Vitreous history in the making

Take-home

Much has changed since the early days of vitreous surgery, as exemplified in ophthalmic texts.

Our Ophthalmic Heritage

No mention of vitreous surgery is found in the 1892 edition of “Diseases of the Eye,” by G.E. deSchweinitz, MD, then professor of ophthalmology at the University of Pennsylvania, Philadelphia. In the 1910 edition of the book, by John Elmer Weeks, MD, professor of ophthalmology at New York University, Dr. Weeks comments on vitreous surgery in two situations:

• If vitreous is encountered during a cataract operation, it may be excised if only to allow the lips of the wound to be approximated.

• If vitreous opacity is dense and immobile, it may be incised.

Short of these two states, little to no surgery on the vitreous had been done. This was primarily due to the belief that it was dangerous, because of a probability or possibility of injuring the surrounding tissues, such as the retina.

Fast forward: In 1968, David Kasner, MD, an ophthalmologist at Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, and a respected teacher of cataract surgery, excised the vitreous in a case of primary amyloidosis. In this open-sky technique, he also showed that vitreous excision postcataract surgery was well tolerated by the eye. This technique was fraught with potential complications: expulsive hemorrhages and iris and corneal damages, as well as needing to render the patient aphakic by removing the lens.

Dr. MachemerWith these thoughts in mind, Robert Machemer, MD (1933-2009), was then doing research to develop a closed system for operating on the vitreous body. The technique became known as pars plana vitrectomy. Dr. Machemer and his associates, Edward Norton, MD, and Thomas Aaberg, MD, would report on their early experiences with vitrectomies in 1969 and 1970. Most of these patients had vitreous hemorrhages. Later on, they would operate on patients with proliferative diabetes.

In 1979, Dr. Machemer and Dr. Aaberg from Wisconsin co-authored a book about vitreous surgery. The same year this book was published, Dr. Machemer moved to Duke University, Durham, NC, where he became chairman of the Department of Ophthalmology. In 2003, the American Academy of Ophthalmology honored Dr. Machemer as the inaugural recipient of its Laureate Recognition Award.

How times have changed

The vitreous infusion suction cutter (VISC) was the name of the original instrument that Dr. Machemer developed. Irrigation, aspiration, and cutting all were done within this single-port, 19-gauge instrument. (Photo courtesy of Norman B. Medow, MD, FACS)

Much has changed since these early days of vitreous surgery.

Now, vitrectomies are performed using a 23- and/or 25-gauge, three-port system. The earliest vitrectomies were used for vitreous hemorrhage, whereas now vitrectomies are coupled with membranectomy, retinotomy, and retinectomy-all of which are coupled with either the use of silicon oil replacements or heavy gases to aid in securing the retina in place postoperatively.

Only time tell what advances over the next 20 years will aid vitrectomy specialists with this surgery and with fewer complications.

Norman B. Medow, MD, FACS, is editor of the Our Ophthalmic Heritage column. He is director, pediatric ophthalmology and strabismus, Montefiore Hospital Medical Center, and professor of ophthalmology and pediatrics, Albert Einstein College of Medicine, Bronx, NY. He did not indicate a financial interest in the subject matter.

Reference

Kasner D, Miller GR, Taylor WH, Sever RJ, Norton EW. Surgical treatment of amyloidosis of the vitreous. Trans Am Acad Ophthalmol Otolaryngol. 1968;72:410-418.

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