Incisions are critical in small gauge vitrectomy. This technique explores if an incision performed parallel to the scleral fibers could potentially seal quicker.

New 23-gauge technology has enabled surgeons to take the cutter extremely close to the retina surface and almost shave membranes without having to use specialised scissors, etc. Alcon has been able to move the port of their 23-gauge probe 50% closer to the distal tip than standard 20-gauge probes. This is extremely useful for diabetic cases which have membranes attached to the retinal surface.

Phakic refracive lens (PRL) has been designed for high myopic patients. It has to be positioned between the iris and the lens. It can potentially move and break the zonula.

For this reason it is not infrequent that after years it falls into the vitreous chamber. In my opinion the best way for removing it is a combined phaco-vitrectomy surgery. The advantages of the phaco procedure are two:

1. The phaco procedure corrects the refractive error.
2. After the phaco a posterior capsulorexis creates a way to bring the PRL from Vitreous Chamber (VC) into the anterior chamber and remove it through the corneal tunnel.

The vitrectomy is perfomed using a 23 gauge system. This is much less traumatic and there is no residual astigmathism, so the refractive error can be perfectly corrected. In this particular case a 28 y.o.w. presented a 15 diopters myopia with PRL in VC. There is a break of the zonula inferiorly. The difficult part of the surgery is to create the anterior and posterior rexis in the center of the capsular bag. The zonular tension ring must be inserted after the posterior rexis because if the bag is too tense it could break during the rexis.

It is not necessary, in my opinion, to remove all the vitreous but just a limited vitrectomy around the PRL. It is very easy to bring it into the anterior chamber and remove it through the corneal tunnel. This kind of surgery is completely sutureless. The day after the patients VA was 20/25 without correction.

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Uveal melanoma is the most common primary malignancy of the eye. Its treatment must look for saving the patient’s life, and in second place preserve the visual function and the cosmetic appearance of the eye.

Endoresection has been described as a primary or salvage procedure in tumors that are not expected to do well after more conventional forms of treatment. Rapid growing melanomas in the posterior pole usually are thicker compared with the thickness at the base, because of morbility of radiotherapy this high tumors usually are enucleated; indications of endoresection in this case have been described. Local recurrence of tumors after brachytherapy, TTT or photocoagulation, have been described as well as one of the possible indication of endoresection. This technique has also been used in patients in attempt to preserve central vision in his their only useful eye.

Inclusion criteria are, for primary procedures: Tumors thickness 8 mm or higher, with base less than 15 mm, posterior tumors not exceeding the equatorial area.

The surgical technique varies depending on the degree of retinal involvement by the tumor. If the tumor has not invaded the retina, a vitrectomy with panoramic viewing system with 130º precornal lens is performed, followed by posterior hyaloid dissection, 120º anterior retinotomy, and 810-nm diode laser endophotocoagulation 2mm beyon the tumor margins, using continuous mode of the laser and 600 to 800 mW. Laser photocoagulation is followed by removal of the melanoma with the vitrectomy probe using bimanual technique. The retina is lifted with forceps and held away from the vitrectomy probe. The intraocular pressure (IOP) was increased to 100 mmHg with the infusion global control connected to the vitrectomy surgical system to inhibit blooding of choroidal vessels. Patient’s arterial pressure remains in normal values. Tumor excision is begun at the tumoral apex until the scleral bed inside the circle delineated by the laser is free of tumor. The cellular remnants at the scleral bed are photocoagulated with the endodiode laser probe. The retina is reattached with liquid perfluorocarbon and air. Laser retinopexy endophotocoagulation is performed at the limits of the retinotomy and was followed by fluid-air exchange and silicone oil-air exchange.

If the tumor has invaded the retina, the diode laser is applied through the retina, and tumor and the retina are removed together. Adjunctive treatment with brachytherapy was performed. Rutenium 106 plaque is sutured to sclera to cover as much of the coloboma as possible. The plaque is removed after a dose of approximately 80 Gy had been delivered to a depth of 3 mm.

Silicone oil is removed at 3 months.

In conclusion, endoresection in high uveal melanoma may conserve the eye and vision while other forms of conservative treatment are likely to cause severe ocular complications, with enucleation probably the only alternative treatment. Medium- time follow-up of these patients doesn’t reveal higher risk of metastasis or local recurrence, and survival rates are similar to other techniques despite the difficult of comparison because of the unusual presentation of this kind of melanoma. Further studies and longer follow-up are needed to establish safety of this procedure, considering endoresection as a standard of care and not as an investigational technique.

Endoscopes enable the surgeons to observe from the posterior pole to the Ora Seratta without scleral depression. It also enables you to check retinal breaks and to shave peripheral vitreous easily, safely, and completely.