Live Surgical Demo: Pars Plana Vitrectomy for Complex Retinal Detachment Repair – Silicone Oil

Dr. Miller: All right, well, welcome, everyone. I’m Dr. David Miller with Retina Associates of Cleveland. Can we turn down the music. Coming to you from Retina Associates of Cleveland and production by Cybersight. You’re joining us for a live surgical vitrectomy for complex retinal detachment repair. We’re in the laser surgery center, and I have my team. Maybe see them behind me if I change the camera angle. We have the fellow, Alex Miller, who is also my son, actually matched into the program. We have Rachel here with the technology. Another Rachel who is circulating, Tracy is our scrub. Michelle is our physician assistant, and Angelica is our anesthesia. So, without any more ado we’ll start into the presentation. It’s a brisk minus 10 degrees Celsius here in Cleveland this morning. All happy to be inside bringing you this case. Here’s a picture where we’re working from, Fairview Park outside of Cleveland. For those coming from International locations, in Cleveland, Ohio, kind of on the Eastern half of the United States. And my practice is 16 retina physicians scattered across Northeast Ohio with the little bubbles you’re seeing there around Northeast Ohio. Next slide there. So, I want to go over a few quiz questions. Things we should be able to answer after the presentation and the surgery. And number one, first question, a relaxing retinectomy is indicated when? You can see the choices, A, B, C, and D. And go to question two, and we’re gonna cover these questions after the surgery again. We’ll come back in and do this again. And Andy, we can advance the slide. Question two is single-operation success rate for grade CPVV approximately. We should know how well this will work. The questions and the choices are up. You can select your answer now if you’d like. Give you a few moments. 10 to 20%, 30 to 40%. 60 to 75%. Give everyone a few minutes to get their answers in. Very good. We’ll probably review the answers in the midsection after the case. Slide number three. Silicone oil is preferred over a long-acting gas when? Choice A, all breaks are superior and the PVR is minimal. Patients can not position, chronic PVR, proliferative vitreoretinopathy, or inferior breaks, there is no risk of glaucoma, answer C, and a second surgery must be avoided at all costs. When is silicone oil preferred? You can chick your answers there. I thank Andy and Cybersight to make the live quiz. I didn’t know we could have live responses until sigh this here. Perfluoron, PFCL, is primarily used intraoperatively to prevent post operative inflammation, B, stabilize the posterior pole and prevent slippage during A/F exchange, provide long-term tamponade of inferior breaks or D, enhance laser uptake long-term. And give that a few seconds and see the response bars pop up and kind of cover this again after the surgery is complete. There we go. People honed in on choice B.
The next slide is the case we’re working on today. A 74-year-old male presented back in March with a Mac on retinal detachment with a giant retinal tear covering about five clock hours of the left eye. Patient underwent initial vitrectomy surgery with 15% C3F8 gas on March 11th. That surgery subsequently failed and required re-operation in May 27th of 2025. That was done with vitrectomy techniques again. Peeling of membranes and gas again. That surgery then failed again. And the patient’s most recent surgery was October 25th, 2025, requiring silicone oil and a scleral buckle. All performed outside the center by another surgeon. We’re picking up for the fourth surgery in the left eye, diagnosed January 15th of this year, recounter mac with a macular hole. And a retinal peel, probably a retinectomy, and filling the hole and replacement with silicone oil. Next slide. We’ll skip that for now. We’ll cover that if we get a chance to do the second case. I want to coffer the definition of a complex retinal detachment. Features include peripheral vitreoretinopathy, giant retinal tears, trauma, prior surgeries and require advanced techniques. We will cover that today. Next slide. Identifying complex cases. PVR, peripheral vitreoretinopathy come in different cases, A, B, C, D. I don’t get caught up with looking at the patient. Fixed folds in quadrants, a giant retinal tear greater than 90 degrees. Include poor visualization in some cases, a rigid retina and a high risk of fibrinoid or post-inflammatory reactions. And here’s a couple of photos of peripheral vitreal retinopathy. On the left, sub-retinal bands with retinal detachment. The right, multiple foci of epiretinal feature obscuring the nerve and macula both temporally and nay anyway sally. Here is a photograph of a giant retinal tear, it’s torn away for 4 clock hours and over the fine fear your macula. Here is a diabetic. And this is also a complex retinal detachment. And along the arcades, peripheral detachment, associated with neovascularization and vitreous hemorrhage. The surgical techniques. Basically, we have done other talks and there’s other ones online about the basics, all that applies. The pre-op evaluation, where they make the incisions, things like intraocular pressure and wound construction. But maybe a little bit more in these kinds of cases. Cover that today, membrane peeling, retinectomy, we will talk about that, and I saw questions before the start of the presentation, and endolaser photocoagulation, and long-term tamponade. On this case, both going out and back in. So, membrane peeling and PVR management really helps if you can see what you’re peeling. Adjuvants like brilliant blue G or triamcinolone are useful to peel away tissue. Bimanual, a chandelier light, or pinch and peel technique. The goal is to remove the contractile tissue to have the normal elasticity. And check for retinal bands if it remains tethered. A relaxing retinectomy, is one of the main tools in re-operations. Indication is when there’s subretinal or epiretinal peeling, fails to allow the retina to reach the periphery without tension. So it doesn’t have to be in every case, but quite often when you get to a fourth surgery, it’s probably the step that’s needed. So, I’m kind of expecting to do that going into this case. But we’ll look around and make that decision once we’re in the eye. The technique is the diathermy edges of the retina, followed by 90 degrees, more often 180 degree of the peripheral retina relaxing tension. Critical step is to ensure that the retinectomy is posterior enough that you’re removing all the contractile tissue. And to help, you can use adjuvants like Perfluoron to stabilized, PFCL helps stabilize the posterior pole. Using it to sandwich the retina against the RPE while performing peripheral shaving, I’ll demonstrate that today. And parentheses the slipping, or even with the, you don’t want the Perfluoron going through it. And next. Tamponade agents, leave it filled with, choices are basically silicone oil which we tend to use in re-operations when you get to the third and fourth case. Gas, C3F8 or SF6. PFO or heavy oils. In Europe there are Densiron, and we don’t have that here. And considerations for each case. Which agent you want to use. Most commonly and the setup for today would be the silicone oil. There’s 1000 and 5000 sc oil. And that’sbest for patients unable to position. And especially useful making an inferior retinectomy, which we’re doing today. Long-acting gas can work well in PVR. I think it works best in cases of more minimal PVR and avoids a second surgery. The oil provides a longer splinting or tamponade effect than what gas can. Next slide. And I wanted to touch a little bit on the use of methotrexate, which we will not be doing in this case, but I have done in others. There’s been some literature in the last several years and even clinical trials looking at methotrexate intravitreally into the eye. And at post-op visits, week one, two, and over the months to lower the rate of peripheral vitreal retinopathy. There’s studies that I’m not going into as part of this discussion. But I’m hopeful that methotrexate and other medications can be proven to be useful to increase our success in complex retinal detachment repair. I think there’s a lot of developments there. And so, the success rates of this and a single operation success rate is probably in the 60 to 75% for grade CPVR. Final success, greater than 90% with multiple procedures. My takeaway, you generally have to be fairly aggressive in these types of cases, relieving all the traction. Retinectomy is a more conservative move. And that conservative peel willing often lead to early failure. In the last case, look at this gentleman’s case, he went through three prior, and the last case, put the buckle and failed and peeled. Probably a bit predictable in my mind. Success rate depends, of course, on the complexity going in. But I think we generally hover between 80 and 90% here. And a visual outcome, of course, will vary depending on the macular involvement. Okay. I think probably that’s the end of the slides. We’ll start the case. And we’ll talk our way through that. So, we know going in that we have oil in the eye, and interestingly, this is 5000 centistoke in the eye. And the difference is the 5000 is much more thick and goes out slower and comes out a lot slower. I intend to