Modified 23-Gauge Vitrectomy System for Stage 4 Retinopathy of Prematurity

CLINICAL SCIENCES Modified 23-Gauge Vitrectomy System for Stage 4 Retinopathy of Prematurity

Wei-Chi Wu, MD, PhD; Chi-Chun Lai, MD; Rey-In Lin, MD; Nan-Kai Wang, MD; An-Ning Chao, MD; Kuan-Jen Chen, MD; Tun-Lu Chen, MD; Yih-Shiou Hwang, MD

Objective: To evaluate the outcome of a novel, modi- 40.5 (3.0) weeks. Overall, 20 eyes (77%) achieved reti- fied 23-gauge vitrectomy system in the treatment of stage nal attachment in a single operation, and 23 eyes (88%) 4 retinal detachment in retinopathy of prematurity. achieved retinal attachment after multiple procedures. Postoperative complications included disc dragging (5 Methods: Consecutive patients with stage 4 retinopa- eyes [19%]), cataracts (4 [15%]), glaucoma (2 [8%]), per- thy of prematurity treated with modified 23-gauge vi- sistent vitreous hemorrhage (1 [4%]), and posterior syn- trectomy were included in this medical record review. echia (1 [4%]). Major novel modifications included the use of a small infusion cannula, a 20-gauge blade for the creation of scle- Conclusions: This 23-gauge vitrectomy system seems rotomies in the pars plicata, and a 23-gauge endoillumi- to be a safe and effective approach for treatment of stage nator and vitreous cutter. Conjunctival dissection and 4 retinopathy of prematurity. This modified system com- suturing of sclerotomies were performed using this modi- bines the benefits of 20- and 23-gauge vitrectomy and fied 3-port, 23-gauge vitrectomy technique. Anatomic suc- offers safer insertion of infusion cannulas in smaller eyes, cess and surgical complications were analyzed. more working space in pediatric eyes, a cutting port that is closer to the retina, and a faster cutting speed with less Results: Twenty-six eyes of 17 patients were included and analyzed. The mean (SD) gestational age was 28.0 vitreous traction during the operation. (2.5) weeks, and the mean birth weight was 1199 (449) g. Mean postmenstrual age at the time of vitrectomy was Arch Ophthalmol. 2011;129(10):1326-1331

ETINOPATHY OF PREMATU- tomy has a more favorable anatomic suc- rity (ROP) remains one of cess rate (70%-95%) compared with scleral the leading causes of child- buckling.2,4-6,9,10,12,13 Functional outcome is hood blindness world- even more impressive for stage 4A ROP wide. Surgical interven- treated with vitrectomy, allowing pa- tion is indicated once stage 4 or stage 5 tients to achieve an average visual acuity R 4,14 ROP with retinal detachment occurs. Sur- of 20/58 to 20/62. gical procedures should be performed as Newer, smaller-gauge vitrectomy is be- early as possible when retinal detach- coming more popular than traditional 20- ment develops because the prognosis of gauge vitrectomy for treatment of vitreo- stage 4 ROP is much better than that of retinal disorders because of several stage 5 ROP. For stage 4 ROP, both scleral potential benefits.15-19 The reported ad- Author Affiliations: buckling and vitrectomy have been used vantages in adults are reduced surgical time Departments of Ophthalmology to treat retinal detachment.1-10 Scleral buck- achieved with the sutureless nature of this (Drs Wu, Lai, Wang, Chao, ling achieves moderate anatomic success system, increased patient comfort, faster K.-J. Chen, T.-L. Chen, and but is limited by a high incidence of in- visual recovery, and low complication rate. Hwang) and Pediatrics duced refractive errors and the need for Smaller instruments might have addi- (Dr Lin), Chang Gung additional procedures to dissect or re- tional advantages in infants with ROP. Memorial Hospital, and move the buckling material.8,11 Recently, There are few reports20-22 of surgical Chang Gung University, Department of Medicine, vitrectomy has become popular for the management of ROP using 25-gauge in- College of Medicine (Drs Wu, treatment of stage 4 ROP because of im- struments with various modifications. Lai, Lin, Wang, Chao, proved instrumentation and the ability to However, the efficiency of such a system K.-J. Chen, T.-L. Chen, and directly release transvitreal traction re- seems to be limited because 47% of eyes Hwang),Taoyuan, Taiwan. sulting from fibrous proliferation. Vitrec- require multiple operations when 25-

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 gauge vitrectomy is carried out for stage 4 and 5 ROP.22 In this report, we describe our modified 23-gauge approach for treatment of stage 4 ROP. This is a single- surgeon, consecutive case series performed over several years. To our knowledge, this is the first report of this approach for retinal detachment associated with ROP.

