Surgery: Live Surgical Demonstration: Vitreoretinal

During this live surgical demonstration, two cases were performed with step-by-step narration by the surgeon, who also took questions in real-time.

1st case: vitreomacular traction syndrome with full thickness macular hole.

2nd case: proliferative diabetic retinopathy, epimacular membrane, neovascularization.

Surgeon: Dr. Steve Charles, MD. Founder, Charles Retina Institute, USA.


DR CHARLES: Hi. I’m Dr. Steve Charles, in Memphis Tennessee, the founder of the Charles Redden Institute, and I’ve worked with Orbis for some years. Today is vitreomacular syndrome, the patient has 1+ sclerosis, which will not inhibit the view. (inaudible) if there’s 3 to 4+ negative sclerosis or subcapsular cataract, I recommend that the cataract surgery be done first, but it’s very important to measure from the pigment epithelium, to get the axial length, as opposed to A scan, which will have an incorrect axial length, shortened by the elevation of the macula. With vitreomacular traction syndrome, it’s important in my view to peel the ILM. Some surgeons don’t peel the ILM over the macula. They leave a little island to avoid unroofing the (inaudible). I’ve done that. But what others do is to pull aggressively on the posterior vitreous cortex over the optic nerve head, not paying attention to the macula, and to make a macular hole at the outset of the case, basically. So that’s absolutely to be avoided. So I will often take the scissors, and even cut in a circular pattern around the mac hole, and literally cut the posterior vitreous cortex at that place. I didn’t say macular hole. I meant to say macular cyst. Staining is absolutely essential. We didn’t know this disorder existed until we had OCT, so in the operating room, even if your illuminator makes it somewhat better, you still can’t see. Many doctors use triamcinolone for marking of the vitreous. I don’t have a problem with that. I don’t do that, I don’t use a chandelier. I use endo illumination so I can see the cortex better, and I’m happy with that technique, although I have no problem with people who use the triamcinolone, though they should use the preservative-free, if they can. With respect to the posterior vitreous separation from the macula, obviously this is essential, but you can do this slowly and carefully, if you use the cutter and use scissors and use forceps to peel the ILM. With respect to staining, in the US we cannot use brilliant blue. It’s the safest thing that’s available virtually everywhere, except around the United States. I do have access to brilliant blue, and I use it routinely in macular surgery cases. One of the questions is whether or not (inaudible) when you do vitreomacular traction syndrome. Presumably, since the retina is concave, there’s no (inaudible) so a gas bubble is not necessary. Gas bubbles don’t press hard on the retina. They’re all about surface tension. (inaudible) epimacular traction syndrome cases, and I think it’s unnecessary in this particular case. One of the questions is: How much peripheral vitrectomy to do. Some surgeons believe you need to shave the vitreous in every single case. I think that’s ridiculous, and it’s commonly done all around the world, and I don’t do that. Things I see commonly done when I travel around the world and operate in different places and attend meetings is phaco vit in everybody. The outcomes are terrible and I do not approve of that approach. I already mentioned how I do lens management. The other thing I see people do is this tedious peripheral vitreal shaving before they even pay attention to the macula. If you have any lens changes at all, those can get worse while you’re dealing with periphery, and there’s simply no need to shave vitreous down to the retinal surface in patients that are having macular surgery. So I do core vitrectomy, take a careful look at the periphery with wide angle visualization to make sure we didn’t make a retinal break or one is not already present that we somehow missed in the office. Operating times are typically 15 minutes. We never use general anesthesia unless the patient is a child or claustrophobic. So local anesthesia is quite adequate in these patients. The forceps are essential to peel the ILM. Forceps that (inaudible) do not work. They have to be forceps that close right at the tip. (inaudible) not only are they end-grasping, which is a technique I developed for macular surgery many years ago and we’ve all adopted for ILM peeling, but they actually go like this, so the leading edge is where it first grasps, and that’s essential for so-called pinch peeling. I don’t use any forms of membrane scrapers or picks or bent MVR blades or anything like that. I’m not trying to find an edge. So I find any place that I can get good visualization of the retinal surface, whether it’s an epimacular membrane or in this case an ILM, and peel from that location. They’ve got the patient ready now, so I’m gonna go scrub, which will take a couple minutes, and then we’ll start operating. And thank you for your patience while we had this little lecture at the beginning. So now we’ll switch to the microscope view. We always drape the microscope. I think that’s important. In previous years, I didn’t tape the head, but Dr. Jonathan Brugger, my current fellow, has taught me that taping the head allows more stability, and I certainly agree with him. (inaudible) for all tasks and all cases. In this case, it’s 10,000 (inaudible) lowering the cut for vitrectomy (inaudible) is not some ridiculous term like (inaudible), which is not even a physical term. (inaudible) cutting rate is to reduce pulsatile vitreoretinal traction. An essential element to safe surgery. With respect to the placement of (inaudible)… They say… They confuse trocars with cannulas. Trocars are the pointed thing that we use… Okay. Can you move the microscope? The patient is fine. The microscope needs to move this way. All right. Now we’re good. So what I was starting to say about trocars