This video demonstrates surgery in a few different scenarios of complex retinal detachment with Proliferative vitreoretinopathy (PVR).
Surgeon: Dr. Manish Nagpal, Retina Foundation & Eye Research Centre, Ahmedabad, India
It gradually peels off from the central area. This releases the contraction in the macular area.
You can see the folds ironing out gradually as the membrane and the ILM peels off. After that the retina appears well settled.
This is a case of a complex retinal detachment which has been buckled earlier and then PVR changes have caused a lot of contractions. Vitrectomy is done where all the cold vitreous is removed and after that, gradually, the peripheral attachments of the blood stained vitreous is being removed.
Small gauge cutters with ports closer to the shaft are extremely useful for such maneuvers. As you get very close to the retina which is detached and mobile without creating breaks.
Once vitrectomy is done, PFCL is injected to stabilize the posterior pole and then peeling is done in the peripheral part. The PFCL supports the posterior area. Now as the retina settles in the PFCL, the buckle effect is seen in the periphery. However, superiorly, there is still a contraction which is released by a small retinectomy. And then drainage is done from the retinectomy edges. Endolaser is being carried out to all the 360 degree areas as well as the breaks and the retinectomy site. The retina appears well settled at this stage. The residual PFCL is removed and silicone oil is injected.
In this case, there is an extensive contraction with the retinal detachment with multiple breaks with folded edges. Vitrectomy is being done. All the peripheral attachments of the vitreous, or the retina, as well as the underlying breaks is being carried out gradually. You can see the sclera coming out from those breaks. Some more vitrectomy is done in the peripheral area to release the traction.
The anterior edges of the breaks are cleared as well as the inferior areas with peripheral circumferential traction is being released.
Perfleurocarbon is injected on the posterior pole to assess the traction.
Forceps is used to peel membranes and the shaft of the light pipe is used to stabilize the retina while the forceps is peeling the circumferential membranes.
Gradually the contraction releases and the retina becomes mobile.
This procedure is carried out 360 degrees.
Further vitrectomy is done on the released areas of the vitreous traction. Peripheral indentation is done so that extensive cleaning of the passburn area can be done in such a case.
After that, endo drainage is carried out and the retina flattens. To look for some more residual ill-formed membranes, brilliant blue dye is injected on which perfluorocarbon is injected.
Gradually, the membranes are removed. Endolaser is done 360 degrees and the retina is well settled. Silicone oil is placed.
This is a case of a myopic retinal detachment with extensive PVR and contraction changes. One can also see this stiff element area on the posterior part. Vitreous is being removed and then the contractions are clearly visible. Gradually the vitreous is cleared from all the 360 degree areas.
Triamcinolone is injected to look for the posterior attachment of the vitreous. And as soon as the staining happens, one can see the residual attachment of the hyaloid, which was not visible earlier quite clearly. It helps us delineate the margins of the attached hyaloid and then using higher vacuum, gradually peel it off the underlying retina. This would help release the contraction.
One has to be patient with this process as these myopic retinas tend to be very thin and fragile. And any inadvertent sudden movement or higher vacuum at times can lead to breaks. So one has to constantly assess the way the retina moves under the vacuum of the cutter. And gradually release the contractions. After that, forceps is used to pick up the membranes. Once again the shaft of the light pipe is used to gradually pull back the retina whilst the membrane is being removed with the forceps.
You can see that the membrane has now come off quite well from the surface of the retina.
The residual parts of the membrane are cut using the cutter. Other membranes are removed in a similar fashion.
As the membranes get removed more and more relaxation of the retina keeps on happening.
Once sufficient traction is released, perfluorocarbon is injected to assess if there’s any residual traction or not. The posterior pole has flattened, we’re gradually removing the residual vitreous and trying to debulk the fluid under the retina to repair the break.
A few more membranes are then removed and the retina starts to flatten. The buckle effect is seen now quite clearly. Fluid is absorbed from the posterior area, endolaser is carried out. There is still some residual fluid under the posterior pole because of the stiff hyaloid membranes. So we make a paracentral small retinotomy and then drain it. After the drainage, endolaser is carried out to that side as well.
