Vitrectomy surgery has become a mainstay of rhegmatogenous retinal detachment repair. This course will review case selection for vitrectomy for retinal detachment repair, reproducible techniques of vitrectomy repairs, safety, complications and post op instructions.
Lecturer: Dr. David Miller, Retina Associates of Cleveland, USA
>> Dr. Miller, can we switch to the microscope view?
DR MILLER: I use very little sedation. I use (audio drop) and that’s about it. We prep with Betadine, being essential for any eye. Properly draped with the lashes out of the way. You’ll notice there’s no eyelashes in the field of view, because we do consider that a higher risk for endophthalmitis infection. So Mike is giving me the first trocar and cannula. 4 millimeters to the back mark. 3 on this one. To the front mark. So we measure from the limbus, and I tend to put the sclerotomy — I tend to put them all in an angle beveled incision here. Pretty much 45 degrees or less. Maybe 30. Push them all the way in like that. I don’t go up and drive in. I want a longer tunnel through the sclera. This leaves the sclerotomies… This leaves the cannulas, rather… At an angle where they’re almost facing me, as you can see. We also displace the conjunctiva a little bit. You can see it facing this way, not straight up. I put the working sclerotomies, like I mentioned, between 3 and 2:00 and 9 and 10:00. Again, with this instrumentation, 25-gauge instrumentation in particular, instruments are very flexible. So you don’t want to be too high in your site selection, because it makes it tough to get to rotate the eye more. Whereas if I have the instruments here, I can just pivot to reach the bottom of the back. Come down here. I have to drive the eye and the instruments will flex. So now all the cannulas are in with the valves. I’m gonna pull this valve off. Sometimes they’re a little sticky. We just pop that off. Turn our irrigation on. Take a look here. I’m gonna tape that into location there. And then we’re gonna take a quick look to make sure by looking off to the side and pressing that in that I can see it in the eye and I can. I doubt that’s visible in the microscope, but when you look outside the microscope, looking around to the side, I can see that quite well. By pushing it in. Then we start the vitrectomies with the vitrector in the temporal side. We’ll put a little Gonak on the eye to keep the cornea lubricated, and drop in the wide field visualization system. There we go. Now we’re gonna get this focused up for you. Get you a nice magnified view. I believe… How are we doing there, Mike? Pretty good? I think it’s pretty good on the screen. Lawrence, if you think we need more zoom or something, let me know during the surgery. The videos come out better with higher zooming than what I normally use. I start in the middle here. Quickly you can identify the retinal detachment. Running from superotemporal down across the macula, down to inferonasal. The macula is off. It’s pretty close to the drawing, is what we saw. And the preoperative evaluation. Other information we’re gathering here… Is, one, the blood flow is good in the eye. The vessels aren’t flashing. The eye walls are not enfolding. We’re maintaining good intraocular pressure. I pretty much have the vitrector pedal all the way to the floor for max aspiration. The 25-gauge system. I’m starting to move around a little bit. You can see I’m cutting the vitreous back to the skirt, a little enfolding there. So we’re gonna have the eye kind of reinflating, Mike is gonna bump the pressure up for me a little bit… I suspect… The bottle is not high enough. Because I don’t normally sit this high. So sometimes… One thing we notice is that the eye wall is enfolding a little bit more than usual. I didn’t check before I sat down — was the height of the bed versus where I normally sit and the bottle chamber. And that can affect intraocular pressure. I’m on a DORC machine, the EVA. And though it’s a pressurized infusion, bottle height to seat height still counts. So we’re going around the eye, getting the vitreous skirt out. Very nicely. And once we got a nice working space in here… We’ll talk about things like identifying the retinal breaks. Whether to shave the vitreous. Get the transaction off the tear, et cetera. All that’s coming up. While we’re doing the vitrectomy here, I’m gonna ask for an occasional question from Rachel, who maybe can take a look at the list of questions that are submitted, or the live question and answers that are coming in as we’re working here by the chat button on the computer. So Rachel, do you have any questions? What speed? Gauge? I prefer the 25 gauge. I do pretty much all my retinal surgery — actually, all my retinal surgery on 25 gauge. Why do I like that? Small wounds. No sutures for closing. They’re functional enough. Even though they’re thinner and more flexible. I just like the smaller wounds. I think it’s a good instrumentation. So the scleral depressor there, Mike? So I tend to scleral depress myself. When I get the free hand like this. And we’ll take a look here. Mike is an expert at helping me out and doing this over a decade. The entire room was expert. We’ve done many, many cases together. A nice team approach. We depress in under high zoom, looking for the retinal tears. Now, in a pseudophakic patient, quite often these tears can be very small. So you have to be very efficient as you’re moving around, dynamic examination like this. Looking for any flap. That looks like it will pop open. And show us the cause of this gentleman’s retinal detachment. We do get cases where we cannot find the retinal tear. That’s rare. When that occurs, we end up having to put more laser treatment than we prefer. Going… We really just treat the area of the tear. And what we’re looking for — the reason I’m staying in this quadrant so much — is you can see the detachment is higher than it is typically. Typically the retinal tear most often will be located in the first couple clock hours of the higher side. So if the retinal tear knew where it was supposed to be, it should be right in this area. That’s where it’s supposed to be. It looks like there’s a suspicious spot right there, in the right… Right there. Right. You see little holes right here, everybody? It’s gonna be really hard. These are tiny. So again, pseudophakic — we’re gonna have to mark this before I lose it. There’s a nice angle on it, too. Maybe I can get some zoom to focus that a little bit for the audience. There you go. The little dark spot right there? That’s our guy. That ain’t much. So it’s nice to mark that or treat it with cryo while you’re here. We’re gonna do that right now. That’s just a really thin area of the tear. Just this spot. That little flap right there, even. So what we’ll do is… What cause my eye is the elevation of that right there. So