Macular hole surgery has become highly successful in restoring vision for a once irreversible condition. We will stress the basics of obtaining successful outcomes for macular hole surgery, beginning with case selection, safe vitrectomy techniques, reproducible cost effective surgical techniques for ILM peeling, and post operative instructions.
Lecturer: Dr. David Miller, vitreoretinal surgeon at Retina Associates of Cleveland, USA.
DR MILLER: Welcome, everyone. This is Dr. David Miller, coming to you live from the Cleveland Eye and Laser Surgery Center, here in Cleveland, Ohio. Thank you to Cybersight for hosting this program. We have over 400 attendees watching this live demonstration of the basics of macular hole surgery. My plan this morning is to give you a didactic, a little lecture and some review questions, perform a surgery, the patient, Caroline, has already been blocked with a retrobulbar behind me, and my assistant is prepping her now for the surgery. And then we’ll answer some more questions after the surgery, and then we’ll try and come back and maybe even get a second surgery. And we have two macular hole patients lined up this morning. So to start, we’ll go off with the lecture slides. If Lawrence could advance me to the first slide. So by definition, a macular hole is a full thickness retinal defect in the central macula. Next slide. This picture here shows the macular hole centrally. Next slide. On a color photograph. Here’s another color photograph of a smaller macular hole. Next. A little higher magnification there of the center of the macula, with the defect in the middle there, and a little pseudo-operculum over the center. Thank you. Next slide. Just some histopathology of a macular hole under the microscope. The retina is a little elevated there. I don’t think I have the — maybe I have the benefit of you moving the cursor around. So there’s subretinal fluid undercutting the cuff of the hole. Here’s the gap, which is the true macular hole. And there’s a little fluid underneath. Next slide. So what causes a macular hole? Well, there’s idiopathic, which is also related to vitreomacular traction. Trauma. Cystoid macular edema, laser burns, retinal detachment, and epiretinal membranes. The most common is idiopathic or senile macular hole. Women are afflicted more than men. Most commonly in people, as they age, and the risk of bilaterality is about 10% to 15%. Next? Don Gass did the staging of macular holes many years ago. Several decades ago. And came up with the classifications of stages I through IV. And the visual acuity through these stages can range from 20/20 down to count fingers. A little cartoon drawing here of the vitreous laying on the retina. The vitreous has a clear circular area right over the center of the macula, where it attaches itself to the optic nerve as a Weiss ring, but there’s also an attachment point around the center of the macula. Next? As the vitreous begins to separate away in a vitreous separation or vitreous detachment with age, it will be pulling some on those areas, and that includes pulling on the central macula. This slide here is trying to demonstrate the traction on the central macula. Next. So what is the differential diagnosis of a macular hole? Possible other diagnoses include: Drusen, cystoid macular edema, central serous retinopathy, pattern dystrophy, lamellar macular hole, and epiretinal membrane or macular pucker. Next. This is a slide of a not true macular hole. If you look at the base of that hole or excavation, you can see the photoreceptor layer is still intact. So that hole does not reach all the way to the bottom. That’s a deep lamellar macular hole. An eye like this can easily still see as well as 20/20 or 20/25. Next. This is the schematic of that same situation. The upper schematic is showing an epiretinal membrane growing over the surface of the macula. And the lower photo, showing, as that membrane evolves and thickens, it changes the contour of the foveal depression into a lamellar macular hole. But again, the photoreceptor layer is intact at the bottom here. This eye is probably also very well seeing. 20/20 or 20/25. Next. This is demonstrating cystoid macular edema. Big cystic spaces that can imitate a macular hole on clinical exam. Next. Pseudohole, secondary to intraretinal telangiectasias, are idiopathic juxtafoveal retinal telangiectasias. Next. Geographic atrophy can also simulate a macular hole. When the RPE drops out here at the bottom. The overlying retina will thin out. P and you get the appearance of a macular hole. Next. So how do you make the diagnosis of the macular hole, then, with these different choices? Well, one is the natural course of the condition. The cuff of subretinal fluid, a smooth circular margin, overlying operculum, a poor visual or decreasing visual acuity, drusen-like deposits in the base of the hole, deposit of Watzke-Allen sign, which is when you line the slit beam up and down, right over the macular hole, and the patient can pick out the defect in the beam of light, and testing. Most importantly probably OCT, optical coherence tomography, which can actually show you the retinal defects, and then fluorescein angiogram still has a role too. Next. So here’s an OCT of a lamellar macular hole. You can see that the outer plexiform layer is intact, number one. And number two, the photoreceptor layer is not affected. Here’s a stage one macular hole. We’ve got a posterior vitreous detachment at number 1. You have a pseudohole or possibly a stage I macular hole, and again, the photoreceptor layer is intact, with visual acuity of 20/30. Next. Here’s a stage III macular hole, corresponding Stratus OCT image. And you can see the pulling up on the edges of the macular hole. A pseudo-operculum is laying right over the center here. And here’s the vitreous attachment still. Kind of edging its way out from the edges of the hole. And here’s a stage IV macular hole, which is just a complete vitreous separation. There’s no vitreomacular traction left. It’s separated. The holes tend to be a little larger, and you can see the bare retinal pigment epithelium and lack of photoreceptors. Next. So the indications for surgery: Successful repair for idiopathic, traumatic, and laser induced macular holes have all been described. There’s really no benefit for surgery in stage I holes, but there is a benefit from stages II through IV. The reason for that is: In stage I holes, which are so early that you don’t have a full thickness defect yet, if the vitreous would just separate and let go of the cuff of the fovea, cuff of the macula, those will fix themselves. So if you have a situation where the vitreous is pulling up on the fovea, and it looks like it’s gonna form a macular hole, you have at least a 50% chance that that’s gonna separate on its own and the fovea will resume its normal contour. Those probably don’t need surgery. But there is a benefit in stages II through IV. And if the hole is chronic, very old, in particular I would say anything over 3 or 4 years old, your visual acuity recovery is not gonna be that great. Surprisingly, even up to one or two years, though, you can get a marked improvement in visual acuity. Next. So the surgical technique — we’ll discuss this while we’re doing the case, of course, but standard vitrectomy techniques, creation of a vitreous separation, to separate all that vitreomacular traction that’s pulling, removal of any epiretinal membranes with retinal forceps, removal of the internal limiting membrane. It’s been a bit controversial over the years, but I think almost all surgeons are doing that now, with a higher success of closing the macular holes. Removing the ILM definitely ensures the release of all vitreofoveal traction. A gas fluid exchange. C3F8 or SF6. We’ll discuss that during the case. And again, face down positioning, anywhere from a few days to one week, depending on surgeon preference. I prefer two days. Results of surgery. Closure success is at 90+%. Macular appearance is normal to faint RPE changes. Visual acuity can change from 20/20 to no improvement. Next slide. And that’s a histology there of a macular hole following closure. The photoreceptor layer is a little bit in disarray still, but there’s no gap anymore in the macula. Next. Complications of surgery