Expert perspectives on the evolution of retina practice, procedures, technologies and instrumentation.
Tamara Lee Lenis, MD, PhD; Anton Orlin, MD; Donald J. D’Amico, MD, FASRS
The development of vitrectomy—a notably disruptive innovation in ophthalmic surgery—depended on many innovative surgeons, researchers, skilled instrument designers, new and improved ocular diagnostic technologies, and a host of collaborations, breakthroughs, and failures. Although the term vitrectomy itself most properly refers to the removal of the vitreous, it has come to denote the increasing array of maneuvers performed within the vitreous cavity with the aim of improving vision, principally by improving or restoring retinal function, as well as additional uses such as repositioning of intraocular lenses, removing dislocated cataract fragments, securing biopsies and cultures from the eye, and many others. In this brief review of the development of this remarkable field of surgery, only a very few of its many important contributors and significant advances can be acknowledged. With the greatest respect for all involved, it is clear that vitrectomy in its modern form had its most significant developmental inflection due to the transformational work and insights of Dr. Robert Machemer beginning in the latter part of the 20th century.[1,2]
A modern understanding of ophthalmology and a refined approach to the vitreous and retina set the stage for the introduction of vitrectomy in the 20th century. Descriptions of vitrectomy in the 17th and 18th centuries include anterior approaches for surgical removal of the vitreous for blind painful eyes (Anton Nuck, John Warren).[3,4] In the late 1800s and early 1900s, a pars plana approach was adopted to cut vitreous membranes in the setting of vitreous hemorrhage and tractional retinal detachment (Albrecht von Graefe, Charles Bull, Eugen von Hippel, Rudolph Deutschmann).[5-8] Around the turn of the 19th century, we also learned that removal of vitreous does not require replacement with vitreous, but that saline is sufficient (Anton Elschnig). In the mid-1800s, pioneers like Hermann von Helmholtz allowed us to adequately visualize the retina for the first time with ophthalmoscopy.
Tsugio Dodo performed the first open sky vitrectomy with scissors for vitreous hemorrhage in the 1950s, and the significant advancements in this technique by David Kasner in the following decade a created fertile ground for a major breakthrough in vitrectomy.[11-12] During this same period, on a parallel and immensely important track, innovative surgeons notably including Jules Gonin and Charles Schepens developed and refined techniques for successful retinal detachment repair.[13,14]
In the 1960s, Robert Machemer, who is credited with the transition to modern vitrectomy, had the audacity to apply a drill bit to an egg yolk in his home and discover that the vitreous gel could be cut and removed in pieces with a mechanical, rather than manual removal process. This led to transitions from open sky to closed and pressure-controlled approaches, allowing Machemer to perform the first pars plana vitrectomy in 1970. Parallel development of the Vitrophage® by Gholam Peyman in 1971 described successful removal of vitreous hemorrhage using pars plana vitrectomy with a 3-mirror lens and operating microscope.
Multiple iterations of the vitreous infusion suction cutter (VISC)®, including Nicholas Douvas’ RotoExtractor®, Conor O’Malley’s Vitritome® and Jay Federman’s suction infusion tissue extractor (SITE)®, allowed for enhancements in simultaneous infusion, cutting and aspiration.[17-19] With additional innovations, one-port led to 20-gauge three-port, the VISC® led to the Ocutome®, and foot pedals and enhanced viewing systems allowed for better ergonomics, access, illumination, and bimanual approaches (Jean Marie Parel, Ralph Heintz, and Gholam Peyman).[20-23]
Steve Charles greatly refined vitrectomy with improved fluidics, linear (proportional) suction, fluid-air exchange, and endoillumination; and he would (and continues to) introduce numerous foundational maneuvers in tandem with his inspired instrument refinements. Specifically, in 1983, Steve Charles and Carl Wang designed the first single pulse cut and spring return disposable vitreous cutting probe, which was one of the most important advances in modern vitrectomy technology. Further developments with dual pulses and the recent dual port systems have allowed significantly higher cut rates.
Expansile and long-acting gases, previously used in scleral buckling surgery (Edward Norton, Harvey Lincoff), were later applied to vitrectomy (Steve Charles, Carl Wang, Gary Abrams); continuous air infusion during surgery was another substantial advance (Alexander Brucker).[25-27] The use of perfluorocarbon liquid (PFO), pioneered by Stanley Chang, and the application of retinotomy and retinectomy by Charles and Machemer have allowed vitrectomy to tackle the toughest cases.[24,29-31] Refinements in viewing systems with the AVI® contact lens, the BIOM® non-contact lens, the Resight® non-contact lens, and now 3D digitally assisted vitrectomy (DAVS) systems, have also allowed vitrectomy to reach its modern potential. The transitions from 20-gauge surgery requiring conjunctival incisions to transconjunctival vitrectomy with 23- (Claus Eckardt), to 25- (Eugene DeJuan), and now 27-gauge (Yusuke Oshima) platforms have allowed for decreased complications, shorter operating times, cutter access to tighter surgical planes previously requiring additional instrumentation or bimanual surgery, quicker and smoother postoperative recovery, as well as the development of a host of new microinstruments.[32-34]
The story of vitrectomy is an ever-evolving, deep commitment to technological advancements in the name of safe and successful restoration and preservation of vision. Vitreoretinal surgery has become one of the most elegant and delicate surgeries in medicine, and we have only seen the first chapter. Although it is impossible to recognize all the individuals who have made modern day vitreoretinal surgery possible, we are grateful for their many contributions. Indeed, we honor their work best by our continued commitment to further refine and expand this remarkable surgery.