In this lecture, Dr. Nagpal talks about retinal detachment and shows surgical videos to demonstrate various steps of the surgery. He shows how to reattach the retina in various situations using high quality videos.
Lecture location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Lecturer: Dr. Manish Nagpal, Retina Foundation & Eye Research Centre, Ahmedabad, India
(To translate please select your language to the right of this page)
Dr. Manish Nagpal: So, I’ll just take you through the instruction and then basically I’ll be showing you a lot of surgical videos where you can see what’s happening during the surgery and how step-by-step we reattach the retina in different situations.
So, this is how a retinal attachment is. You have a retina at the bottom is attached. You can see clearly that is a detachment. It has lifted up. There is a hole that you can see somewhere here. This is a hole. And then this part has detached, it’s a superior detachment and the fluid is coming up to here. This is detached, this is a macula.
So, you have a few different options of how you can repair it. You have scleral buckling. You are pneumoretinopexy, you do a laser or a cryo to the break and put gas and positioning to the patient. And third is vitrectomy. Now, most commonly what we do is vitrectomy for these patients.
So, I’ll take you through step-by-step. In vitrectomy what we first do is the removal of the vitreous. So, as you can see here, what we are doing is a detached retina. We have gone in with a cutter and a light pipe. The light pipe is giving us the view — giving us a good light for the vitreous in which we work. And the cutter is going in. This is a break that you can see. They are working with the cutter close to the break and removing all the vitreous which is attached to that particular area so that it becomes free and mobile in that situation.
And after that, we go and — this is a different case, where there is no pre-existing hyaloid detachment. So, here we are staining the hyaloid with triamcinolone which helps us see the vitreous better. So, you can see here that I’ve put my cutter into the vitreous which is stained with these crystals, white crystals of triamcinolone, which helps me see better because otherwise it’s transparent. And sometimes I don’t know the plane between the vitreous and the retina which is there behind.
So, I’m just trying to peel that whole vitreous off that tissue at this particular point. But this is a surgery that I’m showing you, again, with the same steps. That we first remove the vitreous. You can see this flappy, mobile retina that you can see, which is very typical of a fresh retinal detachment. And I’m trying to feel the hyaloid. You see, I’m going in — I’m trying to feel the hyaloid and at some point I realize that it’s too transparent and I may not be getting a good grasp on it. so, I put triamcinolone. So you see it’s a stain of triamcinolone and it basically typically stain this is particular area which has got the attachment of the hyaloid in the center.
And at this stage I’m trying to use a very high vacuum to hold that stain area and pull it. I want to separate it from the retina itself so that the retina becomes freely mobile. So, at this stage you are seeing that slowly it is peeling off. You can see how it peels off from that particular area. But it’s a gentle process, and in some patients this attachment is very rigid. And in some patients it comes off very easily.
So, slowly, with patience, you keep on pulling at it gently because you don’t want to pull too much. If you pull too much, you can create a break in the retina or you can tear the retina also. So, you can see that it’s a slow process. We start from the posterior part, which is this area and then slowly keep on extending to the whole of the peripheral area.
And you can see when it separates how the retina also — you can see these are the edges from where it is still attached. And then I use the cutter to cut some of it, and then, again, I go and hold it and again cut a little bit and again go and pull at it as to take me as peripheral as possible. And here you see there is a lattice degeneration. You’re familiar with the lattice degeneration? These are weak areas in the retina which have vitreous adhesions. You can see how the vitreous is adherent to this area.
So, now I’m going and trying to separate the vitreous from this particular area and trimming it. Because here sometimes you cannot totally remove. The retina is in there. If you pull too much, you can keep on creating more break. So, you trim it. If you cannot — you try pulling it, if it doesn’t come, then you trim it.
Now, here I put some perfluorocarbon liquid, which is a heavy liquid to just stabilize the posterior pull. And after that do an air-fluid exchange. Which means that we are replacing the cavity from fluid to air. So, we have replaced the cavity from fluid to air, and then we drain from the hole, which is there. So, now you see the retina has flattened and I’ve done a laser to all the breaks and a 360 laser barrage to secure the retina and later for silicone oil. So, this is typically how step-by-step we reattach the retina in this case.
