A step by step approach for the surgical management of a retinal detachment will be discussed using video footage of various situations. Standard primary vitrectomy for retinal detachment as well as Chandelier based Buckling surgery will be shown. PVR is the most common cause of failure of surgery for retinal detachment. Various surgical steps and situations related to different grades of PVR will be shown and discussed. Hence a overall approach to management of retinal detachment and PVR will be covered during the webinar.
Lecturer: Dr. Manish Nagpal, Vitreo Retinal Consultant, Gujarat, India
DR NAGPAL: Hello, everyone. A very good evening to you from this part of the world. I’m Dr. Manish Nagpal, and will be speaking to you about surgery for retinal detachment and PVR. I would like to thank Orbis for facilitating this interaction between all of us. So fasten your seatbelts, and we’ll go on to a journey of retinal detachment and PVR. So here you see a classic superior bullous detachment with a horseshoe tear, and for this the management can be of three types. Typically a scleral buckling could be done, a pneumoretinopexy could be done, or a vitrectomy could be done. Usually this is based on the experience of the surgeons or the success rates of each of them. The most popular procedure right now is primary vitrectomy. Scleral buckling works very well for certain kinds of detachments, and pneumoretinopexy has not been that popular over several years. Although certain classic tears do quite well with a pneumoretinopexy also. So we have a question for you. For a superior RD with HST, which of the following procedures would you prefer? Okay. So people have clicked. And 41% would choose primary vitrectomy. 38 would choose pneumoretinopexy. You can see a shift towards primary vitrectomy at this stage. So let’s go on to primary vitrectomy for a classic detachment. We’ll start with the incision. Typically nowadays we use a 25-gauge or a 23-gauge approach, and this is how we would put the incision. You put in all the three cannulas, and then you’re ready to start the surgery. Once you go in, the most important part of the surgery is to remove the vitreous. Once you have a good view, you’ll do a core vitrectomy, visualize the vitreous, and remove it as far as possible. And this particular situation, what I’m showing you, is with a preexisting PVD, where the hyaloid is already detached from the retina, and that makes it much easier. So all you have to do is go in and remove all the vitreous, without having to go in and create a PVD in these situations, and then after that, go in and do the next steps. The second example is where you have no preexisting PVD. With a detached retina, creating a PVD becomes difficult, because the retina is not stable. It is moving. Every time you pull at the vitreous, the retina also moves, and it creates more difficulty in separating it, because you worry if you pull it too much, you’ll create a iatrogenic tear. So we usually try to stain it. If you’re not visualizing the hyaloid very well, you can use the stain and that will help you see better, although the procedure itself can be available in younger patients. In high myopics, it’s very difficult to remove. But the staining will help you to a large extent. There’s another myopic case, where you see a triamcinolone-stained hyaloid, and it peels off gradually as we use the vacuum, and you gradually peel the whole hyaloid away from the retina. As it keeps separating, you’ll see the hyaloid separating, and the triamcinolone staining of course helps the whole process, because you can see it much better. So as it keeps getting clearer, we use the cutter, the vacuum. As it keeps peeling, you use the cutter to clear off the vitreous, and then as you go to the periphery, this is the lattice, and as we peel it, you can almost see that it starts shredding and creating a tear of its own at times. So in these places, it’s nice to trim it, rather than totally trying to peel it off. Just trim and leave it at that place. So this becomes the most crucial part of detachments. The vitreous removal, especially in situations where the hyaloid is still attached. And then of course once you’ve dealt with the hyaloid part of it, then you go and remove the peripheral part as far as possible. So once the hyaloid is detached, you have a freely mobile vitreous. You can remove, you can go to the periphery. The key is visualization. Whatever systems you use, it could be contact, non-contact. I personally use contact, and I prefer that visualization to the non-contact variety. And here you can see that there’s a typical detachment with the large tear with rolled edges, and we’re making sure that we see that very well in our view, and zoom it up so you can see the interface of the vitreous close to the retina, so that you can remove the vitreous without actually touching the retina, as far as possible. So the visualization is important. Any good wide field viewing system, with a good microscope, XY zoom, these become mandatory to do this process. And here you can see that we’re externally indenting, to bring the peripheral vitreous. At times if you feel it’s a phakic eye, and you have difficulty in reaching the periphery, one could indent from the periphery. An assistant can indent. Or you could put a chandelier in, and indent yourself with the other hand. So these are typical processes, where you go and remove the vitreous as far as possible. All 360 degrees. And after that, do the next steps as you progress. So this is an example of a pre and a post-op in such a situation. There’s another case with multiple