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 Table of Contents  
Year : 2015  |  Volume : 108  |  Issue : 2  |  Page : 32-42

A new approach for sutureless 20-G vitrectomy

Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt

Date of Submission05-Sep-2014
Date of Acceptance15-May-2015
Date of Web Publication23-Jul-2015

Correspondence Address:
Dikran G Hovaghimian
Department of Ophthalmology, Research Institute of Ophthalmology, 17 Roushdy Street #2 Midan Safir-Heliopolis, Cairo 11361
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2090-0686.161381

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Aim of the work
To assess the safety and the effectiveness of a new approach for sutureless 20-G pars plana vitrectomy using N-butyl-2-cyanoacrylate 'Histoacryl' glue, aiming for the conversion of the conventional 20-G vitrectomy to a sutureless technique.
An interventional study.
Patients and methods
About 40 eyes of 40 patients attending the surgical retina clinics of the Research Institute of Ophthalmology were subjected to the new technique. The selection criterion included patients with diabetic and nondiabetic vitreous hemorrhage, rhegmatogenous retinal detachment (RD), recurrent RD, pseudophakic RD, giant retinal breaks, macular hole, proliferative diabetic retinopathy, complications of anterior segment surgery, posterior dislocated IOL, vitreomacular traction syndrome, macular pucker, idiopathic epiretinal membrane, and dropped nucleus. Patients were selected randomly. There was no age limitation, sex choice, or race preference. All the patients underwent a modified 20-G sutureless vitrectomy surgery. Periotomy was performed in the upper part of the eye, and the sclera was exposed, three 1/2-thickness scleral flaps were fashioned using a crescent knife for a length of 2 mm, and a 20-G self-retaining infusion cannula was introduced at the 12 O'clock position. At the end of the surgery, Histoacryl tissue glue was applied to close the scleral flaps and the conjunctiva. Different vitreal substitutes and tamponades were used according to the case. All the patients had undergone ultrasonic biomicroscopy at the sclerotomy sites 6 weeks postoperatively. Our main concern was to assess the success and the effectiveness of the procedure, wound integrity, intraoperative and postoperative complications, the efficacy of the N-butyl-2-cyanoacrylate to hold the tissues, tissue reaction related to cyanoacrylate, patients' satisfaction, and the final surgical outcome. The postoperative intraocular pressure (IOP) and the Snellen visual acuity relative to the preoperative values were recorded. Patients were evaluated postoperatively on the first day, the first week, and then weekly for 1 month and monthly for 6 months or till the time of removal of silicone oil, which was also removed by the same aforementioned technique.
The proportion of male patients was 47.5% (19 patients) and that of female patients 52.5% (21 patients). The mean age of the male patients was 49 ΁ 12.5 years, whereas the mean age of the female patients was 44 ΁ 15.5 years. Different vitreous substitutes/tamponades were used, including air, SF6, ringer lactate, and silicon oil 5000 cSt. The mean operative time was 61.75 ΁ 13.8 min and the mean time fashioning and closing the sclerotomies and the conjunctiva was 7 ΁ 1.8 min. No sclerotomy-related intraoperative difficulties or complications were seen and none of the patients required stitching of the sclerotomies at the end of the surgery. All patients were discharged from the hospital immediately after the surgery. Ultrasonic biomicroscopy (UBM) revealed complete wound closure in 36 patients (90%), partial internal wound dehiscence in four patients (7.5%), and three patients (10%) showed microcyst formation under the conjunctiva. Postoperative hypotony was not seen in any of the patients.There was no single case of endophthalmitis or chemical uveitis. The visual acuity was improving along the follow-up period, except for one uncontrolled diabetic patient, who developed rubeosis iridis and the condition deteriorated. Most patients presented with an initial increase in the IOP followed by stabilization of the IOP thereafter.
The new approach of 20-G sutureless vitrectomy utilizing N-butyl-2-cyanoacrylate is a safe and effective technique for the surgical treatment of a variety of vitreoretinal pathologies. Conversion to this technique is very simple. A very short learning curve is required, with no need for new expensive instrumentation. It combines all the advantages of 20-G vitrectomy, adding to it the sutureless advantage of the technique.

