Lecture: Update on Retinal Detachment: Tears & Floaters

During this live webinar, we will review current options of retinal detachment repair, retinal tears, and management of proliferative vitreoretinopathy (PVR). We will also look at floaters and its implications for treatment.

Lecturer: Dr. Gaurav Shah, Ophthalmologist, The Retina Institute, United States

Transcript

DR SHAH: Good morning, everybody. Let me share my screen with you. I appreciate you guys joining. So good morning, good afternoon, or good evening, wherever you guys are at. So today we’re gonna talk about floaters, tears, retinal detachments, a primer. I will go through some slides, quicker rather than slower with others. So we’ll get to the main point of the topic. We’re gonna talk about retinal tears, floaters, wide angle imaging, repair retinal detachment timing, and some anterior segment issues. So these are some infrared photographs that show a vitreous hemorrhage with the retinal tear. I find these to be quite useful. But we’re often faced with patients such as this who come in with a vitreous hemorrhage and have tears and/or detachment, so a common dilemma we face: When we have a phakic patient with a spontaneous dense vitreous hemorrhage with no history — what do we do? Images on B scan. There’s a question of early versus delayed vitrectomy for these patients. We published on this and I’m gonna go through what we found. This is a frequent reason for referral to us and to general ophthalmology. Ultrasound is useful as an adjunct, but it’s gonna miss these low lying detachments. The options include observation or early surgical intervention. Here’s a patient that shows vitreous hemorrhage, on the left, and here’s on the right. A retinal detachment. That another patient had as well. So we look at these patients, and we’re talking really about grade 3 and grade 4 hemorrhages, hemorrhages that are too dense to allow visualization of the optic disc. Not grade 0, 1, or 2. So what do we recommend? Do we wait? Do we do surgery? Does it matter? Phakic, pseudophakic, blood thinners, and are there other factors to consider? Etiology is typically retinal vascular disease if it’s not retinal tears. But the most common in these patients after retinal vascular disease is tear and/or detachment. If you look at the ultrasound detection, detection on ultrasound for both retinal tears and detachment really wasn’t as great as we would think. Detachment was about 54%, and tears about 20% or so. So we know that small gauge surgery has good outcomes. And there’s really low risk of complications. Certainly it’s not zero. But there’s not — it’s a low risk compared to before. I always tell our fellows and my patients that if I can’t see in and you can’t see out, it’s really hard to guess what happens in these patients, in terms of what they have. So we looked at… Looking at the surgical and visual outcomes for patients, non-diabetic, fundus vitreous hemorrhages, that underwent early or delayed vitrectomy, and we looked at this over a five-year period, and all patients underwent B scan. If there’s a high suspicion of tears or detachment, obviously surgery was performed. So we excluded those patients. We had 275 patients, 52 eyes of 52 patients, average age 61. Discretion of the clinician — early was less than 10 days. Later was after the 10 days. They underwent standard 23 or 27 — typically most of my cases for retina I do 27. Sometimes 25. We hardly ever do 23. But again, that doesn’t really make a difference. The gauge doesn’t make a difference for this. So here’s a patient. A video. Who was found to have a vitreous hemorrhage. And you can see dense vitreous hemorrhage, as we’re removing the hemorrhage… And as we remove the hemorrhage, you can see down below, we have never really seen this, because there’s blood down below. Even on ultrasound, it would have been difficult. So she had a tear up above. A pretty large break. Also tear down below. And you can see that most patients — and here’s the break, down below, get a vitreous hemorrhage for unknown reason, but typically tears and/or detachment. This would have been missed and the patient would not have done well. And they’ve actually done well, with vision returning to 20/20 actually, so again, this is 27-gauge surgery. I just cauterized the incisions with the conj over it. So what do we find? Retinal tears, retinal detachments, as you can see, in about 75% of these patients. And if you look at the initial and final visual acuity, the p-value is 0.67, because obviously our numbers are small. So there was no statistically significant difference in the visual outcomes. But the number of operations, when we looked at the larger group, did vary between the groups. The type of tamponade did not vary either. What we did find was sensitivity for retinal tears was 24% and detachment 58%. So a large number of detachments and tears were missed, despite having ultrasound. Of the 16 eyes with retinal detachment, 12 were phakic, 4 were pseudophakic, and this did not achieve statistical significance. Again, the numbers were small. So our results show that there’s a