On the heels of widespread adoption of wideangleviewing systems and new light sourcesfor small-gauge vitrectomy, a variety of chandelierlighting systems have been developedto provide stationary, wide-angle and uniform endoilluminationfor obtaining adequate visualization of theretina during surgery. During the past several years,Synergetics, DORC, and Alcon Laboratories Inc. havemanufactured a variety of chandelier lighting systems,including a single-fiber system available in 25-gauge(Figure 1) and 27-gauge (Figure 2) formats and a separated2-fiber system in a 27-gauge (Figure 3) or 29-gaugemodel (Figure 4).1-4 In some models, the tip of the chandelierlight probes can be placed into the cannula, whileothers require a separate needle to create an additionalsclerotomy for inserting the fiber tip into the vitreouscavity. Generally, chandelier endoillumination with2 optic fibers,1 first described by Eckardt as the twinlightchandelier, is more useful than a single fiber systemfor obtaining homogeneous and more widespreadillumination. The 2-fiber system eliminates the needto reposition the fiber and minimizes the shadow seenwith single-fiber chandelier endoillumination becausethe illumination comes from 2 different directions.2-4,5
Basic roles and Techniques forChandelier Endoillumination
The basic advantages of using chandelier endoilluminationhave been described in several articles.1-7 When
considering retinal phototoxicity, the working distance forlight irradiation is important, and holding the light probeas far away from the retina as possible increases safety.8 Forthis reason, I use the chandelier fiber for most of my cases. Insimple cases such as macular surgery, I hold the chandelierprobe with 1 hand in a manner similar to which I woulduse a light pipe to control the illuminating direction duringsurgery (Figure 5). In addition to the safety advantage, theself-retaining nature of chandelier endoilluminators frees upmy hand from holding a light probe, allowing true bimanualmanipulation during surgery. In retinal detachmentcases, I can perform scleral indentation and achieve morecontrolled and smooth peripheral vitreous base shavingwithout the need for an assistant (Figure 6). For membranedissections in challenging cases, such as diabetic tractionalretinal detachment or proliferative vitreoretinopathy,the freed hand is helpful for holding forceps to grasp themembranes for separation from the retina or for dissectionusing scissors or a cutter (Figure 7). For cases in which I usea self-retaining chandelier system, I prefer to set up the fibersuperiorly—eg, a single fiber at 12 o'clock or dual fibers at2 and 10 o'clock—to make the instrument shadow appearanteriorly and not interfere with the working area view. Notonly is it easy to adjust the optic fiber tips from this angle,but illumination is optimized and glare from the tips of theinstruments is minimized. Thedirection of illumination canbe changed from the posteriorpole to the periphery bychanging the curvature of thechandelier fiber outside theorbit (Figure 8).
ImprovingAnterior ChamberVisualization forPhaco-vitrectomy
Case 1: Corneal Opacity
A 71-year-old woman withcornea opacity and densecataract had a total retinaldetachment in her only seeingright eye (Figure 9A, 9B). Although crystalline lens removalis preferable to improve the fundusvisualization for safer vitrectomy,capsulorrhexis and phacoemulsificationthrough a hazy cornea are verychallenging under the conventionalmicroscopic illumination because ofpoor visibility of the anterior capsule and crystalline lens.To overcome the difficulty to perform phaco in eyes withcorneal haze, retroillumination generated by a chandelierlighting system inserted transconjunctivally into the vitreouscavity is a helpful illumination technique for clearly visualizingthe crystalline lens for safer phacoemulsification surgery(Figure 9C, 9D).9 Once the lens is removed, vitrectomy canbe performed sequentially with the chandelier illuminationas is (scan QR code for video).