Now I’m showing you a different situation. These are inferior breaks. Again, the idea is to remove the vitreous. So, with this repetition you will know the steps much better. So, I’m showing you in a high zoom how we are working close to the mobile retina with open breaks and removing the vitreous. With the present day machines, the constellation with the high cut rates, the safety is much better. You can work so close to the retina without actually getting the retina inside your cutter hole.
Now, this is, again, a situation where there’s a large break superiorly. Now, you can sees in a huge break with a lot of vitreous adhesion. I’ve stained with triamcinolone and removed some of the vitreous. I’m taking off the vitreous now. I’m gradually removing it from the edges of the break. You can see the movement of the break and you have to make sure that your cutter does not take and suddenly into the retinal tissue. So, you have to control the vacuum based on how you see the movement of the cutter at that particular point.
As you can see, we are working close to the retina. Also, the other thing — technique I wanted to show you is I put a chandelier light which allows me a flexibility that with one hand I can indent. So, you can see, I’m indenting with my left hand. The light is coming through a chandelier. And the cutter can then eat up all the pars plana tissue of the vitreous which is there which otherwise is difficult probably to reach too. Especially if it’s a phakic patient, a clear lens patient. If I go too much to the other side I will touch the lens shaft.
So, to avoid that I bring the retina to the center rather than taking the cutter all the way there. So, you can see how effectively we are able to push the retina towards the inside so that we could remove all the vitreous well. And removing the vitreous is the key to your eventual success for any retinal surgery. Because otherwise it leads to PVR, which is the next part of my talk eventual, how do we dilute PVR at that point?
So, these are the situations. Now wire them across if you have any questions because you are the ones who operate these cases in and out. Please feel free to stop me and ask them. One second, if you want to speak, speak in the mic because it goes —
>> So, you are talking about a chandelier. So, if you want to use a chandelier, what should be the preferred ilea? Which clock?
>> So, if I want to put the chandelier, you’re asking what is the preferred clock hour? Well, some people put it at 12:00. Some people put it at 6:00. Or you could put it anywhere between your two temporal side pores. So, you have three options to do it. And I’ve tried these different methods and I think now I put it usually at 6:00 typically. But I’ve tried 12 also, and you can also vary it based on a particular eye. Sometimes the orbit is tall and 12 and 6 might be more difficult. You could put it between your two temporal pores. So, the small gauge, is that you’re not stuck by a certain clock hour routine.
You can choose to modify it according to — and you can also choose it based on where the break is. If your break is at 6:00, you would rather have the light coming from 12 than vice versa. So, you could also choose based on where the breaks are there.
So, this is the pre and the post of the same patient that I showed you attached and after. And you can see the reflects of the oil that is there at this particular point. This is, again, showing you with a 25-gauge high cut rate we go close with the cutter and remove this bloodstained vitreous that you are seeing at that particular point. And, again, we go very close to the retina and do it, control the vacuum is the most important part. Because you have seen that I keep a linear vacuum with the highest vacuum of 650. But it doesn’t mean that I’m using 650 at any given point. I use it only when I’m in the central area where I know that it’s safe. I can use the full. But, if I’m working close to the retina, I might be working with just a vacuum of 50 or a hundred or based on how I see the movement of the retina at that stage.
This is another similar case. You see large tears in this area. You can see how the retina moves. We are removing all the bloodstained vitreous in the center that you see, and also the area of the breaks that are there that you can see the vitreous being moved. And all throughout you keep watching the pore because the retina is mobile. And no matter how careful you are, if you’re not looking exactly at the pore, you may sometimes get the retina incarcerated or you may make a small break suddenly which you want to avoid in these cases.
