Περιεχόμενα
1. Surgical Anatomy 1
Cristian Fernández-Martinez, José Juan Martinez-Toldos
Introduction 1
Anatomy of the Vitreous 1
Vitreous Base and Vitreoretinal Interface 2
Anatomical Distances in Vitrectomy 4
Crystalline Lens 4; Extraocular Muscles 4; Ciliary Body 5; Blood Vessels 5
2. presurgery Examination 9
Manolo Baeza Diaz, José Juan Martinez-Toldos
Medical History 9
Visual Acuity 9
Pupil Reflexes 9; Color Perception 10; Vascular Entoptic Test 10; Slit Lamp
Microscopy 10; Tonometry 10
Examining the Fundus 11
Indirect Ophthalmoscopy 11; Biomicroscopy of the Retina 11
Ultrasonography 11
Vitreous Disorder 12
Fluorescein Angiography 16
Electrophysiology 17
Electroretinography 17; Evoked Visual Potentials 17
3. Vitrectomy and Optical Coherence Tomography 19
David Salom, Patricia Udaondo, Manuel Díaz Llopis, José Juan Martínez-Toldos
Introduction 19
Optical Coherence Tomography in Macular Holes 20
Optical Coherence Tomography in Epiretinal Membranes 21
Optical Coherence Tomography in Vitreoretinal Traction Syndrome 22
Intraoperative 25
4. Anesthesia 28
Manuel Baeza, José Juan Martínez-Toldos
Introduction 28
Types of Anesthesia 29
General Anesthesia 29; Local Anesthesia 30; Retrobulbar Block 33;
Peribulbar Anesthesia 35; Sub-Tenons Anesthesia 36
5. Instrumentation 43
José Juan Martínez-Toldos, Cristian Fernández-Martínez
Operating Room 43
Introduction 43
Requirements 43
Ophthalmologic Surgery Table 43; Instrument Column 45; Integrated
Vitrectomy Systems 45; Image Recorder 45; Operating Microscope 46
Visualization Systems 49
Introduction 49
Upright Image Contact Lenses 50
Landers Biconcave Lens 50; Machemer Magnifying Lens 51; Peyman
Wide-angle Lens 52; Machemer Plano-concave Lens 52; Tolentino
Twenty Degree Prism Lens 52; Tolentino Thirty Degree Prism Lens 52;
Woldoff Biconcave Prism Lens 52
Wide-Angle-Viewing Systems 52
Use of the Erect Indirect Binocular Ophthalmic System 56
Other Visualization Systems 58
Combined Procedures 61
Endoillumination 65
Introduction 65
External Systems 65
Internal Systems 65
Chandelier System 67
Infusion pressure 71
Introduction 71
Hydrostatic Pressure 71
Infusion Pump or Gas Forced Infusion 72
Pressure Control 75
Low Intraocular Pressure 75; High Intraocular Pressure 75
Infusion Devices 76
Twenty-Gauge Incisions 76
Opening the Conjunctiva 76
Twenty-Gauge Transconjunctival Vitrectomy 78
Suction and Cutter Systems 79
Introduction 79
Active Aspiration 79
Passive Aspiration 83
Vitrectomy Probes 84
Constellation Vision System 85; Stellaris PC Vision Enhancement System 88
Diathermy 90
Introduction 90
Retinopexy 93
Introduction 93
Laser Endophotocoagulation 93
Argon Laser 96; Diode Laser (810 nm) 96; Green Diode Laser (532 nm) 96;
Yellow Laser (577 nm) 97
phacoemulsification 99
Introduction 99
Ultrasonic Fragmentation 102
Introduction 102
Forceps and Scissors 104
Introduction 104
Vitreous Substitutes: Manipulators 109
Introduction 109
Hyaluronic Acid 109
Perfluorocarbon Liquids 109
Vitreous Substitutes: Tamponades 113
Introduction 113
Intraocular Gases 113
Silicone Oil 115
Silicone Solvent 116; Heavy Silicone Oil 117; Densiron 119
6. Basic Vitrectomy 121
Cristian Fernández-Martínez, José Juan Martínez-Toldos
