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17.3 Vi trectomy
Instruments
1. 27G three-port trocar system with or without chandelier illumination
2. 120D lens
3. Vitreous cutter
4. Backush instrument
5. Scleral depressor
Tamponade
Air, SF
6
Individual Steps
1. Three-port trocar system with or without chandelier illumination
2. Core vitrectomy
3. Peripheral vitrectomy
4. PRP
5. Tamponade and intravitreal anti-VEGF treatment
6. Removal of the trocar cannulas
17.3.1 The Surgery Step-by-Step
319
1. Three-port trocar system with or without chandelier illumination
2. Core vitrectomy
The vitreous hemorrhage reduces the illumination of the light ber, because the
light cone is hidden by blood. Therefore, the surgeon should rst make a core vitrectomy. Keep the vitreous cutter behind the IOL and remove all vitreous gel. It
might be easier to work rst without BIOM and use the microscope only as you
would in cataract surgery. If the visibility is not improved, then try only to aspirate
the liqueed blood. Try next to cut a break in the posterior hyaloid in order to obtain
a view of the fundus. It is important to identify the retinal vessels to make sure that
the surgeon is in the right plane (and not in the subretinal space). If successful, continue the vitrectomy from the break into the posterior hyaloid.
Surgical Pearls No. 97
Blocked infusion: The hemorrhagic vitreous blocks sometimes the infusion. Check
the infusion trocar before vitrectomy, and if in doubt then cut the hemorrhagic vitreous around the infusion trocar.
Surgical Pearls No. 98
Removal of anterior hyaloid: In the case of a hemorrhage directly behind the lens,
it may be necessary to remove the anterior hyaloid. This is an easy procedure in
pseudophakic patients but a lens threatening procedure in phakic patients. We
320
17 Easy Diabetic Retinopathy
perform two techniques: Work at the edge of the lens (i.e., behind the zonules) in
order to avoid a lens touch. (1) With help of a serrated jaws forceps, grab the anterior hyaloid/vitreous and pull it towards the center of the globe. Work from both
sides. (2) With the help of a vitreous cutter, suck the anterior hyaloid/vitreous (only
aspiration), and pull the vitreous cutter toward the center of the globe. Cut the vitreous there. Work from both sides.
3. Peripheral Vitrectomy
Proceed to trim the vitreous base. Do not trim the vitreous base completely
because the risk of causing damage to the retina is higher than the benets. If the
posterior vitreous body is not detached, then a PVD should be performed now. If the
etiology of the bleeding is, for example, a bleeding vessel, treat it now with laser,
diathermy, or cryo.
Surgical Pearls No. 99
How should epiretinal blood be removed? (1) Aspirate epiretinal blood by sweeping
with a silicone tip ute needle over the retina. (2) By pressing several times on the
side opening/tubing of the backush instrument, water is ejected from the tip of the
ute needle and blows the epiretinal blood upward. The blood can then be easily
aspirated at the same time with the vitreous cutter. (3) Clotted blood can be grasped
with an ILM forceps and be removed with the vitreous cutter.
4. Panretinal Photocoagulation (PRP)
We recommend completing a PRP intraoperatively in all cases of vitrectomy for
proliferative diabetic retinopathy. This is the best opportunity to complete the PRP,
as rebleeding into the vitreous cavity is a common problem following vitrectomy,
which will have a negative inuence on performing additional PRP after the vitrectomy. Use the scleral depressor and apply a dense PRP up to the ora serrata
(Fig.17.6). For PRP we recommend the following laser parameters: power: 100–150
Fig. 17.6 Perform a PRP
up to the ora serrata
17.4 FAQ
321
m我; duration: 200 ms; and interval: 200–300 ms at an OcularLight GL Company
Iridex. These values are dependent on the device and the pigmentation of the fundus.
After endolaser photocoagulation check if a new hemorrhage occurred at the
central pole, and treat it before you move on to the tamponade.
Surgical Pearls No. 100
Small pupil: If the pupil constricts during surgery, inject 0.01% Adrenalin into the
anterior chamber. The pupil enlarges within seconds. If the small pupil is caused by
posterior synechiae, use stretching instruments such as a push-pull or insert iris
hooks to enlarge the pupil.
5. Tamponade and Intravitreal Anti-VEGF Treatment
An air or gas tamponade is recommended to avoid a rebleeding into the vitreous
cavity. Inject 0.2ml bevacizumab at the end of the procedure to inhibit proliferative
vessels.
6. Removal of Trocar Cannulas
The trocars are removed, as described above. In cases of a 25G trocar and silicone oil tamponade, suture the sclerotomy.
Postoperative Tamponade and Posture
For a mild PDR, we use in the most cases air and sometimes SF6.
17.3.2 Complications
Important Air does not expand at sea level. But patients with an air tamponade are
not allowed to y because air expands with increasing altitude. The air pressure in
the plane corresponds to an air pressure at 2500m above sea level. Travel to higher
elevations should also be avoided.
