Lecture: Management of Simple to Complex Retinal Detachments Without Scleral Buckling
In this lecture, Dr. Steve Charles discusses the incremental reattachment process, vitrectomy under air, interface vitrectomy, medium term PFO, retinectomy instead of relaxing retinotomy, punch thru retinotomy for subretinal bands and the argument against scleral buckles. Dr. Charles also answers questions submitted by the live audience.
Lecturer: Dr. Steve Charles, MD. Founder, Charles Retina Institute
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Hi. I’m Steve Charles. I’m a surgeon from Memphis, Tennessee, and I’ve been working with Orbis for some 30 years. I’m delighted to participate via this wonderful vehicle, Cybersight. I want to welcome Hunter back to Orbis and the Orbis enterprise. We’re so delighted to have this opportunity. I’m going to talk today about everything from straightforward retinal detachment to the most complex, breaks and PVR, and a cohesive approach to that. There’s several themes I a want to cover.
In the first section, the core theme is that there’s too much scleral buckling going on. We have a cataract surgery community that produces patients that have very little refractive error, very little pain, no ptosis, no strabismus, and we cannot accomplish that with a scleral buckle. It’s said that it’s the gold standard. We’ve always done it. It works for me. And they make comments that vitrectomy causes cataract. Not true. It causes progression of pre existing cataracts. It’s my strong view that vitreoretinal surgery should emulate the type of experience of today’s refractive cataract patients have, or even standard non refractive cataract surgery. There’s also the notion of those who move to vitrectomy instead of buckling or are starting to illuminate buckling combined with vitrectomy, that, oh, well, if it’s a tough case like PVR, you must use suture 20 gauge or you must use 23. Simply not true. 25 gauge and 27 gauge vitrectomy are optimal for everything from straightforward retinal detachment to giant breaks and PVR. There’s no need to make larger wounds or somehow revert to older 20 gauge suture technology simply because it’s a more complex retinal detachment. I’m absolutely unaware of any data to support that adding a buckle to a vitrectomy improves outcomes. Numerous outcomes in the field use phrases like, “Well, it supports the vitreous space” or, “I have always done it that way.” I do numerous PVR re ops for other surgeons, and very commonly the PVR and the retinal breaks are posterior to a very broad, encircling buckle.
So, what does a patient want? They want a white, pain free eye with no sutures. They want no surgery induced refractive error. They want no double vision, and they want a surgery that lasts 30 to 45 minutes, not two to three hour procedures. Let’s move forward to the minimally invasive vitrectomy and advance our techniques without doing a buckle.
What about the advantages of 25 or 27 over 23? There are no disadvantages except this tool flex issue that I’ll address. But what are the advantages? There’s less pulsatile vitreoretinal traction. It’s not just about less wound base. It’s not just about easier access to small spaces because the tip’s smaller. I’s not just about more comfortable. All of which we’ve proven in randomized trials. It’s about the fluid being better, not worse. We had an era where people said 23 gauge is better because it has higher flow rates, and they used terms that are simply inappropriate from a physics perspective like “flow efficiency.” Those are separate things. There are flow rates, and there is efficiency, which is how much material, vitreous tissue, that you removed per unit of infusion, and that has nothing to do with machine, but has to do with technique.
With respect to vitrectomy, what are the success rates of primary retinal detachment? They have been as low as 75% but good surgeons are achieves as much as 90%. There’s a notion that it causes cataract, therefore phaco is excessively done worldwide. If you’re 20 years old and they decide to use vitrectomy, they’ve got to use phaco. Patients like to accommodate, and they can accommodate until they’re 40 years old or so. There’s zero evidence that you induce cataract when you use today’s small fluid volume and today’s advanced infusion fluids. The incidence of endophthalmitis is extremely low. The last one I had was 25 years ago, and this was a patient who refused any antibiotics. The other two were diabetics, and I probably shouldn’t have operated because they had systemic infections.