and cannulas… Frank Koch and others have shown that once the trocar enters the eye even a little bit — you’ve already created the tunnel and all you do by tipping the handle is ripping out the posterior wall that you worked so hard to create. Collagen isn’t elastic. Sclera is made of collagen. So if you move slowly and carefully, it’s far better. With the Ingenuity system, which we use on every case — and I strongly prefer visualization with the Ingenuity system — you’ve got to keep the screen 42 inches away, which is is 1.2 meters. This is absolutely essential to avoid accommodative convergence conflict, as well as to match pixel size to viewing distance. The aperture should be set at 1/3, or 30%. Why? That gives you the 4.5x greater depth of field, which is one of the principal advantages. So the advantages are: Greater depth of field and greater magnification. There are some more subtle advantages. Now, notice that I’m at a 30-degree angle, and I displace the conjunctiva, and I’m maintaining that angle without putting any forceps on the globe, which is essential. Can we irrigate right there? Can I have the Bishops, please? These are valved cannulas. Some people put all three in and then put the infusion into the first one. I don’t like that idea, because if the eye is somewhat soft, you’re not doing as good a job of penetrating the non-pigmented epithelium when we insert. So we always (inaudible) — kind of tilted up, as you can see here. Why do you want it tilted up? If you’re gonna do fluid air exchange, for pseudophakic eye, if it’s tilted down, what will happen is you’ll see an air bubble in the anterior chamber, whenever you go to fluid air exchange. So watch again. Displace the conjunctiva, so the conjunctival incision is displaced, relative to the sclerotomy. Then hold this finger on the other hand here to guide it. No need to grab the eye with forceps or anything like that. All right. Thank you for keeping the globe nice. We never scrape the corneal epithelium. Probably once a year. And we always use balanced salt, and why do I use this instead of non-contact visualization? I do that because it eliminates all corneal asphericity, which is obviously quite common. RK, LRI, just native irregular corneal astigmatism, form fruste, keratoconus, previous corneal scar or laceration. There are so many reasons for corneal asphericity. So when we do the… These cables need to be tucked over there, so we can see. The cables are right in my view. Okay. So we always want to zoom up like so. As soon as I center, I will zoom more. Maximize the capability of the Ingenuity system, and just do a better job surgically. We need to make the light a little dimmer. The illumination. I never pull back the cutter while cutting. I always hold it and sort of cut free, before I move. And I use an illuminator to see the vitreous going in the port. Which I’m kind of illustrating here. You can see some movement of the retinal surface. Because the vitreous of course is attached to the retinal surface. Okay. Let’s use wide angle visualization to do some peripheral vitrectomy, and we’ll check that again after we lift off the posterior vitreous cortex. Can we invert, please? Thank you. The basic principle of vitreous is don’t pull it centrally. Cut it in its original position. And that’s what I’m trying to do now. As you can see. Okay. Let’s see if we can go inferiorly a bit. Okay. Let’s go back to the flat contact. And we’ll uninvert, please. Let’s use a little less illumination if we can. There it is. So you can see a change in retinal contour. I never move side to side when I’m making a PVD. So you can see kind of a Weiss ring being created. Try to pull straight back to avoid a vector on the periphery. I’ll check again. Carefully go in toward the macula. Let’s go in this way. Okay. We don’t want to unroof the cyst. Good. We’ve got a nice lift of vitreous over the macula. That’s exactly what we wanted. So we were able to… Can we have a little less illumination, please? The foot pedal is in the wrong place, so I can’t reach the on/off thing very nicely. At any rate, we’re carefully peeling vitreous away from the macular surface, watching the macular contour, to make sure we’re not unroofing that macular cyst, and it’s going well. Okay. Let’s go here. Okay. Let’s put the wide angle on and look around the periphery one time just carefully, since we made a BVD. Okay. Way out here. And there. I can get a little more light level. Just want to really make sure we’ve got… (inaudible) Okay. So the point of what I’m doing is not so much peripheral vitreous shaving. It’s about inspecting the periphery. Okay. So let’s go back. And I use always the dual bore needle. I have no commercial interest, but I use the MedOne dual bore. Why? If you inject far away with the 20-gauge needle, it makes a powerful stream that can enter the subretinal space, but it drips, drips, drips all over the place. Whereas if you use a 3 cc syringe and a dual bore… This isn’t a dual bore. I’m sorry. I spoke incorrectly. I use the dual bore for PFO. I don’t use the dual bore for this. Because we’re not injecting enough fluid volume to pressure equalize, although you can use the dual bore for this. But the 3CC syringe is essential, because it allows you to inject at one third the velocity and allows you to have one third the force, so you can have a very controlled injection. If you inject with a tuberculin syringe, the throw of your finger, your second digit, to operate the syringe, is very long and it’s hard to hold it still. You want to let brilliant blue, unlike ICG… Since it’s not as intense a stain, as I said, we don’t put any additives in it, in order to make it sink to the retinal surface any more lightly. We’ll see. Okay. We’ve got just exactly what we wanted. Perfect. And we’ll need less light while I do the membrane peeling. Thank you. (inaudible) over any other handles. They’re not disposable living hinge handle. Because they have the least actuation force, which allows you to be, in