Basic step in vitrectomy

CEH Retina Team

The basic steps for a 20-g PPV

Prepare the eye with dilute povidone iodine

and
topical anaesthetic on the conjunctiva.
Drape and insert a lid speculum.
Incise the conjunctiva and Tenons layer at
three
sites: superonasal, superotemporal, and
inferotemporal.
 Insert a 7/0 absorbable suture to fix the
infusion cannula (tie with a bow).
Incise the sclerotomy.
Secure the infusion cannula and check.
 Incise the other two sclerotomies.
Insert the endo-illumination and focus
the viewing system.
Insert the vitrectomy cutter and excise
the vitreous.
Take as much vitreous as possible
 Search the retina for breaks (iatrogenic or pre-
existing) with endo-illumination and
indentation.
Close the superior sclerotomies and
conjunctiva with a 7/0 absorbable suture.
Close the inferior sclerotomy with the pre-
placed 7/0 suture.
Insert a sub-Tenons injection of antibiotics and
anaesthetic (for postoperative pain relief)
Conjunctival incision

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sclerotomy
The sclerotomies should be placed 4
mm from the limbus in the phakic eye
and 3.5 mm in the aphakic or
pseudophakic eye
None of the sclerotomies should be placed on
the horizontal meridian, where it would
damage the long ciliary arteries and nerves
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 Incision are best made circumferentially
to the limbus because of the orientation
of the scleral collagen fibres
Radial cuts are also safe and effective
and are useful in repeat operations by
preventing coalescence of adjacent
circumferential wounds.
 Mark the site with a caliper measure and place
a 7/0 absorbable suture with two parallel and
radial bites,1.5 mm apart and 1.5 mm in
length.
The bites are place in the same direction to
create a diagonally placed loop of suture
between the two bites.
Insert the microvitreoretinal (MVR) blade
between these bites, perpendicularly pointing
towards the centre of the eye and deep enough
to hole the choroid and make a 20-g sclerotomy
Where to Place the Superior
Sclerotomies

One in the superotemporal quadrant

and one in the superonasal quadrant.
Place these approximately 150 apart. If
the sclerotomies are too close together,
they will force the surgeons hands close
together and reduce maneuverability.
If they are too far apart, movement of
the eye becomes difficult
Core vitrectomy
Vitreous cavity consist of formed
and liquefied vitreous
Volume 3-4 ml
Strongly adherent to the retina at
the vitreous base, 2 mm anterior
and 2-3mm posterior to the ora
serrata
 To remove the centrally formed vitreous and
move gradually toward the peripheral retina
Scleral depressiom permits trimming the
vitreous toward the peripheral vitreous base
The vitreous is shaved in vitreous base,
taking care to reduce any unnecessary
traction to the retina
360 degree until total parsplana vitrectomy
is complete
Removal of the posterior
hyaloid
In patient without PVD, posterior
hyaloid is attached to the optic
nerve, retinal vessels, over macula,
and area of old retinal scarring
Any undue traction, can result
retinal tears or detachment (in
macula can create macular hole)
 Posterior hyaloid is typically
engaged in the peripapillary region
The lowest potential damage to
the retina
Inspection the peripheral
retina
Should be performed after vitrectomy
with indirect ophthalmoscope and
scleral depression to ascertain that NO
RETINAL TEARS occurred as a result of
the surgery
Directed to the region of the retina
directly posterior to each sclerotomy
Closure following
vitrectomy
Superior nasal and temporal closed
with 7-0 vicryl suture
Any vitreous protruding should be
trimmed
Conjunctiva is closed using
interrupted 6-0 plain gut suture
Thank you