Lecture: Retinal Detachment

Retinal detachment is one of the most common conditions operated by vitreo retinal surgeons. Techniques and technology have both evolved over the years. This webinar will include step-by-step, video-based examples of simple-to-complex procedures in relation to vitrectomy for retinal detachment and Proliferative Vitreoretinopathy (PVR).

Lecturer: Dr. Manish Nagpal, Vitreo Retinal Consultant, India


DR NAGPAL: Hello, everyone. I’m Dr. Manish Nagpal. It’s a great pleasure to be with all of you here. It’s always a pleasure to collaborate with Orbis, and reach out to all of you across so many different countries. Today I’m going to be talking about retinal detachment and PVR, its management, surgical approaches, the technical aspects, as well as the various advances which take place over the years in how we manage these situations. So when we talk of retinal detachment, it occurs in many different types, in terms of the location, the size, bullous, non-bullous, macula on, macula off, and there’s a lot of different aspects to it. And the various management aspects are scleral buckling, which has been there as a gold standard for the longest time ever. And then pneumoretinopexy, which works in various cases where there is a single break with a bullous element, with no other breaks existing inferiorly, and of course, the most common approach today as we stand is vitrectomy. I’ll take you through these approaches, and first of all we’ll discuss vitrectomy, because that’s what is most commonly done today. There’s a choice of gauges with which we operate all these cases. And for me, the personal preferred choice is 25 gauge, because it’s a great balance between what we used to do, in a 20 gauge surgery in the past, and now you have almost up to 27 gauge, but the instrumentation, the stiffness of the instruments, the way we can manage oil injections, removals, I think it’s a good balance between large gauge and the smallest gauge available, as of today. But as advances take place, we move from 20, 23, 25, a lot of people use 27, so I guess as the technology improves, maybe the smallest would always become the best, at some point of time. So when we manage a case of detachment with vitrectomy, the first thing is to remove the vitreous. And this is the case of a detachment where there is a preexisting hyaloid. The detachment has already taken place. Because you could have a situation where the hyaloid is still stuck. Both are managed differently. This is an example of how we start the vitrectomy. The hyaloid is not attached here. All we do is remove the vitreous from all the areas, 360 degrees. This is vitreous being removed from near the break. In this case, we don’t have to go and specially remove the hyaloid. As against this situation, which you see here, where the hyaloid is well stuck on the mobile retina, we have stained it with triamcinolone, so that it makes it easy for us to identify the plane, and so that we can see the vitreous better. Also see the plane of the retina. And it avoids an inadvertent touch of the retina, an iatrogenic break, and also make sure that we know how it is detaching, peeling from the retina, to ensure that we do a complete PVD properly. And once the retina is mobile, it can become a little difficult. Because as we pull the vitreous and it now also moves — so one has to constantly engage the vitreous and move it tangentially, in a way that the retina does not interfere with that removal process. So this is a classic example of how we remove in an eye which has a mobile retina with the attached hyaloid. When we remove vitreous, sometimes in the phakic eyes with clear lenses, it’s difficult to go to the periphery. And in some of these cases, we would use indentation from outside, so that we don’t have to go as much to the periphery with the shaft of the instruments touching the lens. So we try to bring the periphery closer to the center, in order to avoid a lens touch. So if you have a clear lens, and you have a detachment, and you want to remove the peripheral vitreous, as far as you can, without touching the lens, this is a great way to do it. Of course, you may need to have an assistant indenting for you, or you could have a chandelier light, as in this case, so that you can yourself use your other hand to indent with an assistant indenting for you. So it is your choice in these cases. This is a pre and postoperative view of the patient I showed you just before this. So once we remove the vitreous, and the eye is free of the vitreous, we do an air-fluid exchange. This brings up a bulla. As you can see, I’ll go back and show this to you again. You brought in air, the fluid is gone, and the bulla has come up. Because all the fluid has pushed under the retinal surface to the existing breaks. Which in this case you see superiorly. And once that happens, we go to the break and the endodrainage is done. You can do it with the cutter itself, because they are pretty fine these days, or you could use a soft tip. Whatever modality. You see the reflection of the retina going back, as soon as the fluid goes away and the retina goes back into its place. Now, at times, what happens is that, after the air-fluid exchange, the fluid collects posteriorly, and the break is very anterior. In that case, I use perfluorocarbon to push this fluid peripherally. And you can see as the perfluorocarbon has pushed the fluid to the peripheral part, I can drain easily from the break. Otherwise I need to make a separate retinotomy posteriorly to drain this fluid. So PFCL is extremely useful for such a situation. This is again to emphasize on the same situation — you’re doing the vitrectomy, you see a temporal detachment with a temporal break, and at the end of air-fluid exchange, you put perfluorocarbon and push the fluid, and after that, flatten the retina with endodrainage and endolaser. Now, if the macula is on, you want to make sure it doesn’t detach. So