my view, and the least extraneous movement of the tip, when you actuate, which I think is essential for safety and precision. So center the contact for me, and turn the light down a little bit. There we go. We’ve got a fair amount of movement up here. Can you make the light a little bit dimmer for me? Thank you. It just won’t move in that direction, because of where it… Well… I’ll do the best I can. I can’t move it up. I’ll take this ILM out. I’m recentering the microscope. It got moved quite a bit. There we go. We’re probably done. But I just want the microscope down, thanks. There we go, thank you. I think we peeled sufficient margin. So let’s do fluid air. The air is on, right? Focus. We’ve got a lot of movement for some reason. I often do vitrectomy under air. I saw a little strand of vitreous there and resected it. A great way to see if there’s residual vitreous, obviously crucial in a retinal detachment case. Not likely an issue here. That looks good. All right. So let’s pull a port, and then we’ll do air-gas exchange. Zoom out a little bit, lift up a little bit. We’ve got to uninvert, please. There we go. A little cramping. I always press on the scleral tunnel, as I pull it out. Much as if you’re taking an IV out of somebody’s arm, and that closes the scleral tunnel. Apply additional force with this. Again, the point is: Collagen is inelastic, as I said earlier. And that works nicely to close the lens. Cotton tip applicator is not the way to go. Let’s do that again. All right. So once again, I’m gonna press on the scleral tunnel. And press again. Got a little subconj. Remember, the pressure is higher than usual. All right. Why don’t I go over there and lecture a little bit, while you inject antibiotics? And I’ll go over and talk a little bit. So we use subconjunctival antibiotics and Decadron. Decadron is shorter acting, but it has a higher peak pharmacokinetic level. So we like that, unless the patient is of course a steroid responder. I’ve used subconj antibiotics, I’ve done 8,000 cases now. I’ve had three postop endophthalmitis. The first one was 30 years ago, in a patient that had a systemic infection and had been operated on. So let me switch to the other camera and lecture a little bit while we move to the next patient. So here’s the circular Polaroid glasses I have to use for the Ingenuity system. To tell you a little bit more about so-called heads-up surgery, heads-up surgery is a misnomer. The point of this is not that we used to look down and now we look heads up. Why that point was ever brought up has simply confused people looking at these systems. It’s not an ergonomic solution. It can be for the cataract surgeon, because they operate temporally and look across the patient, so the microscope arm that supports Ingenuity is not in the way like it is when you operate at the head of the table and do vitreoretinal surgery. But in short, it’s about better visualization. How can you have better visualization? I said some of it already. One is better depth of field. Because you have an F22 optical system that’s a very small aperture, and it gives you much greater depth of field, just like a pinhole device allows you to read more or less without reading glasses. So that’s one major aspect. Because the chip is small and they match the point spread function of the optical system to the chip fundamental resolution, you don’t need or want a 4K chip. These are a pair of 1080p chips, and they have the same resolution edge to edge, corner to corner, as they do in the middle. That’s not what happens when you look through an operating microscope when there’s higher order aberrations outside the bundle down the very middle of the view. When you look down the operating microscope, it’s rod and cone vision, but when you look down this, because it’s 5 times more light sensitive than looking through a microscope, now you have the ability to decouple the amount of light on the patient from the amount of light that the surgeon sees, and now the surgeon is photopic, all cone vision, throughout the case, and as I said, the resolution is great, edge to edge. Because of the capabilities I mentioned, it allows us to therefore utilize higher magnification, so we have a 55-inch screen. Why is it an OLED, organic light-emitting diode? It goes to black whenever it’s off, so it has higher dynamic range. So now let’s focus back on surgical technique. With ILM peeling, obviously a non-moving patient is crucial and a stable hand position is crucial. And you’ve got to get a start somewhere. Because there was patient movement exactly as I approached the retina, there was a little contact. No retinal break. That’s why you saw that little spot of retinal whitening. Won’t hurt anything. I’m a perfectionist. Things like that make me unhappy, but in fact do not affect outcomes. But it’s far better if you don’t do that. Why do I prefer contact-based visualization? Even though it means somebody’s gotta hold it, or it’s get be one of the self-centering lenses, again, it eliminates all corneal asphericity, but it also gives you greater depth of field, just as the so-called heads up surgery Ingenuity system does, and depth of field is absolutely crucial to peel ILM. So in this case, what did we learn? We learned that it was possible to safely create a PVD very slowly and carefully, without unroofing the mac cyst, and then we learned we had to peel this tissue off the retinal surface, which was nearly invisible until the brilliant blue stain, and then I peeled that 360 around the macula, and now we know the macula will go back where it belongs. It’s probably overkill to use a gas bubble. Others don’t do that in purely vitreomacular traction syndrome cases, but this patient — it will position well, and will do what we said, and I think it may add a little bit in the success rate. I’m opposed to the use of air in full thickness macular holes. It simply doesn’t have the same closure rate. When people make this statement, with my technique, and again, referring to