But what are the buckle complications? I hear people who advocate buckle, and in my view, are living in the past, saying wow, I have never seen these complications. They’re not looking, because they’re there. If you encircle, you’re going to get induced myopia. Let’s assume the patient has had Lasik, and then you throw a buckle around the eye, as people say, you encircle the eye, and now they have somewhere between two and four diopters, and they’re not happy. They’ve had cataract surgery. They have worked to get the refractive outcomes and hopefully your distance correction, and then your patient gets a detachment, and now the surgeon elects to throw a band around the eye and induces myopia. Is there data to support induced myopia? There is. There was an elegant buckler who sent all patients to a strabismus clinic and had a really careful refraction pre op and post op. Average, 2.75 diopters of induced myopia. What about ptosis? I can commonly walk into a room and ask, “Have you had a scleral buckle? Yes, I have. Why? Because they’ve got a little ptosis. And my colleague, Chris Flemming, has worked with Orbis quite a bit, tells me it’s probably damage. What about strabismus? Back in the late’80s and possibly back in 1990 sent all patients back to the strabismus clinic and had them measured. He was, very, a very meticulous scleral buckler. 50% of the patients had increased [ indiscernible ]. Patients are not happy with double vision. Today there’s more and more emphasis on ocular surface disorder. And we’ve learned that ocular surface disorders are not just about discomfort. They’re about visual disturbance because the first optical element in your eye is the tear fill. So I noticed that many scleral bucklers support one suture at 3 and one at 9. A ridge overlapping the peripheral cornea. That disrupts the tear film. It will cause discomfort and cause blurred vision. Persistent subretinal fluid is more common in buckling cases. Buckle extrusion, intrusion and infection all occur. I haven’t done a buckle in 12 years. Others put in more recently by others. So with all careful technique of covering the buckle, but with capsule, suturing it properly, being careful to do the buckle, there are still extrusion rates. Why? Because the tension on the sutures causes them to cut, particularly in [ indiscernible ] syndrome or myops. When it makes a vexity, the tear film is disturbed, and they developed a causing the patient to have an extrusion or an infection.
Retinal incarceration occurs in up to 5% of patients with conventional drainage. That is not good. And there’s also bleeding that occurred at the cut drainage site. But if you have a large detachment, and you try to do it in a non drainage, you have the problem of elevated pressure. Again, vit buckles, what are the problems? Longer operating times. General anesthesia increases morbidity, mortality, and cost and discomfort. There’s no evidence that adding a buckle improves outcomes. I’m trying to push our whole community of surgeons in the other direction.
So what are some of the enabling technologies and techniques that allow us to get rid of the scleral buckle and repair with retinal detachment with vitrectomy alone? I have alluded to 25 and 27 gauge vitrectomy. Cutting rates make a difference as well we’re in the 7500 to 10,000 cuts per minute and we have FDA approval on the language pulsatile vitreoretinal traction. That’s a big deal. Fluidics used to take up to two seconds to respond a a foot pedal command and now they’re in the 50 millisecond range. We have sutureless vitrectomy procedures. Wide angle viewing is essential. Contact base wide angle viewing was introduced and then the non contact. So now we have both various wide angle contact lenses as well as other non contact viewing systems. I have been historically a big advocate of contact based, but 70 to 80% of surgeons use non contact viewing. I have revisited that and beginning to combine the use of contact lenses and the non contact systems as advocated by several of our colleagues in Japan. And I emphasize once again this notion that the de novo cataract is not caused by vitrectomy when you use fluids and keep your operating times and fluid throughput reasonable. You can get a subcap but not nuclear sclerosis. Why do they get it? That occurs because as Nancy has shown, when you remove the vitreous, you reduce the viscosity by about 900 fold, and therefore diffusion of oxygen the sterling principle can occur at a greater rate. And it’s shown that the partial pressure after vitrectomy increases by about 12 millimeters of mercury, and nuclear sclerotic cataracts are known to be by oxidative reaction. If you have no known nuclear sclerosis, it doesn’t produce it. I’ve had hundreds and hundreds of patients that are 20, 30 years out from vitrectomy that still have a clear lens. What’s the trick? They were 20, 30 years old and had a clear lens when we started. We have to get rid of the notion that vitrectomy always causes cataract; therefore I do buckles. I’ve heard it a thousand times. It’s wrong. I’m not going to review these references, but I want to make the point that yes, I’ve done 38,000 vitrectomies. I have looked at the success rates and the various complications, and there’s quite a few papers to support vitrectomy repair. There’s a paper from Greece with a doctor who trained at Cornell. Shows slightly higher success rates. The paper from multiple authors in Europe that purported to show that buckles were better was a very flawed design where the doctors could change techniques. The papers often reference, but in my view, in error.