what we’re gonna… I’ll raise this here. Give the depressor to Mike. We’re gonna come back and take a look at that same area, this kind with cautery. And the point of this is gonna be… To mark the retinal tear so we can find it later. A little higher, towards me. And of course, everything changes when you move the light to the other side. Right. That’s the weak spot. We’re gonna mark that, because we know it’s really close to that, basically. Give a little cautery burn there, and we kind of know about… It’s gonna be within a millimeter of that, all the way around. Laser that area without having to get more particular. Very good. Now, as far as draining the retinal detachment, I’m about to make that retinotomy while I’m here. I’ll use a posterior drainage retinotomy. Can you focus the posterior? There you go. So you can see the detachment goes this way. I’m not gonna drain in the macula. I don’t like to drain too far temporally, because it’s hard to drain. I like to make the retinotomies more posterior, within a few millimeters of the optic nerve. Nasal is a nice side to drain on. Away from the macula again. So we’re gonna drain right in here. Make a little cautery burn. So we can pop the retina there and make a drainage site for ourselves. And we’ll come back and confirm the location of the retinal break with the scleral depressor. Putting the light back on the other side, project the light onto the tear location. Focus, Mike. Go from posterior — because we’re going to higher mag. It kind of throws off… And there’s the tear. Again, very subtle, very tiny tear. Right there. Yep. Could be a little hemorrhage. We’ll get that, though, too. Certainly. A little bit of condensation on the eyeball, because I’m so close. So would you back it up and… Mike is gonna wipe it for us. Another way is just to back it up, so you’re not so close to the cornea. Of course, we’re gonna continue looking around the eye. There’s quite often more than one retinal break. Even in that area alone, I’m suspicious that there’s two small ones, not one small one. Down here, we have some chorioretinal scarring, paving changes — that’s not the retinal tears. We’re gonna check the other side. I’m moving my hands. Rachel, what other question do you have for me? Do you have another one? I’m sure… Right. So… We tend to run the cutter speeds pretty high when we’re shaving, and turn the aspiration down to low flow mode. Actually, I use flow more than aspiration. So cutter speed is what, Mike? 7,000? And it’s a dual cutting vitrector. So it’s probably higher than that. You know. By how the machine is engineered. And we’re flowing at 7 CCs per minute during the normal case. Shaving is 7 CCs. So 15 CCs a minute is normal. I go down to 7 for shaving. I don’t tend to shave very much. So this is a common point when I lecture on this and discuss it. Because I think shaving is way overblown, in terms of importance. That may be heresy to some of you in the audience. But we’ve been doing this a long time, and shaving didn’t come up until the vitrectors got to be higher speed, kind of a machine looking for a purpose, a little bit. Shaving became all the rage. For the most part, those little retinal tears you saw me cauterize don’t have much traction on them at all. It’s not gonna take… The retina wants to reattach itself. The retina wants to be against the back of the eye. So we don’t have to get out every little piece of vitreous around a tear site to make for a successful surgery. And quite often, people get themselves into more trouble with things like shaving, creating extra tears, as opposed to helping themselves. My advice would be: You know, if you’re not in a PVR-type case, you have to wonder how much shaving you really need to do. But certainly, I’ll take some of the vitreous away from the break sites, just to make the laser better. It does have optical effects that can make things more difficult. And if you have an area that’s gonna take multiple — you can do this under scleral depression. I think a large core vitrectomy will get the job done. We saw only one break, kind of matched the expectation, gonna drain it, drain out the retinal detachment here, apply our laser, shortly after that, so the retinotomy is quite often less simple than it looks. So you see the white area? There’s lots of blood vessels around it. There always are, if you’re posterior. And too often, the retinotomies get away from you. It’s large and bleeding. So we’re gonna first engage it… To make the hole. I’ve got a hole there. I’m aspirating. And I’m just using minimal aspiration. I’m not trying… I’m less than 1/4 of the way down on the pedal. Very gentle aspiration. You want to know where your reflux is so you can get off the retinotomy. Too often you see younger surgeons pull away from the retinotomy site while they’re still aspirating and the retinotomy enlarges and runs away from them. So we’re seeing it enlarging already. I’m sucking out thick subretinal fluid at the start there, first under fluid. Now I’ll flip over to air. Here comes the air bubbles. We’re just gonna drain over the optic nerve until the fluid accumulates over that retinotomy site. The fluid is accumulating posterior. The retina will elevate itself around the retinotomy, give me a nice pocket of fluid to elevate against on the retinotomy site. Even when I take the fluid all the way out of the eye, you can see the detachment. It’s here, kind of posterior now. Here’s my retinotomy. I can go down and aspirate really gently, pull the subretinal fluid out without stressing the retinotomy site, without getting enlargement. It does happen sometimes, even being the most cautious that you can. You just have to deal with it. But the goal is to keep the retinotomy small, keep it tight, and it’s one less possible break… That could be a problem postoperatively. Letting the fluid reaccumulate here for a minute, 30 seconds, drying it a little bit more. Wait again a little bit. Sometimes you get fogging on the back of the IOL. That is condensation. And you can… We don’t have that problem here. You see it only with an open capsule. Number one. His capsule is open, but it’s not condensing on the back of the IOL. Temperature differences between the chambers of the eye, posterior to anterior. You can deal with it, if it’s problematic. You’re wiping it off with the SofTip. That works for a minute or less. Take the laser next. Or you can put some viscoelastic on the back of the IOL. That will always work. So this is a flexible laser. Adjustable. Just trying to find my laser pedal. We’re just gonna laser down the retinotomy site so it’s white around the edges. This doesn’t have to be done too harsh. It wants to stick. I’ve maybe had one patient ever redetach from a retinotomy site that wasn’t adequately treated. So for the most part, that’s all it takes. Small retinotomy. You