use 1000 centistoke with the intent of taking the oil out in two to three months. What properties does this give to the oil? 5000 centistoke is less likely to multiply or break down in the bubbles. Other than that, one is not better than the other for keeping it on. I think that’s not true in terms of the surface tension, not much difference. But in terms of emulsification, there’s a difference. Because the 5000 is a bit messy in terms of getting out in particular, I prefer the 1000 centistoke. I’m gonna show you why that’s a difference here. As we start the case. And I’ll cover some of the basics of the vitrectomy as we’re going through it. Very good. So, I’m using the DORC — Dutch Ophthalmic Vitrectomy Machine, cannular system. And we can see right here the markings on the back of the cannula give us some idea of where they go. Distance-wise. And I like to make these pretty beveled, purposely. It’s a little soft. I’ll tell you what. Turn off the irrigation, go back to cannula. You’re right. A little soft going in. We have some hypotony, measure for the next one. That’s all right. I like to keep my trocar placement at horizontals, maybe a touch above. That gives us a little better access when we’re trying to reach around in the eye, especially if they are phakic, he’s pseudophakic. And sometimes you get cyclitic membranes, and that so far folding of the ACOIL and the anterior and posterior can be difficult to deal with, and sometimes you’re better not having a lens implant in these eyes. Not a big fan of cataract surgery with lens placement in these cases. I would rather just get the retina reattached and deal with the cataract later, especially if I’m gonna take out the lens. Yeah. Especially if I’m gonna take a lens, I would rather take everything out, including the capsules, even. Here we’re gonna remove the valve over the top here back on to our — you can hold the cannula down there for me there. Just so I don’t peel it out. Thank you. Get it out later. The reason I’m uncoping this valve, we’re going to put our oil extraction device over the top. And here comes the 5000 centistoke oil coming out right now. This is normally how we would remove 1000 centistoke, and it works well. But you’re gonna hear the difficulty it’s gonna have in pulling out the oil. It’s coming. You can see right here. It’s not coming terribly quick. And I think our choices are, either wait a long time while I try and explain what we’re doing or just make a larger incision. What really impacts the flow of oil going in or out of the eye is its viscosity and the size of the cannula you’re pulling through. So, a choice here for us is to cut down on the conjunctiva and remove in oil. Which I think we’re gonna do to — we haven’t gotten a third of a cc of oil out. That’s a long extraction. For the purpose of time, I’m gonna pull this out. Oh, you want to slow down somewhere else. Take it out somewhere else. We’re gonna make another incision. We’re gonna make a fourth , which is Michelle’s suggestion. And I usually do that, that’s one of the old wounds right there, avoid that. And go in a 20-gauge MVR blade here. You notice I’m not using cautery and just knowing it’s about 3 millimeters. And we’re gonna use a bigger cannula. We’re gonna do this with an 18-gauge. So I caught that — cut it open a little bit larger than 20 gauge. You can leave it open for now. But let’s just grab this, yep. Now we put an 18-gauge catheter on our viscous fluid extractor and she beveled the tip for me. Easy insertion. Now you’re gonna see a much more rapid — now I’m being a little cautious here as I apply the suction. Because I want the infusion to keep up. But you can see the oil is gonna start coming out much more quickly. And then we’ll have to sew that wound shut. But this will be much preferred time-wise to get out this thicker oil. Just be patient. I know I’m watching the lens here through the pupil. So, I can see when the oil is getting almost all the way out of the eye. With all this aspiration, we don’t to want really have the eye deflate, which can happen if we get into a pocket of fluid or if we get into the end and we start pulling fluid out of the eye instead of oil, it’s gonna come out very rapidly. Normally we’ll see a bit of a vortex like that. See the vortex through the pupil and there’s the edge of the oil. Here comes water out there have. I’ll keep my cannula away from that I got in the eye. Here comes the oil line across the pupil. And it’s coming across nicely. Is my plunger all the way up? Probably not yet, right?
>> No.
>> Dr. Miller: It’s still moving a little bit. We’re getting there. Sometimes the syringe will fill with fluid if fluid is coming in. Just let the rest of the oil. You got a forcep, we can try to express that. Let it remove passively. You can let it come out passively, if you don’t want to use the extractor or the cost of the kit. And you can let it come out. Probably what I’m Oregon do is cap that valve back on. You’re correct about that. Is we’re gonna put the valve back on the working site. You get the valve back on, not as difficult as you can think. Hold the cannula so you’re not pressing it into the eye. That’s the key part. Grab with that hand, otherwise you’re not ramming into the eye. Get the oil out. It’s a little bit easier to work in the eye without any oil whatsoever. And there’s still some in there. You can see it swinging around. And I’m gonna slow down the flow to try to get it to come over to my side. I will say, I do prefer, again, the less viscous oil. Just saves a lot of this type of problem. Michelle, you will probably take that cannula back if this thing doesn’t catch. I’m having trouble influencing that oil droplet. Oh, and there it is. That’s the last of our oil bubble. We’ll just let it work its way out. I’m gonna sew this up next. And we can bump up the infusion if we want, which will force this last bit to come out a little quicker. So, even though that bubble did not seem that large when it was swinging around inside the eye, it’s always more than you think. So, if you get in there with your instruments, and the problem is to leave it in there, you know, if you get that oil in your vitrector or your soft tip, it’s gonna have a hard time clearing itself of getting to the point of — second instrument that’s thin. Oh, there it is, good. Okay pop so that oil in the eye can be very difficult in a 25-gauge vitrectomy setup, which is what we’re doing here. Okay. I’ll sew this up. So, we’re using — looks like 7-0. And I kind of prefer 6-0 plain, but that’s all right. I think both are adequate. I think the 7-0 vicryl, a little bit inflammatory in an eye you are going to have to go back into again. I don’t make my incisions at this location. The vicryl will thin out the sclera. I try to avoid it if possible. Try to avoid any suturing if possible in these cases. I think one difference between adults and — can I get that scare squared off there? Keep going. Looks like we got most of the oil out. Looks like we do. The children we work on, we do some pediatric work, we use oil quite a bit in the children. And the children’s sclerotomy sites, even though constructed well, et cetera, tend to be so malleable that the holes kind of stay open and you get oil leaking out of the conjunctiva. Which we prefer not to have. You can do that, but less of an oil fill, foreign body sensation. If ever you’re in doubt, better sewing a sclerotomy shut over — I’ll wait for the 6- 0 to close that up at the end. Now we’re going to move on to the surgery that involves looking at the retina and seeing where we’re at. You notice I didn’t really look in the eye as we were taking the oil out. So, here I put the vitrectomy into the temporal side first, gives more room, I’m not naturally left handed, I’m right-handed. But I start with the vitrectomy temporal, more range of motion with the devices. And get this in focus for ya. And there’s a little oil bubble on the tip of my vitrector, which I would rather not have. And a quick look around here. There we go. Right. We’re gonna get the focus a little better for everybody. Including the Eye BOSS. What do you think, Michelle? How about the Eye BOSS? Can you focus the Eye BOSS for me? Michelle is using an Eye BOSS visualization system. That’s good. You can see the focus, and you can see the macular hole. Post with this instrument, the light washes things out. We have got a sub retinal membrane over here, right? We can see the macula is being dragged a little inferior temporal. The superior arcade running this way. We can see the fold up here. And how I approach a PDR case, look around, superior retina is attached, right? We got a buckle in the eye. We got contraction out here. We got dragging. We got contraction down below here right here. It gets very difficult to peel membranes in the periphery. But in the posterior, generally around the nerve and around the macula, maybe out to the equator. And from there, I think past that you’re looking at retinectomy work. And that would be within my peel range. So, with this and this, right? And this. But when you get out to here, we’re probably just gonna have to cut. And that is the big difference, As far as when to make the retinectomy, you get this, very unlikely we’re gonna peel that adequately and it’s gonna have to be cut. You can see me playing with a little bit right here.
