Lecture: Update on the Management of Giant Retinal Tears

DR. NAGPAL: Hello, everyone, I’m Dr. Manish Nagpal. And very good morning, good afternoon, good evening from wherever you are located. It’s a great pleasure to be always on this Orbis and Cybersight platform. I’ve always enjoyed all the interaction I’ve had in the past. And in time we are going to work on the giant retinal tears. So, before I start, just to let you know that you can post any questions that are there in the Q&A here. And at the end of 45 minutes after the talk we’ll take in some questions for 15 minutes. They also send me about 50 questions which people sent beforehand. A lot of them are answered in my presentation, and some I will take in as time comes. So, let’s get on with the presentation.
So, fasten your seat belts and let’s get on with the journey with Orbis. So, giant retinal tears are any tear which is greater than 90 degrees defined as a giant retinal tear. But all of them do not behave the same way. Some behave like a smaller retinal detachment with a smaller tear. Some have huge tears that fold and you know fold itself over the retinal surface and cause a lot of problems. Someone asked what’s the difference between a dialysis and a giant retinal tear? A dialysis is the disruption of the retina, the vitreous base is still there, keeping the retina attached with the fluid going in with the detachment. A giant tear, the whole retina, posterior part of the tear is attached, and that pulls away from that and starts to go forward. That’s the difference between the two, and the management differs a lot. Giant retinal tears come in all shapes and sizes. 90 degrees, some can be 360 degrees, some are 200 degrees, some are changes, some are folded, some are not folded. And we will go through these as we go on. But before we do that, for doing these cases, must adapt to wide field viewing systems. Because without that, it’s difficult to do these cases. You need to see in the periphery. And for both wide field viewing systems, and perfluorocarbon heavy liquid. Can you do it without perfluorocarbon? I don’t think I would like to do a case without one. Thank you to Dr. Charlie Chang. He’s part of the wide field viewing systems and the heavy liquids. I personally like contact-based viewing systems and visualization is the key. And my favorite lenses are the Volk or the HRX. And they now have a disposable one. This is what I preferably use. A lot of you use non-contact systems as far as I know. I would like to poll all of you as to how many of you use a contact-viewing system and non-contact. You can take this poll in the next 30 seconds and we can get an idea of who is using what at this stage. So, keep posting at this point of time and we’ll wait for the 30 seconds to pass.
And viewing is extremely important — while we wait for the poll results to come in — and all the time during the giant tear surgery you need to keep a view on what’s happening in the periphery. Because the bare edges, everything has vitreous attached at times and you need to see and laser all the peripheral areas. We have a poll of the people at the moment viewing it, we have about 66% versus 34% in favor of non-contact viewing systems. I’m not surprised. Because a lot of you use non-contact viewing systems.
So, let’s go on to now some examples of the giant retinal tears. There will be some repetitive steps in the next view videos, but I would like to do it because it’s a teaching concept. There’s a strategy to go about working on these tears. And the first thing is to get a good view. As you can see, you can see the tear as a hole. This has folded itself over the retinal surface. This can not be seen. Your first is to assess how big is the tear and what is happening where, and then remove all the vitreous there in the core area and the peripheral area. Also, the peripheral edges of the tear, any attached vitreous should be removed. Once you are sure that the vitreous is gone, you start unfolding the tear, which is the most pleasant thing of the whole surgery to see how it unfolds and flattens the retina using perfluorocarbon heavy liquid. This is why this surgery today is almost impossible without access to perfluorocarbon. There’s nothing else that can so beautifully flatten it passively without causing trauma to the tear. Any other instrument you use will be traumatizing to the retina. Once it’s flat, you do a 360 laser barrage. You barrage all the edges of the tear as well as the 360. All of these cases have weak areas in the periphery. And once the patient is taken for surgery, it’s best to have a 360 barrage. And another crucial stuff, at this step I do a air exchange, two-step. The second is later, but just to show you the steps, once I’ve finished the PFCL air exchange, I put on the top and the silicon at the end of the surgery. Two step. This is similar, again, repetitive steps. But it will be good because that’s how one will know what to do when you see giant tears of different types. Again, you see me remove all the vitreous, assess the tear, remove the peripheral interior edge of the tear next to the bare choroid. And once you clear the vitreous, put in the perfluorocarbon, do the edges of the care, all the way around, remove some of the vitreous if you still see it at this point in time. And then do this exchange. This exchange is very important. You can keep the edges dry and we take it up in detail a bit later. Another case where you see folded edge isn’t temporal side with anterior edge and attached vitreous. And you also see the tear. This is what I was telling you, most of the cases are exposed to peripheral weak areas. And one where the detachment occurs. It instantly can cause a giant tear. And along with it there can be multiple tears in a lot of patients. So, you’ve removed all the vitreous, again, lasering all the edges, the horns of the tear, and removing