can see… The areas of pigmented lattice, down below. Some chorioretinal scarring. We can put a little bit of laser around that. I don’t think it’s absolutely necessary to even do this. If we didn’t find any tears down here, we’ve got a nice clear look… We’ve got good visualization in this case. Which is a nice help, in terms of being confident. But just in case we missed a tiny break around these weak areas, or these thin areas, it never hurts to put a little laser near them. Now we’re gonna come back and get the tear site. Which was temporal. Any questions, Rachel? While we’re going through this? That’s a good question. In terms of percentage? Here’s our retinotomy site, by the way. I’m sorry, our cautery mark. And we knew we were suspicious of tears right in this area, from about here to here. And this optical effect you’re getting is from the vitreous space, the insertion right there, so we’re just gonna work around that. And make this area white. With some laser burns. And we’re probably gonna have Mike depress in this area too. Because of the optical effect, it’s making it a little tough. Seeing how posterior we are while we’re doing it. Mike, if you can depress this area, we’re gonna get a little better view from me and the audience here. What percentage of the vitreous? That’s good. He puts that depressor in there. Now the vitreous base starts right here. But now it’s not a problem. So — that little pigmented spot right there, huh? That could have been it. This way more. And so we probably take out around… Oh, 80%. 80% to 90%. Again, you don’t really need to get all of it. All you’re trying to do is get access to the tear. And get the tear reopposed. If the vitreous can stay in the eye at even a higher percentage, I’m fine with that. As long as you’ve got enough space for your tamponade, your gas bubble. And the less you’re in the eye, the less can go wrong. The less iatrogenic-type troubles. You don’t have to make the case more complex. By trying to get more vitreous out. The other question is am I gonna laser all the way around or what? The answer is no. I find that lasering 360 — some questions came in the day before. One of them was: Do you laser 360? My answer was: Almost never, unless there’s pathology all the way around. Multiple tears, 7, 8, 9, multiple tears, lots of lattice. Then we wind up with laser patterns like that, but the real goal is: Find the break and you’ll be fine. I think we’re in pretty good shape. So that’s about all it’s gonna take. We’ll drain the fluid. You see the fluid reaccumulated back here, while we were doing that. So we’re gonna take that fluid out again. And then we’re gonna put a gas bubble in, and I’m gonna use… C3F8, because the break is above the horizontal. I use 15% C3F8 gas for this case. Pull the fluid out first and then go back to the retinotomy site. You can get the gas, Mike. So Mike and Julia are gonna get the gas prepared. And you can see the retina flatten right back down from that little bit of reaccumulation. I’m a little concerned maybe that the retinotomy site is a little not treated on the posterior edge. Can I have the laser back there, Kim? It’s still on, right? I’m just gonna treat the posterior edge there a little better. And not have to worry about it. There you go. Very good. So we’re nicely attached. Retinotomy is lasered. Some laser down below at the lattice. Some laser… Orbit the tear site temporally and superotemporally, and now we’re gonna swap out the air for the gas. So we’re gonna pull the one sclerotomy site. On this side, I’m gonna press this sclerotomy site closed with my forceps. Because it was a bit of an angled incision. So what we’re gonna do is press on the top of that incision. Not at the incision, but kind of on top of the tunnel to collapse it. And that kind of works. See? The gas stopped. And we’re gonna vent through this side. As Mike pumps in the new gas. Displacing the air from inside the eye. And so this hole is here. The conjunctiva can be displaced here, pump the eye up a little bit, I’ll press against the pressure he’s putting against the eye. Very good. I can feel that with my finger. We’re in good shape. We can pull out the infusion cannula next. I lost quite a bit of gas there. So we’re gonna reinflate the eye with the same solution. And I’m gonna press this one flat too. Then hook this up to the same syringe of mixed gas. And go ahead. Typically use my finger for intraocular pressure. Keep going. Keep going. Keep going. I gotcha. Right there. Keep going. Got a Q-Tip there? There you go. You’re fine. So now the leak has stopped. There we go. Little small leak right there. Got a Q-Tip. Gonna work on this leak a little bit here. Which is kind of nice to show you. First I use my finger. But we’re gonna wait a little longer. Quite often, the wounds, if they are leaking a little bit, it’s actually kind of odd to get the infusion one as the leaking one. More often, it’s the working ones. But when you do get a leak like that… Get a 0.12… Wait just a little bit as the sclera regains its normal shape and elasticity. The hole will close. You see it used to be a round hole. Now it’s just a slit. I’m gonna press right here, over the top of that tunnel. Kind of press that tunnel flat. Get the gas in. And now it’s just a little bit of… A little firmer than I wanted. There you go. Okay. So no leaks. Eye is nicely pressurized. And that concludes the case. I’ll let you get that out. I’m gonna go back to the slides. Review our questions. And take some more questions and answers. And move Robert out. And bring the next patient over. So we may run over the hour. But that’s okay. Happy to at least start the next case, which is different from this one. So what was interesting in that particular case is a couple things. One was… You had a vitreous separation. You had a pseudophakic patient. That’s ideal. The tears were very small. So the toughest thing about being successful in retinal detachment and repairs — can you find the retinal break? It’s like a game of hide and seek. Those tears can be extremely small. Especially in pseudophakic patients. And I can still find them. That was a nice challenge to show everybody. But you can use the clues about where they should be and look at those areas more closely. Again, it’s usually on the higher side. The detachment was like this, higher on the temporal side, and the breaks are usually in the first few clock hours on the higher side. That’s exactly where it matched up in this particular case. Also nice to show you — while on the eye wall enfolding on the start of the case — I don’t know if that was visible to you. That’s because the bed was high compared to the bottle. Normally I work with the bed lower but got distracted a little bit with all the video-ing. And the other thing that was interesting — the wound leak at the