Keywords: 20 G, N-butyl-2-cyanoacrylate adhesive, pars plana vitrectomy, scleral flaps, sutureless vitrectomy

How to cite this article:
Hovaghimian DG, Adel SS. A new approach for sutureless 20-G vitrectomy. J Egypt Ophthalmol Soc 2015;108:32-42

How to cite this URL:
Hovaghimian DG, Adel SS. A new approach for sutureless 20-G vitrectomy. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2020 May 29];108:32-42. Available from: http://www.jeos.eg.net/text.asp?2015/108/2/32/161381

  Introduction Top

Pars plana vitrectomy as a technique has revolutionized retinal surgery since its advent and initial report by Machemer et al. [1] Since that time, the evolution of vitrectomy surgery has seen experimentation and implementation of smaller surgical instruments aimed at greater functionality and minimalization of ocular trauma, as well as shorter operating times, greater patient comfort, and quicker recovery times. Conventional 20-G vitrectomy involves making three sclerotomy ports after a limited conjunctival dissection followed by suturing these sclerotomies and conjunctiva at the end of the procedure. The quest to find ways to shorten the surgical time and to minimize trauma to the eye led to the development of the first 20-G transconjunctival sutureless approach in 1996 by Chen et al. [4]. The introduction of 23-, 25-, and the recently introduced 27-G vitrectomy systems has reduced the surgical time and improved patient comfort, enabling early rehabilitation [3],[4]. The basis of a sutureless pars plana sclerotomy was to stabilize the intraocular pressure (IOP) during surgery, reduce the surgical time, and avoid wound-related and suture-related complications. However, an incomplete armamentarium and overflexible instrumentation coupled with the increased risk of postoperative hypotony, endophthalmitis, and compromised fluidics have limited the application of these new systems. Another limiting factor was the increased cost of instrumentation. In contrast, a 20-G system has sturdy instruments and excellent fluidics besides being faster in gel removal, more efficient in peripheral vitreous dissection, and easier in silicone oil injection [5],[6]. The retinal surgeon desires a single vitrectomy system that could deal with varied surgical situations, such as lensectomy for advanced nuclear sclerosis, membranectomy of thick papillary membranes, advanced proliferative diabetic retinopathy with extensive fibrovascular proliferation, advanced proliferative vitreoretinopathy, and the management of a dropped nucleus or a retained intraocular foreign body. The purpose of this study was to evaluate a new proposed 20-G sutureless technique with the aid of an N-butyl-2-cyanoacrylate tissue adhesive for various vitreoretinal pathologies aiming for a new era of 20-G sutureless vitrectomy.

  Patients and methods Top

The cohort enrolled in this study included 40 eyes of 40 patients attending the surgical retina clinics of the Research Institute of Ophthalmology (RIO). Patients were randomly selected for surgery, irrespective of their race, age, and sex. After the explanation of the foreseen advantages and disadvantages of the new procedure, an informed consent was taken from all the patients. All the surgeries were performed between May 2012 and April 2014. Each patient had a complete preoperative anterior and posterior segment ophthalmic examination. Patients' data were recorded, including the best-corrected visual acuity, slit-lamp examination, IOP measurement, and fundus examination. The only exclusion criterion was patients with corneal opacities hindering the visualization of the posterior segment.

