ORIGINAL ARTICLE

Outcome of Bimanual 23G, 5-Ports Versus 3-Ports

Pars Plana Vitrectomy for Advanced Diabetic Eye

Disease

Rana Naveed Iqbal¹, Asad Aslam Khan², Khalid Waheed³Haroon Tayyab⁴, Mohsin Ihsan⁵

Intzar Hussain⁶

^{1’3’5’6}Services Institute of Medical Sciences, ²King Edward Medical University, Mayo Hospital Lahore

⁴Agha Khan University, Karachi

ABSTRACT

Purpose: Evaluation of efficacy and safety of 23 – guage five ports vitrectomy versus 23 – guage three ports

pars plana vitrectomy (PPV) in diabetic tractional retinal detachment.

Study Design: Prospective Interventional case series.

Place and Duration of Study: Mayo hospital and Services hospital, Lahore, from February 2018 to December

2018.

Material and Methods: Forty eyes of forty patients were equally divided into two groups. One group which

underwent five ports PPV and the other group had three ports PPV. Patients with tractional retinal detachment

(TRD) with fibrovascular membranes were included and patients who had undergone previous ocular surgery

(except cataract surgery) or having TRD due to other ocular diseases were excluded. Preoperative work-up

included visual acuity, intra ocular pressure measurement and slit lamp examination of anterior and posterior

segment. Gender, age, pre-operative and post-operative BCVA and intraocular pressure presented by calculating

frequency and percentages.

Results: Pre-operative BCVA improved from 1.11 ± 0.5 to 0.66 ± 0.5 in 3-port groups and from 1.7 ± 0.9 to 0.87

± 0.8 in 5-port groups. Duration of surgery was 74.40 ± 5.4 and 53.40 ± 2.5 minutes in 3 ports and 5-ports group

respectively. Iatrogenic retinal tear developed in two patients in each group. Per-operative vitreous hemorrhage

developed in three patients in 3-ports group and in two patients in 5-ports group. Two patients in each group

developed post vitrectomy cavity hemorrhage.

Conclusion: Bimanual 5- ports 23-guage vitrectomy is a faster procedure than three ports 23 – guage vitrectomy

in diabetic tractional retinal detachment but with similar intraoperative and postoperative complications.

Key Words: Pars plana vitrectomy, Tractional retinal detachment, Vitreous haemorrhage.

How to Cite this Article: Iqbal RN, Khan AA, Waheed K, Tayyab H, Ihsan M, Hussain I. Outcome of Bimanual

23 – Guage, 5 – Ports Pars Plana Vitrectomy Versus 23 – Guage, 3 – Ports Pars Plana Vitrectomy for Advanced

Diabetic Eye Disease. Pak J Ophthalmol. 2020; 36 (3): 241-246.

Doi: 10.36351/pjo.v36i3.1041

suffer from diabetes mellitus by 2030. Diabetic

retinopathy causes blindness in 4.8% people globally

INTRODUCTION

About half a billion of world population is expected to

and is one of the most common diabetic

____________________________________________

complications.¹Various anti vascular endothelial

Correspondence to: Rana Naveed Iqbal

growth factors have been used intravitreally in patients

with vitreous hemorrhage caused by proliferative

diabetic retinopathy but still pars plana vitrectomy is

required for one third of these eyes.²

Services Institute of Medical Sciences, Lahore

Email: rananaveediqbal14@yahoo.com

Received: April 16, 2020

Accepted: May 4, 2020

Revised: May 4, 2020

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246

241

Rana Naveed Iqbal, et al

We have seen a revolution in the treatment of

diabetic retinopathy with the introduction of various

anti VEGF agents and advancements in laser treatment

for Diabetic Retinopathy (DR) but surgical treatment

in the form pars plana vitrectomy is still required in

non-clearing vitreous hemorrhage (NCVH) with and

without TRD.