for macular hole. Cataract, retinal break, retinal detachment, reopening of the hole, phototoxicity from the surgery, or endophthalmitis, of course. Next. So our first patient. Our first patient is Caroline. She’s 61 years old. She’s had symptoms of blurry vision for 4 months in the left eye. Acuity of 20/20 and 20/200. Here we have some photographs and OCTs. Caroline just came through our clinic actually last week, and by the way, it kind of takes a team effort here, on the workup there. CeCe got the visual acuities and the tension, and here we have photography by Robert, one of our retinal angiographers. And you can see in the angiogram the circular defect in the early phase of the angiogram that then stains in the late. Next slide. Robert also got these OCTs for us. You can see in the right eye her normal right eye, and in her left eye, she has the retinal break. Right at the fovea here, the defect of the macular hole. So… Next slide. So we’ll come back to the review questions. We had help in the room too also from Sarah, who got the consent and talked to Caroline about being involved in the surgery. And she’s graciously agreed to donate her eye, to show you how to repair a macular hole. So we’ll start the case. Thank you. So my assistant today is Mike Hart. Mike. We call him Tennessee Mike, from Tennessee. And he’s gonna be helping us get this done in an efficient and proper fashion for you. Tennessee has been getting the patient prepped while I’ve been talking, which I appreciate. And we’ve got a nice crew of people here in the operating room. Typically I work with a physician assistant like Mike. And we’ve got Christine circulating for us. One of the circulating nurses. And our scrub. Kim. Kim probably thought I forgot her name. It took me a year or two, but I got it. We have a few other people in the room helping us out with the AV equipment and the technical stuff. Can someone grab my glasses? Missed on that one. How are you doing, Caroline? You okay? So Caroline is awake. We do our cases under just local anesthesia, using MAC. She had a little bit of sedation with Versed and some fentanyl, and I blocked the eye with a retrobulbar, using lidocaine. Right before we started the lecture. She has a little bit of eye movement, but not much. Can you look to the right for me, Caroline? Look to the left. And that should be fine. If it’s too much eye movement during the case, we can always supplement the block with a sub-Tenon’s injection. Thank you. So we’re gonna move — does this pinch here at all?
>> A little bit.
DR MILLER: A little bit? How about here? No? If it’s too much, let me know. Again, we can always supplement. We’ll mark the eye for the location of the sclerotomies. She is phakic, but I generally make mine always at the 3.5 mark. I tend to put these cannulas in very beveled, for better wound closure. Less leaking. I also tend to put all of the cannulas in first. And then come back. And put the infusion line in. Some BSS for the cornea there. I tend to put my working sclerotomies pretty low. Not directly at the horizontal, but pretty much down at 10:00 and 2:00, or maybe even 9:30 and 2:30. Get another… We’re using the DORC EVA system. As our vitrectomy unit here. And these are their valved cannulas. 25-gauge surgery, for those wondering the size. I’ve got the infusion running here. We’re gonna put the cannula over the top. Very good. How are you doing, Caroline? You doing okay?
>> Yeah, thank you.
DR MILLER: I tend to always start the vitrectomy with the temporal location. In this case, that’s my left hand. I am right-handed. But I would suggest everyone try and use their off-hand as they’re learning these techniques, to develop their skills with the vitrectomy probe and the laser probe, and even peeling. Can you focus that? Yeah, we will. So Lawrence asked me, back at Cybersight Control, to try and zoom as much as we can. How are we doing there, Lawrence?
>> I think that looks good.
DR MILLER: We’re good? Okay. So I probably don’t zoom quite this much when I’m normally doing surgery, at this stage of the game, but I want to try to make a nice view for everybody. Here you can see the macular hole. Right? Right down here. There’s a few drusen-like yellow spots in the base of the hole. And we don’t really see a vitreous separation. Right? That was also evident on the OCT. When we reviewed her case. So now we’re gonna try and create that vitreous separation. I’m just kind of coring out the vitreous. Moving around the edges and the corners. Moving as much vitreous as we can. And there’s many ways to create a vitreous separation. But what I’ve found works quite well and saves time and also costs — I’m gonna try and also discuss cost during this case — so right now, all we’ve used is the basic vitrectomy pack. So to create a vitreous separation, you can use the vitrector itself. To go down by the optic nerve cup. And slide out. And try and engage the vitreous. You can see that line moving away. If you watch closely, you’ll see the vitreous coming up. See the floaters and the shadows. What’s nice about this is it saves us using a Softip. Or triamcinolone to stain the vitreous. Or show where the vitreous is at. So again, we’re gonna try and do this in a way that’s cost-efficient too. For everybody. So the vitreous is off the optic nerve and off the macula. There’s a good chance now if we stopped the case and filled the eye with a gas bubble that this macular hole is gonna close. And by good chance, I mean 90%. Right? Now, we’re gonna go a little further. And stain the internal limiting membrane, and also remove that. And that’s to pick up the extra 9% or 8%. Closure rate for a macular hole, in a review in our practice most recently, it was about 99%. So once the posterior vitreous has separated, we excise it out to the periphery. I will switch hands here eventually. How is the image on the TV? Is it staying centered for us, Mike? Thanks. Okay. Now, what we’re gonna do next is we’re gonna stain the internal limiting membrane by using IC-Green dye. Different techniques for this too. You can stain using IC-Green, you can stain using Brilliant Blue, some people use triamcinolone. Give me a little squirt there. There’s our green dye. This is just the IC-Green vial, diluted in its normal ampule of saline. We do not dilute it further. I do not use dextrose. Again, all those extra steps, little extra steps people have to do, a little confusion can be introduced. And cost. I tend to try and avoid it. I do not inject the dye directly into the hole, of course. I inject around it. I let the dye just bounce off the macula. I know it looks a little bit messy right now. But we let the dye bounce up, and then we just aspirate it off. Again, I’m very cautious not to let the dye enter the hole. There is certainly a risk of toxicity from chemicals, including the IC-Green dye, entering the hole, and that’s certainly not what we want. Also, you may notice that I don’t get too aggressive with the vitrectomy anterior, because she is phakic. And Caroline knows — we discussed beforehand — that she has a little bit of cataract now, but not much. And the cataract will likely progress to the point where she’ll need cataract surgery. She doesn’t have too much now. Sometimes that case can be combined. Right? You can do the cataract and the macular hole, and save the patient a return trip. In some cases around the world, that’s the more common way to do it. It’s not our most typical approach here in the United States. So now I’m gonna use a contact lens. We’re gonna get a little different view here. Mike is getting us set up with a macular contact lens. And what we’re gonna do is get a more magnified view of the macula. Switch the light pipe over to my left hand. What I want to do is get the internal limiting membrane elevated. And to do that, we’re gonna create a little edge. So here’s the optic nerve again. Right? Here’s a little bit of vitreous, stained green. Here’s the macular hole with the drusen-like changes in the base of the hole. And we’re gonna come down and take a look here. Get the focus how I want it. Give me a moment. And I tend to use the pick from the side. A little bit out. I don’t run the pick along the point. It’s a little too sharp. So I’ll start a little nick there in the ILM. And try and get