ENDOSCOPY IN 2003 Claude Boscher, MD I . endoscopic viewing at the anterior vitreous base (AVB) A. by pass anterior segment B.

instant evaluation of entire vitreous cavity from capsulozonular system to optic disc, and subretinal space eventually C. switching from panoramic to high magnification viewing in a few seconds (pictures 1 and 2) D. both frontal and tangential approach without need for scleral indentation E. detailed enhancement of the two parts of AVB : 1) anterior zonular , from Wieger ligament to mid pars plana 2) posterior , from mid pars plana to vitreoretinal juncture (pictures 3 and 4) F. detailed enhancement of pigmented and non pigmented clumps at the ciliary margin (stem cells ?), inside the vitreous cortex , at the vitreoretinal juncture , on the retinal surface G. detailed enhancement of early vitreous and retinal contraction at the vitreoretinal juncture , and of early ERMs and star folds. H. high magnification evidence of persisting vitreous cortex leading to uncomplete flattening of anterior retina during exchanges (under air and/or PFCL) I. high magnification evidence of pigment dispersion during cryopexy. II . developments in instrumentation for routine use of fiber optics probes at the AVB Sterilization problems, akward setting and handiness, fragility of probes, overestimation of training difficulties, advertising for anecdotal use in case of non transparent anterior segment only, have delayed comprehension and faisability of routine use of endoscopy.

1. autoclavability (18mn at 118C) 2. strong sheath 3. easy plug in console and start 4. design for assistance in orientation inside the vitreous cavity 5. enhanced image sharpness with 1)440 000 pixels videocamera with white balance function, adjustable luminosity, adjustable focus 2) green endoillumination light optional 4) improved visualization of superior ciliary body and retina 6. highly performing integrated pulse /continuous 532 nm laser 7. bimanual surgery 8 .smaller probe diameter : 1mm 9 .world wide maintenance assistance centers III . routine endoscopic control of the vitrectomy procedure - direct visualization of every step with one single probe, beeing used as an endoillumination device, as a viewing device, and as an endolaser - adaptation of the procedure to every individual case A. Setting up the procedure 1. placement of sclerotomies : disposal and distance 2.penetration of infusion line and instruments inside the vitreous cavity Advantages: avoid wrong tracks , subciliary/retinal infusion , ciliary/retinal perforation Limitations : no control of introduction of endoscope itself ; massive fresh blood on probe tip may prevent viewing,i.e. trauma C.Vitrectomy at the Vitreous Base 1.360hyaloido-capsulo-zonular dissection, ciliary dissection , wash out of the ciliary margin allow total disconnexion from

anterior segment structures ,cleansing of blood, fibrin, pus and cell migration ` Advantages : treatment of aphakic/pseudophakic retinal detachment , treatment and prevention of anterior PVR, cyclitic membranes and hypotony , prevention of anteriorfibrovascular proliferation Limitations : around 10% iatrogenic lens injury in phakic eyes ; necessity of perfect knowledge and control of aspiration flow of vitrectomy machine to avoid zonular or capsular injury 2. High magnification peeling of the posterior border of the AVB allows removal of scaffold for epiretinal membranes and star folds formation , removal of migrated deposits from retinal tears and ciliary margin at the vitreoretinal juncture and over the retinal surface , identification of early retinal rigidity and shortening . Advantages : prevention and treatment of PVR Limitations : additional intraoperative duration; higher risk of iatrogenic retinal tears requiring perfect knowledge and control of aspiration flow of vitrectomy machine 3.Maneuvers at posterior pole creation of PVD, epiretinal membrane peeling, ILM peeling under adjuvants, optic disc neurotomy Limitations: training with acquisition of pseudodepth perception and stereopsis ; ILM peeling without adjuvants is impossible with fiber optics probes 4. Subretinal maneuvers drainage of subretinal fluid and liquefied blood , peeling of subretinal membranes and removal of blood clots, PFCL bubbles Limitations : training with acquisition of pseudodepth perception and stereopsis 5. Cryopexy high magnification evidences dispersion of pigments during cryo and their removal Advantage : prevention of PVR

6. endodiathermy, retinotomy, retinectomy Limitation : training with acquisition of pseudodepth perception and stereopsis` 7.Endolaser integrated fiber inside the endoscopic probe ensures constant perpendicularity of the probe to the target Advantages : any area of the fundus , including the ciliary body, can be easily reached ; intraoperative PRP until ora serrata, treatment of neovascular glaucoma and severe resistant glaucoma . 8.Tamponade exchanges fluid/air exchange, PFCL/air exchange, PFCL / silicone exchange a. bypassing the anterior segment b. high magnification evidence of small PFCL bubbles at the border of the main bubble and prevention of passage under the retina ; c. evidence of emulsified silicone oil droplets trapped into the zonular system, the ciliary valleys , on the retinal surface Advantages : no residual PFCL, no persisting glaucoma after silicone oil removal 9.Cleansing of sclerotomies Advantages : prevention of fibrovascular proliferation, retinal detachment after vitrectomy, failure of vitrectomy for retinal detachment 10. Management of intraoperative difficulties, incidents and complications of conventional vitrectomy a.poor viewing corneal transparency, pupillary dilatation, capsular bag and IOL, cataract, unplanned incident b. subciliary, subretinal infusion c. incarcerations at sclerotomy site d. intraoperative bleeding IV . current state of clinical studies