high rate of retinal tears and detachment in these dense vitreous hemorrhages. Although early vitrectomy did raise visual outcomes, it did show suspicion for the treating physician that the ultrasound was only able to show a quarter of tears and detachment, 50%. What’s interesting is that phakics had a higher issue of retinal detachment than pseudophakic eyes. I think the odds ratio was 2.14. This shows the abnormal vitreoretinal interfaces that are incomplete. So we think early vitrectomy is safe and effective and can certainly be very useful in these patients. We all know myopia is a worldwide epidemic and we expect this condition to increase over time. So really young phakic myopes are the highest risk for retinal tears and detachment, and my conclusion would be: If they can’t see out and you can’t see in, just don’t rely on the ultrasound. Now, where would I put the use of OCT in some of these patients who come in just with an acute PVD? Can that tell us something about maybe a small amount of hemorrhage that has been noted and missed in a clinical sign on examination? We know that Shaffer’s sign is presence of photoreceptors or tobacco dust. OCT has been shown to demonstrate these posterior vitreous opacities that may correlate with these signs. So we want to look at sensitivity and specificity of these findings. So this was a retrospective chart review by us. And we did masked qualitative review of SD OCTs by single reviewer to identify these PVOs. And they were considered positive if 3+ opacities were seen in the vitreous. Sensitivity and specificity of presence of PVOs was then calculated. So this was looking at demographics, and comparisons of patients with a break or PVOs against those without. You can see in this chart and I’ll go through the data. So when we looked at it, the presence or absence of PVOs with and without breaks, if you look at all breaks down here, in patients without vitreous hemorrhages, the sensitivity was 76%, specificity, 75%, sensitivity 82%, and specificity 86%. So in patients with systematic PVD, the presence of these things that we see right here, and this is easy to get, correlates with the presence of a retinal break. The absence of the opacities makes it much less likely the retinal break is present. So almost — there’s a 9/10 chance there’s a break if you see these findings on OCT. So that’s really important. And if you see that without a vitreous hemorrhage, but you see these findings, then you’ve really got to look carefully for a retinal break. So that’s a very important take-home message with imaging. Now, we also often get asked about floaters and the management of floaters. It’s a common thing that a lot of our patients complain about. Both primarily, from just a PVD, and/or let’s say status post scleral buckling surgery. So 71-year-old female presents with floaters, recent cataract surgery, vision worse after surgery, and this is what she sees. She sees this big glob. And I use the infrared video on the Heidelberg. It works really well. If you have a machine like this, it’s really important to use it. And we can see what she’s seeing. In this patient, it’s really the quality of vision that makes the big difference. And we need to make sure that we understand the terminology myodesopsias are floaters and vision degrading myodesopsias are clinically significant floaters. So you’ve got to make sure — the terminology is important. You can also look at contrast sensitivity function, quantitative ultrasound, or the visual function questionnaire. We don’t typically use this. But we probably should. But a functional questionnaire is quite important for these patients. Multifocal lens really makes it difficult, since you have different areas of near and far focus with these different types of refractive IOLs. And makes floaters even more prominent, as you can see here. So what all these do is decrease the contrast sensitivity. So therapeutic options really are observation. Not sure about psychological counseling. Vitrase, which we don’t have, holistic treatments, YAG laser, or vitrectomy. And there are a lot of people who do YAG for floaters. I certainly have not done it. Because we think vitrectomy is a really good option, along with observation. You know, in this procedure, you’re kind of moving the problem from one area of the eye to the other area. So YAG vitreolysis — there was a randomized clinical trial in 2017. This was for symptomatic Weiss ring. Not floaters only. But just for symptomatic Weiss ring. They looked at the BCVA and fundus. And did observation for six months with a qualitative scale. At 6 months, YAG was superior to sham, but there was no difference in visual acuity. So there’s a moderate improvement. Small sample size, limited follow-up, no comparison to PPV. And Weiss rings only. A lot of these patients will have anterior and posterior PVD. The anterior PVD is the anterior vitreous that will cause the problem that this will do nothing for. Also no contrast sensitivity function assessment for these patients. This was another study in 2019. Of 132 eyes. And these are the different outcome measures. And