This live surgical demonstration covers a step by step explanation of the basics to vitrectomy. Emphasis includes the most common approach to safe and predictable surgical outcomes.
Case demonstration: Epiretinal Membrane Peel.
Surgeon/Lecturer: Dr. David Miller
DR MILLER: Good morning, everyone. Welcome to our OR. I’m David Miller, a retina surgeon at Cleveland, at the Cleveland Eye and Laser Surgery Center, broadcasting live for Cybersight. And today we’re gonna go over the basics and the essentials of vitrectomy surgery, in addition to showing you one or possibly even two live vitrectomy surgeries. I’m gonna start the morning with a didactic presentation of a few slides, and while I’m doing that, my OR staff here will get the patient prepped and ready for surgery. So hold on one second. Let me move over. And we’ll go through these slides here. Please advance the slide. Thank you. So the indications for vitreous surgery are many. Some of the most common are diabetic retinopathy, macular degeneration, retinal detachment, macular holes, macular pucker, vitreous opacity, and vitreous infection. Next slide. Risks of vitrectomy I want to spend some time on today, and include, of course, infection or endophthalmitis, retinal tear, retinal detachment, choroidal effusion or hemorrhage, cataract, glaucoma, after gas tamponade or vitreous hemorrhage removal, and anesthesia block-related complications. Next slide. So essentials of any eye surgery, and in particular vitrectomy surgery, include a good pre-op evaluation, adequate anesthesia — in our case, here, the patient’s already received her retrobulbar block. We gave her good anesthesia for pain control, eye movement, and also to block any visual sensation. A good sterile prepping technique, which my assistant is helping us with, a good surgical assistant. Michelle James will be helping me throughout the case. Proper wound placement. Intraocular visualization. I want to stress that. In any eye surgery, particularly retinal surgery, you really need to see what you’re doing. And if you can’t get a good view, no matter what viewing system or microscope you’re using, this surgery will be extremely difficult and hazardous. So you have to do anything you can to maximize the view into the eye. If a cataract is in the way, you have to get the cataract out. If the cornea turns hazy or cloudy from edema, you have to somehow improve that view, including removing the corneal epithelium. You want to control any intraocular bleeding, which kind of goes along with the emphasis of having good visualization. If there’s bleeding in the eye and you can’t see the retina, you’re working in a very dangerous situation. Tight wound closure goes along with preventing infection and endophthalmitis. We’ll be working today in a 25-gauge system, off a Dutch Ophthalmic platform called the EVA. And these wounds need to close and be tight at the end of the case. If they’re not tight, you want to put a suture in place to make sure they stay closed. Any open wound can lead to postoperative infection, which is probably our most feared complication. And, of course, a postop evaluation is essential. Whether that’s one day or two days — there’s some debate. I generally check all of my patients one day after surgery, to make sure their eye pressure’s okay, no signs of infection, and the eye is healing as we’d expect. Next slide, please. This is a photograph of where we’re working here, in beautiful Cleveland, today. Next slide. A quick view of me before the surgery, talking to the patient, looking at the chart, reviewing the instructions. Telling the OR staff what our goal is for the case. Next slide. In the operating room, we like to have a controlled environment with properly trained people. This is myself at the microscope with my assistant. Anesthesia is there in the background, and also a surgical scrub. And typically we also have a nurse circulating the room, getting instruments, opening things up, and doing a lot of charting. Next slide. Good visualization is key. Our microscope here, including assistant oculars, and on the bottom of the microscope, you can actually see there hanging off is an EIBOS wide field visualizing system, which is what we’ll be using today during these cases. Next slide. The basic setup to any pars plana vitrectomy is a three-port system. You can see in the top right there, that’s the infusion cannula, pumping fluid into the eye. And then you can see the other two instruments going into the eye. One is a light pipe, labeled LP, and the other one is the vitrector. So there’s fluid being pumped into the eye, the light pipe is putting light into the eye, and the working hand is the vitrector hand, which can be a vitrector, cautery, a scissor, a forceps, or a pick. Of course, we’re seeing what’s going on by looking down through a dilated pupil. Next slide. This just shows the insertion of an infusion cannula through the pars plana. Next slide. Now, the placement of the infusion cannula through the pars plana is measured off the limbus. So looking at the external part of the eye, where the cornea hits the sclera, and if we measure back from there, anywhere between 2.5 to 4 millimeters, you’re in a pretty safe spot. If we get farther back than 5 millimeters, you definitely run the risk of entering through the peripheral retina, which would be ill-advised. You don’t want to create a retinal tear. So we try to make our incision somewhere between 2.5 and 4 — is usually a pretty safe range. If you go more anterior to that, getting up around 1 millimeter, you risk actually entering the anterior chamber and the peripheral iris. Even at 1.5, you go through the ciliary body, which is a higher risk of bleeding. Next slide. This is just illustrating the mechanics of a vitrectomy surgery, for those unaware. Again, the infusion cannula, pumping fluid into the eye, the light pipe, and then the vitrector trying to carve out the vitreous, which is a gelatinous-like material. Next slide. A little close-up of the schematic with the same information. The next slide, please. We have other instruments we can use in the eye. This is a cutaway of the back of the eye, the retinal surface, showing the optic nerve. And you’re seeing a little pile