If you look at specific complications, the papers are out there. Many years ago, one was published. Papers on extrusion are out there, and exploitation of the buckle. The Smiddy paper alludes to the diopter shift. I use the standard endoilluminator. I don’t have a problem with the chandelier. But I’m careful to make scleral tunnel sclerotomies. I’m transitioning from using contact based wide angle to now using non contact combined with a contact lens, an idea that came from colleagues in Japan.
The crucial elements are never pull back a cutter while the cutter is operating. If vacuum is applied, don’t pull back. There’s too much aggressive PVD creation with induction of retinal tears. It is essential to excise the flap, but to remove the vitreous anterior to all of the retinal breaks. That means it’s a little more peripheral, and has to be careful not to bump the lens. And again, we must try to remove the vitreous 360. Sometimes a small depression can be very helpful there. But often you can do an excellent vitrectomy without the need scleral depression.
What are the options? In standard without giant breaks or PVR, I normally did not use liquids unless there’s fogging of the eye because there’s been a laser capsulectomy. When you do a yag laser and you disrupt the entire face, now the air bubble in the vitreous cavity can have contact with the lens. Of course silicone lenses have a lower index of refraction. They’re thicker and therefore a greater thermal mass, and therefore they store cold and cause the condensation to be worse. But the condensation also occurs with acrylic lenses, not limited to silicone IOLs. So in short, I whether use PFO to reattach the retina only in the instance of fogging of the IOL as we just discussed. I used confluent laser around the tears, but I never use spots. Why do I use confluent laser? When you have a thermal base of energy that you’re using to create thermal energy, the heat cannot diffuse out of the center of the spot as effectively as the periphery of the spot that you create. Every laser spot is much hotter in the center than it is on the periphery. But if you move the laser while it’s being applied, you smear it, so now there’s a uniformity. If you use spots, you can overlap them. Then it’s too hot, the burn is too intensive. Or to make a term up, you can underlap it, where there’s a gap between. So called painting, a better term is confluent. And I have always used them. They need to be relatively light burns. You don’t want to call full thickness necrosis of the retina or excessive inflammation. I no longer use C3F8. It’s too much of a problem for patients to have bubbles lasting three to four weeks so I always use SF6. It’s off label in the United States, not fluorinated silicones but PFO, I leave it in for two weeks for inferior detachments. I have a series dating back over 20 years now. It is absolutely, unequivocally not toxic. It has two three issues. One, you got to remove it. Two, residual bubbles must be removed, and three, some patients have inflammation.
Wide angle illumination is important. If you have too wide angle and you have an IOL, there tends to be more glare. So I’m not a big fan of the bullet or chandeliers for routine cases. I normally use the standard illuminator so that if you’re doing focal, specular, and vitreal illumination. What do I mean by specular? That’s the way you inspect the surface of something shiny like an automobile to make sure there’s not little defects. That’s the best way I can describe it. And that’s the way you can find the transparent membranes on the retinal surface or areas of fluids you might have missed with wide angle illumination. Instead of illuminating everything like high beams in your car, you want to have a bit of a narrower beam that you can move around and use retro illumination bouncing off of the vitreous cutter. By doing that, it often illuminates the need to mark the vitreous.
Now let’s talk about non routine cases, but ones that are more complicated. I used the term reattachment experiment. But I have been asked quite a bit about when do I do retinectomy? First of all, never do this under saline. Don’t do it under infusion, always under air. And don’t do it under PFO, because, you know, you’ll have a greater risk of having PFO droplets under the macula, which is not a good thing. So what I routinely do is to do the reattachment experiment. So let’s tell what I mean by that. First, in every detachment case, and especially in PVR, you must dissect the anterior loop traction. These are radial fibers that used to be in contact with the retina. They’re now contracted because cellular elements cause contraction of the collagen fibers. The membranes never grow anterior to the posterior edge of the vitreous base. They’re not peelable. And to call it shaving is a bit of a misnomer as well. So what are we talking about? We’re talking about there’s three orientation of fibers. Fibers that run across the eye equator to equator, I call them frontal plane. And PVR, they there is no core vitreous. There’s a confluence of the anterior posterior vitreous cortex in the frontal plane. Everybody knows to remove that. There’s no core, it’s a sheet of confluence. Then, there are fibers that run in a circle that the posterior edge of the vitreous base, they’re virtually impossible to peel without tearing the retina. Then there are these fibers demonstrated in this graphic, and these radial fibers I call anterior loop traction, those must be resected in every detachment, but clearly in PVR. When cutters were 20 gauge, I had to do it with the scissors, but now there’s enough space to get in there. If you’re more peripheral, you’re less likely to catch retina. The retina’s on a short leash. There’s not as much slack. So try to get real anterior if there’s cataract or after cataract surgery. I don’t use it as much as others do.