end there, you can see the bubbling going on. But if you’re patient and work with that just a little bit, you can do pretty well, and not have to get out the sutures and cut down the conjunctiva. So that’s all well and good. We got a nice successful case done. Very confident. Him leaving the room, I would expect the chance of that working to be 97%, 98%. I’m pretty sure we’re in good shape. The one thing about small retinal tears is that the success rate is very high, as long as you can find the tear. The bigger tears can have more complications, like PVR. This should not be a PVR case whatsoever. So to go back to the questions, Lawrence, with the answers and the audience polling, we can go through that. Discuss it a little bit. The review question — where do you like to make the sclerotomies? I would tell you 3 and 9 at 3 millimeters. All the answers that are 5 millimeters are too far back. We can be into the ora serrata, making retinal tears. It’s better to flex the instruments and pivot them, as opposed to moving the eye. Next. Possible risk to vitrectomy. The audience was good with this. Basically all of these are possible risks to vitrectomy surgery. All of the above. And next? What are the causes of failure for vitrectomy RD repair? Number one, missed retinal break. Number two, proliferative vitreoretinopathy, number three, leaking retinal break. All of these are possible, but missed retinal break is number one. What criteria are most helpful? In terms of doing a vitrectomy, for RD repair? I would say that in terms of success, what you would like the most is a superior location of the break. Because you need less patient cooperation with head positioning. Speaking of — I didn’t discuss this, but Mike was already doing it. Robert’s position can really be upright during the day, and then sleep on his right side, so we’re gonna put him on his right side when he sleeps. The bubble tamponades the temporal breaks. He has a C3F8 bubble, I’ll let him be upright during the day. He doesn’t have to be face down in this position. The bubble will last long enough to keep those breaks all well sealed. If you’re more cautious, you can put him face down during the day. That’s very difficult for older patients. Any patient, really. If I was doing face down, it would be 45 out of 60 minutes during the day, and sleeping on the right side is probably the number one thing. Right side, face down — I know the retinotomy is over on the right half, but near the optic nerve. It’s not far out. If he’s on his right side, rolls his head down, keeps the bubble in the back of the eye, against the retinotomy, keeps the break high, he should be fine. So as far as my favorite — I would say the superior location of the break and a vitreous detachment being present. Clear media doesn’t bother me. Clear media — you want that for cornea or lens, but you can always take the lens, and if it’s in the vitreous, you can always take out the vitreous. Phakic is never a help. It’s basically a more negative indicator for vitrectomy surgery, for retinal detachment repair. Next? Oh, good. So the next patient — I’ll tell you what. The next patient for those who are gonna stick around — 69-year-old gentleman, with a recurrent retinal detachment. So he’s one month post-op. He came in again, Dr. Hall is our partner, who found a couple of retinal detachments on Friday. Set us up today. This is a prior mac off detachment, repaired months ago by one of my partners, phakic, 50% gas bubble in the eye, and the macula is on. This is the teaser about whether you want to stick around and see another case. It is different. So retinal break… As I identified down here, inferotemporally. This is the gas bubble up here, at the top half, so this gas bubble is obscuring the vision. Some. The macula is attached. And this is the bottom part here. And the OCT shows you the macula is attached. Next? I think that’s the end of the slides. We’re gonna bring him in now, get him blocked up, get him going. Okay. Yeah. Let’s do the Q and A while we’re kind of hanging out here. How much gas do you inject? Any criteria for that? If you were using oil, it would be great to show you that technique. What we do with the oil is we fill it up to the infusion cannula, so it’s just coming back up the infusion line. Probably 90% — the posterior segment is probably 90% full with oil. Gas… Same. Probably more than that. More than 95%. Yeah. How would you navigate around a that’s correct bleb or glaucoma drainage device when placing your trocars? I stay away from those like the plague. Any glaucoma devices or glaucoma surgeries can be very dangerous to incorporate into your wounds. It makes for all kinds of problems. So I’ll put my wounds anywhere where there’s not prior glaucoma surgery. Do you use any pharmacological vitreous detachment prior to surgery? Do I try and induce a PVD prior to surgery? No, I do not. There are medications out there. ThromboGenics had Jetrea, thromboplastin, also just plasmin from the serum, some people put gas in the eye, trying to induce a PVD. I do not do any of those maneuvers. I just do it mechanically in the operating room. You can get a PVD virtually in every case. Children are the hardest, of course. But you can still get it there, by working it mechanically. I’m gonna block the patient, I think, Angelica. Ready? I’m gonna block the patient so they can prep while we do some more questions and answers. And probably you can just spin this a little bit to see… You can watch us working here at the head of the bed. Okay, John. How are you doing? Dr. Miller here. We’re doing our time out. Okay? Working on the right eye. Working on the right eye. Julia is getting it written on the board for us with John’s name. And we’re doing a vitrectomy for retinal detachment repair, right eye. You okay? Look straight up there. So just look right up at the ceiling. About one third from the lateral canthus. Give the needle a little shake, then I inject — is it 2% lidocaine? And 0.75 marcaine. We do cases like this. Sometimes you don’t think too much about the steps that have been the same for many, many years. Not bad, huh, John? We’ll get drapes over your head in a moment and we’ll get the case started. So we’re gonna go back to the questions and answers. And see what we got here. So… Do you find utility, pre-op performing scleral depression to properly identify the breaks, or do you… You can do it with the indirect ophthalmoscope first? I think there is utility in looking in the operating room to find the breaks. You want to know what you’re coming into. This case was identified — the prior case, where it was hard to identify the break, I had a question mark from my partner. Looks like break here. He kind of nailed the area. Dr. Hall has a good eye. He nailed the spot where the retinal tear was at. That told me there