Heads-Up Macular Surgery with a 27-Gauge Microincision Vitrectomy System and Minimal Illumination

Abstract

Objective: We combined heads-up 3-dimensional (3D) 27-gauge microincision vitrectomy surgery (27GMIVS) with a very low-intensity illumination system.

Methods: This study was based on a retrospective, interventional case series of 6 eyes of 6 patients with macular disease. All patients underwent heads-up 3D 27GMIVS and the power of the intraocular illuminator was set to its minimum level, 1% (approximately 0.1 lm), throughout the surgery.

Results: We found that the procedure was easy when the heads-up 3D system was used, but not through the eyepiece of a microscope. All surgeries were successfully finished without any complications. Postoperative visual acuity was restored or maintained in all eyes during the follow-up period.

Conclusion: Heads-up, 3D system-assisted 27GMIVS with minimal illumination enabled excellent intraoperative visualization of retinal tissues, caused minimal phototoxicity to the macular retinal cells, and might therefore represent the next step in the development of an ideal, minimally invasive method of treating macular disease.

Keywords: 27-Gauge vitrectomy; Epiretinal membrane; Heads-up surgery; Macular hole; Phototoxicity.

Fig. 1

Intraoperative retinal images showing various illumination intensity levels during heads-up, 3D system-assisted 27-gauge microincision vitrectomy surgery. For ethical reasons, these example images were obtained from a patient with rhegmatogenous retinal detachment, rather than one of the macular disease patients included in this study. This patient underwent fluid-air exchange and cryoretinopexy. The arrowhead and arrow represent the optic nerve head and macula, respectively, in all images. Top left: moderate illumination power (39%, the level of the Constellation system; approximately 4 lm). The optic nerve head and macula are clearly visible. Top right: low illumination power (10%; approximately 1 lm). Bottom left: very low illumination power (5%; approximately 0.5 lm). Bottom right: lowest illumination power (1%; approximately 0.1 lm).

Fig. 2

Representative intraoperative retinal images of eye with a 441-μm macular hole. Heads-up, 3D system-assisted 27-gauge microincision vitrectomy surgery with minimal illumination was used. The Constellation intraocular illuminator was set to its minimum level, 1%, in all images. Top left: after resecting the vitreal core, we performed triamcinolone acetonide-assisted internal limiting membrane (ILM) peeling. Top right: the ILM was peeled 360 degrees around the macular hole, with its edge attached, and carefully trimmed with a 27-gauge cutter. Bottom left: the ILM flap was inverted and placed over the macular hole. Bottom right: fluid-air exchange was performed with 27-gauge instruments. The macular hole closed completely postoperatively.