Check List 121
Positioning the Patient 122
Visualization Systems 122
Contact Systems 122; Noncontact Systems 122
Conjunctival Incisions 123
Sclerotomy 124
Pupil Management 127
Phacoemulsification 128
Surgical Technique 128; Special Cases 129
Removing The Vitreous Humor: Basic Concepts 129
Aspiration Systems 131
Active Aspiration 131; Passive Aspiration 132
Peeling Membranes in Vitrectomy 132
Segmenting Membranes 134; Delaminating Membranes 135; Staining
Membranes 136
Perfluorocarbon Liquids 140
Uses of Perfluorocarbon Liquids 141; Intraoperative Management of
Perfluorocarbon Liquids 142; Potential Problems during the Use of
Perfluorocarbon 146
Fluid-Air Exchange 146
Use of Gas in Vitrectomy 147
Nonexpanding Gas 147; Expanding Gas 148; Clinical Indications
of Gases 148; Air–Gas Exchange 148; Postoperative Management of
Patients Receiving Intraocular Gas 149
Silicone Oil in Vitrectomy 149
Injection of Silicone Oil 149; Emulsification of the Silicone Oil 150;
Indications of Silicone Oil Tamponade 150; Inferior Peripheral
Iridectomy 151; Removal of Silicone Oil 151
Closure After Surgery 152
7. pars plana Lensectomy 156
Carlos Mateo, Anniken Burés
Introduction 156
Surgical Technique 156
Advantages of Pars Plana Lensectomy 158
Pars Plana Lensectomy Indications 159
Vitreoretinal Proliferation 159; Perforating Ocular Trauma with or without
Intraocular Foreign Body 160; Proliferative Diabetic Retinopathy 162
8. Basic Endoscopic Vitrectomy 164
Vicente J Chaqués-Alepuz, Enrique V López-Sánchez
Basic Equipment for Endoscopy 164
Technical Aspects: Visualization 166
Image Rotation 167; Image Artifacts 168; Technical Tips for
the Beginners 169
Endoscopic Posterior Vitrectomy: Basic Concepts and Indications 170
Surgeons Position 170; Image Size and Lighting 171; Blurred Image 171
Complications of Vitreoretinal Surgery that can be Avoided by
Endoscopy 171
Vitreous Incarceration 171; Controlling Intraoperative Bleeding 172
Techniques and Maneuvers of Vitrectomy and Endoscopy 173
Vitrectomy 173; Membranectomy 174; Fluid-Air
Exchange 174; Endophotocoagulation 174; Pars Plana Lensectomy 175
Capsulectomy 175; Introducing Silicone Oil 175; Introducing
Perfluorocarbon Liquid 176; Diabetic Retinopathy and Endoscopic
Vitrectomy 176; Vitreous Hemorrhage 177; Neovascularization of the
Iris with Opacity of the Media 177; Retinal Detachment Surgery 177;
Proliferative Vitreoretinopathy 178; Endoscopic Vitrectomy for Crystalline
Lens Fragments Luxated in the Vitreous Cavity 180; Endoscopic Vitrectomy
in Endophthalmitis 181
9. Minimal Incision Vitrectomy Surgery: Twenty-Three,
Twenty-Five and Twenty-Seven Gauge 184
José Juan Martínez-Toldos, Javier A. Montero-Moreno, José M Ruiz-Moreno,
Félix Armadá-Maresca, Natalia Pastora-Salvador, Anna Grabowoska, María
Granados-Fernandez, Beatriz Manzano Muñoz
Twenty-Three Gauge Vitrectomy 184
Introduction 184
Incision Construction 185
Vitrectomy 186
Closing the Incision 187
Benefits of Twenty-Three Gauge Surgery 187
Complications 187
Twenty-Five Gauge Vitrectomy 189
Introduction 189
Benefits of Microincision Vitrectomy 192
Drawbacks of Microincision Vitrectomy 192
Complications 192
Future Perspectives 193
Twenty-Seven Gauge 196
