Table Of ContentPractical Handbook
for Small-Gauge Vitrectomy
Ulrich Spandau (cid:129) Heinrich Heimann
Practical Handbook
for Small-Gauge
Vitrectomy
A Step-By-Step Introduction
to Surgical Techniques
Authors
Ulrich Spandau, M.D., Ph.D. Prof. Dr. med. Heinrich Heimann, M.D.
Department of Ophthalmology St. Paul's Eye Unit
Uppsala University Hospital Royal Liverpool University Hospital
Uppsala Liverpool, Merseyside
Sweden UK
[email protected] [email protected]
ISBN 978-3-642-23293-0 e-ISBN 978-3-642-23294-7
DOI 10.1007/978-3-642-23294-7
Springer Heidelberg Dordrecht London New York
Library of Congress Control Number: 2011941508
© Springer-Verlag Berlin Heidelberg 2012
Authorized translation of the 1st German language edition
Spandau HH, 23G-Vitrectomie
© 2009 by Kaden-Verlag, Heidelberg
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication
or parts thereof is permitted only under the provisions of the German Copyright Law of September 9,
1965, in its current version, and permission for use must always be obtained from Springer. Violations
are liable to prosecution under the German Copyright Law.
The use of general descriptive names, registered names, trademarks, etc. in this publication does not
imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protec-
tive laws and regulations and therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about dosage and
application contained in this book. In every individual case the user must check such information by con-
sulting the relevant literature.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
This book is dedicated to my teacher Zoran
Tomic, who inspired me for retinal surgery.
He is a pioneer in the development of
bimanual surgery and in particular the
bimanual removal of membranes. It is he,
who should have written this book.
Ulrich Spandau
Foreword 1 (German Edition)
In 2002 when the team of Eugene de Juan, Los Angeles, published their fi rst experi-
ence of the transconjunctival sutureless vitrectomy with 25-gauge instruments, it
could not be foreseen that the “small gauge vitrectomy” would become the new
standard procedure of vitrectomy within a few years.
Most retinal surgeons had previously considered the conjunctiva and sclera in a
20-gauge vitrectomy as a more or less troublesome and time-consuming obstacle
before and after their true passion, the vitreous cavity. The extensive opening of the
conjunctiva in conventional 20-gauge vitrectomy, the suture material used for the
closure of sclera and conjunctiva and the sometimes wide-scale application of dia-
thermy resulted often in a pronounced trauma of the outer layers of the eye. Thus,
any revisional surgery became increasingly diffi cult due to the increased scarring of
conjunctiva and Tenon’s capsule and the atrophy of the sclera in the pars plana.
Due to their fl exibility, the fi rst 25-gauge instruments were initially only used for
relatively simple vitreoretinal surgery at the posterior pole. However, the minimally
invasive approach by de Juan was from the beginning fascinating, because not only
was the extraocular part of a vitrectomy signifi cantly shortened, but the trauma of
conjunctiva and sclera were also signifi cantly reduced.
In 2004, inspired by de Juan’s method, Claus Eckardt developed a trocar cannula
system and instruments with a diameter of 23-gauge in Frankfurt-Höchst. This
invention had on one side the advantage of the 25-gauge vitrectomy and on the other
side the effi ciency of the 20-gauge instruments. The aim was to carry out all possi-
ble vitreoretinal surgery with the same instrumentarium, and this has since then
become reality in our department.
A key to the success of the 23-gauge technology step has been Claus Eckardt’s
concept of a tangential insertion of the trocars and the use of valves for the cannulas:
Due to the tunnel-shaped incision technique within the sclera, an intraoperatively
stable positioning of the cannulas and a sutureless closure of the sclerotomies after
removal of the cannulas, postoperative hypotension or even endophthalmitis could
be prevented. The valves allow a vitrectomy in a closed system and reduce the fl ow
of infusion fl uid through the vitreous cavity.
Ulrich Spandau presents in this very practical book on 23-gauge vitrectomy the
latest equipment and instruments needed for a 23-gauge vitrectomy and he explains
in detail the most important surgical techniques.
vii
vviiiiii Foreword 1 (German Edition)
A lot of useful tips, and last but not least the included DVD with a variety of
surgical videos, make this book a very useful surgical compendium.
This practical book will be a great guide for young ophthalmic surgeons who
want to familiarize themselves with modern vitrectomy.
Even experienced vitreoretinal surgeons, who wish to switch from 20-gauge to
23-gauge vitrectomy, will benefi t from this compendium.
Frankfurt-Höchst, Germany Tillmann Eckert
Foreword 2
Dr. Ulrich Spandau confi rms with this compendium to be the most dedicated of my
so far eight fellows in vitreoretinal surgery. He presents here our current surgical
concept, instrumentation and operative techniques that have been developed in
Uppsala in the last 17 years. It is a transconjunctival, 23-gauge Microincision
Vitrectomy Surgery (MIVS), combined with phaco-emulsifi cation in elderly
patients, performed bimanually for the most of complex indications. To the best of
my knowledge no comparable practical guide for current vitreoretinal surgery has
been published since Zivojnovic’s S ilicone Oil in Vitreoretinal Surgery , in 1987.
Since then vitreoretinal surgery has changed very much, from 20-gauge macroinci-
sional vitrectomy with silicone oil tamponade in most of the cases, to 23-gauge
microincisional, bimanual vitrectomy with gas tamponade that we use today.
Dr. Spandau has opened a treasure box that he has fi lled patiently for several
years and presents here some genuine surgical pearls, both those that he has discov-
ered for himself, those that we have discussed together, those that I have shown him
and furthermore those that were known since before. That gives an opportunity to
both beginners and more experienced vitreoretinal surgeons to improve their practi-
cal knowledge and refi ne their procedures in this fi eld. It is our duty to share all the
surgical skills and knowledge with each other in order to provide the best results for
our patients. This book is a genuine account of our practical work dedicated to
them, which Dr. Spandau has written in collaboration with Dr. Heinrich Heimann.
Thank you Ulrich and Heinrich!
Dr. Zoran Tomic
Chief Vitreoretinal Surgeon
Department of Ophthalmology
University Hospital
Uppsala, Sweden
ix
