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214 Original article

A comparative study of 23 G vitrectomy and bimanual surgery

in the management of epiretinal membranes in diabetic eyes
Mohamed M. A. Lolah, Ashraf S. Shaarawy
Department of Ophthalmology, Faculty of
Medicine, Alexandria University, Alexandria,
Egypt
Correspondence to Mohamed A. Lolah, MD, 54
Eleskandranyst Moharambeek,
Alexandria 21515, Egypt
Tel: +20 100 626 8798/+20 339 302 15;
fax: +20 279 415 38;
e-mail: mohamedlolah75@yahoo.com
Received 9 March 2014
Accepted 1 July 2014
Journal of Egyptian Ophthalmological Society
2014, 107:214219

Purpose
The purpose of the study was to compare the anatomical and functional outcome of the use
of high-speed 23 G vitreous cutters shaving versus bimanual surgery in the management
of epiretinal membranes (ERMs) in eyes with diabetic tractional retinal detachment (TRD).

Design

Prospective comparative double-blind study.

Setting

Modern Ophthalmology Center, Alexandria, Egypt.

Patients and methods

The study was conducted on 60 eyes with diabetic TRD, divided blindly into two equal groups.
Informed consent was obtained from all patients before participation in the study. Group I was
operated upon with the Twinac cutter on Oertli OS3 NovitreX using the foot-controlled peristaltic
pump. Group II was operated upon with a chandelier light using twinlight on BrightStar. The
ERM was operated upon using curved 23 G scissors and end-gripping forceps. All eyes were
followed up for 6 months after surgery.

Results

Complete removal of ERM was achieved in 20 (66.7%) eyes and 30 (100%) eyes, iatrogenic
breaks in 10 (33.4%) eyes and five (16.7%) eyes, postvitrectomy bleeding in five (16.7%) eyes
and two (6.7%) eyes, retinal tamponade was not needed in six (20%) eyes and eight (26.7%)
eyes, in groups I and II, respectively. There was significant difference between the two groups
in complete removal of ERM, use of gas or air as a tamponade, and use of silicone tamponade.

Conclusion

Although the advent of high-speed 23 G vitreous cutter facilitates dissection of ERM in eyes
with diabetic TRD, bimanual surgery is associated with statistically significant more complete
removal of ERM, more use of temporary tamponade as gas or air, and less use of silicone oil.

Keywords:
23 G vitrectomy, bimanual, epiretinal membranes, diabetic TRD
J Egypt Ophthalmol Soc 107:214219
2014 The Egyptian Ophthalmological Society
2090-0686

Introduction
Dissection of epiretinal membranes (ERMs) is the
most challenging event of diabetic tractional retinal
detachment (TRD) surgery, but fortunately results
have improved dramatically over the years because of
new tools and techniques [1].
High-speed 23 G vitreous cutters enable conformal
cutter delamination as well as segmentation of the
bridging tissue between different epicenters of the
ERMs [2].
Bimanual vitrectomy is used in difficult cases of
diabetic TRD for the complete and safe removal of
ERMs [3].
The general concept of bimanual surgery is to offset
the unwanted pull and push-out forces of scissors and
pics that are produced on the retina during dissection
of the ERMs [4].
2090-0686 2014 The Egyptian Ophthalmological Society

In challenging cases of diabetic TRD and proliferative

vitroretinopathy, it is easier by bimanual vitrectomy to
grasp the membranes using forceps and separate them
from the retina by means of dissection using scissors
and cutters [5].
The chandelier lighting system is a new tool for
bimanual vitrectomy, which uses 25 and 27 G format
or 29 G endoillumination [6,7], that can be placed
into the cannula or introduced through a separate
scleretomy [8,9].
The use of twinlight chandelier (two optic-fiber
system) is highly beneficial in minimizing the single
light shadow, with more homogenous and widespread
illumination [10].
It is preferable to set up the fiber superiorly as a single
fiber at 12 oclock or dual fibers at 2 and 10 oclock
positions to make the instrument shadow appear
anteriorly and not interfere with the working area
view[11].
DOI: 10.4103/2090-0686.150656

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A comparative study of 23 G vitrectomy Lolah and Shaarawy 215