Now this is a case of retinal detachment with silicone oil inside. And there has been a redetachment with contraction inferiorly. Our first step is to remove the oil. Once the oil is removed, we put perfluorocarbon to assist the peripheral traction. The inferior retina is contracted and we decide to do a retinectomy. In preparation for a retinectomy, we do an endodiathermy, so that there is no bleeding when we cut the retina. The area of contraction is decided and one does a little extra few hours upon both the sides so that the relaxation is complete. And you can see that with the cutter, we are cutting the retina just peripheral to the diathermy marks so that there is no bleeding. While the perfluorocarbon keeps the posterior area well stabilized.
Once the retina is well relaxed, we further fill perfluorocarbon to go on top of the retinectomy, just like one would do for a giant retinal tear. And then do an endolaser and do a series of PFCL and air.
Once again, this is a case in which there is PVR with silicone oil. So our first step is to remove the silicone oil and then note the whole traction inferiorly as well as on the surrounding areas. This eye requires a much more extensive retinectomy, extending on both the sides apart from inferior area. And you can see that we’ve done diethemy marks to all the areas around, and inferior retina is totally fibrosed and contracted.
Gradually the retinectomy is being done while the perfluorocarbon is holding the posterior pole just like I showed you in the previous case. In this case, there are regions that are stronger because of the prior laser marks which were carried out with fibrosis which has happened. And gradually as the retina is relaxed, we do endolaser to all the edges and you can see a 360 laser barrage. The retina is well settled, perfluorocarbon is extended to all the areas around the retinectomy. And after that the perfluorocarbon air exchange is carried out. The perfluorocarbon is aspirated, the air fills up, and the retina looks well settled.
Now this is a case of a still more extensive PVR change contraction which is seen along with the retinal detachment. A hazy view of the disc is seen, while amazedly there is an extensive interior contraction noted. Vitrectomy is carried out so that as much relaxation of the peripheral area can be done. Perflurocarbon is injected on the posterior pole which helps us stabilize that area as well as assess where the traction starts from. And once we realize that this peripheral contraction is difficult to remove, we plan to do a retinectomy in this area.
There is also a chronic contraction which has led to neovascular areas within this contraction which were bleeding.
We try to remove a few membranes and then prepare for a retinectomy using diathermy. You can see the contracted thick white edges of the retina which are being cut now so that the posterior part can get relaxed. Then we gradually extend it as we assess the area and the clock hours of the contraction.
Now there is an area of traction superiorly which we are trying to remove with the forceps. And as soon as we do that, suddenly the retina gets pulled, and the perfluorocarbon goes under it. Now at this stage, our job is to first remove the subretinal perfluorocarbon and only then can we proceed again. So we gradually remove the perfluorocarbon, come back again, and try to remove that contraction. Put perfluorocarbon back again over the disc and the posterior pole, and further relax the retina otherwise the perfluorocarbon may go back subretinally inside again. So we increase the retinectomy area as well as the clock hours because otherwise the retina is still appearing contracted.
So this would require an extensive retinectomy. And gradually we are increasing it to superior aspect as well. We first leave a few stumps so that the retina can be held properly while we are assessing the faction, instead of doing a full 360 at one go. Gradually the perfluorocarbon is increased once we are visibly sure that we’ve done sufficient retinectomy to relax all the edges 360 degrees. Only then allow the perfluorocarbon to extend beyond the edges of the retinectomy. Now it’s like a 360 ragged, giant tear. Endolaser is being carried out to all the edges.
Once the endolaser is done we will replace the perfluorocarbon with air. At this stage, we realize that there is still some contractions superiorly, which will create problems in the postoperative period, even though it appears settled right now. So we further cut some of the retina and do some more laser to that area.
This is the final appearance of the retinectomy and endolaser done. Silicone oil is placed as a tamponade in this situation.
March 25, 2021