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25-Gauge transconjunctival sutureless pars
plana vitrectomy
A. YANYALI, E. CELIK, F. HOROZOGLU, S. ONER, A.F. NOHUTCU
Department of Ophthalmology, Haydarpasa Numune Education and Research Hospital, Istanbul - Turkey
European Journal of Ophthalmology / Vol. 16 no. 0, 2006 / pp. 1-000
1120-6721/1-07$15.00/0
© Wichtig Editore, 2006
PURPOSE. To evaluate the effectiveness, feasibility, and safety of the transconjunctival su-
tureless vitrectomy (TSV) system for a variety of vitreoretinal diseases.
METHODS. In this retrospective study, the authors evaluated 71 eyes of 63 patients who un-
derwent pars plana vitrectomy (PPV) with the 25-gauge TSV system. The indications for sur-
gical intervention were diabetic vitreous hemorrhage (29 eyes), diabetic macular edema (14
eyes), macular epiretinal membrane (13 eyes), endophthalmitis (5 eyes), vitreous opacities
secondary to Behçet’s disease (4 eyes), vitreous hemorrhage secondary to branch retinal
vein occlusion (4 eyes), and vitreous hemorrhage secondary to age-related macular de-
generation (2 eyes). Epiretinal membrane and internal limiting membrane removal, endolaser
photocoagulation, and air-fluid exchange were performed when required.
RESULTS. Mean follow-up was 3.6 months (range 1–8 months). Mean overall visual acuity (VA)
was counting fingers (range light perception to 0.4) preoperatively and 0.2 (range 0.1 to 0.8)
postoperatively (p=0.000). Statistically significant VA improvement was observed in eyes
with vitreous hemorrhage, diabetic macular edema, and macular epiretinal membrane. VA
improved postoperatively in all eyes with endophthalmitis and vitreous opacities secondary
to Behçet’s disease. The surgery was completed without conjunctival and scleral suturing
in all eyes. Mean intraocular pressure (IOP) was 17.2 mm Hg (range 10–26 mm Hg) preop-
eratively, 12.4 mm Hg (range 6–24 mm Hg) on the first postoperative day, 16.6 mm Hg (range
10–33 mm Hg) at 1 week, and 15.4 mm Hg (range 10–20 mm Hg) at 1 month postopera-
tively. On the first postoperative day, IOP was below 10 mm Hg (between 6 and 9 mm Hg)
in 12 eyes (16.9%). In these eyes, IOP was normalized within 1 week without affecting the
visual outcome. Five eyes (7%) had transient increase of IOP controlled by topical antiglau-
comatous medications. Vitreous washout using 25-gauge TSV system was performed in two
eyes, in which vitreous hemorrhage recurred.
CONCLUSIONS. The TSV system was observed to be feasible, effective, and safe for a variety
of vitreoretinal diseases. This minimally invasive and completely sutureless (transconjunc-
tival) technique appears to decrease the convalescence period, operating time, and post-
operative inflammatory response, and improve patient comfort.(Eur J Ophthalmol 2006;...)
KEY WORDS.Pars plana vitrectomy, Transconjunctival sutureless vitrectomy, 25-Gauge pars
plana vitrectomy
Accepted: September 7, 2005
25-gauge TSV
2
INTRODUCTION
Pars plana vitrectomy (PPV) is conventionally per-
formed through sclerotomies placed in the anterior
pars plana. Sclerotomies are performed with a 20-
gauge microvitreoretinal blade 3–4 mm behind the lim-
bus, depending on the phakic status of the eye, and
are closed at the end of the surgery with sutures (1).
Suture-related complications such as suture erosion,
scleral necrosis, and granuloma formation can be ob-
served at the sclerotomy sites (2).
Sutureless PPV was proposed by Chen (3) in 1996,
and was based on sclerotomy sites prepared 6 mm
behind the limbus, with the aim of creating 0.3 mm
length self-sealing scleral tunnels. This method
aimed to avoid suture-related complications, and to
shorten the operation time. However, related to the
technique, surgical difficulties and several complica-
tions such as wound leakage, dehiscence and hem-
orrhage, retinal break, vitreous and/or retinal incar-
ceration, and dialyses have been reported (4, 5). Fur-
thermore, the scleral tunnel technique requires con-
junctival dissection and subsequent suturing (5, 6).