or a puddle of blood there. This instrument is called a soft tip or a flute needle that can actively suction the blood off the back of the eye, or passively remove it, just from the flow of fluid. Next slide. There’s a multitude of surgical instruments that we can use in the eye, including a vertical scissor there in B, forceps seen here in slide D, a pick is what C is showing, and A is that soft tip or that flute needle, for passive aspiration. Next slide. This is a diagram of showing the scissors in use, in the case of fibrovascular proliferation in probably a diabetic. The optic nerve here is covered. We’re using a light pipe for illumination there on the left, and on the right, you’re seeing the scissors elevate that membrane and cut through the tissue. Next slide. Here we’re using forceps to peel away a macular pucker. Next slide. Cautery can also be used in the eyes. I mentioned prior that you can cauterize any bleeding, control bleeding. Next slide. Here you’re seeing again a macular pucker being demonstrated, with the retinal pick being elevated. Also looking at a retinal detachment being illustrated on the right, using a retinal pick to try and peel away scar tissue from the retina, so we can reattach it to the back of the eye wall. Next slide. Another little diagram, showing how to reattach a retina, by draining fluid out beneath the retinal surface there. And using a flute needle or a soft tip. And on B, you’re seeing laser photocoagulation being applied. That’s a laser beam, being illustrated, trying to cauterize or treat the retina, to create a chorioretinal scar around a retinotomy site. Next slide. And at the end of the case, it’s always helpful to check with the patient here, in the postop area. I try to speak to every one of my patients after surgery in the postop area, to make sure they’re comfortable, to explain to them how things went during surgery. I also meet with the family. And also to give them a couple points about how to hold their head and positioning, and discuss the most important factors of anything going wrong. To please call the office. In particular, I always warn them of looking for increasing eye pain or decreasing vision. And if that occurs, I like them to call us as soon as possible, so we can evaluate them. You can continue with the prep, because — don’t worry about my view. It doesn’t matter. Next slide. So for safety techniques, we like to confirm there’s an intraocular placement of the infusion. We like to maintain intraocular spatial orientation. When you’re in the eye, with the instruments, just like with any ophthalmic surgery, you want to know where you’re at and where your instruments are at. One problem that we hear about — the biggest problems we hear about in retinal surgery and things going horribly wrong is when the surgeon kind of loses track of where he’s working inside that space, inside the eye. So if you think you’re in the midvitreous, but you’re actually in the posterior vitreous, running up against the macula or the optic nerve, and if that macula’s detached, people can actually get into a spot where they’re taking out the retina with the vitrector. And not just the vitreous. You want to control the intraocular pressure, so it’s not too high or too low. Too high can cause ischemic damage. You see a flash in retinal vessels. Too low will lead you to the risk of uncontrolled bleeding and choroidal hemorrhage. You would like to avoid iatrogenic trauma, such as retinal tearing, retinal breaks, and the formation of a traumatic cataract. You want to check your wound integrity at the end of the case. You should visualize the periphery at the conclusion of every case through a scleral depressed exam. We’ll demonstrate that today. Again, we’re always looking to prevent postop complications such as retinal tearing and detachment. And you’d like to give patients postop instructions with contact information if something’s going wrong within the first few days of surgery in particular. Next slide. So here’s a photograph of a patient of ours who’s a one-day postop. Very minimal injection of the conjunctiva. This was a sutureless vitrectomy, again. A 25-gauge case. And nice really quite quiet or non-inflamed eye. Next slide. So I want to discuss basically what we’re doing today in our first case here. This is patient number one. 80-year-old woman with blurry vision at distance times several years. Her visual acuity, measured in Snellen, is 20/160, and the diagnosis is an epiretinal membrane or macular pucker. When we’re looking there at the OCT on the right, she’s lost the normal macular architecture and contour of the retinal surface, with the overlying epiretinal membrane or macular puckering tissue. So the goal of surgery here is gonna be to take out the vitreous gel to create a working space, to get back to the macula, and elevate or peel away that epiretinal membrane. Next slide. Okay. So we’re gonna save the review questions until the end of the case, and if we have time, we’ll do the review questions and start a second case, and also take your questions during the surgery. So I’m gonna get prepped here, myself, and we’ll begin the case. Just give me a moment. Thanks. If anyone has any questions, feel free to text them in to us. I know there were some that were pre-placed. Anything on there, Dan, that… Okay. So… One of them is: For every kind of vitrectomy, do we need to do a complete vitreous removal? I would say that you do not need to do that. And in general, just take out enough vitreous to get the job done. It depends on the case. In a macular pucker like this, very little vitreous needs to be removed. And in a case where you need a greater gas bubble fill, like in a macular hole or a retinal detachment, a more complete vitrectomy needs to be performed. People often ask about — do we need to shave the vitreous base in all these cases? And my answer there would be — in most cases, I do not shave the vitreous base. If there’s a lot of inferior retinal tears, and I need a larger gas bubble, we’ll take out more vitreous. But to truly shave the vitreous base, I have to see indications — or concern about peripheral vitreal retinopathy and further scar tissue development. And in most cases, that’s not a