the anterior edge of the tear. Drying up the — the peripheral edges very carefully so that there’s no slippage. And you can see that at the end I scrape from the disc and it’s dry and this is the place to put silicon oil post-op. Some cases you need to reach the periphery, need indentation. You can do it yourself with a chandelier light source. Or have an assistant in case you’re having difficulty seeing in the periphery. This is a technique in phakic clear eyes, you’re worried about touching the lens. In those cases, you can reduce the tone of the eye and then go in and indent from the periphery yourself or with an assistant and you can go to the periphery yourself rather than taking the cutter all the way there. Now, this is a case which has two separate giant tears. Now you can see that the central part of the retina is attached, macula is on. But the patient has developed two separate independent giant tears. The treatment doesn’t differ. Your aim is to do the same thing. You remove the vitreous, assess. The only thing you’ll be careful with macula-on giant tears, you never want the macula to get detached at any point of the surgery. Make sure you have perfluorocarbon on before there’s any chance of a retinal elevation and so that the macula remains on. And then, of course, do the same thing that we discussed in the previous view cases. This was a case that was previously laser barraged. Someone saw a giant tear and laser barraged it. But despite that, the fluid collected and went posterior. I don’t like to laser giant tears. Because of the sheer size and mechanics. They tend to usually go beyond any lasered areas and by doing laser, you would have compromised some of the area of the retina while — because when you do the surgery, you’ve already lost that area of the retina with the laser. And you’ll still have to do more laser in the peripheral part. So, that’s the only difference that would be there. Now, air collude exchange in a normal retina detachment is like this and first the disc, and then the bullous and go to the breaks and do the endo-drained. And the retina flattens out. If you do in a giant retinal tear, it would fail miserably. Because of the sheer size of the tear. If you go to the periphery and start draining from the edges of the tear, it would go down instantly. There would be slippage of that tear and you will fail. In the giant retinal tear, I want to look at the exchange part very carefully. Two ways to do it. I do a two-step approach. Here is a PFCL live and exchanging it to air. I’m carefully aspirating on the edges of the tear, 360 degrees. You can see I’m trying all the areas of the edges so that there is no fluid left. Only perfluorocarbon and air is exchanging it gradually. So, once I’m sure that the peripheral edges are totally dry, I would let the meniscus of the PFCL go below the edges of the retina. Before that, I would keep on making sure that all the edges are dry. This is crucial. Because otherwise some of the fluid would get pushed under the retina which is called slippage. And after this you had this one, and did all the PFCL. And then you can put oil inside. This is how it’s a two-step approach which is how I do all my cases. But sometimes you can get a slippage like this and this is what is avoidable in the circumstances. So, wanted to show you a case I had a month back. A very high myopic case with retinal detachment. And in this case, all the steps are similar. You remove the vitreous and then put in perfluorocarbon. You can see I’m pushing the perfluorocarbon and inflating the retina. But they have a previous position to a weakness. And while doing the exchange, my cutter might have touched the choroid or something in the periphery. At some stage a small bleed started. You can see in the superior half here on the temporal side that a bleed has started. Now because of the bleed starting to trickle down, it caused slippage. And you can see that the blood has reached the area of the orchid and my PFCL was gradually decreasing because of the exchange. I instantly put in fresh PFCL. This is what you do. Let the blood get pushed out from where it started. And after pushing in PFCL, I aspirated most of the hemorrhage which occurred from that edge. Also, there was a trapped hemorrhage which I made a small retina and also aspirated. This is something — a bleeding happened which led to a secondary slippage and I put in perfluorocarbon and did the same maneuver of the exchange after that. And everything was fine. But a bleed caused this thing. So, this is a example of a sort of a slippage which can occur. If it occurs, you have to go and put in PFCL again and flatten it again and do your exchange after that. I wanted to show you a small video for direct exchange, which is the other way to do it. I’ve borrowed it from my friend Dr. Sangeet Mittal. I don’t do direct exchange. This is how he’s doing direct exchange. Some people like to put the oil during the diffusion. He likes to put a chandelier and use one of the ports to put the oil and the other port to use the soft to aspirate the PFCL meniscus to go down from there. And this is how air PFCL is done. And it’s how someone thinks they can avoid with doing the maneuver. Whatever is more comfortable. I like the two-step approach. After the exchange, I like to top up with some laser. The view gets much better — the peripheral view — once you have a totally air-filled eye, you can do tip of the laser to the top of the tear which you may have missed earlier. Make sure you have assessed the peripheral retina at this stage and fill it up with silicon oil at this stage. Let me bring you another poll question at this stage of all of you that joined. Which exchange do you prefer? Direct PFCL oil exchange or indirect PFCL air/air silicon exchange? Which is what I usually do. Okay. So, again, there’s a 71% who are indirect PFCL air/air