So, here, again, the same technique I’m showing so that you get familiar with it. You indent from your other hand while the light is coming from an independent source of a chandelier. Because most of the times we are doing surgery with fiberoptic in one hand — and especially for phakic eyes with detachments, clear lenses where I don’t intend to remove the lens, this is what I would prefer to use. That indent and bring the retina close. For this, you can reduce the infusion pressure to maybe 10. It allows you to indent better. Because if the tone is high, you cannot indent.
So, you can ask your nurse to reduce the infusion to 10. The eye becomes soft. And then you indent and effectively remove. So, this way you can reach the far periphery. You can see how close you are to the peripheral part, the pars plana. And then any tissue there, this is bloodstained vitreous you can totally shave off, you know, from that particular area. Then you do an air-fluid exchange. I use the cutter itself to do the air-fluid exchange. This is typical that as soon as you do the air-fluid exchange you will see the fluid collecting into the retina. The form bullous. Then go to the periphery and do an endodrainage from that area. And then your final step is to do a good laser to all the breaks. And if there are multiple breaks, you are intending to put silicone oil, I like to do a 360 laser barrage because at that time everything will settle. But oil has to be removed also after four months, six months. And if you have any weak areas, it can re-detach. So, you want an extra few layers of safety in these patients.
So, step-by-step, I showed you a few complete surgeries. Now, this is air-fluid exchange which we do in a retinal detachment. Where you go to the disk, the bullous come up, this is exactly what happens. After that, you go to the periphery, find the break, and then drain it. Now, what happens sometimes is that the bullous comes to the central part and you lose your connection of fluid from the peripheral break. So at that time you have two choices. One is to make a new retinectomy to brain, or I put PFC and push the fluid peripherally. So, that now the fluid I can drain from that same break.
So, now, I push the fluid. It went to the periphery. Now I’m spreading from that break itself so I don’t have to make a new retinotomy site to drain. So, those are the two choices that you have at that. And then, of course, laser that.
Now, inferiorities, the best, again, I’m doing the same thing. I put PFC up to the edge of the break. I removed — this is a step after we have done all the vitreous removal, everything — and then I just drain from that area. And after that remove the perfluorocarbon. So, perfluorocarbon is a great tool for such a situation also. It’s not that you need it only for giant tears.
And then, of course, endolaser. This is — endolaser is fantastic because you don’t — in the past we had to do bio laser or other which where the viewing is difficult during surgery to do, or you have to resort to a cryo which has got much more inflammation. Now, with endolaser you can go and very precisely treat these areas.
At the end of surgery for a classic retinal detachment with air or gas inside, you have already been seeing every day that we do this, but this is the technique. This is the metal spud that I was talking to you about that we have especially got these. It gives a much better indentation. You can use a normal orbit, but the metal spud has a better effect. So, you just press it for 10 seconds, massage it, let the tissue’s elasticity come back. And then usually the ports will not leak. But, of course, if there is a leak if you have hypotony, don’t hesitate to take one single stitch. It’s the best.
Now, this is when we inject gas, this is what I typically do. I take off one cannula most of the time, or you could let it be there, but I prefer at this particular stage here you inject — you switch off the infusion and from the remaining port you inject the gas, which is there. Now, once this gas is inside, then you can remove the ports from both the sides and the gas remains inside.
So, gas injection varies with people to people, and some of them total flush it through the infusion. But this is the technique that we use at our state.
Now, I wanted to show you that you see the vitrectomy part of it, but we have worked on a technique I presented at the Vail vitrectomy in 2013, and then we published this technique also. That classic buckling surgery is done using indirect ophthalmoscopy, right? But we have started doing buckling using the vitrectomy viewing systems by chandelier light and I wanted to show you that because it makes it much better.
So, we use the same lens that you see me using for all my surgeries. And the classic buckling technique that you use. There’s no change in the buckling technique. Now, we put a chandelier light on these patients and this is the view you get inside. So, you can indent and do a cryo. This is a break, you are doing a cryo here. I will show you a surgical clip so that you can understand this is how we do a classic. So, we have tagged the muscles. This is the view you get inside. Now, imagine the view from indirect is different and this is like your vitrectomy view, which is fantastic.