concern, for most detachments. So I think that can actually lead to more problems than help, for most people. What’s the next question there, Dan? I have not used any Chinese-manufactured products for vitrectomy. I have used non-Alcon packs on Alcon machines, a few years ago. Again, I’m using a Dutch Ophthalmic machine today called the EVA, and we’re using the Dutch Ophthalmic packs, but on the Alcon Accurus in particular, I did use some off-manufacturers for those packs. They were still United States-based packs, though. So I can’t speak to the Chinese question. But I do think… And they did work quite well. So I do think we can consider that. So my patient, who is nicely prepped and draped, sterile prep — and what we’re gonna do here is begin with our incisions. I like to use a Bonaccolto forceps. Displace the conjunctiva a little bit. And place my infusion trocar. There’s little marking spots here on the back. That’s about 3. You can see right there. And that’s about 3.5. So this one’s about 3, right here. And we put this in, in a nice beveled fashion, all the way into the eye. You can see when I’m done, it’s kind of pointed — not straight up, but it’s pointed back towards me. The reason we put in a beveled incision is because it’s a better wound closure. We do the same thing here to measure again, to show you how we do that. We put the one little reticle right there. Another one, make a small little indent. You see the indented marks. And then we drive this in. These are valve cannulas. I’m in a 25-gauge system. There’s four on this side. That’s to the far point. I use about three and a half. Well, we’ll go this way. Again, you see the little marks we create. I’m just indenting lightly. And again, a nice beveled incision to make a long wound tunnel there, instead of going straight into the eye. Now, we have a subconjunctival hemorrhage here, noticeable to everybody, from breaking those blood vessels on the surface. That’s quite common, and not a concern. We’re gonna pull off the cap to the valve on this first one. And we’re gonna place our infusion. Now, we can turn off the infusion, and we’re gonna look at cannula placement. Again, you want to make sure this is in the eye. And the best way to do that is using your light pipe to shine obliquely, and actually looking outside the eye — not through the microscope, but actually outside the eye — just to make sure that cannula’s in there. I can’t quite get through the view — maybe I can. There. I can just see the tip in my field of view, that metal tip. So we know that’s in the eye. So now we’re gonna begin the core vitrectomy. Again, this is the infusion line. Here’s the light pipe. Nicely dilated pupil here, with a PCI well centered in place and clear. And my assistant’s helping me get everything nicely lined up. I can’t stress the importance of having a knowledgeable, helpful assistant to make the case go well. Get our good focus here. Thank you, Michelle. And we begin the core vitrectomy. So what you’ll see here is I’ve got the lights right here, I kind of tend to hold the light farther back. And instead of chasing the vitreous around, you know, I kind of hold the vitrector stationary, and let the vitreous come to me. I’m using a Dutch Ophthalmic machine, again, called an EVA, and I’m using what we call the flow mode. So I’m aspirating fluid out of the eye here, at a rate of 15 CCs a minute. Other machines work off a vacuum principle. I found that I like the flow mode of the DORC instrument here, the EVA, more than the aspiration, because it gives a more stable intraocular environment around the tip of the vitrector. I also — many of you probably noticed how I put the infusion cannula on. That’s a high flow infusion cannula. It goes over the top of the 25-gauge cannula, because it allows for a broader stream of fluid to come into the eye. Less intraocular turbulence, which is very nice, especially in cases of mobile retina-like retinal detachment. Okay. We’ll take the IC-Green dye. So that’s the core vitrectomy, pretty much completed. We’re gonna now stain the macular tissue with some IC-Green dye. Give me a little injection there, Michelle. Good. I’m just using a 25-gauge needle. 1.5 inches, straight needle. And we’re gonna focus that a little bit more. There we go. My assistant is giving me gentle pushes of the dye. Over the macula. To highlight the epiretinal tissue. And give us some definition as to what we’re gonna remove when we get down to the retinal surface to remove the macular pucker. I’m now gonna evacuate that same dye so I can see the surface of the retina clearly. Any more questions there, Dan? Okay. I know there were some questions sent in prior. I appreciate those. One of those was: Any tips for pediatric vitrectomy and posterior capsule opening? I don’t do pediatric retinal surgery. But I can give you a couple tips in terms of posterior capsule opening. These vitrectors cut — at least in an adult — they cut a very nice posterior capsule opening on the back of an IOL. We may even do that here today yet, at this case. And you can be pretty aggressive with the tip. You go right up on the back of the IOL. And just go in a circular fashion, and it almost looks like it was done by a peel. Such a nice sharp edge is created. So I’m not sure if it’s quite the same in a pediatric case, but in adults, it’s quite common, and it works quite well. Just using a vitrector. We don’t typically use a curvilinear peel like with a forceps or something. So here we switch lenses for a better view. A more magnified view of the posterior pole of the macula. And there’s the optic nerve here. Okay? Just to get it back — get you oriented again. The macula is kind of the yellow spot right in the middle, and the macular pucker is why the vessels are all kind of pulled and squiggly here. And you can see how the green kind of stained around the macula. Highlighting the epiretinal membrane, as well as internal limiting membrane. So what I’ll typically do is start my peel away from the center of the macula, because I don’t want to have inadvertent damage to the fovea. So I’ll come down with our forceps. And we’ll pinch. And we’ll begin our peeling. And this is certainly the most delicate part of this type of case. And