This video demonstrates surgery in a patient with traumatic macular hole. The hyaloid was detached from the hole and it was probably a grade 4 macular hole. The hyaloid was removed and the ILM was peeled after staining it with brilliant blue dye. Fluid air exchange was done at the end of the surgery using C3F8.
Surgery location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Surgeon: Dr. Manish Nagpal, Retina Foundation & Eye Research Centre, Ahmedabad, India
Dr. Manish Nagpal: Yep, this is okay. So, for macular hole, traumatic macular hole. Macular hole is basically split in a small opening that takes place right at the fore there. And the iris is detached from the hole. So, it’s probably a grade four hole. Grade one to four of the hole that we classify based on grade four, where the highlight has already moved away from the hole. And it’s a traumatic one.
So, I’m about to start. The first step is to put a cannula. An infusion cannula. We measure by caliper. This is a phakic eye, so we do about four. If it’s a phakic eye or a pseudo phakic, we do 3.5. So, you can see this is the infusion. I’m plugging it in the conulid. It will stay there and supply infusion during the case.
Is that 25-gauge?
Yeah. This is 25-gauge. Yes. So, now I’m putting the other one. We go in and come out from there. This is the port from which I will use my cutter or a forcep. And I will make the third port from where the illumination will go. So, now we have our three ports ready and we are ready to start.
So, this is the illuminator, the light which will go into this port. This is a white fill lens that I use. So, what you see floating up is the hyaloid. You see a floating membrane? Okay. Now I’ve inserted my cutter. And I’m moving it now. So, this is the hyaloid. What do you see there? So, I’m splitting that hyaloid. Can you see them?
So, from the center they are already detached. So, now that it’s detached, I cut it and then I explore it to the periphery as much it can easily go. So, here we don’t need to identify it with the hyaloid. Normally we cannot see it as clearly. But this is a traumatic case. And so, it’s been there for a while. And so, you can see the hyaloid very easily.
Otherwise, like I was showing you in the morning in some of the surgical cases we use the dye to look at the vitreous. I’m just removing some of the residual hyaloid from the edges.
Okay. So, we have removed from the vitreous from the central area and trimmed up to, like, the equator. In this we don’t go right up to the side because it’s a young phakic person with a clear lens. We don’t want to disturb his lens. So, now we will see the eye. So, as you can see, we will are inject the dye. Do you see a blue dye coming? Aim towards the macula and inject it.
What kind of dye? Can you explain for news
Yes. This is the brilliant blue. Which takes the stain of the ILM quite well. I’m going to do a very fine field. So, I need a lot more magnification than what I was using. I’m switching the lens to a plain old lens. With the trephine that used to be there, we had to wait a lot longer. With brilliant blue, what I do is — as I said, I switched from the white free lens to the other lens. It’s just that much of a waiting time that I give. I go back in and we are ready to remove. So, we don’t have to wait much more beyond that.
With brilliant blue that we use, we don’t need to go into air-fluid exchange. With trephine blue, it used to be that we had to — because it doesn’t stain very well, so, we had to go for the air-fluid exchange and that would — air would press the dye and then stain it better. But with this we don’t have to. As you saw, I just injected into fluid. And now I’m just aspirating the residual floating dye. So, I’ll just let it clear. And then we’ll go and peel.
And you see the wrinkling holes of the ILM? Okay. So, now this is an ILM-peeling forceps. Do you see I’m pinching and I’m trying to get a lock on the ILM which is on top of the retina. So, our aim is to move it all around the circumference. This is just like the capsular axis you do for the surgery, the same way that we do it.
So, we have to make sure that we circumferentially finish the peel. This whole thing has come off. It’s actually thicker than an eye line. In some patients you find this possibly a small membrane. As soon as I remove this, I’ll just put the stain again and check for — if we need to peel anymore or not.So, we have peel from this whole circumference that you see. Because it had a thickish sheen, I’ll just stain once again to double check that we are not missing anything in the central area.
This is brilliant blue, correct
This is brilliant blue, yes. Now, I will just aspirate the residual one. And now you will see the edges much better than what you saw before. Because there was some tissue on top of it, maybe, an epi, or a compliment, which was not allowing the dye to fully take the stain. Now that we have done one round of that peeling, you can see this edge here. So, I’ll just enlarge the radius of that circumference of that peel now.