In the last few years, 25-gauge transconjunctival
sutureless vitrectomy (TSV) system and vitreoretinal
surgical instruments have been developed, and suc-
cessful results have been reported (7, 8). In this study,
the effectiveness, safety, and feasibility of the TSV
system were evaluated in a variety of vitreoretinal dis-
orders.
METHODS
In this retrospective study, we evaluated 71 eyes of
63 patients who underwent vitreoretinal surgery us-
ing the 25-gauge TSV system between August 2003
and April 2004. Twenty-nine of these eyes had per-
sistent diabetic vitreous hemorrhage, 14 had diabet-
ic macular edema unresponsive to macular laser pho-
tocoagulation, 13 had macular epiretinal membranes,
5 had endophthalmitis, 4 had vitreous opacities sec-
ondary to Behçet’s disease, 4 had vitreous hemor-
rhage secondary to branch retinal vein occlusion, and
2 had vitreous hemorrhage secondary to age-related
macular degeneration.
Cataract extraction with phacoemulsification and in-
traocular lens (IOL) implantation combined with TSV
were performed simultaneously in six eyes with vit-
reous hemorrhage and two eyes with diabetic macu-
lar edema.
The possible merits and risks of the treatment were
explained to the patients and an informed consent
was obtained in accordance with the Helsinki Decla-
ration prior to inclusion in the study. No Institutional
Review Board approval was required for this study.
All patients received a best-corrected Snellen vi-
sual acuity (VA) measurement, anterior segment ex-
amination, intraocular pressure (IOP) measurement with
applanation tonometry, and biomicroscopic evalua-
tion with both fundus non-contact and contact lens-
es. B-scan ultrasonography was performed in all eyes
in which visualization of the fundus was not attained.
The TSV system was not used in eyes with exten-
sive fibrous proliferation detected by ultrasonogra-
phy. Optical coherence tomography (OCT) was per-
formed in patients with diabetic macular edema.
Three vertical and horizontal manually assisted OCT
scans were obtained to locate the fovea and analyzed
from each studied eye by the same experienced oph-
thalmologist, who was masked to the conditions of
the patients. Patients were evaluated postoperative-
ly using the same preoperative tests.
The TSV consists of a 25-gauge microcannula sys-
tem and an array of vitreoretinal instruments specif-
ically designed for this operating system. The 25-gauge
microcannula system includes a microcannula with-
out a valve, an insertion trocar, an infusion cannula,
and a cannula plug (Fig. 1). The vitrectomy probe, mi-
croforceps, microvertical scissors, aspiration pick, sil-
icone-tipped aspiration cannula, endoilluminator, en-
dodiathermy probe, and endolaser probe are the spe-
cial vitreoretinal instruments developed for the 25-
gauge TSV system.
TABLE I - PREOPERATIVE CHARACTERISTICS OF PATIENTS
WHO UNDERWENT 25-GAUGE TRANSCON-
JUNCTIVAL SUTURELESS VITRECTOMY
Characteristic Mean Range
Age (yr) 57 22 to 77
Preoperative IOP (mmHg) 17.2 10 to 26
Preoperative visual acuity CF LP to 0.4
Follow-up (mo) 3.6 1 to 8
IOP = intraocular pressure; CF = counting fingers; LP = light
perception.
Yanyali et al
3
Surgical technique
All the operations were performed by the same sur-
geon (A.Y.) under sub-Tenon anesthesia. The microcannulas
were inserted transconjunctivally with the help of the
insertion trocars in the inferotemporal, superotempo-
ral, and superonasal quadrants. The trocars were ro-
tationally moved during insertion to create scleral inci-
sions measuring 0.5 mm. The overlying conjunctiva was
pulled aside with forceps during the entrance of the in-
sertion trocar in order to avoid the alignment between
conjunctival and scleral incisions. The infusion cannu-
la was placed in the inferotemporal quadrant, and plugs
were used to temporarily close the other entry sites. A
cutting rate of 1500 cuts per minute and a vacuum lev-
el of 500 mmHg were used during PPV. The balanced
salt solution (BSS) bottle height was set at 40 cm. The
whole amount of infusion fluid used during the opera-
tion was not measured. Epiretinal membrane and in-
ternal limiting membrane (ILM) peeling, endolaser pho-
tocoagulation, and air-fluid exchange were performed
when required.