What about if there’s subretinal proliferation? If it’s clear that it tents up the retina, you don’t need to make a big retinectomy. What I do is go to the place where the membrane is the most taunt, close the forceps and simply punch through. I call it punch through retinectomy. I grasp the membrane and I use the endoilluminator like a second tool as I pull the string up as depicted here. On occasion, you can pull such a great length of membrane that you can use the illuminator like a pulley and pull it over the end of the end illuminator. You have got to be very careful if these bands extend to observe the macule. There is a tendency to look at the instruments and focus on where you’re gripping the tissue. It looks pretty on the video but that’s not where the safety issues arise. You have to pay attention to the macula. People were proud to pull out the membrane, only to realize that the membrane went under the macula and ended up with a tear. So keep your eye there.
So this sequence is the most important single thing that we can talk about other than elimination of scleral buckles and moving to all 25 to 27 gauge vitrectomy. What’s the sequence about? We know to do the vitrectomy and illuminate tear in the flaps first. Then, you start a procedure I developed over 42 years ago, internal drainage of subretinal fluid. You don’t flatten the retina. You have to drain the fluid out somewhere. So I invented the notion of draining through the retinal drain. First, you initiate draining. When the retina stops moving back, you turn on the air, it acts as a surface tension agent to drain up and to seal up all the additional tears so you don’t just recirculate fluid. Some people call that fluid fluid exchange. It’s internal drainage of subretinal fluid. The air level goes down until it seals up the breaks.
If as it starts going back, it gets hung up, it won’t move anymore, that means there’s traction. So first inspect and see if there’s vitreous traction. If there is, then you could do the vitrectomy under air. So implicit in my retinectomy is the notion of doing it under air.
So, let’s assume now the retina moved back. You found a little vitreous. You did vitrectomy under air, being careful because it can be a bit deceiving about where the tip of your instrument is located. Then you transition to the membrane peeling under air. Often, if there are two large bulla side by side, you won’t see the valley between the two convexities. As you continue to drain fluid, the retina starts to go back. If you see a membrane, don’t stop and put PFO in the eye. Simply peel the membranes under air. The only time you can’t do that is if there’s fogging or if it’s an aphakic eye or a corneal or laceration repair. In most instances you can do it. In those patients go ahead and put oil in the eye and do this work under oil. It was taught and it’s an excellent technique. Once again, the retina starts moving back and it hangs up. Move back further, it hangs up. Peel back membrane. Further, hangs up, air. Then you can say the peripheral retina is too contracted. I’ve eliminated everything I can take care of and I’ve eliminated the band. I guess I have to do a retinectomy.
This just illustrated in text that sequence. Remove of the frontal plane vitreous. The radial fibers, anterior loop traction, and then forceps membrane peeling. Removal significant subretinal bands, accessed by punch through retinectomy. Internal drainage. You continue the drainage, search for residual vitreous, residual membrane, residual subretinal, and then start the incremental retinectomy. How much do you know to do? If you do it under saline, I don’t know how much to do. That’s why I don’t do it that way. What I do is cut enough until the retina reattaches. But if it required going to 270, I go ahead and take it to 360. Usually it’s in PVR, and so I tend to carry a little bit above the 3:00 and 9:00 meridian. So once the retina’s attached, then careful confluent laser to the edge and severed large vessels. I can bump up the pressure if there’s a bleed from the vessels. I normally don’t use thermal. This eliminates the need for a buckle.
What are the advantages of retinectomy under air? For one, you do the correct amount not too little, not too much. The retina is stabilized. Thirdly, if you choose to do it under PFO, it’s easy. Every meeting I go to, someone discusses how to remove PFO from under the macula. My answer? Don’t put it there. And if there’s a bleed, it confines the bleeding to the area of the break. It doesn’t diffuse the vitreous cavity and destroy your view.