So, this way we can enlarge the radius. What I typically do is about 1.5 to 2 decimeters of the peel what we do. Some surgeons like it still wider, some — if there’s a re-surgery, some people like to do it wider. But as of this surgery, I think a 1.5 decimeters is fine. As we go to the periphery, we still have this issue that you saw here. Which is still there as a membrane. We need to talk to the cutter.
But first we’ll first finish the eyelid peel. Okay. So, now we have this radius of 1.5 decimeter. And this has loosened up the margin of the whole of it. Previously it was very rigid. Now it’s slightly lax, which was the purpose of all of this peeling that we do. So, that the elasticity of the hole can be the worst — oh. There’s a small tag which I touched which is bleeding. Can we — we just raise the pressure to stop it. 60? Okay. So, this will stop in a second.You’re going to raise the intraocular pressure?
We already do. So, it instantly stops to increase. You just gently aspirate that. Wait for a few seconds and that should clear up. This is that membrane which had to come off which will lead up.
Okay. Now, we’ll change the lens to see the wider view and the air-fluid exchange. So the peeling part is over. Yes, please?
The staining brilliant with the —
With the locus blood, do you mean? Yeah, in the past, people were using it. But now with these dyes one doesn’t really need outer locus blood. In fact, in the very beginning, people used the blood for the BGF meter factors which was to promote the closure of the hole. But a lot of studies were done that did not find any difference between the cases where they used the blood or where no blood was used.
So, now the blood is not used, actually.
What is the minimum diameter of the ILM?
Typically we peel 1.5 decimeters. But as I said, it is a little variable factor. Some surgeons like it more, and some people would be. So, I’m now switching to air. You can see bubbles coming in. It will replace the fluid which is there.
That is the purpose. And at the end we will inject gas. So, I’m going to the disk and gently aspirating. So, as you can see, the air tends to come — with the buoyancy, it goes up and then slowly fills from the top to the bottom. And I’ll keep looking down at the disk to see a complete drying of that — of the eye. So, now the whole fluid has gone from there. I’ll just crossly check the periphery. You can see a rim of slime which is there. I’ll just cut it while seeing it under the air.
And then go back and aspirate. And spilled a little fluid over the hole, but not inside the hole. Showing you the science of shrinking. If it’s — this is a grade four hole. If it was a grade two or three, sometimes it can also show up in point closure in such a thing. But grade four sometimes will not close because it’s been there for a longer period. There is a bit of redundancy. And, yeah. His coma was in 1997. So you can imagine how many years this may have formed. So, let’s hope that if it doesn’t close fully, it will at least reduce the amount of fluid circumference and reduce the size — it will become smaller and that will benefit the patient.
But traumatic holes can sometimes close better also. Because they’re younger patients with better healing capabilities. So, this is where we closed. You can see the rim of the eyelid which is peeled, the colored part versus the non-colored part in the center is the end point of the surgery. Now, we’ll remove the cannulas and inject gas before that. Okay. So I just put a — here —
Set of the —
This is C3FA.
You use C3FA, how much will you keep that down?
About five to six hours for the first week. And maybe a couple of hours for the next week.
Can the patient travel?
Yes. The patient can travel, but not in air. So, we are flushing the air out and putting the gas is the whole idea. Our incision is off at this too, yeah. Can you start the infusion at one-five? Okay. Now, we’ll take off the cannulas. So, the way we take it off, so that we are more likely to have a good, suture-less closure, I just remove it and instantly put something on it like this and keep it pressed for 10, 15 seconds. This louse the wound to get back its elasticity which was being opened up by the cannula forcibly. So, these 10 seconds of pressure and massage allowed it to heal. Now, you can see a small snip-like dot there. That’s all you can see. It’s not leaking or anything. The same thing we’ll do in this port.
You can see closely, you’ll see a small slit. But we have to see if air comes out or not. It looks fine. And now the last port. Again, the same way. You keep pressure on that. So, we just put saline. Also, it helps us check if there’s an open air bubble, the saline will pick it up much better. And it also cleans up any debris lying on top. And at the end, put a sub conj injection in the intranasal cordon. Because this is the only cordon where we don’t make a port because we don’t want it to totally go inside the eye. So, it’s in this cordon that we put it and then spread the rest of it on the surface. So, that’s the end of it. Thank you, everyone.