Lecture: Vitrectomy: It’s (Mostly) About the View

During this live webinar, Dr. Shakir will overview the non-contact and contact visualization options during vitrectomy surgery. We will discuss reusable versus single-use, wide-angle view versus detailed macular work, and contact versus non-contact lens systems. Videos and real intraoperative photos will be used to demonstrate these options. There will be ample time for questions. (Level: Beginner and Intermediate)

Lecturer: Dr. Omar Shakir, Ophthalmologist, Coastal Eye and Coastal Eye Surgery Center, USA


DR. SHAKIR: All right. Welcome, everyone. It’s morning here, but I know this is all over the world. So, good afternoon, good evening wherever else you may be. This is a huge honor of mine. So, first of all, thank you to Orbis, thank you to Cybersight. You know, I’m early in my career, but I feel I do have some things to share and that’s why I’m here. So, thank you all for listening. Thank you to Andy Chen, thank you to Lawrence, thank you to Dr. Hunter Cherwek and Abraham, formerly at Volk and the team for bringing this opportunity to me as well.
We’re going to be talking about vitrectomy, and I say it’s mostly about the view, because there’s a lot that goes into vitrectomy. It’s not just the view, but it is mostly about the view. And I say that because you can’t see — if you can’t see, you can’t operate. Period. Right? We know that from all types of different type was surgery, anterior and posterior surgeons know this alike. You have to have great visualization for great surgery. It starts with visualization. I say it’s mostly about the view, but there’s so much more to vitrectomy. First our polling questions. I want to get a sense of our audience. Queue up the first one. Which is have you ever personally used a viewing system for vitrectomy? Any type, a contact lens, a wide angle system, older system, newer system. I just to want see what our audience has experience with.
We’ll have a series of three questions here. So, that’s just the first. Oh, perfect. So, this is good. We have about half of the audience that has used some type of viewing system for vitrectomy. And more than half that has not. That’s good. We have learning opportunities and we have experience here to ask some good questions. Let’s queue up question two.
So, which of these types of viewing systems are you familiar with? Non-contact wide angle, contact wide angle, non-contact macular viewing lens, contact macular lens, all of them, or you’ve not heard of any of these. And that’s why you’re here.
Thank you for everyone who is participating, by the way, and engaging with these polls. It really does shed some light on the topic.
Okay. So, we’re seeing about the majority have either no experience or have some experience with non-contact wide angle systems. Which that doesn’t surprise me. That’s the most popular system in the world. And then there’s contact wide angle lenses which are less — are gaining less and less popularity over time. And the non-contact macular lenses are more than contact macular lenses. That’s a little bit of a surprise to me. So, we’ll go through these. Let’s queue question three.
This is sort of just a quiz-type question. Sort of gaining the insights here. So, what does air in the vitreous do to the view of the retina? Does it magnify the view? Does it obscure your view completely? Does it give you a wider angle of view? Or not really have any effect?
By the end of this webinar, I think you’ll know. So, we got a pretty even split between — among the three options which is magnifies, obscures, or makes a wider angle of view. Let’s keep this in the back of our mind as we go through the slides. And that will become way more evident. Okay.
So, why should you listen to this? First of all, because you signed up and you’re here. So, that’s number one reason. Number two is to gain some insights into the retina surgery world. And then three, of course, understanding that view in the retina is the most important part of retina surgery. Just as I said, if you can’t see, you can’t operate. Now, I say that but are there exceptions? Think to yourself. Do you jump into a situation surgically where you just don’t have a view? And I can think to myself, of course. I mean, the view, of course, is the most important thing. But, of course, there are certain situations where you don’t have an option. If I’ve got complete and total vitreous — ophthalmitis. That’s the reason to operate. If they are coming with low perception vision and they can’t see. You may not have an idea with an ultrasound or a scan of what might be going on in the posterior segment. Or for anterior segment surgeon, an obscuration by hyphema. But you go in and do the best you can with your view. But, of course, barring those exceptions. Viewing is important. And also understanding that retinal viewing is complex. Very complex. That’s probably the hardest part of retina surgery is what we train on. For us in the US, it’s 2 year fellowship after 4 years of residency. So, I did my 2-year fellowship. And a lot of that was learning how to view, simply. And then we’re also gonna learn about what’s on the horizon. That’s another reason to listen to this. Is this talk important? We talked about why you should listen. Should you listen for any particular importance. Yes, I’m biased. That’s why I’m giving this talk. But we also have to take a 30,000-foot view of what is going on here. And what we’re doing is sight-saving and sight-restoring surgery. This is happening every day all over the world to restore sight in individuals. And the gravity of that is so powerful, right?