macular hole surgery, positioning isn’t necessary, it’s really not the case. It’s from… I don’t know why people make such a huge big deal about it. If you lay on your back for one week after macular hole surgery, not one hole is gonna close. So in fact, everybody positions by saying — don’t lay on your back full-time for a week. If you are phakic, and you lay on your back, you get a gas cataract immediately, in most patients. Sometimes if the anterior cortex is completely intact, you won’t get a cat cataract if you lay on your back, but you won’t close the hole. If the patient is pseudophakic, we can say… Sit up, walk around, go on the treadmill, go to the gym. Don’t need to tip your chin forward. But if you’re phakic, I say keep your chin down, like you would to eat or look at a laptop on a table or fix a watch. And it’s better not to drive, because they’re not used to having one eye blocked by the gas bubble, and we don’t let anybody fly on an airplane until the gas bubble is essentially gone. We used to think if it was 10 or 15% it was okay, but we’ve heard of instances where the patient had pain. Back to ILM. For ILM peeling, it’s important not to start in some standardized location, but to peel the ILM wherever your hand is most comfortable. This particular patient happened to raise up from the table just as I was approaching. That’s where you saw the little white spot, which won’t hurt anything. But in fact, it’s far better if you don’t do stuff like that. Instead of saying oh, you always start supratemporal, always start supranasal, or start near the arcades — I don’t buy that. Start where your hand is comfortable, and where the staining is the best. Where you can best see what you’re doing. I always double stain only with brilliant blue. So when I put the brilliant blue in, if there’s an epiretinal membrane, it of course doesn’t stain the ILM very well, or patchwork — doesn’t matter. And I begin to peel away the epiretinal membrane first. With brilliant blue, you can stain multiple times, and I always do, so once you’ve peeled off posterior vitreous cortex, stain again with brilliant blue. Once you peel off epiretinal membrane, stain again with brilliant blue. And then to make sure you’ve got all the ILM, you can even stain another time. You simply can’t do that with ICG, and I don’t use ICG, because it’s toxic. I know that many surgeons, well over half of the United States, use ICG and quote-unquote “get away with it”. I’ve seen a few cases of ICG toxicity. But again, these people are very careful about concentration, for good reason, and about exposure time, and I’ve only heard of one or two doctors that would even consider retaining with ICG. The issue of patient stability is one of the biggest challenges that we have. We use — particularly now with so-called heads up surgery, very high magnifications, and the slightest patient movement, whether it’s a saccade or head movement or respiration-related movements, make it quite a challenge. But you just have to sort of calm down. The most important thing with all the membrane peeling, and in fact, all of vitrectomy, is you operate quickly by being efficient, and not wasting time, by not thinking through upcoming steps. You can’t say… Oh, would you get the laser? Well, hold on. It’s down the hall. We’ll be here in ten minutes. We’ve got to go get it. Plan ahead. Think through all the steps you might need. Don’t open up expensive things that you might not need and waste money, but have them readily available in the operating room, and think several moves ahead, like apparently great chess players do. But it’s not about your hand moving rapidly. To improve your dexterity, what you should practice is to move your hand as slowly as you possibly can. Practice that not just with forceps and scissors. Practice it when you’re injecting PFO. Practice it when you’re injecting brilliant blue. Practice it when you’re using your endo laser. So one of the things, when I watch young people operate who are just getting started or frankly not doing a very good job, is the instruments just move too rapidly inside the eye, with respect to approach to the retinal surface. There’s almost a fear factor associated with ILM peeling that kind of makes people do it abruptly. That’s exactly what I don’t want to do. I want to move my hand as slowly as possible, and I think this is an essential step. With respect to diabetic traction detachments, for example — let’s talk about that for just a moment. When I hear people say scissors are no longer necessary, I simply do not buy that argument. I use scissors for every tabletop traction detachment. Any time that membrane is close to the macula, or over the macula, any time there’s tight adherence. Membrane peeling is seldom possible in the diabetic traction detachment context. Sometimes if it’s very recent you can lift, but instead of starting with the notion: I’m gonna peel, and only go to cutter and scissors if necessary, start with the notion: I’m gonna do what I can do safely with these beveled cutters, and with cutter delamination, either pull back delamination or conformal. Conformal means like this, and fullback means like that. It this is fullback, and this is conformal, feeding it in like so. That’s the best way to approach such patients. But if you’re at all concerned that you’re gonna make a retinal break with the cutter, instead of saying it’s a difficult case, therefore I put in oil, what you should do at that stage and time is to move to scissors delamination, always with the curved scissors, usually in inside-out orientation. In the diabetic patients that we operate — in my view, if there’s not a sufficient PRP, patients that had enough proliferative retinopathy to require a vitrectomy should have PRP completion, with this caveat: Do not treat areas of TRD, even if you acutely attach them in the operating room. There’s always subretinal fluid left, the retina is often edematous, and there’s a real temptation to overtreatment, which can result