tears. Myopic eye, large superior tear and multiple tears. These are multiple lattices which have torn up — the PVD occurs many times with high myopics. So you can see the retina, some attached vitreous, and as you keep tearing the central part, you go to the periphery again, you can see that with an indentation, this is a phakic eye, so we indent and lower the IOP so that you can indent comfortably and remove the vitreous close to the retinal attachment. You can also see the cannula in the extreme periphery, with these wide field systems. So 360 degrees slowly you go on clearing this hemorrhage, which is there. The vitreous with heme attached, as you can see in the periphery, and you can remove that, and after that, of course, do a stain and drain it. At the moment, our main concern is the vitreous removal at the beginning. And the next step is air-fluid exchange. Once your vitreous is gone, you can switch to air. The air replaces the fluid, and the freely mobile retina would usually become bullous at this stage, which is a good sign. It means there’s no traction. It has lifted — the bullas have formed, because the air has pushed the fluid through those breaks inside. Then you go to the disc and do a complete exchange. And once you’ve done that, you go to the break. The predefined breaks, or or create an otomy, based on the ergonomics of drainage. So you see the retina gradually flattens. This is the next step, endodrainage. It was a break we used to do that. After you do the air-fluid exchange, the bulla is formed, but the break is too peripheral and unconnected to the fluid, and you cannot drain from there. So in this case one of the options is that you push perfluorocarbon, which allows you to drain from the peripheral area, and that’s where you do the endodrainage. It keeps the posterior pole flat through the process, and then of course once it’s flattened, you do a retinopexy with laser. This is again another example, where after clearing the vitreous, you see that once the periphery is clear you do air-fluid exchange, you put perfluorocarbon, and when it reaches the fluid, you drain from that area and perform the retinopexy. In macula on RDs, it’s best you push some perfluorocarbon in, so the macula always remains attached through the surgery. Otherwise if you do air-fluid exchange, sometimes the bullas, as you saw in the previous slides, would come to the central part and create macular detachment, which you don’t want. In a case like this, as you saw, this is a macula-on RD. We push perfluorocarbon, making sure that this fluid would never come to the central part. And then of course once you’ve done air-fluid exchange, remove vitreous, you can aspirate the fluid from those holes, without having the macular area involved through any part of the procedure. Once the macula detaches, it does leave behind some damage. So you have to take advantage of the fact that it’s macula-on. At this point, I also want to talk about the value of valved cannulas. Here you can see turbulence. This is a non-valved cannula. In detached retina, I think it effect is most obvious. As you can see this perfluorocarbon. And as soon as we push an instrument inside, everything quietens. But you can see that when you remove the instrument, how much turbulence takes place. And this is not so good for the eye, because this means that things are moving. There’s a lot of dynamics inside the vitreous cavity. You could push some perfluorocarbon in the subretinal space to the breaks. Especially with giant retinal tears. It happens much more often. But it’s something that is not desirable. And you don’t want this kind of turbulence happening. So I always prefer to use valved cannulas, through all the surgeries. And that maintains a very good non-turbulent vitreous cavity quality of procedures to a large extent. And then of course the last step in any primary detachment is to do an endolaser. So once you’ve flattened it, you seal it with a laser, or a cryo, based on the location. And seal it totally. At the end of the surgery, this is our typical method of removing the cannulas. We remove the cannula and give pressure with a smooth massager. For 10 to 15 seconds. So if it’s a fresh case with no silicon oil, one could just do a massage, and most of the times the incisions will hold. But if you feel there’s a leak, if you put oil inside, those are situations where we would always like to suture with 8-0 vicryl, which is absorbable, and usually pulls the wound quite well in these cases. So while we are talking of primary vitrectomy, I would like to bring you to the other option that we have, which is the buckling. We see a decline in the overall buckling procedure. And that’s primarily because less procedures are being done. And so the teaching of these procedures become less and less and so the skill is not going further. And what we do at our center is that — just to make it visible, we use a chandelier-based buckling surgery. Most people doing retina, I use vitrectomy-based visualizing systems. The contact or the non-contact. And then… So it becomes easy for them to adapt to a viewing which is based on vitrectomy-based systems, rather than indirect. Because it has a lot of advantages. As I will try and show you. So what we do is wherever indicated, we will do a classic buckling, but without the role of indirect ophthalmoscopy. We use a vitrectomy-based visualizing system. I use a contact Volk SSV system. One could use that. But one could also use the Biom or any non-contact system. We put in a 25-gauge chandelier, which is typically available with vitrectomy procedures, and you insert that, and