was no obvious retinal break, sow we had to struggle to look at that a little bit. You don’t want to be surprised. It’s nice to know what you’re coming into. Certainly I want to confirm everything in the operating room, under the anesthesia and the firmer scleral depression. Do any systemic diseases lead to retinal detachment? The answer is certainly they do. Exudative detachments — almost always systemic disease related. Posterior scleritis. VKH, et cetera. Tractional detachments, things like diabetic retinopathy, rhegmatogenous detachment — things like high myopia to many others, actually. I won’t get into them. But that’s certainly more rare. How do you control intraocular bleeding? The best rule in intraocular bleeding is not to get any. If you’re in a retinal detachment case like the first one, we don’t expect to get intraocular bleeding. We don’t want to hit the retina accidentally, cut open a retinal vessel. We use cautery to create the site. Some people don’t. That can create more bleeding. You don’t want to bounce into the choroid, which is vascular rich. You can get more bleeding from wound creation, putting in the trocars. The best thing to control that is with elevated intraocular pressure and waiting a few minutes. The role of silicon oil in surgery. Silicon oil is nice to use for long-term tamponade, especially in patients who cannot position face down and for repeat surgeries, where there are indications of proliferative vitreoretinopathy. So I try to stay away from oil. I try to use it for reoperative cases or patients with breaks inferior that I know they can’t position well and the gas won’t be at the bottom of the eye long enough. I prefer not to use oil because you have to come back and get it out. It’s always a little more complicated, always little oil bubbles left behind, it can cause elevated eye pressure, it can emulsify, it can cause chronic or smoldering uveitis. So I prefer not to use oil. The gas is nicer. I have used oil for people traveling, business trips they could not avoid or some other function, and if they were flying, oil is tolerated for airplane flights and gas is not. It does have a role, but I try to stay with the gas. Yeah. Is retinal detachment related to neovascularization? It can be in diabetics. Again, you get neovascularization, proliferative diabetic retinopathy and the neovascularization can contract and pull the retina apart and tear it. So it can be. Okay. Here’s a question. I’ll just load that. Which is better? An iatrogenic break near the disc, more posterior where the fluid accumulates, or at the anterior retina? Here we’re talking about where the retinotomy was created. Do I make it near the optic nerve or in the periphery? When you make the retinotomy in the periphery or drain near the original retinal break, you can do that, it’s a more skillful procedure, and the talk of the day is the basics for retinal surgery with retinal detachment repair. I think it’s better to make posterior retinotomies and drain posterior. I think draining anterior, which I do in many cases, takes a higher repetition, more skill, and it’s not as reproducible. And you always have some residual fluid that will track down into the macula and you’ve got risk of retinal folds, macular folds. You just want to be a little careful with that. If you’re starting out, I would highly advise posterior retinotomies. I know there’s more nerve fiber layer down there, more condensed fibers, might get a larger scotoma, perhaps, but if you can keep that small, keep it nasal, which projects way out to the temporal field, not anywhere near the macula, I’ve almost never had a patient complain of visual field loss from their… I’m gonna have to look at what that was. Almost never complain of visual field loss from the retinotomy site. Am I left-handed? No, I’m right-handed. I’m thinking where that question is coming from. It was a left eye. So I always start on the temporal side. So I use my left or right hand… Fairly evenly throughout the case. I guess I drained left-handed too. I drained the retinotomy site left-handed and lasered left-handed. You probably saw me going back and forth left and right-handed. I’m right-handed. I grew up very strongly right-handed. I couldn’t do much left-handed at all. But you want to kind of push yourself, as you’re doing surgery over the years, to use your left hand. Otherwise, maneuvers get very difficult. It’s much simpler to fix a retinal detachment if you can flip your hands back and forth like that. I would encourage anyone to get a little ambidextrous if they can. If I can do it, anyone can, really. Do you aspirate subretinal fluid? Yes, we did. We did use active aspiration. It’s hooked up to the vitrectomy machine, soft silicone tip on there. I’m using very little aspiration. Probably at the most a quarter of the pedal being depressed. Does the illumination help find the retinal tear? Absolutely. When you saw us struggling to find the retinal tear during the case, I was moving the light pipe in different positions and angles. You don’t want to just be static. You want to be shifting and moving. I’m a little fidgety anyhow, maybe a little hyper, so I’m always looking, tweaking, it’s a two handed maneuver, trying to get different angles on the retina to get a better view of these tiny tears. Do I use any stains in these cases? Not for this type of case. I use stains for macular holes and epiretinal membranes. I use green dye. I have used the blue stain also, but I prefer the green. Let’s see. What is the pressure when doing the scleral depression? The scleral depression doesn’t take that much pressure. It’s just enough that you can indent the eye, so it’s all by feel and vision. It’s more than I do in the office, because that would be uncomfortable in the office setting. But here under anesthesia, we can get a better scleral depression, putting the rod against the eye and moving it around. When you make a nasal retinotomy, would it cause a temporal field defect? The answer to that is it does. You can map those out, but I’ve never had a patient be symptomatic from it. Almost never, I should say. I can’t think of the last time someone has complained of it, honestly. Do I always perform a retinotomy? No. Sometimes we will drain through the retinal breaks or put in perfluorocarbon liquids to press the fluid out through the anterior breaks. You can put in these heavier than water fluids and it will press the fluid out. Those can be nice, but the perfluorocarbon fluids — then you have to drain that under air-fluid exchange, and it’s an oil, you leave behind small droplets of oil, it’s an extra step, and for reproducibility, safety, efficiency, and cost, it’s very tough to beat a posterior retinotomy drainage. More advanced techniques — certainly there are other ways to do it. We don’t use Densiron heavy