Vitreous Surgery

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Von Graefe and Deutschmann were the first clinicians to advocate cutting vitreous and/or retina in order to treat retinal detachment; however, they did not cut vitreous gel, but mainly cut vitreous membranes with a knife [17,110]. Von Hippel in 1915 cut a vitreous membrane and successfully treated a tractional retinal detachment [111]. The first modern intraocular instruments, made specifically for cutting vitreal membranes, were developed in the second half of the twentieth century. Neubauer in 1963 described intravitreal scissors that were activated by finger pressure [112,113]. Cibis in 1965 devised a tissue cutter that consisted of a hook and a trephine [114]. Kasner in 1962 was the first to advocate open-sky vitrectomy to remove vitreous gel for the treatment of eye diseases [115-118]. Kasner engaged the vitreous with cellulose sponges and cut it with scissors. He proved that the eye can tolerate the removal of the vitreous gel. Stimulated by the pioneering work of Kasner, Robert Machemer initiated and developed closed vitreous surgery (Fig. 1.5) [119-121]. He and Parel developed instruments that could, through the pars plana, suction and cut vitreous and infuse replacement fluid all in one single probe [122]. His original instrument was called the VISC (Vitreous Infusion Suction Cutter). Machemer performed the first pars plana vitrectomy in April 1970 and first published the technique in 1971 [119]. In a remarkable series of publications from 1971-1976, Machemer and coworkers described the original instrumentation and technique, initial indications and results, new instrumentation, and expanded indications, techniques (such as bimanual dissection techniques and relaxing retinecto-my), and results [123-134]. Independently, Peyman et al. reported their experience with vitrectomy in 1971 [135]. The next step in the development of the instrumentation was reduction of the diameter of the probes by separation of the infusion, the endo-illumination, and cutting/aspiration probes. The Ocutome system was introduced by O'Malley and Heintz in 1975 [136]. Another milestone in vitreous surgery was improvement in the operating microscope.

Fig. 1.5. Robert Machemer. (Reproduced with permission; Wilkinson CP, Rice TA (1997) Michels retinal detachment, 2nd edn. Mosby St. Louis MO. pp 241-333 [10])

Littmann in 1954 first described a telecentric device with a paraxial illumination source [137]. Parel et al. in 1974 developed an operating microscope with foot control and X-Y movement that led to the development of the modern operating microscope [129]. Many different intraocular instruments, infusion systems, and illumination sources have been developed.Vitrectomy is now the standard treatment for many forms of retinal detachment including traction retinal detachment, retinal detachment due to giant retinal tears, any retinal detachment associated with opaque vitreous, retinal detachment with posterior retinal breaks (including macular holes), proliferative vitreoretinopathy, and other forms of complicated retinal detachment. Although studies have yet to show a conclusive advantage, some surgeons favor vitrectomy over other methods for repair of primary retinal detachments [138].

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