I just was corresponding with a surgeon today, this morning, about his transition from hospital-based surgery to ambulatory surgery into office-based surgery. Talked about a doctor who came to him and just lost vision from a vitreous hemorrhage due to diabetic retinopathy. And because of advances in anesthesia and techniques, this gentleman walked out of the office with vision. This was a guy who could not go back to work because he couldn’t see out of an eye. This is the gravity of what with we do. It’s important. This is our mission. Surgery needs innovation. This is the other important part of this talk. Okay. We’re shedding light on these amazing things that we do, and how complex it is. But we shouldn’t want it to be complex. We want more ease. We want more affordability to these systems. They’re very expensive systems a lot of times. It’s a barrier. Not just a barrier to affordability in certain community clinic setups. But it’s a barrier to training, to getting new physicians, new surgeons out there. It’s a barrier to training. You can’t see, you can’t teach how to see what you’re seeing and it’s hard to share that. And we need to make surgeries better, quicker, more efficient. And viewing is part of that. So, what are we gonna talk about? We’re gonna first jump into what is vitrectomy surgery. Because it would be silly to jump into this without having a context. We’re gonna talk about vitrectomy. Talk about wide-angle versus macular viewing, contact versus non-contact, reusable versus single-use. To me, those are self-explanatory, but that means more view. A wider field of view. And a macular viewing being a more zoomed in view of the central retina. Contact versus non-contact. Meaning are we in contact with the surface of the eye, the cornea? Or are we hovering above? Reusable versus single-use. From case-to-case, we can clean, sterilize and reuse. Single-use being we open up a brand new product every time. And then we talked about what’s on the horizon as part of this talk. And can we do it better?
So, who am I? I am a cataract and retina surgeon. So, I’m a little bit less popular in the US than it is in the rest of the world to do both ends of the eye. But I do. And I did this straight out of fellowship. I went to Yale for my 2-year retina fellowship. I did residency at University of Florida. I myself am born, raised in Florida. Now I practice in Connecticut. And I’m coming to you live from New York where I live. I just am about 45 minutes north of Manhattan. And my kind of claim to fame is I have pioneered office-based retina surgery. So, this is a new space to do surgery. It’s not the hospital, it’s not the surgery center. It’s in your own office. We’re showing we can do complex surgeries. We’ll talk about this in a slide later on because as you can tell, I’m passionate about where I think the future of retina surgery is going, which is into the office. I say I’m pioneering it, but really I’m standing on the shoulders of people who have done this with complex surgery and procedures before me in other fields. So, we’re taking playbook plays from them and learning from it. I found in my own clinic about 5 years ago, 5.5 years ago, right out of fellowship, and been fortunate enough to grow and have this innovation experience in my own practice. And in my last point there is just another personal point about me. I was a college baseball athlete. Not so much an athlete anymore. But that is part of who I am. Why am I qualified to talk about it? First of all, most importantly, I’m passionate about this topic. I’m passionate about retina. Very much a tech guy. This is more than just a surgical field to me. This is a profession. It’s a calling. And that leads me to want to investigate and learn more and share with you. I do perform vitrectomy surgeries every week. I do anywhere from a handful to as many as ten to 15 per week for various reasons. I’m involved in many retina projects. So, helping develop vitrectomy systems, the machine itself. Viewing systems. Technology that will go into future retina surgery. Different products. And actually right now a little shoutout to my team at Yale. We are working on a way to improve the retinal surgery viewing system and we’re very close to developing hopefully a prototype within this year.
So, what is vitrectomy? So, the first point I want to touch on here is never be embarrassed to ask the obvious question. This is more philosophical than it is about vitrectomy. But this is a lesson to myself as well. Oftentimes we’re scientists, we’re in the medical field. We’re obviously very motivated and very smart. But it’s tough sometimes to ask the question that might give the other person the insight that you don’t actually know anything about this. And that’s okay. That’s the learning part of this. So, in this situation, if we were all talking and we were in-person, you don’t know what vitrectomy was, ask the obvious question. What exactly is vitrectomy? Right? Because then we can work on learning together. But if you don’t even know what that is, then I haven’t done my job to shed light on this topic before getting into the details.
So, strictly speaking, vitrectomy is vitreous removal. We all know vitreous, it’s inside the eye. Attached at the optic nerve, the macula, the vitreous base, it’s collagen and water. And it’s there as a vestigial organ. It’s there since we’re born. Vitrectomy is removal that have. And then you can do the other things that come with it. The retinal part of it. So, loosely, vitrectomy is the umbrella term used to describe many types of retina surgeries. That kind of seems counterintuitive, right? Why are we calling it vitrectomy when it’s surgery on a retina? A retinal peel or a retinal detachment surgery? Why is it vitrectomy? You can’t call it retinaectomy, that’s removal. We can’t call it retinaectomy. The field has never called it by its retinal name. Instead, it’s called vitrectomy or — surgery. These are types of vitrectomy. I do all of these. Vitreous floaters, debris, veils, strands, membranes, those are one category. Those are floating opacities that are visually significant to the patient. Vitreous hemorrhage, an epiretinal membrane peel, or macular pucker. Macular hole, submacular hemorrhage, vitreomacular traction. That’s causing systems for the patient such as metamorphopsia. Intraocular foreign body. I removed a nail sitting on the retina. I did that in the office. Retinal detachments. Endophthalmitis, we talked about. Retained lens fragments, retinopathy of prematurely, diabetic traction, persistent diabetic edema, malignant glaucoma, vitreous biopsies, looking for features. Dropped IOLs, and the list goes on.