oil. We just use perfluorocarbons, and our oil is 1,000 silicon oil. I prefer that over the 5,000. So our next patient is set. I’m gonna jump do that. However long the case wants to go. If you want to stick around, it’s fine. Get it going here. This case is a little different because of the recurrent nature of the detachment, phakic, gas bubble in the eye. We’re wondering whether there’s gonna be a cataract that’s gonna obscure our view because of the gas in the eye. Gas in the eye tends to make cataract develop, or sometimes posterior feathering, which can make the view difficult. Also why the retina redetach? We see the bubbles coming off — I did not do his first case, but we’re suspecting that there’s a break somewhere that — as the gas bubble is receding, the break is uncovered. The possibility would be some early PVR, proliferative vitreoretinopathy in the inferior half of the retina, creating a new break. We’re gonna create PVR inferior, or we’re gonna look for a break that developed or was missed in the first surgery, perhaps. And we’ll see. So the Mike has the patient again expertly draped, eyelashes out of the way, table is lower this time. Thank you. And there is our right eye. This is really good. I’m hesitating… I always pause here when I do this part. I don’t usually measure much anymore. We kind of just go. Starting out… I think measuring it is safe. I prefer not to hit the old wounds, by the way, if I can avoid it. So fortunately… On the horizontals… I’m usually pretty safe down there. There we go. How are we doing there? All righty. You’re doing fine. We create wounds which are typically more commonly higher. Wherever you go, try to go somewhere a little different. If you hit the old wounds, it’s tougher to close the eye. They tend to leak more. Okay. Forceps there again? So we pull off… There. Tape it. Quick look here. It’s in the eye. Excellent. Put it into the suprachoroidal space. A tougher start. You have to deal with that, then, in the surgery. So a couple things. Out of the gate — one, the lens isn’t that bad. He’s phakic, but I don’t see that much of a cataract. That’s a big help. Don’t have to worry about fragging the lens. I’m gonna zoom in here and see what we got. Okay. We can see the bubble in the eye still. We’re gonna grab some of that. Some of it already came out. There we go. We’ll remove the bubble. Don’t have to get all of it. Just enough so it’s not interfering. Some debris lying around from the prior surgery. There’s the detachment, running right down here at the bottom. You can see laser scarring up top. We know the detachment appeared about one month out, which tells us there may be a break somewhere at the horizontal or just below the horizontal. Here we’re engaging some vitreous already. Coming towards the portal. I’m gonna guard the light pipe so it doesn’t accidentally jump into the vitrector. That can happen. If it does, you just deal with it. The retinal tear is made by the vitreous pulling. Or whether it’s made by… The vitrector… We got one right there. I just did that one right there. That’s okay. I’m looking at the contraction down here. So we can see that the vitreous is definitely not normal. I don’t see any folds in the retina. You can see the laser down here where the retina is very thin. Mike is pointing out this little spot of maybe hemorrhage right there. Let’s see if we can find all the retinal breaks. The vitreous is a little bit stiff. There’s a vitreous skirt there that was contracting. We did cut into that inferior, to relieve that traction. And again, you get more of that… When there is more cryo or laser in the eye. I think… One of the reasons I prefer not… To laser the eye too much… Is because… Or cryo the eye too much is because the rate of PVR seems to be much higher. And so we’re using the light again. Moving this light around. Looking at this area, that was lasered prior. It’s pretty suspicious. Especially… Down at the edge right here. Maybe a little traction from the vitreous. I wouldn’t call it PVR. If it is, it’s early. Very early. So I may also ask about… You see the pigment in the vitreous down here too. Right? So I can kind of… Pull the vitreous a little bit. Right there. Yep. There’s the break. So the causative break is right here under the vitreous. Right under that pigment. There’s a break basically at 6. We’ll get it with the vitrector. It’s right here. The technique here is kind of interesting. We used the light pipe to push it out of the way and see whether it’s gonna open up a little bit. And that shows us the break. It’s a tiny break. It’s right here. Not gonna take much to reattach that, frankly. Just a few laser shots. And we’ll be on our way. We want to do this pretty quickly. Better to have the cautery… We have Mike with the depressor. I have the cautery. We’re gonna mark that. 6:00. That will do it. Mike, I think you’ll do fine right there, and that’s our guy right there. Okay. Let’s go the other way now. Keep going. Here’s the one I snagged. Well, we’ll switch hands. How about the… Scleral depressor. Now, don’t be fooled just to check the bottom half because that’s where the retinal detachment is. Sometimes you can get a retinal tear in the top half, the fluid will drain to the bottom half, and it can be more tricky with gas in the eye, because the break above gets pressed flat during the day, opens up at night, and accumulates at the bottom. So you always want to look around, even in the clock hours that don’t seem like that would be the cause. This looks pretty clean on the nasal side. For sure. You’re doing fine. We’ll just scleral depress that, take some of the vitreous pigment out, Mike. How are you doing? In much pain? Okay. He’s having a little discomfort. If he can work his way through it, we’ll let it go. If it gets to be more discomfiting to him, we’ll supplement the block with a sub-Tenon’s cutdown work. Go back to 6:00. So here what we’re doing… This is more of a shave. What we’re doing is using very little aspiration. And the flow is probably… What is the flow? 4.2 CCs per minute. That’s a very small flow. We’re kind of working our way down in this vitreous base here. Down where that cautery mark is. Where we found the tear. Okay. Very good. That’s all right. I don’t think so… I think it’s this. So I’ll take out this vitreous below. This gives us a little bit better view. Now, we have to be a little careful. We’re risking hitting the lens here too. Trying to hold it… Even at low flow, you can get engagement… Of the retina. Come out of there for a second. Can you bring the Eibos over? It’s hitting on something. There’s our guy. A little break right there. This one… Ended up being close to this one. But they’re not the same. They’re just the same clock hour. Ironically. I was getting down there. So how about I just mark that one too? So this case is