in that case, I use perfluorocarbon before doing the air-fluid exchange. So once you do a good vitrectomy, cleaned up, don’t do an air-fluid exchange in such cases. Put perfluorocarbon up to the equator or up to the edges of the existing break, so that much retina remains stable. And I’ll show that to you again. I’m injecting perfluorocarbon so that the macula remains attached, throughout the case, and we never give it a chance to be detached inadvertently, because we don’t want to disturb those crucial aspects of the retinal architecture. Due to these exchanges. And once again, we’ve pushed the fluid to the periphery. And then we are draining from those existing inferior breaks in this case. So retina will flatten without the macula ever getting detached in such a case. So it’s very important to recognize these differences, in these cases. And then of course we do endolaser to most of these cases, once you finish the surgery. Once you finish the vitrectomy, endodrainage. Retina is flat. You do a good laser, as retinopexy, to end the case. Sometimes I use cryo. If the break is extremely peripheral, small, superior, 10 to 1 o’clock, a small break can be difficult to reach with the laser at times. I pick up my cryo, indent it, and you can see very easily how the cryo comes on this horseshoe tail, which is sometimes difficult to visualize in myopic eyes. So I pick up a cryo at times. This is always a good option to keep. Of course, endolaser is there. Some people can also use another laser. But these are options to do retinopexy, once you’ve finished that aspect of the situation. A couple of cases to show you some additional aspects. This case has a posterior break, as you can see near the cutter, and also a macular hole. So in this case, we peel the ILM, and as you can see, I’ve stained it with brilliant blue, I’m picking it up with an ILM forceps, and gradually the ILM gets peeled. Sometimes with detached retina, one has to be careful, and always move the forceps from the disc to away, instead of coming towards the disc. Because otherwise the mobile retina will keep pulling it. Then of course, I’ll put in perfluorocarbon to flatten the posterior pole, just like I showed you in the previous cases, so the fluid gets pushed to the break, and then drain it from the break, and after that, do an endolaser. You can see the ILM peel in the central area in this case, and then put gas at the end of surgery. But this is a case with large ragged tears with everted edges. As you can see. In the superior break. We’re doing a vitrectomy at this stage to clear up and loosen up the retina from all aspects. You can also see vitreous hemorrhage, resolving inferiorly, admixed with the vitreous. So our first step is to clean up everything. Because there’s a bridging vessel, if it gets cut during the vitrectomy, I don’t want a bleeder starting, and then I put perfluorocarbon to stabilize the posterior pole. I bring it up gradually to the edges of the break, and go on top of it also, because I know there’s no traction here, and gradually will allow me to passively flatten this retina quite well. And then the ragged edges I’m flattening with an instrument we call the massager. We use it for macular holes, typically, but I also use it for these types of holes, to move over the retinal surface and help bring back those folds, and flatten it as far as possible in this situation. So the retina looks well flat. These maneuvers are best done by zooming in. So that you can see the details better. Rather than working on a low magnification. But of course, every case we do is on a wide field imaging, wide field viewing, so you can see the best all around. After that, do endolaser. These are ragged tears, very prone to PVR, but we’ve removed the vitreous as far as possible, to give them the best chance of remaining flat postoperatively. This is again something similar. That you can see mobile retina, large tears, superiorly, and some other smaller tears inferiorly. So these multiple tears will happen with acute occurrence of PVD in a patient, that will pull open multiple tears like these. You can see we’re removing the vitreous carefully. Removing it from the edges of the break, as far as possible. And then once we are sure that the vitreous is gone, we flatten the posterior pole. I always like to use perfluorocarbon. I’m repeating it again and again, because it’s a great passive tool, and I feel we should use it for a lot of our cases as an adjunct. It also allows you to keep the posterior pole really stable, while you work in the periphery. And then of course, you do the same thing, you drain from the periphery, from these breaks. There are multiple lattices here, which you can see, and then of course do a good laser to these areas at the end of surgery. In multiple tears, I always like to do a 360 laser, and most of the time, if there are multiple tears, I would put oil and remove it at 3 to 4 months, 5 months, based on how the eye is behaving. Now let me take you to the other aspect of the scleral buckling, which is done for certain kinds of cases. That used to be the gold standard for all retinal detachment surgeries in the past. But now is a lost art. I don’t think buckling will survive another 5, 7, 10 years, because it’s a dying art. We are fortunate to have learned it in our time, and we still practice it in a certain number of our cases, but all of us are getting more and more comfortable with vitrectomy now, just because of the way the technology, the viewing, everything is improving. So what we did is that, to improve the viewing, and the ability to teach, we combined the benefits of viewing with vitrectomy-based lenses, and do the classic scleral buckling. So you can see this is the Volk SSV lenses that I use for contact with wide field view, you can also use non-contact viewing, whatever BIOM or lenses that you use, and do classic scleral buckling. We were one of the first few people to bring this