METHODS

DATA COLLECTION

This study was performed using consecutive medical record re- Figure 1. Comparison of infusion cannulas used during vitrectomy. view. Written informed consent had been obtained from the A 20-gauge infusion cannula (4 mm long; BD Visitec, Waltham, Massachusetts), 20-gauge anterior chamber maintainer (3 mm long; PMS, parents or legal guardians of the infants before intervention. Tuttlingen, Germany), and 23-gauge infusion cannula (4 mm long; Alcon, The study was approved by the institutional review board of Fort Worth, Texas) are placed from left to right. The 20-gauge anterior Chang Gung Memorial Hospital, Taoyuan, Taiwan. The rec- chamber maintainer has the shortest length and slimmest size among these ords of patients with stage 4A or 4B ROP who underwent the 3 infusion cannulas. It is the most suitable infusion cannula for pediatric modified 23-gauge vitrectomy technique between June 1, 2007, eyes with retinopathy of prematurity. and May 31, 2010, were included. The following information was collected from the medical records: sex, gestational age, birth weight, laterality, previous treatments, postmenstrual age at the time of surgical intervention, intraoperative complications, anatomic success, and postoperative complications. The records of patients with a follow-up time of less than 6 months were excluded.

SURGICAL TECHNIQUE

When the plus disease or pre-plus disease was eminent or there was extensive proliferation of fibrovascular membranes in the ROP eyes, bevacizumab (Avastin) was administered intravit- really less than a week before vitrectomy. Injection of bevacizumab was used primarily to reduce the chances of bleeding during the subsequent vitrectomy. Three-port pars plicata vitrectomy using 23-gauge instrumentation was performed by one of us (W.-C.W.). The pupil was dilated with phenylephrine, 1.25% (Wu Fu Laboratories Co Ltd, Yilan, Taiwan), and tropi- camide, 1% (Mydriacyl; Alcon-Couvreur, Puurs, Belgium), before vitrectomy. Conjunctival dissection was performed to ex- Figure 2. Setup of modified 23-gauge vitrectomy for retinopathy of pose the pars plicata. The sclerotomy was made approximately prematurity. The infusion cannula was placed in the inferior temporal 0.5 to 1.0 mm posterior to the limbus through the pars plicata quadrant. Because of the smaller size of the infusion cannula, a contact with a 20-gauge microvitreoretinal (MVR) blade. Trocar can- wide-angle viewing system or the pediatric contact prism lens could be nulas were not used. The MVR was directed perpendicularly placed on the cornea without bumping the infusion cannula or other to the globe initially and then directed toward the center of the instruments. eyeball after the MVR blade passed the lens equator. The infusion was placed at the sclerotomy in the inferotemporal or inferonasal quadrant by an anterior chamber maintainer with ridge to lens, ridge to ridge, and ridge to the optic disc were ad- a length of 3 mm (self-retaining anterior chamber maintainer dressed (Figure 3). Care was taken to avoid a retinal break or 20 gauge; PMS, Tuttlingen, Germany) (Figure 1) depending hemorrhage during the procedure. The lens was not removed on the configuration and extent of retinal detachment. The po- unless the proximity of the retina to the lens greatly limited the sition of the infusion tip was confirmed with an endoillumi- space available at the surgical entry site. Partial gas-fluid ex- nator before initiating the infusion. The remaining 2 scleroto- change was performed at the end of the operation to prevent ocu- mies were made at approximately the 3-o’clock and 9-o’clock lar hypotony during suturing of the sclerotomy. The conjunc- positions so that both the superior and inferior vitreous could tival wound was then closed with an 8-0 polyglactin 910 suture be addressed with a vitreous cutter without damaging the lens (Vicryl; Ethicon, Inc, Somerville, New Jersey). At the end of the (Figure 2). The 23-gauge vitreous cutting tool and endoillu- operation, a transparent plastic eye shield was used to reduce minator were then inserted through the remaining 2 scleroto- the chance of eye rubbing or direct trauma by hands. mies in the horizontal region. The vitrectomy machine (Accu- rus; Alcon, Fort Worth, Texas) was used with vacuum levels of RESULTS 150 to 250 mm Hg and cutting rates of 1200 to 1500 cuts per minute. The traditional proportional vacuum mode was used. A wide-angle viewing system (Volk Optical Inc, Mentor, Ohio) Twenty-one patients underwent modified 23-gauge vi- was used to view the peripheral retina. A corneal contact lens trectomy between June 1, 2007, and May 31, 2010. The was used for central retina viewing. The surgical goal was to re- records of 4 patients were excluded because of fol- lieve vitreous traction on the retina to the greatest extent pos- low-up of less than 6 months. Therefore, data on 26 eyes sible. Traction forces from the ridge to peripheral retinal walls, from 17 patients (10 boys and 7 girls) were included and