that creates illumination enough for you to see with any contact or non-contact system. You can see a still picture of a view of an indentation taking place inside the eye, and you can see a cryo being done with a cryo mark on this side. And I’ll show you a video clip of a classic procedure of buckling. Here you have a myopic eye with an inferonasal detachment. You can see this is an indentation going on. Now, all the steps are the same as the classic buckling using indirect ophthalmoscopy, except you’re seeing inside with a contact or non-contact-based system, instead of indirect. All the external steps remain the same, and they all happen under the microscope. So you take the localizing stitch. You do diathermy, define the area of drainage, redo the needle drainage, you can see the fluid coming out from there, look at the drainage site, make sure there’s no bleeding. If there’s bleeding, you need to give pressure to that, and then you look at the buckle effect, which you can see now, and the retina is flat with the buckle effect. So all of those things that you usually would try and look with an indirect ophthalmoscope, you can see it much better with these systems. You have a much wider view. You can zoom in where you feel like, and it’s good for teaching, because indirect ophthalmoscopy, you cannot see much inside. Even if you put a video inside, it’s not something that’s so apparent. Here you see sequentially a break identified with the cryo lesion coming, and then thawing, and after that, we indent externally, after doing the cryo, we localize the break, take a marking suture, identify the area of drainage, drain it, put the buckle, check for the buckle effect, as you can see here, and this is how we do a typical chandelier-based surgery. This is a young patient with inferior holes, a classic indication for buckling. You can see you can zoom in, you can bring the holes closed, you can see the dynamics much clearer. This is cryo being done to that area, the hole being covered, and you allow it to thaw, and the reaction gradually subsides from that area. Your aim is to cover the whole lesion in that area. After that, you’ve localized, you’ve taken a suture, you’ve defined the area of drainage. As you can see, the fluid comes out. Some pigments come out from that area. And once you’re satisfied with the drainage that’s happened, you make sure you keep the pressure on. Because sometimes these procedures can lead to a small bleed. So if you keep the pressure on, that bleed would not increase. Here you see this is the drainage site. You see the white dot here, which is over the buckle as well. These are the holes, and the retina is flat. So the view is actually — those of you who do indirect-based buckling, you would appreciate that the view is much better than what you see inside. Especially for teaching purposes, we’ve published this a long time back in 2013, and since then a lot of teaching centers have adapted this, and they now have been using it for all their buckling procedures, and are quite happy with it. And for a period of time, we had a lot of people discussing it at various forums. And they feel that this would help keep the whole process of scleral buckling a bit alive longer than one could. So everything about these procedures is visualization. That’s the key, whether you do a primary vitrectomy or a buckling. So everything depends on visualization. So make sure you have the right visualizing system that suits you. Contact, non-contact. Or even indirect ophthalmoscopy if that’s what works for you. It would be very easy for a surgeon comfortable with vitrectomy-based visualization to adapt to this modality, in case there’s an indication for buckling, and better visualization with zooming capabilities and ability to transmit or record surgery to a viewing monitor makes it a much better teaching tool. Also it allows you to sit and do buckling surgery on a microscope instead of all the time bending with an indirect ophthalmoscope, which over a period of time takes its toll on the neck and back of most of the retina surgeons who do buckling in these cases. So at this stage, I have a polling question for you. For a classic buckling procedure, what would you prefer during a surgery? Indirect ophthalmoscopy-based visualization, or a chandelier-based visualization? Okay. So I think I’ve been able to convince a lot of people for chandelier-based visualization. And I think if we have to sustain it, that’s probably the way to go ahead. Those who are comfortable with overhead can obviously carry on doing so. Either way it will help the process of keeping the art of buckling alive in some form or other. So now that we’ve gone through the primary vitrectomy or buckling for a regular rhegmatogenous detachment, we move on to a more complicated area of the PVR. PVR is when a normal fresh detachment starts turning old, and membranes start forming, either in the retinal plane, the intraretinal or subretinal plane, and they start contracting and create all kinds of problems. So we’ve been working on PVR for a long time and have been associated with the fifth and sixth editions and at the moment are working on the seventh edition as well for this, and we have a lot of videos for the book itself. When we talk of PVR, the simplest form of PVR, which is a macular pucker, is something that you would very often see associated with a detachment. Now, this is a detachment, this is a macular pucker, and once you see a pucker, it is now quite well accepted that it’s better that you now also go and remove the ILM. Because that may prevent the chances of recurrence of