in proliferation on the retinal surface if you PRP an area that’s had a traction detachment. I always inject Avastin at the end, and preoperatively, within a week of surgery. The fear of so-called crunch syndrome has caused people to give up preoperative Avastin, which is a big mistake. It’s far better to inject it and operate within a week. But remember you’ve removed all the Avastin during surgery, so you have to put it in at the end of the case. This is a major step. Let me take a five-second break and just check on the next patient. Okay. I will now describe what we’re gonna do in the next patient. The next patient has diabetic retinopathy, proliferative retinopathy, with a vitreous hemorrhage and epiretinal membrane. So in this case, there’s really not traction detachment. Therefore we will be able to peel membrane. Invariably, if I peel membrane and stain with brilliant blue and peel the ILM, if I mentioned earlier, if the PRP is not relatively confluent, we’ll do a light PRP. I don’t use repeat mode on the endo laser. Most folks do. Why am I opposed to it? I’ve seen people treat the fovea that way, with a pattern, left to right, top to bottom, in a Western way, like you read, and losing their spatial orientation, and lasering the fovea. Not a good thing. So I want to volitionally — most of these patients have intraretinal hemorrhage. Many of these patients that have had prior laser, you don’t want to put a spot at any of those locations. Why have repetitive laser mode to keep from tiring your foot out? I strongly urge people to use continuous, instead of pulse laser. And repetitive laser, and volitionally treat each spot. If it’s lightly pigmented, you need more energy. If it’s heavily pigmented, you need less energy. And it’s very important to focally treat any area of neovascularization. You can even treat elevated neovascularization on the disc with laser, but not with diathermic. I have promoted heavily the use of endo laser for hemostasis, not just endolaser for panretinal photocoagulation. This is a very important principle. Why? Years ago, I did thousands upon thousands of traction detachments, and because that was sort of catching on, I took many postoperative photographs. And a year or two or sometimes three years later, I would see large round holes that weren’t present six months out develop in the posterior pole. So the conventional explanation for that was: Oh, it’s atrophic or it’s ischemic. And I said… Well, wait a minute. Why did we not see that in the non-operated patients? So I traced back their records, and in every instance, it was a location where I had applied diathermy for coagulation. When you use diathermy, it’s indiscriminate. It makes coagulative necrosis of everything within the energy field. Unlike photocoagulation. So photocoagulation is far better, particularly along the nerve head. Why? Because green laser energy is confined — the absorption is confined to the hemoglobin blood column. So it only coagulates that part, and unless you turn the power up too high and the duration way too long, it doesn’t treat the areas away from that vessel. So again, I use continuous, and I hold down the pedal until I get sufficient response. Be careful about using short duration, because the vessel will go into spasm. You’ll think it’s coagulated, when it’s not. So that’s an important thing to keep in mind. And using hemostasis, particularly in diabetic traction detachment or proliferative retinopathy context. What about peripheral vitreal shaving in these cases? Many surgeons go immediately to wide angle visualization, when they’re doing a diabetic traction detachment, for example, for a vitreous hemorrhage. I think it’s far better to use higher magnification and a flat contact lens, and do most of it that way, and only if the traction detachment extends out to the equator do you use the wide for the basic elements of surgery. The notion that you need to do PRP anterior to the equator is complete nonsense. Some programs have pushed that for years. That retina is all perfused from the choriocapillary side, because the oxygen in the vessels, the saturation is virtually nothing way out in the periphery. So the far peripheral retina — you don’t want it to be detached, because it will create VEGF. So I’m not saying it’s okay to let it be detached, but remember it gets its oxygenation primarily from the choriocapillary. Trying to PRP anterior to the equators is nonsensical and results in phakic eyes and people bumping the lens. Let’s come back to the lens for a minute. This emphasis on phaco I see worldwide should be coupled with an emphasis on better refractive outcomes. I’ve talked to many vitreoretinal surgeons throughout the world, operated in 25 countries, and it’s interesting to me that people do phaco, and I say: Do you use toric lenses? No, never do that. What formulas do you use? Do you know Graham-Barrett, Warren Hill? Never heard of that. Do you use intraoperative aberrometry? No, I don’t. So I feel a push that when people take out the lens, they should get better refractive outcomes, which patients have come to expect today. But another story: Does vitrectomy cause cataract? It does not. It causes nuclear sclerosis progression. If you’re a 20-year-old diabetic and you have a vitrectomy, 20 years later your lens is often clear. The idea that oh, you must take the lens in a 20-year-old or 25-year-old diabetic, or a foreign body case or macular surgery, because they’re going to get a cataract is simply fallacious. And it’s been stated on the podium a thousand times. If you’ve got 1+ nuclear sclerosis and you’re 47 years old and you have a vitrectomy, no question — 3, 4, 5 months, not 12, you’re gonna get phaco. And instead of combining the procedures, I prefer to get the retina fixed, let the eye become uninflamed, so-called “quiet”, and let a cataract surgeon do a great job with cataract surgery later. If socio-economic issues drive a combined procedure, let’s amp up the emphasis and get refractive outcomes