not gonna be too long. The question with think is… You would say: Oh, hey, should you do a scleral buckle? Should you use oil? I don’t think oil is needed. I don’t see enough PVR. There was some stiffness in the vitreous for sure. Inferior. And we kind of cut that out. But no fixed folds in the retina. Draining — not in the macula. It’s mostly inferior. The nasal is kind of attached right here. I don’t want to go that far nasal. Want to stay somewhat posterior. I’m gonna drain it here. People sometimes don’t like inferior drainage retinotomies, but they work fine. Certainly higher than the tear site. So the other test is scleral buckle. Would you come back and do a scleral buckle vitrectomy in this case? That’s reasonable. What I find is that it’s not needed. Unless there’s traction you can’t account for by doing the vitrectomy. Air? So again, very gentle at the retinotomy site, so it doesn’t enlarge on us and get away from us. And in comes the gas bubble. The choice of silicon oil — at the conclusion of the case… These are small tears. I don’t see fixed folds or traction. I’m gonna go with gas and spare us having to use the oil and come back and get it. Sometimes… A patient that’s holding the head down would make me reconsider that. So you can see the retinotomy enlarged there a little bit as the thick fluid comes out. Just chasing the retinotomy down. Sorry for the lighting on that. I should have been doing a little better job for you guys. The retina is nicely attached. Inferior. Letting fluid accumulate near the retinotomy site. Kind of diving up and down, drying it out. Drawing it out a little bit more. We’re gonna laser the retinotomy site, laser the tears, and we’re set. So we take the laser probe… Any questions there, Rachel? Only if there’s a macular hole. I should probably rephrase that. Not often. More complex cases with PVR recurrences… Sometimes I use the ILM plane to get my PVR up and get it removed. And also in the mac hole ID case, I’ll peel the ILM. It’s a little more difficult to peel of course… In an area of detached retina. Here’s the two tears, Mike. One, two. So you’re gonna see… I can see the tears without scleral depression here quite well. Vitreous has been removed that does make it easier with the laser in this one. And the other question is gonna be how much laser to put in for the prior laser spots. Right? That really thin area of retina. I am gonna retreat that area. Certainly an area of prior laser — that’s the probably. You laser everywhere and get a redetachment, it’s almost like it’s moth eaten. That’s not great. So it’s like Swiss cheese. Very holey. Rather not have the extra trouble of having overlasered it. The first time around. So we’re gonna back that up a little bit. Here’s the prior laserwork. We didn’t mark this, but I know I want to get around the edges. A little bit over the top, just to give it a little more work. Just in case any of these little thin areas — to the point where it actually breaks, or small holes that could sink our success. Okay. Switch hands here again. Any other questions, Rachel? I’m sure there are. What else you got? So the reason for recurrent RD in this case — there was a new break near 6:00, or it could have been a missed break. Hard for me to tell if that was new or missed. The vitreous was pulling down there, so it could have been contraction of the vitreous from the first surgery, reaction to the first surgery, but it’s a very tiny break. So it’s easy to imagine it was a mixed break too. That can happen. And we’re just kind of going over this area of treatment. That was done prior. And putting a little more laser too. But mainly along the edge. Let’s dry out the retinotomy site again. Switch hands again. That looks a little better on the right. So we’re gonna dry the retinotomy site. The laser is well done for the retinal breaks down below. And again, as far as where the break was gonna be in this case, the retinal detachment was fairly equal, left and right. Prior vitrectorized eyes, the rules are kind of off. Can you focus for me, Mike? We’re losing our view a little bit. Let’s see if it looks better under here. Cornea is… Is it wet? Are we lubricated there? It looks pretty good. There you go. Gonna splash the cornea a little bit. It worked. We’re drying at the retinotomy site, remove the subretinal fluid. A little more laser on the posterior margin again. That’s typically where we have trouble getting the retinotomy while lasering, where the fluid accumulates. That’s it! C3F8, for sure. Mike is gonna get that for us. And we’ll wait for the gas to come over. And I think we’re in pretty good shape. Looking at the characteristics of the detachment. The size of the breaks, the amount of what’s going on here. I think our chance of success in this case is also very high. John, I think you’re gonna do very well. I think the case went really well. We’re just putting the gas bubble in the eye. Have you hold your head down for the week, looking at your toes. And reading a book in your lap, looking at your toes, or a flat screen TV on the floor will work. We’re asking you to hold your head down for 50 out of 60 minutes. You can pick your head up for 10 minutes an hour, stretch your neck, eat, and drink something, and when you sleep, really probably the left or the right side is fine, but face down. When you sleep, you’ve got to sleep on your left or right side. But we want your nose kind of… On the mattress. Your face towards the mattress as much as possible. Now… Since his breaks are directly at 6:00, more inferior, we do like to leave these patients with as large a gas bubble as we can. And so I go back and dry one last time. It looks really nice and dry. And then there’s your laser down below. Hang on. I’ll get the light pipe going the right way here. Laser down below, laser around the old laserwork. And then at the retinotomy site. Okay. One thing about… John’s case too, in this instance, we’re looking at how he was detaching, but now all the way up to the gas bubble… It gives you a clue that the tear was somewhere in the bottom, towards the very bottom. If it was all the way up to the gas bubble, those are the ones more commonly that get exposed when the gas uncovers a tear on its way up. So that site looks like it’s not leaking. We’re in good shape. Could you get that for me? Now we’ll put in the C3F8 gas. I’ll hold the Q-Tip here. And we’re pretty much… Get down the 15. Okay. Go ahead. Very good. Some gas again. Just like the last case. And then… Everything seems to be shutting very nicely. We’re gonna inflate the eye a little bit. Again, to keep a nice firm eye, gas bubble in there. That looks good. And that’s good. That’s kind of the case. We’ll get you out of here in a moment. John, it went very well. So thank you, everybody. If we’re still streaming and live. I think we are.