>> Oh, they said it’s blurry.
>> Dr. Miller: Just go with our image, because it if it’s a little bit blurry with what you guys are looking at. There’s slurring there, and some of the view may go in and out as we get into the periphery, unfortunately. But what we’re gonna try here first is a little fore accept action, Michelle. What do you got from me? Great. I’ll take a disposable one, too. Because it’s very tough to peel.
>> Would you like the —
>> Dr. Miller: Yeah, the regular — I think the — I think the ILM because we’re gonna be trying to get that mac hole. These are reusable forceps here, 25 gauge. What I’m looking at was down here. As an easy — it’s always a bit more difficult to engage the retina when it’s detached. So, especially with pinch and peel because the retina moves away. So you candidate of need a sharp fair of forceps. And I do think the disposables work better for that.
>> I’ll take those ILMs.
>> Dr. Miller: You can see the purchase and the start the strip gently and you can see this membrane coming up right here. Yep, good tip. So, we’re trying to peel that take that right into the periphery, wherever it will go, and it stopped there. So, here’s the first little piece of PVR getting peeled off. Coming from up here. Now this band here is subretinal and we can get access to that when we cut the retina down, we can reach down and grab that easy enough. As far as where the peel, we look for the contraction points, right? Like the epicenter of a fold. Anything that looks like it’s under traction. Probably our best bet. So that’s why I kind of peeled here. I’m not too worried about retinal trauma. You, don’t feel bad if you make extra holes. Believe me, you’re in a bad spot being here and a couple extra stretch holes or pull holes is not gonna make or break your case. And let’s see what we got over here. These look like — so, a little bit of PVR associated with the prior — this contraction over here as a prior retinotomy, right. So, I’m gonna have to switch hands there. I think to get that. We’ll take the other forcep if you got it. I do find the disposable forceps for this type of case to be valuable. Again because they’re sharper-tipped. So, for the pinch and peel. How is our view there? So I pull gently to see what’s happening. So, I can get an idea if I’m pulling the retina or the membrane. Or both. You can see that tear down there, but that’s okay. Better to get the traction off. And sometimes this may not come out well on your view because I have to use my light as my secondhand. But I can use it to drive the membrane out in a certain way without pulling on the break. There you go. So now we got this.
>> They’re asking what gauge it is. 21.
>> Dr. Miller: This is 25 — this is a 25-gauge case instrumentation at this point. It’s all 25-gauge other than when I took out the oil with that cannula. That was an 18 gauge. You can see this cannula going out. The reason I want back to the retinotomy, and the PVR, sorry with the light, the PVR was here. You look for, you can grab it and then just see where it goes. Expecting to hopefully peel it out into the periphery. Now we’re getting out into the area that I was hoping to be able to peel at the start of the case because I didn’t want to cut this far back. You can see that out there.
>> They’re also asking how come you haven’t used a dye yet?