The surgical technique

All patients received preoperative sedation and local anesthesia consisting of a peribulbar injection of 10 ml, 80 : 20 mixture of O.5% bupivacaine and 2% lidocaine. About 100 U of hyaluronidase was added to the mixture. A modified three-port sclerotomy was fashioned. All the surgeries were performed through the upper part of the eye, which is our method of choice for years besides the advantage that postoperatively all the sclerotomies will be covered by the upper eyelid [Figure 1]. A fornix-based conjunctival peritomy was performed in the upper half of the bulbar conjunctiva, followed by the measurement of the sclerotomy sites at the 10, the 12, and the 2 O'clock positions, 4 mm posterior to the limbus in phakic and 3.5 mm in pseudophakics and aphakics. About 1.5-2 mm posterior to the predetermined point of entry, an angled bevel crescent knife was used to create a partial-thickness (1/2 depth) scleral pocket perpendicular to the limbus and extending for 1 mm anterior to the sclerotomy site; then, by means of Vanas scissors, the two parallel sides of the tunnel were cut, converting the pocket into a scleral flap. All attempts were made not to cauterize the bed, but if there was a bleeder hindering the view, a mild cauterization was performed with unipolar diathermy. A 20-G microvitreoretinal blade was used to make the sclerotomy in the usual manner in the scleral bed. A self-retaining 20-G 4-mm infusion cannula was used in most of the cases at the 12 O'clock position; another alternative was the use of a 20-G infusion cannula secured with 7/0 vicryl. During surgery, the infusion bottle height, the suction, and cutting rate settings were the same as in classic 20-G vitrectomy. All surgeries were performed with the Alcon Accurus 800CS U.S.A vitrectomy machine and Universal 20-G high-speed vitrectomy probes [Figure 2]. The surgery was proceeded as conventional 20-G vitrectomy, utilizing all the necessary tools for the case [Figure 3]. At the end of the surgery, removal of vitreous knuckles around the sclerotomies was carried out to guard against vitreous incarceration, the wound was irrigated copiously to remove any trace of foreign material or silicone oil if it was used as a tamponade; then, the wound was dried gently with a microsponge. One drop of N-butyl-2-cyanoacrylate 'Histoacryl' was applied at the scleral bed, and by means of a spatula or an iris repositor, pressing and stretching gently, the scleral flap was reposited [Figure 4]. Before closure of the third sclerotomy, the IOP was rechecked and then the flap was reposited.
Figure 1: Sutured sclerotomies of three-port vitrectomy performed in the upper part of the eye.

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Figure 2: (a) Fashioning of the scleral tunnel. (b) Fashioning the scleral flap. (c) Scleral flap created. (d) 20-G microvitreoretinal blade sclerotomy under the flap.

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Figure 3: The new proposed three-port 20-G vitrectomy system: infusion cannula at 12 O'clock, vitrectomy cutter at 10 O'clock, and light pipe at 2 O'c lock.

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Figure 4: Closure of the sclerotomy with Histoacryl. (a) Preparation of the conjunctiva for closure. (b) Application of Histoacryl under the sclera flap. (c) Histoacryl applied under the flap. (d) The sclera flap closed with Histoacryl.

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In our early cases, we observed that one drop of N-butyl-2-cyanoacrylate was more than the required amount, with overflow around the wound; hence, we started to press the tube of cyanoacrylate till one drop was dripped out, and maintaining the same pressure (to keep the Histoacryl within the tip of the applicator), we just touched the scleral bed with the applicator and reposited the flap. Alternatively, we applied one drop of Histoacryl to the shaft of a hypodermic needle or the tip of the crescent knife and left it to flow on the shaft by gravity, and then we applied N-butyl-2-cyanoacrylate to the bed of the sclera by capillary action [Figure 5].
Figure 5: Histoacryl applied by capillarity after the removal of silicone oil (red arrows); note the previous sclerotomies closed by cyanoacrylate 6 months earlier (black arrows).

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The conjunctiva was reposited where the two ends of the wound on each side were grasped with non-toothed forceps, the wound was dried, followed by the application of Histoacryl using the side of the applicator as a tool to spread the Histoacryl along the entire length of the wound. At the end, a combination of antibiotic+steroid was injected subconjunctivally [Figure 6] and [Figure 7].
Figure 6: Closure of the conjunctiva with Histoacryl. (a) Approximation of the edges of the wound. (b) Application of Histoacryl. (c) Spreading along the entire length of the wound. (d) Excess of polymerized Histoacryl on the wound.

