While seldomly used nowadays, there are still indications for which gauge is necessary including removal of retained lens material using the fragmatome and removal of intraocular foreign bodies IOFB using IOFB forceps. In addition, patients with gauge, sutured wounds may have a decreased rate of endophthalmitis compared to patients undergoing smaller-gauge vitrectomy surgery, a finding possibly related to hypotony and wound leakage more commonly seen in sutureless surgery.
Previous studies have found endophthalmitis rates twelve to twenty-eight times higher with gauge vitrectomy compared to gauge vitrectomy although endophthalmitis rates were low in both groups. Moreover, the previously held concern that small-gauge vitrectomy systems were only suitable for cases not requiring extensive vitrectomy or membrane dissection — such as epiretinal membrane or macular hole cases — due to lack of instrumentation is no longer true given advances in technology.
Visualization of the posterior segment is critical to performing pars plana vitrectomy. The advent of wide-angle viewing systems in the s has revolutionized vitreoretinal surgery by enabling a panoramic view of the posterior segment, thereby enabling safer and more efficient surgery.
There are two main categories of surgical viewing systems: non-contact systems and contact lens systems. Both require the use of an operating microscope. An example of a contact lens system is the Advanced Visual Instruments or AVI system which offers two different handheld lenses: one with a degree view to the equator and one with a degree view to the ora serrata.
It is usually used with Leica scopes. Both lens systems do not require coupling to the corneal surface but viscoelastic is placed on the corneal surface to help maintain a clear view. In addition, no assistant is needed to hold the lens in place as the lenses attach directly to the operating microscope, and they allow for up to degrees of visualization.
For macular surgery, special contact lenses such as the DORC flat vitrectomy lens enable higher resolution and magnification viewing of the posterior pole for more delicate maneuvers such as epiretinal membrane ERM and internal limiting membrane ILM peeling. Below is a list of commonly used instruments in pars plana vitrectomy: [29]. Adequate visualization of tissues and tissue planes is a prerequisite for safe and efficient surgery. Chromovitrectomy — the use of vital dyes during vitreoretinal surgery — aid with such visualization.
An ideal dye should be safe to use intraocularly, easy to apply and remove, and provide adequate staining of the desired tissue. The following section provides an overview of three common surgeries that utilize pars plana vitrectomy: 1 retinal detachment repair, 2 membrane peeling, and 3 crystalline lens removal. The principles of retinal detachment repair via pars plana vitrectomy are to remove the vitreous gel and any vitreoretinal traction, locate and laser any retinal tears, and insert an intraocular tamponade.
To treat conditions such as epiretinal membranes, macular holes, vitreomacular traction, tractional retinal detachments, and proliferative vitreoretinopathy, membrane peeling may be necessary. As with retinal detachment surgery, the initial steps of inserting trocars, performing a core vitrectomy, and inducing a posterior vitreous detachment if not already present are similar.
The degree of peripheral vitrectomy performed may depend on the clinical scenario. Next, attention is turned to the membrane itself that requires peeling. A different set of techniques is used here compared to retinal detachment surgery. With any membrane peel, an initial flap must be created if not naturally present, followed by peeling of the membrane off the retinal surface. Removal of the crystalline lens during pars plana vitrectomy may be needed in several situations.
If visualization of the posterior segment is poor due to media opacity from a cataract, either phacoemulsification or pars plana lensectomy can be performed. If there is retained nucleus or retained cortical fragments causing significant inflammation and intraocular pressure rise, pars plana lensectomy must be performed.
For pars plana lensectomy, soft lenses can be removed using the vitrectomy cutter, but denser lenses may require use of the fragmatome. The fragmatome operates similarly to a phacoemulsification probe although use of the conventional fragmatome requires enlarging sclerotomies, often using an MVR blade.
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