So, what is the technique to do a vitrectomy? Typically we go pars plana approach. Most of retina surgeons are doing a pars plana approach. The reason why, that’s an entry point into the eye why God willing we’re not going to lit vital structures. When we enter into the pars plana region, we’re 3 millimeters behind, avoided the zonules and the back of the lens, hopefully. The retina should kick in after ora serrata, 5, 6 back. And we have the opportunity to enter the eye and we’re not going to damage any vital structures. That’s why we go pars plana. Technically speaking, what we’re doing, modern day retina surgery, transconjunctival, minimally-invasive, valved three-port, small gauge vitrectomy. That’s a mouthful. That’s why you hear PPP or pars plana vitrectomy thrown around. It’s too much to say transconjunctival. We don’t transect the conjunctiva. Minimally invasive. They have valves that allow entry to the eye and do not allow exit of fluid. That maintains pressure. And small gauge coming in 23, 25, or 27-gauge sizes. I do mostly 25-gauge. I think probably 23 and 25 is the most popular worldwide. And 27 as the technology on strengthening the instruments gains, I think that will gain more share as well.
So, do only — do only retina surgeons do vitrectomy? Clearly not. Here is anterior segment surgeon. This is a typical scenario that we have all been in. And we don’t like to admit it, but of course that happens. That’s surgery. It’s life. Is where we can break capsule. If we break posterior capsule, there’s vitreous behind there and sometimes it comes forward. As anterior vitreous surgeons, we have been trained to do that. One way to deal with prolapsed vitreous is to do a vitrectomy. You know how to do vitrectomy. That’s anterior vitrectomy. Whether it’s with a vitrector instrument or vitreous prolapsing out of the wound that you have to manually incise. That’s a technique we all know as well. If vitreous makes it not only to the wound, but out of the wound, we learn how to cut that. We have to sever the attachments. Why do we do that? If you have never stopped to do that, right now is the time. We have an opportunity to reflect on why do we do the things we do? So, if vitreous prolapses out of the wound, take a Weck-Cel, and cut it. Are we doing this so it’s not in the chamber and having vitreous interfering with vision? That goes to somewhere. Talked about the attachments at the nerve, macula, and the vitreous base. And the rest of the retina is attached until later on in life we undergo posterior vitreous detachment. So, we care about relieving traction on the vitreous, cutting it, and incising it because it’s attached somewhere else on the other end. And that might be the retina. If you don’t relieve that force, that tractional pull, then it may pull the retina off. So, if you just left vitreous in the anterior chamber after a prolapsed during a broken capsule case, it’s not just that it’s gonna interfere with the IOL or the vision, it’s that you’re putting this patient at risk for a retinal detachment. So, we have to relieve that traction. It doesn’t guarantee that they’re not going to develop a retinal detachment or tear, but it reduces the risk if you can relieve this. A pause to shoutout to Cataract Coach. If you’ve not familiarized yourself with his website or his YouTube videos, please do. This is the best way to learn is to learn from other people. And to learn from excellent teachers. And he’s an excellent teacher. He’s got videos on everything cataract-related. And I’ve just looked up anterior vitrectomy. One of many videos. Here’s a valuable learning lesson of someone who handled it very well.