In eyes with diabetic macular edema, ILM that was
stained with 0.1% (1 mg/mL) indocyanine green (ICG)
under intravitreal air was peeled from the macula us-
ing 25-gauge microforceps, following PPV and poste-
rior hyaloid removal. Coexisting cataract was observed
in four eyes with vitreous hemorrhage and in two eyes
with macular edema. In these eyes, cataract extraction
with phacoemulsification via a clear corneal tunnel was
performed simultaneously with TSV. An IOL was implanted
in the capsular bag in all eyes. In these cases, all the
microcannulas were inserted and closed temporarily with
plugs before phacoemulsification. After phacoemulsi-
fication, the corneal tunnel was temporarily closed with
a 10/0 nylon suture, which was removed at the end of
surgery. In eyes with macular epiretinal membrane, mem-
brane removal with ILM peeling was performed with 25-
gauge microforceps, following PPV. In eyes with en-
dophthalmitis, a total vitrectomy and intravitreal van-
comycin and amikacin injections were performed. In
eyes with vitreous opacities secondary to Behçet’s dis-
ease, vitreous opacities were removed. At the end of
Fig. 1 - The 25-gauge microcannula system; infusion cannula,
cannula plug, insertion trocar with microcannula, insertion trocar
and microcannula (from top to bottom).
TABLE II - SURGICAL INDICATIONS AND PREOPERATIVE AND POSTOPERATIVE VISUAL ACUITIES (VA) OF THE
PATIENTS
Indications N (%) Mean pre Mean post p Value*
operative operative
VA VA
Vitreous hemorrhage 35 (49.3) HM 0.2 0.000
Diabetic macular edema 14 (19.7) 0.1 0.2 0.002
Macular epiretinal membrane 13 (18.3) 0.2 0.4 0.001
Endophthalmitis 5 (7) LP 0.2 †
Vitreous opacities (BD) 4 (5.7) CF 0.2 †
*Wilcoxon test.
†Statistical analysis was not performed because of small number of patients.
HM = hand motions; LP = light perception; BD = Behçet’s disease; CF = counting fingers.
25-gauge TSV
4
the procedure, the insertion trocars were removed with-
out air or fluid leakage. The conjunctiva overlying the
sclerotomy was slightly displaced to disrupt the align-
ment between both entry sites, and an antibiotic and
corticosteroid combination was injected into the sub-
conjunctival space. No sutures were required to close
the scleral or conjunctival openings in any eye.
Main outcome measures were IOP, VA, and intra-
operative and postoperative complications. Preoper-
ative and postoperative best-corrected Snellen VA were
converted into logMAR (the logarithm of the minimal
angle of resolution) units for statistical analysis. One-
way analysis of variance, Tukey, Student’s t, and Wilcox-
on tests were used for statistical analysis.
RESULTS
Preoperative characteristics of the patients are shown
in Table I. Of the 63 patients, 22 were men and 41
were women. Mean follow-up period was 3.6 months.
Mean overall VA was counting fingers (range light per-
ception to 0.4) preoperatively and 0.2 (range 0.1 to
0.8) postoperatively (Tab. II). The improvement in VA
was statistically significant (p=0.000, Student’s t test).
Overall VA improved in 63 eyes (88.7%) and remained
stable in 8 eyes (11.3%) and no major intraoperative
complication was encountered. IOP changes after 25-
gauge TSV are shown in Table III. IOP changes be-
tween preoperative and postoperative 1 day and post-
operative 1 day and postoperative 1 week were sta-
tistically significant (p=0.000, Tukey test). IOP
changes between postoperative 1 week and postop-
erative 1 month were not statistically significant (p=0.058,
Tukey test). On the first postoperative day, IOP was
below 10 mmHg (between 6 and 9 mmHg) in 12 eyes
(16.9%). In these eyes, IOP was normalized within 1
week without affecting the visual outcome.