membranes from that particular area. So this is a detached retina. Buckle has been removed. You can see the residual striae left by the pucker, we stain with a Brilliant Blue dye, and gradually remove it from that area. With the detached retina, sometimes the ILM removal can be a little awkward. Unlike with a flat retina, where the retina puts itself on the hole or macular pucker, with this when you remove the ILM, it tends to move. So sometimes it’s simple and sometimes it’s more difficult. At times we use perfluorocarbons to give support. Sometimes you don’t need it. Best is to stain and try to remove it. If you think it’s easily possible to remove without any other agent, you can just go ahead and remove it. But if you feel it’s coming in the way — the whole mobility of the retina, maybe it’s a good idea that after the staining you put perfluorocarbon and go and remove the ILM at that stage. So let me ask you here another polling question. That during vitrectomy for a primary detachment, I’m not talking with or without a pucker, but specifically here the question is addressed: Would you always people ILM, never peel ILM, or only peel if there’s an existing macular pucker like I showed you? Okay. So I’m glad that most people would agree to the fact that they would peel an ILM only if there is a preexisting pucker. A lot of surgeons would do it for all detachments. I’m not totally sure of the advantage of that. Epiretinal membranes are not that common, post just a regular detachment. I’m not sure if peeling the ILM would ensure there is no pucker. I peel it only if there is an existing pucker that requires that. So this is another example of a similar situation. Where — as you can see, the striae which formed, and after that we are removing the ILM from that particular area. Here you can see there’s a bit of difficulty. I put the perfluorocarbon. Another tip is: Always peel away from the disc. The disc is where the retina gets attached. It would keep the retina intact while you peel away from the disc, like I’m doing right now. But if you pull this towards the disc, you will pull the whole detached retina with you, and it will make it more difficult. So pulling it away from the disc helps you. So these are small tips that can help this whole process better, once you are removing a membrane or an ILM under a detached retina. This is another case which has a much thicker traction pucker, which is radiating down inferiorly. Here you can see that we remove the thick pucker from the macular area, and part of it is radiating to all the sites with the thick radiation inferiorly. So once that is removed, we look for how well the retina has released itself from the traction, and you can see that inferiorly there is a hole here, with a stretching effect which is still seen after the air-fluid exchange. Even though most of the retina is flattened, there is a traction here. So I go on to do a small relaxing retinectomy here. This is a small retinectomy. You have to do it where you feel there is persisting traction. Because this is an inferior area of the retina. And any tamponade you give here is going to be inadequate to give good pressure. So you have to make sure the retina is well released of the traction. You can still see some stretch marks, which are relaxed, but they may take some time to flatten with silicon oil inside, over a period of time. This is a case of a buckle many years back, and the patient came to us with recurrence of detachment. You can see the buckle is intruding. This whitish shining area is actually an intrusion of a buckle. These are actually very dangerous situations, because on the one hand you cannot remove the buckle, because you are worried that you may perforate that area. So you have to be very careful not to meddle too much with the buckle and just passively repair the detachment as far as possible. Use perfluorocarbons, flatten, don’t use too many other variables. You can see here the intruding buckle, this white whole area, and what we did was also with a lot of laser all around it — at least the barrage would prevent the detachment from increasing in that area. So these are peculiar situations. They happen with many years of buckle being inside, over a period of time. Especially in myopic eyes with thin scleras. You can get these quite often. This is again a case of PVR with no classic puckers. But you can see a lot of striae, star holes, with ill formed star holes. Here what works best is… When you go and peel, you may not find a membrane that easily. So it’s a good idea to stain this, once you remove the vitreous. You go and put the stain inside, and then as you wash out the residual stain, put perfluorocarbon. That helps stain the whole area of the retina very well. And then you could look for a membrane edge. You could also use a loop at times, gradually moving it over these folds. You could achieve both of the things. You could iron out the folds, as well as, if there is a membrane, you may be able to find an edge, or you may be able to find the ILM in those areas, which will help you to release the ill-formed membrane quite well. So this is something one could use in situations with ill-formed star folds, which are in definite areas. This is the post-op image of this particular case. This is another case with a thicker traction membrane, which is also forming a scar on the central part of the retina. But no specific area of membrane, except the one which is near the macula. So you can see that the stain helps you to a certain extent of where it goes, and then it can help to remove the traction and relieve the central area as far