So this shows you the major difference between relaxing retinectomy and what I recommend, which is retinectomy technique. My technique and his were developed at the same time and independently. He just made a cut and left the tissue anterior. This results in a higher incidence of anterior segment neovascularization. It’s released from the ischemic retina that is removed from its blood supply. And I believe it results in a higher incidence of hypotony because of epiciliary tissue, and I believe a higher incidence of PVR recurrence because of seating of the cells stored in this vitreous base area. In short, it’s about retinectomy, not the technique of relaxing retinectomy.
This is text based fashion in case you didn’t catch it when I was talking in front of the slide. This is quite interesting. Flynn talks about donut detachments, and this is from people that do 360 laser, but they make a row posterior to the equator or right at the equator, and all remains detached anterior. That’s a bad plan. You’ve got to get it all, because the peripheral will migrate, which results in anterior segment. I have had to go in to other cases where there are so called donut detachments where we excise all of the peripheral retina in order to cause the iris neovascularization to go into remission or regression.
So let’s generalize this concept of vitrectomy under air. What do I mean? I call that interface vitrectomy. Some say, “You can’t do vitrectomy under oil.” Sure you can, but you can’t do it in the oil, hence the term interface. If you’re always operating in the vitreous space, the retinal space, the subretinal space, you can do retinectomy, anterior loop dissection, drain, all the techniques that work under BSS also work under liquid, air, and oil. All that you do in diabetics. Punch through all work under air. We all know we can raise retinal breaks and drain fluid under air. Many people forget the techniques work not just under air; they work under oil or PFO. I use medium term PFO. If they can sit up, stand up, go to work, go in a car, go in an airplane, then the PFO stays in two weeks. On occasion, I’ll see vitreous that’s outside and therefore anterior to and peripheral to the PFO bubble. I can remove that with the cutter and then top up the PFO and remove further traction of the PFO. But I do that once the retina is largely attached so I won’t get PFO under, and I won’t use the technique in PVR.
What are the advantages? One, improved visualization of residual visit retinal traction. And subretinal fluid remains stable instead of having it accumulate and increase. This dampening is a big advantage, and as I mentioned earlier, it confines bleeding to the interface.
So what’s the basic technique? Always keep the cutter port in the fluid or in the complex outside the interface between the fluid and the surface tension agent. You don’t lose the PFO and you don’t plug the cutter with oil. I’m going to speak about this further. But every time I use oil for PVR, if they develop an epimacular membrane or a recurrent PVR, I re op with oil in the eye. You’ve got to use max vacuum, and again, 25 and even 27 gauge technique works. You can’t put a 27 gauge cuter in oil and turn it on and expect it to work. That’s why you work at the interface, always staying in the aqueous/tissue space.
If you look at the agents, what’s different about them? They’re all by all, I mean air, oil, and heavy liquids are all immiscible in water. One floats and others sink. That provides two firms of stabilization of the retina. One is because it’s twice as heavy, it actually puts a gravitational force to the retina. That helps express subretinal fluid through the retinal breaks. It literally is a gravitational force issue. There’s also inertial stabilization of the retina. With air, it’s a spring damper like shock absorber in your car. But with silicone oil, it provides viscous dampening. Many shock absorbers in a car have compressed gases as well as oil to slow down the oscillations. So what are the clinical scenarios in which I use interface vitrectomy? One is residual VR noted during FAX and internal drain of SRF. That’s the reattachment sequence I just alluded to. Another one is residual VR traction noted after the PFO is injected. A third one is excessive movement of the retina with saline in the eye. If it’s jumping around, put air in it. It will keep it from jumping around. If it happens to be in a phakic eye with a corneal laceration that obscures the view with interfaces to the back of the cornea, fill the eye with oil and you will see better and you can go ahead and continue to operate with oil in the eye.
And then if you put PFO in and the retina starts going back and it hangs up, you can remove some residual traction. And then lastly, and I’ve already mentioned this, I do all silicone re ops under oil. But here’s what I hear about around the world. People say well, the PVR came back, so I took the oil out, I put PFO in. Then I put in a big buckle around the eye, and it took about three hours and then put the oil back in. Why? Why put the eye through that much trauma and induce inflammation and ax Esser bait PVR? If you have oil in the eye, peel membrane under oil, do retinectomy under oil, drain the fluid. It takes two ports only. Typical reoperation time? 20 minutes. PVR under oil? 25 minutes instead of the three or four hour pain producing procedures.