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Ridge to peripheral retinal wall Ridge to ridge Ridge to disc

Figure 3. Tractional vectors involved in retinal detachment in retinopathy of prematurity. Traction forces from the ridge to peripheral retinal walls, ridge to lens, ridge to ridge, and ridge to the optic disc were addressed during vitrectomy. A to C, Progression of retinal detachment is illustrated if the tractional forces are not relieved.

analyzed in this study. The mean gestational age was 28.0 tional vitrectomy was performed to clear the hemor- (2.5) weeks (range, 24-31 weeks), and the mean birth rhage. Posterior iris synechia occurred in 1 eye (4%) weight was 1199(449) g (range, 556-2400 g). The mean during follow-up. None of the patients developed en- follow-up time of the patients was 13.9 (9.5) months dophthalmitis during follow-up. (range, 6-34 months). The patient characteristics and surgical results are shown in the Table. Fifteen eyes of 9 patients were stage 4A ROP, and 11 COMMENT eyes of 8 patients were stage 4B ROP. Twenty-three of 26 eyes (88%) were subjected to laser treatment before Vitreous operations in infant eyes remain challenging. vitrectomy. The mean number of laser treatments was Because newborn eyes are much smaller than adult eyes, 1.5(0.5) (range, 1-2). Eight eyes (31%) received a beva- the anatomy and the surgical approach are different. In- cizumab injection before vitrectomy. Scleral buckling had struments are also adjusted for use in smaller eyes. Most been performed in 4 eyes (15%) at other hospitals be- important, the chance to amend undesirable complica- fore they received vitrectomy at our hospital. In these eyes, tions, ie, retinal break, is much slimmer. Therefore, a bet- scleral buckle was dissected at the time of vitrectomy. ter approach that offers both safety and efficacy is sorely Combined vitreous or preretinal hemorrhage was found needed. in 5 eyes (19%) with stage 4 ROP. One stage 4B eye was Modifications of smaller-gauge vitrectomy are neces- found to have combined tractional and rhegmatog- sary in ROP because of these differences. We have made enous retinal detachment. For the other eyes, the reti- several modifications. First, sclerotomies are made in the nal detachment was only tractional. Mean postmen- pars plicata because of underdevelopment of the pars plana strual age at the time of vitrectomy was 40.5(3.0) weeks in newborns.23 The MVR blade should be directed in a (range, 36-50 weeks). Final retinal reattachment was more perpendicular direction to reduce the chance of lens achieved in 23 eyes (88%). Two eyes (8%) with stage 4A damage.20 Second, trocars are not used in newborn eyes ROP progressed to stage 4B ROP after initial 23-gauge because of the chance that the retina could be damaged vitrectomy and received additional vitrectomies to reat- by distortion of the globe during insertion of trocars into tach the retina. One eye (4%) with stage 4A ROP pro- such small eyes. Third, the 23-gauge infusion cannula is gressed to stage 5 ROP, and successful retinal reattach- replaced with a smaller anterior chamber maintainer so ment was achieved after surgical intervention. Overall, that a contact prism lens or a wide-angle viewing lens in 20 eyes (77%), retinal attachment was achieved in a can be placed on the cornea without bumping the infu- single operation and, in 23 eyes (88%), retinal attach- sion or other instruments. Fourth, sclerotomies and con- ment occurred after multiple procedures. The retina failed junctiva are sutured to ensure wound integrity. Self- to reattach in 3 eyes (12%) after 23-gauge vitrectomy and sealing of sclerotomy wounds may be difficult; adequate additional operations. These 3 eyes had retinal breaks coverage of the conjunctiva is not always possible be- either before or after vitrectomy. Postoperative compli- cause of proximity of the wound to the limbus. In addi- cations occurred in some infants. Disc dragging was noted tion, we are concerned about the integrity of the wound in 5 eyes (19%) during follow-up. Four eyes (15%) de- if left unsutured because of the potential harm when in- veloped cataracts and underwent subsequent cataract op- fants cry and strain during eye examinations. In our cases, erations. Two eyes (8%) developed glaucoma during post- we did not encounter postoperative hypotony or endoph- operative follow-up and underwent filtering surgical thalmitis during the follow-up period. procedures after medical therapy failed. Persistent vit- Because it is important to plan for ROP repair before reous hemorrhage was noted in 1 eye (4%); an addi- the intervention, anesthetists are consulted beforehand