in the interests of time, I’m not gonna go through all these. But it basically showed that there’s a limited benefit of YAG for these patients. Certainly I think that it’s… If that’s all you have, and you want to attempt this, I don’t think there’s any danger in doing this. But you have to remember that it is not always as successful as we think for moving a Weiss ring back and forth. This was another study from 2019 of a limited vitrectomy. And again, when I do a vitrectomy for these patients, I think it’s important to remove the hyaloid, make sure you have a PVD, induce a PVD. Typically they should have a PVD, if you pick the right patients. And then do vitrectomy for them. And these are the outcome measures. In this study. With contrast sensitivity. They also did a cost utility analysis as well. And this was looking at the cost utility analysis. And this is a subgroup analysis. And look at the cost effectiveness for this procedure. So there’s a significant improvement in all outcome measures. It was cost effective. Vitrectomy — the adverse events, cataract formation, retinal detachment. Small sample size. And my rule is they must be pseudophakic if you attempt this, because only then can you make sure you remove all of the vitreous in these patients. And again, there’s no studies that have really looked at one versus the other. This is looking at a flow sheet that shows the Cochrane database for vitreolysis versus vitrectomy. So what about topical anesthesia? This is a study from 2018 from China, looking at 27-gauge PPV for floaters. They looked at analog pain scales. Typically when I do surgery for this, I do them topically. And this is the pain scale they used. The problem is that in these patients — this was unclear, the extent of vitrectomy performed, and there’s no stratification by PVD in these eyes. So we want to look at our experience with topical anesthesia for vitrectomy for certain diagnoses such as floaters. And we published this back in 2018. This was a prospective study. Patients were selected primarily if they could cooperate in the clinic, and lack of significant squeezing with instillation of drops. For anesthetic approach we used proparacaine and lidocaine gel at the beginning of surgery, which is washed off. If needed, rescue was available. But this was really not needed. And these are the patients that we operated on. 37 eyes with different diagnoses. Vitreous hemorrhage, VMT, submacular hemorrhage, vitreous opacity, and endophthalmitis. Excluded conditions, such as retinal detachment — cases require peeling, extensive endolaser, or prolonged surgical time. Let’s see if this video plays. Modern technology. It was playing before. But we’ll go to the next one. This slide seems to be stuck. Okay. Anyway, that video is not playing, but I have another video to show you. This shows you day one the presentation. You can’t even see which eye had surgery. And the characteristics in our group were 72 years of age. Who was the mean age. We did have our fellows participate in surgery, greater than 90% of the cases. And the data we collected was the most painful steps. Amount of liquid… Amount of IV anesthetic that was used. And the perceived adequacy of anesthesia. And this was a pain scale we used. And we collected this data. And this basically showed you the amount of pain at each time. So trocars, endolaser, scleral depression, and conjunctival closing. So the mean pain score was 0.7. Quite low. Three patients presented with greater pain. They all had a corneal epithelial defect. And this was due to a pH problem with the corneal lubricant. No defects otherwise were encountered when the change was made, and the mean postoperative week one pain score was 0/10. No predictable risk factors for pain scores 3 and higher. It really depends on cognitive experience, maybe their emotional state, maybe cultural background. But it was… Not unusual for most — if not all of these patients — to feel almost minimal to no pain. We also looked at the supplemental IV anesthesia that was given in topical cases, retrobulbar, and you can see that we looked at our previous historic data, and there was minimal change. So you can look at this. During vitrectomy, we actually used very little in terms of more — compared to retrobulbar cases. So these were topical cases. But not topical with IV sedation. So just to be very clear on that. And this was another case. 71-year-old with floaters, follow-up 3, 4, 6 months, vitrectomy, and this is what it showed. And this is the post-op. Shows the video quite nicely, showing complete resolution for their symptoms. So yes, it does have risks, but all of life has risks. These patients have real visual problems. Some patients hate these changes. Multifocal eyes with floaters. And topical vitrectomy can be a great option for these patients. So I think it is important to consider surgery. Have they tried observation, do they have a multifocal lens, convincing story. If the patient is phakic or has had multiple procedures, I typically tend to not do them in these patients. So hopefully more and more outcome measures will be noted