>> We could just switch back to the laptop camera. And if you have time to answer some questions, that’s great. If not, we can end it…
DR MILLER: I have some time, Lawrence. No trouble. So thank you, everyone, for attending. Glad we could… Here. Yeah. That’s better. Glad we could study these two cases, interesting cases both. Always something to learn. The things in this case that’s interesting — one, there was gas in the eye but no contract. True, prior surgery. Stiffness in the vitreous from early PVR and the cellular vitreous there. We were able to incise that under scleral depression, shaving in the bottom half just to relieve the traction. Had an iatrogenic break, a break I created with the vitrector at the start of the case right near 6:00, and the causative break also ended up being 6:00, under a vitreous skirt there. So even when you get a retinal tear like I just did, very recoverable. You just treat it like the rest of the tears. In fact, this one is in the same location as the tear that was causing the detachment. And it won’t have any bearing on the case. Again, I used a posterior retinotomy. Very reproducible. The fluid drains back very nicely. Back to the optic nerve. You’re not struggling with residual fluid and possible retinal folds, or concerns about residual fluid leaving your break open. Large gas bubble. C3F8 is adequate. Oil could have been a choice for this case, but the patient looks capable of holding his head in the right position. Avoid a second surgery and the scarring process, the PVR process it was very mild — so I don’t think oil was indicated. Scleral buckle would be an option in a case like this, too, plus or minus scleral buckle, but we avoided that. I think we’re in good shape. See you in a bit. So I can go to a few questions and answers. What is this patient’s vision prognosis? Very good. He was in here… Macula off in his first case, count fingers vision. He recovered with the gas in the eye to about 20/80 with his macula on. I bet we end up with about 20/40 or 20/50 vision when it’s all said and done. What are your postoperative timetable and medical regimen? We’ll see him tomorrow, pull the patch off, then start steroid and antibiotic for 3 to 4 weeks. I did touch my phone and didn’t wash my hands again. Washed my hands at the beginning of the day at the sink and our protocol here at the surgery center is to use the antiseptic foam over to the side. You didn’t see me. I hit it both times on the way to the operating theater there. I actually did use antiseptic foam. Can perfluorocarbon liquids be left in the eye? You can. I’ve done that trick a few times. Especially for retinal tears and some other cases. Not often. But enough to say that it works quite well. There are some people who use it in almost every giant retinal tear, and it can be very helpful. It’s a nice reproducible way to repair some tougher detachments. You do have to go back and take it out. I think it’s fairly well tolerated in the eye. At least up to a few weeks. What are the indications for vitrectomy and scleral buckle? Really it’s surgeon preference there. If you feel you’re getting better success with buckling all your vitrectomy patients, I would tell you to go ahead. And do that. It’s more surgical trauma. It lengthens the case. There are more… Steps involved. And risk of complications. Perforation of the eye. Diplopia. Patient discomfort. But if that’s giving you the better outcome, I’m certainly all for it. I think if you’re doing vitrectomy only for cases like this, the key is you’ve got to be able to find the breaks and not leave any uncovered. If you’re struggling with that, scleral buckle will give you some advantage of closing retinal breaks, even if they’re not lasered or cryoed for a chorioretinal scar. When do you perform 360 degree laser retinopexy? As little as possible. I really prefer not to do laser all the way around. One, I think… It’s unnecessary. Two, I think it sets you up for possibly PVR. Proliferative vitreoretinopathy. I think the goal is to find and laser the breaks. But if you’re having trouble with that… And you have to put some extra laser in there to increase your success, that’s very acceptable. Let’s see here. Do you give anything to prevent PVR formation like steroids? Not really. Medications used to prevent proliferative vitreoretinopathy has been used for many years. I don’t do anything special to prevent it. Even in the cases where I’m reoperating patients with PVR, I try to remove as much as I can safely. I use retinotomies and oils in even buckles in those cases, but I do not use postoperative medications in the eye or orally. There’s some ongoing work on that. I know it’s exciting. But maybe some options in the next few years. So what are the options if the primary break wasn’t found, despite careful inspection? If that happens, you’re obligated to at least laser the entire area of the retinal detachment. Probably out near the ora serrata — I’m sorry, the vitreous base, the inferior half of the retina. It doesn’t have to be heavy burns. I make my burns gray to light burns throughout the region. Typically those cases go very well, because the tears are very small. Doesn’t take much. Just gotta be close with some laser shots and they’ll stick. I think that about wraps us up. Lawrence, thank you so much, everyone. I know it’s been an hour and a half now. A little over. I appreciate the questions. They were all great questions. I hope we can pick up a few pointers to help you out in these cases and try and pick the most reproducible techniques, and use them over and over, and then advance to other techniques as you get those down, would be my advice. Thank you for the kind words from everyone who is typing in now. You’re all very welcome. I really enjoy it. Hope to see you all again soon. Bye.
>> Great. Thank you, Dr. Miller.
February 22, 2021
1 thought on “Live Surgical Demonstration: The Basics of Vitrectomy for Rhegmatogenous Retinal Detachment Repair”
Very interesting two cases and comprehensive overview of rhegmatogenous RD (small tears)