Recurrent Vitreous Hemorrhage After a vitrectomy for a vitreous hemorrhage,
bleeding may reoccur after surgery. If the recurrence is associated with a hyphema,
then check if the patient takes anticoagulants, i.e., aspirin. The patient should stop
taking blood thinning medication for approximately 1 month. In most cases the
hyphema resolves. Do not reoperate on the patient before the hyphema has resolved.
17.4 FAQ
Do you peel the ILM in diabetic retinopathy?
No, never. The only exception would be a very difcult case complicated by
PVR.There are no double-blind studies published which justify the prophylactic
removal of physiologic tissue such as ILM.
Part IV
Difficult Vitrectomy in Europe
Usage ofaChandelier Light
18
Surgery for retinal detachment means bimanual vitrectomy and the usage of a chandelier light. Bimanual vitrectomy is an essential part of modern minimal incision
vitreoretinal surgery (MIVS). By inserting a stationary chandelier light in the sclera
(four-port vitrectomy, Fig.18.1), the surgeon has two active hands. To operate with
two active hands is a new and exciting method of surgery. For example, in retinal
detachment surgery, you can indent the sclera with one hand and vitrectomize the
vitreous base with the other hand. In diabetic retinopathy, you can apply laser photocoagulation up to the ora serrata with the help of a scleral depressor. You can
remove membranes with two different instruments and also apply counteraction
and so on.
For optimal use of a chandelier light, three requirements have to be met:
1. Inferonasal insertion enabling a good rotation of the globe
2. A rigid cable allowing the light source to be aimed in all directions in the vitre-
ous cavity
3. Strong light source for optimal illumination
The chandelier light is best positioned inferonasally, because here its location
does not affect the rotation of the eye. The 12 o’clock or 6 o’clock insertion sites
disturb the rotation of the globe, and the light ber is easily dislocated when the
globe is rotated upward or downward. The rigid cable allows the light ber to be
bent and therefore allows the light to be directed in different directions within the
vitreous cavity. The light source of modern vitrectomy machines (Constellation,
Stellaris, Eva) is sufcient for optimal illumination of chandelier light. The light
source of old vitrectomy machines (Accurus) is not sufcient for optimal illumination of chandelier light. In the latter case, an external light source (Photon or Xenon)
is required for a sufcient illumination of the vitreous cavity.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_18
325
326
Fig. 18.1 An eye with
four-port vitrectomy. In
addition to the known
three-port system, a
chandelier-light bre was
rmly inserted into the
sclera (top left)
18 Usage ofaChandelier Light
Table 18.1
Chandelier light
Light source Photon Xenon Photon
Illumination Good Good Very good
Rigid cable Ye s No Yes
Maneuverability Average Reduced Good
Method of insertion Trocar Trocar Sclera
Difculty of insertion Simple Simple Average
ALCON
Synergetics
Features of different types of chandelier lights
ALCON
a
: Chandelier Accurus 8065751574; DORCb: 23-gauge Chandelier light 3269.EB06;
c
: 25-Gauge Awh Chandelier 56.20.25
a
DORC
b
Synergetics
c
18.1 Insertion ofChandelier Light
If you have never used a chandelier light before, then start with one which can easily
be inserted. The 25-gauge chandelier light from ALCON and the 23-gauge chandelier light from DORC are relatively unproblematic to use (see Table18.1) as the
light ber can be placed inside a normal one-step trocar (Figs.18.2 and 18.3).
The chandelier light from Synergetics is trickier to be put in place but on the
other hand provides an excellent panoramic illumination of the vitreous cavity.
Rotate the globe with a swab in a superotemporal direction so that there is space for
the insertion of the chandelier light inferonasally. With the sclerotomy needle supplied by the manufacturer one rst performs a transconjunctival sclerotomy 3.5mm
posterior to the limbus with a perpendicular (not lamellar) path. The chandelier light
is then inserted into the sclerotomy. This procedure requires some practice. The
Synergetics chandelier light requires an external photon light source. By bending
the rigid cable of the chandelier light, you can manipulate the light source.
Sometimes you need to tape the cable to the drape.
18.1 Insertion ofChandelier Light
Fig. 18.2 A 23-gauge
chandelier light from
DORC, which is very easy
to insert because it is
placed in a trocar. Similar
chandelier lights are
available from Alcon and
Synergetics
Fig. 18.3 Same 23-gauge
chandelier light. Place a
23-gauge trocar
inferonasally. Then insert
the light ber into an
ALCON or DORC trocar
(with or without valve).
DORC: 23-gauge
Chandelier light
3269.EB06
327
Surgical Pearls No. 65
Chandelier Light
1. The insertion of the chandelier light is easier using your hands than with the
trocar forceps. But you must exert a relatively strong pressure to insert the tip of
the chandelier through the sclera. If you fail, you can expand the sclerotomy with
a 23-gauge cannula/needle. The insertion is easier, but the chandelier sits a little
loosely in the sclerotomy.