Patients and methods

The study was granted approval by the ethics committee
of Alexandria University Faculty of Medicine. Patients
who required surgery for TRD with ERMs resulting
from diabetic retinopathy were included in the study.
Sixty eyes were divided into two semirandomized
groups. Thirty eyes were operated upon with Twinac
cutter on Oertli OS3 (OertliInstrumente AG, Berneck,
Switzerland) NovitreX vitrectomy system using the
foot-controlled peristaltic pump with a cutting rate of
3000 cpm, vacuum of 50 mmHg, and flow rate of 10
ml/min coming very close to the retinal surface. The
remaining 30 eyes were operated upon using chandelier
light with twinlight on BrightStar (DORC International
bv/Dutch Ophthalmic, Scheijdelveweg) and the ERM
was operated upon using curved 23 G scissors and endgripping forceps from Eye Technology, Essex, UK.
Patients were excluded if they had undergone previous
laser, vitrectomy, or scleral buckling surgery.
The surgeries were performed by a single surgeon, and
the same retinal inspection regime was used in both
groups, with the same wide-angle viewing system.
We used the SDI-BIOM panoramic viewing system
(Insight Instruments Inc., Stuart, Florida, USA)
for wide-angle viewing. The 23 G sutureless trocar
system by Alcon Laboratories Inc. (Fort Worth,
Texas, USA) was used for microincisions (groupI),
and a 27-G dual-port chandelier light fiber
BrightStar (DORC) was used for auxiliary lighting
(group II).
Complete pars plana vitrectomy was performed on all
patients using Twinac cutter on Oertli OS3 NovitreX
23 G cutter with a cutting rate of 1500 cpm, vacuum of
150 mmHg, and flow rate of 25 ml/min.
Triamcinolone acetonide (Alcon Laboratories Inc.)
was used as a vitreous highlighter. Dye-assisted
(Brilliant Peel, Ulm, Germany) internal limiting
membrane peeling and endolaser treatment were used
when required.
In Group I, the cutter probe was used as scissors and pic
to perform segmentation and delamination of ERM
above the optic disc. With the use of the peristaltic
pump, the cutter acts as forceps to pull on the ERM for
complete removal of the membrane.
In Group II, the 27-G dual-port chandelier was
inserted at 2 and 10 oclock positions 3.5 mm posterior
to the limbus in phakic patients and 3 mm posterior to
the limbus in pseudophakic or aphakic patients.

The chandelier light fiber should be inserted before the

infusion cannula to avoid conjunctival ballooning.
Removal of ERMs in group II was performed with the
use of forceps or pics and curved scissors to stabilize
the membrane during cutting of the bridging tissues
along with the retina.
Gas or air and silicone tamponade were used
according to the retinal condition at the end of
surgery. All surgeries were performed by a single
surgeon.
The anatomical outcomes were collected from the
intraoperative events and at 6 months postoperatively.
In terms of the visual acuity as a functional outcome,
the data were collected and analyzed 6 months
postoperatively using Snellens chart and logMAR.
Statistical analysis

Statistical analysis was performed using Statistical

Package for Social Sciences software (SPSS for Windows,
version 18). The c2-test and Fishers exact test were used
for comparison between the two groups. P-value less than
0.05 was defined as statistically significant.

Results
The age of patients ranged from 21 to 78 years, with
a mean age of 46.26 16.32 years. The mean age
of the first group (46.9 15.54 years) was higher
than that of the second group (45.63 17.3 years),
but this difference was not statistically significant
(P = 0.77).
Anatomical outcomes
Intraoperative

Out of 30 eyes operated upon using high-speed

23 G vitreous cutters shaving (group I), complete
removal of ERM was achieved in 20 (66.7%) eyes
compared with 30 (100%) eyes of those operated
upon using bimanual surgery (group II). This
difference was statistically significant (P < 0.001,
relative risk = 2.5, 95% confidence interval
1.783.51). Iatrogenic breaks occurred in 10
(33.4%) out of 30 eyes in group I compared with
five (16.7%) eyes only in the second group, with no
statistically significant difference.
Out of 24 (80%) eyes in group I that required retinal
tamponade, gas or air was used in six (66.7%) of them,
and in the remaining 18 (66.7%) eyes silicone oil was
used. In contrast, silicone oil was used in only two
(66.7%) out of 22 eyes that required tamponade in

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216 Journal of Egyptian Ophthalmological Society

group II, and this difference was statistically significant

(P < 0.001, relative risk = 7369, 95% confidence interval
2.0329.13) (Table 1).
Postoperative

Residual retinal detachment was noticed in five

eyes in group I with absence of this complication in
the second group; however, this difference was not
statistically significant. Similarly, postvitrectomy
bleeding was diagnosed in five (16.7%) eyes in group
one and in two (6.7%) eyes in the second group, and
these differences were not statistically significant.
Postvitrectomy rhegmatogenous retinal detachment
occurred in one (3.3%) eye in group I, with no cases in
group II (Table 1).
Functional outcomes