>> Dr. Miller: That’s a good question. The dye doesn’t stain. What we have here is ice blue — sorry, brilliant blue dye. It doesn’t stain membranes that well in detached retina or in the mid-periphery like this. I’m a little — try to use the visual clues as to where the contraction is first. And then I’ll come back with the blue to see what else I get. But at this point, I just haven’t needed it yet in terms of why. And I know you’re looking at this hole here and that’s fine. That’s gonna be incorporated into retinectomy eventually. I’m actually quite pleased. I’m going to use the light again as a fulcrum to kind of push this PVR a little further out and try and separate this. So, I’m sure some of the view here is not great. Just give us a minute. We’ll get back to it. If I can get that off. I can always cut it off there. That’s not a problem. It’s peripheral. But that’s what we wanted to do, free up this entire area and hear from contraction. It’s free. This will be incorporated into a our retinectomy. It’s right along here. So, pretty far out. Go at least a clock hour beyond that up to here. So that’s looking pretty good. And this looks pretty good. That peel looks good. The nasal part looks good. The subretinal band we’re gonna go for later. This little piece of con traction underneath I think is related to the prior membrane and/or the subretinal membrane or just the pulling way out here. But I don’t really see epiretinal tissue. Let’s see, I’m a little out of focus myself now. Yeah, we’ll redo the cornea. We’re gonna take a look. Because as we move things around, right? And I’m torquing the eye quite a bit to get to the periphery, it runs under the lid speculum, some, and it disrupts our tear film. I will tell you, any time you reset things, pull your instruments way back, out of the eye or almost out of the eye. Don’t leave your hands where you may speak in half a centimeter and the next thing you know, you’re impaling the back of the eye and you’re not even looking. Be cautious. Eventually, I want to get back to my right hand, if I can. There we go. And there we go. Very good. So, now I’m looking at — my next move is this spot right out here. That’s what’s causing this tension line. So I’m not standing again until I take out what I consider to be, you know, the low hanging fruit or the stuff that’s obvious. The stain won’t help me anyhow. And this out here, we’re never gonna get to peel this in that thin retina that is that detached. Same thing here, go posterior to this PVR. But I’ll just show you all that. All right. And I think people are probably a little surprised at the aggressiveness of the surgery with the break here and the break out here. But again, don’t let that detract you from what you’re trying to do. What you’re trying to do is get this part right, you know, right in the center, you know, the macula. So, don’t be worried about adrenergic breaks doing membrane peeling cases. We’re to the trying to make breaks, but at the same time you got to be pretty aggressive. And this here can also be part of the retinectomy. By the way, the scleral buckle is way out here. So you know, you can tell this is all posterior to the buckle which is quite common in my experience when it comes to buckling and PVR cases. Just not that helpful. You can see as I grab this how it’s gonna pull away. How the retina is gonna elevate out here. It’s gonna be a tough spot to peel. And you can do this, but you can see how it’s just gonna tear. It’s really thin from prior laser out here. And this is not gonna want to peel for us out here well at all. But it’s also far enough peripheral that I’m comfortable putting that right into my retinectomy. Come out to the edge. I had to come at least this far anyway. Same here. There’s contraction here, but again I’m gonna have to use a retinectomy and go through that area so I’m not gonna waste time there. And on this side, too. The retinectomy is gonna go through here. But I can demonstrate maybe a little bit more peeling, perhaps. Or maybe not. I can’t even get it to pick up. So just my forceps a little bit. Kind of clean them off a little bit. You can see how that’s gonna go. But you can see the membrane, too. I just don’t see the point. Yeah. So, we’re gonna cut that into the retinectomy, too. And that leafs us with the mac hole. Now my strategy is, I peeled everything in the posterior pole. We’re pretty good out towards the equator everywhere. There may be a little glint of a membrane here, which is minimal. It’s not contracting, but I can see the reflections of it. I saw it earlier when we were peeling down here. We’re gonna try and get the ILM up off the macular hole. That’s where I’ll stain. I think that’s gonna be a useful place for the stain. But out here, the stains are not gonna help me that much. We’ll see. We’ll take the brilliant blue. Sure. Off the soft tip. And you can push that in gently. And I’ll try and keep it away from — I’m not worried about it going under the retina. We’re gonna be putting PFO in and everything else. I got to get at the stain. There you go. We can put some stain out here, sure. To show you allow well it works or doesn’t work. And out here, you know. But again, brilliant blue tends to need some soaking time. So, a lot of times you don’t get great staining. When it just kind of touches the periphery.
>> I’ve got some other questions about 23 versus 25 versus 27 and how you determine —
>> Dr. Miller: I’ve operated on all the platforms, 23, 25, and 27. And 23 I haven’t used in years for anything. I prefer smaller wounds. I think the smaller the wound, the lower your chance of infections as well as leaking out tamponades and not needing sutures. I prefer 27, but for this type of case using oil, to manipulate the oil, that’s way too small. So, I normally will use 25 for all my oil cases. Oil going in and out works well at 25 without the extra incision. Also, the forceps are more robust at 25 and 27. 27 is getting a little small for me to effectively do the case. And 23 I don’t think is needed. No knock against 23. If you want to use it and that’s your game, you know I think it’s fine to go with 23. You may have to suture a little bit more on the sclerotomy. I’m going to try to not suture these. See at the end whether we have to or not. And I think we some blue there under the retina is my bet. Yeah. Michelle was questioning whether there’s oil under the retina? I don’t know about that. But… we can get that blue out and we will. I’m not worried about it. I don’t like leaving anything in the retina in the subretinal space, obviously. A couple things you can do here, right? You can use the reflux of your machine. I’m a big fan of reflux through these instruments. And you can get some of that to blow out. I’ll grab these fragments here. Let’s use aspiration here for a second. And we’ll see what happens. We can direct the infusion little bit. I’ll have Michelle do that to point it down towards the macular hole. And we’re gonna kind of flush that blue out of there. From the subretinal space. And I’m gonna grab all these fragments while we’re doing this. You can see the subretinal blue is really getting faint at this time. I don’t want to get too close. I don’t want to aspirate up the fovea up into the vitrector, being a little cautious. I don’t want to chase the subretinal blue to the macula. And shoot it in this hole, may do that, too. Sometimes — that’s all right. Oh, yeah, you’re getting it. You can see when it fluctuates and kind of flutters. The whole retina does. We’re gonna go to the contact lens and see what we can peel around this macular hole or not. I still like to use a contact lens in this setup and not peel through the wide field. Reason we’re doing that is — oh, and by the way, there’s posterior capsule still intact in this eye, which is nice. Keeps the oil from collecting on the back of the lens implants. I can cut that open and get a little better view. But the down side will be the oil will sometimes stick to the back of the lens implant, and that’s disappointing. So, we’ll get a little different view here. Now whether you’re peeling in detached retina, it’s always easy to peel from central to peripheral. And we’re gonna try the same thing here. If possible. I’m gonna try and just pinch and peel. Maybe the forcep to get this started. I think so. You got a little pick?
>> Yep.