silicon exchange. And about 30% do a direct PFCL oil. That’s interesting to know. Okay. So, let’s go ahead. So, let’s see some more tears. This is a giant retinal tear, again, nothing much differs in the management. You have to look at what’s in front of you here. You can see ad mixed with hemorrhage which was there. The tear is flapping and unfolding. And a peripheral tear. And it was lasered elsewhere. You can see the small rim of laser that was detached and became a full detachment. The rest is similar, fill it up with perfluorocarbon, then a 360 endolaser and doing an exchange. Making sure that the peripheral edges are dry at this stage. This is a tear which you see which has a macular hole. This is traumatic as well. And a very posterior edge of the giant tear. The giant tear edges are very close to the macular area. So, and there is an adherent vitreous with the hemorrhage. So, here we cleared the vitreous and also peeling to the macular hole. What I did is that I extended the healing up to the edge of the giant tear. Because the macular hole is very close to that temporal area and we don’t want a contraction between the tear and the macular hole. And you can see I did a peel and extended up to the periphery to relax that area. And after that, trying to unfold the edges and then do a very mild laser to the posterior rim on the temporal side because we have very little surface area of the healthy side. And the rest of the routine, three or four holes to close which are there. This is a case which is almost 360 degrees, but not 360 degrees and totally folded on to it itself. All you see is a bare choroid. After we remove some of the vitreous, we try to peek and get a view into the posterior hole of the disc. And after slightly unfolding it, push in some perfluorocarbon. But the inferior tear is attached. Here because of some contraction, I’m worried if I keep filling it, the PFCL will go behind because the inferior part has some flexion which is a contraction. What I do is I convert this tear into a 360-degree tear. I do some — and cut off the inferior half. And it’s relaxed and I treat it like a 360 tear and do it like we showed in the other cases. This is a 360-degree giant tear in a one-eyed young child, very high myopic who came to us a totally 360 degree tear. The problem with the tear was that the vitreous was still attached. He was a 10-year-old boy. And after removing some of the core area, I realized that all the vitreous is attached to the rim of the tear. And that made it very difficult because in such a situation, we don’t have any hole over the retina. When you try to remove the vitreous, the retina is turbulent and keeps on moving all around. So, every time I would try to pull the PFCL, meniscus would go behind the retina. So, three or four times I would have the chance. And every time I would pull on the vitreous to aspirate and pull on the retinal surface, the PFCL goes behind and it was difficult. At one point, change the approach. I kept a tool called — we called the massager which I use as a multi-functional tool to keep the retina at bay while I remove the attached adherent vitreous. So, you can see that I’m using my left hand with that instrument which is atraumatic to keep the retina on one side and then with the cutter trying to remove the adherent vitreous on the edges. The triamcinolone stain is seen quite well, but is difficult to handle because the whole retina has no hole. All 360 degrees, it keeps on moving. With some efforts, I could finally manage to get most of the vitreous out using this maneuver. You can see that how gradually we kept on feeling and removing — peeling and removing this vitreous from each of the edges. But this is a unique challenge in young children. Does not happen so often in the adults usually. So, finally, I could get most of it out and then I re-injected PFCL you can see that because it’s a 360 tear, the retina had rotated itself. It falls and had to be re-rotated back into a normal landscape with the normal landmarks of the macula. Otherwise it folded down towards itself. Once I had done that, I treated it like a normal tear, 360 laser and do a normal exchange at end which flattened the retina and put the oil inside and the patient finally was well. Now once you have changes coming up in giant tears. Here this is a case which has a few star folds which have come up along with a giant tear. One superiorly and one on the temporal side. After clearing the vitreous, I put in the perfluorocarbon. Once the perfluorocarbon reaches the edges of the star fold, I explore it with the forceps. Otherwise you don’t have the hole and the PFCL helps you assess the retinal — the membrane edges. And you can see that gradually I can release some of the superficial membrane of the star fold from the superior star fold and then go on to do the same with the one which is on the temporal side. After that, you treat the tear in the same way. But you can see wrinkling here and all. And these are cases which are prone to PVR and contractions post-surgery at times.
Some of these cases there are folds which are there. I iron them out. You can, again, with the same instrument which I showed you earlier. This is a massager that we call, it’s like a miniature version of an external indenter. It’s a 25-gauge instrument and I use it to massage some of the larger macular holes that we have. But it’s also a multi-functional tool which I showed you in some of the cases. And these are more aggressive PVR contraction cases where this tool comes in handy because here the retina falls on to itself and then we use any other instrument becomes a bit traumatic. So, this has rounded edges with no sharp areas, no areas which can damage. And we gently kind of iron out these folds which have formed in the retina. So, that it — the retina itself can get some sense of semblance of normalcy from those folds.