concept. I talked about it at the Vail meeting in 2013, initially, and slowly it has become quite popular, especially with teaching-based hospitals, where one has to teach scleral buckling, as it’s getting to be a dying art nowadays. So what we do is classically put a chandelier light, as you can see here. We opened the eye, we’ve taken the muscles, just like you would do for classic buckling, put a chandelier, and this is the view that you would get. Because the view is the same as what you would get with a vitrectomy. So I’ll show you a couple of clips. This is a case of detachment. Myopic detachment. Inferiorly extending temporal, the break is temporal, you can see that we’re doing the indentation, this is just like how you would see except the view is much better, more magnified. You can zoom in, we’re doing cryo to that area, after that, you localize the break and take the sutures, pass the sutures externally, after localizing. We use a sponge. What we prefer — the newer drainage with the needle. You can see the fluid coming out from the inferotemporal area, which we localized. And once the fluid has come out, we check inside, and we can see the retina is flat inside. And then we’ve tightened the buckle, and then the buckle effect is seen. So this is a classic buckling procedure, except that you see it better. It’s great for teaching purposes. So this is just a sequential… Pictures of a case of how you would do a localized cryo, and after that, you drain… You localize and then take a suture, externally. After that, you drain, and then you see the buckle effect. So this is how we’ve been using the combination of advantage of viewing systems of vitrectomy with a classic buckling surgery. One more clip to show you inferior detachment with peripheral breaks. Which is a classic indication for buckling. These are more often young people with traumatic origins, at times. And so you can see that you zoom in, you can see the break very well, you see the cryo coming in, the reaction as it comes in, and then it thaws and completes the reaction over the break. So you can zoom in, and appreciate it much better than with direct. It’s easier to teach. We are localizing, it’s diathermy, with the needle, you see the fluid coming out, viscous in nature, because of the longstanding nature of a lot of these inferior detachments. You’re clearing up the fluid externally, keep the pressure with the back of the forceps, and once you’re satisfied with the drainage, you look inside and you can see a very good buckle effect, which has come, and the cryo holes are seen on top — the buckle effect is seen on top of them. This is a desirable buckle. So we published data on this initially in 2013, and then of course in Retina Today, as well as the Retina Times, and a lot of institutes have started following this. And they like the idea of using it, so that they can teach it much more easily to the fellows. Because they can see how you localize, how you do cryo, how you do all the steps. Which becomes a great challenge. So everything is about visualization, as far as settling retina is concerned. Whether it’s scleral buckling or vitrectomy, you need to make sure your view is good. As far as the buckling is concerned, it would be very easy with a surgeon, comfortable with vitrectomy-based visualization, to adapt to this modality, in case there is an indication for buckling. Better visualization with zooming capabilities and ability to transmit/record surgery — all that makes it a great tool for teaching, in short. Then let me come to the PVR aspect, the proliferative vitreoretinopathy. Which is a complication in a lot of these cases. Maybe you see a patient with existing PVR, a fresh detachment, you operate, and it fails because of PVR, or you’ve done a successful surgery, and the patient comes back with PVR and it leads to the failure of that surgery. There could be many aspects to the PVR area. And it’s something that we don’t know everything about it, in terms of prevention. But we know over a period of time, a lot of techniques, a lot of instrumentation is developed by which one can tackle it much more atraumatically, much more delicately, and to ensure that you can settle the retina again, after the occurrence of PVR. We’ve been contributing to the Ryan’s Retina, the 5th edition, 6th edition, you see here, and now there’s an ongoing process of the 7th edition going on, where we’ve updated the chapter, along with various surgical videos, which can be accessed on this as well. Of which some of them I’ll be showing you in the next few slides. So PVR can be something as simple as a macular pucker. Once the retina is detached, nature tries to proliferate cells on top of it, under it, inside it, in all layers, trying its best to attach it. But in that process, it is not able to control its proliferation, and that’s what leads to these proliferations and membranes. So in this case, there is a detachment with a pucker. We’ve removed the pucker, and now we’ve stained with brilliant blue, so that we can remove the ILM. This ILM removal in cases of puckers and retinal detachment with puckers is basically aimed at trying to reduce the recurrence incidence. Also, the scaffold on which the pucker grows back again — you have removed it. And also released the contraction to be more level. So it’s always a good idea to do a ILM peeling with detachments with a pucker. There are surgeons who do ILM peeling for all detachments. I’ll do it if I see a frank pucker, which I am removed, or an ill-formed pucker, I might stain and remove these areas of ILM. But not for regular retinal detachment, which does not have a pucker. We don’t have data yet to say that is useful for regular retinal detachments. At this stage, I would recommend using it for stages where there is a pucker. So sometimes ILM peeling can be difficult. In this case, we managed it without the PFCL, but if you feel it’s challenging during the procedure, you