>> Dr. Miller: We’re gonna use the — yeah, the retina is pushing away from me so easily, so mobile. So, peeling ILM, or peeling a macular hole in detached retina can be a bit frustrating. But what I’ll try and do is create an edge. A little bit of a sharper instrument. That could be a needle tip. This is gonna be a bit tricky. Because I’m not even picking up the blue that well. Maybe it was already peeled, huh? That’s a good question. We don’t have access to all the records, but it does look awfully clean. And being that he’s been through three surgeries and probably had the macula peeled using dyes, I’m suspicious that this is what Michelle just pointed out. And the way we’re not standing at all. Can you center that for me? The way we’re not standing at all, I’m suspicious that instead of this being a real even stain over this, that it’s already been peeled. And that would be quite normal for someone to have already gone through and peeled the ILM everywhere. It’s another reason I don’t jump to the stains right out of the gate looking at the PVR. It’s really about what the tension is more than what stains. And I think that’s exactly what happened here. What about the flex loop? So what we’re gonna use now is a flex loop device where I can kind of brush along the retina if nothing else. It allows us to loosen those retinal edges around the hole. Better chance of it closing. What’s the visual potential? Looking at this eye, we know the macula is off, it’s been off. Looking at the membranes, pigmented down by the nerve, I think we’re good there, actually. We have a forcep here. Yep. I’m waiting for the flex loop. Out of the room to get the flex loop. Oh, it’s coming right now. Here we go. So you know, the visual potential, right? A macular hole on closed patients at 2400 or something lifelong. This visual recovery, visual potential, probably isn’t much better than that anyhow. You don’t want to get lost with the idea of trying to do something when the visual benefit is gonna be not there and, you know, delay the case or make you — in the case — the objective of the case is let’s get — let’s get the retina reattached. You can always deal with the macular hole, too, there, when you take the oil out and the retina is attached. But you can see, we’re getting no elevation. With pretty aggressive brushing on this… on this retina. So, we’re giving nothing that’s scrolling up. I brush towards the macular hole with the goal being trying to make it a little more loose. Make the hole smaller. Take off any epiretinal proliferation that may be stretching this hole open, even if I can’t see it. So lots of different techniques going on here. Kind of pulling all the tricks out. I don’t use a loop scraper like this more than a couple times a year. You recall usually for macular holes that are really large. Or failed or something. We’re getting nothing out of that in terms of actual membranes. Okay. On with the case. We’re going back to repairing the retinal detachment. I reviewed his OCTs, the serial OCTs on this gentleman. And at one point, had a macular hole and got the edges to flatten down. I think the PFO in the wide field. Put some PFO on now in Perfluoron, put that in to hold down the retina while we’re making the peripheral retinectomy. Okay. We’ll focus that. I think we should turn the radio off. There’s like no — just turn a all the way to zero. Yep. There you go. So, here we go. PFO is coming in. We start at the nerve. Look at it enlarged. Don’t worry about it going into the holes. It should relax, and push it flat like a steam roller. And there you are. Keep going. Put a little bit bigger bubble in. This bubble can’t be too big. That’s good, we’ll stop there. It’s Just enough to hold the peripheral down — the central retina down while we’re working some in the periphery. Because I will roll this over, I don’t want it in my way. But you can see how this is gonna lay down real nice like we are. So, we take the cautery. We’re gonna cauterize some in the periphery where I think you’re most likely to experience bleeding. And so look at major vessels, right? And then also the mark so we can find ourselves easily enough at a later time when it’s time to do the laser work. I don’t think you need to cauterize all the way around. Most people will. But over the years, I’ve gotten away from that. I’ve kind of used the cautery more as a guide to where I’m going. And I’ll deal with the bleeding second. And so, we’re gonna take this retinectomy all the way up to here, all the way to the attached retina. And on the other side, I’ll switch hands. On the other side I want to mark it over here. We’ll incorporate all this into our retinectomy. And I want to get at least a clock hour or more above all of this. And I’ll show you guys where I’m gonna spelter pressure to show you what mean by that. You got a spelter pressure here? Depress here temporally and you can see where my cautery ends is basic I up in attached retina. And you see something that’s not a problem. When it comes to making the retinectomy, you want to go farther than you think by about one clock hour. And the most important thing that fails in retinectomy techniques is the surgeon was not aggressive enough and left it the a clock hour short. And though people don’t like the idea of cutting the retina, right? Maybe a little bit of the eyeballs here. We’re gonna get that into focus for ya. Because this is interesting here. You can see this looping piece right here. No good. So, we have to do something here. That’s my cannula, yeah, sorry, okay. Basically I have to go farther than what I — the cautery is right to here. So, we’ll just have to talk that all out. Okay. I’m gonna have Michelle depress that a little bit. I’m gonna take the cutter. We’re gonna do our retinectomy. I don’t worry about fancy modes or settings for cutting out a piece of the retina. I can control the aspiration with my foot and I’m pretty comfortable with that. So, you know, we’re under very low aspiration. I do like to amputate the anterior piece of it. And go a little bit more superior for me. Right. So again, the goal here is to go further than you think. Give us some anterior loop traction in this area in particular. Which you can sometimes — put the pressure up for me, too? Yeah, got a little bit of a bleed. Control that with pressure and kind of save myself some cautery. If I can save cautery at the end of the day — if I can save cautery action, it’s less inflammation in the eye. So that’s what we’re trying to do there. And we’re gonna cut. You can come off, Michelle. Okay. So, there’s our first — focus that, great. So we’re trying to make a free edge here that’s still rolled. If it’s still rolling on you, then you’re not far enough back. This is pretty free. And that bleeding stopped here in response to the pressure going up to 60. I do not shy away from using interocular pressure as a third tool. People, I think, quite often underestimate it as their third hand. And so, they get in there with cautery right away, I can kind of just — I can — and I’m gonna take all this out. Yeah, right. She’s pointing out the subretinal band. But we’re gonna get to that in time.
>> I mean, the ones over here.
>> Yep. Yep. Nasally. Again, we’re trying to get a nice, clean edge. But, of course, the peripheral is possible still. So, I can live with that. I like how that looks. A little bit more focus there? I like that better. We’re trying to keep this in as good of focus as we can for you guys. Sometimes when the retina gets real flat like this with the retinectomy, you want to be careful. Because you don’t to want cut the RPE, it causes bleeding. Sometimes I aspirate and go up a little bit, just to make the retinectomy a little easier without hitting the RPE just like that. Now what she’s looking at is the subretinal bands down below here. I find the vitrector really good at lysing over this be, just running over it. And they’re all broken. And if we can get it to kind of snap into the vitrector, they generally pull out easily. Those are gone. I’m gonna switch hands and continue. But always looking at the edge. Do I like the edge I got? This looks a little rolled, still. Another subretinal band right there. And reflex, because my vitrector jumped in. Maybe I’ll switch hands and get little bit more off this edge right here as I work my way around to the temporal side. End up with something over 180 degrees for the retinectomy. I would say we’re going to end up at 7 to 8 clock hours. Okay. I’m not a fan of that right there. And that’s how you can use the reflex to shoot it out. Just taking off a little bit if I can. I think this always run away from you, you can end up chewing away more than you wanted. So, I tried to be as cautious as I can there. There we go, I’d like that. Now we’re gonna go back to extending our retinectomy around. I’m gonna go with aspiration again so I can get some elevation between the retina and the RPE. Whoop. Hang on there, you’re doing fine.Let see. I can always start over here. We’re running into some of the laser scarring on this side posterior to my retinectomy. It’s holding me up. So, what we’re gonna do is try to grab the retina out here and peel it up a little bit. Like