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Trimanual Anterior Vitrectomy: A Novel Technique to Manage Vitreous Loss during Phacoemulsification.

Taggart MG, Morshedi RG, Ambati BK - Case Rep Ophthalmol (2014)

Bottom Line: The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision.The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material.While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy.

View Article: PubMed Central - PubMed

Affiliation: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, and Harvey and Bernice Jones Eye Institute, University of Arkansas, Little Rock, Ark., USA.

ABSTRACT
We report 2 cases illustrating the use of a new technique to manage vitreous loss during phacoemulsification, which we have termed 'trimanual' anterior vitrectomy. In each case, after recognizing posterior capsule tear, the remaining nuclear pieces were removed with low-parameter phacoemulsification. The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision. The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material. While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy.

No MeSH data available.


Related in: MedlinePlus

Diagram showing the appropriate relative positions of the 3 instruments. The irrigation handpiece (far left) stays within the anterior chamber. The aspiration handpiece (far right) is used to remove cortex. The vitrectomy probe is held posterior to the capsule defect.
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Figure 3: Diagram showing the appropriate relative positions of the 3 instruments. The irrigation handpiece (far left) stays within the anterior chamber. The aspiration handpiece (far right) is used to remove cortex. The vitrectomy probe is held posterior to the capsule defect.

Mentions: Bimanual anterior vitrectomy also theoretically reduces the risk of hydrating the vitreous, as the irrigation cannula can be left more anteriorly in the anterior chamber while the vitrectomy probe is placed through the posterior capsule defect and used to cut the vitreous. In this system, the vitrectomy probe has both cutting and aspiration functions, with the order of the 2 functions dependent on whether the machine is in I/A-cut or cut-I/A mode. Since the same port is used for both cutting and aspirating, even surgeons using fine foot pedal control will occasionally aspirate vitreous when cutting is instead indicated, which places traction on the vitreous and increases the risk for retinal tears and/or detachment. Additionally, in our experience, attempting to remove remaining lens material (especially epinucleus and cortex) in a ‘stripping’ fashion with the vitrectomy probe can be difficult, as the sharp edges of the port can cut (and thereby release) the accumulated cortical material, even when the cutting function is not involved. This limits the attainable vacuum, which must be of a sufficient level to be able to strip the cortical material off of the capsular bag. In contrast, the smooth round port of the bimanual aspiration handpiece is more easily obstructable and less likely to cut the cortical material, making the removal of the remaining cortical material more efficient (fig. 3). Therefore, when a posterior capsule rupture is identified prior to the complete removal of all epinuclear and cortical material, a potentially valuable alternative may be the trimanual anterior vitrectomy technique. The remaining nuclear material, depending on the density, would likely have to be dealt with first, either with a continued low-parameter phacoemulsification or a conversion to extracapsular cataract extraction.


Trimanual Anterior Vitrectomy: A Novel Technique to Manage Vitreous Loss during Phacoemulsification.

Taggart MG, Morshedi RG, Ambati BK - Case Rep Ophthalmol (2014)

Diagram showing the appropriate relative positions of the 3 instruments. The irrigation handpiece (far left) stays within the anterior chamber. The aspiration handpiece (far right) is used to remove cortex. The vitrectomy probe is held posterior to the capsule defect.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4264489&req=5

Figure 3: Diagram showing the appropriate relative positions of the 3 instruments. The irrigation handpiece (far left) stays within the anterior chamber. The aspiration handpiece (far right) is used to remove cortex. The vitrectomy probe is held posterior to the capsule defect.
Mentions: Bimanual anterior vitrectomy also theoretically reduces the risk of hydrating the vitreous, as the irrigation cannula can be left more anteriorly in the anterior chamber while the vitrectomy probe is placed through the posterior capsule defect and used to cut the vitreous. In this system, the vitrectomy probe has both cutting and aspiration functions, with the order of the 2 functions dependent on whether the machine is in I/A-cut or cut-I/A mode. Since the same port is used for both cutting and aspirating, even surgeons using fine foot pedal control will occasionally aspirate vitreous when cutting is instead indicated, which places traction on the vitreous and increases the risk for retinal tears and/or detachment. Additionally, in our experience, attempting to remove remaining lens material (especially epinucleus and cortex) in a ‘stripping’ fashion with the vitrectomy probe can be difficult, as the sharp edges of the port can cut (and thereby release) the accumulated cortical material, even when the cutting function is not involved. This limits the attainable vacuum, which must be of a sufficient level to be able to strip the cortical material off of the capsular bag. In contrast, the smooth round port of the bimanual aspiration handpiece is more easily obstructable and less likely to cut the cortical material, making the removal of the remaining cortical material more efficient (fig. 3). Therefore, when a posterior capsule rupture is identified prior to the complete removal of all epinuclear and cortical material, a potentially valuable alternative may be the trimanual anterior vitrectomy technique. The remaining nuclear material, depending on the density, would likely have to be dealt with first, either with a continued low-parameter phacoemulsification or a conversion to extracapsular cataract extraction.

Bottom Line: The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision.The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material.While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy.

View Article: PubMed Central - PubMed

Affiliation: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, and Harvey and Bernice Jones Eye Institute, University of Arkansas, Little Rock, Ark., USA.

ABSTRACT
We report 2 cases illustrating the use of a new technique to manage vitreous loss during phacoemulsification, which we have termed 'trimanual' anterior vitrectomy. In each case, after recognizing posterior capsule tear, the remaining nuclear pieces were removed with low-parameter phacoemulsification. The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision. The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material. While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy.

No MeSH data available.


Related in: MedlinePlus