so what we do is peel… Not over the fovea, but around the fovea. And you can see a little bit of that tissue coming up with my forceps, which I’ll knock away with the light pipe. Many surgeons will tend to pull the instrument out of the eye and wipe it off. Yeah. Go ahead. Right. Okay. The one question was: How do we avoid traumatic cataract when putting in the instruments? So the most important thing there, when inserting the cannulas earlier in the case, is your orientation, when you’re putting them in. And you saw how I was kind of flat on the incision, but also you would have noticed I wasn’t going towards the lens. So it’s really the orientation, when you start. And you don’t — you want to be — if you’re going straight in, you want to point towards the optic nerve. You don’t want to point across towards the pupil. And what was the other question there, Dan? Absolutely. So the question is: Compare and contrast pars plana vitrectomy and scleral buckle for retinal detachment. Both procedures are well within the scope of the methods you can use to repair retinal detachment. Scleral buckling is probably the more difficult procedure, in terms of acquiring the skill needed. Now, here you’re seeing the macular pucker, as we’re getting a little bit more elevated. Again, the goal is to clear this entire green membrane from the center of the retina. Now, we’re getting a little bit of traction here, right over the fovea, which I would like to avoid. So instead of just grabbing this and pulling over, I’m gonna go around more and try and pull back towards the fovea. I don’t wanna displace or pull the fovea up or disrupt those photoreceptors right at the fovea. So we’re gonna keep going around and out over the top. So scleral buckling, to get back to that question — scleral buckling is a more delicate — a more art-like procedure, and takes quite a bit of skill to actually place well, and every eye is a little different. Scleral thickness, size of the eye, height of the buckle, and it’s a very good procedure. But if you’re not doing many, you’re doing them rarely, I would caution that you may want to just stick with vitrectomy. I do scleral buckles. I don’t do as many as I used to, but I still do them. And they work quite well, like I mentioned. One thing that’s nice about it is maybe you don’t need the vitrectomy pack and the vitrector. So in some ways, it’s maybe less technology-intensive. But it’s probably more skill-intensive, I guess, is my point. So you can see right now where I’m at. We’ve got this part of the macula peeled. We’ve got our free edge to this epiretinal membrane right here. We’re trying to work our way around the macula. Again, I prefer to come back towards the center, not over the center, if at all possible. Very tight membrane. You can see the underlying retina moving and pulling with me. Something we’d rather not have. We’d rather see it being really stable and not pulling. That’s why I’m being careful, going over the top. This membrane has been here a while, and it’s very adherent. So we’re just gonna move our way around. There we go. All right. For combination cases, there’s a question about combination cases for phaco and vitrectomy. Which I don’t do many of. Quite often in the United States, we let the anterior segment surgeons place the lens implants and do cataract surgery. And so my skills at that are not as good as many of my colleagues for phacovitrectomies, for the phaco part. Occasionally I will get a cataract surgeon involved to remove a lens for me prior. Or at the beginning. And usually I’ll do that part of the case first, if we’re gonna do a combination case. So here we kind of gently tease that membrane off, going around the macula and not over the top. And the reason we did that — because it was very adherent to the fovea. And you can see the luteal pigment here. Here’s the membrane we removed. You can see the luteal or the yellow pigment from the foveola. So if we were to pull just straight across the top in one vigorous movement, you risk more foveal damage or even creation of a macular hole. And if you look down here — just gonna knock this off for a second — if you look down here, the fovea is actually pulled up a little bit. A little bit. Now, the vessels are not back to the normal shape or origination here in the macula quite yet. That’s gonna take some time, over the next few weeks. But we’re gonna extend this peel out a little further, because this membrane is still out here. It’s still distorting quite a bit. So we’re gonna try and extend the peel out. It doesn’t have to go all the way to the arcades. But I have to get at least a couple disc diameters from the fovea in all directions. IC-Green dye. The question was: What type of dye I’m using during the surgery. And I’m using indocyanine green dye, which I’m gonna use more of right here. Quite often, I’ll restain during a surgery at least once, if not two restainings. I use the concentration — there’s many formulas, in terms of mixing up this dye. There you go, Michelle. A little bit of dye. And my assistant is pushing this in for me. Very good. I’ll use the concentration of the dye that comes in the box. I don’t dilute it, and I also don’t add dextrose to make it a heavy solution. And what I do — the dye itself can be toxic, which is a concern. And what I do to avoid complications from dye toxicity, IC-Green dye toxicity, is I do not inject the dye into a macular hole. I’ll take great care to avoid an open break in the retina. And you want to keep the dye in the subretinal space. So the dye itself is not toxic on the retinal surface, like we’re using it. But if it gets below the retina, to the photoreceptors on the bottom layer, that’s where it can be a problem. So we’re gonna see some things here. You see this little flap moving around down here? That’s a piece of the internal limiting membrane, or the surface layer of the retina, that we were peeling away. You can see it down here too. So we’re gonna use the vitrector itself here a little bit. Sometimes you can use the vitrector in these small-gauge surgeries to function as your peeling device. So we’re gonna… You see I’m kind of just brushing against the retinal surface here. And it’s kind of pulling up the