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Table. Individual Patient Characteristics and Surgical Results for 26 Eyes of 17 Patients

Patient/ GAB, BW, PMS, Retinal Follow-up, Sex, Eye wk g wk Stage Zone Attachment Complications mo 1/M 26 920 40 34 1 4A 2 Yes Cataract, glaucoma 2 4A 2 Yes Cataract, glaucoma 2/M 25 684 34 11 34A2Yes 44A2Yes 3/M 31 1328 38 6 5 4A 2 Yes Disc dragging 64A2Yes 4/M 29 1452 41 6 7 4A 2 Yes Iris synechia, VH 84A2Yes 5/F 25 798 36 10 94A2Yes 6/M 27 980 38 24 10 4A 2 Yes 7/M 30 1435 38 7 11 4A 1 Yes

12 4A 1 Yes Progression to stage 5 ROP 8/F 26 840 42 27 13 4A 2 Yes Disc dragging, progression to stage 4B ROP 14 4A 2 Yes Progression to stage 4B ROP, cataract 9/F 31 1320 39 26 15 4A 1 Yes 10/M 30 1590 38 6 16 4B 1 Yes 17 4B 1 No RRD 11/M 25 755 45 11 18 4B 2 Yes Disc dragging 19 4B 2 Yes Disc dragging, retinal break 12/F 24 556 50 10 20 4B 2 Yes Disc dragging 13/F 30 2400 48 29 21 4B 2 Yes 22 4B 2 Yes Cataract 14/F 31 1625 41 9 23 4B 2 Yes 15/M 30 1174 42 11 24 4B 2 Yes 16/M 27 1104 40 8 25 4B 1 No Progression to stage 5 ROP 17/F 28 1148 36 21 26 4B 1 No RRD before vitrectomy

Abbreviations: BW, birth weight; GAB, gestational age at birth; PMS, postmenstrual age at surgery; ROP, retinopathy of prematurity; RRD, rhegmatogenous retinal detachment; VH, vitreous hemorrhage.

to evaluate the risk of general anesthesia. This is neces- termine the configuration of retinal detachment. The area sary because the operation may need to be postponed if with the least retinal dragging is selected as the infusion the infant’s condition is unstable. If plus or pre-plus dis- site. The vectors that involve tractional force on the retina ease is noted on the fundus, bevacizumab is injected less are dissected until the surgeon determines that the force than 1 week before vitrectomy. Hemorrhage in the vit- was relieved by the vitreous cutter. Aggressive mem- reous or in the proliferative fibrovascular membranes dur- brane peeling is avoided, and efforts are made to reduce ing vitreous shaving in the course of the subsequent vi- the possibility of iatrogenic break, which usually carries trectomy could be reduced. Although angiogenesis is a poor prognosis. Retinal flattening takes several months inhibited after bevacizumab use, the fibrotic compo- because of the exudative component in the subretinal nent of ROP may accelerate and retinal detachment might space. Documentation of the surgical procedure is im- worsen.24 Thus, we suggest that vitrectomy be per- portant and is done using a video recording system. formed within 1 week of bevacizumab injection. If pa- The benefits of 23-gauge vitrectomy compared with tients have received scleral buckling beforehand, the di- traditional 20-gauge vitrectomy for ROP include easier vision of buckling material is performed before vitrectomy. insertion of the instrument because of its smaller size, Before the operation, the fundus is checked again to de- more working space in the vitreous as a result of the use