can put perfluorocarbon. I keep it as a backup. In some cases, I am able to remove it and don’t bother in it. In some cases, I would put perfluorocarbon and peel under it. In this case, we finally settled it, and then drain, and then after that, do endolaser to that area. In this situation. This is again another case. Here you don’t see a well formed pucker. This is what I was telling you about. You see radiating folds, you know there is something which is forming under it. But it’s not a classic pucker, which you saw in the previous case. So here you’re better off staining and removing so that whatever element of cells are proliferating over the surface of retina will get removed once you remove the ILM. So here I’m extending it with perfluorocarbon’s help. Because I feel there is a contraction which is extending beyond the macular area, a bit more temporal, so that the overall contraction of these folds relaxes in this case. But otherwise, typically, I would stick to the macular area. As far as the peeling is concerned in these cases. So the pucker is removed, as well as the ILM, which is going off, towards the arcades. You can see most likely it had ill formed pucker, which came off with the ILM, and then the retina looks much better in the central area. This is a thick buckle, which has got a radiating fold inferiorly. Now, this is because of post traumatic — there was probably some inferior area which had a contraction. Which led to the central pucker. It’s quite thick, as you can see. And crumpled up the whole macular area. Which we removed. And after that, we are doing air-fluid exchange, to check for mobility, because of the inferior fold. And as you can see, there’s a break with some contraction here. So as I’m trying to laser, I realize I need to release this contraction. I do a localized retinectomy here at this stage. Because otherwise this contraction — even though it may look fine right now, and I may be able to do a laser by increasing the power, but this is inferior and it’s a potential area for contraction, postoperatively, and it could lead to recurrence of PVR inferiorly. So you should always keep the retina as relaxed as possible. In these situations. Now, this is a case of detachment. Again, with not a classic PVR pucker that you see, but you see a wrinkled retinal surface, which tells you that there are grades of small ill formed membranes all around it, which are possibly there. So these are best tackled, again, with the help of a dye. You inject the dye, and typically I put PFCL. You put in the dye and inject PFCL. Under the PFCL, you look at these membranes, which are finely stained. I use the finesse loop at times for such cases. Under PFCL, you can move over these ill formed membranes and folds, and at times, you can find the edges of these ill formed membranes, which may help you to release the contraction a bit better. So this is something one could take advantage of. The staining. In certain types of cases, where you don’t see classic membranes away from the macula. But you see wrinkling and then some folds around it. So here, as you can see, we’ve removed a few of these membranes, spanning over the macular area. You can see this is not just the ILM. Thicker component coming off with the stained ILM that you see here. Which is basically membranes. So this is something which is useful, so that you achieve a complete flattening of these areas. And after that, of course, an endolaser, which is done to all the breaks, which are there in the 360 barrage. This is a postoperative picture of this patient with oil inside. Now, this is a case, again, with PVR, and I put perfluorocarbon, and as you can see, I peeled off the central part under perfluorocarbon. This helps a lot, because the perfluorocarbon instantly tells you that the traction is gone and your pucker is fully removed, and instantly stabilizes the posterior pole. And this is something you can do if there’s no posterior break. Because if there is a pucker or a traction on the macula, and you also have a posterior break, you can’t put perfluorocarbon until you relax that traction. So whenever you don’t have a posterior break and you have a pucker or traction, without a break, perfluorocarbon is a great tool to have along. Like, this case, again, there’s a pucker, and I’m putting in perfluorocarbon. Before removing the pucker. Because I feel that it helps me… It tells me exactly where the traction is, and as I’m pulling it, it instantly also confirms that the traction is relieved, and I don’t need to peel anymore in that situation. So this is something that is extremely useful. So perfluorocarbon, I use it at multiple times, based on situations that I showed you for simple detachments. I use it at times to stabilize the posterior pole. If the macula is on, I always put it — after air-fluid exchange, I feel that the bullas have come, but the fluid has come posteriorly, and the break is peripherally, I would put some perfluorocarbon so that the fluid gets pushed to the periphery and I can drain easily, without having to make another retinotomy. Now, this is a case of extensive PVR. You can see a shortening on the sides. This is kind of a tangential circumferential traction on the periphery. Our aim is first to remove the vitreous properly. Because you need to do it 360 degrees, as much free of vitreous as possible, so that then you can assess the contraction of the retina once you finish that. You can see the viscous nature of the slurry, the fluid which comes out. It’s a good idea to aspirate some of it, because it debulks the retina and allows you to work better in some of these cases. Always use wide angle systems. You can see the periphery very well. I use the Volk ones. And you can go very close to the retinal surface. See the periphery, the attachments of the vitreous, very well. And then of course once you feel that there is a bit of relaxation, you put in perfluorocarbon, now you see that