with further clinical trials. In terms of contrast sensitivity, VFQ results, and quantitative ultrasound. So one of the other things we want to talk about is wide angle photographs. A lot of us probably get these. And you can see here’s a wide angle asymptomatic retinal tear patient. Here’s another one. Another one. So what is the sensitivity and specificity of these wide angle photographs? So in Retina 2007, 60 patients with peripheral pathology, scleral depressed, Optos images taken in four quadrants. The sensitivity of Optos was 74% for lesions, 76% for lesions requiring treatment and 45% for lesions anterior to the equator. BJO, 2009, 219 patients presenting with floaters and/or flashers. Sensitivity was 100% for detachments, 33% for holes and tears, 97% for retina specialist, 67% for presenting physician. 30% for other significant pathology. So Optos is good, but clinical examination, especially with depression, detected more tears. So use imaging, but certainly use your clinical examination along with imaging when you see these patients. And if you do find a tear, what do you do with these patients? Do you treat, not treat? Let me go back. This is a very old paper looking at evidence-based analysis for prophylactic treatment for asymptomatic tears. And most asymptomatic tears really don’t go on to have detachments, unless they have a flap or traction associated with them. So the question is: Do we always treat asymptomatic tears? Typically not. We always do treat symptomatic flap tears. We treat asymptomatic dialysis. Sometimes we treat asymptomatic flap tears if they’re gonna undergo cataract surgery, but we typically don’t treat asymptomatic flap tears if they have lattice degeneration in the fellow eye. But if the patient wants treatment for lattice in the other eye… I don’t think it’s anything wrong. But there are some patients who sometimes don’t want to have treatment in the other eye and others who do. But if they have a flap tear, we certainly treat those patients. Here’s a patient who came with multiple flap tears. One, two, three, four, five, along with a vitreous hemorrhage. So certainly those can be treated. Here’s the treatment with laser therapy. Here’s cryo. I typically tend to prefer laser if I can get it, over cryo. In general that’s my preference. One thing that’s really nice about tears and detachment is to do infrared imaging. Infrared reflectivity. Gives you beautiful photographs of tears and detachment. We published back on this in 2016. Rapid acquisition works well with small pupils. And I’m not sure why it’s going faster, but here’s retinoschisis. Easier to see, compared to retinal detachments. You can also do OCTA. Here’s pattern one on retinoschisis. There’s different patterns. There’s schisis detachment. And OCT will give you these different findings of different patterns. And this has been clearly published in the literature. So one of the keys is… I don’t really have wide angle OCT at all offices, but we do have infrared imaging, which tells us the difference between a schisis and a retinal detachment. So ultrasound wide autofluorescence — I don’t typically use that for this, because I use infrared imaging. But that’s another way to differentiate retinal detachment and retinoschisis. And this has again been published in the literature. So we talked about cryo versus laser for retinal breaks. The question is: Are there more epiretinal membranes in one mode versus the other? And we published data that I was sort of amazed that it didn’t turn out to be true, in terms of giving the result. Whether we treated them with cryo or laser. So we looked at this study. Looking at epiretinal membrane formation over a ten-year period, and looking at these different diagnoses of macular pucker. Time to development, time between treatment, and ERM development, and surgical intervention for ERM progression. We almost had 2200 eyes that underwent treatment for retinal breaks. Majority treated with laser and the rest with cryo. And overall, about 3% developed an ERM. The average time to develop ERM was about… Less than a year, for both groups, for cryo and laser. So ERMs progressed to requiring surgery. 2 in the 5. Not a lot of progression either. But in the treatment of retinal breaks there was no statistical difference in ERM timing between these two modalities. So that was a paper that was published, it was well received, and kind of showed you that two different things — which I was surprised — did not make a difference. So let’s talk a little bit about retinal detachments. The incidence, obviously, in the US, of about 36,000 annually. Risk factors include cataract surgery, myopia, lattice, and trauma. All known to us. Patient status post cataract surgery — 3% of the general operation, but 40% of patients with retinal detachment. And most of them occur in the first postoperative year. Also pseudophakic retinal detachments are more advanced, macula off, and higher incidence of PVR. The cumulative probability within three years after extracapsular cataract surgery is about 0.81. The risk factors again are myopia, 5 to 6 times risk of retinal