where they should be. Instead of using one formula and getting very average refractive outcomes. It’s tough enough to get good refractive outcomes if you measure with multiple machines. In the presence of a vitreous hemorrhage, how do you measure optically? You can’t. You have to use A scan. What if the macula is elevated? You don’t know the axial length. These are issues that need to be considered to get better outcomes. In some parts of the world, general anesthesia is used quite a bit. I’ve heard the excuse… The operations take too long. That’s not an excuse to put the patient under general. General anesthesia in great hands — the patients do very well. On the other hand, it does add risk. Oh, no. Go ahead. Sorry. They were just asking me… I happen to be trapped between the anesthesia machine and the visualization machine. And they were asking me if I wanted to move, but I want to continue this lecture about anesthesia for a moment. So with local anesthesia, there are certain things I think are important. One is we want to do minimal sedation. And we use typically… Versed, just during the block. But what kind of block? 27 1 1/4 sharp needle. Never use retrobulbar needles. The ophthalmic anesthesia society emphasize that a straight in trajectory to the muscle cone — start here, and aim for the muscle cone, and a straight-in trajectory. It’s been shown in the interventional radiology world that once the needle enters tissue, your attempt to steer it is zero. Straight in path, aim for a point halfway between the orbital apex and the optic nerve head, have the nurse hold the eyelid open as far as possible, so you can visualize the equator of the eye, and keep your bearings, because you’re trying to do an intraconal injection. The proper name for a retrobulbar block. I never use wide. The studies show it just changes the onset by about five seconds. I never use norepinephrine. I don’t use any adrenaline. And if you mix it, it has half the concentration, so I don’t do that either. But the operating times are never over an hour, and 2% Xylocaine is adequate for that. It’s possible to reblock. I’ve done that a few times, when we stay a little too lateral during the block. This last patient had a little pain when the nasal cannula went in, and the medial rectus was functioning a little bit during surgery, so the block could have been a little more nasal. But again, it’s natural to be cautious. To not perforate the globe. When you do local anesthesia, it’s essential to put a vacuum line under the drape, because when patients say I can’t breathe, I want more oxygen, what they’re telling you is that they have a rise in their CO2 levels. Well, they’re about ready for me, so I’m gonna extricate myself from this location. That I put myself into. And then I’m going to scrub, and I’ll start operating here in a moment. Thank you so much. Start operating in two minutes after I scrub. There you go. All right. And let’s turn the room lights off, so I get a better view here. Let there be stereo. So the conjunctiva is displaced. So its opening will not align with the scleral opening. There’s no need for me to measure, because I’ve done it so many times, but I urge you to measure with the calipers. So I’m trying to go in at a constant 30-degree angle, not a biplanar. I steer with this finger on the other hand, as you can see. Let me zoom out just a little bit, so you can see what I mean. It’s already zoomed out. So let me have the Bishop. Although these are relatively self-retaining, I find it better to make sure you don’t pull out even the slightest bit — by it, I mean the cannula. Let me have infusion. Thank you. And you’ve got to snap us into the detent. Partial pullout of the infusion cannula has been a big problem. People think the infusion failed or the patient got a choroidal. No, you used in in the choroid. It’s very common and can be quite a serious problem. It is manageable if you catch it early and do it right, but it’s far better to prevent it. So taping, once again, conjunctival displacement, the conj from the sclera, put this finger forward on the other hand, preserve the angle or the pose relative to sclera. You want to be always limbus-parallel. Thank you, Dr. Brugger. Conjunctival displacement. Obviously you want to make a radial incision, because you’re building a scleral tunnel. These two temporal ports need to be just above and below the horizontal meridian. People say… What hour of the clock? This isn’t about telling time. The hour of the clock doesn’t matter. This is about orbital anatomy. So where should the nasal one go? That one should be on a line between the lowest point of the bridge of the nose and the pupillary axis. Why? That allows you the greatest angular access anteriorly. And if these had straddled the horizontal meridian — I could have made them even slightly closer — that allows you better orbital access. If you make the incision up here, the supraorbital rim interferes with your anterior access. That’s why I snapped the handle off the back of the (inaudible), because I want to be able to treat it like a ball joint. So let’s turn the light way down. There we go. Zoom out. Light is too bright still. So as I said, minimal amount of vitreous hemorrhage. But largely about an epiretinal membrane, in areas requiring focal treatment. If you treat a case like you would with Pascal and similar lasers in the office, you want to use short duration. We’ll need a laser probe and brilliant blue and ILM forceps. Rhetorical question: So are you gonna peripheral vitreous shave in this patient? Why? It’s not a retinal detachment. Vitreous hemorrhage has mostly settled to the bottom. We want to get that out. Let’s go to wide so we can get that inferior vitreous hemorrhage. Thank you. There we go. The depth of field is great. You can see the capsulotomy and the peripheral retina at the same time, hopefully in focus. Always 10,000. Never use 3D or dual linear. You always want to use proportional vacuum. The pedal has up-down travel