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Figure 7: Microsponge soaked with Histoacryl used to close the conjunctival wound in an attempt to apply the least amount possible.

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The injected silicone oil was removed in the same manner, where two sclerotomies within the two scleral flaps were created: one for the infusion cannula and the other for silicone evacuation. At the end of the surgery, the sclerotomies and the conjunctiva were closed likewise with N-butyl-2-cyanoacrylate [Figure 5]. We documented the operative time, sclerotomy-related and other intraoperative complications, and the need for sclerotomy suture placement at the completion of the surgery.


Postoperatively, all the patients were given antibiotic eye drops, corticosteroids, and mydriatics.

Complete ophthalmic examination including the best-corrected Snellen visual acuity, Goldmann applanation tonometry, slit-lamp biomicroscopy, and indirect ophthalmoscopy were carried out on the first day, the first week, weekly for 1 month, and monthly thereafter. UBM at the sclerotomy sites was performed in all the patients after the sixth week postoperatively.

Postoperative complications such as hypotony, choroidal detachment, endophthalmitis, and retinal detachment were recorded. Foreign body sensation, pain, and chemosis were graded in each patient. The severity of the pain was graded on a scale from 0 (no pain) to 10 (worst eye pain) according to Fekrat et al. [7]. The foreign body sensation was graded subjectively on a severity scale from 0 (no pain) to 10 (severe foreign body sensation).

  Results Top

The proportion of male patients was slightly lower (19, 47.5%) compared with the female patients (21, 52.5%). The age of men ranged between 19-70 years, with a mean of 49 ± 12.5 years, and among women, it was 14-68 years, with a mean of 44 ± 15.5 years. Indications for surgery are recorded in [Table 1].
Table 1: Indications of surgery for all the patients

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In 16 patients (40%), air was used as the intraocular tamponade, 13 patients (32.5%) needed silicone oil injection 5000 cSt, nine patients (22.5%) required SF6, and in 12 patients (30%) no intraocular tamponade was used (left with ringer lactate). Silicone oil was removed from the eye after 6 months in four patients, after 9 months in seven patients, and after 1 year in one patient.

None of the patients required stitches intraoperatively to close the sclerotomies or the conjunctiva. UBM performed at the sclerotomy site revealed a good healing pattern (wound closed internally and externally) in 90% of the patients (36 patients), whereas 10% (four patients) of the patients showed partial wound dehiscence. In the first patient, it was at the 12 O'clock position, in the second patient at the 10 O'clock position, and the third and the fourth patients at the 12 O'clock position [Table 2].These patients had silicone oil injected [Figure 8]. Slit-lamp examination revealed no abnormality in the eye integrity or at the sclerotomy site as compared with the rest of the patients [Figure 9]. The IOP was within normal levels, the retina was attached, VA was stable, and there was no patient complaint. Later at 6 months in one patient and at 9 months in three patients, during silicone oil removal, the wound integrity was examined and trial was made to dissect the scleral tissues bluntly, pressure was applied over and adjacent to the sclerotomy site, and the wound was found to be healed completely. A new scleral flap was fashioned to remove the silicone oil, and at the end of the procedure, N-butyl-2-cyanoacrylate was applied for both the scleral flaps and the conjunctiva [Figure 5]. About 7.5% (three patients) of the patients presented with a microcyst under the conjunctiva opposite to the sclerotomy site. We believe that this is polymerized N-butyl-2-cyanoacrylate rather than a microcyst; likewise, this patients' IOP and the visual acuity were stable. No vitreous incarceration at the wound site was detected by UBM.
Figure 8: UBM performed at 6 weeks (a) shows complete healing (note the lining of the pars plana and the pars plicata with silicone oil); (b) the sclerotomy site shows a minute conjunctival cyst measuring 465 × 267 μm with fibrous encapsulation (as indicated by the surrounding two shadow lines). The underlying sclera is regular and homogenous. The underlying pars plana shows only minute localized thickening, but with no interruption of the tissue. The lining silicone interface shows a false linear irregularity (due to the shadowing effect caused by the conjunctival fibrous caps ule); (C)The superior postlimbal scleral area shows a deep partial dehiscence.