The interfacial tension agents, you can see the differences in specific gravity and viscosity. The viscosity of water is one CS and oil is either one or 5 thousand times as much and PFO is actually less viscous than water. I have had people say how do you do PFO with small gauge incisions? It’s less viscous than water. You can put it in a 30 gauge needle.
So what are the advantages of air? It’s free. It’s easy to inject and remove. It has the highest interfacial tension. What’s the disadvantage? IOL fogging or striated keratopathy. This makes the spring dampening point of air. What about PFO? 2X inertial dampening, 2x gravitation down force. It’s very easy to inject and remove, less viscous than saline. It’s median cost. Disadvantages? You have to remove residual droplets. The droplets, it has modest surface tension, and the little droplets spin off the big bubble. Any time I leave PFO in for two weeks, I fill it all the way up. That’s essential to reduce the number of small bubbles. They get hung up and they’ll migrate. We have a nice technique that my partner and I reported about how to remove the little droplets, the two needle technique.
So the PFO, as I said, supplies both inertial and gravitational dampening of the retina. So if you have PFO in the eye, you can do some removal at the posterior edge. This ill straight doesn’t show that very well, but in short, it is possible to carefully avoid removing the PFO and remove residual traction.
And finally, interface vitrectomy with silicone oil. Why not see if you can attach the eye under oil and not air? Here’s a common scenario. You do vitrectomy, complicated attachment with PVR, you get it reattached under air, laser the breaks, and then do an air/oil exchange and the patient comes back and says there’s a little detachment. What did I do wrong? What you did wrong is forget and I have done this. The surface tension of fluid air exchange is about 70 times percent meter and with oil it’s 42. So there’s 50% less surface tension with oil than there is with eye. Bear that in mind and make certain that you get rid of all the traction. But if you operate under oil, you’re much more likely to see an attached retina.
And so here’s that viscous dampening point I made before. So these scenarios that’s a repeat slide. So what about the two port technique? If you have a retinal detachment and oil’s in the eye or I put two ports in the eye, not three. No infusion of fluid. I don’t use two being connected to the VFC. If I eat an epimacular membrane, you don’t remove any oil, so you don’t have to add any oil. You don’t even have to open the oil and save cost. You simply put the forceps in there, peel the membrane. You have the end illuminator in one hand and the forceps in the other hand. If you have got to remove some of the subretinal fluid. The eye gets soft. I top up the oil by taking the cutter out of the port. The oil doesn’t run out like saline would. And then I reinflate the eye, then I remove the fluid. It might take three or four iterations like that. With a two port technique, you can re op under oil.
So here is silicone’s in the eye and I’m peeling the star fold under oil. Or in this case, the EMM membrane, this shows topping up the oil on the end. These are the older type of cannulas there. This medium PFO concept, I’m excited about. There’s a series, New Zealand started when I did. They do a lot of the cases and are very happy with it. Many people are getting back to me that they’re using the technique and very happy with it. What are my what are the key elements? As we know, when you, if you’re doing macular hole surgery, that the interaction of the bottom surface of the bubble can cause an inferior retinal break. This certainly happens, or just superior detachments. So if you learned that lesson that if you put something in the eye that floats, you’ve got to be careful to remove it all because of where it interacts with the surface of the bubble. But if you put PFO in the eye and leave for two weeks, it sinks. So now you have to be very careful to remove all the vitreous superiorly. But not in macular surgery cases. There’s excessive peripheral vitreous shaving going on in macular surgery cases. There’s simply no reason for it. It increases the chance of damaging or bumping the lens. Back to this technique, do a vitrectomy. Let’s say it’s a young myop, don’t pull on it aggressively and make other breaks. Don’t say oh, I must do a buckle. Put the PFO in. The retina will slowly attach right before your eyes. It might take five minutes for the viscous subretinal fluid to come out of the break. Occasionally you have to apply a little vacuum. Once it’s completely attached, you removed apparent traction. And when you come back in two weeks to take the PFO out, it’s not just an exchange. You put the cutter in and you will find they have a slowly created PPD during that interval. By then, the laser marks have maximum tensile strength and usually pigmented in. If you leave it longer, there’s increasing inflammation. It’s not toxic, it’s a foreign body reaction. When you remove it, any white deposits on the retinal surface goes away in a couple of days without a problem. You’ve got to remove it. Two weeks. And you have residual droplets which can be removed with two needles in the office. One to infuse from above, and one 30 gauge needle inferiorly right at 6:00, because, of course, this is heavy liquid. You can remove the bubbles carefully. And very safely, even in phakic eyes. I have done it many times.
