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J. Comander, C. M. Andreoli, S. Kiss, D. Vavvas; Intraoperative Switch to a Temporal Approach in 25 Gauge PPV: Anatomic and Visual Outcomes and Comfort Level of Trainee Surgeons. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5994. doi: https://doi.org/.
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To evaluate a technique for overcoming the limitations of flexible 25-gauge vitrectomy instruments by switching to a temporal approach intraoperatively. We compare the characteristics and outcomes of vitrectomy surgery as well as the comfort of trainees performing the surgery.
We reviewed cases of 25 gauge pars plana vitrectomy (PPV) with difficult access to the pathological site, including superior retinal detachments, giant retinal tears, or a requirement for supplemental superior peripheral retina scatter laser. Contributions to difficult access included the decreased stiffness of the 25 gauge instruments, phakic status of the patient, and patient anatomy, including deep sockets, prominent nose bridge, or tight orbit following anesthetic block. In these cases, the surgeons intraoperatively switched to a temporal approach. Intraoperative ease and complications were noted as well as comfort of the trainee surgeon.
In all cases, 25-gauge PPV was begun in the traditional manner with the infusion attached to the infero-temporal insertion port. When the decision was made to alter the surgeon’s access, the infusion cannula was removed and then reaffixed to the supero-nasal insertion port. The surgeon and microscope were adjusted to a temporal orientation and the instruments inserted through the 2 temporally placed insertion ports. In cases in which an intraoperative switch of infusion cannula was undertaken, there was no increase in intraoperative time nor increase in intraoperative or postoperative adverse events. Subjective benefit was noted by the surgeons in their ability to clearly identify retinal/vitreous pathology and to perform maneuvers such as sub-retinal drainage and superior laser. For cases requiring access to the superior retina, trainees graded their comfort as increased compared to cases performed by superior approach alone. Visual and anatomic outcomes were comparable to cases performed using superior approach alone and stiffer 20-gauge instruments.
An intraoperative switch to a temporal approach with 25-gauge PPV can readily be accomplished by simply unsnapping and then reattaching the infusion cannula to an alternate insertion port. Superior and inferior retinal pathology can more easily be accessed. Operator comfort is increased. Eyes with deep sockets and/or extensive superior vitreoretinal pathology may be better accessed with a temporal approach. Moreover, this technique also has the potential to decrease iatrogenic cataract formation when accessing inferior pathology in phakic patients.
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