there is definitely something in the posterior pole, which is holding up the retina. We remove the membranes also, peripheral membranes, which are circumferentially working, you could use a bimanual approach. Because this is just a couple of membranes here. I sometimes just use the shaft of my light pipe to hold the retina, while I pull it with the forceps. But you could use any multiple instruments that one is using from the inventory. But the simplest way is to use the shaft of your light pipe. Because it can keep the retina at bay, while you pull and relax this whole circumferential component of vitreous traction, admixed with some blood that you see here. And slowly the retina relaxes. Although it’s a 360-degree tangential circumferential traction that you see here. So as we free more areas, then you use the cutter to again cut, and again, as we see, we are indenting from the periphery, so that the periphery gets relaxed. And then we can remove all the vitreous that is there. And these high grade PVR cases, you should remove everything, as far as possible. So at the end, we have relaxed everything. I’m still putting the dye to stain and check for residual membranes. As you can see here. Because even the seeming relaxation, the kind of contraction this retina had, does not seem to be totally free of it. So it’s a good idea to free, as much as possible, the preretinal component of these cases, before you finally finish the case. And then of course do a good 360 laser, and put oil in such types of cases. And then give a prone positioning. A situation to look at: A subretinal band removal. Now, subretinal bands don’t always need to be removed. But wherever you feel that it’s spanning in such a way that it would cause traction, or would keep the retina held up, and not flattened, then you need to either remove it or make sure that it’s cut or relaxed. So here I’m trying to remove it. But as you see, it breaks at some point. So then all you need to do is just trim it and leave it. So that the continuous traction of the band is gone. And that’s what is your aim at this stage. And this is the other end of the band, where also it had a potential — and we’re just trying to pull at it with suction of the cutter, as much as it comes out is fine, otherwise we just cut it and leave it. Because the purpose was to just relax that area. Otherwise, there would have been a traction inferiorly, just because of the band in this case. But there are certain cases where the subretinal band is spanning a certain area of the retina, but is not causing traction, per se. So there you can just leave it and don’t have to remove it. So I suggest if you see a subretinal band which is holding up — just relax it. Don’t try all sorts of stunts to remove it. Because in doing so, sometimes you may increase the size of the retinal hole that you make, there may be a bleed that may start. So best to just cut and relax it, is what I have learned, over years and years of trying to remove these bands. Now, this is a case of — a complex case where it has been previously operated with oil inside, and there is PVR, as well as subretinal oil inferiorly in this situation. So we’ve removed the oil. The oil in the vitreous first. And then I’m just putting some perfluorocarbon, which is helping me delineate the traction, and I’m removing the central pucker, which allows the flattening of the central retina. And inferiorly, there is oil subretinally. Now you can see that by injecting PFCL, I push passively that oil inferiorly to come out to that inferior break. And it has come out. So of course, there’s a contraction. At this stage, I do a diathermy to the inferior part, with the idea that I’ll do a large retinectomy, as you see here, so it gets relaxed. This is how you approach these kinds of cases, where you need to do a retinectomy. Now, this is another case of where we have removed the oil. The patient had come with recurrent PVR, with inferior contraction. Which had come up. And this is how — so you first remove the oil, put some perfluorocarbon in the center, and we are preparing retinectomy. So I do diathermy, after that, I’m cutting the area just above the diathermy component, which is there just so there is no bleeding. Essentially what you’re making is a giant tear. And the perfluorocarbon posteriorly is holding and keeping the posterior pole safe while you do this maneuver. Because sometimes there may be a bleed, sometimes there may be the contraction, and the perfluorocarbon is a great tool in such cases to hold the fort while you are relaxing the peripheral part. You can see the previously pigmented areas, the raised areas, the contracted areas, and once you are sure that the retina is flat, it is basically behaving like a giant retinal tear now. You fill more perfluorocarbon, after that, do an air-perfluorocarbon exchange, and flatten the retina in this case. So these are some of the varieties that I was trying to show you, from a simple retinal detachment, various types of detachments which come up, and the strategy, and I showed you many similar cases at times, so that the technique is sequentially followed, and it’s easy to remember. That you first remove the vitreous, relax the retina, do an air-fluid exchange, do endodrainage, endolaser, cryo, and then give a tamponade based on what is there. You use perfluorocarbons as adjunct whenever you feel like it. I use it a lot, because it is a great passive tool to be used at various stages of the surgery. From simple to complex cases, it’s a great tool in all sorts of situations. It’s a great savior, and today I can’t imagine doing surgery without a tool like that. And of course, the great instrumentation, in the form of the final gauges which have come, the cutters, light pipes, the fluidics, all of these go a long, long way in making surgery quite predictable to a large extent. Of course, we get complex cases, and every case is different, and may not turn out