Dikran G Hovaghimian, Saleh Sherif Adel, Tarek Saleh, Mohamed Tarek El-Naggar
Journal of the Egyptian Ophthalmological Society 2016 109(2):71-84
Objective The aim of this study was to present and evaluate the efficacy and safety of a newly designed multifunctional retinal membrane twister in vitreoretinal surgery for the management of diabetic epiretinal membrane in patients with advanced proliferative diabetic retinopathy by evaluating the anatomical and the functional outcomes of the surgery. Design This was designed as an interventional study. Patients and methods Fifty-two eyes of 52 patients (23–71 years) attending the Research Institute of Ophthalmology with advanced proliferative diabetic retinopathy were included in this study. All patients underwent standard three-port 20-G pars plana vitrectomy and membrane dissection with local anesthesia by means of a newly designed multifunctional retinal twister to peel and remove the proliferative membrane. Phacoemulsification was required in 11 patients at the beginning of the surgery. Relaxing retinectomy was performed in two cases because of severe retinal shortening. At the end of the surgery a silicone oil 5000-centistoke tamponade was used in all patients without supplementary scleral buckle. The primary and final anatomic success rate, incidence of retinal breaks, intraoperative instrument-related complications, duration of surgery, postoperative intraocular pressure, retinal reattachment rate, and final visual acuity were recorded and analyzed. The patients were evaluated postoperatively on the first day, first week, then weekly for 1 month, and monthly thereafter and were followed up for 10–24 months (15.5 ± 8.8 months). Results The retinal twister was successful in managing the intravitreal and epiretinal membranes in all cases. Among the 52 patients, 22 (42.3%) were male and 30 (57.7%) were female. The mean age of the male patients was 48 ± 13 years and the mean age of the female patients was 41.8 ± 10.8 years. Eighteen patients (34.6%) had type I insulin-dependent diabetes mellitus and 34 patients (65.4%) had type II non-insulin-dependent diabetes mellitus. Eight patients (15.4%) were pseudophakic, 11 patients (21%) had cataract, and 33 patients (63.4%) had a clear lens. Panretinal laser photocoagulation had been performed before surgery in 19 eyes (36.5%); the remaining 33 eyes (63.5%) had undergone no previous laser treatment. Fourteen patients (26.9%) had been previously given an antivascular endothelial growth factor intravitreal injection. Twenty patients (38.5%) had tractional RD, three patients (5.8%) had combined tractional and rhegmatogenous RD, six patients (11.5%) had proliferative diabetic membrane without RD, and 23 patients (44.2%) had nonresolving vitreous hemorrhage and TRD. Pars plana vitrectomy was combined with phacoemulsification and intraocular lens implantation in 11 eyes (21%). The mean surgical time was 70 ± 6.5 min (range = 60–90 min). Intraocular bleeding was encountered during the peeling process and was rapidly managed by elevating the infusion bottle and using the bipolar diathermy attached to the twister. Inadvertent very small iatrogenic retinal breaks were encountered in seven cases (13.5%) during the peeling process of severely adherent epiretinal membranes. The retina was reattached in 42 eyes (91.3%) out of the 46 with detached retina and remained attached during the follow-up period in these eyes without any further surgical intervention until silicone oil removal. Four eyes (8.7%) had recurrent RD after surgery and three eyes (6.5%) had recurrent RD after silicone oil removal. Vision was improved in most eyes as compared with the preoperative visual acuity. Final best-corrected visual acuity at 6 months showed improvement in 43 eyes (82.7%), partial improvement in four eyes (7.7%), and remained unchanged in five eyes (9.6%). Sixteen patients developed cataract during the follow-up period until removal of the silicone oil. Conclusion Epiretinal membrane dissection with the new multifunctional retinal twister appears to be a safe and effective technique in the management of epiretinal membranes. The new multifunctional retinal twister proved its efficacy and success in grasping, holding, twisting, pulling, and dissecting epiretinal membranes; further, the bipolar diathermy attachment for quick management of retinal bleeders was a great advantage for shortening the surgical time and providing a bloodless working field. The encouraging anatomic and functional outcome with the least complications met with during surgery favors its safe use. The twister proved to be a useful adjunct in the armamentarium of retinal microsurgical instruments.
