The efficacy of the three-port bimanual technique for direct perfluorocarbon liquid-silicone oil exchange in vitrectomy for the treatment of advanced proliferative vitreoretinopathy

Abstract

Purpose: To evaluate the therapeutic effect of three-port, bimanual technique for direct perfluorocarbon liquid (PFCL)-silicone oil (SO) exchange in avoiding retinal re-detachment and shortening the surgical duration in 23-gauge (23 G) pars plana vitrectomy (PPV) for the treatment of advanced proliferative vitreoretinopathy (PVR) complicating primary rhegmatogenous retinal detachment (RRD).

Methods: A Retrospective, comparative, consecutive, single-center study was conducted. Fifty-one eyes of 51 patients diagnosed with RRD complicated by PVR at the severe C stage, according to the standardized grading system, were retrospectively reviewed over a 3-year period. All patients underwent three-port 23 G PPV following a standardized protocol. Twenty-three eyes underwent the bimanual technique for direct PFCL-SO exchange during the final surgical steps, while twenty-eight eyes received conventional air-fluid exchange (AFE) for PFCL removal before SO tamponade. Primary outcome measures included visual acuity (logMAR), retinal status, intraocular pressure (IOP), surgical time and incidence of intraoperative and postoperative complications over a minimum 12-month follow-up period.

Results: The primary anatomical success rate was 86.9% in the bimanual group versus 85.7% in the AFE group (P = 0.898). Visual acuity on postoperative day 1 was significantly improved in the bimanual group compared with the AFE group (P = 0.022). The surgical duration of bimanual group was significantly reduced compared to that of AFE group (P < 0.001). Two eyes in AFE group developed intraocular lens decentration during the surgical procedure. No statistically significant differences were observed in the incidence of postoperative complications between groups.

Conclusion: The bimanual technique for direct PFCL-SO exchange is advantageous for enhancing the efficiency of surgical procedures, reducing the incidence of intraoperative complications and maintaining the re-flattened retina in the process of PFCL aspiration and SO injection. This novel approach presents a feasible and cost-effective strategy to enhance both operational efficiency and rapid visual rehabilitation in the immediate postoperative period.

Keywords: Bimanual technique; Pars plana vitrectomy; Perfluorocarbon liquid; Proliferative vitreoretinopathy; Retinal detachment; Silicone oil.

Fig. 1

Intraoperative image demonstrating the preparation prior to the procedure of the modified bimanual technique for direct Perfluorocarbon liquid (PFCL) - Silicone oil (SO) exchange (left eye)

Fig. 2

Schematic picture representing a three-port pars plans vitrectomy (23-gauge) in conjunction with bimanual technique for direct Perfluorocarbon liquid (PFCL) - Silicone oil (SO) exchange. SO filling syringe is docked at the inferotemporal port (trocar). The fibroptic probe is inserted through one of the superior ports. The aspiration needle is manipulated by surgeon’s dominant hand and is inserted through the other port for the removal of PFCL

Fig. 3

Operative steps of bimanual technique for direct Perfluorocarbon liquid (PFCL) - Silicone oil (SO) exchange. A The SO filling syringe is controlled by the assistance and is docked at the inferotemporal trocar. A peribulbar anesthesia needle, truncated to a secure length and with the tip removed, is connected to the aspiration cannula and is inserted through the upper trocars manipulated by the surgeon’s dominant hand. The SO is injected while the fluid (saline) at the interface is removed via active aspiration simultaneously. B The active aspiration needle is positioned at the PFCL–SO interface to evacuate residual fluid, followed by a gradual and controlled extraction of the PFCL. C Next, the aspiration needle is extended below the PFCL surface and the PFCL is gradually removed meanwhile the SO is continuously infused into the vitreous cavity. Finally, the needle follows the PFCL bubble toward the posterior pole until fully extracting the PFCL