that. Same thing here. I can always reflux instead of cutting it off. Here almost tempted to make two retinectomies, a nasal and another one, there’s so much contraction. But I think it’s not going to work. I think always more aggression is better. Probably the PFO is holding me back, too. So, I’m gonna pull some of the PFO out, just with the vitrector. There you go. That way it will… sometimes that’s useful, someone asked about a radial retinectomy. I don’t see the need here. So now we’re free on the inferior half. And look at the lack of bleeding, even though we didn’t cauterize everywhere. I think that’s worth pointing out. And that’s extending radially there a little bit. As far as a retinectomy, we have a tiny one here. Unintentional. So, we’re gonna put that back down just like that. Again, the reflex is another third hand you can use besides the eye pressure. So, keep that in mind as you’re going along. And I don’t like this edge, right? So we’re gonna get that edge a little cleaner. Because it’s rolling. And now we’re gonna go down here and see what we got under the retina. And maybe… we can grab it with the vitrector again. And if you don’t get the membrane out, but you break it, probably just as effective. Let’s pull the PFO out. I want to save it. If I pull it out with the vitrector, I may be short PFO at the end of the case. So, we’re gonna pull it out with the soft tip and I’m gonna flip the retina up and work on the backside a little bit. Go ahead and grab all that, yeah. You can see how nicely it stayed. That’s good. How nicely it stayed pre-retinal. Sure. We’re just gonna re-lubricate here and get a better view. Thanks, everyone, for sticking with us. I know we’re running probably even a little longer I was thinking. But for a PVR case, I think not that uncommon. I’m sure the lighting here is a little bit difficult from everyone. But I’m trying to get a view. Let’s see, is that… can we focus right there? Indeed. No, not without cutting it more. Which I can do. So, we’re folding the retina up, looking underneath. Trying to see all the tension points. This was one of them from the subretinal band. But it’s done. But the retina is little bit folded there. And I don’t know that we can necessarily — that — right. Right here, yeah. That’s the bandwidth snapped free. So, you don’t have to get there that. We probably can. Because we would cut this a little further and reach a little further. So, you could see. Michelle’s — I had the same interest in getting that piece out. If I can, it just seems like we’re right there, why not? But also not that easy. So we cut a little bit more of the attached retina away. And that’s gonna bleed a little bit more. Those vessels are going to be bigger. We’re gonna try and get that band again. And the band came out, except the last the piece back there which isn’t tethered to anything. I think we’re fine. Now it’s just a matter of laying the retina down. Cauterizing. Take the cautery first, take the pressure and see where it’s bleeding. Now we’re going to systemically take care of our hemostasis. Kind of get the retina ready to be positioned and lasered. Right out of the gate, I’m going to cauterize the retinectomy, and hit a couple of big vessels that I expect to bleed as we lower the pressure. And we’re another 25 now and very little bleeding. Right? So, any bleeding anywhere? That’s bothering you. I don’t see any leaking out. We’re in good shape. We’ll put the PFO back in and here’s the last remnant of that subretinal band. But again, as long as it’s no longer connected, you don’t get tension. And subretinal bands are generally very forgiving in terms of not holding retinal tension. I think we got some — a bit of a fold — this fold in the retina here is not that bad. It’s — you can see the vessel still completely. The vessel is not disappearing into a crevice, you know? So we know the fold isn’t deep. Okay. We’re good. And here goes our PFO again. I don’t worry too much about subretinal PFO either, you can get it, but you can easily evacuate it, especially in a big retinectomy case like this, fold the retina up and take it out. And if you think the retina is getting caught, stop for a second. Make sure it’s gonna go where we want it. Okay. Keep going. I just inject over the optic nerve so we’re not shooting through the retinal hole or through a — site. And she’s gently putting the PFO in. And this retina is gonna unfold itself nicely. And the edges look quite nice. Stop again. I just do that a little bit sometimes to help the edge where I want it to go. Okay. Keep going. And helps to have a talented assistant. Michelle has been doing this with me 20-some years. And recently now doubles as the medical editor for everybody. Which has been quite good. Very successful year as a medical editor. Okay. Keep going. We’re going. And the retina always looks good under the PFO. Which I was showing in a moment. And do this nice and slow. Keeps unfolding. And sometimes there seems to be a misconception about how to use the PFO, but for the most part, it doesn’t want to go — that touch there, you can keep going. We’ll work around it. We’ll clear the view in a second. The PFO, interesting, it does not want to go up under the retina. And roll under the edges, and don’t worry about it going under. The only way to go under is if the retina is held up by a band or some type of severe traction. If the PFO is running under the retina, that’s more proof that you did not go far enough. Keep going with the retinectomy, where we are, just keep putting in the PFO and everything flattens out and the PFO stays on this side of the retina. Very nice. Keep going. I tend to almost fill it up right to the incision sites. There’s no advantage in being under-filled. That’s good. Okay. We’re gonna clear the view. And take the laser. And from here, we kind of know how it’s gonna go. Touched again, Michelle. That wasn’t too smart. So, anyhow, clear the view again. Look at our laser. We are using an adjustable laser probe here. Show you that in a second. So a 25-gauge flexible laser probe. Trying to get the view a little better. Hang on. We’re flat out here. It’s to the quite — this fold was there from the start with all the tension. And we’ll have to cut this out yet when we back it out. We put the lazier in now along the edges. And I don’t think you need more than just a couple rows here. Again, it’s all about the retina with wants to stay attached, if the tension is off and the edges are fresh, you’re good. You’re never gonna be for PVR with nor laser. You’re going to incite the laser. The trick isn’t in the lasering, it’s everything before the lasering. And so, just two rows of moderate burns, heavier burns are probably more inflammatory. So, I don’t like to make, you know, white hot burns. And you can just — you have to find the edge, the PFO. Another trick is that the PFO will boil if the retina is not covering up the RPE. So, if you hit the RPE, generate the heat. I can show you that — see the bubbles? You are boiling the PFO, there’s no retina there. You’re not lasering in the right spot. I should not get bubbles if you’re lasering the retina, not just the RPE. A few bubbles is fine, of course. But just you know that’s probably an indication you’re lasering in the wrong spot. Here. I like how all this came out. Very good. A little brighter over here. I want some brighter burns. So, you probably noticed I’m to the doing six rows or something. This is the part that looks abnormal to me is right here still. I don’t see the vessel in that. That was the subretinal bands under that area. We’re gonna leave that alone and just continue with the case. But all the contraction and pulling, there can be some memory to the retina. It takes a while to kind of unfold itself. Which it can do with the oil in the eye and time. Get my laser ready here, get my light pointed the right way again. There we go. Did I — am I deflating or something? No? Okay. Let’s focus that a little bit. There you go. So we’re just going along the edge. Couple rows. Again, very little cautery. Cautery also tends to chew up more retina, you know? Like you start doing the vitrectomy on the cautery burns, you end up taking out more retina than you wanted. A little bit of bleeding there, not much. Not worried about the blood in the inferior area. If I find it, I’ll cauterize it. Baa it was probably there at the start. And the question is, how far do we go? Well, we’re gonna have Michelle come over and depress and show me where I get to quit lasering. Which I know is somewhere up in this area. So, depress superior nasal.
>> A little pressure check. How are you doing down there?
>> Dr. Miller: We’re doing this under a local, by the way. Those who are wondering. Patient’s awake. Right, patient’s awake and we have some IV sedation a little bit. Not much, I don’t think. And hang on one second. Gonna have to get just by back and not in. There you go. And certainly helps to have a good block. Alex put that in at the start of the case. And, you know, I think anesthesia, certainly it’s much easier to work without the patient. But it doesn’t have to be a general case because it’s complex. I guess that’s my other point.
>> Are you feeling that?