light chandelier, is more useful than a single fiber

system for obtaining homogeneous and more

widespread illumination. The 2-fiber system

eliminates the need to reposition the fiber and

minimizes the shadow seen with single-fiber

chandelier endo-illumination because the illumination

comes from 2 different directions.^6,13,14Mercury vapor

and xenon have been used in chandelier lights of

smaller size for improved illumination with wide angle

view of retina.^15,16,17,18

TRD is an advanced and devastating complication

of PDR which can cause irreversible damage to retinal

architecture. The most important part of vitrectomy for

diabetic TRD is careful segmentation and removal of

fibrovascular tissue that can cause severe

complications.³There are different surgical techniques

for delamination of taut and tough fibrovascular

membrane using bimanual delamination technique like

En-Bloc perfluoro-dissection in vitreoretinal surgery

and the 'suck-and-cut' bimanual technique for

delamination of fibrovascular membranes in

proliferative diabetic retinopathy.^4,5More expertise

can be achieved for bimanual vitrectomy for more

extensive and threatening TRD especially those with

more adherent and widely spread fibrovascular tissue

which can cause per-operative complications that may

become very difficult to manage.⁶Various studies

have been conducted in the past which involved

bimanual dissection of proliferative retinal membranes

and for this purpose specially designed sophisticated

instruments were used in these studies.^7,8,9

In our five ports bimanual vitrectomy, the fourth

and fifth port were made at 5 and 7 o'clock position.

Main outcome measures in this study include

preoperative and postoperative best corrected visual

acuity along with intraocular pressure, intraoperative

and postoperative complications and duration of

surgical procedure. The purpose of our study was to

observe the outcome of 23-guage, 5-ports versus

23-guage, 3-ports pars plana vitrectomy in advanced

diabetic eye disease.

MATERIAL AND METHODS

Total eyes of 40 patients were divided into two groups

with one group undergoing 23 – guage three ports PPV

and the other group undergoing five ports PPV. There

were 20 eyes in each group. Patients with TRD and

fibrovascular membranes extending over an area of

greater than two quadrants of retina and also having an

impending or actual macular detachment irrespective

of the presence or absence of vitreous hemorrhage

were included in the study. Those patients who had

undergone previous ocular surgery (excluding cataract

surgery) or having TRD due to other ocular diseases

were not included in our study.

23–gauge vitrectomy has been used by many

surgeons worldwide and over the years it is found to

be a safe and swift technique with less ocular surgical

trauma, shorter duration, less inflammation in

postoperative period and most importantly better and

quick recovery in patients with retinal surgery

including those with advanced diabetic eye disease.⁹

Previous studies have been conducted to observe the

safety and efficacy of four ports pars plana bimanual

vitrectomy, which has been found to be an excellent

surgical procedure that helps in safe and adequate

removal of proliferative fibrovascular tissue in

advanced PDR.¹⁰The structural and functional results

of bimanual 23 – gauge vitrectomy were reported with

illumination source, which did not require manual

fixation by the assistant during surgery for

complicated vitreoretinal cases.¹¹A variety of

chandelier lighting systems have been developed to

provide stationary, wide-angle and uniform endo-

illumination for obtaining adequate visualization of

retina during surgery.¹²Chandelier endo-illumination

with two optic fibers described by Eckardt as the twin

Every patient was examined for pre-operative

best-corrected visual acuity, intra ocular pressure

measurement and slit lamp examination of anterior and

posterior segment especially for Tractional Retinal

Detachment. Patients fulfilling the inclusion criteria

were selected for 23 guage five ports bimanual pars

plana vitrectomy or three ports conventional

vitrectomy and the duration of surgery along with per-

operative and postoperative complications, post-

operative best corrected visual acuity and intra ocular

pressure were noted.