A.severe Proliferative Diabetic Retinopathy : prospective consecutive study 1.60 consecutive phakic eyes NVC3 and 4(DRS3,1988),medium age 39 years , follow up 6 months -10 years 2.no case of Anterior Fibro Vascular Proliferation and neovascular glaucoma 3. 1 eye with recurrent intra vitreal hemorrage future perspective : early vitrectomy, with less posterior dissection problems , as anterior causes of post operative morbidity can be reduced. B. aphakic/pseudophakic RD : prospective consecutive study 1.71 eyes ,follow up 6 months-4 years 2. PVR 0 : 11% , PVR A+B : 42% , PVR C : 46% 3. primary endoscopy : 73% , endoscopy after failure of conventional surgery(ies) : 27% 4.retinal reapplication : 68/71, 96% 5.retinal reapplication after primary endoscopy : 52/52 , 100% 6.retinal reapplication after secondary endoscopy : 16/19 , 84% future perspective : vitrectomy without buckle C. PVR 1. established PVR C : prospective consecutive study 55 eyes , follow up 6 months-4 years retinal reattachment : 53/55, 96% 2. PVR A and B : prospective consecutive study 50 eyes, follow up 6 months-4 years retinal reattachment : 48/50 , 96% future perspective : vitrectomy without buckle D. lens/IOL dislocation 1.85 consecutive eyes , follow up 6 months-10 years 2. one case of RD after vitrectomy E. endophthalmitis 1. informations on the severity of tissue damages in eyes with LP only at presentation 2.iatrogenicity of vitrectomy in these cases

3. extensive dissection , although made possible with endoscopic viewing, must not be performed future perspective : earlier vitrectomy F.expulsive hemorrage 1. treatment and prevention of PVR 2.associated damages make long term prognosis reserved . G.hypotony and cyclitic membranes 1. 9 eyes , dissection of ciliary body 2. intraocular pressure was elevated postoperatively in 7 (78%) 3. it is normalized in 3 (33%) V. clinical investigation in submacular surgery for treatment of ARMD A . creation of macular detachment through retinotomy B. application of laser on pigment epithelium under direct viewing endoscopic control after i.V.injection of ICG C. in cases of visible and occult neovascular membranes conclusion Clinical studies illustrate that endoscopy is not an anecdotal tool in vitreoretinal surgery, but an illumination and viewing device which can be used routinely, according to a deliberate elaborated different approach of AVB , oriented towards prevention of anterior PVR and of complications and failures of vitrectomy . New technology will facilitate training and routine utilization of endoscopy in vitreoretinal surgery. Clinical investigation of endoscopic submacular surgery is still underway . References
1) Thorpe H. Ocular endoscope: instrument for removal of intravitreous non magnetic foreignbodies. Trans Am.Acad.Oph.Otolaryngol. 1934, 39: 422.

2) Norris J.L., Cleasby G.W., Nakanishi A.S., Martin L.J. Intraocular endoscopic surgery. Am.J.Ophthalmol. 1981, 91, 5: 603. 3) Koch F., Spitznas M. Video endoscopic vitreous surgery. Ophthalmo.Chirurgie. 1990, 2: 70 4) Uram M. Laser endoscope in the management of proliferative vitreoretinopathy. Ophthalmology. 1993, 101, 8: 1404. 5) Boscher C, Lebuisson D.A. , Lean J.S.Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lenses . Graefes Arch Clin Exp Ophthalmol ,1998, 236 :115. 6 ) Boscher C. Endoscopic Vitreoretinal Surgery of the Injured Eye . In Vitreoretinal Surgery of the Injured Eye , D.Virgil Alfaro III and Peter E . Liggett , Lippincott-Raven Publishers , 1999 , chapter 25: 301 7 ) Boscher C. Endoscopy, in : Ocular Trauma :The Essentials,,F.Khun,Thiemes, NY, 2001, 414 - 418 8) Boscher C . Endoscopy for Anterior Proliferative Vitreoretinopathy, 2001 AAO Subspecialty Day , Retina 2001 : A Retina Odyssey ,151-157. 9) Boscher C , Cathelineau C , Amar R, Cathelineau G.Hyaloidocapsular dissection for severe Proliferative Diabetic Retinopathy , combined Retina and Vitreous Societies meeting , San Francisco , Sept 28-oct 3, 2002, abstract p 118. 10) Boscher C, Amar R , Lebuisson D A : endoscopy assisted vitrectomy ( eav) for lens / IOL dislocation, poster, combined Retina and Vitreous Societies meeting , San Francisco , Sept 28-oct 3, 2002, abstract p 208 11) Boscher C, Amar R , Lebuisson D A : endoscopy assisted vitrectomy ( eav) for severe endophthalmitis with visual acuity limited to Light Perception, poster, combined Retina and Vitreous Societies meeting , San Francisco , Sept 28-oct 3, 2002, abstract p 256 12) Boscher C, Amar R , Lebuisson D A : endoscopy assisted vitrectomy ( eav) for expulsive hemorrage , poster, combined Retina and Vitreous Societies meeting , San Francisco , Sept 28-oct 3, 2002, abstract p 196 13) Hammer M.E. ,Sanderson Grizzard W. Endoscopy for evalauation and treatment of the ciliary body in hypotony, Retina , 2003 , vol 23,1, 30-36. 14) Koch F, Hattenbach L, Kacer B, Augustin A, Luloh P : advancements in pigment epithelial endoscopic laser surgery (PEELS)for treatment of CNVs in ARMD, combined Retina and Vitreous Societies meeting , San Francisco , Sept 28-oct 3, 2002, abstract p 181

- current clinical experience - endoscopy as a routine part of the retinal armentorium