a second one somewhere, just in case I need it. But not always. Okay. So that’s a reusable pick. Again… I forgot the manufacturer of that pick, Mike. You wouldn’t happen to know? It’s a small 25-gauge pick with ridges on it. And I think it’s from Bausch and Lomb. Synergetics. This forceps here… Is also from Bausch and Lomb. The pick there again, Mike. Just trying to get a little bigger edge. To grasp with my forceps. When you see the retina indent a little bit, that’s how you know you’re in a pretty good spot. A little bit of bleeding on the retina is not a problem. We expect to get small hemorrhages during this type of peel. You can see the retina kind of push and pull. And all of that is acceptable. I’ll try and keep the zoom up. I’m trying to adjust the view for you guys, to make this a little better. And at the same time, allow me to do the job. So we grab it. And you can see the faint green staining. As it pulls around. Over the hole. Sometimes I’ll regrasp. You can see the nice green. And we try and go all the way around the hole. I’m gonna show you one other technique, real quick. Sometimes, if you don’t like your grasp position of the vitrector — thank you — we can use the vitrector itself, these 25-gauge cutters, under aspiration. You can engage the ILM quite nicely if there’s a loose edge. So I don’t want to go right over the fovea. You can see how it grabs it in that cup. The vitrector itself. And the ILM is now peeled around the hole. Not perfectly circular, but it doesn’t have to be. It just has to be off the edges. You can use the vitrector even now to start when the edge is flat. And see it coming up with a few rubs. And here it comes again. A bigger flap of ILM. And this is something these small gauge vitrectors really do much nicer than the older models could do. And again, that’s pretty well peeled out. We’ll just grab this last piece. I don’t think you have to go any particular distance. Arcade to arcade, or nerve to 2 disc diameters temporal. I tend to just stay… If I can get a disc diameter around the hole, I’m very comfortable. Very good. Not exactly sure what those little white specks are. Came off the bottom of the vitrector. But that’s okay. And then with the wide field viewing system, I didn’t discuss that yet. The first view we had, which was the wider field of view, is the EIBOS and it gives us a view of the retina pretty much from equator to equator. Tennessee is getting our cornea recoated. And we will keep it going. Mike, I did have another nickname for you, but we can’t use that one live. Just so you know. So we’re gonna focus that again. Using a focus on my depression point. So part of doing surgery, no matter what the case is, is avoiding complications. Right? Probably the most common complication with macular hole surgery is retinal tearing and detachment, as far as the big ones go. And that reason is because you’re pulling on the vitreous, right? And you’re distorting the eye. You’re distorting the vitreous in there, you don’t know where you’re pulling, you can’t see everything at one time. So if you end up pulling on the vitreous and not cutting it out, obviously you can create retinal tears. So I think one of the key things to do — let me have the vitrector and cut from this side. I haven’t done that. Let me just make sure — yeah. Make sure we’ve got our vitrectomy fairly complete here. What we want to do is, before we go all the way to scleral depression and the gas-fluid exchanges, look around, get the vitrectomy maybe a little more complete, because it will determine your gas bubble size. So just make sure we didn’t miss anything that’s too big. Also any fragments of the ILM. Can’t reach directly across. We’re in a spot here with this thick eye. Very good. Mike is giving me access here, again. For my scleral depressor. Okay. That was on the cornea. That’s okay. I can see… Okay. Go ahead. Here we’re just trying to get the cornea a little more clear for you guys. We’re seeing fine, but it’s a little… Has some keratitis. Some superficial punctate keratitis that’s gonna affect the view a little bit. All right. Checking how the scleral depressor is going in. Again, we’re gonna check that vitreous base for 360. That’s where those retinal tears will be sneakily happening on us. And we wouldn’t see that retinal detachment in the clinic. It would show up in week two or three. Then we’re coming back to do a second surgery, which we’re trying to avoid. So as the gas goes away, the tears are uncovered. So you want to do a thorough look around, to make sure you’re not having that problem. So now we’re gonna do the air-fluid exchange. We’re gonna pull the fluid out of the eye. Put the gas bubble in. How is the view up there? We doing okay? Okay. Air is on. Good. Here comes the air bubble. Again, I’m draining with the vitrector. Probably many of you have noticed the advantage there is not using another instrument, not opening another instrument. So what we used in this case is the basic vitrectomy pack, a reusable pick, and one reusable forceps with IC-Green dye. And that’s about it. We’re gonna get gas. Mike is gonna get some gas for us. We’ll use C3F8 in her eye. Now, the choice on that is — you could use SF6, at 20%. We’re using 15% C3F8. Why is that? C3F8 will last quite a bit longer in the eye. Leave a bigger bubble in the eye for a longer amount of time. And make the positioning less critical, in terms of face down. So depending on the patient and the case and the size of the hole, phakic and pseudophakic, and so on, I think both can do an excellent job closing the macular hole. The C3F8 has the disadvantage of taking longer to get the vision back. But has the advantage of a bigger bubble, less worries about positioning, and so when you’re starting out in particular, learning the basics here, I think C3F8 is probably the way to go. I’m gonna drain a little more fluid. You don’t have to wait. Sometimes people will wait for more fluid to accumulate. You really don’t need to do that. I think just grab it twice and go. Especially if you’re using C3F8. SF6, I would be more inclined to get as much of the vitreous out as possible. So starting out, you have less fluid in the eye. Less residual vitreous. So now we’re gonna pull one of our cannulas. And leave the other one in as a vent. Here’s our little hole here from the sclerotomy. We’re gonna press on that a little bit, just to collapse it. Press on the roof of the tunnel, so to say. Mike is gonna inject the gas for me. I’m gonna vent this by pushing on this valve. Right? In comes the C3F8. Again, 15% is our solution mixture. Very good. We’ll do the same thing on this side. Gonna give a little more pressure. He’s gonna pressurize the eye. I’m gonna press against that. I’m gonna use my tonometer here, my finger. There we go. And this one here. Now, as far as me checking the pressure with my finger, that is what I typically do. A little bit more gas, Mike. We’re a little soft. So we’re gonna inject a little bit more. You can certainly use a tonometer, you can use a Schiotz or the Tono-Pen or other systems to check eye pressure. Again, I tend not to introduce those extra things. If you’ve done enough cases, you’ll get a pretty good feel for the eye pressure. Go ahead. That’s fine. So we’re probably somewhere in the mid-teens, probably pushing up on 20. And there we go. There’s no leaks. There’s no gas coming out. All the wounds look nicely closed. Collared the case beautifully. Now, Caroline, how are you feeling there? Oh, there’s a little gas. See it coming out? So we’ll just kind of check it again. You’re feeling fine? Well, the case went very well, Caroline. We’re gonna give you instructions to maintain your head down only two days. Because the case went so well. So during the day, just keep your head down for two days, and on the third day, you can put on your red dress and dancing shoes, and head out on the town, no problem. Okay? All right. We will ask you to sleep face down, though, for at least a week. Okay? But during the day, just two days. So we’re gonna get you going. All right. And thank you so much for participating in this live demonstration of the basics of macular hole surgery. You were an ideal patient. So what we’ll do now, while they are turning the room over, and getting Caroline checked through, let