So, let’s talk about the first visualization method. The first visualization method is what we just watched. It’s direct viewing. Right? So, that doesn’t require a lot. So, we don’t have to put in a contact lens, a wide angle viewing system. We don’t have to get complex. We can just directly view with the microscope. What can we view with that? You can actually you quite a bit. You can definitely see your vitreous at the wound. If it’s prolapsing out of the wound. You can definitely see if it’s in the anterior chamber. And you can see into the anterior vitreous cortex. If you focus with your pedal down through the iris plane, down past the capsule and keep going deeper and deeper and deeper, you can view a good amount of vitreous. You can sometimes get into the mid-vitreous, depending on your scope. So, here is a case where obviously I’m going to the macular lens there, but before that, I had taken a pause to clear out some of the posterior capsular pacification behind an IOL before proceeding with the rest of my surgery and I’m direct viewing here. So, I’m just taking my vitrector behind the IOL, cleaning up the posterior capsule so I don’t have to have that obstruct my view. That’s the first visualization method is direct viewing. Now why are there other — if we can directly view, why would there be other visualization methods? Well, we need two specific visualization methods. We need a high MAG and we need a low MAG. Under low MAG, we don’t just want low MAG, we want a wide field of view. So, if we view directly and we put a contact lens on, on the right side, that’s your macular view. That’s all you can get. Maybe you can extend it out. And we’ll talk about strategies here — maybe you can extend that view out to 40 degrees, 45 degrees at the most. It’s just the optics of the eye are gonna prevent you from seeing beyond that. If your nodal point or your focal point lies way in front of the lens and it lies at the corneal surface, then you don’t get a wide-angle field of view. So, you can’t see in the peripheral retina once you attach a mirror or some angled lens. Which is how it used to be done. That was the only way. Attach some mirror to see far into the periphery. So, we need another visualization method, which is the wide angle field of view. And here you can see the nodal point where the focal plane lies is different from the direct macular view. There it has to lie inside the eye. And because this picture depicts it very well. Because of that, it has to flip the image. So, we’re gonna talk about how reversal of the image factors into wide-angle viewing. But you can see a lot more this way. And by doing so, you minify the image. You get a wider field of view, but you make a smaller image. Here’s an example. A real-world example. These are not surgical views. But you’re about to see that. These are taken from fundus cameras. On the left, Optos view, you know that patient, that’s on your screen. That’s me. So, that’s an Optos photo. And you can see what a wide angle field of view looks so different from a macular field of view. So, the macula gives you the zoomed in view of nerve, blood vessels in the macula and the fovea itself. And the wide-angle gives you the mid-periphery. With dynamic viewing, you move the image and start seeing into the periphery. So, were here’s real world. Left being a wide-angle view. And right being the macular view. If I am correct, I believe this is the same patient… I think the I put the same patient here to illustrate the example. You can see here, way more zoomed in view, way more detail on the right. Which is great. But then that doesn’t work so well for — for wide angle needs such as clearing vitreous from the vitreous pace which is what you’re watching happen on the left. Taking care of retinal detachments. Okay. So, this sounds relatively simple, right? We’ve got wide angle view systems, macular view systems, can’t be that complicated, right? These are just some of the options that exist. So, my point in showing this is that there is so, so, so much to retinal surgeon viewing. And these are just a handful of selection of products that exist to help us see better. And we’re gonna go over some of those. So, but why is it so complicated? Why are there so many systems out there? So, wide-angle systems, they can come in many flavors, right? We talked about contact versus non-contact. They can touch the surface of the eye or not touch it. Float above it. If it’s a contact system, it can be held by an assistant. Oftentimes you have to have something or someone holding it because that contact lens will just fall. It will just fall to the side if it’s not stabilized. Or use a sutured lens ring to hold in place. If you don’t have an assistant and you’re operating solo, you got to hold that lens in place, you put a lens ring on which you suture to the eye or hold it in place with the speculum. There are many other ways to do this as well. I’m not touching on all of them. Non-contact systems usually held by the microscope. Floats with the microscope, or to a wrist rest or to the bed itself. And then there are different materials for wide-angle viewing, refractions, different lens designs, different fields of view. There’s single-use versus multi-use systems. So, that’s why it’s so complicated because there’s so many options. And then for macular viewing, same thing. It can be attached to a non-contact system. But most commonly, as you guys answered in your polling questions, that there — there is a contact — you just put the contact lens on and that’s the most common way to do it and those come in different materials too. Glass, PMMA, silicon ring to stabilize the feet. Biconvex versus biconcave, minification versus magnification. So, let’s jump into non-contact wide-angle systems. This was the most popular. Something you answered in the polling question something you’re most familiar with. Probably you have seen or heard of one of these systems. These are, again, not all — this is not an exhaustive list. But these are most of the ones that you’ll come across in different operating rooms, different countries. I myself use a ZEISS RESIGHT, I trained on an Oculus BIOM, Merlin. I’m not familiar with the others, but there’s the ocular landers wide angle surgical viewing systems, and Haag has one, and Leica does as well. Basically anyone who wants to play in the market has a microscope to attach it to. They usually have a wide-angle system. There’s a lot of options out there. These are some of them. So, on the left, that would be a BIOM system. And then in the center, that’s the ZEISS RESIGHT that I use. On the left, the Merlin system.
Why I use this one, I think it’s got a never way about how to control the angle of view compared to the other systems. So, if we go back here, mostly as other systems, if you go to the very bottom of the image where the lenses are floating, that’s how you control — control the view and the focus is by moving that lens.
And the ZEISS RESIGHT system does not involve movement of that lens. That’s fixed, actually. That arm that you see coming down, it doesn’t change the distance of that lens from the microscope. What does change is there is a reducing lens in the side of the microscope that changes. And that effectively changes the focal point. So, that means that all the internal mechanics of the microscope act to bring the image into focus which I prefer rather than messing around with the outside of the — the external environment. So, the main concept, though, which is similar to all of the systems, not just the RESIGHT, is you have to have this floating, high-powered, condensing objective lens. That’s the yellow lens you see floating here. The other ones in the image that float above the eye. Usually high powered. Above 100 diopters. Because they’re high-powered and sit above the eye, they flip the image. Now, the concept here is we need to get as close to the cornea as we can, but not so close that we’re touching. Not so close that it fogs from temperature difference of the room being cold versus the eye being relatively warm. So, balancing that is a challenge. You know, we have — as clinicians and for those of us that are not retina surgeon, that aren’t as familiar with this — you actually are familiar with this world. When you are examining at the slit lamp and you’re using a 78 or 90 diopter, whatever lens you’re using to view the retina, it’s the exact same concept. You’re floating in front of the cornea. It’s a high-powered lens and it’s flipping your image. That’s why you have to invert in your eye or when you draw.