In eyes with vitreous hemorrhage secondary to pro-
liferative diabetic retinopathy (29 eyes), branch reti-
nal vein occlusion (4 eyes), and age-related macular
degeneration (2 eyes), the vitreous hemorrhage was
removed successfully. VA was hand motions preop-
eratively in all of these eyes, which improved to a mean
of 0.2 postoperatively. The improvement in VA was
statistically significant (p=0.000, Wilcoxon test).
Transient increase of IOP (4 eyes) and recurrence of
vitreous hemorrhage (2 eyes) were the postoperative
complications of this subgroup. Recurrent vitreous he-
morrhages did not resorb spontaneously, so vitreous
washout using the 25-gauge TSV system was per-
formed at postoperative month 1. Vitreous hemorrhage
did not recur in these eyes.
In 14 eyes that underwent PPV and ILM removal for
diabetic macular edema unresponsive to macular pho-
tocoagulation, mean VA improved from 0.1 preoper-
atively to 0.2 postoperatively. This improvement was
statistically significant (p=0.002, Wilcoxon test).
Mean foveal thickness was 382 ?m preoperatively and
264 ?m at postoperative month 1. No postoperative
complications were encountered in these eyes.
Macular epiretinal membrane removal was performed
successfully in 13 eyes. Mean VA improved from 0.2
preoperatively to 0.4 postoperatively. The improve-
ment in VA was statistically significant (p=0.001, Wilcox-
on test). No postoperative complications were observed
in these eyes.
In five eyes with endophthalmitis, intravitreal an-
tibiotic injections were applied following PPV with the
25-gauge TSV system, and mean VA improved from
light perception preoperatively to 0.2 postoperative-
ly. VA improved postoperatively in all eyes. Statisti-
cal analysis was not performed because of small num-
ber of patients.
In four eyes that underwent surgery for vitreous opac-
ities secondary to Behçet’s disease, mean VA improved
TABLE III - INTRAOCULAR PRESSURE CHANGES AFTER 25-GAUGE TRANSCONJUNCTIVAL SUTURELESS VIT-
RECTOMY
Preoperative Postoperative Postoperative Postoperative p Value*
1st day 1st week 1st month
Mean IOP 17.2 mmHg 12.4 mmHg 16.6 mmHg 15.4 mmHg 0.000
(range) (10–26) (6–24) (10–33) (10–20)
*One-way analysis of variance
IOP = Intraocular pressure
Yanyali et al
5
from counting fingers to 0.2. VA improved postoper-
atively in all eyes. Statistical analysis was not per-
formed because of small number of patients. Tran-
sient increase of IOP controlled by topical antiglau-
comatous medications was observed in one eye in
this subgroup.
The mean total operative time was 21 minutes (range
16 to 34 minutes). No difficulties were encountered dur-
ing the insertion of the trocars into any eye. Passage
of the 25-gauge instruments through the trocars was
found to be easy, and the required procedures were
performed with ease in all eyes. A cutting rate of 1500
cuts per minute and a vacuum level of 500 mmHg with
a bottle height set at 40 cm were adequate to avoid a
collapse of the globe. Furthermore, these settings did
not induce an elevated IOP causing corneal opacity in
any eye. There were no complications such as wound
leakage, extension, dehiscence and hemorrhage, or vit-
reous or retinal incarceration at the external side of the
sclerotomies. The internal side of the sclerotomies was
not evaluated by ultrasound biomicroscopy. No sutures
were required to close the scleral or conjunctival open-
ings in any eye.
DISCUSSION
We currently perform 25-gauge PPV in approximately
15% of our routine PPV cases. In this study, we per-
formed PPV with the 25-gauge TSV system in eyes
with persistent vitreous hemorrhage, diabetic macu-
lar edema unresponsive to macular laser photocoag-
ulation, macular epiretinal membrane, endoph-
thalmitis, and vitreous opacities secondary to Behçet’s
disease. In these eyes, PPV, epiretinal membrane and
ILM removal, endolaser photocoagulation, and air-flu-
id exchange procedures were performed with ease.