as possible. So this is a bit of chronic traction, and you can see a lot of stretching, loss of elasticity here, a contraction. But once you relieve the gross traction, it may help that central area to get a little more anatomically similar to a normal macula. You can see this is a post-op photo after a month, and you can still see the lack of differentiation of the retinal tissue. Because it was so chronically pulled that it’s very difficult for it to get back to normal. But it will, over a period of time, flatten. Which may make the vision a bit better for these patients. This is another case where you see classic detachment with central star folding. And these are easier to identify, because the radiations start from the macula, and I often use perfluorocarbon to — as soon as I remove the core vitreous, with a basic vitrectomy, I would put perfluorocarbon and then remove it, because it helps you understand to what extent the traction is and identify the whole process, and then you can take care of those areas. This is a detachment with multiple areas of contractions happening. As I said before, I’ll put perfluorocarbon. It opens up the funnel to some extent. And gives you the first view of where the membrane or the star fold is. And as you release the perfluorocarbon, it pushes the retina back, and gives you almost a certainty that that retina is flat. And then you can proceed to the periphery. So in this particular case, the peripheral part also needed a release, a retinectomy, and you can see that you put it back. This is a multiple times operated case, where these contractions come up. This is a case of extensive PVR. Which you can see that there’s a lot of radiations of the poles where centrally the vitreous — there are large tears with folded margins on this side. First of all, you have to create space by removing the central vitreous, and that’s when you get a view — and remove all the vitreous which is adherent, and also all the vitreous adherent to the edges of the breaks. And you can see that that’s the first thing that we are trying to release. Because unless you release all this, it will become more and more difficult. Once you have some space, you put perfluorocarbon, it will go gradually up to the edges of the break. You don’t want to inject too much, because it may instantly jump to the break otherwise. Once you have a flat posterior pole, you can then work on the peripheral part. So here you can see that we’re removing the stuck membranes to the peripheral part of the retina. At times, you could also use your light pipe as a second hand — or if you need more manipulation, you could put a chandelier, and then put two instruments inside, to deal with this. So gradually, we segregate the whole vitreous content from all these areas. You can see almost a 360-degree adhesion is there of the vitreous attachment. We gradually remove all around. There’s also a buckle in these cases. We would use a buckle, so there would be a buckle in the periphery. And here you can see I’m using the staining to identify and release, because still the retina does not look so traction-free, so the more and more you can release, you’re better off. You can see here that at the end of the surgery, it has flattened, and then you do more extensive laser on it. Then oil, of course, to give tamponade to these areas. At times, there is a radiating subretinal band that you can see here. Which can pull the retina as a stretching effect. Because at times, they are flat, and you don’t need to do anything. You can just let them be while you flatten the retina. But at times, when it doesn’t settle, or you see obvious traction, you can remove them. Here you can see we pulled it, but it broke. It’s extending to the other end of the retina. So in that case, you can also leave it, because you’ve released it, and the retina will flatten. In this case, we can pick up the strand from the other end, and that part also came off. But if you cannot remove it easily, then it’s best to just release it, so that it does not apply any new stress to the retina, while it can settle without having to totally remove the band. Because it can be traumatic at times. Now, this is a case of more aggressive PVR. You can see that there’s much significant contraction inferiorly. Which is there. That’s probably a buckle as well. But still the retina is contracted. So here, once again, after clearing the vitreous with perfluorocarbon, the typical thing that I would do is put perfluorocarbon and remove the membrane from the central part, which is identified at this stage. As long as there are no posterior breaks with traction, you can always use perfluorocarbon. If you have posterior breaks, that’s the only time one would be wary of using perfluorocarbon, because with traction the perfluorocarbon tends to go behind very easily. Most of these had not have a posterior break. They’ll have the classic peripheral break. And that’s what you see here. We did diathermy to the big vessels in the area we’re planning to cut, after that, you cut the retina peripheral to it, and this is how it looks like at the end. Make sure you always have perfluorocarbon kind of there as a safety, in the whole posterior pole up to the edge of the retinectomy. Treat it as a giant tear, because it pulls that area as you do manipulations. Also if there is a bleed from this site, it will prevent it from going to the posterior area. So I always use perfluorocarbon in these cases. This case has PVR, but also has subretinal oil. So here you see contractions which are there, and then inferiorly, there is subretinal oil, so here once again, these