Introduction 196
Instrumentation 196
Indications 199
10. Vitrectomy in Anterior Segment Surgery Complications 202
José Juan Martínez-Toldos, Juan Carlos Elvira-Cruañes
Introduction 202
Ocular Perforation in Retrobulbar Anesthesia 202
Transconjunctival Sub-Tenons Anesthesia 203; Ocular
Perforation 203; Treatment 204
Retrobulbar Hemorrhage 205
Anterior Vitrectomy 205
Vitrectomy Following Vitreous Loss 206
Retained Lens Fragments 209
Surgical Indications 211; Associating Surgery at the Time of Lens
Dislocation 211; Surgical Technique 212
Intraocular Lens Dislocation 216
Surgical Technique 219; Late Intraocular Lens Dislocation with the Capsular
Bag 222; Mechanisms 223; Prevention 223; Treatment 224
Endophthalmitis 225
Etiology 226; Treatment 227; Vitrectomy 228; Late-Onset
Endophthalmitis 229
11. Eye Trauma Vitrectomy 235
Joséfina Bañuelos Bañuelos, Patricia Martínez-García, Javier Orduña-Azcona,
Ana Orive-Bañuelos
Introduction 235
Vitrectomy in Open Traumatisms 235
Clinical History and Initial Examination 235; Presurgical
Considerations 236; Surgical Technique 237
Special Situations 240
Trauma and Dense Vitreous Hemorrhage 240; Trauma and Retinal
Detachment 241; Trauma and Intraocular Foreign Body 241; Trauma and
Endophthalmitis 244
Vitrectomy and Compliactions of the Ocular Trauma 246
Macular Hole 246; Ocular Hypotony and Bulb Phthisis 247
12. Basic Vitrectomy in Diabetic Retinopathy 250
Jose Garcia-Arumi, Anna Boixadera, Laura Distefano, Vicente Martinez-Castillo,
Miguel Angel Zapata
Introduction 250
Surgical Approach 251
Vitrectomy for Diabetic Macular Edema 257
13. Macular Surgery 261
Amparo Navea, Elena Palacios, Carmen Desco, Jorge Mataix
Surgery on the Surface of the Macula 261
Preliminary Considerations 261
Interview with the Patient 262
Surgery Preparation 263
Technical Requirements 263; Human Requirements 263; Patient
Preparation 263; Surgeon Preparation 263
Vitrectomy 264
Specific Technical Points in Macular Hole 265
Surgery in the Subretinal Macular Space 267
Severe Submacular Hemorrhage Located into the Macular Area 267
Masive Subretinal Hemorrhage that also Affects the Macula 269
Subfoveal Perfluorocarbon Bubbles 270
14. Vitrectomy for Retinal Detachment with and without
proliferative Vitreoretinipathy 272
J Fernando Arevalo, Reinaldo A Garcia, Veronica Oria
Introduction 272
Combined Vitrectomy and Scleral Buckling 273
Scleral Buckling Technique 273; Encircling Exoplants 275
Scleral Suture Technique 277
Primary Vitrectomy 277
Basic Operative Steps in Primary Vitrectomy 277
Intraocular Tamponade 283
Small-Gauge Pars Plana Vitrectomy 283
Sclerotomies with 23-Gauge Vitrectomy 284; Sclerotomies with 25-Gauge
Vitrectomy 284
New Considerations in Fluid Dynamics During Small-Gauge
Vitrectomy 285
Increasing Safety 286; Wound Closure 286; Retinal
Tears 287; Hypotony 288; Endophthalmitis 288
Vitrectomy for Retinal Detachment with Proliferative
Vitreoretinopathy 288
Risk Factors for the Development of Proliferative
Vitreoretinopathy 289
Diagnosis of Proliferative Vitreoretinopathy 290
Classification of Proliferative Vitreoretinopathy 290
Type 1 291; Type 2 293; Type 3 293; Type 4 293; Type 5 295
Surgery for Proliferative Vitreoretinopathy 295