to control vacuum for a reason. Use it. The idea that you should adjust the level at the console and then always put the pedal all the way down makes absolutely no sense. Having multiple presets for core and shave and posterior and anterior and all that — I simply don’t get it. I use proportional vacuum for all. And if there’s too much vacuum, I don’t push the pedal down as far. So instead of all these complicated modes that I don’t think are actually very well understood, that make the procedure take longer, and be harder to learn, just really use the bandwidth of the pedal, and don’t push the pedal down all the way if there’s too much vacuum. Even with highly mobile retina, you barely touch the foot pedal. Just like you would in your car. (inaudible) startle the people across the street when you enter the living room. All right, put some brilliant blue on, and see if we need to peel. We do? Thank you. We’ve got wide so we need to invert. I mean… Yeah, thank you. We’ll have to come down a little bit. All right. So how fast do we inject the brilliant blue? Slow. Why? So we don’t make a stream. Wallace Folds and the late Robert Latimer invented the two retinal detachment models people use in the laboratory. How did they do that? They shoot a jet of fluid at the retina. We don’t want a jet of ICG or brilliant blue or anything else under the retina. So inject slowly. 3CC syringe and practice. Slow is good. So let it sit there and stain for a while. We jokingly call it marinating. And we’ll have to turn the light up a little bit at this stage. Remember that your eye has 10^7 dynamic range, whereas camera heads and display have about 10^3, 10^4. So you have to adjust light levels more. Small price to pay for having 1/5 the light exposure. I typically have the light set on 2 or 3 during membrane macular surgery, whereas before it needs to be 10 or 12. By that number, I mean percent on the constellation. So we’ll take the blue out. We’ll be able to turn the light down a little bit. If you’re not sure the first time, but you think you’re gonna have to peel, stain the second time. So let’s go to the disc and see if there’s a PVD. Can we turn the light down, please? So vacuum only. Over the optic nerve head margins. Pull straight back. Usually when there’s a vitreous hemorrhage, a PVD has occurred. There’s a little vitreous there. Do I know yet if there’s a PVD? I don’t. That’s why I’m checking. There was impressive staining. There’s a little bit right there, but the retina contour is not changing when I move like this, and I’m at max vac, 650, so it’s not engaging vitreous, therefore a PVD is present. So you can see the cystic space is in the macula, but I’m gonna stain again, because the stain is non-dramatic. One cause of minimal staining is residual vitreous membrane. We ruled out residual vitreous. But let’s do that one more time. Can’t do it with ICG, as I said. Or shouldn’t do it. All right. It’s hard to be patient, but it’s the right thing to do at this stage. Foot pedal — it’s so close to me. There. Now that’s better. Okay. There’s a little bit. Not a lot. It’s always in the light colored fundus — it’s harder to see the brilliant blue. Of course ICG is a more intense stain, but as I’ve said many times, somewhat toxic. Although many real good surgeons still use it. But short exposure times and low concentrations. A patient has rather significant respiratory movement, so I’m trying to time my ILM peel with when the head moves back and forth. Try to stay awake, sir. I’m being really careful. I always am, but there’s a lot of vertical motion from the patient’s breathing, so I’m having to compensate for that. Now you can of course… (inaudible) There’s both movement along the patient’s long axis, so to speak… Okay… Pseudophakic? Cutter in my left hand. Let me see here. No, let me just have the cutter in my right hand. With valved cannulas, a membrane like that, you can’t… We just invert it. So anyway, with valved cannulas, a membrane — fairly sizable one, like the one I just removed, is gonna get trapped in the cannula. So this little piece right here is well away from the macula, and there’s no point in adding risk by peeling that. And so I got rid of it. So now let’s go with the laser. And remember, you can focally treat neovascularization — not only could. You should. In a vitrectomy context. Because you don’t have to worry about contraction of the posterior vitreous cortex. In the office, most people are taught not to focally treat. Aiming beam is too bright. And the white light is not bright enough. Back down a little bit. Now a little bit up with the aiming beam. Sorry, we have to fine tune this. There we go. Laser filter is in, right? Let’s see where the macula is. Make sure we’re in the right place. Patient movements, making this a bit of a challenge. Nice. You know what? I don’t think I’m gonna do a big PRP. I don’t think he needs it. Exactly. So by combining focal treatment to these areas with Avastin at the end, we can avoid having a giant PRP. Which can contribute to macular edema, as well as some night vision issues and loss of peripheral field. So the combining of discrete focal laser like this — just kind of check to make sure I didn’t miss anything. I think we can do IVA now. And that’s it. So now we’re gonna do Avastin. I’ll give you that back. So remember, when we pull, we pull them out at the angle they went in. Not perpendicular to the globe. And we press on the scleral tunnel as we do it, like so. And that closed. That’s Avastin. Got it. All right. All right. Going to inject antibiotics. I’ll go over here. Just to wrap it up. Okay. We can turn on the room lights. Room lights. So… He is now injecting the antibiotics and the Decadron we discussed in the earlier case. There are those that no longer use subconjunctival antibiotics, including Dr. Flynn, the world’s expert in endophthalmitis. Maybe it’s a bit superstitious, but having done 38,000 cases with only three postop endophthalmitis cases, one had a cystotomy that