ILM, under aspiration. Let’s come over here and get the same thing. Notice I don’t go too far. I just keep coming back and repurchasing under aspiration, as we remove that ILM. I don’t generally use many instruments in my cases. You don’t really need much in the way of instrumentation. There’s lots of stuff sold out there. And you can use five or six different things to get a case like this done. I tend to stick with the basics: A forceps, a pick maybe, which I didn’t use in this case, and the vitrector itself. And so I don’t think you have to overinstrument yourself to get these cases done. And you can see here’s another — this is working very nicely to get the rest of the ILM up. Especially in these tight, tenuous cases like this. And here we go, very nicely releasing all the traction over here. Yes, the question now is: Did the patient already have a posterior vitreous detachment prior to surgery? And she did. I did not need to go down and peel up the posterior hyaloid. That’s gonna be fairly common in a macular pucker case. Not always, but most of these puckers are created by a prior PVD, which then stimulated some glial proliferation along the retinal surface. Sometimes the… So I just gently brush under aspiration my vitrector against the retinal surface. I’m gonna switch hands. Which is very helpful in vitrectomy surgery. I’m right-handed dominant. I’m right-handed. But with many things — and retinal surgery is one of them — if you can use the non-dominant hand, your left hand, to some degree — it doesn’t have to be as good, but just use it some — it can be very helpful in maneuvering yourself inside the eye. I think it’s very difficult to do retinal surgery if you’re completely only using your dominant hand. So this gives us a different angle of attack on this membrane down here. A little aspiration on the retinal surface there. We’re gonna avoid that. That’s okay. I’ll get the forceps back. Oh, question about the microscope I’m using. I’m using a Leica microscope with an EIBOS visualization system on it. The question asked about other manufacturers of scopes, versus superior depth of focus. I am not aware of any scope truly being superior for what we’re doing here. So I would say there’s lots of marketing for different products. But I don’t have direct experience to compare all those brands. I have used Zeiss scopes. For much of my career. And those worked quite well. And I find the scope I’m currently using to be quite fine too. So what we have here at the end of this case, at the completion of the peel — we’ve peeled all the way around, almost arcade to arcade, well out into the temporal macula, the fovea is yellowish, there’s some drusen changes in here, from a dry macular degeneration. And we have a small retinal hemorrhage right here, from some trauma, which is not uncommon at all, when you’re peeling a tight membrane. And here we have a spot where the retina was pulled by the vitrector itself, into a little tuft, but again, not torn or even bleeding at that site. So a little bit of trauma is common in a macular pucker. I would not be alarmed or discouraged by that. Here’s a few more hemorrhages from peeling that membrane, farther out. There’s a lot of edema in the retina too, from the peeling, and from the presence of the membrane itself. So at this point, the peel is actually quite complete. We’re gonna go in there and remove any residual fragments of epiretinal tissue. And do that under the EIBOS. So again, when I’m doing the macular pucker work, I’m using a more magnified view, or what we call a flat lens, laying on the cornea, to give us a better view for that detail work. Now we’ll go back to our wide angle view, where we can see more of the retina in total, where I don’t need the same depth of — the same focusing on the macula itself. We’re gonna have Michelle focus that. Great. So you can see these little fragments zipping around here some. Or maybe not. Yeah. Another question that came up is: Is it okay to perform vitrectomy for just floaters and PVD? It is, and I have done those cases. You know, to take out floaters used to be considered, like, a trivial indication for vitrectomy. But what I found, being in practice for 20 years, is that some patients are very debilitated by their floaters. A lot of times, it depends on the patient more than the degree of the floaters. I’ve taken floaters out for a watchmaker and a jewelry repairman, because he was unable to perform his job. I’ve taken floaters out for an airline pilot. And though that may sound trivial, it was getting to the point where he could not do his job. So it kind of depends on the individual. Just taking away a little more ILM there with the vitrector again. So here we are. Nice clear vitreous cavity. Nice macular peel. You can see the highlight or the edges of where we peeled out from the macular pucker. Now we’re gonna take a look around and make sure there’s no peripheral retinal pathology or retinal tears or detachments, which I mentioned in the Essentials of Safe Vitrectomy Surgery. I would rank this right near the top, next to the wound closure, as things you want to be careful with. So the most common complications — and preventable, at that — from vitrectomy surgery is retinal tearing and detachment. So I’m looking through the EIBOS here, I’m using scleral depression. Just a typical scleral depressor, metal probe, looking at the peripheral fundus, looking closely for any tears. There’s the infusion cannula kind of popping into view there. A little bit right there. Yep. And we’ll do a close look-around. So I really think probably the three most important things to take home from this, if you’re doing retinal vitrectomy surgery, is: Scleral depression at the end of the exam. Wound closure. And then maintaining your spatial orientation. And the visualization. So you don’t get into places like eating the retina with the vitrector instead of the vitreous. You don’t want to be doing an unexpected retinectomy as opposed to a vitrectomy. And that especially is important during… The view sometimes won’t be as good for you guys during this part of the case, but I’m getting a nice scleral depression in. And we’re gonna make sure everything’s good here before we patch her