me just sign a few sheets of paper here… Very good. And my glasses went which way? Oh, maybe I don’t even need them. Who knows. So no open questions from the audience. That’s fine. We can go to the lecture questions. So we’re gonna go back to the slide show, is what we’ll do. And kind of review the pre-questions with everybody. So the question about… And by the way, so right now what we’re doing in the room is: Mike applied a pressure patch on the eye. A couple pads. Some tape. He put the Fox Shield over the top of the eye. Typical eye surgery patching. We do patch the eye. We’ll leave that patch on there all day. And we will take it off tomorrow in the clinic ourselves. We’ll start our typical post-op drops. I typically use an antibiotic, four times a day, and a steroid four times a day. We’ll drop the antibiotic as quickly as about one week. And then we’ll taper the steroids probably as quickly as two to three weeks, to stop those completely. Typically, these eyes are not inflamed at all. Very little inflammation. And she’ll do quite well. She’ll start holding her head down here in the post-op period. The nurses will give her an instruction sheet, which is pretty critical. We do give patients a lot of information ahead of time. They can sense the staff all do a great job, and the team out front, all the nurses there, are gonna give her instruction sheets about how exactly to position her head and how many days to do it, and also how to sleep and how many days to do that, and give her the appointment time to come back in and get checked tomorrow, so we can pull the patch off and kind of see where her eye pressure is at. That’s the big thing. And also the size of the gas bubble. So I’m going to check a few questions here. From the people observing live. So thank you for the congratulations of the surgery, and why not use Brilliant Blue instead of ICG? That’s a good question. Brilliant Blue is now available in the United States. More recently, as of the last year or two. And I’ve been using IC-Green for decades, so I think that’s part of it. The other issue is: Brilliant Blue, on cost, if you’re doing multiple cases in a day, between epiretinal membranes and macular pucker peels, I can use one vial of IC-Green dye and cover all the cases. Whereas I would have to open up a separate Brilliant Blue vial for each one. So there’s a bit of a cost advantage, if you’re doing multiple cases a day, like today. We’re probably doing 8 to 10 cases, and half or more of those will be membrane peels of some sort, so we tend to go with the IC-Green, mix it up once, and use it all day long. Someone else typed in: They feel that C3F8 — from Stephen — C3F8 is not required. SF6 maintains adequate drawing of the perifoveal reflex to allow closure of the macula and much less cataract formation. I do agree that SF6 can work quite adequately. Again, I do think there’s a bit of an advantage in terms of positioning and gas bubble size. And there’s never been any studies comparing — is one better than the other, and are the failure rates a little higher with one over the other. My own experience is that I have had a few failures in SF6 patients, because the bubble was just a little too small in the first few days, and the patients couldn’t hold their heads down very well. Typically with C3F8, I’ve had many patients come through who don’t hold their head down at all. They just look straight ahead, and they’re down. And that’s a bit of a trick with SF6. So if you get to a spot where you cannot get a patient into position, you can still do the surgery with C3F8 for sure, and just have them look straight ahead and not lay down on their back, and this will work. Another question from NT is: What do you think about inverted flap? The inverted flap with ILM is something I have used for really large macular holes. These are typically not gonna get great vision anyhow, so a lot of those I don’t even bring to the operating room. But the inverted flap technique of ILM laying over the top of the macular hole, I think, is beneficial in very, very rare cases. So when you’re kind of looking at picking cases, and if you’re starting out, I would not do that technique or pick those cases. I would go with ones like this, where you can just peel off all the way around, whether you’re staining with IC-Green dye or the Brilliant Blue dye, and pick your gas. Question from King. Why take out the valve, then insert the BSS solution? Oh, so what that’s about — on the DORC EVA, they don’t have a connected trocar infusion line system. So all the trocars and cannulas are the same, with the valves on top. You have to put that in. And one of them you have to uncap, and then plug the infusion over the top. That’s how the system is made. That’s not my preference. I believe that’s actually changing here, in the next few months. DORC has come out with a valve infusion cannula line that’s one piece, that can just be punched into the eye, and you can skip that step. Question from Samia. What is the most common complication after this operation? I think the most common complication is retinal tearing and detachment. So when we were first doing these back in my fellowship days, it seems like we had a retinal detachment in one out of ten or one out of twenty patients in these patients. And we didn’t have the wild field viewing systems to see where we were pulling the vitreous to. We didn’t have great scleral depression at the end of the case. Under a wide field viewing system. And so there would be these retinal tears that were undetected. And you’re pulling on the vitreous pretty hard. And that rate has dropped significantly with the advent of wide field viewing systems using the EIBOS or using the BIOM, that many of you may have. We can detect those tears and treat them well in the operating room. We didn’t have that situation in Caroline’s case. I also think tear rates are lower in 25-gauge surgery than 20. So it’s just less common. Question from Stephen. ILM peeling associated with frequent occurrence of perivisual axis VFD, on the omnifield. This is associated with traumatic NFL injury. I’m trying to convince DORC to make an angled tip to give illumination parallel to retinal service to allow better visualization of the traction. What about chemical loosening of vitreoretinal traction? So several questions in there. Certainly there has been reports of ILM peeling being traumatic. You saw that in the last case, we were able to get her ILM off without too much difficulty, using the pick gently and using the forceps. It looked like a rather atraumatic peel. Of course, you can still have microtrauma. Things without bleeding or hemorrhage or holes being obviously visible and disrupting photoreceptors. We do see OCT imaging after surgery, after she recovers. We could do an OCT and pick up defects in the NFL. Not loss of tissue, but just kind of ridges and undulations that are not normal, that do not appear to affect visual acuity, but it’s still a bit of a concern. So at this point, we continue to peel the ILM just to get the higher closure rates. As far as better ways to do it that are with less trauma, using new illumination or better visualization, those are all great. When it comes to chemical loosening of vitreoretinal traction, there is a medication made by ThromboGenics, a European — a Belgian company — where you can inject — the trade name is Jetrea. The generic name is ocriplasmin. So it’s a plasmin-like product that can lyse collagen fibers and create a PVD if there’s abnormal vitreoretinal traction. The downside to that medication, at least in the trials — I was in the trials — is the success rate hovers around 50%. So half the time, it fails anyhow. And then on top of that, there’s some complications with visual changes and photoreceptor dysfunction that takes some time to reverse. So when you introduce extra steps and chemicals, and in particular chemicals, you’re always gonna be very cautious about the toxicity effect on the surrounding tissue. Question from Winston. About epiretinal peeling and internal limiting membrane peeling at one step. Should we peel in one step or two steps? I would say if you’re lucky enough to peel it in one step, peel it in one step. Everything is easier if you do less. You have to get a little lucky. It ends up in