detachment. It’s directly related to myopia — one millimeter increase gives you a 1.3 times incidence of retinal detachment. Risk factors. We already talked about this. Are lattice degeneration, thinning, and adhesions. So symptomatic breaks. We treat symptomatic. Asymptomatic I typically do not treat unless it’s a flap tear. So the options are really pneumatic retinopexy, scleral buckle, primary vitrectomy, or combined buckle and vitrectomy. We’ll look at these three primary factors and obviously our own experience and training in how we treat these patients. So pneumatic retinopexy — uncomplicated. Typically the patient is done with retinopexy, cryo or laser, and gas injection of C3F8 or FS6. The highest single operation success is in phakic eyes, one quadrant detachment, one break, and upper 8 hours. We avoid eyes with high risk of redetachment, obviously. These are the different things we use. Tires, bands, and sponges. And this just kind of shows you from a retinal detachment chapter in Ryan that we wrote — shows cryo being done. Here’s the drainage being made. And I like to use this Alimera with a cutdown to cauterize the choroid, so I don’t get bleeding at the time of surgery. And this is a 41 band, I usually use a tire for this or a 41 band for these patients. You have to make sure you have a nice conj closure in these patients. This is a retinal detachment you can see, fixed with a buckle. I like doing buckles. They work well for atrophic holes in lattice, inferior dialysis, and especially in young patients, it’s a good procedure. The advantages of vitrectomy, we work from the inside, identify and treat all retinal breaks, release traction. It’s certainly a more expensive procedure. But it can work well for many patients. And I think more ask more people are being more comfortable with this. So I think you should do the procedure that works best in your hands. But I certainly think it’s good to have as many different tools in your armamentarium. And here’s a patient who has a retinal tear. With a retinal detachment. And you can see post-buckle vitrectomy. Here’s the buckle and the laser treatment. Here’s just some intraoperative photographs of patients who are having a depressed examination, which I think is really important, when we do a vitrectomy in these patients. Now, one thing — this is post-op day one. You can actually get a photograph. Here’s a patient who had a retinal detachment, post-op day one. You can see through the air bubble — and typically I use air. I don’t use gas for superior detachments. You can see the laser treatment. Nice to show the patient. You can get a beautiful photograph with a wide angle imaging system, just post-op day one. So I also want to talk about the PRO Trial. This is looking at which procedure works best for these patients. This is a series of papers that Ed Ryan spearheaded. We’re participants in this. This shows the groups in Minneapolis, St. Louis, Detroit, Boston, and Philadelphia. So the Minneapolis group, our group, Mass And Ear, and Philadelphia hospital. So these are the lead authors at each institution. We looked at all primary retinal detachment cases from 2015. All OR. Usual exclusion factors. We looked at… These are the numbers. Males, age… Follow-up. Total number of phakic patients before exclusions. And then we looked at who was eligible. Scleral buckle, 91%, vitrectomy, vitrectomy and buckle. And we found that vitrectomy was inferior to vitrectomy and scleral buckle for phakic retinal detachments. Again, phakia. If you just did vitrectomy alone, it was inferior to both of these procedures. And you can look at the numbers for vitrectomy, scleral buckle, and vit/buckle. What’s important to know is in the vitrectomy book, there are more patients with final acuity of vision 20/200 or worse. And the principal reason was really unknown, of why this occurred. But it might have been maybe due to an optic nerve or neuropathy. Which I think is an important cause of vision loss in vitrectomized eyes. So I think it’s important for phakic eyes scleral buckle still remains a really good procedure to learn and to do. And certainly had not only as good of a success, but better success than primary vitrectomy. Okay? So… Let me sort of go through… This is for pseudophakic eyes. And for pseudophakic eyes, anatomic outcomes were superior in the vitrectomy/buckle group versus buckle. So again, kind of complemented what we know. If you have a pseudophakic eye, I certainly think you can do a buckle if that’s all you have, but vitrectomy or vitrectomy/buckle works well in these patients. And relying on vitrectomy alone for inferior detachments is where… Vitrectomy buckle was superior to vitrectomy alone. So it is important that maybe for pathology that is inferior — that it’s important to use maybe a vit/buckle. And also if you have multiple breaks and hemorrhages and so on and so forth. And what about timing of retinal detachment? We’re often asked about… Gee, when should we do this? Here is a patient. Let me go back. Who has a macula threatening detachment. Certainly I think timing is always difficult. With availability