This is, again, a case of extensive PVR that you see. A lot of folds and the significant PVR is always going to be inferior. But, of course, you could look at all 360 degrees and take care of any membranes or contractions which are there all around. So, once again here the vitreous needs to be cleared, assessed from all sides. Here also there is the reciprocal attached. You can see that we are gradually removing by using the same maneuvers and the retina is mobile. You can carefully watch how the retina behaves when you are feeling the vitreous of it. And then, of course, unfolding these edges of the tear and flattening all the folds so that the retina can go back and then we laser all the peripheral edges of this particular area. Sometimes with giant tears you can have the choroid, which is very boggy. And you start the case. You thought the cannula was inside. And you have a boggy choroid. You might have to reinsert. I do it very anterior. This is a case, I’m not bothered about the lens. I just put in the cannula and put it extremely interior. Because I do not want to end up with the choroid becoming boggy and the whole situation becomes difficult and messy once the fluid is not going in. Once you have the cannula in properly, you can — the surgery becomes simpler and you can clear up all the vitreous and proceed with the regular stuff. Put in the perfluorocarbon eventually, settling the retina back to its normal place. So, suprachoroidal cannula can be an issue. This is with choroidals which are existing in this place. You have to be cautious, the retina is contracted. We put in a little bit of PFCL and try to mechanically open up these edges. Because they are full of membranes and you have to gently unfold them. Remove as many membranes. Or eventually cut off some of the tissue which is very, very contracted. But your first is to save as much surface area as possible. Because you are also lasering in that area in the periphery. If you have an extra surface area, you are saving much more of the posterior retina which is there. And you can see the residual choroids there at the end of surgery. This is a giant tear with a lot of extensive choroid on the temporal side. You can see the angry boggy choroid which is there in the temporal area. Start the case, remove the vitreous, assess the peripheral edges, put in perfluorocarbon up to the edge of the temporal side. You can see there’s so much choroidal bogginess that the edges of the tear are pushed by the choroid. This is not something that the — that will allow the retina to settle. I open up the conjunctiva and allow it to drain externally. You can see a lot of fluid comes out, yellow, viscous fluid which comes out. See this nature which comes out from that area. Which is what would allow that full bogginess to come down eventually. We drained this externally and then when we looked back in, the choroid seems to have flattened to a large extent. And this looks much better than what we saw before. Because that would have been surely something which would lead to a failure of the surgery because of extreme under-fill of the oil which will also happen because of so much choroid which is there. So, sometimes you may have to drain the choroid externally in these cases. Unfolding edges I showed you in some of the cases. Here you can also see to buy some more surface area, you are always better off trying to unfold and flatten. Because you can — that retina may not be very healthy. You can cut it off also. But I would rather keep it because that’s an area which the laser can be applied and you can save more posterior if not for the better feel of the patient generally. And anyways, the lazier is done to hold that part of the retina. If you unfold it, you get a better surface area in those cases. I either the massager or a soft tip to do that in most of these cases.
Now there is a situation where you can also do a two-step approach. By two-step, I mean, that you can leave PFCL inside for about 15 days or 20 days and then exchange. So, this is a case where you can see a lot of PVR changes. You can see rolled up edges of the tear, wrinkling and folds which are there. And this is a situation where, again, the chances of high-risk PVR re-contractions is high. So, after I’ve remove all the vitreous, you can see how much wrinkling is there on the surface of the retina. This is not a very good sign. Because this indicates that this may contract. Even on the table, you may be able to settle it. But it will soon contract. I try my best to iron out and buy as much surface area as possible. But my gut feeling says that this will not stay. So, here I decide to do as much as possible and then fill up the eye with PFCL. Totally in this situation. You can see that I’ve — I’m bringing a 360 laser and keeping the eye filled with PFCL. And this go back again after two weeks. And this is after two weeks. I go back in again and you can see that the retina looks much more healthier. The folds — a lot of the wrinkling and everything has disappeared. The laser marks have taken over to a large extent and the retina looks healthy. At this exchange, I do the air PFCL at this stage. This is more likely to stay back in place rather than if I had done this exchange if the first surgery itself. Sometimes for such cases I would use a two-step approach where I leave intra-operatively. There were some questions asked earlier which was talking about leaving perfluorocarbon in giant retinal tears. We used to do it in the past. 20 years back we were not using wide-angle systems and not able to assess. We were regularly putting PFCL for two weeks in the eye and then going in after two weeks and then removing the PFCL and it was — it was quite good at that time. Today I do it only for select cases which have a lot of PVR or wrinkling or contractions and I feel that they may re-detach before surgery. So, PFCL can be used post operatively in some of these situations. This was the post-operative picture of this particular case. Where we put perfluorocarbon and exchanged it with oil and it was well-attached after a month of the same. This was a situation where a patient operated on with a giant air with silicon oil had re-detached. And you can see a pucker forming in that area along with inferior PVR. And I’m trying to remove the pucker under the oil which you see here. And I have to relax that area and also after that, trying to relax the inferior retina which are the side contraction from that particular area. So, this is sometimes a surgery which is required in these cases. And this is what I’m worried about. If you leave wrinkle, contracted retinas, you can have at times re-detachment coming up from contracts or puckers which may happen in these situations. This is an old case. There was a giant tear with a nucleus drop inside. Now, maybe a person who was doing phaco had dropped. And after that may have gone with the phaco probe to retrieve it. Because the way the ragged, giant tear had formed superiorly. You can see the edge of that tear and the nucleus was lying in the vitreous cavity inside. So, this is a situation which is quite messy. It’s always good if a nucleus drops to leave it right there and wait for it. But sometimes phaco probes go in with large suction in the part and that’s how a large tear can happen. This is one of those situations. Here I removed some of the vitreous and put in perfluorocarbon. Because with such a detached retina, it is difficult to remove the — flag the nucleus. So, you want the PFCL to push back all the retina. And once the PFCL is keeping the retina at bay, you can use the high vacuum of a fragmatome to remove the nucleus. If you flag it with such a mobile retina, it is likely it will cause more damage. Here you can see the tear damage was going right up to the superior arc in a ragged manner. After removing the nucleus, put the tear back, come back, and then lasered all the edges of that tear. And once it was flattened, exchange it with silicon oil. Another situation for giant tears is when it can occur — co-exist with a colobomatous eye. We know they’re more prone to retinal detachments. And once in a while you get these situations. They already have weak peripheral retinas and at times they can have a giant tear along with a coloboma. This is oftentimes a lot of young patients with a vitreous tear. Once again, these are situations where you have to remove the vitreous well, look at colobomatous area, remove everything that’s there, and then put perfluorocarbon in and try to flatten and see the whole borders between the coloboma and the retinal surface, the whole extent. And you can see now after the unfolding you can see that the viscous seen partially involved with the coloboma. And then you do an endolaser to the areas of the colobomatous area. Sparing what is the macular area, of course. But the rest of it you do a good lazier and also a 360 laser and and settle that particular part.