cases like that, which are more difficult macular holes, I end up almost always having to stain twice. And sometimes I’m like… Look at that. Everything is gone. And sometimes I’m not so lucky and I end up peeling off the top layer, then going back and peeling the second layer. Next question. From Shalom. Is there an advantage in starting the flap on the nasal side, close to the nerve, or the temporal side of the hole? That’s an interesting question. I probably instinctively — I haven’t thought about it a whole lot, but I probably almost always start on the nasal side. And the reason is the retina is a little thicker. So the retina is thicker and it’s more forgiving when you’re poking at it and pinching, and not having to worry about going too deep and hitting the RPE, or creating a confusion like white defect in the RPE, or even an RPE hemorrhage. So I tend to want to stay where the retina is thick. And there’s no doubt it’s thicker nasally, and the nerve fiber layer is more cushioned there. A lot of times, we use a pinch and peel technique. You go down and kind of just pinch and peel. And that’s probably my favorite technique. I think that’s a little tougher, starting out. And that using a pick or a bent needle for most people is the way to start to create an edge and then use that edge with the forceps. Next question is from Cecu. Do you ever stuff large macular hole with ILM? Similar to the inverted flap with ILM. You can take the ILM remnants and put them in the hole. I don’t do that. I think they tend to just shake free or move out of the way. If I’m gonna try to use ILM to bridge the gap, I’ll tend to just do the inverted flap technique, where we take it and peel it back over the top. Next question from Aquasy. Do you have any experience with placing platelet-rich plasma in the hole, especially for big ones, and what is your opinion? That debate’s been going on for a good 20 years. No, I don’t do that. I’ve been a part of cases, again, in my fellowship training, 20 years ago, where we did that. And I don’t think it really has any role. I don’t see where there’s any benefit. I think this is purely a mechanical problem, like a broken bone. If you get the pieces set right, and then wait for healing, that should be adequate. Another question from Stephen. The DORC non-valved inflow is for high flow. It prevents collapse of the eye at high flow suction. Right. There is — again, that’s a particular question about the machine. And I’m gonna kind of defer those questions back to DORC reps and the company. Because they may have different platforms in different countries, even. So if you start talking about the nuances of what valves we have or don’t have, I don’t want to get too much lost in the weeds there. Next question is from Sarah. Why does ILM peeling have to be done? Sarah. So… It doesn’t have to be done. If you have a clean vitreous separation, like we had in Caroline, that type of case, where it stained green all the way around and it peeled off in one sheet, probably is the exact case we didn’t need to peel it, and she would have closed. You don’t know that until you put the green down and start peeling around a little bit, so you can always have some residual cortical vitreous or epiretinal tissue attached to the edge of the hole. The reason you want to peel the ILM is really to relieve all vitreomacular and epiretinal traction. And in a lot of cases, that does — there is residual traction, even after peeling the posterior vitreous. I’m gonna break and block the patient. Right, Tennessee? We’re good? Then we’re going to go over and get that done. I’ll be right back. And then we’ll answer some more questions and start this. So I don’t know that the camera can see me over here. But maybe a little bit. If you rotate it this way… The whole desk, Rachel… Am I in there, Rach? Turn the desk this way. Oh, there I am. So Rachel is helping us out with our IT. Besides being the best billing supervisor in the world for ASCs. She also got the default job of being the IT person for live surgery, which I think is fascinating, how you got that role. I’m not quite sure how that happened. Okay, Jane. We’re gonna get this eye blocked up. Dr. Miller here. You feeling okay? Just look at the ceiling. You’re doing great. I feel for the inferior temporal orbital rim. Do a little pullback and inject about… There’ll be a little burning and pressure here, Jane. I inject about 5ccs of lidocaine. And in all the confusion, I forgot to do our time out. That we’re doing surgery on the left eye for Jane, for our macular hole. Everybody agrees? Christina agrees. Thanks. Sorry about the distraction with the video. So we can go back to the questions, and we can also answer the lecture questions. Let’s see where we’re at here. Oh, here’s a question I think is interesting. From NT. What are the reasons for not doing full peripheral shaving on this type of surgery? In Caroline’s case, a couple of reasons. One is: She’s phakic. That’s gonna be difficult. High risk of cataract formation, traumatic cataract formation. And number two: You don’t need to do full peripheral shaving almost in any case. We won’t get into that discussion. But even in the retinal detachments, I’m not so sure that’s really what people should be doing. It you just want to get the tears flat and attached. And in these cases, the only advantage is a larger gas bubble, if you need it. You can get around that with basic techniques of doing just a nice core vitrectomy, out to the midperiphery, saving trauma in the vitreous space, possible inadvertent retinal tears, saving cataract. You’re better off using a longer acting gas bubble. C3F8 over SF6. At a bigger size. So if your skills get to a point where you can get shaving in and get a huge gas bubble, SF6 is probably gonna be your choice. Question from King. ILM peel using Synergetics ILM forceps. Which model feeling good? I do use Synergetics ILM forceps. I have for over a decade. One, they’re reusable. They’re 25-gauge. They’re reusable. So it makes it cost-efficient for us. Sometimes the tips can be a little misaligned. You send them out for repair. And sometimes the tips can maybe get a little less sharp for the pinch and peel technique. So sometimes the tips aren’t quite sharp enough, as the disposable forceps are more consistent. So that’s another advantage in using a pick to start the peel. I was gonna go to the questions from the lecture at this point. I think we’ve gotten through most of the open questions. Yeah. So the first question was: Which sex has a greater chance of forming idiopathic macular hole? Men, women, or the same? And we put you through the survey there. And the choices people made. Let’s see if that shows up, what people picked, if Lawrence has that. There it is. So people knew this pretty well. 11% picked men. 67% picked women. 22% picked the same. It is indeed more common in women than men. Probably 2/3 to 1/3. And in fact, both of our cases today are women. Caroline and Jane. Next question. That was coincidental, by the way. Etiology of macular hole includes which of the following? Idiopathic, trauma, retinal detachment, or all of the above? Let’s see the answers pop up here. Let’s see what we’ve got. Okay. That’s pretty good. You came up with 93%. All of the above. And that is very true. 7% picked idiopathic, but the vast majority knew that all those causes could be related. And the next question. The main cause of idiopathic macular hole formation is vitreomacular traction. True or false? Very good. Let’s see what the audience survey showed. Like Family Feud. And the answers were true in 94%, false in 6%. I suspect 6% just misinterpreted the question, because idiopathic is the common macular hole. And most are caused by vitreomacular traction. It used to just be called idiopathic. It’s a matter of names. The next question. There is a known benefit for vitrectomy at which stage of macular holes? Let’s see what we’ve got here. And the survey showed for us… Very good. Interesting. Very interesting. Thank you, Lawrence. The audience did pick 81%. Stages 2 through 4. Only 3% picked stage 1. Again, in stage 1, where there’s just vitreous traction to the fovea, you just want to let that wait and see if it won’t pop off on its own and let the macula resume its more normal contour. It’s