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Figure 9: Slit-lamp examination of the sclerotomy sites showing successful wound closure. (a) Sclerotomy at 10 O'clock. (b) Sclerotomy at 2 O'clock. (c) Sclerotomy at 12 O'c lock.

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Table 2: Ultrasonic biomicroscopy finding in patients

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Visual acuity outcome

The best corrected Snellen visual acuity was recorded in all the patients during the follow-up period.

Gradual improvement of VA was seen in most of the patients postoperatively during the follow-up period. Improvement in the visual acuity at 3 months was obvious, which then started to stabilize, except for one uncontrolled diabetic patient in whom after an initial improvement, the VA started to deteriorate, with the development of neovascular glaucoma [Table 3].
Table 3: Best-corrected visual acuity of all the patients

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Intraocular pressure analysis

All patients in the study groups showed an initial increase in IOP on the first postoperative day as compared with the baseline. Throughout the 6 months, six patients required antiglaucoma medications [Table 4].
Table 4: Intraocular pressure changes of all the patients (mmHg)

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The intraocular pressure was within the normal level all through the follow-up period and there was no hypotony or complaint from the patient. The average intraocular pressure changed from 10 ± 2.9 mmHg preoperatively to 18.5 ± 3.5 mmHg on the first postoperative day and 16 ± 3.1 mmHg 1 week after the surgery; these differences were not statistically significant (P > 0.05). IOP variations using the t-test were statistically insignificant on comparing the preoperative IOP with that found on the first day postoperatively; also, IOP variations were statistically insignificant on comparing the IOP of patients on the first day postoperatively and the first month, the first day and the third month, the first day and the sixth month, the first month and the third month, and the third month and the sixth month.

The mean operative time was 61.75 ± 13.8 min and this is almost the same as in classic three-port 20-G vitrectomy surgeries. The mean time in the fashioning of the sclerotomy flaps and the closure of the flaps and the conjunctiva was 7 ± 1.8 min. Examination of the eye on the first day postoperatively showed mild chemosis adjacent to the sclerotomy site, but it was nothing more than that seen in case of vicryl suture closure of the sclerotomies that subsided within 7-10 days. In patients with silicone oil injected, the sloughing of the polymerized N-butyl-2-cyanoacrylate over the conjunctiva was earlier than in the rest of the patients where silicone oil was not used as internal tamponade. In these patients a small part from the nasal or the temporal side of the wound on one or both sides started to separate from the conjunctiva and the patient complained of FB sensation. They were assured that this is normal with N-butyl-2-cyanoacrylate and will be relieved within a few days. The edge of the sloughed polymerized Histoacryl was removed with non-toothed forceps and the underlying conjunctiva was adherent to the sclera, while the central part was left to fall spontaneously.

No subconjunctival bleb formation was detected in any of the eyes on the first day after surgery. In our early cases, seven patients presented with a slight 1-mm elevation above the scleral level at the sclerotomy site and remained so for the rest of the follow-up period. There was no complaint or discomfort. Pressure was applied with a cotton-tipped bud to test the intactness of the wound; it was holding nicely and no leak or hypotony was observed. We attributed this to the excess use of N-butyl-2-cyanoacrylate; later when we modified the application technique of Histoacryl, the elevation was much decreased, proving our theory. No intraoperative wound-related complications were noted. No other complications, such as scleral flap necrosis or infection, choroidal detachment, retinal detachment, or infectious endophthalmitis, were observed in any of the patients. Subjective postoperative pain and foreign body sensation on postoperative day 1 and during the first week were mild to moderate. No staphylomata was detected at the sclerotomy site throughout the follow-up period.