(1) The mean best-corrected visual acuity (BCVA)

of the first group (logMAR) did not differ

significantly after intervention compared with that

before (0.12 0.07 after intervention compared
with 0.16 0.11 before) (P of paired samples
test = 0.08).
(2)
The mean BCVA of the second group
(logMAR) did not differ significantly after
intervention compared with that before
(0.130.11 after intervention compared with
0.09 0.08 before) (P of Wilcoxon signed-rank
test = 0.064).
(3) On comparing the mean visual acuity (BCVA)
of the first group (0.12 0.07) to that of the
second group (0.13 0.11) after intervention,
no significant difference was found (P = 0.75)
(Table 2).
Although the improvement of visual acuity by more
than two lines was recorded in 14 eyes in group II
versus 12 eyes in the first group, this difference was not
statistically significant (P = 0.54) (Table 3).

Table 1 Anatomical outcome of the use of high-speed 23 G vitreous cutters shaving versus bimanual surgery
Anatomical differences

Shaving (n = 30
eyes) [n (%)]

Bimanual (n = 30
eyes) [n (%)]

Test of significance (P-value)

Complete removal
of ERM

20 (66.7)

30 (100)

(P < 0.001) *RR = 2.5 (1.783.51)

Retinal tamponade

24 (80)

22 (73.3)

2 = 0.38 (0.54)

Gas or air (n = 26)

6 (25)

20 (90.9)

2 = 20.29 (<0.001) RR = 7.69 (2.0329.13)

Silicine oil (n = 20)

18 (75)

2 (9.1)

Type of tamponadea

Residual tractional RD
Iatrogenic breaks
Postvitrectomy bleeding
Postvitrectomy
rhegmatogenous RD

5 (16.7)

0 (0)

(0.052)*

10 (33.4)

5 (16.7)

2 = 2.22 (0.136)

5 (16.7)
1 (3.3)

2 (6.7)
0 (0)

2 = 1.46 (0.23)
(1)*

ERM, epiretinal membrane; RD, retinal detachment; RR, relative risk; an = 46 who require retinal tamponade; *Fishers exact test was used
as more than 20% of celled have expected frequency less than 5.
Table 2 The mean visual acuity before and after intervention
Parameter

Before
intervention

After
intervention

t = 1.81a

Visual acuity of the first group (logMAR) (n = 30)

Minimummaximum

0.030.4

0.020.32

Mean SD

0.16 0.11

0.12 0.07

Median

0.10

0.11
Z = 1.85b

Visual acuity of the second group (logMAR) (n = 30)

Test of
significance

Minimummaximum

0.030.4

Mean SD
Median

0.09 0.08
0.06

P-value
0.08

0.064

00.4
0.13 0.11
0.09

t = Paired t-test; bZ = Wilcoxon signed-rank test.

Table 3 Functional outcome of the use of high-speed 23 G vitreous cutters shaving versus bimanual surgery
Visual acuity after 6 months

Shaving (n = 30 eyes) [n (%)]

Bimanual (n = 30 eyes) [n (%)]

Test of significance (P-value)

2 = 1.24 (P = 0.54)

Improved by 2 lines or more

12 (40)

14 (46.7)

Remained the same

Worsened by 2 lines or more

6 (20)
12 (40)

8 (26.7)
8 (26.7)

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A comparative study of 23 G vitrectomy Lolah and Shaarawy 217

Discussion
The reported intraoperative and postoperative
complications found during vitrectomy for proliferative
diabetic retinopathy (PDR) have been higher than
those during vitrectomy for other indications [12].
The introduction of microincison vitrectomy surgery
(MIVS) is the most impressive evolution in retinal
surgery [13,14], especially for diabetic TRD cases,
which are considered to be ideal for using small-gauge
vitrectomy [15].
Chandelier light probes of 25 and 27 G provide us
hands-free illumination of the vitreous cavity; it can
be placed inferiorly or elsewhere according to the
surgeons preference [16].
Our study discusses the benefits of using bimanual
vitrectomy with chandelier endoillumination in
challenging cases of diabetic TRD in comparison
with the standard 23 G vitrectomy. The anatomical
outcomes revealed better results for bimanual
vitrectomy.
Although the difference in the functional outcome was
not significant, it is still better for bimanual vitrectomy.
The current study showed that BCVA at 6 months
after final vitrectomy was better than preoperative
BCVA after both traditional 23 G vitrectomy and
bimanual vitrectomy, but the difference was still not
significant. The bimanual vitrectomy group showed
better anatomical outcomes with easier complete
removal of the ERMs and less complications.
The retinal manipulation time was less in the bimanual
vitrectomy group, with difference in the percentages of
type of intraocular tamponade.
Many studies reported that transconjunctival MIVS
for diabetic vitrectomy has several advantages over
conventional 20 G instrumentations [17].
In the current study, we usually used the cutter in
membrane peeling instead of forceps or end-gripping
in group I. Charles [18] described using a small-gauge
cutter for membrane dissection, which was called
cutter delamination.
McLeod
and
James
[19]
described
the
viscodelamination technique in the 20 G using
hydraulic force to overcome the strongly adherent
premature fibrovascular membranes from the retina
in diabetic cases. However, the hydraulic force may
tear the retina and intervene the viscoelastic into the
subretinal space.