was infected, one had bad oral sepsis, and a third one also a diabetic — again, some 30 years ago had, quote, allergy to all antibiotics. All those patients lost their eye, and it was dramatic. So I’ve never had an endophthalmitis since then. That’s 30, 35 years. So again, I use subconjunctival antibiotics. Unfortunately the aminoglycosides hurt, because they’re myelinolytic. That’s the pain you heard the patient express at the very end. And the retrobulbar block doesn’t tend to block the inferior cul-de-sac very well. Which is where you inject these, so if you’ve got a subconj hemorrhage, it’s hidden under the upper lid. You always inject parallel to the surface, so you don’t penetrate the globe. Clearly you don’t want to inject gentamicin in the globe. So in this case, trade-offs. Some people would have done a PRP. I don’t fault them for that. But we know from the study comparing laser to anti-VEGF compounds and anti-VEGF compounds have less complications, or are equally affected if not better, so why not avail us the opportunity to avoid destroying his peripheral field and decreasing his dark adaptation capabilities? So we do that by focally treating areas that might bleed postop. As you saw me do. And again, diathermy would be a big mistake in any of those cases. It would lead to necrosis. So that’s why I chose to use hemostasis with the endophotocoagulator. Some of those areas look like large aneurysms, others look like NVE, but since the patient had a hemorrhage, by definition it’s proliferative retinopathy, so it’s necessary to inject Avastin at the end of the case. Had we injected it a week ago, we still would have injected it at the end of the case, because of the rebound phenomenon I mentioned earlier. This patient was already pseudophakic, so we didn’t have to enter into the trade-offs I mentioned earlier. But this idea that this always results in cataract is wrong. When you remove the vitreous, you permanently decrease the viscosity 800-fold, and oxygen diffusion has a viscosity factor in that equation. So there’s marked diffusion. The fixed Starling principle is where you can look that up. But in short, increase the diffusion is the reason you have partial pressure of oxygen increase. Some people thought it was ascorbate completion or something to do with infusion fluid. That’s fallacious. It’s about having a partial pressure of oxygen 20 millimeters of mercury higher for the rest of your life when you’ve had a vitrectomy. Nuclear sclerosis is an oxidative reaction. It does not de novo cataract. It causes NS progression. Do these patients a favor when they’re still able to accommodate and leave the lens in place. I think this is very important for patients’ utilization of their accommodation capabilities. We only have 6 or 7 minutes left, but I think in terms of training and learning, the most important steps that I can emphasize are, number one, moving your hands incredibly slowly during vitrectomy. Why would you do that? Always cut vitreous free before you move the probe to a new location. Don’t grab vitreous and pull back, like you do in IA during phaco. So never pull back. Always use the highest cutting rates, always use proportional vacuum, not 3D. Try to stay away from complicated modes, and shave and blah-blah-blah, anterior, posterior. Just use proportional vacuum, highest cutting rates, and always push the pedal down if you see excessive movement. With membrane pulling scissors, as with injection, always move your instruments as slowly as possible. Why is that? You’re operating at great magnification, which scales up position. What’s the first derivative of position? Velocity. What’s the first derivative of velocity? Acceleration. So scale down your movement just as you scaled up your vision, particularly with these 3D visualization systems. The next thing that’s very important is to think through not just a linear approach to surgery. We’re gonna do this, this, and this. But think through that often you find things different than you expected. You might create a complication. You might find a break you didn’t anticipate. So having gas, laser, oil… Various other instruments readily available in the room, not off in some storage area, and having the staff and yourself ready to get these, but not to open excessive disposables and drive up the operating cost — it’s very, very important. And keeping your calm with the staff, and even yourself, so that you don’t get angry, upset, nervous allows you to do a much better job. I’ve been flying jets for over 30 years, and that lesson is learned over and over again in the cockpit. Anger, panic, disagreement between people leads to bad outcomes. So keeping your calm and pausing for a minute and saying… Wait, this is different from what we thought. Let’s take this approach instead of that approach. Very important way to do high quality surgery. I appreciate all those people who took the time to tune in to this. I hope the surgery met everybody’s expectations, and that the teaching did as well, and hopefully we can do more of this. I had the opportunity a week ago today — the Orbis plane came to Memphis, and we had a fundraising thing. The Orbis team did an extraordinary job of demonstrating the capabilities of the airplane, to philanthropists and a whole team of people who loved the airplane, loved the team, loved the mission, and are totally engaged in trying to help it go forward. Where was the airplane? At FedEx, one of our major benefactors at Orbis. So I want to thank Orbis, the entire IT team, as well as Danielle and others and Dr. Haddad. It’s an extraordinary team that has a great mission. I encourage all of you to participate both in the online learning, as well as try to volunteer, as your skill set and confidence is built up, to go on missions and help Orbis. I think I’d better get on with some other cases now, but thank you again, everybody, for participating.

May 14, 2019

Last Updated: October 31, 2022

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