Now, there’s contact wide-angle systems as well. Way less popular than the non-contact systems. But, you know, rewind through the decades, this was the way to view the retina. So,s in not like a fringe way of doing retina surgery. This used to be the way. Here you can see in this picture that the surgeon is requiring assistance to hold the contact. So, what I’m pointing at with the red arrow there is the left hand of the assistant is holding a handle of a lens on the eye. And if you have been there before, you know how frustrating this can be as a resident. This was my job with my chairman. To stabilize the image with my wrist and make sure they followed whichever way he was going. So, if he was going out to the periphery, I needed to tilt the lens to follow him out to the periphery. This adds a new layer of complexity. That’s very difficult. One of the original lenses for this was the AVI lens, the A-v-i. And now we have Volk and Ocular Instruments and all these other players in that space as well. Interestingly enough, it gives you some of the best viewing that you can ever see. Because when you’re in contact with the eye, you neutralize any effect of the cornea. Corneal astigmatism is neutralized. Don’t have to worry about the surface drying. You can get around corneal opacities in the lens and it gives you a wider field of view.
Stabilization, as I said, is the most difficult issue. So, stabilizing in that case left hand that have assistant, it’s hard. And it looks like he’s floating without — without even using the wrist rest. And this does usually require larger pupil to get a good field of view versus non-contact systems, they can shoot through a smaller pupil. Is there anything such as a contact wide-angle that doesn’t need an assistant? That would be a real breakthrough. Volk came up with this — and I’m showing on the next slide the view through the lens — that’s game changing. It’s got self-stabilizing feet. Most important part, it’s light. It’s narrow enough so that your instruments to the left and right of the lens can slip in and out of the eye. You can manipulate without knocking this lens over. A lot of other contact lenses are wide and big and bulky and heavy. So, this does not require suturing, doesn’t require a lens ring. You could do this without an assistant. And this is the view through — it’s a very wide field of view. So, you can see way out to the periphery with this lens. It’s a beautiful system. Now, what about — where does the microscope fit into all of this? Because can we just do this with any system? Any microscope anywhere in the world? Unfortunately, that’s not the case. Most microscopes you can fit a wide-angle viewing system on. But not all of them. And that’s where the complexity of this comes in. So, when I say there’s things to improve, this is one of the things that has to be addressed is universal compatibility. Here is an example. So, I used to operate at a surgery center before I moved into my office for surgery. And here’s a typical combined case. Anterior and posterior segment. That I would have to have set up for me. Or sometimes do it myself because it was so complicated for the staff. Five different petals, one for phaco, vitrectomy, and a separate scope pedal, inverter for the system. There’s an attachment to the microscope to allow the wide-angle viewing system, allow the inversion. That is complex. And retrofitting this on to an older scope, if you want automatic inversion because the wide-angle is going to flip the system, and you need to re-flip it, otherwise you’re operating backwards and inverted, that’s a lot to ask. And in certain situations in certain countries where you may not have access to all of this, that may be a barrier to doing retinal surgery in a high-fidelity manner. You can’t do it with the comfort of a flipped image because you can’t put an automatic inverter in, that’s something we have to address. And, of course, adding a wide-angle viewing system, you saw them in the previous picture. They’re very tall. They add a lot of working distance to the microscope. It’s tough for surgeons who are shorter, have a shorter mid-section. You have to crane your neck to get the oculars. It’s not ideal. There’s definitely room to improve there.