The vitrectomy system in our study used the footcontrolled peristaltic pump instead of the venturi pump.
The EVRS retinal detachment study demonstrated
better outcomes with a flow-based peristaltic system
compared with vacuum-based venturi systems
(P=0.006) in retinal detachment surgery [20].
In group II (bimanual vitrectomy) of the current study
we used curved 23 G scissors and end-gripping forceps,
whereas Eckardt [21] reported not needing scissors in
the bimanual approach, as he could perform the entire
procedure with cutters. However, we believe that the
scissors, especially for complex membranes, should still
be used. Moreover, the cutter-only approach is highly
risky in diabetic cases.
A comparative study between the optical fiber-free
intravitreal surgery system (OFFISS) and traditional
vitrectomy in eyes with severe PDR was conducted,
and it reported full attachment of the retina for all eyes
using the bimanual approach 6 months postoperatively
[22], which is similar to the results in our bimanual
group.
BCVA of 19 of the 22 eyes in the OFFISS group had
improved by two lines or more compared with the
control group (17of the 22 eyes). In our study, 14 out of
30 (46.7%) eyes improved by two lines in the bimanual
group, compared with 12 out of 30 (40%) eyes in the
traditional 23 G group. There are many factors affecting
the functional outcome, such as the duration of retinal
detachment and vascularity of the retina.
The anatomical outcome in our study revealed fewer
iatrogenic breaks in the bimanual approach group,
with no statistically significant difference between
the two groups. The use of gas and air was more
than the use of silicon in the bimanual vitrectomy
group, denoting less surgical complications.
According to the OFFISS study, there was no
significant difference in surgical complications
between the bimanual group and the traditional
vitrectomy group [22].
We consider that bimanual vitrectomy for diabetic
cases is safer and effective during complicated surgical
manipulations compared with the traditional vitrectomy
system, in agreement with the OFFISS study.
Iatrogenic breaks in our study occurred in 10 (33.4%)
out of 30 eyes in the traditional 23 G vitrectomy group
compared with five (16.7%) eyes only in the bimanual
vitrectomy group, with no statistically significant
difference.
Issa et al. [23] stated that iatrogenic retinal breaks
found during 23 and 20 G vitrectomy for PDR were as

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218 Journal of Egyptian Ophthalmological Society

follows: six (7%) eyes in the 23 G group compared with

16 (18.8%) in the 20 G group (P = 0.04).
It was reported by Farouk and colleagues that 14.5%
of 200 eyes operated upon using 25 G for PDR had
retinal breaks, with the rate rising to 31.5% in those
requiring dissection of membranes [23].
Our rate of postoperative retinal detachment was low
in both groups, at 3.3% in the traditional 23 G group
and 0% in the bimanual vitrectomy group compared
with a study by Issa and colleagues in which the rate
was 1% in all groups [24]. This difference in rates
was due to different number of eyes included in the
study.
Another study using bimanual vitrectomy reported
complete retinal reattachment in 62 (93%) eyes and
stabilized or improved vision in 51 (72%) eyes, with no
unique complications, such as incision-related retinal
tears [25].
Removing all traction on the retinal surface mostly
affected the percentage and type of tamponade used, as
we found in the bimanual vitrectomy group.
As regards post-25 G vitrectomy complications,
Ozone et al. [26] reported vitreous hemorrhage
in 36 (22%) eyes, retinal detachment in two (1%)
eyes, and neovascular glaucoma in 12 (7%) eyes. No
endophthalmitis developed.
There was no incidence of neovascular glaucoma or
endophthalmitis in our study. There was one eye with
postoperative retinal detachment in the 23 G group
and 0 eyes in the bimanual group.

Acknowledgements

The authors thank Dr Heba El Weshahi, Lecturer of

Biostatistics and Community Medicine in the Faculty of
Medicine in Alexandria University for the statistical work
of the study.
Conflicts of interest

There are no conflicts of interest.

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