exactly the way that we desire, but if you have a sequential way of looking at things and tackling them, I think it makes the whole approach much simpler. At times, if it is too contracted, a funnel detachment, things may not settle, or even if it settles anatomically, functionally it may not make much sense, even if you put it back, but still, our aim is that we should be able to put back all sorts of retinal detachments, as possible, using all these techniques. Adjuncts, whatever resources we have together. So what I showed you was a sequence of cases from simple to complex. There’s a lot more which can be done. But I think that this is something that would be a good platform to look at. This kind of a scenario. And I would be happy to take any questions at this stage. I’ll go through whatever Q and As you’ve sent so far. This is a postoperative picture of one of these inferior retinectomy patients, with laser done first post-op day, well settled under the oil. Eventually this will get pigmented, scarred, and we will remove the oil in this case. Once again, I would like to thank Orbis for facilitating this. I’ve had some great times with Orbis in the past. And I look forward to working with them again actively. Although we’ve been working online with a lot of things with Cybersight. And it’s always a pleasure to collaborate with them, and I would love to continue doing so. And get back on the plane again, once in a while, whenever I get a chance. Thank you very much. Okay. So let me look at whatever the Q and A is there so far, and feel free to type anything that comes to your mind. Okay. So the first question is for this phakic eye, why you didn’t use scleral buckling? So I think this is a question which will keep coming. Why scleral buckling — I’m not sure I want to answer it. Because that whole time period is gone, where we look at why not scleral buckling and why this. I use scleral buckling in a very select group of cases, where I’m doing it because I’ve known scleral buckling since the past. But today, I personally feel way more comfortable with vitrectomy. But I still continue to do so, for certain cases. So I’m not sure I would be able to answer your question, as to why I didn’t use scleral buckling. At times, I would use a belt buckle for PVR cases, with vitrectomy. At times, I would use only a scleral buckle for classic inferior detachment with a couple breaks inferiorly. So I’m not sure if that is a question which is relevant today with the whole scenario. So I don’t think I can totally say that I would do scleral buckling here and I would do this. Scleral buckling I would surely do for a young patient with just a single break inferiorly. Dialysis patients. But for all the rest, I pretty much now prefer vitrectomy, for all the reasons concerned. What is the next question? Okay. Xi Rao is asking… I want to ask for pneumatic retinopathy — how do you do it? In which cases? I’ve done two cases. I didn’t have good results, which finish in VPP. Great. Personally, I’ve not had great success with only pneumoretinopexy. I’ve used it as an adjunct sometimes. If after surgery I feel there is a break, I put in. But classic pneumoretinopexy, I’ve not had great success in those cases. In the US, it’s done in a large number, and I think they have good success with that procedure. But personally, maybe the patients that we have, the positioning, the understanding of all these things is challenging. So I don’t do much pneumoretinopexy in my cases. I would straight away go to a surgical procedure with a more definitive outcome in most of the cases that we do. Do you use PFCL as short-term tamponade? Yes, but not for normal detachments or whatever. I’ve used it only for cases of bad traumas with a lot of bleeding issues inside. If the choroid — a lot of blood in the subretinal space, so at the end of clearing up everything, if I feel that there is still some residual blood which keeps trickling back, I would put perfluorocarbon, fill it up, close the case, do a 360 barrage, at times, before closing the case, and then after 15, 20 days, come back in when the eye is totally quiet, the blood has cleared up, there’s a good scarring of the laser marks, go back and just do an exchange of the PFCL. In the past, before wide angle systems, I used to use perfluorocarbon for giant retinal tears and leave them inside for ten days and remove it. But I’ve not done it for the last 20 years now, because the wide field viewing allows us to see the peripheral laser well. Before that, there was a challenge in those cases. I don’t use it for classic cases, if you’re asking me, as a short-term tamponade for those cases. Thank you, Alok, for your kind words. Jocelyn says… In very stiff and shortened… No, before that. When is the ideal time for silicone oil removal? Okay. So ideal time… I would say any time after three months is good. A lot of factors can delay it at times. It depends. A patient sometimes is reluctant, because he’s just recovered vision and is seeing well, and you say that you have to remove it. There’s a 1%, 5% chance of sometimes a detachment. So he wants to delay it sometimes. Or if you had a one-eyed patient, you may want to keep it longer. One of the key factors I look for — especially in multiple times, operated eyes with silicone oil, is the tone of the eye, the IOP. At times, these patients have very low IOP. IOP of 10, 11, 12 with oil inside. These are cases where you should be very scared of oil removal, because the minute you remove oil, they sometimes go into phthisis, because they probably have a ciliary shutdown, because of multiple surgeries. They’re doing fine just because the oil is inside, and they’re keeping the pressure up to 10, 11. So always make sure if the pressure is 9, 10, 11, 12, lower, be wary of just an oil removal. Look at replacing the oil if it is emulsified. And on the other spectrum is high IOP. Because of that, at times, you have to remove the oil early