Currently we’re over 900 eyes. I did them topical for two weeks. We have got the procedure to remove the PFO.
360 peripheral vitreous removal has been emphasized over and over again. Here’s the PFO filling. What do I inject? I use the met one dual bore cannula. It allows, through the illustration here, to achieve egress, so you have a normal tensive procedure. You don’t have a tiny needle with a leaky port that you’re injected through. So this dual bore cannula is a nice idea. So the up port is the one that allows fluid egress, where the distal port, the side or the the tip is where the PFO is injected. How should you do it? You should always have the tip of the cannula in contact with the top surface of the bubble. So you have got to slowly withdraw while observing the interface and raising up the focus in your Mike scope. That is crucial. Why? If you always do that, you can make a single bubble. People say I always have a problem with fish eggs and multiple bubbles. You did it wrong. If you lay the patient on their side and barely put the needle in, you can make a single bubble. When you inject PFO, if you stick a short needle in the top part, you will have a bazillion droplets and you have got to wait around for them to coalesce. So the side flow dual bore cannula from med one works well. Or just inject slowly over the nerve until you get a two or three millimeter bubble. And then hold the tip of the cannula right in contact with the bubble and withdraw it slowly as the bubble increases in size, and you can create one single bubble. But you’ve got to really have sharp focus with the Mike scope. The interface has a small refraction difference, and it’s hard to see.
And so then, confluent laser as depicted here, I know it looks like a smile. But, that’s the confluent laser motion instead of spots. Get rid of the notion of spots. That’s for cryo. If you’ve got the PFO in place as depicted here and there’s some subretinal fluid, you can drain it here just by putting a soft tip cannula or tiny metal cannula through the hole. Or you can extend the break so you can get rid of the the anterior fluid. You’ve got to get rid of all the fluid and raise confluently around all the retinal breaks. And this shows you the cannula that med one makes.
That is the end of my formal presentation. Now we can take any Q&A questions if you have some questions.
Well, we don’t have any open questions out there. So, let’s do this over the remaining ten minutes or so, unless some questions pop up, let’s review what I’ve talked about. Number one, advance your techniques, challenge yourself to learn to repair every retinal detachment without a buckle. Implicit in that, learn to use medium term PFO. PFO that stays in there for two weeks for inferior retinal attachments. And what else? Giant breaks. If I have a temporal, nasal, or inferior giant break, I put it in, laser the whole break, and let the patient lay on their break or reclining. In two weeks, I go take the PFO out. I don’t do exchange. If I have a superior break, then I have exchange it for gas or silicone, mindful of the David Wun technique, that you must stay between the PFO/liquid interface in the far periphery, so the meniscus is curved upwards. It’s convex. You don’t want to be at the apex, you want to be at the periphery. So that’s the point I want to make there. Let’s get this out of the way. I guess I was talking with my hands. As the bubble is moving up like so, as you want to as you’re exchanging it, here’s the bubble, and you’re doing a direct exchange, you want to stay at the periphery of this convexity, because that’s where the little meniscus of subretinal fluid, vitreous and occlusion fluid is. So, think about that. That’s the inverse of how you inject PFO. You inject PFO by starting in the optic nerve head, making a small bubble, and withdrawing your cannula with the tip always aligned with the top surface of the bubble as you grow the bubble and fill it up. So always remember that it’s central and on the top of the bubble when you inject. And it’s peripheral, on the outside edge of the bubble when you exchange for either gas or exchange for oil with the PFO. So this medium term PFO technique, I want to bear in mind. Another point we’ve got to emphasize is don’t think it’s the tough case, therefore I must use to gauge. And don’t think, well, I’ve got to support it’s a tough case, therefore I’ve got to put a buckle. Change your mindset, try to put that behind you. If you look at it this way. Do we try cataract extraction and if it doesn’t work out, try phaco? So why should you put a buckle in and if it doesn’t work, do vitrectomy. Learn to do vitrectomy properly. Do the various exchange techniques, to operate under air, under oil, peripheral to the PFO. You have created a quiet comfortable eye without refractive error. It’s far better for the patients. And the other point I emphasized earlier in my talk is the number of patients that I see that they did the phaco bit, but they had trouble, the people came down and now they had to do something that induced inflammation and iris damage. I couldn’t see the periphery well enough. I had to do such and such. So many patients have, for one, significant refractive error after phaco because they don’t use the knowledge of formulas, they only use ultrasound to measure axial length. And so we see refractive outcomes that are not good.
