Clear Corneal Vitrectomy Combined with Phacoemulsification and

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Clear Corneal Vitrectomy Combined with
Phacoemulsification and Foldable Intraocular
Lens Implantation.
Takeshi Iwase?, Tsuyoshi Yoshita? and Kazuhisa
Sugiyama2
1) Toyama Prefectural Central Hospital, Toyama,
Japan 2) Kanazawa University Graduate School of
Medical Science, Kanazawa, Japan
None of the authors have a financial or
proprietary interest in any product mentioned.
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Purpose

• Recently, modification in vitrectomy instruments
  have led to a decrease in size of the instruments
  and consequently in smaller incisions. It has
  been introduced a 25-gauge transconjunctival
  sutureless vitrectomy system (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
  disease. On the other hand, in cataract surgery
  alone, it is possible to reduce postoperative
  inflammation with a clear corneal incision rather
  than a corneoscleral incision. Herein, we have
  invented a vitrectomy in which all wounds could
  be closed without suture in simultaneous cataract
  surgery and vitrectomy from clear corneal
  incision.

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Patients
Surgery was carried out based on the approval of
the institutional review board and the ethical
standard established by the Declaration of
Helsinki. 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.
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Excluded criteria

• History of intraocular surgery
• Uveitis
• Retinitis pigmentosa
• Pseudoexfoliation syndrome
• Retinal tear, retinal detachment
• Lattice degeneration

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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.)
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Surgical technique

• Retrobulbar anesthesia (2 Xylocaine).
• Corneal side ports (0.5 mm in width, at 2, 4, 10
  oclock ((and 8 oclock in right eye)).
• CCC (5.0 to 5.5 mm diameter, from the 10 oclock
  port).
• clear corneal tunnel of 3.0 mm in width.
• Hydrodissection.
• PEA(a phaco-chop hook was inserted from the 4
  oclock port )
• (Fig. 1A).
• I/A.
• Posterior CCC (25-gauge ILM forceps through the
  10 oclock port ) (Fig. 1B).

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• Infusion cannula (23-gauge) was inserted from the
  infero-temporal port (Fig. 1C).
• 30contact lens (the brim was partially cut)
  (Fig. 1D).
• 25-G vitrectomy(vitreous cutter and a light guide
  were inserted from the 2 or 10 oclock 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).

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Results

1. Two patients required sutures to close the 10
   oclock 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 surgery.
6. There was neither any residual pre-macular
   membrane nor retinal detachment or hemorrhage.

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7. The condition of the IOL fixed in the
capsule was satisfactory . 8. A paired t test
revealed a statistically significant improvement
in visual acuity at 1 week (P 0.011) and 3
months (P 0.002) postoperatively. 9. There
were no significant differences in IOP throughout
the follow-up (paired t test).
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Discussion
In the present system, postoperative inflammation
was less probably because only corneal incision
was performed without conjunctiva and sclera
disturbance. Only small sutureless clear corneal
incision even in vitrectomy is of great advantage
to both patients and surgeons. For patients, it
causes less postoperative foreign-body sensation,
allows a shorter recovery time, and absence of
incision in the conjunctiva and sclera results in
better appearance of the operated eye after the
surgery due to the absence of conjunctival
hemorrhage or congestion. For surgeons, it
simplifies operative procedures, not required
peritomy, infusion line fixation and suturing the
incisions. In the TSV25, high force is required
for incision, because of the needle-like design
of the trocar and the stepped-up diameter at the
transitional area from the trocar to the cannula.
In contrast, high force for incision is not
needed
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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 the vitreous body into the scleral
incision ports in the TSV25. Retinal tears may
also develop due to traction force on the retina
accompanying postoperative contraction of the
vitreous fibers, which are incarcerated into the
sclerostomy incision. The present system is more
advantageous than TSV25 from the aspect of
preventing postoperative complications associated
with retinal disease.
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Conclusions
Clear corneal incision vitrectomy caused shorter
operating time and less postoperative ocular
irritation than combined surgery with 25-gauge
transconjuntival vitrectomy. Therefore, this
procedure would be a good option for selected
cased with cataract and vitreoretinal diseases.