are vitrectomized eyes, we remove the oil, put perfluorocarbon, remove the posterior buckle which is there, and you can see the releasing effect on the posterior pole. And as you increase perfluorocarbon, you can see that the subretinal oil comes out inferiorly from the preexisting break of contraction. And just like the previous case, we do diathermy and prepare and do a good retinectomy in this case to release the area. This is another case, previously operated with oil inside, and now has PVR with subretinal oil. The first thing is to remove the oil from the vitreous cavity. You let the oil go out, so that you can assess exactly how bad is the traction. And once this oil is out, you can then get a good view of the subretinal oil here. There is a lot of fibrosis, contraction, which is built up. So at this stage, you inject perfluorocarbon. The perfluorocarbon becomes very important. You can see it pushes the oil globule passively, And it comes out from the inferior area and you can remove it separately. After the oil has come out, you assess the residual traction. Do diathermy, prepare for the retinectomy, because these are too fibrous to retain. All the vessels are diathermized, and then you cut. Keep yourself steady for raising the pressure, in case you see a bleed happening. You can see how well the perfluorocarbon keeps the posterior pole at bay, while you do these procedures. You can see a small bleed in the periphery, but it has not come beyond the edge. It gives you time to take care of these situations. Otherwise this blood will straight away trickle to the posterior pole and create more problems for you. This is another case. You can see myopic with extensive contraction. And also has a subretinal oil. In the previous case, it doesn’t have an opening. So here anyway we have to do a relaxing retinectomy, so we release it in the area of the huge globule, which is there. In this particular area. And you can see that once that area is released, the globule would come out, and allow you to then assess the residual traction. Which is there. So here, after we’ve released this part, we also go on to the left — on the left area as well, and then release all that contraction, which is there. You can see there’s still a contraction which is going from the horizontal meridian so you have to do various areas of relaxation, ’til you make sure that you gradually flatten the retina. At times, you may also have to do some radial nicks to release this traction. Here you can see the irregular shape of the whole retina has formed, but that’s the only area which one could retain with releasing the traction in this particular situation. This is again to show you an example of inferior retinectomy. We have removed oil and there is inferior detachment with PVR. So we put perfluorocarbon, diathermy to all the big vessels, perfluorocarbon is bordering the anterior part of your retinectomy site, keeping you safe while you cut the retina beyond the diathermy mark. Try to remove as much of the peripheral retina as possible. This is a redundant retina which becomes a scaffold — things can form on this and sometimes create problems. So make sure you can remove this before you proceed. You can see small oozes. Make sure you raise pressure and stop them. The advantage is the perfluorocarbon will not trickle to the central part. This is a large tear, a giant tear, with very aggressive PVR that you see. With a giant tear, the problem is that you don’t get a hole. Whenever you inject or do anything, it starts to spill over. One has to do it very carefully. Inject PFCL only in the central part gradually, then remove more vitreous. Assess more as to what can be done. Gradually keep increasing the PFCL, and then assessing which area needs to be released. So you can see that there’s a contraction. This whole area is folded onto itself. And then we are gradually releasing the whole area. This whole enfolding of the retina, which is happening in this area. As we release the traction, and put more PFCL, we try to iron it out gradually. And you can see the shape of the macula coming back, which was totally folded onto itself. Because of this tear. So in these situations, one has to be careful how to proceed, because very easily the perfluorocarbon can come back and complicate things for you with PVR. Once we flatten it, you can still see this radiating hole superiorly. At this stage, I decided I need to do a radial retinectomy and release this, so that this area gets relaxed. Otherwise, this area will keep again a traction on, and create a torsional effect on the retina. To a large extent. So these things you have to judge based on a case to case basis and add these retinectomies along. Not just a classic circumferential retinectomy is always required. Here’s another case. You can see there’s barely any retina on the sides and a lot of contraction. You can see that we’ve released a lot of areas, and then there’s still a lot of folding. Now, here we use an instrument called the massager, that we’ve developed for massaging macular holes in such kind of cases where there are holes. So here you can kind of iron out these folds. You don’t have to use your cutter or a soft tip to do it. Because they can become traumatic. This is a round bodied small instrument, which can be used to iron out these stiff folds of PVR which are there especially in these kinds of cases, which have very taut traction. So once you release the traction, the retina tends to gather onto itself. So this way, you can iron out and gain more surface area, before you can do the laser in these cases. This is a giant retinal