ANTERIOR VITRECTOMY TRICKS FOR PC RENT

1. Anterior Vitrectomy
foR Posterior Capsular
Rupture AND GLOBE
DECOMPRESSION

2. AJAY DUDANI
ZEN EYE CENTRE
Mumbai Retina Centre
Mumbai
Prof K J Somiya Medical College
SURYA

3. PRINCIPLE
 IT IS A TOILET VITRECTOMY
 NOT A TOTAL VITRECTOMY
 NO VITREOUS IN AC
 KEEP VITREOUS IN PC

4. TOILET ANTERIOR VITRECTOMY
 CASES WITH SHALLOW AC
 CREATE ADEQUATE SPACE AND DEPTH
 HELP IN ANTERIOR CHAMBER SURGICAL
MANEOUVRING

5. INDICATIONS
 LENS INDUCED PHACOMORPHIC
GLAUCOMA
 URRETS ZAVALIA WITH PAS
 POST INFLAMMATION IRIS BOMBE
 PAEDIATRIC CATARACT SURGERY WITH
PCC

6. INDICATIONS
 NARROW ANGLE GLAUCOMA
 COMBINED CAT AND TRAB
 POST TRAB PAS
 VITREOUS LOSS WITH PAS
 NANOPHTHALMOS
 RAM

7. TECHNIQUE
 23 G PPV SUTURELESS
 TOCAR CANNULA SUTURELESS
 4 MM FROM LIMBUS
 AC MAINTENER
 HEALON IN PAS

9. TOILET ANTERIOR VIT
 ENDPOINT IS DEEPENING OF AC AND
SOFT EYE
 ALWAYS VISUALIZE TIP OF CUTTER
 AND CUT TOWARDS THE DISC AND NOT
THE LENS
 SAVES MANY A DAY IN OT

10.  Most frequent significant complication
encountered by Phaco surgeons in their
learning curve
 Can happen even with masters
 Incidence of PCR 0.05 - 10 %
 Incidence of Vitreous Loss 2 – 5 %
Posterior capsule rupture
SURYA

11.  At the time of hydro dissection
 Phacoemulsification
 Cortex removal by I / A
 During IOL insertion
Can happen at various stages
SURYA

12.  Gel like due to arrangement of long thin non
branching collagen fibrils suspended in a network
of glycosaminoglycan chains.
 Is attached densely to Ora serrata and is loosely
adherent to optic nerve and macula.
 Therefore Vitreous loss can lead to complications
like CME and RD.
Vitreous Anatomy
SURYA

13. Basic Principle of vitrectomy
 Vitreous is supposed to be in the posterior
segment so prevent vitreous traction intraop
and postop
 Maintain normotensive globe and leave a clean
anterior segment
 Protect cornea,iris,capsule from collateral
damage
SURYA

14.  Total and safe removal of remaining lens material
 Preserve as much capsule as possible to place IOL
 Thorough removal of vitreous from wound and
anterior chamber
Management
SURYA

15. Controlling damage of PCR
Use a dispersive and cohesive dispersive
viscoelastic to compartmentalize and
pressurize the globe
Convert rent to CCC
Raise nuclear fragments over the iris :
dial,lift,cantilever with nuclear spears
through sideport and trap with
viscoelasticuse
SURYA

16.  If PCR occurs, closed chamber system necessary.
 If remaining surgery managed without disturbing
the anterior hyaloid phase, then vitrectomy may
not be required.
 However, once anterior hyaloid is breached, then
vitrectomy necessary.
SURYA

17. ANTERIOR VITRECTOMY
 Establishment of semi-closed pressurized system
necessary as chamber collapse will promote
forward movement of vitreous.
 Avoid burnt hand reflex – Phaco tip should
not be removed. Aspiration stopped immediately
after identification of PCR.
 Continue in position 1 ( irrigation ).
 Second instrument removed from side port and
Viscoelastic filled in AC.
 Then Phaco tip is removed from eye.
SURYA

18.  Vitreous body similar to semi elastic material - slinky
toy
 If one pulls on the top few coils of the slinky, it stretches
but no tensions are exerted through out the remaining
toy.
 Similarly if amount of anterior vitreous disturbed is
limited, then tensions are not exerted throughout the
vitreous body, therefore CME and RD is decreased.
Vitreous as Slinky Toy
SURYA

19.  If one forcefully pulls on all coils of the slinky toy,
tension is exerted all the way down the toy.
 This is similar to extensive vitreous loss exerting
traction at vitreo-macular interface and vitreous base
causing CME and RD.
 So DO NOT STRETCH THE SLINKY.
Vitreous as Slinky Toy
SURYA

20. Vitreous as Slinky Toy
SURYA

21. Co-axial infusion not to be used
 Force can rip open the posterior capsule permitting
more vitreous loss.
 Hydrates the vitreous causing forward movement.
 Shakes and wiggles the vitreous causing forward
movement.
SURYA

22. SURYA

23.  Infusion and cutter should be divorced:biaxial
 Main Phaco incision should not be used.
 Eye filled with visco.
 New incision little right to Phaco incision for
vitrectomy tip (if only one side port).
 Left side port for infusion, right side for vitrectomy.
 Phaco incision closes spontaneously.
 Therefore closed system vitrectomy.
Procedure of ant vit
SURYA

24. SURYA

25. SURYA

26. Ant vit (contd)
 Infusion should be gentle and limited to AC
with Canula parallel to iris.
 Vitrector should be passed below the
posterior capsule at the point at which
minimal anterior vitrectomy should be done
and stopped when the vitreous is removed
below the level of posterior capsule.
 Advance towards vitreous while cutting and
anticipate repeat vitreous presentation
 Fill the eye with Visco, and insert three piece
foldable IOL on CCC
SURYA

27. SURYA

28. Triamcinolone staining
Triamcinolone acetonide binds to vitreous
Facilitates vit recognition and removal
Reduces postop inflammation
Use diluted 10:1
Use highest cut rate and vacuum of 200-
300 for vitrectomy to minimize traction
SURYA

29.  Instead of using original incision, a pars plana
vitrectomy with low suction, high cutting rate can
be done if surgeon well versed.
 23 G or 25G Trocar Cannula System of Sutureless
Vitrectomy has the advantage of fine instruments
and no sutures
SURYA

30. Residual cortex removal
 Alternative technique : Dry (no infusion)
vitrectomy – viscoelastic agent used
to maintain anterior segment while
vitrectomy performed through opening
in torn capsule.
 Cortex is best removed under viscoelastic
using Simcoe cannula
SURYA

31. Post - Op
 Monitor IOP and treat
 Warn patient to expect floaters
 Detailed retinal examination
 Monitoring for CME
 DISCLOSURE TO PATIENT
 Antibiotic and NSAID and long taper of
steroid
SURYA

32. DON’T STRETCH THE SLINKY SURYA

33. THANK YOU
T