In all patients, a 23 – gauge trocar cannula was

inserted at 15° to 30° angle through pars plana at 3.5–

4.0 mm from the limbus. The cannula for infusion was

inserted inferotemporally. The remaining two ports

242

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246

Outcome of Bimanual 23 Gauge, 5-Ports Versus 3-Ports Pars Plana Vitrectomy for Advanced Diabetic Eye Disease

were for fibreoptic light and vitrectomy cutter. BIOM

postoperative visual acuity was defined as a decrease

or increase of log MAR units by 0.3 or more. A p-

value of less than 0.05 was defined as statistically

significant. Gender and all the variables including age,

pre-operative BCVA, post-operative BCVA, pre-

operative and post operative intraocular pressure,

duration of the surgery and increase in visual acuity

were presented by calculating frequency and

percentages.

was used to get the wide angle view of the retina

during vitrectomy. The surgery started with core

vitrectomy along with clearance of vitreous

haemorrhage (if present) and then the removal of

posterior hyaloid was performed. Peripheral

vitrectomy along with vitreous base shave was done to

get rid of anteroposterior tractions. In the five ports

group, bimanual surgery helped in easy and more

appropriate removal of fibro vascular tissue. The

fourth and fifth ports were placed at 5 and 7 o’ clock

position. As the illumination source was self-retained,

so bimanual technique was used for peeling,

segmentation and delamination of fibrovascular tissue.

All the instruments used were of 23 – gauge including

vitreous cutter, endo-illumination light, micro-scissors,

forceps, laser probe, intraocular diathermy probe and

flute needle. Tractional tissue was removed with

vitrectomy cutter or micro-scissors and the

proliferative membranes were elevated with end-

gripping forceps or with cutter through aspiration.

Intraocular diathermy was used to control the

bleeding. Pan-retinal photocoagulation was performed

up to the peripheral retina. Endolaser was applied

around iatrogenic breaks. After the fluid was

exchanged with air, silicone oil was injected only in

those patients who developed iatrogenic break. At the

end, micro-cannulas were removed with firm pressure

applied on to the sclerotomy sites with a cotton-tip

applicator to enhance the sealing of the sclerotomies.

A nylon 10/0 suture was applied if there was any

leakage through the sclerotomy site. Finally, injection

of dexamethasone and antibiotic was given sub-

conjunctivally. Topical antibiotics and steroids were

advised post operatively. Patients with silicone oil

tamponade were advised to maintain face down

position for initial 5 to 7 days.

RESULTS

Mean age in 3 port group was 54.50 ± 7.7 years and in

5 port group 57.60 ± 9.8 years with p-value of 0.273

(Table 1). Gender distribution showed that there were

Table 1: Age Distribution.

Age (Years)

Total

Mean ± SD

Minimum

Maximum

p-value

3 – Port, n (%)

20 (100.0)

54.50 ± 7.7

5 – Port, n (%)

20 (100.0)

57.60 ± 9.8

0.273

8 females (40%) and 12 males (60%) in 3-port pars

plana vitrectomy group while in 5 – port pars plana

vitrectomy group this distribution was 5 females

(25%) and 15 males (75%). Overall collectively both

the groups consisted of 13 females (32.5%) and 27

males (67.5%) with p value of 0.501 (Table 2).

Table 2: Gender Distribution.

Gender

Female

Male

Total

P Value

3 Port n (%)

8 (40.0)

12 (60.0)

5 Port n (%)

5 (25.0)

15 (75.0)

20 (100.0)

0.501

Total n (%)

13 (32.5)

27 (67.5)

20 (100.0)

40 (100.0)

Snellen visual acuity was converted into

logarithms of the minimum angle of resolution for

statistical analysis. Counting fingers vision was

defined as 0.01 (2.0 log MAR), and hand movements

were defined as 0.001 (3.0 log MAR). Statistical

analyses were performed using SPSS version 20.0.