tear. Which is very posterior. You can see it’s posteriorly placed, and along with it, there’s a macular hole. This becomes tricky, because the macular hole is very close to the posterior area. So here first of all you remove the vitreous. You remove this whole bloodstain, which is the hyaloid, so that the whole retina relaxes. And once you finish that, you have to look at the macular area. And here you’re removing the ILM, and we take the ILM right up to the temporal edge of the tear. Here there is a traction up to the temporal area. It’s best that when you’re removing the ILM, keep on extending it to the extreme periphery. That will help release some of the contraction, which is there in this whole temporal area. Because of the tear. You can see that I’m extending it right up to the periphery. And the whole ILM up to this area is gone. And there’s also folded retina here, which we are unfolding to some extent, to gain surface area. And then of course to a laser in that area. So this is a case of a giant tear, which has folded onto itself. And also is inferiorly attached. It’s almost like just a few degrees are attached inferiorly. So once you identify, after removing some of it, you identify the opening of where the disc is, and then your first step should be to put perfluorocarbon, because that’s the only thing which will keep the retina pushed away, while you can do more vitrectomy and make sure that the retina flattens. As you can see, when I pushed so much, because of the inferior attachment, certainly the PFCL will tend to spill over, because there’s traction on the inferior side. So here we’ve got a 360 giant tear. One has to consider this, because otherwise the PFCL would not flatten the whole retina. You can see there’s a certain contraction to it, which was holding on, on the inferior side, and creating that effect. But once you make it 360, it becomes easier to flatten that whole retina eventually. With that. So these are some of the examples of post-op of a patient who has underwent a large retinectomy. You can see the laser marks. And typically for resurgeries with bad PVRs, with inferior retinectomies, we would do a much more aggressive laser inferiorly. Because that’s an area which reproliferates, and it’s best that you do a small PRP in that area in these cases. These are examples of how we would manage a detachment with various modalities, as well as take care of PVR, from simple puckers, to thick membranes, inferior contractions, star folds, using dyes, retinectomies, perfluorocarbons. So all of these things go hand in hand, but the most important part is visualization. I think wide field visualization with good view — whatever procedure you use is mandatory for all these cases. And I think we’re coming to the end of the talk. Any questions which are there and not answered to the talk, I think you can type in and I will try to answer them, to the best of what is remaining from the talk. And I would like to thank Orbis for facilitating this once again and allowing us to interact on this forum. Thank you very much.
>> Great. Thank you, Dr. Nagpal. There are three questions so far, if you want to open up the Q and A.
DR NAGPAL: Okay. So the first question is: I’d like to know when you decide not to do surgery. I’m not sure what you exactly mean. But I probably mean that it’s a very longstanding detachment, and one may not decide to do a surgery. So that would be based on how long the history is. Is it an exotropic eye with a very longstanding detachment, or a disc, or you meant RD surgery? Sorry, that clarifies. When not to do RD surgery. We do RD surgery in young patients with single breaks, inferior breaks, whenever the lens is clear in the younger patients. But if there are multiple breaks, older patients, pseudophakics, all those we would do primary surgery. Buckling is left for the younger patients with clear lenses. Do you keep PFCL in the eye postoperatively for sustained retinopexy? And for how long? For typical cases, we would not use it postoperatively. The only time we keep it is for bad trauma cases, where there is a totally mangled retina with subretinal blood and bad choroidals. If you’ve managed to salvage the retina back, because there’s a lot of blood in the subretinal space, those cases we at times put perfluorocarbon and keep it for two to three weeks, and after that, go and check, do some more laser, and replace it with silicon oil at that stage. So in those cases, perfluorocarbon postoperatively is quite good. But we don’t do it for PVRs or regular detachments. We just use it intraoperatively. The next question is: If macula on occurs during vitrectomy, how can I manage it? I guess you probably mean macula off occurs during vitrectomy? Because if the macula is on, it’s best, as I said, to retain it. You should just keep it pressed with perfluorocarbon while you do the procedures, and at the end, remove the perfluorocarbon once you know that the retina is flat after endodrainage. Because after that, the fluid is not going to come to the macular area. The next is: Is air-PFCL exchange or PFCL-silicon oil exchange advisable in GRT to prevent slippage? Yes. If air-PFCL exchange is done properly, which means you keep the periphery dry, you keep the edges of the tear dry, through the air-PFCL exchange, usually the slippage doesn’t occur. The second time slippage occurs is when there is persisting traction or contraction which has not been resolved, and you’re trying to do the exchange. Then again a slippage may occur. But if one prefers the PFCL oil and is happy doing it, that has less chance of slippage in either situation.