No difficulties were encountered during the passage
of the instruments through the insertion trocars. No
major intraoperative complications were observed. Mean
overall VA improved significantly from counting fin-
gers (range light perception to 0.4) preoperatively to
0.2 (range 0.1 to 0.8) postoperatively. Overall VA im-
proved in 88.7% of eyes and remained stable in 11.3%
of eyes. Significant improvement in mean preopera-
tive to mean postoperative VA was observed in eyes
with vitreous hemorrhage, diabetic macular edema,
and macular epiretinal membrane. VA improved post-
operatively in all eyes with endophthalmitis and vit-
reous opacities secondary to Behçet’s disease. Fujii
et al (8) have also reported that the 25-gauge TSV
system can be used with comfort and success in many
vitreoretinal procedures that do not involve extensive
intraocular tissue dissection, such as epiretinal mem-
brane peeling, vitreous hemorrhage removal, macu-
lar hole surgery, branch retinal vein occlusion
sheathotomy, diabetic macular edema, and uncom-
plicated retinal detachment surgeries.
In some eyes operated with the TSV system, tem-
porary IOP alterations have been reported in the post-
operative period (8). In the same study, relative hy-
potony (6 to 9 mmHg) has been observed in 22.8%
of eyes on the first postoperative day. In our study,
mean IOP decreased significantly on the first post-
operative day (mean 12.4 mmHg) and then increased
significantly at postoperative 1 week (mean 16.6 mmHg).
Mean IOP at postoperative 1 month (mean 15.4 mmHg)
was not significantly different from mean IOP at post-
operative 1 week. We observed relative hypotony in
16.9% of eyes and IOP was normalized within 1 week
without affecting the visual outcome. We assume that
slight displacement of the conjunctiva, overlying the
sclerotomies while inserting and removing the trocars,
prevents intraocular air or fluid leakage. We observed
a temporary IOP rise in 7% of eyes and Fujii et al (8)
have also reported a temporary IOP rise in 8.5%.
Numerous studies have shown that sutureless
small-incision cataract surgery reduces the postop-
erative inflammatory response (9-11). Similarly, it has
been proposed that there is a reduced postoperative
inflammatory reaction and faster postoperative recovery
with the 25-gauge TSV system, compared with the
conventional method of PPV (7, 8). In addition, there
would be no suture-related irritation or local inflam-
matory reaction at the sclerotomy sites (8). The fre-
quency of local inflammatory reaction has been re-
ported as 32% with Dacron, and 5% with polyglycolic
acid suture (12). Eyes operated with the TSV system
have been observed to be less-injected on the first
postoperative day when compared with convention-
al PPV (8). Furthermore, there is no limbal stem cell
damage due to conjunctival dissection, so it may be
advantageous in eyes with corneal or conjunctival dis-
eases such as dry eye. In our study, we observed a
less traumatic postoperative appearance, and few com-
plaints due to ocular surface irritation.
25-gauge TSV
6
Vitrectomy is indicated in certain cases of endoph-
thalmitis (13, 14). Performing a complete vitrectomy
(with peripheral vitreous removal) is theoretically ben-
eficial by debulking more inflammatory debris and tox-
ins, allowing better penetration and distribution of in-
traocular antibiotics and removing the scaffold for the
formation of epiretinal membranes (15). In our study,
with the use of TSV system and wide-angle viewing
system, a complete vitrectomy was performed at ease
in eyes with endophthalmitis. Furthermore, since eyes
with endophthalmitis have severe inflammation, the
selected surgical procedure should not provoke this
inflammation. The TSV allows a completely suture-
less closed vitrectomy, obviates the need for conjunctival
peritomy and suturing, and decreases surgically in-
duced trauma and postoperative inflammatory response.
We used the 25-gauge TSV system in four cases
with vitreous opacities secondary to Behçet’s disease,
and mean VA improved from counting fingers to 0.2.
It has been suggested that PPV is effective in the treat-
ment of complications of uveitis, such as medium opac-
ities on the visual axis, vitreous hemorrhage, and cys-
toid macular edema (16). It has been advocated that
PPV eliminates the inflammatory components and growth
factors in the vitreous, and decreases macular ede-
ma (17, 18). In these eyes, it may be possible to in-
duce only minimal surgical trauma due to the minimal
touch of small diameter (25-gauge) microsurgical in-
struments to the sensitive uveal tissues. After con-
sideration of all these facts, the TSV system may be
advantageous in the surgery of complications of uveitis.
