 Hello again, I'm Dr. Andrew Davis and I work in a local retina practice here, solid retina, and I'm going to be showing you all today a very brief edit of a 25 gauge vatrectomy of a vitreous hemorrhage associated with a small retinal tear. So the whole purpose of doing posterior segment surgery is to try to get into the back of the eye as minimally invasive as possible to be able to diagnose or correct or treat or prevent some retinal or vitreous or other posterior segment problem. To do that we introduce into the side of the eye the pars plana three small cannulas. It used to be that it was done 23 gauge and now we have 25 gauge. They're even working towards smaller bore cannulas and the whole thought process of using smaller cannulas in our vatrectomies is that by doing so there's less trauma to the eye. The eye maintained its integrity and its pressure after the surgeries and hopefully there'll be less inflammation, less chance for secondary complications associated with the surgery. So in this video presentation you're going to see this 25 gauge entry into the eye and and then the surgery that follows. In the first part of the image here we're giving a peri bulbar anesthetic. This is done using small 0.124 seps and blunt Westcott scissors and a small opening is is created into the subtenon space and then a blunt cannula is used to introduce the anesthetic. Same anesthetic used in a retro bulbar block into the subtenon space posteriorly near the optic nerve and this provides adequate anesthesia for the vatrectomy surgery. A point is then measured approximately three or 3.5 millimeters posterior to the limbus and you'll see that the first trocar cannula will be introduced into the eye. That measurement three or 3.5 depends on if the patient is fake or pseudo fake. This patient is fake therefore the measurement was done at 3.5 millimeters. There's two different ways that the cannula can be introduced the trocar cannula. The cannula sits over a very sharp trocar. One can be as you saw in this in this or as you're seeing in this video introduced directly into the posterior segment of the eye. Another common way that is done it's will be done through a beveled approach using a three level or triplanar insertion similar to how a cornea incision is done during cataract surgery. In this case the surgery we went straight into the into the posterior segment of the eye. This is being done in fear temporal and the inferior temporal cannula is specifically set in place for the infusion line. We infuse a fluid into the back of the eye and that maintains the shape and the integrity of the eye during the surgery so the eye doesn't collapse. The fluid infusion into the eye can also be used if there's hemorrhaging as a tamponade to decrease the hemorrhaging. So next you're going to see that the infusion line is inserted. You run the infusion for a small bit before its insertion to make sure there aren't any air bubbles in the line. You stop that infusion and then insert the infusion line through your inferior temporal cannula. At this point the light pipe will be used to verify that the tip of the cannula is located in the vitreous cavity. You certainly would not want to put the cannula behind the coroid or behind the retina and then run the infusion into it. So that visualization of the cannula within the vitreous cavity via the pupillary aperture and the light pipe is a very important step and then you'll see now as we insert two other cannulas, superior nasal and superior temporally. A point is measured again 3.5 millimeters posterior to the limbus. The trocher cannula is inserted directly into the vitreous cavity. In this case we're using valve cannulas. This is the superior nasal cannula here. This is the superior temporal. Those are the two candidates through which the small 25 gauge instruments are placed into the posterior segment of the eye. In this part of the video you're seeing where the vitreous cutter has been inserted via the superior temporal cannula and we're starting to remove the vitreous fluid as well as hemorrhage that can be visualized in the video here. You'll also see where a posterior vitreous separation is created or a posterior vitreous detachment is created. This will be elevated. You can see the margin of the elevation here and extended into the periphery. This step of any vitrectomy surgery is very important to create or verify that there is a posterior vitreous separation. The vitreous is a wonderful part of the back of the eye but it can cause a lot of problems. Retinal terrors, a medium for growth of neovascularization and diabetic patients or retinal vein occlusion patients. It can cause traction with retinal tears or retinal detachments. Now you're going to see where a small 25 gauge soft tip extrusion cannula is being inserted to remove in a very delicate and precise manner blood that is laying on top of the retina or pre-retinal hemorrhage that was not able to be removed with the vitreous cutter for the fact that you don't want to get the vitreous cutter that close to the retina. So now you'll have seen where intraocular laser was done to surround the area of the retinal tear and barricade that area so that the retinal tear can't get any bigger or that if there were chance for detachment in there that detachment couldn't enlarge. The last part of the video you'll see where there scleral depression was done to ensure that there weren't any other retinal tears and now you will see where each of the cannulas will be removed. The advantage of small gauge or vitrectomy especially 25 gauge or smaller vitrectomy is that the sclerotomies tend to remain sealed so that when you check the intraocular pressure there's no leaking of vitreous fluid or fluid out of the eye and the eye maintains its integrity. So again my name is Dr. Andrew Davis. I've hoped that you found this small tutorial to be helpful as an introduction to small gauge vitrectomy surgery.