>>> We can always supplement the block. Because he’s starting to feel a little bit. But almost done. So, I’m not going to bother. Because we are done. That’s the end of the laser. And I’m gonna take out — I think the vitrector first. I think we’re okay. We’re done with the laser, don’t done with the pressing. Good point. Michelle pointed out, got a tear down by the old retinotomy, of course. Let me get the light correct. So my experience in retinotomy, they stay flexed because no traction, the oil is gonna cover easily. You don’t have to kill this area with laser. Just enough to make a gentle reaction. And because it was a bit large, I’m just gonna around the whole thing right down to the nerve. I know we don’t like to get so close to the nerve. But I was committed to that when the retinotomy was first made here and it tore open. That’s fine. I’m pretty good with that. Any questions? Let’s see, Michelle, anything else? A little bit of whiteness everywhere. I’ll take the vitrector now. Pull a little bit of the PFO and excise some of the anterior retina that we left in the eye. Down here. Okay. So even though we’re under PFO, I can excise this. And frankly, I can just take this right down to there because I don’t need the PFO in this area. And looking at the fluid, which is easier. If the retina is down, like this one is, I just take off the flap. I don’t chase all the retina out. The peripheral retina is scarred down. We’ll leave it. Same down here. This is not going to impact the case other than forming cyclitic membranes, which I’m trying to lower the risk of by taking away the anterior scaffolding or the retinectomy material that could lead to that. But it’s not worth causing a hemorrhage over so we’re not gonna chase it. I’ll take the soft tip. We’ll go to air. So now we’re doing our air fluid exchange. I don’t go straight from PFO to oil. I’ve done that before. It is a — certainly can be a nice technique. And when I was using it years ago, I ended up just kind of not being worth the learning curve perhaps, and the extra change over in equipment, you know, the high pressure infusion lines, et cetera. So, first we take out the liquid on top of the PFO. The BSS. And that’s how we’re gonna avoid slipping. So, we’re taking out fluid, fluid, fluid. And we’re gonna try and get down to the edge of the oil which is down there, the PFO, that is. Getting close. So, take out all the water first. Right where the water meets the POP PFO, then back the PFO up a little bit more. And I’m rotating the eye inferior a lot while I’m doing this. Trying to get all the water. The BSS, to run. Back here. Come right down on the edge. Grab all the water before it runs under the edge. The last thing we’re gonna do is grab the PFO from over the macula and the optic nerve. But this looks nice and dry down here. You can check a few spots along the edge, but typically if you’re at the most posterior spot, you’re pretty good. The most posterior spot for us has been the temporal. Inferior temporal. And you’re gonna find very little PFO left here in the middle. Maybe a little, little bit. And that’s about it. So, there’s our reattached retina. And you can see under the air, the big retinectomy, you know?
>> Of the glare, there.
>> Dr. Miller: Right. So, that’s where we’re at. And we’re gonna leave it right there with oil in the eye. Turn it down. Go talk to them. Alex?
>> Well, not now.
>> Dr. Miller: Well, it’s the cornea. Can you fix the cornea. We’ll show everyone again. Drop it in there. She’s wondering if you could —
>> Get a better view.
>> Dr. Miller: There’s something on the bottom of the lens, Michelle. Go ahead, you have to move a little bit? That’s fine. Okay. Go ahead. There you go. So there’s our retinal detachment repair under air. We’ll put in the oil. And that’s it. Okay. So, we’re gonna put the oil in. I’m gonna pull this one over here. And you can see the air coming out. I’m just gonna try and tamponade that. We’ll put the pressure down to like 10. And the oil is being injected. I can see it making a little reflex there through the pupil. Can you scrub for me? Scrub in? It’s already 10:30 so we’re running a little bit long. I’m gonna maybe jump to the lecture while you’re doing some of this. Here it comes across the back of the lens implant. You have the Q-tip there. Let’s dry this up a little bit. We’re rotating the globe away from where I’m injecting. And this seems to have quit leaking air. As the oil comes across the back of the lens implant, you’ll see me flatten this out a little bit. Be careful of the pressures. And I’m waiting for the oil to come up. When the oil comes up the infusion line, then I know I’m in the right spot. Gently and slowly. So, I don’t want to get too fast on that. Now we check our incision sites and we’re gonna pull this one. Got a Q-tip there, Michelle? We’re gonna hold that a little bit. We got some local to spread over the top. Can you lower the pressure down to 5, even? Sure. Just some local medication there. Doing fine, Charles.
>> That one spot.
>> Dr. Miller: Yeah, we gotcha. Let the oil come out here because the pressure is a little firm. Okay. Alex is gonna sew up that last sclerotomy site for me. Not sew them up, but the conjunctiva. Okay? And I think we can cover some things. I’m gonna take a quick break and I’ll be right — right back. Just let them watch the surgery for a second. Finishing up the close, all wrapped up, everything is oil tight. So, again, we didn’t have to suture the sclerotomy site. And I can answer a few questions and then we’ll go over the slide presentations also. There we go. That’s good. Yeah. So you know, let me answer a few questions and then we’ll go back to the slide deck. What are the indications for the retinectomy, radial, and circumferential? It’s all about where the traction is, you know? If the retina is rolling all the way down to the optic disc, you have one of two things, up epiretinal tissue still on the retina that needs to be peeled, the posterior peeling, or there’s so much retina shortening that you’re in a really bad spot. You can make a postage stamp retinectomy where you cut the retina all the way down and see the outside of the arcades of the disc. And those go very poor in terms of success and visual outcome, too. If your case is that bad, you’re probably approaching inoperable. Your best bet is to try to peel every part of epiretinal tissue and even subretinal tissue and see if that won’t relieve that folding down to the disc. In some cases, I get that, too, and you’re just kind of stuck. Next question is, if it’s funnel-shaped, what is the ideal time for sill done removal? You know, we didn’t talk about this yet or the positioning, I’m going to cover that. I’ll have my patients face down for one day and then upright after that. And then I have them sleep on their left or right side face down for a couple weeks. But during the day, they can be upright after the first day. Once I know the aqueous is circulating through the eye, coming to the front, oil, going back to the back, I’m comfortable, won’t have a pupillary glaucoma, and I find that upright is quite sufficient for these patient after doing this for 30 years. So, I really don’t think you need food face down positioning for the day or two weeks. I have colleagues who do that. I think many people feel that’s necessary. But it’s probably not true. I think if you experiment with yourselves a little bit or read up ton more, you will with surprised with what you can get away with in positioning. As far as taking the oil out, I generally wait 90 days or more. I’m at least three months, sometimes four or five or six. Sometimes there’s oil for life cases. You can’t take the oil out. There’s gonna be no improvement in vision, it’s well-tolerated. Most part, a case like this, come back in three to four months and remove the oil and see where we’re at. I think we have a very good chance of success in this case, 80 to 90%, leaving the room, from where we’re at right now. because we accomplished the goals of the case and looks good. Another question from Matilda, use of methotrexate. I think this would be a reasonable case for methotrexate. I won’t be doing his post-op care and not many of the surgeons in the United States are using methotrexate. He’s from farther away, and won’t be in the post-op clinic. That’s kind of what necessitated me not recommending methotrexate in this particular case. And I was using it, I would have injected it right here on the