In a previous study (7), to evaluate the time efficien-
cy of the TSV system, the 25-gauge TSV and the 20-
gauge PPV were used by the same surgeon in similar
cases; the mean operation time was significantly
longer with the 20-gauge vitrectomy (26 minutes) than
with the 25-gauge vitrectomy (17 minutes). It has been
shown that the time-saving benefit results from the open-
ing and closing of the conjunctiva and sclera. Howev-
er, in order to benefit from all these advantages, it has
especially been emphasized that the 25-gauge TSV sys-
tem should be used in selected cases not requiring ex-
tensive intraocular tissue dissection (7, 8). In our study,
since the TSV system was not used when extensive fi-
brous proliferation was detected by ultrasonography
and biomicroscopy, shifting to 20-gauge PPV was not
required in any eye. We also observed a reduction in
the operation time (mean 21 minutes) with the 25-gauge
TSV system; however, we did not have the opportuni-
ty to compare it with the 20-gauge system.
It is difficult to examine the sclerotomy sites ade-
quately through biomicroscopy and indirect ophthal-
moscopy. This becomes possible with the introduc-
tion of ultrasound biomicroscopy, which is an excel-
lent tool for examination of the pars plana. It has been
reported that the rate of ultrasonically visible vitre-
ous incarceration in pars plana sclerotomies is 85.4%
after standard conventional sutured sclerotomies, and
85.2% after modified sutureless sclerotomies (19). In
the same study, it has also been reported that longi-
tudinal ultrasound biomicroscopy examination of in-
carcerated vitreous at the sclerotomies over a post-
operative period of 6 months does not reveal any pro-
gression. In 25-gauge TSV, the possible mechanism
for closure of sclerotomy wound is vitreous incarcer-
ation. Vitreous incarceration in sclerotomies can
cause anterior vitreoretinal traction and subsequent
retinal tears or detachments during the postoperative
period. In our study, although no vitreous or retinal
incarceration was observed at the external side of the
sclerotomies, the internal side of the sclerotomies was
not evaluated by ultrasound biomicroscopy. Additionally,
our follow-up period (mean 3.6 months) is relatively
short. Thus, we were not able to evaluate the closure
of sclerotomy wound, and possible vitreous incarceration
and its progression. Further studies with a long fol-
low-up period and ultrasound biomicroscopy exami-
nation are required.
The 25-gauge TSV has several shortcomings. In 25-
gauge TSV, the ability of the surgeon to move the eye
during the operation is more limited due to small and
more flexible intraocular instruments, when compared
with the 20-gauge vitrectomy system. In addition, there
is a limited range of commercially available 25-gauge
intraocular instruments since the system is new and
the sclerotomies are small. For these reasons, it would
be more appropriate to perform the 25-gauge TSV in
eyes without complex or peripheral vitreoretinal
pathology. This is especially important during the learn-
ing curve of the surgeon using the small, flexible in-
traocular instruments. Furthermore, the aspiration flow
in 25-gauge TSV is lower than the aspiration flow in
20-gauge vitrectomy system. Therefore, maximum as-
piration settings should be used to prevent the oc-
clusion of the 25-gauge vitreous cutter with the as-
pirated material. In our study, a cutting rate of 1500
Yanyali et al
7
cuts per minute and a vacuum level of 500 mmHg
were used during PPV. The BSS bottle height was set
at 40 cm. We observed neither occlusion of the vit-
reous cutter nor hypotony during 25-gauge TSV.
In our study, we did not observe any postoperative
complications except for transient increase of IOP in
7% of all eyes included in the study, and recurrent
vitreous hemorrhage in 3.3% of eyes with vitreous he-
morrhage secondary to proliferative diabetic
retinopathy. There was no reason leading us to be-
lieve that these complications were specifically re-
lated to the use of TSV. In these eyes, IOPs were con-
trolled by topical antiglaucomatous medications, and
vitreous hemorrhage did not recur after vitreous washout
with the TSV system. There is theoretically increased
risk for endophthalmitis due to unsutured scleral and
conjunctival openings in the 25-gauge TSV. Howev-
er, this devastating complication was observed in nei-
ther Fujii et al’s (8) nor our study.