This is the post-operative picture of that particular eye that you see here nap you see the disc and the whole colobomatous area which formed, which was there and it’s properly placed. These are some of the pre- and post- op pictures of tears. Giant tears. Some of them are different shapes and sizes. This is the pre and the post image. What you see on the left is a recently-operated one with fresh laser marks. And then you see it later once the laser marks become pigmented. This is a situation where you see a large tear which has folds itself torn from the periphery and folded itself over the disc area. And then once it’s flattened back, and the laser marks are pigmented, the oil is removed and you can see a picture of that. Then you see this, again, another case which has a giant tear which we have lasered. And at the end you can see that there are a few residual PFCL — there’s a bubble there. This often occurs with giant retinal tear cases. You getting a PFCL bubble, sometimes in the periphery, sometimes it’s multiple bubbles, sometimes it’s a single bubble. Because of the sheer extent of the tear edges which are open to bare choroid. When you inject PFCL, always be careful that you have no fish egging. If you have fish egging, you are more likely that some PFCL bubbles may escape into the sub-retinal area. And as long as they’re in the periphery, you’re fine. But at times they enter the space of the macular area or near the macular area and then you may have to do something about it. Where you go in and if it’s affecting the macular area, you can go in and remove it. And sometimes you wait until the oil removal is required at 2 to 3 months. Or if it’s extremely significant, you may have to go in earlier. Always be careful about injecting the PFCL. When you inject, it has to be a very slow process. Never be in a hurry to inject. That’s when fish egging occurs. And during the exchanges, some of them they go behind. Another important aspect of giant tears, always screen the other eye off in these patients. Giant tears occur in patients that have predisposed weak areas of the retina that is there. They have a propensity — whenever it occurs, it slips away, a very large quadrant of the retina causing a giant tear. And sometimes these patients will have peripheral lesions in the other side. May have pressure-spanning lesions. Be careful and assess individually in each case and decide to do prophylaxis laser in those cases where you feel it’s required. if you see pigmented I would be concerned if it’s only pigmented. But if I see associate areas that are not pigmented or show any sort of traction, maybe I would go in and laser some of these. Always look at other eye of these patients carefully when you’re assessing these situations. Getting to the end of the talk. Basically I also wanted to tell you and ask you that all of you are involved with the retinal imaging. I at the moment look after the curation of the Retina Image Bank. Which is the largest image bank, belongs to the American Society of Retina Specialists, ASRS, and I curate them. All of you should share your best images of any case that you have. It adds to the library there. You can go to the website of ASRS and anyone — you don’t need to be a member of ASRS. You just have to log in and have your registration done and go to the image bank section and upload your best images. We would like to see them and increase the collection. And it’s a huge library. Anybody can use it. You can go and see almost every type of situation which is there represented in this library. And also, you have a chance that we also do image of the week selections from the submissions which are there. And then there’s an image of the year. So, you also have a chance to win some of these image competitions which are there as a part of it. So, these are some of the situations and cases that I wanted to share with you. There’s a lot more which can be done with giant tears. But these are some classic situations that I showed you that we encounter routinely where giant tears are concerned. Giant tears are different than normal retinal detachments because of their sheer size and their folding on to itself and that’s why you need a perfluorocarbon heavy liquid to unfold them. That’s why you need a different sort of exchange that has to be done to make sure there’s no slippage and you get a good attachment of the retina. There are peculiarities of this condition that is different than a normal retinal detachment. That’s why it’s important to know how to manage them. And here, the most important part is viewing. And I insist that wide field viewing is very important. Whether you use contact or non-contact is, of course, your personal choice. Your training, whatever you are more comfortable with. But as long as you are keeping the periphery visible to you all the time, it makes a lot of difference to this. And perfluorocarbon, there’s not much you can do without it. Without perfluorocarbon, never take up this case. It will always be a challenge and then there may be slippage and a lot of other things that may come up. At this point, I’ll stop sharing my presentation and we’ll look at the Q&A. You can still keep — ask the questions in the next ten minutes or so also. And we’ll keep picking them up. I also have some questions which are already sent to me. So, what I’ll do is I’ll go through some of the relevant questions which I feel may add value to all the listeners and then take them up one-by-one.
