Sir,
We read the article by Taylor and Aylward1 with great interest. We congratulate the authors for publishing the first reported case of successful management of 25-gauge transconjunctival sutureless vitrectomy (TSV).
We agree with the authors that smaller incision, reduced operative time, lack of suture material and limited manipulation may reduce the risk of endophthalmitis with TSV. However, reduced flow rate (6 times) may facilitate bacterial foothold inside the eye during surgery.2 Alignment of the conjunctival and scleral incisions and unsutured sclerotomies may increase the risk of postoperative hypotony allowing influx of microbes. This makes the eye more susceptible to postoperative endophthalmitis in comparison to the watertight wounds of a sutured 20-gauge sclerotomy.
To overcome this potential complication of postoperative hypotony and resultant potential increase in bacterial influx, we suggest displacing the conjunctiva superiorly while introducing the 25-gauge trocar and cannula at the initiation of the surgery. At the end of surgery, when the trocar and cannula are removed, the conjunctiva moves back inferiorly covering the sclerotomy. This misalignment of conjunctival and scleral wound prevents a continuous tract for fluid egress, hypotony and bacterial influx.3
We believe that at the completion of surgery, removing the superior cannulas while maintaining infusion creates high pressure within the vitreous cavity and promotes the vitreous to occlude the sclerotomy. This can reduce the incidence of postoperative hypotony. We also suggest suturing the sclerotomy with a single 10-0 vicryl suture when integrity of the wound is doubtful.
We congratulate the authors for reporting this uncommon but grave complication of 25-gauge TSV.
References
Taylor SR, Aylward GW . Endophthalmitis following 25-gauge vitrectomy. Eye, advance online publication, 22 October 2004; doi:10.1038/sj.eye.6701737.
Er H . Successful management of cataract surgery associated vitreous loss with sutureless small-gauge pars plana vitrectomy. Am J Ophthalmol 2004; 138(6): 1090–1091.
Fujii GY, De Juan Jr E, Humayun MS, Pieramici DJ, Chang TS, Awh C et al A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology 2002; 109(10): 1807–1812.
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Shah, V., Shah, G. & Chalam, K. Reply to endophthalmitis following 25-gauge vitrectomy. Eye 20, 735–736 (2006). https://doi.org/10.1038/sj.eye.6701981
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DOI: https://doi.org/10.1038/sj.eye.6701981