Retina Today - Comparing Two 20-gauge Trocar Systems for Sutureless Transconjunctival Vitrectomy (January/February 2010)

摘要

Since the introduction of systems for sutureless vitrectomy surgery, there has been debate about which approach is best. We now have options for 20-, 23-, 25-, and 27-gauge instrumentation. Which can provide the best results: the most efficient surgery with the fastest healing, the least inflammation, and the fewest postoperative complications? Which is the most cost-effective? It will take time to answer all these questions. Of the available options, 20-gauge non-trocar or trocar systems hold the possibility of providing some of the advantages of smaller-gauge systems without the need to adopt a lot of newer instrumentation in switching to transconjunctival sutureless surgery. We retrospectively reviewed our early results with two relatively recently introduced 20-gauge trocar systems: the Claes 20 Gauge Vitrectomy System (DORC International, Zuidland, Netherlands), and the One-Step Surgical System (Synergetics, Oa??Fallon, MO).1 FIRST 40 CASES We performed a retrospective, comparative case series review of the first 40 surgeries performed by a single surgeon with the two above-named 20-gauge trocar systems for transconjunctival sutureless vitrectomy surgery. The 40 cases with the DORC system (Figure 1) were performed from May to July 2008, and the 40 cases with the Synergetics system (Figure 2) from January to April 2009. Charts and videos for these 80 cases were reviewed. Sclerotomies with the DORC system were created using a two-step procedure; a regular 20-gauge microvitreoretinal knife is inserted at an estimated angle of 10° to 20° using the DORC fixed footplate; then the trocar is inserted (Figures 3-5). For insertion of the Synergetics trocars, the bladed trocar inserter is used. I use the same DORC footplate with the Synergetics trocars, as it provides good stabilization of the globe (Figures 6-8). I always make sure that I see the tip of the trocar after inserting, to ensure that it does not end up in the subretinal space. Standard wide-angle vitrectomy is then performed. The trocars are removed either by reinserting the guide inserter on the trocar before pulling it out of the sclerotomy, or by pulling out the trocar directly without the guide. The sclerotomy sites are checked for leakage before the conclusion of the case. Standard postoperative care instructions are given. Vitreous substitutes used in these cases included SF6 or C3F8 gases, silicone oil, balanced saline solution, and air. I used more air/fluid exchanges in the second series, as I have found that air has a greater surface tension and it seals the sclerotomies better. RESULTS Baseline visual acuities and intraocular pressures were similar in the two groups. The demographics and the mix of indications for surgery was also similar between the groups (Table 1). Intraoperative hypotony was noted more frequently in the cases performed with the DORC system (n=3) compared with the Synergetics system (n=1). Hypotony usually occurred during instrument exchange. Suturing of sclerotomies was performed in an equal number of cases in the two groups (n=3 in each group). All additional suturing required only one suture on only one sclerotomy. All three of the cases requiring sutures with the DORC system were performed with silicone oil. Of the cases requiring sutures with the Synergetics system, two had silicone oil and one had balanced saline solution. No additional suturing was done postoperatively in either group. No postoperative complications were noted at up to 3 months follow-up after the procedure, including no occurrences of endophthalmitis and no retinal detachments. Surgical time was similar with both systems. Intraocular pressures at 1 day, 1 week, and 1 month were also similar (Table 2). COMPARISONS AND CONCLUSIONS These two 20-gauge trocar systems are comparable for use during transconjunctival sutureless surgery. However, we observed some differences in the course