Age, pre-operative BCVA and post-operative BCVA

of patients, pre-operative and post-operative

intraocular pressures were presented by calculating

mean and standard deviation. Mean improvement in

BCVA was obtained by subtracting mean post-

operative BCVA at 4 weeks from mean pre-operative

BCVA. Improvement or deterioration of the

Safety of the surgical procedure was considered in

terms of intraoperative and postoperative

complications. Two (10%) patients in each group

developed iatrogenic retinal tears with a p-value of

1.00. Iatrogenic per-operative vitreous hemorrhage

developed in three patients (15%) in 3-ports group and

two patients (10%) developed this complication in 5-

ports group (Table 3). Two (10%) patients in each

group developed post vitrectomy vitreous cavity

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246

243

Rana Naveed Iqbal, et al

Postoperative

Table 3: Intraoperative Complications.

16.35 ± 1.9

1.35 ± 2.2

74.40 ± 5.4

1.11 ± 0.5

0.66 ± 0.5

14.35 ± 2.3

1.20 ± 2.4

53.40 ± 2.5

1.71 ± 0.9

0.87 ± 0.8

0.001

0.837

0.001

0.022

0.345

Intraocular Pressure

Change in Intraocular

Pressure

Duration of surgical

procedure

Preoperative BCVA

(Log MAR)

Postoperative BCVA

(Log MAR)

3 – Port

5 – Port

n (%)

18 (90.0)

2 (10.0)

18 (90.0)

2 (10.0)

Complications

n (%)

Value

Iatrogenic Retinal

Tears

Iatrogenic Vitreous

Hemorrhage

Yes

18 (90.0)

2 (10.0)

17 (85.0)

3 (15.0)

1.000

Yes

hemorrhage which did not require any intervention and

resolved by itself 4 weeks post operatively. None of

the patients developed any rhegmatogenous retinal

detachment because in those patients who developed

iatrogenic retinal breaks the complication was

promptly managed with the use of endo-laser

application around the break. There was no iatrogenic

cataract formation in each group (Table 4).

DISCUSSION

With the development of advanced and smaller gauge

instruments, the safety and efficacy has improved due

to which pars plana vitrectomy is now performed more

frequently in proliferative diabetic retinopathy and

even at an earlier stage, especially in cases with

diabetic vitreous hemorrhage.^19,20

Table 4: Postoperative Complication.

In our study intra operative complications included

iatrogenic retinal tear formation in two (10%) patients

in each group while in a previous study, 4 ports pars

plana vitrectomy group had lower number of

iatrogenically induced retinal tears (22.2%) than in 3

ports vitrectomy group (43.3%) and this difference

was statistically insignificant (p = 0.067)¹⁰. This

difference in the formation of retinal break is due to

the fact that bimanual surgery allows more and safer

dissection and peeling of proliferative tissue because

of both hands being used. Improved illumination of

vitreous cavity also plays a pivotal role in this whole

mission. A study from Thailand evaluated the results

of three ports 23-guage pars plana vitrectomy for

tractional retinal detachment and they found that

iatrogenic retinal tear formation leading to retinal

detachment occurred in 20/434 (4.6%) eyes of the 23G

pars plana vitrectomy group.¹¹

3 – Port

n (%)

18 (90.0)

5 – Port

n (%)

18 (90.0)

Complications

Value

Post vitrectomy

vitreous cavity

hemorrhage

Rhegmatogenous

retinal detachment

1.000

Yes

2 (10.0)

Yes

20 (100.0) 20

0 (0.0)

20 (100.0) 20

0 (0.0)

Cataract

Yes

0 (0.0)

Pre-op intraocular pressure in 3 ports group was

noted to be 17.70 ± 1.6 mmHg and postoperative

intraocular pressure was 16.35 ± 1.9 mmHg with a net

change of about 1.35 ± 2.2 mmHg. In 5 ports pars

plana vitrectomy group, pre-op IOP was 15.55 ± 1.6

mmHg and post operatively it changed to 14.35 ± 2.3

mmHg. The change in intraocular pressure between

the two groups was insignificant as the p value was

0.837. Duration of surgery in 3 ports group was 74.40

± 5.4 minutes and in 5 ports group was 53.40 ± 2.50

minutes with a difference of about 21.00 minutes. It

was statistically significant with a p-value of 0.001. In

3 ports group pre-operative BCVA (Log MAR) was

1.11 ± 0.5 which changed to 0.66 ± 0.5 and in 5 ports

group pre-operative BCVA was 1.71 ± 0.9 and this

improved to 0.87 ± 0.8 (Table 5).

