Table Of ContentPractical Handbook
for Small-Gauge
Vitrectomy
A Step-By-Step Introduction to
Surgical Techniques
Ulrich Spandau
Heinrich Heimann
Second Edition
123
Practical Handbook for Small-Gauge Vitrectomy
Ulrich Spandau • Heinrich Heimann
Practical Handbook
for Small-Gauge Vitrectomy
A Step-By-Step Introduction
to Surgical Techniques
Second Edition
Ulrich Spandau Heinrich Heimann
University Eye Hospital Royal Liverpool University Hospital
Uppsala, Sweden Liverpool, United Kingdom
ISBN 978-3-319-89676-2 ISBN 978-3-319-89677-9 (eBook)
https://doi.org/10.1007/978-3-319-89677-9
Library of Congress Control Number: 2018946623
© Springer International Publishing AG, part of Springer Nature 2018
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This book is dedicated to our parents.
Foreword 1
In 2002 when the team of Eugene de Juan, Los Angeles, published their first 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 difficult due to the increased scarring of
conjunctiva and Tenon’s capsule and the atrophy of the sclera in the pars plana.
Due to their flexibility, the first 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 significantly shortened, but the trauma of
conjunctiva and sclera was also significantly 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 efficiency 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 flow
of infusion fluid through the vitreous cavity.
vii
viii Foreword 1
Ulrich Spandau presents in this very practical book of 23-gauge vitrectomy the
latest equipment and instruments needed for a 23-gauge vitrectomy, and he explains
in detail the most important surgical techniques.
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 the 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 benefit from this compendium.
Frankfurt-Höchst, Germany Tillmann Eckert
April 2010
Foreword 2
Dr. Ulrich Spandau confirms 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 vitrec-
tomy surgery (MIVS), combined with phacoemulsification in elderly patients, per-
formed 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 Silicone Oil in Vitreoretinal Surgery, in 1987. Since then vitreo-
retinal surgery has changed very much, from 20-gauge macroincisional 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 filled patiently for several
years and presents here some genuine surgical pearls—those that he has discovered
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 practical
knowledge and refine their procedures in this field. It is our duty to share all the
surgical skills and knowledge with each other 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!
Department of Ophthalmology Zoran Tomic
University Hospital,
Uppsala, Sweden
ix
Preface
Since the first edition of this book vitreoretinal surgery with trocars has won the race
against non-trocar surgery. 20-gauge surgery is a chapter in history books. And an
end to this rapid development is not foreseeable. When the first edition of this book
was written, 23-gauge was the gold standard in Europe. And today, when the second
edition is published 25-gauge is becoming the most popular gauge and 27-gauge is
growing fast.
It is difficult to give a vitreoretinal surgeon a good advice for his surgery. In con-
trast to the cataract surgeon who has a clear surgical aim, which is the removal of
the opacified lens and implantation of an IOL, the vitreoretinal surgeon faces many
pathologies and many possible surgical approaches.
Two factors are essential for high standard vitreoretinal surgery:
1. Correct assessment
2. Surgical technique
If correct assessment is the theory, then surgical skills are the praxis. What is the
difference between theory and praxis? Theory means that you know everything but
nothing functions. And praxis means that everything functions but you do not know
why.
Correct assessment you acquire with time and experience. Correct assessment is
required before surgery resulting in a good timing and planning of surgery. Correct
assessment is also required during surgery guiding you through the operation and
changing surgical techniques if necessary. Correct assessment is finally required
after surgery in order to assess postoperative complications. The next important fac-
tor is surgical technique. Surgical technique is a combination of skills and rigorous
training. Every pathology can be operated with several techniques. A detachment
can be operated with buckling surgery or with vitrectomy; a luxated IOL can be
refixated with scleral fixation, intrascleral fixation, iris fixation, and so on. Learn as
many techniques as possible, as it will improve your surgical outcome immensely.
We often overtreat when performing vitreoretinal surgery and we should there-
fore reflect our surgery critically with the aim to find a surgical approach with
maximal results and minimal overtreatment. In retinal detachment, for example, the
xi
xii Preface
surgical spectrum has a big range with episcleral buckling at one end of the spec-
trum and vitrectomy with encircling band, lensectomy, and silicone oil on the other
end of the spectrum. Maybe the best surgical advice is: Operate as much as neces-
sary and as little as possible.
All chapters of the second edition have been revised to take account of the advent
of 25G and 27G vitrectomy. New chapters have been added: PPV for dummies,
vitrectomy with a cataract machine, submacular hemorrhage, macular transloca-
tion, and intraocular tumor biopsy. In addition, the video section has been com-
pletely reworked and many new videos have been added.
We wish every reader, may he or she be a beginner or an advanced surgeon, to
enjoy reading this book and watching the surgical videos.
Uppsala, Sweden Ulrich Spandau
Liverpool, UK Heinrich Heimann
January 2018