The second thing we see is compromised vitrectomy, because the phaco didn’t go exactly as you hoped, and therefore the view is compromised. What I tend to do is staged procedures. Patient presents with necrosis. They need a vitrectomy to repair a retinal attachment. I tell them that you’re going to need a cataract surgery by an expert; that’s not me. Let me fix your retina. When it is stabilized, a cataract surgery will do a great job. On the other hand, the patient needs macular surgery and they have a posterior subcap, cataract surgeon operates, you come back in a couple weeks and do the macular surgery.
If you’re a really good phaco surgeon, okay. Do it. Unless you’re really good at it, there’s no problem with lensectomy. We’ve done many, many anterior chamber lenses. I’m very happy with it. I don’t think it’s absolutely necessary that everybody must have an inner ocular lens in their eye.
So we have a question about a patient who developed an RD. I have not done this, but people have reported using sutures a couple of sutures that go across the eye at the pupillary plane, or there would be a pupillary plane, and it held back the oil. Some reliable people reported that. I don’t have the reference in my head at the moment, but I think that’s an interesting approach to try. I would not recommend this artificial iris approach. Those are very rigid, and I’ve had the opportunity to operate on a young girl that had this and it was a huge challenge to do the vitrectomy. I tell patients don’t lay on your back, and I’ve had good results with that. I’ve probably done 15 or 20 anoretic patients over the years. If you just tell them don’t lay on your back to sleep; lay on your side or face down, I’ve had good results. You can wait several weeks or months and take another look at that point.
We don’t have any other open questions, and we only have about four or five minutes left. Unless there’s more questions, let me provide my e mail address. SCharles@ATT.net. I thank you for listening
>> I put up on the screen some of the questions asked in advance. Maybe have a quick scan through those to see if there are any relevant questions or topics.
>> Sure. When was the last time I did a buckle? 12 year ace go. Do I do a vitrectomy on young phakic patients? I do. I use a wide angle contact lens. I currently use not the ovi. I use the vokhrs acs [ phonetic ]. It fogs if there’s high humidity in the room. I never use heavy silicone oil. A lot of they are not approved in the United States and my friends in Europe say it causes a lot of inflammation, and I don’t do that.
It says how I… okay. How do we manage flour carbons under the macula? I make a slit over the bubble and the PFO will pop out and I put air in and that’s all you need to do.
If the patient reattachs with 360 in oil, I’ll peel membrane, defer the retinectomy if required. Particularly young people have wonderful visual outcomes, particularly with vitrectomy. If you do a big buckle, it’s a three, four hour operation, there’s so much inflammation that their visual outcomes are not so good. I have been happy with doing vitrectomy, only repair. How do I choose? I never use a buckle. That one’s easy. Oil is for a couple things. One is a patient that can’t position at all. A patient that must fly, or PVR. I manage PVR re ops under oil by operating under oil.
I don’t understand that one. Oh. Double vision after buckles. If someone has a buckle in place, and the buckle is a high buckle, in particular, and PVR, and the buckle’s extruding or causing strabismus, if you remove the buckle, on occasion, the retina will re detach. It is now detracted in a new configuration. So it’s another okay. What percentage of complex RD do you receive? And when do I operate? I do around 800 vitrectomies a year, many of those are macular many, many of these are complicated complex retinal attachments, PVR, giant breaks, detachments. Do I have a protocol or when to operate? Yes, instead of rushing in a re op setting, let it quiet before you operate. It was talked about the life cycle of PVR. Operate on quite eyes.
What technique do I prefer for giant retinal tears? You got to use PFO. Leave it in two weeks. Never use a buckle in giant tears. Never never never. If it’s superior, exchange it carefully with the technique I described. Exchange it for oil or gas.
Now it looks like I’ve answered all 17 questions and time’s up. Thank you everyone for listening, and feel free to get in contact with me via e mail if you have further questions.