Per-operative iatrogenic hemorrhage during

membrane peeling occurred in three (15%) patients in

3 ports group and in two (10%) patients in 5 ports

group and this is in comparison to previous study

where it was similar in both groups.¹⁰

Post-operative vitreous cavity hemorrhage

developed in 2 patients in each group of our study.

This has also been reported in another study conducted

by José Alberto Lemos and his companions that post

vitrectomy cavity hemorrhage occurred in 19 eyes

(17.6%) which was quite high as compared to both

groups in our study.¹²There was no rhegmatogenous

retinal detachment and surgically induced cataract

formation in our study.

Table 5: Preoperative and post-operative intraocular

pressure, duration of surgical procedure and

BCVA.

3 – Port

5 – Port

Parameters

Mean ± SD Mean ± SD Value

Preoperative

Intraocular Pressure

17.70 ± 1.6 15.55 ± 1.6 0.001

244

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246

Outcome of Bimanual 23 Gauge, 5-Ports Versus 3-Ports Pars Plana Vitrectomy for Advanced Diabetic Eye Disease

Duration of surgery was shorter in 5 ports group,

Asad Aslam Khan; Professor: Research design,

where it was 53.40 ± 2.5 minutes than in 3 ports group

in which it was 74.40 ± 5.4 minutes. This can be

attributed to significantly better illumination due to the

use of chandelier light which led to better visualization

with wider view. Due to this bimanual surgical

intervention was quick and swift with safe handling of

tissues.

final review.

Khalid Waheed; Professor: Research design, final

review.

Haroon Tayyab; Assistant Professor: data

collection, data analysis, final review.

Mohsin Ihsan; Associate Professor: Research

There was no significant change in the intraocular

pressure between the two groups under study which

shows that increasing the number of ports does not

affect intraocular pressure provided the cannulas used

are valved and also the use of chandelier light in

additional ports does not allow leakage of intraocular

fluid. BCVA was noted pre operatively and post

operatively in both groups and was found to improve

post operatively in both groups but the improvement

was more prominent in bimanual 5 ports pars plana

vitrectomy group than 3 ports pars plana vitrectomy

group. In a previous study, the vision improved

significantly in patients who underwent bimanual

vitrectomy for diabetic tractional retinal detachment.¹³

design, final review.

Intzar Hussain; Associate Professor: Research

design, final review.

REFERENCES

1. Yau GL, Silva PS, Arrigg PG, Sun JK. Postoperative

Complications of Pars Plana Vitrectomy for Diabetic

Retinal Disease. Semin Ophthalmol. 2018; 33 (1): 126-

133.

2. Bhavsar AR, Torres K, Glassman AR, Jampol LM,

Kinyoun JL. Evaluation of results 1 year following

short-term use of ranibizumab for vitreous hemorrhage

due to proliferative diabetic retinopathy. JAMA

Ophthalmology, 2014; 132 (7): 889-90.

3. Newman DK. Surgical management of the late

complications of proliferative diabetic retinopathy. Eye,

2010; 24 (3): 441.

4. Cheema RA, Sengupta R. The 'suck-and-cut' bimanual

technique for delamination of fibrovascular membranes

in proliferative diabetic retinopathy. Acta Ophthalmol

Scand. 2007; 85 (2): 225.

5. Arevalo JF. En bloc perfluoro dissection in

vitreoretinal surgery: a new surgical technique. Retina,

2008; 28 (4): 653-6.

6. Eckardt C. Twin lights: a new chandelier illumination

for bimanual surgery. Retina, 2003; 23 (6): 893-4.

7. Gonvers M. New instrumentation and technique for

epiretinal surgery. Arch Ophthalmol. 1987; 105 (9):

1292-3.

