.Best corrected visual acuity（BCVA）,astigmatism and endothelial cell loss were evaluated before and after surgery at 7,30d and 6mo.Anterior segment-optical coherence tomography（AS-OCT）of CCI was performed at 1,3,7,30d,6 and 18mo.PCO incidence was evaluated at 18mo using EPCO 2000 Software.RESULTS：Mean BCVA improvement and endothelial cell loss were statistically significant at 18mo in both groups with no difference between the two groups;no statistically significant difference in surgically induced astigmatism（SIA）was noticed in the two groups.At AS-OCT the only significant alterations in the CCI were endothelial gaping and local detachment of Descemet’s membrane at 1 and 7d after surgery;no statistically significant alterations were found at 1,6 and 18mo.PCO score at 18mo was 0.03±0.07for group A and 0.08±0.18 for group B（P=0.11）with no sign of central optic plate invasion in both groups.CONCLUSION：The implant of the new Incise？MJ14 IOL through a 1.4 mm CCI and B-MICS technique appeared to be a safe and effective procedure with rapid visual recovery.PCO rate resulted very low and the CCI presented few morphological alterations which were only detectable in the first days postoperatively and achieved fast corneal healing during the long-term follow-up.

Endoscope-assisted vitrectomy

Ocular endoscopes enable ophthalmologists to observe any part of the retina without any limitations, including those caused by corneal opacities, the rim of the intraocular lens, cortical remnants, capsular opacities, a small pupil, and vitreous opacities. Moreover, ocular endoscopes enable the management of peripheral lesions without scleral indentation and are compatible with microincision vitrectomy surgery. The enlarged view under the endoscope, as obtained by drawing towards the lesion, appears to be another advantage. Rhegmatogenous retinal detachment with undetectable retinal breaks, trauma, endophthalmitis, scleral wounds with incarceration of the vitreous, and microcornea are indications for endoscopic vitrectomy. The combination of endoscopy and a wide-angle viewing system could compensate for the deficiencies of each technique and achieve more effective and safer surgical maneuvers. Endoscopy skills appear to be a great advantage for vitreoretinal surgeons;however, because endoscopies require a learning curve, becoming familiar with the handling of the endoscope through stepby-step learning is necessary.