So, somebody had asked me: Can GRTs have attached vitreous and how to use it in some of the cases. You have seen the videos, and a lot of them unfortunately have vitreous which is already it’s occurred and it’s easy to remove. In younger, highly myopic patients, may have to use triamcinolone dye, and like I showed you for some of the cases. You have to indulge in a PVD cleanup. You have to make sure that the PVD is happening if it’s not there already. You have to remove as much vitreous as possible. Because otherwise the residual will cause post operative issues that are there. Is there pneumatic retro pexy in giant retinal tears? I don’t have much experience with that for giant tears. I’m not the right person for that. I would not use it for a giant retinal tear. You get almost 100% attachment rate with a vitrectomy, and there will be a failure rate. You are in the best of hands. Having said that, I think a very superiorly-located giant tear that has not unfolded itself is something that you might look at if pneumatic retro pexy is something that can work in these cases. Do you prefer silicon oil for all GRT cases? This is something — I personally prefer silicon oil. Almost 100% success rate and remove it after three months. Does require additional surgeries. It is depending on the patients and the direction and the area which the giant tear is there. Again, it if it is just a superior tear, might put in gas. Otherwise I prefer oil which is much safer — the patients start seeing the next day. You can assess the tear edges from the next day externally. If off gas bubble, all the assessment becomes difficult if at all something is happening in the immediate post operative period. What is the rule of scleral buckle surgery in managing giant retinal tears. Typically it’s not used for giant retinal tears. If you saw with the choroidals. They are bulged and what happens is the tear edges are pushed by the choroid. There the choroid is pushing. But suppose you have a buckle that’s putting. And it’s going to give a buckle effect, similar to what the choroid does. It will re-fold the edge of the tear. So, this is not like a normal detachment. This is where it will push the tear edges. So, the only time I think people use buckles in giant tears is with giant tear with a lot of inferior PVR. Where you want to support the inferior base. But the inferior base should be attached retina and the others should be somewhere else. If the inferior retina itself has a giant tear, then I don’t think the buckle will help that without PVR. But if there’s a superior giant tear without PVR, you can use the buckle. But the buckle use has got less segmentation and a much wider buckle element is used for giant tears if at all you are using it in these situations. So, the next question is: Does one require an inverter system to use a contact viewing system? Yes. So, contact system also works on the same principle. What you see is inverted and you need to reward. If you are I suppose using a biome, which is a non-contact system, you are using an inverter along. The same inverter is used for the contact system. The inverter is the same whether you use contact or non-contact. There are some non-contact that don’t use inverter, i-boss, the system and some others. But the biome which is classically used does use an inverter. The similar or same which can be used for the contact system which I was talking about. Do you switch off infusion while injecting heavy liquid? This is a very good question because sometimes what I do is I start injecting. And there are cases because we do at times have leaky — we use wall cannulas. And once you use them, there is really no escape for any fluid to come in. What you inject is the pressure inside. So, it’s always good to assess if you feel any resistance, yes, switch off the infusion and in fact I also removed some of the residual fluid to make the eye hyper — and inject it. And then you can put the chandelier light and then you could have the left port which was originally used for the light, you could have just externally holding any sort of a passive extrusion that you can switch in that sort which can take away the residual fluid while you are pushing the PFCL properly. You could do it in three ways. Either the PFCL-injecting needle, the needle which kind of removes the fluid. Or you could have a chandelier with what I just mentioned to you. Or you switch off the infusion, lower the — two or three phases to lower the perfluorocarbon. Keep looking at the disc, if you feel it’s getting pale, you don’t want that situation. Instead reduce the penitentiary and field the PFCL in some of the other ways we discussed this problem started happening because of the closed chamber, the valve cannulas. We never faced this because there were leaky areas where if you inject PFCL, somewhere the fluid escapes and never release the pressure. So, once again, there is a question: Is it possible to do giant retinal tears without PFCL? Well, I personally would not recommend — there’s no reason. PFCL is easily available. It’s not too expensive. The past it’s availability used to be an issue and other things. So, that’s different. But today I think accessibility, availability is there and one should always do giant retinal surgery with PFCL. Opinion on the use of supplemental scleral buckles, I personally don’t use them. The situation would be if there’s only inferior PVR and a giant tear that’s independent that have maybe superior or on the sides is where it could work. Okay. Next question is 65-year-old female with total retinal detachment, OD and myopic features OS. Do you recommend prophylactic measures in the OS? Yes. So, if — it depends what is there in the other eye. One eye has detachments, the other is myopic changes. They don’t require prophylaxis. But if you see tears or non-pigmented lattices with holes in the other eye with myopic detachment. I would like to laser. But if I just see a pigmented lattice, I would ignore it. I don’t think I would go in and laser it in the eye of these patients. There’s no research to prove that that would reduce the detachment risk per se. I would not do it for those reasons. Must silicon oil be useful for giant tear — or use of gas. We discussed that. I prefer using oil in most of these cases. But gas could be used in very specific situation where it’s a superior localized giant tear which is not got folded edges. Nor a situation where you’re doing a two-step approach. You put perfluorocarbon for two weeks, go back in, the retina looks well-settled, flat. Exchange the PFCL with air and put gas is a possibility. I’m interested in — oh, this is a different question. Can you use Densiron instead of a two step approach? I don’t have experience of using Densiron. I’m not sure. Densiron has its own issues. It’s heavy, silicon removal is difficult at