2. Conjunctival chemosis or hemorrhage may make it difcult to identify the scle-
rotomy. In such cases, open the conjunctiva focally with scissors and forceps in
order to visualize the sclerotomy.
The following surgeries in bimanual technique are listed in increasing levels of
difculty. The most demanding surgeries are PVR detachment and proliferative diabetic retinopathy. In these pathologies, a bimanual peeling facilitates surgery
immensely and is warmly recommended.
Vitrectomy forDifficult Retinal
Detachment (PVR)
19.1 Introduction
The termproliferative vitreoretinopathy was provided in 1989 by the Silicone Oil
Study group (1). The name is derived from proliferation of the retinal pigment epi-
thelial and glial cells and vitreoretinopathy to include the tissues which are affected,
namely the vitreous and the retina (Fig.19.1).
The current management is the surgical relief of vitreal, preretinal, and subretinal tractions. The nal aim is the reestablishment of retinal attachment and visual
function.
The principles of management are (1) closure of all retinal breaks, (2) relief of
traction, and (3) long-term retinal stabilization. The following Table19.1 shows the
principles and surgical procedures for PVR detachment.
19
Fig. 19.1 PVR
detachment stage C3
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_19
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330
19 Vitrectomy forDicult Retinal Detachment (PVR)
Table 19.1
Principle Surgical procedure
Closure of all retinal breaks Identication
Relief of traction Membrane dissection
Long-term retinal stabilization Laser photocoagulation
Principles and surgical procedures for PVR detachment
Closure
Retinotomy/retinectomy
Scleral buckle
Intraocular tamponade
Regarding the timing of surgery an early surgical treatment is favorable because
it limits photoreceptor loss and improves a favorable visual outcome. A delayed
surgical treatment (after 6weeks) is unfavorable for the visual function but surgery
is easier; the proliferative membranes become “mature” and are therefore surgically
easier to remove.
Indication Feasible pathologies for this surgery are the rst surgery of PVR
detachments grade C2, C3, and D.
19.2 Instruments forPVR Detachment
Membrane Removal
# Trypan blue
# 27G endgripping forceps
# 27G DORC wide-grip forceps (1286.WRD04)
# Knob spatula or
# Membrane pic
# Atkinson cannula
# Straight scissors
19.3 The Surgery Step-by-Step
1. Encircling band (cerclage)
2. Phacoemulsication and IOL implantation
3. Pars plana vitrectomy
4. Vitreous staining with triamcinolone
5. Vitreous base shaving
6. Staining of membranes with Trypan blue
7. Removal of epiretinal membranes
8. Removal of subretinal membranes
9. 180° retinotomy
10. Instillation of PFCL
19.4 Every Surgical Step inDetail
11. Laser photocoagulation
12. Prepare the anterior chamber
13. Tamponade
331
19.4 Every Surgical Step inDetail
19.4.1 Encircling Band (cerclage)
Introduction An encircling band relieves traction at the vitreous base. It facilitates
also the closure of peripheral retinal breaks. And nally, an encircling band supports
the vitreous base during anterior dissection. An encircling band is used less and less
nowadays. We place an encircling band in PVR stage C3 and in PVR
redetachments.
The surgery of an encircling band is described in detail in Sect. 12.1.
19.4.2 Phacoemulsification andIOL Implantation
For vitrectomy of PVR detachment, we recommend regardless of the age a phacoemulsication with IOL implantation in the bag. The lens removal allows the visualization of the vitreous base and assessment of anterior PVR, and it allows more
importantly the surgical access to the vitreous base. We avoid a (pars plana) lensectomy because the lens capsule is absent which serves otherwise as a scaffold
between the posterior and anterior chamber. For example, in the case of a silicone
oil tamponade, the oil may prolapse into the anterior chamber and cause anterior
chamber complications.
Surgical Pearls No. 88
Management of miotic pupil: A miotic pupil may be a major obstacle for PVR surgery because the pathology is often located in the periphery. In many cases an intracameral injection of Adrenaline (1:10) is sufcient. Adrenaline may also be given
during surgery. If posterior synechiae are present, then a synechiolysis is recommended. This can be achieved through iris stretching. Insert two Sinskey hooks
through the paracenteses and stretch the pupil (Fig.19.2). Alternatively, iris retractors with four-point xation or a Malyugin ring can be implanted (Figs. 19.3
and 19.4).
19.4.3 Pars Plana Vitrectomy
A main step in pars plana vitrectomy is the removal of the core vitreous resulting in
relief of transvitreal traction.
We use a standard three-port PPV with 25G trocars. We use 25G and not 23G
because smaller trocars require smaller instruments, and this results in less