also. If there is emulsification, high IOP, all these factors, I sometimes remove it early. But any time between 3 to 6 months is when we are removing the oil in these cases. Jocelyn says: In very stiff and shortened retina, do you encounter retinal rip during air-fluid exchange? How do you prevent this? Good question. First of all, before you do air-fluid exchange, try to remove vitreous as much as possible, so that you already reduce the chance of the contraction persisting, because of an epiretinal component, a vitreous component. Then of course, if there is a shortening or a traction within the retina, you need to look at it. And that’s why in my videos, I showed you that I like to put some perfluorocarbon on the posterior pole, and see how the retina is behaving. If it is flattening well, right up to the equator or periphery, then pretty much show that the contraction is not that bad. But if you feel that as you are injecting, you want it near the arcades, or just beyond, the retina is still not flattening well, then you know that it’s stiff and you probably need to look at — either there’s a subretinal component or there’s a contraction. If there’s a subretinal component, you can go and release it, because you already released the epiretinal contraction. But if it’s an intraretinal contraction, then the only option is that you prepare for a retinectomy. In the clock hours that you feel will relax it. So prepare it, put some perfluorocarbon up to the edge of that area, like I showed you in the video. Do a good diathermy, so that there’s no bleeding, and then cut it and relax it, and relax it a few clock hours beyond the actual area of transaction or contraction. Because if the retina should be more relaxed in those clock hours, and don’t kind of do only a minimal retinectomy for those cases. Any tips to prevent slippage in GRT? Even in PFNO silicone oil exchange. Okay. You’ve done your laser and you want to do your exchange. There are two things. You can go to air and then go to oil, or you could do a direct exchange. I personally prefer going to air. So I make sure I dry the edges very well, and I don’t do the exchange by going to the visc and removing the PFCL. I first dry up all the periphery, make sure the edges are dry, and gradually remove the PFO. Then the slippage doesn’t occur. If you go straight to the disc and aspirate the PFO, you are sure to get slippage in these cases. So one has to be careful. But if you do a direct exchange, then chances of slippage are any way less. So I don’t think in that the slippage is a big issue, if you’re used to doing a direct exchange. Okay. So how long do you leave PFO? Longstanding? I don’t leave PFO for any detachment as a postoperative measure. I just put it intraoperative and remove it at the end of surgery. How is the way to make a good retinectomy? What is the ideal location? Location is based on where the traction is. How many clock hours. And as I said, extend it a few more clock hours on both sides. And then release the traction. And make sure you have perfluorocarbon supporting posterior to it. Because otherwise sometimes a bleed or something may go towards — trickle towards the macula, and make surgery more difficult for you. What are your dos and don’t for vitrectomy in high myopic eyes with vitreous bands? Myopic eyes are always a big challenge, especially very high myopic, where the length is too much at times, instruments are not able to reach at times, so they’re always a challenge. But there’s nothing like a dos and don’ts. You take the same approach as you would do for any other eye. Except as I said, sometimes there could be a challenge of reaching, and sometimes you have to take off the cannulas and get the extra few millimeters of length on the instruments. Or use a 23 gauge, which — where the instruments are a bit longer in those cases. To do — or use a soft tip cannula to aspirate wherever you are, instead of a cutter. And also, one of the things you need to do is use triamcinolone for sure in these cases. Because sometimes even though you feel you have removed the vitreous, the hyaloid, it is a liquefied vitreous and you think you removed it, but there could be a sheet of vitreous still lying on the surface of the retina, which would be applying traction. So always make sure, after doing vitrectomy, put in a little triamcinolone, check for that, and then remove it. The vitreous, peripheral, circumferential adhesions are very strong — then you have to trim and leave them. If you are not able to remove the hyaloid, you have to just trim and leave them. Sometimes if you anticipate, you could also put a belt buckle, if you feel as a support to these cases. But I don’t think it’s a must for every case. Sometimes younger patients, younger myopes, can be a challenge in these situations. Would you prefer phakic vitrectomy or buckling? Well, as I said, if it’s a young patient with clear lens, I would choose buckling with a single break, inferior dialysis, those kinds of breaks. But all other situations, I would choose vitrectomy today. Because I think we’ve been using so much vitrectomy, the instrumentation, everything is so much different now. That we’re getting more and more used to handling it, much better today. And even the cosmetic results are better with it as we stand today. But certain cases, as I said, young kids with peripheral breaks, I think buckling — if we can do it, it is preferred. For the same reason that the lens does not get compromised. Do you do phaco with VPP in phakic patients with high myopia and anterior breaks? No, unless the lens has cataract, we would not do this specifically alone. If it has significant cataract, we would do combined. Otherwise we would leave the lens inside. And as I said, you indent from outside, bring the periphery to the central part, so you don’t touch the lens. And leave — because the lens also acts as a good compartment at times, if you’re going to put oil or