times, it causes some reaction. But I’m sure it can be used. It’s not about replacing with a two-step approach. You maw still have to do a two-step approach at times and then replace it with that. But basically, Densiron takes care of the inferior part a little better is all it does. But it does not take care of the rest of it. So, I don’t think I would resort to it for that reason alone. How long can you leave PFCL without any adverse reactions? Well, two weeks is — but there are a lot of reports of a lot of people leaving it for 7 days, 10 days, 15 days. The longer, it does cause mechanical damage because of the sheer pressure of the heavy liquid on the cells of the receptors. But two weeks, 20 days is not something that you see any remarkable change from the literature. And a lot of people use it. So, I would think — I would keep a limit of maybe 20 days as something where you may not get a specific adverse effect because of PFCL in the eye. It doesn’t cause reactions usually. The only thing you’re worried about is if it’s kept for too long, the mechanical pressure will cause damage. How do you approach ILM peeling in detachment case? Do you peel under PFCL or under fluid? So, if it’s a routine detachment, first try without PFCL. And if I feel there’s a difficulty because of the retinal mobility, I may put a perfluorocarbon and then remove it. But I would always first try it without perfluorocarbon. It’s much easier without perfluorocarbon. But it just depends on the way that it is behaving. In some cases, it’s easy to remove. And in some cases, it’s difficult and it moves in a way that you cannot remove it without perfluorocarbon. What is the prognosis of GRT in older patients as compared to young patients? Well, it can be both ways. You can either have — I mean, a young patient has better recovery capability. While it has — they have much more with this and more chances of contractions and failures because of those reasons. While — a patient, the retina will be a little weaker than the young child’s retina. But on the whole, the vitreous attachments will not be bad. And so, chances of contractions and all will be less so. It totally depends on the given situations. Not just about the age of the patient, per se. If silicon oil while doing cataract surgery, not well-informed — how do you — not sure I understood the question. What is the visual prognosis following repairs of GRTs? Well, basically, they behave like any other detachment. As long as you have been able to attach the macula, you can get results similar to other detachments. If it’s a fresh case, 6-6-6-9, if it’s an older case, less. If you have a failure, then the chances of visual recovery will go down. Silicon oil once inserted in eye how long do you keep or can it be kept permanently? I remove it around three to four months. Three months is where we counsel our patients that we will remove. Check monthly and remove it at three months. Earlier only if we feel there’s not a high pressure coming down. Then remove it earlier. Otherwise, most patients around three to four months is when I remove it. Very rarely I keep it long. It can be in cases who had multiple surgeries, or re-detachment post-oil in the past. And in those cases, keep the patient under follow-up every months and look for emulsification and then remove it. If the oil is behaving well, I can keep it longer in those cases. Sometimes, rarely, permanently also if the oil is behaving fine because of the worry of re-detachment in a one-eyed patient. It depends on those situations. But most patients I would remove at three to four months. In PVR cases, role of peripheral retinectomy? It’s if you have contracted retina after you have looked at all of the components. If you have membranes or any — anything holds that retina vitreous. And epiretinal membranes which you can remove. Then you first remove those. After that, you assess if the retina is going back easily without the contraction, you don’t need to do retinectomy. But if you feel that in that stage you have a contraction, then always do a retinectomy to relax the retina, otherwise you will get a failure. When you do retinectomy, do it on both sides of the contracted filament. Because you need to relax it properly. How do you stain ILM for ILM peeling cases in macular hole with GRT under PFCL? My preference for staining is directly. I inject the eye and inject perfluorocarbon over it. So, that you get a stain under the PFCL and then you can remove it. I don’t like to inject after putting PFCL. I prefer the staining — I just inject, whatever goes down, then I immediately inject perfluorocarbon. So, once you’ve cleared the residual dye, your view is clear and then you can see the blue stain, the ILM much better in that stage. Can you explain again the use of scleral buckles in GRTs. Thanks, why to use it and why not? Why not is because they will indent. When a scleral buckle indents, the edge of the tear next to it will get inverted. It will push on the tear. So, you are undoing what you’re trying to do with the vitrectomy. With the vitrectomy, you’re trying to push the retina — the tear edges back on the choroidal surface. While the buckle will push on the outside and try to act against it. I’m not sure if it will help. But the only time you can use it is it you have extensive inferior PVR which we discussed earlier. Do you get fogging of contact lenses that you sometimes get with non-contact viewing systems if not properly draped? Yes, I don’t get it in my OR, but it’s sometimes based on the OR temperature and the humidity. I have operated in other places and I see a lot of people get it in non-contact systems much more often and you have to put a lot of tapes next to the breathing of the patient and all. I personally don’t need to do it at all in mine. I almost never get fogging routinely because of that. Because these lenses are sitting on the cornea and they don’t have a gap in between. With non-contact system there is a gap between the eye and that and that’s why the fogging takes place. What do you prefer: Intraocular ram a or biome? Intraocular camera? I’m not sure what that is. I prefer contact system for all my cases, irrespective of the size of tear. What posture do you advise in patients in which PFCL was kept for two weeks? No posture. 