not really a defect or a full thickness defect yet at all, in the macula. So you just kind of wait for that to clear up. So timing-wise, we’re kind of coming up on the end of the hour. We are gonna do a second case, for those who want to stick around and watch. I’ll narrate through that also. But if Lawrence cuts us off in Cybersight, because one hour is long enough, or obviously people will peel out and do what they need to do and start their day, I certainly appreciate you joining us here today, if that’s the case. It looks like Mike is pretty much about set. So I’m gonna gown and glove up again. And I’ll talk my way through this too. Okay. Those are all very good questions that you guys wrote in. I thought it showed a lot of understanding and depth of the material. And many of those questions weren’t really the basics of ILM peeling. But graduate course level stuff for ILM peeling and macular hole closure. So the audience is certainly very well educated and versed in the topic. Oh, you know what? There is a couple slides. If we could pop over to the slide show again… And go to the end of the lecture. Because we do have Jane’s OCTs and things, which I think are always interesting. So right there. That one. Yep. Let’s go there. So here’s our patient, Jane. Next slide. Can you tilt the screen back a little bit? It’s kind of missing my head. There you go. There’s our patient. So you’ll see our patient. Here’s her fundus photos. And her angiogram. And you can see the nice window defects. What’s interesting in Jane’s case is she has a chronic macular hole in the right eye. It’s been there a decade. And that was also after a mac-off retinal detachment from one of my partners, and that was decided that was inoperable a decade ago. Then in the last few weeks, she’s developed a macular hole in her left eye, which was her good eye. So today we’re here working on that left eye, but not the right eye. So we’ll look at the angiogram here. Left and right eye. You can see circular window defects in the late frames, in both. A little different, though. The one on the left, the left side of the screen that I’m looking at anyhow, bigger and more diffuse. The one on the right is a smaller window defect. Next slide. I’m glad we’re covering this. This was interesting. Here it is again. The top OCTs — that’s her right eye and her left eye, about four years ago. So her right eye had this chronic macular hole on the right. Left eye looked normal. The bottom OCTs were done just last week. So there’s the right eye. And that’s a more chronic-looking macular hole. You’ll notice how you don’t have the cup of subretinal fluid and the cystic changes in the edges of the hole, compared to the left eye, where you do see the cystic changes in the hole, and how it kind of undermines the retina. That’s our more acute macular hole. And the next slide. Go back a couple slides there. I thought there was one… There we go. I was looking for the visions. And she’s 20/400 on the right and 20/60 on the left. And she’s been noticing decreasing vision here. 78-year-old woman. For the past month. So we will get started on her case. Thanks, Rachel. You’re not that familiar with that? Just grab. There you go. Oh, thanks, Kristin. I went through the trouble of putting those clinical slides in there. I don’t want to waste them. Turn your head a little bit this way. I tend to like the heads of my patient — she was like this when I came in. Now, what happens here — I’ll show you on the — she was rotated towards the nose. I don’t like that as much. I’ll do this for you guys to see. Oh, it doesn’t work. I like it so the head’s either perfectly flat or actually rotated so the fluid drains off towards the ear. So fluid is not accumulating on the eye during the case, but running off the field. Very good. She’s pseudophakic. And we’ll measure again. The distant dot being 4 millimeters. The closer one being 3.5. Going in a bevel formation there. Again, a very beveled incision here. Probably 45 degrees or even flatter, from the ocular surface. There we go. Pop the valve off. Put the infusion cannula on. You can always check for infusion cannula placement by bending the — looking off to the side — and we didn’t do this in the first case, but you can see the cannula moving around. We’re in good shape. Again, it’s a left eye. So we’re gonna start temporally with my left hand. And you can see the lens implant and the posterior capsule is open, but there’s quite a bit of — you can go ahead — quite a bit of — hang on one second — quite a bit of posterior capsule changes there. So a lot of times, I’ll start the case by removing a little bit more of that posterior capsule, just so my view is a little bit better during the surgery. Okay. So we’re gonna zoom in again. Try to get a nice view for everybody. She’s had some traction in here. You can see how tight this vitreous is, and how opaque. She’s had a history of retinal tearing in this eye. (inaudible) many years ago. When she had the retinal detachment. In cases like this, we expect more often an epiretinal membrane. Let’s focus that a little bit more. Now I zoomed in more. And that’s just some vitreous opacities that have been around here. But I’ve found a case like this more often to be a more difficult macular hole. I’ve got more freedom of movement in the eye, because she’s pseudophakic. In terms of not having to worry about the lens. And certainly in a case like this, with a history of retinal detachment in one eye, being lasered in this eye, we’re gonna want to take a really cautious look around the eye at the end of the case. To make sure we’re not leaving any retinal tears untreated at the end. So kind of an abnormal vitreous contraction there at the vitreous base, in multiple spots. Very stiff. I’m gonna switch hands and finish this vitrectomy right now. I can see all those abnormal areas. We’re gonna try and release a lot of that traction. Lower our risk of getting into trouble later in the case. The lens implant is a little loose. Some of you may have noticed it moving around too. So we’re gonna be careful not to jostle that too much. And turn this into a dislocated IOL case. That could be our next lecture, Lawrence. Dislocated IOL repair. We’ll have to think about that. Okay. Let’s take — look here down at the macula. You can see there’s a glistening on the macula in this case. There’s like an epiretinal membrane. And let’s see what we’ve got. We’re gonna stain it with the IC-Green dye. Same techniques as before. I’ve got a 25-gauge needle here. Hooked up to a 1 cc syringe of IC-Green dye. That Michael is gonna skillfully inject for me, when I’m down near the surface of the macula. There we go. And again, I’m taking care to avoid the center of the macula. He kind of just bounces that on there in little pulses. And we let it bounce off the macula and back up. No problem. And now we’re gonna aspirate that out. And it’s sometimes a little tough to tell what type of staining you have, until you get down there and make a little nick. But you can see it here. The green in places that it’s stained, versus the unstained areas. The contrast is very helpful. So we’re gonna move on to our contact lens. Get a more magnified view of the retina, and use our pick to elevate an edge. Now, sometimes you can peel through the wide field systems. Certainly the non-contact lenses. It’s just not how we’re set up here. But I know those systems do exist. Whatever works to get you the view you need. To get the work done. So we’ll try and get a little edge going here. The question was: In the last intermission there, do you always start nasally? My answer was… Well, usually. What’s happening here is… The IC-Green dye does not stain ERM that well. And we have an ERM here. So I know I’m deep enough because the retina is moving with me. And a little bit of retinal movement is fine. Drusen changes up here. What we’re trying to do is get the ERM up. Or at least started.. The forceps there. So you’re not getting the color change. But we’re gonna try to get the ERM up first. And then come back and get the ILM. See that retina’s moving? We don’t want to pull against that. She’s gonna bleed a little too much. So what we do is come over and try another spot. Same there. We’re gonna let go. We’re gonna restain it, is what we’re