  Discussion Top

Pars plana vitrectomy has become a routine everyday procedure for most of the posterior segment surgeons and all research and innovations in the field for a better visual outcome, patient comfort, and less tissue manipulation have become a priority to most of the surgeons. Many surgeons agree that sutureless, small-incision surgeries make quieter and happier eyes in the vitreoretinal patient. The advantage over larger-gauge procedures is derived primarily from reduced postoperative inflammation at the sclerotomy site, leading to faster recovery and reduced postoperative astigmatism, besides the operating time being reduced compared with conventional three-port 20-G vitrectomy. Since the introduction of systems for sutureless vitrectomy surgery, there has been debate about which approach is the best. Now we have options of 20-, 23-, 25-, and 27-G instrumentation, providing fastest healing, the least inflammation, and the least postoperative complications [Table 5]. Advances in 23-, 25-, and 27-G vitrectomy offer a good choice for the sutureless technique with the least trauma and insult to the sclera and the conjunctiva, but despite the advantages offered, 20-G vitrectomy still plays a role in difficult and challenging cases that need more intravitreal instruments such as retinal pics, spatulas, and scratchers that are not provided by the smaller gauge and, if available, are very flexible, not durable, break down easily, are very expensive, dysfunction often, and need very good maintenance, limiting its reuse and thus increasing the cost of the surgery. Even while using them, one is always afraid that they may break during surgery or the grasping power of the forceps and the scissors cutting through membranes may not be as strong as that offered by the 20-G instruments and may bend with tougher membranes and fibrous tissue and consequently become useless. The smaller-gauge vitreous cutter also reduces infusion and the aspiration rate, limiting the amount of vitreous per cut. The small size of the endoilluminator also limits its brightness, thus necessitating the use of additional light sources. Twenty-gauge vitrectomy allows better vitreous base dissection, is more efficient in peripheral vitreous dissection, and is easier in silicone oil injection in cases of PVR and the usage of complex instruments to relieve traction in cases of PDR [8],[9].
Table 5: Comparison of 20-, 23-, and 25-G vitrectomy systems

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Small-gauge vitrectomy requires a learning curve, progressing from 20-G to smaller-gauge procedures. Smaller incisions are not automatically the optimal choice. Infact, 20-G surgery is still wisely used in a number of situations. An ongoing controversy regarding the correlation between hypotony and endophthalmitis surrounds small-gauge vitrectomy. To overcome these problems, some studies introduced a combination of 20 and 23-G vitrectomy [9]. Other studies adopted the sutureless 20-G vitrectomy, aiming to overcome the disadvantages and introduce a new technique to simulate smaller-gauge vitrectomy as seen in [Table 6].
Table 6: A comparative table of studies on 20-G sutureless vitrectomy

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Our new proposed sutureless 20-G vitrectomy approach provides some of the advantages of smaller-gauge systems without the need to adopt newer instrumentation in switching to transconjunctival sutureless surgery. Conjunctival scarring, inflammation, and discomfort that are disadvantages of 20-G PPV could be avoided using this technique. Disadvantages of smaller-gauge vitrectomy include subconjunctival bleb formation and vitreous incarceration in sclerotomies that may lead to anterior retinal traction with subsequent retinal tear formation. In addition, both bleb formation and vitreous incarceration may increase the incidence of endophthalmitis after the procedure, but all of these were not seen in our procedure. This study suggests that sclerotomies closed with Histoacryl close better than those with the other nonstitch techniques, with no hypotony observed on day 1 after surgery.

Cyanoacrylate offers the advantage of no suture removal and no needle use; thus, the fear of needle injuries during surgery is abolished, and this is advantageous in hepatitis patients. The price is decreasing everyday with newer brands that offer advantages over the previous ones [18],[19],[20],[21].