Journal of the Egyptian Ophthalmological Society 2016 109(2):71-84
Objective The aim of this study was to present and evaluate the efficacy and safety of a newly designed multifunctional retinal membrane twister in vitreoretinal surgery for the management of diabetic epiretinal membrane in patients with advanced proliferative diabetic retinopathy by evaluating the anatomical and the functional outcomes of the surgery. Design This was designed as an interventional study. Patients and methods Fifty-two eyes of 52 patients (23–71 years) attending the Research Institute of Ophthalmology with advanced proliferative diabetic retinopathy were included in this study. All patients underwent standard three-port 20-G pars plana vitrectomy and membrane dissection with local anesthesia by means of a newly designed multifunctional retinal twister to peel and remove the proliferative membrane. Phacoemulsification was required in 11 patients at the beginning of the surgery. Relaxing retinectomy was performed in two cases because of severe retinal shortening. At the end of the surgery a silicone oil 5000-centistoke tamponade was used in all patients without supplementary scleral buckle. The primary and final anatomic success rate, incidence of retinal breaks, intraoperative instrument-related complications, duration of surgery, postoperative intraocular pressure, retinal reattachment rate, and final visual acuity were recorded and analyzed. The patients were evaluated postoperatively on the first day, first week, then weekly for 1 month, and monthly thereafter and were followed up for 10–24 months (15.5 ± 8.8 months). Results The retinal twister was successful in managing the intravitreal and epiretinal membranes in all cases. Among the 52 patients, 22 (42.3%) were male and 30 (57.7%) were female. The mean age of the male patients was 48 ± 13 years and the mean age of the female patients was 41.8 ± 10.8 years. Eighteen patients (34.6%) had type I insulin-dependent diabetes mellitus and 34 patients (65.4%) had type II non-insulin-dependent diabetes mellitus. Eight patients (15.4%) were pseudophakic, 11 patients (21%) had cataract, and 33 patients (63.4%) had a clear lens. Panretinal laser photocoagulation had been performed before surgery in 19 eyes (36.5%); the remaining 33 eyes (63.5%) had undergone no previous laser treatment. Fourteen patients (26.9%) had been previously given an antivascular endothelial growth factor intravitreal injection. Twenty patients (38.5%) had tractional RD, three patients (5.8%) had combined tractional and rhegmatogenous RD, six patients (11.5%) had proliferative diabetic membrane without RD, and 23 patients (44.2%) had nonresolving vitreous hemorrhage and TRD. Pars plana vitrectomy was combined with phacoemulsification and intraocular lens implantation in 11 eyes (21%). The mean surgical time was 70 ± 6.5 min (range = 60–90 min). Intraocular bleeding was encountered during the peeling process and was rapidly managed by elevating the infusion bottle and using the bipolar diathermy attached to the twister. Inadvertent very small iatrogenic retinal breaks were encountered in seven cases (13.5%) during the peeling process of severely adherent epiretinal membranes. The retina was reattached in 42 eyes (91.3%) out of the 46 with detached retina and remained attached during the follow-up period in these eyes without any further surgical intervention until silicone oil removal. Four eyes (8.7%) had recurrent RD after surgery and three eyes (6.5%) had recurrent RD after silicone oil removal. Vision was improved in most eyes as compared with the preoperative visual acuity. Final best-corrected visual acuity at 6 months showed improvement in 43 eyes (82.7%), partial improvement in four eyes (7.7%), and remained unchanged in five eyes (9.6%). Sixteen patients developed cataract during the follow-up period until removal of the silicone oil. Conclusion Epiretinal membrane dissection with the new multifunctional retinal twister appears to be a safe and effective technique in the management of epiretinal membranes. The new multifunctional retinal twister proved its efficacy and success in grasping, holding, twisting, pulling, and dissecting epiretinal membranes; further, the bipolar diathermy attachment for quick management of retinal bleeders was a great advantage for shortening the surgical time and providing a bloodless working field. The encouraging anatomic and functional outcome with the least complications met with during surgery favors its safe use. The twister proved to be a useful adjunct in the armamentarium of retinal microsurgical instruments.