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Patience and practice with endoscopes

By Courtney Crawford, MD as Interviewed by Michael A. Klufas, MD

Briefly describe your approach to these advanced PVR cases.

Generally, these advanced proliferative vitreoretinopathy (PVR) cases are end-stage in nature. Many patients have had multiple surgeries with poor vision at baseline. Some patients have ocular hypotony secondary to ciliary body shutdown and/or anterior PVR proliferation. Surgeons operating in hypotony-related anterior PVR cases such as this one achieve the greatest visualization via an endoscope. Deep scleral depression with direct visualization of the pars plana/vitreous base does not always allow successful removal of all anterior PVR membranes and requires a skilled assistant. The endoscope provides the advantage of a highly magnified view of the vitreous base and ciliary body complex without the need for an assistant in the OR. Additionally, with the superior view and control by the surgeon, the surgeon can use angled scissors, forceps, and diathermy in addition to the cutter to better facilitate complete anterior PVR removal.

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Endoscopic PPV for Hypotony

Most of us do not use an endoscope regularly. Any early tips and tricks for the newbie?

The key to the endoscope is patience and practice. It is impossible to maximize all the nuances of endoscopy during a surgeon’s first procedure with an endoscope. I suggest that surgeons who wish to learn the finer points of endoscopy begin to familiarize themselves with an endoscope during the end of routine pseudophakic cases. They should orient themselves by using landmarks such as the optic nerve, identify the opposite hand instrument (vitrector/forceps), and view the vitreous base in 360°. After a certain degree of comfort is achieved, the surgeon should progress to using the endoscope for cyclophotocoagulation of the ciliary body processes for primary open-angle glaucoma. Additionally, use the endoscope for “poor view” cases such as those involving endophthalmitis, and in retinal detachment and anterior PVR cases.

Surgeons managing small pupil cases, congenital anterior segment abnormalities, chronic inflammation with band keratopathy, and the aforementioned pathologies may benefit from use of endoscopic visualization. With each use, the once-clumsy endoscope will make more sense in the surgeon’s hands, and he or she will see the true benefit of learning how endoscopy aids surgery.

What are the pros and cons of 19-gauge and 23-gauge endoscopes? Can other ophthalmologic subspecialties find uses for this instrument to make an endoscope a cost-effective purchase?

A 19-gauge endoscope has fantastic resolution with 17,000 pixels and a 140° field of view. The disadvantage of the 19-gauge endoscope is the large incision needed for use. Fortunately, the 23-gauge endoscope works quite nicely for routine endophthalmitis and retinal detachment cases; however, it has a resolution of only 6,000 pixels, which limits high magnification of the vitreous base for anterior PVR peeling.

If an OR is considering an endoscope purchase, glaucoma specialists may find endocyclophotocoagulation, which can be performed from either an anterior or posterior approach useful. Corneal specialists may also appreciate an instrument that decreases the need for a temporary keratoprosthesis in cases in which the anterior segment view is compromised.

Courtney Crawford, MD FACS
• retina surgeon, North Texas Retina Consultants, Dallas–Fort Worth; assistant professor of surgery, Uniformed Services University
• financial interest: none disclosed;

Section Editor Michael A. Klufas, MD
• retina chief,
• vitreoretinal surgeon, Mid Atlantic Retina; assistant professor of ophthalmology, Thomas Jefferson University, both in Philadelphia, Pa.
• financial interest: consultant, Allergan, FCI Ophthalmics


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About New Retina MD

New Retina MD delivers cutting-edge content to retina specialists in their first 15 years of practice. Each issue provides fresh insight from younger physicians plus established mentors on clinical and nonclinical issues affecting ophthalmologists in the earlier stages of their careers. NRMD features surgical pearls, clinical research endeavors, practice management, medical reimbursement and policy, continuing educational requirements, financial planning, innovations, and more.