Reply

To the Editor:

We thank the authors for recognizing the value of limbus-based vitrectomy in their letter entitled “Limbal Approach in Vitreoretinal Surgery in Retinopathy of Prematurity and Chronic Uveitis—Our Experience.¹” In addition to our article, herein,² we previously reported using limbus-based vitrectomy in children and infants where pars plana incisions may best be avoided after retinal detachment, trauma, uveitis, and aphakic glaucoma.^3,4 In each of these situations, the entire vitrectomy was successfully performed using cannulas and small-gauge instruments only with limbal wounds. Like our colleagues, we also noted that postoperative recovery was improved.⁵

Limbus-based vitrectomy was performed in retinopathy of prematurity before the development of small-gauge trocar cannulas.^6–8 At Stanford, we routinely use limbal wounds, now with valved cannulas, in complicated pediatric retinal detachments in scenarios where the status of the anterior retina is unclear: stage 4/5 retinopathy of prematurity, familial exudative vitreoretinopathy, persistent fetal vasculature syndrome, closed funnel detachments in the setting of trauma, etc. The location of cannula placement is thoughtfully planned to maximize exposure, and often, the entire case may be performed through the limbus and reduces iatrogenic retinal breaks, as described in our colleagues’ letter.

In the presence of cyclitic membranes in cases of chronic uveitis or proliferative vitreoretinopathy, for example, we use preoperative ultrasound to determine optimal wound location, and frequently, one or more of the trocar cannulas are safely placed at the limbus. As vitrectomy fluidics and instrumentation continue to improve, we expect more surgeons to adopt a Limbus-based approach in cases with a compromised pars plicata or pars plana.