up. Does not require a gas bubble. Well, here you go. Here’s the retinal tear. See? Now, this is what we check for. Here’s an old retinal tear. Right here. Superonasally. I’m gonna try and get the depressor on that a little better. This was a little bit of my suspicion during the case. That membrane was so tight on the macula, we tend to see that more often in a case where there is a peripheral retinal tear. We did not see this in the clinic, but you can see I’m right out against the ora serrata. Superonasally. That’s a very tough spot to get a good examine in the clinic. You know, you’re up against the nose. And I did not depress the patient prior to surgery. So what we’re gonna do is treat that with cryo. Because, again, that would be tough to even reach with… Well, we could do laser or cryo. So we’re gonna treat that with some cryo here. And maybe leave an air bubble in the eye, to make sure that doesn’t detach during the postoperative time frame. We’ll leave air. Yep. So the question was: What am I gonna do for the tear? The choices are, again — could you focus that for me, Michelle? I’ll try to get better focus here for you guys on this. There you go. So the question is: What am I gonna do for the tear? The choices are laser or cryo. And there may be even a small chronic detachment here, it looks like. A little bit of subretinal fluid up here, superior, way at the ora. That’s why we’re gonna leave an air bubble in there. So we’ll use cryo, because I think this would be awkward to reach with laser, when it’s this anterior. That could be done. It’s just gonna be a little simpler for us to use cryo. I tend to use laser more often, actually, than cryo, but not for this particular case or situation, here. I think it’s interesting — I was gonna point out — was that with that type of macular pucker, when they’re more severe, like hers was, it’s often like a little mild proliferative vitreoretinopathy condition going on, a little bit of scar tissue, which you often see because of a prior retinal tear. So I was a little suspicious, when we were peeling it off — even in the clinic, a little suspicious that we may find something else, once we got here. And that’s fine. This probably happened many months ago, if not years. Go ahead? So it’s not a vision-threatening retinal detachment. So you see the ice ball forming there in the eye, from the cryo. If I can get a little better view of that for you guys — we’re gonna make one more. Okay. And again? So I’m doing the cryo and the scleral depression myself. I’m holding the light pipe in one hand. That’s all, Michelle. Holding the light pipe in one hand, and I’m using the other hand to hold the cryo probe or the scleral depressor. If I was doing a vitrectomy and scleral depression, then Michelle would do the depression for me. I’m just gonna dry her out with an air bubble to hold that area of the retina down. A lot of surgeons will use — now, again, we talked about shaving the vitreous base and so on. So maybe I’ll take out a little more vitreous here. But not to the point where I’m shaving into the scleral depression. This case does not need it. She does not have peripheral vitreoretinopathy. So there’s no real traction on those tears. Those are old tears. So we don’t need to get in there and get real aggressive, trying to manipulate the vitreous face with the vitrector and scleral depression and getting ourselves into more trouble, creating more tears. We want to just do enough to get the job done, to let the retina kind of heal itself. So that should work just fine. The question is: After a membrane peel, how often do I see retinal thinning, and is it okay? Here comes the air bubbles. So we’re gonna take the fluid out of the eye. I’m aspirating with the vitrector. Air is being infused through the infusion cannula. I’m just holding the vitrector itself down near the optic nerve. Some people do this with a soft tip cannula. I don’t think that’s always necessary. Again, I save on instrumentation. And I just prefer to use fewer instruments, for safety. So… Nice clear view. Here’s the peripheral retina. And now we have a nice air bubble in the eye. What was the question, Dan? Oh, a membrane peel. Yeah. So after a membrane peel, typically on OCT, what you tend to see is the macula does not have the normal contour. It tends to be a little thicker than normal. So oftentimes, you don’t see thinning. You see thickening. Or it’s thicker. And that should be fine. Now, the small localized detachment that was up here — I’m not gonna go try and drain it. I want to point out a few things I’m not doing. One of them is I’m not going in there, trying to drain the detachment. It was too shallow. The air bubble itself will be fine to accomplish our goals. Again, to make a retinotomy or try and drain through the break — it’s too far in the periphery to make a retinotomy. Then you have an extra tear you made in the retina. In this type of case, it’s just not needed. I’m gonna take one more look at the area that we put the cryo on in the tear site. Which I think is very instructive. I normally don’t do this, but I just want to kind of show what we’re doing here. Here’s the scleral depressor I’m using. I’ve got my light pipe in my right hand and my scleral depressor in my left. Light pipe goes in. Michelle drops in the visualizing system. And there we go. That’s a good… So the question was: Would I shave more vitreous from around the tear to decrease traction? And that’s a very fair question. The answer is: No, I would not, unless there’s obvious traction there. The retina wants to stay attached. That cryo scar, when it forms, is gonna be very strong. And the vitreous just laying there isn’t gonna pull it back off. Now, if the vitreous contracts, or you get into a situation of peripheral vitreoretinopathy, yes, it can detach the retina again. But the way it’s sitting right now, it won’t do that. So I think there’s a little bit of an overemphasis in general in the retinal community about trying to shave the vitreous base in all these cases. I don’t think that’s necessary, and I do repair a lot of detachments. Let me pull out the infusion cannula here. And there’s our little wound right there. So we’re gonna press a little bit on the wound to