Surgery: The 21st Century Scleral Buckle: Heads up with a Chandelier
In this video, Dr. Riemann uses a 3D heads-up display, digital enhancement and the Alcon Chandelier endoillumination lighting system to perform scleral buckling and cryotherapy for a retinal detachment.
Surgeon: Dr. Chris Reimann, Cincinnati Eye Institute, USA
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DR RIEMANN: The diagnosis of retinal detachment has been devastating for patients and challenging for ophthalmologists since the introduction of the introduction of the ophthalmoscope by Helmholtz in 1850. Historical milestones in retinal detachment repair include Jules Gonin showing that retinal breaks cause retinal detachment, and had to be sealed for successful RD repair in 1920. The first use of foreign substance to create a temporary scleral buckle by Jess in 1937, scleral buckling with retained exoplant by Custodis in 1949, buckling with the indirect ophthalmoscope and external drainage by Scapins in the 1950s, and the introduction of modern silicone scleral buckling components by Brockhurst and Linkhoff in the 1960s. Chandelier buckling was first described by Liu in 2006, and again by Aras in 2012. And several reports have since described the successful implementation and advantages of this technique. Digitally assisted or heads-up vitreoretinal surgery was first reported by our group in 2010, and again by Claus Eckardt in 2013, and the fan base of this technology has continued to grow, myself very much included. This video will show how heads-up digitally assisted vitreoretinal surgery can be beautifully implemented with chandelier buckling, greatly enhancing this procedure. As we start to open the conjunctiva and Tenon’s capsule, we run into some bleeding in this aspirin patient. Turning off the red pixels eliminates the “sea of red”, and allows the case to proceed without resorting to cautery. The digital red-free setting allows the rectus muscles to be easily identified, and distinguishes stray muscle fibers from Tenon’s capsule. The muscle dissection is atraumatic and precise. We place an Alcon 25-gauge chandelier light source 180 degrees from the retinal breaks, and move the Merlin pediatric wide field lens into position. The view is just breathtaking. Retinal breaks are identified and marked using a marker depressor, sterile marking pen, and cold cautery. Illumination is set at 35% on the Constellation. We move on to the cryo, which can be beautifully visualized by everyone in the room. Not only the surgeon wearing the binocular indirect, and perhaps one assistant catching a brief glimpse through a teaching prism. All of this is accomplished without the awful C-spine and whole body gymnastics inherent in binocular indirect ophthalmoscopy. This is the best way to teach and apply cryo. The patient’s head is turned from side to side for temporal and nasal visualization, and the microscope is tilted toward and away from the surgeon, up to 45 degrees, to further enhance the view to the periphery. Harsh traction on the rectus muscles to rotate the eye is eliminated completely. The cryo is finished, and the scope is rotated back into primary position. Significant posterior fluid is present. The macula is detached. A 42 band is placed under the rectus muscles, visualizing with the microscope. Bleeding has stopped, so we don’t need the red-free settings here. It’s important to remember that the 42 band is an asymmetric element, with a flat side and a curved side. The curved side faces the globe. A 70 sleeve is placed superotemporally. The buckle is tightened until it slides anteriorly to seat itself at all four rectus muscle insertions and is trimmed. A double thickness segment of buckle is used to provide extra support to a string of atrophic breaks in the lattice, superotemporally. At this point, the intraocular pressure is in the 20 to 25 range, and the nerve is not in danger. 5-0 nylon suture on a spatulated needle is used to affix the buckle to the globe with a horizontal mattress suture in all four quadrants. Most of the maneuvers used to visualize the quadrants are on the part of the patient who is asked to turn his head and the microscope which is tilted towards and away from the surgeon, as appropriate. Extreme scope maneuvers are easy, because we are operating without oculars, and the camera does not care what position it is in or what kind of acrobatics the microscope is performing. With each progressive suture, the IOP rises, so that the globe is firm after the last suture is placed. The optic nerve and choroid are usually pulsing or closed. A single precise prick from a 30-gauge needle is used to perform the external drain, and pressure is maintained on the globe to avoid hypotony. After replacing the chandelier, we find a nearly 100% internal drain, closed breaks on the scleral buckle, and excellent intraocular hemostasis. 0.7 CCs of pure SF6 gas is injected to restore intraocular volume, and a paracentesis is performed to lower intraocular pressure. The nerve is pulsing, and therefore perfused. The silk strings are removed, and a sclerotomy suture is placed to prevent gas egress when the chandelier port is pulled. The digital red-free setting makes it much easier to close. This patient is now three months post-op, has 20/25 vision, unchanged 1+ nucleus sclerosis, and is enjoying his mini-monovision immensely. I’m never doing a buckle the old-fashioned way again.