of OR resources. And I think each person’s situation. So we have to kind of keep that in mind. Excuse me. My mouth is a little dry. And this kind of shows different types of detachments. So timing is maybe much more important for let’s say a giant retinal tear versus inferior detachment noted here. So we look at the prognostic factors. Acuity, macula on or off status, height of detachment, patient age, and preoperative visual acuity is really the strongest indicator of postoperative visual outcomes for retinal detachments. Here’s a detachment with a break. And another detachment, another detachment, another detachment. So all these detachments — here’s an inferior detachment. So for this, you can see the demarcation line. The urgency for this detachment compared to this is gonna be much lower. Here’s a giant retinal tear that is kind of on this way of flipping over in this patient. And extending. So that one you want to do sooner rather than later. Here’s another patient who has a thin area of fluid. But you can see this has been there for a while. Whenever you see this on the ultrasound, this thickening, that means that detachment has been there maybe for weeks. Okay? And not acute. Here’s another detachment. Shows us sort of what appears to be this dark elevation. This fluid has been there for a long time. And you can see that. So this patient, even though the macula is splitting, you can see this thickness right here. And this has been there for about three months. So no urgency here. You can see this patient right here. This is the chronic fluid. This is more of the acute component. And you can see this on the infrared photograph. This stippling appearance. And here’s the retinal hole that you can see quite nicely on infrared. Another chronic detachment. So when you look at these detachments, they really look like they’ve been there for a while. Here’s the break that causes the detachment, and here’s the guttering of fluid. Important to know chronic. So clinical reality for macula off status — no difference in the first week. For macula on, I think several days can be acceptable, depending on the type of detachment that they have. And again, in the interests of time, I’m gonna kind of skip through this. But basically show that even for macula on retinal detachments, you can certainly wait for a few days, if you cannot get in the operating room. These are patients — 200 eyes, repaired within three days, and only one progressed to macula off status four days after presentation. And this is typically how it advances. About 1.8 disc diameters per day. But again, make sure it’s the state of the vitreous — will depend on how much of the extension. So if you’re unsure, certainly consider OCT. And really look at the patients to look if it’s acute or chronic. Because you can do that quite nicely on examination and OCT. And one of the things that patients get — even after you repair them — is this issue of anisoconia. Image differences. So remember compression of photoreceptors gives you macropsias and stretching gives you micropsia. So it’s not always that their visual acuity is not good, but they’re complaining of image size differences. That’s important to know in cases of retinal detachments. This shows you misalignment of photoreceptors. You have less number of photoreceptors here and more here. So there are fewer signals. In the image on the left versus the right. So the photoreceptor density — this is normal and this is a retinal reattachment. So these patients, when they have less of this, they’re gonna get micropsias. Okay? So this is normal. And this is abnormal. So that’s a very important point. With macropsias and micropsias. So macula on are more likely to have macropsias. So when we look at retinal considerations, people always ask us for LASIK or clear lens extraction. Do we treat these patients for retinal tears? And I certainly don’t typically pretreat. I certainly do an examination. But I don’t really pretreat them. Again, people have thought the mechanism of injury is a suction that is applied during LASIK. Maybe there’s an Excimer shock wave. But I certainly think that nobody really knows why that occurs. And I typically have not really seen too many patients post-LASIK. Right after LASIK. They get it afterwards. Maybe a year or two. But again, they’re high myopes. It’s not the procedure itself, but just the vitreous issue that caused it. So the RD after LASIK — more often involving the macula. PVR is more common. And the incidence is about 0.6 to 0.36%. And if you look at the timings, this kind of shows you that most typically it would occur in the first two years after LASIK surgery. This kind of shows you a flap complication. You want to be aware of this, when you’re operating on a patient with LASIK. I did the surgery two days ago. Somebody had LASIK. You’ve got to make sure you don’t scrape the endothelium. If you do so, you make sure you’re not taking the hinge and you know where the hinge is. So… Usually LASIK is a safe procedure. But again, myopia is not always safe. But again, if you’re not sure, certainly look for retinal