kind of press it shut over the top. We don’t see any air coming out. If we were losing air at this point, if there was a leak here, you would see all kinds of little air bubbles. We’re gonna pull this one too. Press a little bit over the top. Just check the eye pressure there. The other choice here in this case is to put a longer-acting gas bubble in. I don’t think you need to do that. The tear and the break were superonasal. She’s older. The air bubble will last probably 5 to 7 days. And that will be plenty adequate for us to keep that retina reopposed long enough for it to heal. So we pull out the last one. And the subconjunctival hemorrhage here is blocking our view of the sclerotomies a little bit, but they’re a little bit visible. This is one right here. Try and get you — so here’s the original one. Superonasal. Okay? And you can see how the wound is kind of coming together right there. And again, there’s no air leaking out. So it’s kind of easy to tell when you’ve got a leak under air, because you see the bubbles coming out of the eye. We’ll check the pressure a little bit here, just by digital palpation. It’s well within normal range. Not high, not low, not soft. And that’s the conclusion of the case. So nice illustration. We’re gonna talk some about the case and go through some other questions. From the didactic. And we may even start a second case here yet, depending on time. So Michelle is gonna help us out and break everything down. I guess based on time, we’re probably not gonna do a second case. This is scheduled to end at 9:00. So we’ll wrap it up. Don’t worry about bringing the next patient in, Michelle. We’re fine. And I’ll go over the case a little bit, and we’ll take some more questions and go through the didactic a little bit more. So what’s interesting about this case, what was nice, I think, was that we had the surgical plan going in. She had a macular pucker, a severe macular pucker, and vision around 20/200, with a lot of distortion, and we’re going in to do what we think is just a macular pucker, but of course we find a little bit more. We find an old retinal tear, which is probably the cause of the macular pucker, and the severity in particular. And we have to deal with that. So you have to be prepared to deal with unexpected findings during the surgery. In this particular case, the old retinal tear, the localized or small detachments, were unexpected, but not unusual. We find that quite commonly. You just kind of have to adjust your surgical plan a little bit, and treat that while you’re in there, and fix everything at one time. I think this patient’s chances of doing well here, in terms of the repair for the tear, the small detachment, and the macular pucker, are very good. Probably well over 90% at this point. She had no intraocular bleeding, no inadvertent retinal damage to the central macula, or to the intraocular lens. Her pressure is good right now, and the wounds are all closed, and we got a very good thorough look with scleral depression, checking the rest of the retinal periphery. Trying to limit our postoperative complications. So I’m gonna go to the next slide again. And we’ll go through a few questions here, review questions. And the first one is: What is a possible risk to vitrectomy surgery. And the choices are: Endophthalmitis, which is an eye infection, retinal detachment, cataract, choroidal hemorrhage, or all of the above? And it’s a little interactive panel here. And you can pick out your answer. Again, endophthalmitis is eye infection. Retinal detachment. Cataract. And choroidal hemorrhage. And we’ll give you about 20 or 30 seconds. Do that and submit your answers, and we’ll see where people come out on that. As with any surgery, you want to limit or reduce the risk of complications. It’s so essential in any surgery, and it applies to retinal surgery and vitrectomy too. So anything you can do to make complications lower or reduce incidence is very beneficial. And if you go to the next slide — or we’ll do the answers first. So people got that right, generally. 82% picked all of the above, which is true. All those are possible complications. Or risks due to vitrectomy surgery. Cataract — you can either get that from being traumatic during the case, or you can get cataract after surgery, just from a gas bubble. And choroidal hemorrhage can happen when the infusion cannula is either misplaced into the suprachoroidal space or when the infusion pressure is too low, and you get spontaneous bleeding. But all of the above is the correct answer. The next question. What are the best locations for the working sclerotomies in vitrectomy? So the choices there are 3 and 9 o’clock, 3 millimeters posterior so the limbus, 10 and 2 o’clock, 5 millimeters posterior to the limbus, 11 and 1 o’clock, 3 millimeters posterior, and 12 and 6 at 5 millimeters posterior to the limbus. Assuming that 12 o’clock is the surgeon’s position, where I’m sitting at the top of the head, and 9 and 3 o’clock are the horizontals. So I’ll let you guys pick your answers there. We didn’t talk a whole lot about wound positioning and placement during the case. I kind of moved pretty quickly into the core vitrectomy. But in general, we like to make a wound that’s gonna be self-healing when you’re done. You also want to make a wound that’s oriented correctly, to avoid lens damage and also make sure the wound is all the way into the eye and not the suprachoroidal space. So there’s a little bit of — you know, if the wound creation is too shallow, you’re not gonna get into the eye. You want to be able to get all the way through the eye, into the vitreous cavity. And at the same time, you don’t want to place it so posterior that you’re going through the retina. So if you have the answers here… Okay. So it’s a little more divided here. And there is some confusion. I didn’t cover it real well, prior. But the answer, really, of the choices, the best answer is the first one. 3 and 9 o’clock. 3 millimeters posterior to the limbus. So the answers you can eliminate in my mind, right off the bat, are the ones saying 5 millimeters posterior to the limbus. If we make incisions at 5 millimeters posterior to the limbus, you’re gonna have a much higher risk of going through the peripheral retina itself, creating retinal tears and detachment. So I think you want to stay about the 3 millimeter range. Then the choice is just what clock hours. And of those two, there’s 3 and 9 o’clock and 11 and 1 o’clock. 