This is a 64-year-old gentleman who presented with a bullous retinal detachment in the temporal retina with a coexisting cataract. The cataract was extracted using regular phacoemulsification and the IOL was implanted at the end of the surgery. The vitreous was stained using triamcinolone and vitrectomy was completed carefully. The sub retinal fluid was aspirated and drained from the primary tear which reduced the bullous part significantly. Laser was performed and c3f8 was injected at the end of the surgery.
Dr Lee: This is a 64-year-old gentleman who complained of losing part of his visual field for the past month. We found a bullous retinal detachment and the temporal retina when we examined him in the clinic. He also has a coexisting cataract, and the cataract has been extracted using regular phacoemulsification technique. And we’ve decided to defer implanting the intraocular lens till the end of the surgery to avoid edge glare problems during his posterior segment surgery. We proceed to the posterior segment surgery and start with a core vitrectomy. I am now doing an anterior vitrectomy through the port, it’s helpful to have this gas bubble as it will actually help us to know where the posterior capsule is. I’m using retro illumination technique, shining the light on to the cutter to see the anterior vitreous better. We have to be very careful when we come to the area which has the bullous detachment of course, a little more vitrectomy again using caution when we are in the area of the detachment.
And we can see the bullous detachment here, the disc is here, and the macula is somewhere here beneath, we are taking a quick look at the peripheral sections. There is a suspicion for tear here. I am now injecting triamcinolone. This will give us a better view of the vitreous, try to avoid injecting the triamcinolone near the hole as it may go beneath the retina. I like to shake the eye a little bit here to disturb the triamcinolone, helps to disperse it and aspirate it better. It appears that there’s a partial posterior vitreous detachment here. So, I will go ahead and do a core vitrectomy and then some peripheral vitreous shaving.
This part is relatively free of vitreous now, proceeding to the infero nasal part. Now when you are doing vitrectomy, remember that the vitreous cutter is aspirating vitreous out and cutting it, so you don’t want to pull on the cutter while doing vitrectomy. You just want to come close to the area where you want to do vitrectomy and then step on the cutter pedal. You can see that the vitreous will come to the port if you just sit in one spot while you’re cutting. We just found the tear and it is primary tear, there’s some subretinal fluid coming out and I’m aspirating it. You can see the bullous part is slightly decreased now.
There isthat fluid coming out, and as we aspirate that subretinal fluid out, the entire convexity of the retina is flattening. Trying to shave more vitreous around a hole, you can see the vitreous is much flatter at this moment now.
I’m introducing another instrument now; this is the diamond dust scraper and I’m using it to peel the remaining triamcinolone. The vitreous should be removed properly from the surface of the retina or we may have proliferative retinopathy after the surgery. If you don’t stain the vitreous with triamcinolone, you might easily miss this layer of vitreous, you can see how thin it really is there on the retinal surface. I’m trying to pull it away from the disc which is relatively safe. Pulling it towards the disk may sometimes cause a retinal dialysis, so we’re gently very gently pulling it away from the disc. You can see that there’s some traction on the peripheral retina. We will have to clean it before we proceed further. So, trying to clean it as much as possible, preferably all the way to the equator.
I’m now putting heavy liquid onto the retina. I’ve tilted the eye to the infero nasal position, and I use this heavy liquid to press on the retina. The hole is in the uppermost area. So, the heavy liquid should push the fluid out from the subretinal space, out of the hole so that we can adequately flatten the retina back down. You can see the interface between the heavy liquid and vitreous here, the heavy liquid is here and the vitreous is there. When I turn the eye, the perfluorocarbon, the PFC can move to this area. So, I’m doing shaving of this area, you can see the retina is stable. You see an obvious gap between the peripheral part of the retina and the PFC, you know that some of the vitreous is still there, so we can go ahead and do the shaving. The retina is more stable now, there’s no need to risk further shaving of the vitreous near the retina, while there’s no PFC there.
I will do some laser now and see if there’s good uptake. If not, I’ll do the laser after the gas fluid exchange. If you get good laser marks, you know that there’s no subretinal fluid. But here we have a good laser uptake, seems to be most of the fluid is out. If you do see the lasers not working, you can always go back and do the laser after the fluid exchange. I’m now doing the IOL insertion, you can see that the capsulorhexis is potentially small, for the reasons of doing the gas exchange. Doing the fluid exchange at this moment. So, you have to leave part of the heavy liquid here to protect the macula. If you’re not careful, the subretinal fluid may accumulate there in the macular area, and the patient happens to not be compliant with their posturing macular fold may occur which is obviously going to be troublesome. You can see the hole relatively clear, trying to drain the subretinal fluid as much as possible. Again, I proceed to core vitrectomy trying to remove the rest of the heavy liquid and you can see the edge of the heavy liquid coming closer to the disc. Sometimes it’s useful to tilt the eyes so that the optic disc is at the lower left position. You can see the retina is quite flat at this time. I’ll now do more laser. This is taking laser quite nicely and that means that there is no subretinal fluid around the hole. You can see that there’s some subretinal fluid accumulate here after you have done some of the laser procedure. It takes some time for all the fluid to accumulate on the posterior pole. You can see the lens is in good position behind the capsulorhexis, we’re now injecting the C3F8. And at the end of the surgery, I’ll inject some conjunctival dexamethasone and gentamycin and that will conclude the surgery. Thank you.