So, what about the inverted image issue that we have just been talking about? So, one way around it. So, the question is, well, if wide-angle viewing does it, then is that enough? And I would say that’s not enough because we just talked about it can be more expensive. It’s complicated. It requires automation. Can we do this through a direct image system? And this paper in 2021 showed that there is a way to do it with air bubbles. I have thought the same thing. Air has a different refraction than water. Close to 1.0. And water, saline, et cetera, is around 1.3. Vitreous is a little bit more. Silicone is 1 .4. IOL is around 1.4. Can we juice that change in index to refraction to our advantage? They showed in the image if you used an air bubble with a direct viewing system. So, I put a contact lens on, not a wide-angle, but a macular or flat contact lens and use an air bubble under the capsule or into the anterior chamber, you can get a wider field of view. Going back to the polling question, air can be utilized to get a wider field of view. Here is fluid versus air. On the right is air, on the left is fluid. One of the ways you can tell here is on the left of the light pipe, which is the far left of the image under fluid, is giving a shimmery view in the fluid. On the right, that light pipe is reflecting off of the air meniscus at the bottom of the eye. Giving a reflex of the light in a different place. That’s one key detail. When you look at the image, you can tell there’s got to be air in the site. But comparing side-by-side, you can see in the far periphery superiorly, you can see two vortex veins, actually. And you can’t see that under fluid because you don’t get as wide of a view. And one way to assess this, look at anterior structure such as a cortical spoke in the lens of this patient. It’s bigger, it’s more central under fluid. Under air, it’s pushed more to the periphery because the air has created more of a peripheral view. That’s the neat part about air. Air is free. Air is cheap. So, we should use air to our advantage. So, going to that example here on the left is fluid-filled eye. On the right is an air-filled eye. Look at — I just — I just kind of showed a very small glimpse of the superior periphery there. But I’m sorry, that might be the inferior periphery. But look at the vortex veins and the interior field of view. So, if I remind this video back, look at that view. You can see almost all the way to the ora serrata. Versus a fluid-filled way you can’t get that view.
An insight to a typical operating day. What does that look like in the office? This is my typical setup. This is a room dedicated to cataract and retinal surgeries. There is the ZEISS RESIGHT system, right hand pipe, left hand vitrector. There’s an image of the vitrectomy in 3D. I’m wearing polarized glasses. There’s a vitrectomy system. There’s my office. So, I’m at end of the office with floor-to-ceiling glass that patients can see what we’re doing and appreciate that it’s complex work. So, a lot of times patients loved ones are watching what we do. Now, this is a close up view of those two major systems we talked about. First we have been talking about the wide angle viewing systems. On the left here, you can see that lens is floating above the eye. And that’s a wide angle viewing system. On the right you’ll see that there’s a — a flat lens. Give you the detail all the way to the eye. There’s a flat lens on the eye. That’s a contact lens for viewing the macula. And if you look at the microscope, I have pushed back — so, I zoomed out of this picture because I pushed back the RESIGHT out of the way because I don’t need that for direct viewing through a contact lens. That’s what I wanted to highlight there. So, contact macular viewing systems coming in those three flavors that we talked about. Concave-concave, convex-concave, plano-concave. These off different viewing experiences. The far left, plano-concave and a direct view. Unaltered view of the retina. You’re seeing it one-for-one. The Concave-concave lens is going to magnify, a little bit more detail to the ILM, ERM, whatever you might be working on, the macular hole. Convex-concave is a way to introduce a wider field of view. And we talked about this before, but unfortunately you can only get so wide with this strategy. You can’t get 100 degrees of view. You can maybe get 40, 45 at the most. So, here’s a typical contact macular view. Contact viewing gives you high resolution. So, you can see, this is very different than the vitrectomy that I showed you in the videos before. This is high resolution. There you can see that we’re blue straining the residual — that’s ILM that you’re seeing, actually — the residual ILM is completely clear. Completely clear that you can see. And that allows us to differentiate surgical planes so that we can differentiate, where is the ILM and ERM versus the retina. We don’t want to grab the retina. Most commonly, these macular viewing systems are made of PMMA material. PMMA is single use disposable usually. It’s very light. It’s got minimal material. That adds to the stability. That does not require an assistant to hold. You can just put it on the eye and it kind of stays there.
So, what about non-contact macular lenses? So, that was a contact. Can you view the macula without — without putting a lens directly on the eye? So, yes. You can. Here this is with the ZEISS RESIGHT, they’re flipping from the wide angle lens to the green macular lens. That’s like the slit lamp lenses. In slit lens, 90, 78, people use different ones. But we’re in the range. That’s similar to the view you might see in clinic. That’s what you can do. You can do a non-contact macular system. Most surgeons say what’s the benefit? Because if I just put the contact lens on, I get a really beautiful view. In my opinion, I kind of agree that stereopsis is convenient. It might be more convenient to float above the eye and not have to touch the surface of the eye.