gonna do. So we’re getting to the point where we’re struggling getting an edge to the ILM or the ERM. So you come down and you make a few spots like that, to start. And then you come back and restain those, because quite often then, you’ll have a better view. We will see. There you go. Again, taking care not to inject any of the IC-Green dye into the hole. Okay. Take the forceps again. And there’s a little flap there. Take a look at what we’ve got here. Still not getting great visualization. How about over here, Mike? What do you think? Yeah. Right. So we’re gonna come over here, where it’s a little more green. A little pinch and peel technique. Using a little indirect lighting. Sometimes you don’t want to shine the light directly on. You can shine the light away. Little bleeding spots are not… Sometimes the vitrector can do a really nice job here. You can see how gossamer-like, web-like this epiretinal tissue is. That’s what we’re gonna do. We’re gonna switch to the vitrector. It’s a very stretchy, sticky type ERM, over this ILM. And it’ll be nice to get under it and just grab the ILM. It just you snapped off again, I think. You can get under this sticky membrane and not have to pull on it so much as just try to get the tissue under it. So we’re gonna stain again. Okay. Hang on a second. There you go. Go ahead. So we’re gonna — I hope to see a little better staining now. How are you doing, Jane? Are you okay? Okay. Everything is going fine. You’re doing just fine. Hang on. I’ll try and keep you guys under high zoom. Okay. So we’re using the vitrector here. Move some of the edges farther out. So we won’t have to peel so close to the fovea. So this is the exact macula that won’t close without this perifoveal peeling work. A little bleeding there. A little petechial bleeding. We’re not worried about that. And now I’m a little… Perplexed about where I want to go. I can see some green up here. And we’re gonna probably just restain it. Again. No needle. One moment. There you go. Again. I think we’re gonna see a little more sharp relief here, in contrast. What we’re looking at here is this macular hole. There’s a little… Very tight. The entire retina is getting a little boggy and edematous, from the peeling of the tight ERM. That’s working against us a little bit too. Okay. Let me have the forceps there. So we started that flap around the edge of the hole. It’s kind of like not where I want to grab, normally. For obvious reasons. You have the vitrector. But that was the flap that was elevated by ILM. There’s still ERM over the nasal half, on top of that. That’s what’s making it not peel around. So I’m hoping with the grasp of the vitrector… Is irrigation in the 40s, Mike? I don’t want to do that. So that ERM is coming off nasally now. But it’s still gonna give us trouble, in that we can’t see the ILM under it. So we’re still gonna stain again. Then I think we’ll have a nice view to finish the case. So what’s nice about this one is you’ve got kind of a really straightforward easy macular hole in the first case. Then you get this more complicated case. The second time around. Go ahead. But we’re gonna get there. Patience is the key. The things you worry about when the case gets a little longer is like light toxicity issues. But we’re nowhere near that concern. It’s just not quite as straightforward as the first case. There’s a nice — at least for the ILM, you can see how it stains so nicely when it’s no longer covered. Sometimes even grabbing out here, if you can take it around, you know that you’re off the edge of the hole. You can see how this is sustaining up here now, very nicely. The vitrector — may just use this to grab the ILM. That looked just about like it. Now you can see the retina has kind of turned white around the hole. Just looking to see if there’s any more attachment of ILM to the edge of the hole. What do you think, Mike? I think it went 360. Can I have the forceps there? I’ll take a couple more pulls with the forceps. So the hard thing in a case like this is getting it started. Once you get it started, you have something to work with. It takes a little bit of time, but you can get it around. But the start is the key. You’ve got to find something you can start with. Quite typically. It can be a little difficult. Nothing there. Clean the forceps a little bit with the light pipe. Sometimes I do that. That’s about it. We look for the edges of the peel. About there to there to there. To there. It swings way out here up top. And then we have the traction off the macular hole. Again, if you’re not certain, you can stain one more time. We’re not gonna do that. But you could even stain one more time. There’s really no limit to the amount of times you can bounce the IC-Green around in the eye. Other than — I would say — as long as you’re not hitting the hole itself. Okay? Just take a look around the periphery and we’ll see where we’re at. Very good. Hang on one second. Because I’m pretty… So we talked a little bit about the abnormal vitreous base. And tears and the little PVR-like reaction in the vitreous here. But no new tears are visible. Those are all well treated. The traction we severed here at the start of the case, this vitreous is contracted at the vitreous base, but not creating new tears. So instead of getting in here and shaving this, as long as there’s not a tear there, and this has been going on for years, I’m not inclined to try to get in there and fix something that’s not really broke. If there’s no tears, you don’t have to get too exact. Now, here’s a tear. This is an old one. Right? So maybe I’ll add some laser to these couple tears. Why don’t we… I want to get the laser probe out. A couple old tears right here are side by side. No retinal detachment. We don’t have to get too fancy. We’re just gonna put some barrier laser around that, since we disrupted the vitreous. I don’t want it to be a problem later. Another one up here. Again, right here are some more tears. Again, old tears. You can tell by the rolled edges. Nothing acute. No bleeding. I think we can do that all with the laser. Michael will depress for me. So macular holes are really a function of abnormal vitreomacular traction. So it doesn’t take too much of a leap in logic to realize, when the vitreous is pulling on the macula abnormally, it will quite often pull other places abnormally, like in this eye. Creating all these old retinal tears. So we’re gonna get these too. What have you got there for me? Okay. So we’re going to… And I’ll get these little fragments that have been around in the eye later, at the end, when we do the air-fluid exchange. What we’re gonna try and do is laser these tear sites. We have a directional laser probe. 25 gauge. That’s gonna help us reach these areas. By the way, this is how it looks. So I can adjust that. Move that extended probe a little bit. Try and get out to our regions that were of interest. Have Mike depress superior. And there he is. Very good. Always helps to have someone with you when you need that third hand. Whatever it may be. So there’s a little tear. Right? Nicely surrounded. Mike is moving with me. I’m moving less than he is right now, to get me into the right spot. He knows where I’m going. He knows what I’m trying to do. After doing this years together. It’s certainly very helpful. Do the same thing here. Again, I’m not even sure that these would even detach at this point. They’ve been here for a while. So once you get in there and move the vitreous around, and you’ve got open tears that are untreated or unscarred-down, no demarcation, I think the safer thing to do is always just to treat them. These are hard to find in the clinic because of all the posterior capsule opacity. It’s always nice to know all (inaudible) case. Maybe treating it ahead of time, even. Just keep going your way. And not too much over here. This is all away from here. Correct? Right? Yeah. So maybe we’ll cut this little band yet. Do you have the vitrector? Hang on one second. Don’t depress. We can just cut bands. Depress that. Nasally. So what we want to do here is just relieve traction. Not trying to shave the whole base down. But we can just incise it so that it’s not pulling around circumferentially like that. Better off. Very nice. Nicely done. Turning into more of an RD case than a