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 of a smaller vitrectomy probe, a cutting port that is In conclusion, this modified 23-gauge vitrectomy in closer to the retina, and a higher cutting speed with less neonates offers better manipulation and better illumina- vitreous traction during the procedure. Surgeons could tion than the 25-gauge vitrectomy. Moreover, this sys- adapt to this technique easily because the setup of this tem provides a larger working space and reduced pe- system is similar to that of traditional 20-gauge vitrec- ripheral retinal traction with a high-speed vitrectomy tomy. Safety has also been enhanced with a smaller infu- probe and a smaller instrument size than that involved sion line in the pediatric eye. The drawback of this sys- in traditional 20-gauge vitrectomy. Use of 23-gauge vi- tem is the higher expense associated with 23-gauge trectomy for retinal detachment in ROP seems to achieve vitrectomy systems. an excellent balance between the results of 20- and 25- The potential benefits of 23-gauge vitrectomy com- gauge vitrectomy. The anatomic success and complica- pared with 25-gauge vitrectomy include a sturdier probe, tion rates are comparable to those in studies that used which facilitates eye rotation; higher cutting efficiency the traditional 20-gauge vitrectomy system. because of a larger port in the cutter; better instrument manipulation, thus avoiding damage to the lens and retina; and a better lighting source that allows for clearer visu- Submitted for Publication: November 3, 2010; final re- alization of the fundus. The need for an additional op- vision received February 12, 2011; accepted February 20, eration is also reduced. Gonzales et al22 reported that 47% 2011. of eyes undergoing 25-gauge vitrectomy for stages 4 and Correspondence: Wei-Chi Wu, MD, PhD, Department 5 ROP require more than 1 retinal operation for persis- of Ophthalmology, Chang Gung Memorial Hospital, tent retinal detachment and/or vitreous hemorrhage. Of Taoyuan, Taiwan ([email protected]). our patients, only 6 eyes (23%) needed more than 1 reti- Financial Disclosure: None reported. nal operation for persistent retinal detachment and/or vit- Funding/Support: This study was partially supported by reous hemorrhage. The drawback of this system com- grant CMRPG 370751 from Chang Gung Memorial Hos- pared with 25-gauge vitrectomy is the need to dissect the pital Research, Taoyuan, Taiwan. conjunctiva and the suturing of sclerotomies and conjunctiva. In addition, mild leakage from the sclerotomy REFERENCES site occurs because of the 20-gauge MVR blade. Our anatomic success is comparable to that of previ- 1. Beyrau K, Danis R. Outcomes of primary scleral buckling for stage 4 retinopathy ous reports2,4-6,9,10,12,13,20-22 on procedures using a 20- or of prematurity. Can J Ophthalmol. 2003;38(4):267-271. 25-gauge vitrectomy probe. The retina failed to reattach 2. Lakhanpal RR, Sun RL, Albini TA, Holz ER. Anatomic success rate after 3-port lens-sparing vitrectomy in stage 4A or 4B retinopathy of prematurity. in 3 eyes (12%) after 23-gauge vitrectomy and addi- Ophthalmology. 2005;112(9):1569-1573. tional surgical procedures. All 3 eyes had retinal breaks 3. Noorily SW, Small K, de Juan E Jr, Machemer R. Scleral buckling surgery for either before or after vitrectomy. One patient with stage stage 4B retinopathy of prematurity. Ophthalmology. 1992;99(2):263-268. 4B ROP was found to have rhegmatogenous retinal de- 4. Prenner JL, Capone A Jr, Trese MT. Visual outcomes after lens-sparing vitrec- tachment before vitrectomy. That infant had undergone tomy for stage 4A retinopathy of prematurity. 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Ophthalmic Images

Metastatic Breast Cancer to the Eyelid Swetangi D. Bhaleeya, MD Harry H. Brown, MD Abraham J. Park, BA

A 49-year-old woman was seen for an eyelid lesion she noticed 5 months prior to presentation (A). Histological examination showed solid nests of epithelioid-appearing cells with large nuclei (B) (hematoxylin-eosin, original magnification ϫ200); morphology and immunohistochemical staining (inset: cytokeratin 7, original magnification ϫ100) was consistent with metastatic breast carcinoma.

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