So, what are some challenges? We talked a lot of good things about the viewing systems. But there are, of course, challenges here. Here I’m showing you a video of in the middle of surgery my wide-angle lens has this opacity on it from processing. Steam sterilization process that we use left some residue on there. It’s interrupting my field of view. Here I have to stop in the middle of clinic, middle of surgery, and flush this lens and clean it out so I can have a better field of view. There’s other issues too. There’s glare issues. And when you re-process lenses, you lose an anti-glare coating. The clarity of the lens, having to clean it. And air versus fluid. Sometimes we’re under silicone oil. That can add a lot of challenge to viewing. Stability of lenses. The ability to keep them in place without an assistant. That’s a challenge. And then, of course, cost is very important. Different areas of the world we need to factor in cost because we can’t just have everything we want. We need to make sure it’s feasible — financially feasible. So, these systems are very expensive. We need to have a cheaper system. So, what does the future hold? And I just want to give a quick shoutout to my team at Yale. That’s Larence, Nancy and Vi. And they’re working on developing novel contact knack layout lens which we think can give advantage of single use. Cheap, disposable, give a beautiful field of view. So, those guys are gonna be the future of retina surgery. Also, some other future projections that I think. So, I do 2D viewing without microscope oculars. I think that as good as that is, the fixed screen, the 3D screen that I’m looking at, that’s not the future. The future is gonna be some type of floating screen or some type of screen that integrates with the environment such as an Augmented Reality or virtual reality where you can place different information in your real space. That is a part of viewing, right? This is relevant to surgical viewing because that will increase our viewing potential. Guided surgical navigation like pilots have. Their Augmented Reality to the cockpits. They can have lots of instrumentation. We need to be able to do the same thing. We need better endoscopic views. Endoscopic vitrectomy, we have talked about that. We need better resolution and better ease of use of endoscopy. We need real-time, all the time. Swept-source optical integration. There’s something on the market by Bausch + Lomb with collaboration with Heidelberg. It’s very expensive, but at least introducing real-time all the time, OCT. And shoutout to my colleague Dr. Arroyo who launched the Stych platform. If you have heard of Twitch, this is the surgeon’s version called Stych. Surgeons can collaborate and share their surgical views. We can see each other’s surgeries in real-time and comment and collaborate, which is amazing.
And then this is just a personal thing that I wanted to touch on very quickly is I think the future — one of the most disruptive changes, disruptive technologies that the future holds for vitrectomies is where that surgery happens. And that’s going to address a big cost issue and resource utilization issues. We don’t need to be in the hospital or in outpatient surgery centers. We can do this safely in the office. We need to show that we can do this in a highly sterile environment without the big cost of a hospital or surgery center. We can do it in the office which keeps the surgeon where the patients are, where the clinic is, very important.
And that also gives breeding grounds for innovation. The way that I can collaborate with my team at Yale. And a shoutout to Dr. David Almeida introducing Case X, ocular surgery for bringing entrepreneurs and the playground of the environment to take away the barriers and the red tape and allow them an environment where they can do prototyping and do new products. And like I said, I think this solves the access to care issue worldwide. Let’s go through those polling questions and then I’m gonna open it up to question and answer period.
So, let’s queue up our second polling question number two and reengage with the audience. So, if you guys are seeing that, that is — that first — that second question that we had at the beginning of the presentation which is are you familiar with any of these systems? I hope you’re familiar with at least some of them now. Okay. So, we made some progress. A little bit of progress here. And then let’s queue number three. So, what does air do to the view of the retina? We were showing it, did it give you a magnified view? Did it obscure the view completely? Did it make it wider? Did it not have any effect?
Good. So, the answer is: It gives you a wider field of view. All right. So, let’s open it up to questions. Feel free to type them… okay. So, I’m seeing a question come in about — how can you detect vitreous prolapse during cataract surgery if we don’t see any iris irregularities and we don’t have triamcinolone. So, let’s first talk about what we are referring to with iris irregularities and triamcinolone, it can light up vitreous strands. It will attach to the vitreous and light it up so you don’t have to struggle to see. Iris irregularities, referring to pupil peaking. Areas where vitreous may run to the wound. We’ll probably put tension on that part of the pupil and cause peaking. Meaning it’s pulling on that part of the iris and you can kind of — but what in you don’t see that? If you don’t see it, the best way is high magnification. So, you’re gonna need to zoom all the way into the anterior chamber. And then dynamic viewing. Dynamic viewing means moving the eye. Typically, if we’re under a topical block, which means the eye is not completely immobilized, two fixation, meaning primary and secondary instrument in the eye, tilt it left, right, superior, inferior to see if we can view around it. Don’t have to just look at the iris and the wound, there may be other peaking properties. See if the vitreous is putting tension on the posterior capsule where the tear is. But under high MAG and dynamic viewing, sometimes you can see vitreous is clear, but not completely clear. You should be able to see something. If you have access to — to non-coaxial light, meaning not light that comes through the microscope, the light that can come from the side, that can help light up vitreous as well.
Hopefully that helps a little bit. Just going through some of these to see which we can cover quickly.