macular hole case, but like I said, they are related. And we’re in pretty good shape. Okay. I think we lasered that too. Let’s see. You want to press that in? A little farther back. I’ll come around and laser that and this. Okay. Yep. All righty. Here we go. Send the probe out a little bit. A little lattice-like changes there. We’re gonna laser those. That’s what we’re doing. That all looks good. More lattice. Gonna laser that. I’m just lasering everything that’s suspicious, including the lattice areas, like this. That had all the traction. And keep coming towards you. Just go topside. Yeah. Right there. That’s the one I wanted. Something a little more posterior than that. Can you — there you go. Behind it. Right? If you come out, I can probably get that view. I can. Very good. Let’s go back up top. Those we already got. Come back towards you. Okay. Let’s go to the other side. I think. So we worked around our nasal side there. Now we’re gonna go to the temporal side. Pick that up for me. We didn’t see as much temporally, so that’s gonna be a little easier anyhow. Access is always easier temporal. Yep. Those are done. If the view’s not great, for those watching — it’s getting a little tougher for us too. Not surprising. The longer the case. Sometimes we lose our view a little bit. Okay. I think we’re pretty good there. I got it. I got it. We’re fine. Let’s go this way. And… A couple of spots of lattice and trigonal lattice. But no tears. And we’re almost done here with the lasering. So unfortunately, when it comes to macular holes, a lot of them — I would say it seems like a third or so — are the more complex cases. Not necessarily this complex. But probably only a half are as easy as the first one you saw. So this is a good demonstration of how things can go. I’m gonna cut a little more traction down here below, Mike, under depression. We’re gonna cut this band. Okay. Can you depress that for me? Let’s see what shows up. Mike’s gonna depress inferior for me. There we go. Again, he cut the bands. You kind of see them snap. And that’s really what you want to do. You don’t have to get the vitreous completely flat or shaved all the way down, but just relieve the traction. So the choice of gas in this eye, C3F8 or SF6 — we’re gonna go with C3F8. All the lasering, extra tears, the bubble lasting longer is never a bad thing in an eye like this. We’re good. We’ll go to air and we’ll use 15% C3F8. This is, again, opposite from the first case. If you did not peel the macular tissue, and just took out the vitreous and put in a gas bubble, your chance of closing this hole is not so great. We used to do that when we were first starting out. People used to not aggressively peel the macula. In a case like this, leaving that traction behind on edge to the hole, would — the view is a little odd here through the IOL. We’re doing just fine, Mike. We’re doing fine. Yeah. Go ahead. So we used to have a case where you didn’t peel the epiretinal eye. Along with cases that would not go well. In terms of closing the hole. Probably less than half the time, even. Mike is getting the gas. I’m just gonna drain one more time from this side. IOL is giving us a little trouble on the view. But we’re getting it. And I’m sure it’s not projecting great for streaming. But we are set! So now we’re gonna pull one of the cannulas again. I’m gonna press that flat. How are you doing, Jane? Are you doing okay? We put more laser in the eye. We found some old retinal tears. Nothing new, but old ones. I don’t want to leave those untreated. Okay. So there you go. We’re gonna fix that all at the same time. We’re gonna put a gas bubble in your eye here. Have you hold your head down for two days again. Like we talked about before surgery. Face down positioning during the day for two days. And then at night, we’re gonna let you — I think she can go to either side still — at night, we’re gonna do either side for one week. Okay? You can pump me up a little bit more. Keep it coming. And that’s good. There we go. A little leak there. Hang on. With a leak like this, what we’ll do is — a little bit more gas, Mike. What we’ll do is give it… (inaudible) before we leave. Again, a little bit more. There we go. A little subconj gas. We’ll press some of that out, just so we can see what the wounds are doing. The subconj gas will almost always go away in a day. That’s not really a problem. But just to help see the wounds that we’re working on here, before we leave the room, we want to see how things look. So I’ll just kind of push the gas out. And there we go. Very good. We’re gonna stop there. Jane, you did a great job. Thanks for holding still and being so patient. The case went well. And I expect that macular hole to close up very nicely. Okay? So that pretty much concludes the demonstration of the macular hole surgery. You know, kind of a straightforward, typical case, basic case, and one more complex, related to old retinal tears and vitreous contraction and vitreous fibrosis. So it kind of gave you the idea of — easy beginner case, more complex case. I think that’s a nice mix. Thanks, everyone, for attending. I don’t think there’s anything more to do. Any questions? Oh, sure. We can take questions. Sure. So if you have a few questions here: For the punch and peel technique, to initiate the flap, do you pick with the edge of the forceps or from the center? I tend to pick from the center. So I’ll kind of take those forceps and use just the center to go down, make an indentation in the retinal surface, when I see an indentation in the retinal surface, I close the forceps and pull up and just pick. And you almost always get a little petechial bleeding when you do that, but that’s okay. Next question is from Murtaza. For ILM peel, which forceps do you use? I use a Bausch and Lomb. It was a Synergetics ILM peeling forceps. Now Bausch and Lomb has bought Synergetics. So I think it’s the Bausch and Lomb ILM reusable forceps. A question from Murtaza. Also, please tell us about your experience about the role of serum plasmin in the closure of a macular hole. Serum plasmin can relieve — you know, there’s ocriplasmin, which is a bioengineered plasmin, and that’s Jetrea. Serum plasmin — people have talked about putting a few drops in the hole itself. No, that’s concentrated platelets. Serum plasmin I don’t use. That’s something that would compete, I believe, against the pharmacological product that ThromboGenics makes, called Jetrea. And a question from Vignesh. Have you tried using Finesse Loop for ILM peeling? How do you compare it with your method? Vignesh, I have not used the ILM loop, other than when it first came out. I demoed it with Alcon, and I think it’s a fine device and used by a lot of people, and I can’t really say compare and contrast. I don’t use it enough. Or I have not used it, hardly at all. It seems to work for a lot of people. It’s one extra instrument. So I try to limit my instrumentation as much as possible. And keep things as simple as possible. Question from Winston, again. In case of macular hole retinal detachment, do you prefer to peel the ILM under perfluoron or under air? I’ve done both. I prefer to peel under perfluoron. So if I’m gonna peel up a macular hole, in the case of retinal detachment, I prefer to peel under perfluoron. I’ve also peeled it without either. I just peeled it in detached retina. That can be a bit of a trick. Because you can only peel away from the optic nerve. Where there’s tension. So you can peel against the optic nerve. You can’t really pull the other direction, because it tends to want to pull too hard in the periphery. So I’ve done either peeling of the ILM in detached retina or under perfluoron, which I think is probably the simpler method, though the ILM flap is very flat under the perfluoron, and you have to kind of get used to those techniques. Question from Luis. And his question is: I’ve enjoyed your easy flow and explanations. I learned a lot. Oh, you’re very welcome, Luis. I’ve enjoyed doing this, this morning. It’s always a pleasure to work with Lawrence and the Cybersight team and Orbis in general. And I’m glad to share a few things that I’ve picked up over the years, and I hope that it’s been beneficial to those who have watched. Thanks for your participation. Great questions, everybody. Thanks.