something. Instead of instantly changing that whole spectrum. So leave the lens inside. Let the retina settle. And you can always do a cataract… With oil removal or cataract surgery later on, once the retina is well settled. What is your approach for retinal detachments with choroidal detachments also? Do you operate it as usual or give oral steroids before surgery? We still operate it. I think the whole concept of trying to wait with the choroidal, once there is a retinal detachment, give steroids, is gone now. You have to go in as fast as possible, because these cases have potential to go into PVR very soon. Much faster than usual cases. And so it’s best that you go in early. If the choroidal is significant, you could also drain it externally, during that surgery. If it is mild, you could just let it be. In fact, it gives a good buckle effect. At times, the areas of the break — so a choroidal is like a temporal buckle. And leave it at that. It’s a good idea to leave it. But if the choroid is significant, I would give a sub-Tenon’s cort at the end of surgery, for sure. But I would not delay the surgery with oral steroids in these cases. What is your tamponade of choice for inferior detachments? Preferably, if there’s multiple breaks, if it’s a slightly longstanding detachment, multiple breaks, I would use oil. If it’s a very fresh detachment with a single inferior break, if I’m not doing a buckling because of a young patient, I would put gas in that also. But if there is multiple breaks or longstanding, I would put oil for three months and then remove. RD/PVR surgery — what is your thought on the use of intraop mitomycin C? I don’t have experience of using this. I know of some colleagues who used it in the UK. They did a large study in these cases. But as of today, we don’t have good data to say that using this will prevent PVR. And so I’m not convinced in terms of the whole concept, and we still don’t have a good solution to saying that… Oh, this will prevent PVR. So I’m not using anything, except that if I do large retinectomies, or if it’s a high grade PVR, these choroidals — I would put sub-Tenon’s cort at the end of surgery with the idea that the inflammation is much less in the eye in the postoperative period. When do you remove subretinal bands in PVR? During my case, I already said I would remove it only if I feel that the retinal band is responsible for tenting the retina. And will not flatten because of that. If it is a band which is flattening with the retina, then leave it alone. PFCL may be very good to check it, if you are in doubt. You can let the PFCL go on top of the area of the band, and if the retina flattens well, don’t bother removing it. If you feel it’s getting close to the band and it tends to lift, then you can reduce the PFCL and make a retinotomy, in the most prominent area. You would try to remove it, if you like. But if you just snip it in between, it will be great also, because it would have relaxed that. It will go back. What is the lens viewing system and recording camera? I use a Sony HD camera, three chip. And the lens viewing is contact-based Volk lenses, which I use. The HRX wide field lenses that are XL and the contact-based lenses, which I’ve used since they’ve been there, and I’m very happy using them. Is there any way to escape RD due to high myopia? As myopia continuously increases, that’s something which is alarming? No. RD is something which is a spontaneous event. I don’t think you can prevent it, if it has to occur. You can follow up these patients. You can look at high risk factors, in terms of family histories, and look at them carefully, if they have tears or holes, you can do a prophylaxis, but I’m not somebody who does prophylaxis for pigmented lattice, or lesions, other than a frank tear, or a frankly developed hole in a non-pigmented lattice. There’s no data that suggests that if you laser a pigmented lattice in a myopic eye, it could prevent. I’m very conserve with prophylaxis and do it only for very specific indications, and also, of course, other eye with retinal detachment, you might want to do prophylaxis there. But other than that, I would be conservative. Follow-up is mandatory and you need to explain to patients about flashes, floaters, sudden symptoms, and they should come early to you. Any tips to operate cases of FEVR with RRD? Those are always going to be difficult cases. Just like ROP. They will come in all types of different spectrums. I don’t think I have a fixed tip about it. You have to look at how the retina is. What kind of membranes, what kind of contractions are there. And do it — but personally, they don’t do very well, except if you are lucky, and you have cases where the macular area is good. And you have dissections in the peripheral areas. Which would flatten. So I’m not sure specifically what you are asking. Here we can’t exchange pictures or anything, so it’s difficult for me to answer a specific question like that. Do you routinely peel ILM for RRD with choroidal detachment? No, I wouldn’t do it for choroidal detachment. I would only do it if I see a pucker or some sort of a contraction. Or a wrinkling, over the macular area. I would do it. But not because there is a choroidal detachment. With it. Not for that. So I think we have finished the questions. And we are also nearing our time. At this stage, I would like to thank all of you, for participating in asking me all these questions. I wish we could have a dialogue with more pictures, but it’s probably the best at this point in time. And I thank Orbis to facilitate once again this forum. It’s been a pleasure and I look forward to doing this at some point again. Please feel free to send questions if anything comes to your mind later. I would be happy to get back to you on that. Thank you very much.

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March 31, 2021

Last Updated: October 31, 2022

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