Transconjunctival sutureless vitrectomy: comment on O'Reilly and Beatty

Sir,

I congratulate O'Reilly and Beatty on their article on transconjunctival sutureless vitrectomy (TSV).¹ They provide useful surgical tips. I would like to add some tips, having extensively used this system for over four years.

TSV is applicable to the majority of vitrectomy procedures (over 80%). Limited exceptions include silicon oil use, requirement for 20 g instruments, eg a fragmatome or curved instruments. Finally, in cases requiring extensive anterior work, such as vitreous base excision, 20 g is preferred.

Insertion of the cannulae can be initially difficult. The preferred technique is to raise the bottle to 70 cm after infusion placement, plug the second entry, insert the third cannula, then lower the bottle to 55 cm. Also, counter-pressure with a blunt instrument, depressing the sclera in the equatorial region diametrically opposite to the insertion site stabilises the eye. Once the exposed metallic part of the trocar is through the conjunctiva, increased resistance is felt as the polyamide cannula is manoeuvred through; a brisk rotary ‘drilling’ movement facilitates this part of the entry, avoiding deformation of the eyeball. With a phacovitrectomy, one can place the infero-temporal cannula and close it with a plug. Routine phacoemulsification is then completed and the corneal incision sutured. As the superior ports are not in place, there is no interference with access of instruments and incision placement for phacoemulsification (Figure 1). After phacoemulsification the infusion line is inserted and turned on. This firms up the eye, allowing easy insertion of the other two cannulae.

Figure 1

Preplaced infusion port. Phacoemulsification is completed with easy access.

The fragility of 25 g instruments poses another problem, especially when trying to deal with peripheral pathologies, such as tears close to the ora serrata. This is effectively managed by the use of indentation to bring the peripheral retina to the ocutome, rather than tilting the eye to access peripheral pathology (Figure 2). The use of an effective wide-angle light such as the Photon (Synergetics Inc., MO, USA), allows one to plug this into one of the superior ports freeing one hand to indent. True bimanual surgery is thus facilitated allowing access to all areas of retina even in phakic eyes.

Figure 2

A chandelier light and indentation allows access to a small peripheral retinal hole.

Induction of a PVD is more difficult, but raising the bottle to 100 cm momentarily greatly helps (Figure 3).

Figure 3

The posterior hyaloids face is removed facilitated by a raised bottle height and confirmed by triamcinolone ‘staining’.

With an appropriate technique, TSV can deal with the vast majority of vitrectomy procedures, benefitting both the patient and the surgeon.