Timing of Surgery 295; Scleral Buckling in Proliferative
Vitreoretinopathy 296; Lensectomy and Intraocular Lens 296
Vitrectomy for Proliferative Vitreoretinopathy 297
Removal of Posterior Epiretinal Proliferation 298; Removal of
Anterior Epiretinal Proliferation 298; Removal of Subretinal
Proliferation 298; Relaxing Retinotomies and Retinectomies 299;
Creating a Chorioretinal Adhesion 302; Intraocular Tamponade 302;
Removal of Silicone Oil 303; Reoperations for Recurrent Retinal
Detachment from Proliferative Vitreoretinopathy 304
Adjunctive Treatment in Proliferative Vitreoretinopathy 304
Giant Retinal Tears 305
Postoperative Complications 306
Summary 306
15. Current Indications of Antiangiogenics in Vitrectomy 313
Mauricio Maia, Fernando M Penha, J Fernando Arevalo
Antiangiogenics: Overview 313
Introduction: Vascular Endothelium Growth Factor 313; Role of
Bevacizumab and Ranibizumab in the Angiogenesis Process 313
Intraoperative Bleeding During Pars Plana Vitrectomy In Proliferative
Diabetic Retinopathy 315
Introduction 315; Vitreoretinal Bleeding 315
Preoperative Procedures to Minimize the Possibility of Intraoperative
bLeeding 316
Blood Pressure Control 316; Antiplatelet and Anticoagulants—Is it
Necessary to Discontinue Them before Surgery? 316; Intravitreal
Injection of Anti-VEGF Inhibitors in Proliferative Diabetic Retinopathy 317
Intravitreal Injection of Anti-Vegf Before Surgery in Proliferative
Diabetic Retinopathy 317
Rationale 317; Intravitreal Bevacizumab Before Pars Plana Vitrectomy in
Proliferative Diabetic Retinopathy 317; Intravitreal Ranibizumab
before Pars Plana Vitrectomy in Proliferative Diabetic Retinopathy 319;
Technique of Preoperative Intravitreal Anti-VEGF Injection 319;
Care During Preoperative Intravitreal Anti-VEGF Injection Before
Pars Plana Vitrectomy in Proliferative Diabetic Retinopathy 320
Conclusion of Intravitreal Injection of Anti-VEGF Before Proliferative
Diabetic Retinopathy 320
Techniques of Intraoperative Posterior Segment Bleeding Control 320
Rising the Intraocular Pressure 321; Fluid-Air Exchange 322;
Perfluorocarbon Liquids 323; Endodiathermy and Cauterization 323;
Laser Photocoagulation 325; Combination of Techniques 326
16. Use of Sustained Drug Release Implants in Vitrectomized Eyes 331
Jose Maria Ruiz-Moreno, Javier A Montero
Introduction 331
Clinical Case 334
17. Enzymatic Vitrectomy 337
Patricia Udaondo, David Salom, Salvador Garcia-Delpech, Manuel Díaz-Llopis
Introduction 337
Concept of Enzymatic Vitrectomy 339
Methods and Mechanism of Action 339
18. posterior Vitrectomy Complications 343
Carme Guardia, Jaume Catalá, Jairo Hoyos-Chacón
Introduction 343
Intraoperative Complications 343
Sclerotomy Complications 343
Visualization Problems 346
Retinal Tears 352; Retinopexy Complications 354
Postoperative Complications 354
Corneal Complications 354; Ocular Hypertension and Glaucoma 355;
Vitreous Hemorrhage 357; Retinal Detachment 358; Proliferative
Vitreoretinopathy 359; Intraocular Inflammation and Fibrinoid
Reaction 360; Tamponade and Manipulator
Agents Complications 360; Endophthalmitis 364; Cataract 364
To Prevent Vitroretinal Surgery Complications 365
Index 369