11 and 1 will put you very much near the 12 o’clock position, and give you much more limited ocular maneuverability inside the eye, with the instruments. If you get down near the horizontals more, and place those working sclerotomies, with the light pipe and the vitrector, more down the horizontal, you can rotate the eye more freely in each direction, inferior and superior, and by the sweep of the instrument, you can reach inferior and superior without having to reach across the lens, if they’re phakic. So you’re really better off being down near 3 and 9. Mine are generally probably at 9:30 and 2:30. You know, or maybe 10 and 2. But even 3 and 9 directly, people have some concerns about hitting the long posterior ciliary nerves or vessels, and that’s not a very large concern. In fact, I’ve never had that problem. So I’ve done — you know, probably 15,000… Let’s see. I’ve probably done about 6,000 vitrectomies. Pars plana vitrectomies. About 6,000. Never had a complication from hitting the long posterior ciliary nerves or vessels. And I work very close to the horizontal, or just above it. So I think that’s the safest location. I think there’s another question. What is the best way to prevent postop retinal detachment? Using a wild field viewing device, ophthalmoscopy, with scleral depression at the end of every case, low aspiration/vacuum during vitrectomy, avoid vitreous base with the cutter. So what is the best way to prevent postop retinal detachment? So you have to pick one here. I didn’t give you a choice of all of the above. All those are reasonable answers, but I do have one that I think is by far the most important. And certainly avoiding the vitreous base with the cutter — we do shave the vitreous base in some cases. You don’t have to shave in all the cases. So you have to pick and choose where it’s appropriate. Low aspiration and vacuum is important, certainly. If you’re under high aspiration and vacuum, you’re tugging on the vitreous more, and that can lead to retinal tearing. And, you know, ophthalmoscopy, as you saw in this case, is always useful, and wide field viewing is also useful, so you can see the peripheral retina as you’re working. Let’s see what the answers we got are. Okay, correct. Most people picked ophthalmoscopy with scleral depression. I would think that’s the most important thing. You saw me do it in this case to our advantage, to find that old retinal tear, localized detachment. I think it’s the most important thing, at the end of every case. My case went just fine. We could have just ended right there and walked out of the room, but because we went and did that one little extra step — I did my ophthalmoscopy under the microscope, by the way — you don’t have to do it that way. If you don’t have a wide field visualizing system, you don’t need one to do retinal surgery. You can do an entire case through a flat lens. And save the cost and the expense of a wide field viewing system. But then you should check the peripheral retina with your indirect ophthalmoscopy. Everyone probably has one of those. An indirect headset. And you still have the pressure right here in the OR to check around the peripheral retina, before you let the patient get patched up and leave the room. So that kind of wraps up our polling questions. If there are any more questions from the field, I would be happy to take those. I think the case went very well, by the way. I’m glad it did. I know my mother is watching back in St. Louis with my sisters. I want to say hi to them. Things went well. And if it had went poorly, I would have had a lot to answer to. So thankfully, we didn’t have any complications. Also, one or two of my children may be watching, including some friends in their high school class. So hello to St. Ignatius High School class in Cleveland, if you’re watching. Any more questions? If the patient was phakic, what precautions to make in crossing hand to examine and treat the periphery? Right. So if the patient has the natural lens in the eye, what do we do to avoid hitting that lens when we go across? Again, one of the best things you can do is put those working sclerotomies down near the horizontals. 10 and 2 or 3 and 9 will save you a lot of that risk. Because you won’t have to reach across as much. You can just switch hands and go and reach all the way from 12 to 6 on both sides, without ever crossing the midpoint of the lens. If you do have to reach across, to treat something like a giant retinal tear with laser, it does really help to have a directional laser probe. I did not use one in this case, but I do use only directional laser probes. I find them to be a big advantage, because you can put them in the eye, and then extend the tip, where it curves around the lens. So you’re not going through the lens. How do you check the IOP intraoperatively? Intraocular pressure, for us, is being read by the machine. The EVA. From Dutch Ophthalmic. It has settings. It’s not checking the pressure, but the machine estimates the pressure it’s putting into the eye, and it’s pretty accurate. So we tend to set it at 35 millimeters of mercury, which is enough infusion to keep the eye well formed during the vitrectomy. Also, since it’s in a flow mode, the machine matches the output that’s pulling out of the vitrector to the infusion being pumped into the eye. So I’m pulling out 15 CCs a minute, and the machine is pumping in 15 CCs a minute, to keep the situation stable, the intraocular fluidics and pressure. All right. Well, thank you so much, everyone, for attending from Cybersight. It’s been my pleasure to host this meeting today at the Cleveland Eye and Laser Surgery Center, with Retina Associates of Cleveland helping me, and all my staff here. Special thanks to Dutch Ophthalmic, for helping us to arrange today’s surgery, and also sponsor the audio-visual connections. I hope the views were good for you guys, and that we can learn some things from these cases. And perhaps we can do it again in the future. Thank you very much.