I’ll just quickly touch on this question: What can we do if silicone oil comes into the anterior chamber in the presence of PI? So, if a patient has a peripheral iridotomy and have it in the posterior cavity and it comes forward, that’s a tough situation. It’s not causing any pressure issues or visual issues for the patient. It can be monitored if not. And it’s causing issues. And you should be tracking endothelial cell count. Because sometimes oil can cause damage in the endothelial cells. You should aim to remove it. Removing it in clinic is tricky. Yes, it’s possible to stick a high bore — a large bore needle in the clinic under sterile conditions and try to suction it out. Requires a lot of force so you can’t just put it on a 5cc syringe or a 1cc syringe. It would like more than a 10cc syringe to give enough back pressure. And usually an assistant needs to be next to you so you can pull on the plunger while they’re working on the oil. But typically, that’s done under sterile conditions in an OR. This question is — are non-contact lenses a bit inferior to contact lenses? That’s a very nuanced question about what we’ve been addressing here. Which is a contact lens system is always going to give you a better view because of neutralization of the corneal astigmatism or irregularities. It can allow light to pass through opacities all right than a in a non-contact system. So, I would say as far as viewing — as far as clarity of view goes, yes. Non-contact lens may be a bit inferior to a contact lens. But what gives the superiority and why it has so much popularity is the ease of the view. It does not require an assistant. It’s a reliable way that you don’t have to have something in the way. So, contact lenses are also on the eye and bulky and getting instruments in and out of the eye, manipulating the eye, that can be a little frustrating sometimes. So, non-contact lenses take that out of the equation. So, it’s inferior whether it comes to the actual view, but superior when it comes to the other factors that go into surgery.
This question — this is a good beginner level question which is when vitreous is removed, what replaces it? When is the right time to remove vitreous? And does vitreous have time to regenerate? Vitreous, once it’s removed, is not going to regenerate. The vitreous you’re born with is the only vitreous you get and we have not really pioneered a vitreous substitute, an adequate one yet. There’s many — there’s many hydrogels that have been tried in development. But nothing that really works the same way that vitreous does. So, when it’s gone, we are infusing — so, under those three port conditions, you saw there are three. You know what two of those are for, which is the light and the vitrector itself and any secondary instrument, a forcep or scissor or a picc. But that third port, that’s for infusion of fresh balance salt solution to maintain pressure. That’s what fills the vie. Once the vitreous is gone, balanced salt solution fills and repressurizes the eye. I tell patients in the hours after surgery, that’s already being replaced naturally. You make aqueous to fill the anterior chamber. Aqueous will start to fill the posterior cavity. You have the same fluid makeup of posterior cavity in the interior. It takes over hours after the patient goes home with balanced salt solution.
I’m going to address these two questions back-to-back on office-based surgery because I’m passionate about that field and I want to make sure that is answered in this. So, one is how — how do you do office-based retina surgery? There’s something called a surgery queue. You might be familiar with did. And then the follow-up question, another listener is the risk of — is it higher with office-based procedures? Let’s talk about both of those. So, the setup for office-based retina surgery is really no different than a surgery center hospital. It should not be. It should look the exact same. Meaning if you walk in and I blinded you and walk you into the room and minus the floor to ceiling glass of an office, it should feel the exact same. Of course, there are — there are some differences that might not be palpable. Or if you’re in tune with your environments, maybe you can spot them. But in general, the conditions should look and feel the same as anywhere else. I am familiar with the SurgiCube, it adds laminar air flow. I don’t use it, I use just standard HEPA filtration, particle filtration with multistage and run air filters when we’re not in the operating room to create a pseudo-sterile environment. And then is the risk higher in office retinal surgeries? The data does not show that. We have strong data on office-based cataract surgeries. And the data has shown that it’s at par, or maybe even a little bit better. I hesitate to say it’s better. Maybe it’s better in the office. We need probably hundreds of thousands of cases. We have probably 60 to 70,000 cases in the office under sterile conditions. And the rates are better. That’s a longer answer as to why that could be the case. But I think that surgeon involvement and office-based setting makes for a more sterile environment. So, same goes for retina. I think the same will hold true for retina.
We can put up my last slide while I answer maybe one more question. How do we prevent lens fogging in a non-contact viewing system? So, that is tough. And this is one of the challenges. While I’m answering that, I’m just gonna make sure I put up my last slide here. Okay. So, for those of you that want to get in touch, I love to stay in touch. So, here’s my personal email. My personal phone number. You can message me any time on WhatsApp and then connect with me on LinkedIn. I put a lot of videos up and teaching material. I’m always open to conversation, debate, collaboration, anything. I love this stuff. So, please feel free to connect with me and keep the conversation going. Preventing lens fogging is tough. That’s one of the challenges that we need to address. It comes down to material and temperature differences. One of the ways that you can do it is to have the ambient temperature in the room. Be closer to the eyes temperature, the surface of the eyes temperature, it’s not a huge differential. Control the humidity in the room. You can put materials, you know, people who do — surgeons who do endoscopic surgeries, they deal with this with cameras that are inserted in the abdominal cavity or whatever. They have to put certain films or materials on the endoscopic camera to prevent fogging. I’ve employed the same strategy with contact viewing systems. It does work. You can put this film over, or a liquidy-type substance over the lens to prevent fogging. But then it does degrade the view a little bit. It’s a balance. That’s one of the things that we have to address with future innovation. Well, thank you all for listening all over the world. And hopefully we learned a little bit today and shed some light on where we are currently and where we’re going. It’s my pleasure and my honor to do this.

Last Updated: February 16, 2024

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