In conclusion, the TSV system is a feasible, effec-
tive, safe, and practical procedure for a variety of vit-
reoretinal disorders. The TSV allows for completely
sutureless closed vitrectomy, obviates the need for
conjunctival peritomy and suturing, and decreases sur-
gically induced trauma, operation time, convalescence
period, and postoperative inflammatory response. We
suggest that the indications of the TSV system will
expand with the development of new 25-gauge vit-
reoretinal surgical instruments.
None of the authors has any financial interest in the study.
Reprint requests to:
Ates Yanyali
Topagac sok. Akarsu Apt. No: 3/13
Caddebostan/Istanbul, Turkey
ayanyali@hotmail.com
REFERENCES
1. Van Kuijk FJ, Uwaydatt S, Godley BF. Self-sealing sclero-
tomies in pars plana vitrectomy. Retina 2001; 21: 547-50.
2. Kwok AKH, Tham CCY, Lam DSC, Li M, Chen JC. Mod-
ified sutureless sclerotomies in pars plana vitrectomy.
Am J Ophthalmol 1999; 127: 731-3.
3. Chen JC.Sutureless pars plana vitrectomy through self-seal-
ing sclerotomies. Arch Ophthalmol 1996; 114: 1273-5.
4. Rahman R, Rosen PH, Riddell C, Towler H. Self-seal-
ing sclerotomies for sutureless pars plana vitrectomy.
Ophthalmic Surg Lasers 2000; 31: 462-6.
5. Milibak T, Suveges I. Complications of sutureless pars
plana vitrectomy through self-sealing sclerotomies
(letter). Arch Ophthalmol 1998; 116: 119.
6. Lam DS, Chua JK, Leung AT, et al. Sutureless pars plana
anterior vitrectomy through self-sealing sclerotomies
in children. Arch Ophthalmol 2000; 118: 850-1.
7. Fujii GY, De Juan E Jr, Humayun MS, et al. A new 25-gauge
instrument system for transconjunctival sutureless vitrec-
tomy surgery. Ophthalmology 2002; 109: 1807-13.
8. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial ex-
perience using the transconjunctival sutureless vitrec-
tomy system for vitreoretinal surgery. Ophthalmology
2002; 109: 1814-20.
9. Kaiya T. Observation of blood-aqueous barrier func-
tion after posterior chamber intraocular lens implanta-
tion. J Cataract Refract Surg 1990; 16: 320-4.
10. Oshika T, Yoshimura K, Miyata N. Postsurgical inflam-
mation after phacoemulsification and extracapsular ex-
traction with soft or conventional intraocular lens im-
plantation. J Cataract Refract Surg 1992; 18: 356-61.
11. Sanders DR, Spigelman A, Kraff C, et al. Quantitative
assessment of postsurgical breakdown of the blood-
aqueous barrier. Arch Ophthalmol 1983; 101: 131-3.
12. Tardif YM, Schepens CL, Tolentino FI. Vitreous surgery.
XIV. Complications from sclerotomy in 89 consecutive
cases. Arch Ophthalmol 1977; 95: 229-34.
13. D’Amico DJ, Noorily SW. Postoperative endoph-
thalmitis. In: Albert, Jacobiec, eds. Principles and Prac-
tice of Ophthalmology. Philadelphia: W.B. Saunders Com-
pany; 1994: 1159-69.
14. Michaels GR. Vitreous Surgery. St. Louis: C.V. Mosby
Company; 1981: 209-367.
15. Morris R, Witherspoon CD, Kuhn F. Endophthalmitis.
In: Roy H, ed. Master Techniques in Ophthalmic
Surgery. Baltimore: Williams & Wilkins: 1995: 560-72.
16. Nolthenius PA, Deutman AF. Surgical treatment of the
complications of chronic uveitis. Ophthalmologica
1983; 186: 11-6.
17. Dick AD. The treatment of chronic uveitic macular ede-
ma. Is immunosuppression enough? Br J Ophthalmol
1994; 78: 1-2.
18. Mieler WF, Aaberg TM. Vitreous surgery in the man-
agement of peripheral uveitis. Dev Ophthalmol 1992;
23: 239-50.
19. Kwok AKH, Tham CCY, Loo AVP, Fan DSP, Lam DSC.
Ultrasound biomicroscopy of conventional and sutureless
pars plana sclerotomies: a comparative and longitudi-
nal study. Am J Ophthalmol 2001; 132: 172-7.