20 years back we had the patient lie totally supine for two weeks and not let them move. It used to be worried that something will go wrong. But over time, we have learned that the patients move around and nothing really happens. If you have a fulfill of the PFCL, usually patients are fine. If you see them after 10 days, 15 days, you may see some sagging here and there. But don’t tell them to have any strict positioning until the side that there is PFCL inside. How do you manage cases of re-detachment following the removal of silicon oil? The same as any other detachment. Go in, put the retina back, check where it’s re-detached from, oil or laser or gas based on what you see inside. Can you explain how to do oil PFCL exchange? The direct exchange, you put the oil in the infusion and hold some extrusion to take away the PFCL. That is where I first replaced with air, and then go into oil. So, it’s a very straightforward way to do that. Does pigmented lattice carry less risk of detachment than non-pigmented lattice? Scientifically, there’s no greater risk. I mean, in terms of prophylaxis. I don’t do prophylaxis for pigmented lattices. I wouldn’t be worried about a pigmented lattice at all. If it’s non-pigmented with holes with, then I would look at many other factors. But if one eye is a giant tear and if the patient has non-pigmented lattice, I may go in and laser it. It depends on what kind of propensity the patient has on that. Do you use dual bore cannula for injecting PFCL? I have used it in the past a lot. But today I just directly inject most of the time. But dual bore is a very good option to inject PFCL with. An international — an international multicentric study published by AAO recommended combining bulk with vitrectomy in those less than 18 years old. Do you agree? I don’t do that, but when I use the belt buckle, only on younger patients. But I don’t go strictly by age. I look at other factors that I would do with encircling buckle. But not for giant tears at all. This would be for routine detachments with vitreous attached. What’s the easiest way to remove STARFOLD at posterior pole while GRT surgery? I showed with PFCL, this is a flappy, mobile retina. It’s best that if you can push some perfluorocarbon which is keeping the retina at bay while you’re removing it easily. If you’re still having difficulty, you can use a blue stain. It may help sometimes with the membrane. Which silicon oil do you prefer? 1300 or 5,000? I prefer 1300. I don’t like 5000, removal is difficult. 1300 works good for me. Giant retinal tear with nucleus drop. The important point is you need to keep the retina back while doing the fragmatome. It’s a high vacuum device. You don’t to want use a high vacuum device when there’s a giant tear in the retina. That’s an important thing to be causal about. Make sure you have a full PFCL backdrop on which you do the nucleus drop. Because the nucleus drops, I don’t use PFCL that often. Especially with a giant tear, I would use perfluorocarbon and on top of it do the fragmatome. Which cases do you consider removing lense even if there’s no significant cataract? Today I don’t remove a clear lens at all. I think today’s viewing systems and our instruments are so good that I don’t think you need to remove the lens just because the patient has a giant tear. You can easily deal with it. Even if it’s a non-significant cataract, if there is some cataract which is not coming in our way, I prefer to keep the lens in because until the time there is oil inside, you are better off keeping a very good compartment. It does not affect the corneal, endothelium, all these other things. I prefer having the lens inside and maybe removing the cataract at the time of oil removal is a better idea rather than trying to — but if it’s a clear lens, I would certainly not remove it at any point. How do you use the contact lens viewing? Doesn’t that make surgery assistant-dependent? Well, you can have both ways. Contact lens can be held by an assistant with a handle or the Volk lenses have accessory they have self-sustaining flanges. I personally don’t use an assistant. I just keep it with — keep it on — it’s fairly stable. All you need is sometimes your index finger to improve the tilt if you’re moving the eye. But I don’t have an assistant holding it. And I use all my surgeries with contact lens viewing. You could have an assistant who is very good and understands your needs. Or you can just do it without holding — with having an assistant also. I do use — I don’t hold it with a finger. But I use my finger to nudge it straight if at all I feel a small tilt here and there and keep it. So, just use my fingers to nudge it. How do I record such stills and videos? Well, I’m just passionate about seeing good footage on my OR and recording it. So, it’s something that I’m constantly aware of. I keep changing the amount of gain or the — I have an iris adapter on my microscope which allows me to open or shut as much as I like based on the view they get or the brightness I get. And my recording system is a Sony one which is — allows me to have a foot switch by which I can take stills in the surgery. So, at any begin point during the surgery that I want to get a still, I just place another foot pedal. One is for the video to start and stop. The other one is for taking stills. It’s something they enjoy capturing these moments. So, I am constantly aware of the visuals which are there. And all you need is to be looking at the screen and recording. Because sometimes you get so engrossed in surgery that you lose track. So, what is getting recorded is out of your — the brightness isn’t good or it’s too bright. Make sure you see on the screen what is getting recorded. And tweak it before finishing the surgery. Because otherwise your recording would have sub-normal quality at the end. Just be aware of that. How do I ensure no slippage with the air PFCL exchange? What I showed in the multiple cases, very good peripheral drying of the edges of the retina. Before you let the PFCL we discussed go below the edges of the tear. As long as the PFCL is over the tear edge, you cannot slip. Once you are starting to remove the PFCL where the meniscus is below, it will go down. How to avoid lens touch during bimanual vitrectomy with chandelier? Chandelier will not increase chances of a lens touch and stays in the lens port. I don’t think it will increase. Best is that if you want to do something in the periphery in a clear lens, I showed you a footage where you can low the eye and have an assistant intent. Or you can put a chandelier — I use my right hand with the cutter and the left hand is something you can use indent from inside. The chandelier is giving the light. I don’t need to use a fiberoptic. Either way you can achieve this kind of — you can avoid the lens touch in those situations. So, I think we’ve come to the end. And we are short on time. And pretty much finished all the questions at this time. I would like to thank all of you for patiently being here. Although this is not a forum where we can talk about and interact, but I think this is the best way in terms of answering the Q&A that’s available to us. And I would like to thank Orbis and Cybersight for once again allowing me to use this platform. It’s always a pleasure. I almost use it twice a year, I think, over many years and it’s a pleasure to be on this forum always. Thank you very much.