Case 2: Dense Vitreous Hemorrhage
A 61-year-old man with a cataracthad dense vitreous hemorrhageand suspicion of traction retinaldetachment due to proliferativediabetic retinopathy in the right eye.A phaco-vitrectomy is preferable inthis patient. However, phacoemulsification surgery may besomewhat challenging because severe vitreous hemorrhageoften obscures the red reflex from the fundus and interfereswith clear visualization of the crystalline lens structure andcapsule during cataract surgery. Similar to Case 1, the use ofa chandelier lighting system to generate retroillumination inthis case can improve visualization of the cataractous lensand its capsule, thereby facilitating safer cataract surgery inselected patients with dense vitreous hemorrhage (Figure10).10 Once the lens is safely removed, vitrectomy can becarried out sequentially under wide-angle fundus viewingwith chandelier illumination as is (scan QR code for video).
Scleral buckling under wide-angle fundusviewing with chandelier illumination
Scleral buckling is a widely prevalent treatment optionfor primary rhegmatogenous retinal detachment, and it hasusually been carried out with the use of binocular ophthalmoscopyvia the aid of a condensing lens. Although mostbuckling procedures are performed sequentially under surgicalmicroscopic viewing, repeated wearing and removal of the binocular ophthalmoscope for fundusexamination is a routine procedure duringsurgery. The recent widespread useof chandelier illumination in conjunctionwith a wide-angle viewing system offerswide, excellent visibility of the fundus toachieve safer surgical manipulation duringpars plana vitrectomy. The whole surgicalprocedure can be sequentially performedwith viewing through the surgical microscopewithout the burden of repeatedwearing and removal of the binocularophthalmoscope usually needed duringscleral buckling. In addition, adjusting theviewing focus and magnification underthe surgical microscope may be more helpful to identifypreoperatively unrecognized tears during surgery. To enjoythe advantages seen in vitrectomy, scleral buckling can alsobe carried out under wide-angle fundus viewing with chandelier illumination (Figure 11; scan QRcode for video).11,12 The quality andangle of view of the fundus through asurgical microscope with chandelierendoillumination is at least equal toor much better than that observedthrough the conventional binocularophthalmoscope via the condensing lens. The theoreticalconcerns of the current procedure may include bacterialinoculation into the vitreous cavity during transconjunctivalinsertion of the chandelier fiber tip and vitreousincarceration to the sclerotomy after the fiber removal. In my opinion, careful disinfection of the ocular surface byrepeated irrigation with diluted povidone-iodine and theuse of a cannula-compatible smaller gauge fiber would bepreferable in this scenario.
Summary
The utility and efficacy of chandelier endoillumination ina variety of situations during vitreoretinal surgery has beendescribed herein based on personal experiences and preferences.It is clear, however, that there are many differentsurgical situations in which chandelier endoillumination isbeneficial for improving intraocular visibility and therebyachieving favorable surgical outcomes. Nevertheless, surgeonsmust still bear in mind that the final goal of illuminationis to enhance the efficiency of surgery while maintainingsafety. Similar to the introduction of xenon andmercury vapor bulbs in our field, new light-emitting diodelight sources (Figure 12) have recently been developed withunique potential. The evolution of next-generation chandelierillumination systems continues and looks promisingfor the future.
Yusuke Oshima, MD is an Associate Professorof Ophthalmology at the Osaka UniversityGraduate School of Medicine in Suita, Japan,and an Honorary Director of the VitreoretinalDivision at the Tianjin Eye Hospital, Tianjin,China. He is a member of the Retina Today EditorialBoard. Dr. Oshima is a consultant to Topcon MedicalLaser Systems and Synergetics. He has received lecture feesand/or travel support from Alcon Laboratories, Bauschand Lomb, Carl Zeiss Meditec, DORC International,Novartis Pharmaceuitical Inc., and Synergetics, when hespoke at sponsored seminars, but he received no proprietaryinterests or royalties from any companies in relationto any products mentioned in this article. Dr. Oshima maybe reached at yusukeoshima@gmail.com.
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- Jang SY, Choi KS, Lee SJ. Chandelier retroillumination-assisted cataract extraction in eyes with vitreous hemorrhage.Arch Ophthalmol. 2010;128:911-4.
- Venkatesh P, Garg S. Endoillumination-assisted scleral buckling: a new approach to retinal detachment repair.Retinal Physician. 2012;9:34-37.
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