table directly into the oil, inject it again at one week. And then probably would have injected two weeks after that and two weeks again. And then three weeks after that and three weeks again. Working up to a total of eight to ten injections, watching it as it goes. I do tend to use it in more extreme cases like this. Yeah, then the other question is, what performing a retinectomy and the primary surgery result in a better outcome as opposed to waiting until a re-detachment. I think the sooner you can fix a retina, you know, the better off it is. So, perhaps if the third surgery was more aggressive and not using just a buckle, by using — but jumping to a retinectomy, I would say in hindsight in this case, yes. So, at the most part, I think being more aggressive sooner can be quite useful. Someone asked if the fourth incision is prudent. I made a fourth incision there to take out the oil. And I’ve up to five and six incisions in an eye. It’s all about how you construct them and put them back together. There’s really no limit to how many wounds you can make around the pars plana. How do I decide where to someplace the sclerotomy? Kind of the basics of vitrectomy. Generally 3 millimeters back, 3 to 4 millimeters back for most cases, and I tend to rotate the eye a lot. And the cause of the PVR from an anonymous questioner, in this case, the recurrent detachment with the RPE with the giant tear, the giant tear, the previous surgery, and there’s a higher risk of PVR. Take a quick little scan of a few more questions. I did not use any vitreolytic agents. A chandelier could be useful in helping to manipulate the retina. Like when I was flipping it around using the light pipe. I tend to use a bimanual technique using the light pipe. But I could sigh sometimes where we could hold the retina aside and I used chandelier techniques, and not found them to add that much in this type of procedure for me. I would think that — let’s see… another question here… again, another question asking how to see the epiretinal tissue. You know what? You don’t see the epiretinal tissue whether you’re in that case. Point out, go to the traction points, see the radial lines of traction. And you know there has to be an epiretinal membrane around there. Look around it more than looking for the tissue itself. That would be my tips for peeling in a PVR case. I think staining with the dyes could be useful. Question here from Shahira, can you do it under light? You can. I think brilliant blue doesn’t stain as well as the IC Green. We can’t use that anymore with the compounding rules in this country. We went with the blue, it’s probably not as good of an agent for staining the ILM in particular. If we get a chance, we’ll post the OCT preoperatively to show you the macular hole. The edges were actual flat on one of the pre-op scans. And probably prior, and reattached in a prior surgery. I just did not reoppose. Question here from Emma asking about a diamond dusted scraper-initiated peel. That works, too. The flex loop and the diamond-dusted scraper are somewhat equivalent. Either one is adequate, but I probably never use both. Question from anonymous: Is there a definite end point in an oil exchange that tells the surgeon you have achieved a total exchange? You know, when the oil is coming up going across the back of the lens implant, you’re virtually there. And what I really still use is the infusion cannula as oil backs its way up the infusion cannula. I do at that point feel that’s the adequate fill point and that’s our traditional training and teaching here. And the thing that we have to be careful, the infusion cannula is small, it takes a while to work its way up there. You don’t want to over-fill the eye, trying to force oil up that cannula when you know it’s getting close to back off the infusion pressure. Can we use a retinal autograph for the macular hole? I wouldn’t do that in this case. This is probably the visual potential being somewhat poor. Multiple macular off-retinal detachments in addition to the PVR and everything else. I don’t think this would be a great case do get as radical as using a retinal autograph. Autographed for the whole. A question about — from Fabian about whether I use triamcinolone. I can when I’m chasing the vitreous in particular. But if the vitreous is up and you have a PVD, I find it less useful than the stains and just going by the contraction points. Questions from anonymous about what is the pressure when injecting Perfluoron. I would say it’s being done by hands and it’s gentle. As low as 10 to 20 millimeters of mercury, it’s set there, and probably more like 30 millimeters of mercury. Question Mohammad about silicone oil, how do you know when the cure is worse than the disease? Silicone oil can be well-tolerated. I think he’s referring to complications, glaucoma, elevated eye pressure, emulsification. I’m not a big fan of oil for life for those reasons. It can cause those long-term. But without complications up to 3 or 6 months easily. I think oil can be a real help in these cases. In this case, looking at leaving the oil in from — asked how long to leave the oil in. I mentioned that before, 3 to 4 months. And maybe the rest I will answer online. The questions are coming in. I appreciate your attentiveness. These are great questions. One down here from Jose Antonia, would I consider leaving the eye aphakic? Which I was doing a case like this, and the PVR is this severe, and concerned about cyclitic membrane formation and hypotony. And the only way to beat that is when I take out the lens, take out all the lens capsules and zonule structures with it, try to remove the scaffolding for that proliferation around the ciliary body. So, I prefer aphakia, actually, if I get into a case that far along. Once they’re pseudophakic, not a big fan of taking out the IOL and the capsule. But I can at least depress and work in those areas. So, maybe we’ll go back to the questions and just review those quickly, Andy, and we’ll wrap it up. For everyone. Just starting our next case, everyone. Okay. Sounds good, thanks. Doing our time out. So, a relaxing retinectomy is indicated when? And the answers, if Andy is able to pull those back up are what people answered. And it’s A, the retina can be attached without tension after peeling. That would be the opposite. So, the answer is B, which most of the audience was correct in. When subretinal and epiretinal peeling fails to attach the retina, a retinectomy is needed. In this case, I could see the tension in the periphery, I already had large tears. It was virtually a planned retinectomy going into the case. Next question? A single-operation success rate for Grady CPVR? Probably 60 to 75%. And most of you got that correct. 30 to 40% was the second choice. So, the thing that’s variable here is grade C PVR can be quite variable. This was an extreme case. I felt this was a fairly extreme case of PVR with what we peeled off the back of the eye and the size of the retinectomy and how posterior it has to be. None of those are my favorite. If the buckle wasn’t there and we didn’t have the scarring already in place, we could push that retinectomy farther out. But not the situation. But anyhow, 60 to 75% is a nice answer. And after multiple surgeries, probably approaching 90% plus. The third question was: Is silicone oil preferred over long-acting gas when? Patients cannot position, chronic PVR, or inferior breaks. I agree with all three of those. You know? The — shall we say when all the breaks are superior and minimal, get away with gas. Gas tends to float up and do a great job. I don’t worry too much about the glaucoma and the oil. We don’t typically get into trouble. And answer D. So, go to quiz question four. And Perfluoron is primarily used inter-operatively to? Stabilize the posterior pole and prevent slippage during an air/fluid exchange. That is correct. We don’t use Perfluoron in tamponade, I have in serious cases. And sandwich against the RPE and push out the fluid and get the laser in. Thank you for attending and we’re gonna move on with our next case which at this point is also a PVR case. I think it’s oil in the eye we’re taking out and smaller complications than what you saw in the last patient. But we should be able to get — get that done in less time. This has been a pretty long production so I think we’re gonna hang it up here for Cybersight. But always happy to answer questions by email or on the Cybersight platform. Thanks for attending.