Jamming of 23‐gauge instruments in the microcannula during vitrectomy for severe vitreous haemorrhage
Jamming of 23‐gauge instruments in the microcannula during vitrectomy for severe vitreous haemorrhage
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严重玻璃体出血玻璃体切除术期间微插管中 23 号仪器卡住
DOI：
10.1111/j.1755-3768.2009.01551.x
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发表时间：
2009
影响因子：
3.4
通讯作者：
D. Lee
中科院分区：
文献类型：
--
作者：
D. Nam;Myun Ku;H. Sohn;D. Lee
编辑：近年来，经结膜无缝线玻璃体切除术越来越受欢迎。与传统的20号玻璃体切除术相比，使用25号或23号工具具有许多优势，并且已有许多关于25号或23号玻璃体切除术在各种玻璃体视网膜疾病中的安全性和有效性的报告（Fujii等，2002; Eckardt 2005）。然而，与此类小规格器械相关的并发症仍然存在问题（Inoue等，2004; Ooto等，2008）。Shinoda等人（2008）报告了在玻璃体切除术治疗玻璃体出血期间25号器械卡在套管中的情况。我们在一名严重玻璃体混浊患者的23号玻璃体切除术中遇到了23号内照明器或玻璃体切割器在微套管中卡住的情况。一名47岁的男子被诊断为严重的玻璃体混浊和出血与视网膜中央静脉阻塞。右眼最佳矫正视力为20/20，左眼为光感。两年前，患者因左眼新生血管性青光眼接受Ahmed阀植入术。使用DORC两步系统（荷兰眼科研究中心[DORC] International BV，Zuidland，荷兰）进行23号手术。使用由玻璃体切除术单元（Associate 2500; DORC International BV）驱动的23号内照明器和玻璃体切割器（DORC International BV）进行玻璃体手术。在常规白内障手术和随后的核心玻璃体切除术后，进行外周玻璃体切除术（图1A）。当我们尝试在周边玻璃体切除术期间从微套管中取出内镜照明器/玻璃体切割器时，我们发现该工具牢固地卡在微套管内，并且其取出可能会将套管从巩膜切开术部位拉出（图1B）。我们发现，如果我们通过用镊子牢固地握住微套管的套环来稳定微套管的套环，则可以从微套管中取出照明器/玻璃体切割器。此后，我们确定了截留在微套管内管中的有组织的玻璃体膜（图1C）。我们用切割器取出截留的玻璃体，以清除套管内部，并能够将23号器械自由地插入或取出微套管（图1D）。然后，所有其他程序都以通常的方式完成。术中和术后，肉眼和显微镜检查显示微插管或23号器械无特定畸形或损坏。Shinoda等人（2008）在45只玻璃体出血眼中有3只（7%）发生了25号仪器堵塞，而我们在23号玻璃体切除术后约50只玻璃体出血眼中仅1只发生了堵塞。与卡在微套管中的25号器械相比，卡在微套管中的23号切割器或光管可以借助于镊子从23号套管中取出。此外，我们未发现微套管或23号器械有任何损坏。25号和23号仪器在干扰发生率和仪器恢复方面的差异有可能得到解释。一种解释可能与微插管的材料有关。在25号系统中，这是由聚酰胺制成的，但在23号系统中是不锈钢制成的。因此，尽管25号塑料套管很容易损坏，但23号金属套管仍然牢固地保持完整。另一个（A）（B）
Editor, T ransconjunctival sutureless vitrectomy has gained popularity in recent years. The use of 25or 23-gauge instruments has many advantages over conventional 20gauge vitrectomy, and there have been many reports on the safety and efficacy of 25or 23-gauge vitrectomy in a variety of vitreoretinal diseases (Fujii et al. 2002; Eckardt 2005). However, complications associated with such small-gauge instruments remain problematic (Inoue et al. 2004; Ooto et al. 2008). Shinoda et al. (2008) reported on the jamming of 25gauge instruments in the cannula during vitrectomy for vitreous haemorrhage. We experienced the jamming of a 23-gauge endo-illuminator or vitreous cutter in the microcannula during 23-gauge vitrectomy in a patient with severe vitreous opacity. A 47-year-old man was diagnosed with severe vitreous opacity and haemorrhage associated with central retinal vein occlusion. Best corrected visual acuity was 20 ⁄20 in the right eye and light perception in the left. Two years previously, the patient had undergone Ahmed valve implantation for neovascular glaucoma in the left eye. A 23-gauge surgical procedure was performed using the DORC twostep system (Dutch Ophthalmic Research Center [DORC] International BV, Zuidland, the Netherlands). Vitreous surgery was carried out using a 23-gauge endo-illuminator and vitreous cutter (DORC International BV) driven by a vitrectomy unit (Associate 2500; DORC International BV). After conventional cataract surgery and subsequent core vitrectomy, peripheral vitrectomy was performed (Fig. 1A). When we attempted to remove the endo-illuminator ⁄ vitreous cutter from the microcannula during the peripheral vitrectomy, we found that the instrument was lodged firmly within the microcannula and its removal was likely to pull the cannula out of the sclerotomy site (Fig. 1B). We found that if we stabilized the collar of the microcannula by holding it firmly with a forceps, it was possible to remove the illuminator ⁄vitreous cutter from the microcannula. Thereafter, we identified organized vitreous membranes trapped in the inner tube of the microcannula (Fig. 1C). We removed the entrapped vitreous with a cutter to clear the inside of the cannula and were able to reinsert or remove 23-gauge instruments freely into and out of the microcannula (Fig. 1D). All other procedures were then completed in the usual manner. Intraoperatively and postoperatively, gross and microscopic examinations revealed no specific deformities of or damage to the microcannula or the 23-gauge instruments. Whereas Shinoda et al. (2008) experienced the jamming of 25-gauge instruments in three (7%) of 45 eyes with vitreous haemorrhage, we experienced jamming in only one of about 50 eyes with vitreous haemorrhage following 23-gauge vitrectomy. By contrast with 25-gauge instruments that are jammed in the microcannula, the jammed 23-gauge cutter or light pipe could be withdrawn from the 23-gauge cannula by the aid of a forceps. Moreover, we did not find any damage to the microcannula or 23-gauge instruments. There are possible explanations for the differences between 25and 23gauge instruments in terms of incidence of jamming and recovery of instruments. One explanation may relate to the material of the microcannula. This is made of polyamide in the 25-gauge system, but stainless steel in the 23-gauge system. Therefore, although the 25-gauge plastic cannula is easily damaged, the 23-gauge metal cannula remains firmly intact. Another (A) (B)