>> All right, Dr. Nagpal. We’ll wait about another minute for questions.
DR NAGPAL: Yeah, sure, sure. So what are the outcomes in RD surgeries done in PVR grade C? Outcomes would be variable, based on how good the macula is. How good the disc is. You can have an anatomically settled retina in most situations with PVR grade C, but the visual acuity may vary from counting fingers, 3-4 meters, to almost 6-9 also. It would vary on what has happened before. Is it the primary surgery for PVR? Have multiple surgeries happened? And then you’re doing it, and how long it’s been. So it would be variable. But anatomically, I think if you use all the steps that we discussed, in the cases I showed you, I think one could put it back — the retina can go flat in most situations. Indications for encirclage vitrectomy? I don’t do it for all the cases, but whenever I feel there’s a contraction or a traction persisting, I would always encourage you to put a buckle. It will help you through the vitrectomy. It has multiple benefits. One is that it releases the circumferential contraction. It helps you visualize the peripheral, which is better during the surgery. And of course reduces the need for retinectomy. Or reduces the size of retinectomy. Because you achieved a little contraction release by the buckle itself. Have you experienced any side effects from retained PFCL in any of your cases, and how do you deal with those? Frankly, we use it for such bad traumatic cases that I’m not even sure what side effects to look for. Because the pathology with bad trauma itself leaves a lot of effects with the blood inside, the disc is affected, but… In the past, we have used retained PFCL for giant retinal tear cases. But I’m talking almost 15, 20 years back. When wide angle systems were not there, and we used to put PFCL for two weeks, and then remove it. So I don’t think we found any specific problem with retaining PFCL in those cases, and they did pretty well. So if you keep it for two weeks, I don’t think it’s a problem. If you keep it for a month or more, maybe there may be a mechanical pressure problem. You could see atrophy, you could see a disc which is paler than what you would expect. But in a couple of weeks, nothing is going to happen with perfluorocarbon. The advantage of perfluorocarbon is that it keeps moving. Like other tamponades, as the patient moves ahead, it keeps moving. So it never compresses the same area all the time. And does not lead to pressured eyes also in most situations from our experience. How about anteriorly closed funnel RD? They have a very poor prognosis. You have to go in and explain the prognosis to the patient. That you may not be able to anatomically settle in surgery. So the patient needs to understand that you’re going to try and open it, but during surgery you may have to give it up, because it’s so contracted. But nevertheless, if you explain to the patient that there are cases where, once you start opening it up, it may open up better than what you expected, because the adhesions were not that strong. It was only the vitreous which was holding a lot of retina, and not that the retina itself was contracted so much. While there may be other cases where you remove the vitreous, and then the contraction is so severe that even after doing a retinectomy, you may not be able to put it back. So it is variable, and very poor prognosis. When do we remove clear lens with RD? Actually, never. Clear lens is never removed. We only remove a lens if there is a cataract along with it. Because in no situation is the lens coming in your way. You can always indent and do a peripheral clearing of vitreous, without touching the lens, in most situations. So today I don’t think we would ever do a clear lens removal just for a detachment per se.
>> All right. That looks like all of the questions, Dr. Nagpal. So maybe this is a good place to stop.
DR NAGPAL: All right. That looks good. Yeah.
>> Thank you very much.
DR NAGPAL: You’re most welcome. Was everything all right?
>> Yep, everything was good. I’ll send you a follow-up email in a little bit.
DR NAGPAL: All right. Thank you so much. Take care.