examination, for peripheral pathology, and macular causes for vision loss in patients with LASIK. Clear lens extraction… Certainly more and more refractive surgeons are doing that. And that doubles the risk of retinal detachment compared to myopia without surgery. Prophylactic treatments — we already talked about that. Phakic IOLs, similar issues. These are IOLs placed in front of the eye. The eye’s natural lens. Sometimes visualization is hard in these patients. I’ve luckily only had to do surgery twice in patients like this. And sometimes it is difficult to see. So these are these multifocal IOLs that patients get put in. Premium IOLs. And all I can tell you is that these can be problematic to operate. Because of the material. And you have to look for these different rings that these patients have. So the ReZoom, ReSTOR, Tecnis, Crystalens — silicone is a little bit easier, but it’ll cause the problem of condensation during surgery and also centration. So these lenses, if they’re not centered, it becomes problematic. And condensation is an issue. You can use viscoelastic for this, or what I typically do is I put the infusion line through an ice bath to condense the water in the line rather than the eye. That makes it easier for condensation. Also if you have a silicone lens, you’ve got to be careful of silicone oil droplets, because they’ll bind to the material of the lens and they’re also difficult to remove as well. And visualization can become harder, because you will get this image jump in these patients. And this is unique to Crystalens — the Z syndrome, where you have flexion at one hinge, asymmetric torque or forces, and you get this lens that is decentered. So again, you’ve got to be careful. The ideal IOL from a retina perspective is certainly gonna be a nice optic. That is silicone. And then you don’t have this phimosis of the anterior capsule. That becomes problematic. So I think we’ve talked a lot in the last 42, 43 minutes. I think PVD and retinal tears are continuing to increase in the world, with increased incidence of myopia. Wide angle imaging with direct and depressed retinal exam in high risk patients is important, along with imaging. I think retinal detachment repair continues to evolve. There’s new lens technology that adds to the complexity of surgical repair. And I do think that patient expectations have to be managed in the preoperative and postoperative period. So I think that is important. For that. And this is a beautiful picture that I took many years ago, with my iPhone, of sunrise towards a place called Canyon Lands. And one of the things I like to enjoy is to hike and look at what nature has. Because to me, that’s one of the beauties in life. That when we restore vision to people, I want them to see beautiful images like this. That I’ve been privileged to see in my lifetime. And our patients, unfortunately, with their vision problems cannot see some of these images. So our goal is for them to see beautiful images that nature has made for them. So that’s about it for my talk. I hope you’ve enjoyed it. I have some question and answers. That we have… In the interests of time, I can go through some of these. There’s a question of Ocriplasmin for vitreous floaters. We typically don’t use it. It’s not even available because of the issues. Another question is that… It is challenging in patients who have vitreous hemorrhage, about how to look at the retina. Again, try to sit the patient up. Ultrasound. Wait. And if you’re not sure, vitrectomy. Another question was: Looking at floaters in young patients, between 20, how can we reduce them? We really can’t reduce them. They really have vitreous synaeresis. They don’t really have floaters, per se. So it’s important in younger patients… That we make a clear distinction. Retinal detachments… What I mentioned was that if you have an inferior retinal detachment and you cannot get into the operating room, then very few progress within three days. So it certainly is important that you do them in a timely fashion. But if you can’t, then the risk of progression is going to be not as high as you think. How often should we follow up patients with symptomatic PVD to look for tears? We’re gonna have a paper coming out on this. But I typically follow them for about a month. If they have a vitreous hemorrhage associated with them, that issue is going to be very different. You need to see that patient quite frequently. Every couple of weeks, to make sure you’re not missing a tear. So I think that’s really, really important. The cause of floaters in young patients is really not a PVD. It’s more of an anterior vitreous synaeresis, and that’s what happens in these younger patients. Okay? Let me see if there are some more questions. There’s a whole bunch on the Q and A. It’s like a horseshoe tear. Okay. So I think… These are the questions. If there’s any additional questions… We can type them in. But other than that, I think we’re at the end of our time.

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February 10, 2022

Last Updated: September 12, 2022

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