Limitation of this study is that our sample size was

small and the study was conducted in only two

hospitals of Lahore. However, this study will help in

further research in other centers to validate the

findings.

CONCLUSION

Five ports bimanual pars plana vitrectomy is better in

treating extensive diabetic tractional retinal

detachment as compared to conventional three port

pars plana vitrectomy in terms of shorter duration of

surgical procedure. Intraoperative and postoperative

complications were quite similar in both groups.

8. Steinmetz RL, Grizzard WS, Hammer ME.

Vitrectomy for diabetic traction retinal detachment

Ethical Approval

using

the

multiport

illumination

system.

The study was approved by the Institutional

review board/Ethical review board.

Ophthalmology, 2002; 109 (12): 2303-7.

9. Kadonosono K, Yabuki K, Nishide T, Nomura E,

Uchio E, Yamakawa T. Multicoated contact lens for

bimanual vitreous surgery without endoillumination.

Arch Ophthalmol. 2004; 122 (3): 367-8.

10. Wang ZY, Zhang Q, Zhao DS, Zhao PQ. Four-port

bimanual vitrectomy in fibrovascular membrane

removal. Retina, 2011; 31 (4): 798-800.

11. Choovuthayakorn J, Khunsongkiet P, Patikulsila D,

Watanachai N, Kunavisarut P, Chaikitmongkol V,

et al. Characteristics and Outcomes of Pars Plana

Vitrectomy for Proliferative Diabetic Retinopathy

Conflict of Interest

Authors declared no conflict of interest.

Authors’ Designation and Contribution

Rana Naveed Iqbal; Senior Registrar: Research

design, data analysis, manuscript writing,

literature review.

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246

245

Rana Naveed Iqbal, et al

Patients in a Limited Resource Tertiary Center over an

Eight-Year Period. J Ophthalmol. 2019; 2019.

panoramic viewing during micro-incision vitrectomy

surgery. Retina, 2011; 31 (6): 1231-3.

12. Lemos JA, Carvalho R, Teixeira C, Martins JN,

Menezes C, Coelho P, et al. Pars Plana Vitrectomy in

16. Oshima Y, Chow DR, Awh CC, Sakaguchi H, Tano

Y. Novel mercury vapor illuminator combined with a

27/29 – gauge chandelier light fiber for vitreous

surgery. Retina, 2008; 28 (1): 171-3.

17. Williams GA. 27 – gauge Twin light chandelier

illumination system for bimanual transconjunctival

vitrectomy. Retina, 2008; 28 (3): 518-9.

18. Chow D. Tips on improving your use of

endoillumination. Retin Physician, 2011; 8 (4): 43-6.

19. Baig MS, Rehman A, Burney JA. Intravitreal

Bevacizumab (Avastin) for proliferative diabetic

retinopathy. Pak J Surg. 2009; 25 (2): 110-4.

20. Yorston D, Wickham L, Benson S, Bunce C, Sheard

R, Charteris D. Predictive clinical features and

outcomes of vitrectomy for proliferative diabetic

retinopathy. Br J Ophthalmol. 2008; 92 (3): 365-8.

Proliferative

Diabetic

Retinopathy–Retrospective

Analysis of Results and Complications. Oftalmologia.

2017; 40: 279-87.

13. Park KH, Woo SJ, Hwang JM, Kim JH, Yu YS,

Chung H. Short-term outcome of bimanual 23-gauge

transconjunctival sutureless vitrectomy for patients with

complicated vitreoretinopathies. Ophthalmic Surg

Lasers Imaging 2010; 41 (2): 207-14.

14. Oshima Y, Awh CC, Tano Y. Self-retaining 27 –

gauge transconjunctival chandelier endoillumination for

panoramic viewing during vitreous surgery. Am J

Ophthalmol. 2007; 143 (1): 166-7.

15. Sakaguchi H, Oshima Y, Nishida K, Awh CC. A

29/30 – gauge dual-chandelier illumination system for

^.…^….

246

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 241-246