The problem we faced in our study was the amount released and the method of application; we believe that there should be better applicators or specialized brushes or instruments for accurate and fixed controllable released amount application of the cyanoacrylate.

After our relatively short experience using Histoacryl, the following guidelines were suggested for the best results:

(1) The surgical field should be as dry as possible. Application of cyanoacrylate on a wet surface will accelerate the polymerization and will prevent the good apposition of the wound, and there will be more foreign body material within the surgical field.

(2) The least amount of cyanoacrylate should be used. More cyanoacrylate or thick layers retard polymerization.

(3) Edges of the wound should be opposed before application. This was the case in conjunctival application, but in sclera application, apposition was performed after application.

Anatomical closure of the designed sclerotomy sites seen by the UBM favors the use of this technique.

Subconjunctival bleb formation was not seen. No wound leakage or subconjunctival fluid accumulation was observed at the end of the operations and the elevation of the IOP 1 day after the surgery was within normal levels in most of the patients, confirming our finding.

One of the drawbacks in this technique may be the slight conjunctival elevation that corresponds to the elevated sclera flap seen in most patients by slit-lamp examination (due to the excess use of cyanoacrylate); however, there was no complaint about it from any of the patients and we attribute this to the wise choice of the site of the sclerotomies that are all covered by the upper eyelid [Figure 10].
Figure 10: A patient presented with slight conjunctival and scleral elevation 2 weeks after surgery due to excess cyanoacrylate under the w ound.

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The sealing power provided by cyanoacrylate was also greater in this technique as compared with just the simple application of cyanoacrylate to conventional 20-G sclerotomy sites, due to the fact that the scleral flap covering the sclerotomy sites provided an adequate surface area for the sealing of the cyanoacrylate.

Not a single case of wound erosion was observed. Postoperative irritation from exposed sutures was eliminated; consequently, the patients experienced less inflammation and discomfort and the appearance of the eye was esthetically more pleasing

Besides this, the surgery was carried out through the upper part of the eye and the wounds were covered with the upper eyelid. The fact that none of the patients in our study developed endophthalmitis might also be attributed to the effective sealing of the sclerotomies.

The silicone oil viscosity used in our patients was 5000 cSt and was very easily injected and later removed; this is in contrast to small-gauge vitrectomy, which is difficult to perform with 1000 cSt and impossible with 5000 cSt silicone oil. In addition, they require completely different sets of instruments from those used for the standard 20-G sutured vitrectomy, necessitating a learning curve for surgeons and making transconjunctival sutureless vitrectomy cost much higher than the sutured operation. Thus, the spectrum of surgical indications for transconjunctival sutureless vitrectomy may indeed be limited to less complex cases.

  Conclusion Top

The new proposed three-port sutureless 20-G vitrectomy technique with cyanoacrylate is a safe and practical technique for the full spectrum of vitreoretinal surgery. It is well tolerated by patients. It can enable retinal surgeons to graduate into this surgery easily. All routine 20-G instruments can be used; additional investments are not required, and this makes it economical. Not a single case of wound leakage, postoperative hypotony, or endophthalmitis was observed. Healed sclerotomies were assured with UBM, and despite the few cases that showed partial wound dehiscence in the presence of silicone oil during fluid/silicone exchange, no signs of wound dehiscence or hypotony were observed. Modifications in the technique of making scleral flap sclerotomies and the application of cyanoacrylate adhesives to the sclerotomies and the conjunctival wound make this procedure comparable to smaller-gauge transconjunctival sutureless vitrectomies, with the advantage of retaining advanced fluidics and the use of stronger and more durable intraocular surgical instruments, not to mention the cost effectiveness of the procedure. This technique seems to be very promising. Further studies are recommended to use and refine this technique, which we believe will be a good alternative to the new sutureless techniques wherein the advantages overweigh the disadvantages of the technique.

  Acknowledgements Top

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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