You can magnify as much as you like. You can zoom as much as you like. And more importantly, you can teach. If you have fellows, you have observers, they can see this with indirect. We know that even though we attach cameras to the indirect, you cannot really see that well. The glare is too much. So, we localize the break. We drain. All the steps are the same as you do with your classic buckling surgery externally.
So, now we are draining from this particular area that you see. And then you can see inside that area you drain is the area fine? Is the fluid on absorbed? You confirm all that. And then you tighten the buckle. You see the buckle effect just like you see with indirect. So, this is what we use. And at the end of surgery you can confirm everything and then remove the chandelier and take sutures for your conjunctiva at that particular stage. So, this is something that now, if we are doing buckling, the cases I select for buckling typically are young patients with lenses with classic inferior detachments, inferior breaks, all those kind of cases where you don’t want to do vitrectomy because the cataract comes in and other complications come in.
So, you’re asking me if the chandelier can cause a retinal incarceration on that side. But this is actually a partial insertion just like your cannulas. So, it actually does not — is not any different than the three cannulas that you put. So, even if you put a chandelier, it’s going to be the same. Usually it does not incarcerate anything in that area. Of course, this is not a vitrectomy, so, you’re not removing the vitreous, anything. So, you want to make sure at the end of surgery you take a suture to that side. I don’t leave it without a suture because if you put a chandelier at the end, take it out, take one so that there is no egress. Because you also put a buckle — you press the eye and you don’t want something to egress out that have area. So, yeah, you need to be careful of that, yeah.
So, these are the steps that you see through. There’s a break. You’ve indented it, you’ve cryo’d it, you see the cryo reaction thawing after that. You go and take a localizing wipe externally. What you see. After that you drain from the side which has the maximum fluid by your drainage principles. And then you have a buckle effect seen inside. And then you take off the sutures. This is another example, classic inferior that you see. Young patient with holes in the inferior. You can see that — we are seeing all of this through the vitrectomy lenses.
With indirect-only, the operating surgeon can see very well, but, still, also, there you cannot zoom or anything. You have to rely on it. With this you can bring things closer. You can confirm this is a break or something else and be absolutely sure of what’s happening. So you have done cryo, you localize that break, take on a suture. Now you’re draining, localized it from that area. Different draining methods are there. We use this needle drainage. And we make sure that the whole fluid comes out step-by-step, indented. Keep the pressure on. If, suppose, there is a mild bleed, it will — during the operation, it will remain contained until you look inside.
Then you look inside and make sure there is no bleed. You can see that this was the drainage site that was well-covered by the buckle. No bleed. These are the holes which are covered at this particular stage. And the patient has a well-settled retina. So, we have published this in 2013 and then also presented it at a few other papers on it. And a lot of people follow this technique.
So, what we say is vitrectomy detachment is all about viewing. You have to find your best way to view inside. Viewing techniques are the most important for this. And, so, it would be very yeas for a surgeon who is regularly doing vitrectomy to convert to this technique. We are not telling you that you change your buckling technique.
You are doing the same technique. You are putting the same buckles, same sutures, same localization, same cryo, but you could actually make it easier for you by looking through a vitrectomy because nowadays you are doing 90% of your surgeons as vitrectomy. You are way more used to vitrectomy and you do buckling once in a while. So, this becomes a much more simpler technique for you to adapt at this stage. It is better visualization with zooming capabilities and the ability to transmit, record surgeries to a viewing monitor and it makes a great teaching tool because I can show you all this. If you are in my OR watching, I can show you, this is the hole. This is how I localize. This much cryo I do, this is the thawing that happens. I’m grading, I’m looking inside. Every single step that I see, I can tell you. And buckling numbers are going down now. So, even the fellows don’t get to do as much buckling. So, if you at least get to see them, there’s a chance that you may be able to use the technique elsewhere.
Also, it avoids the back and neck pain of long surgeries with an ophthalmoscope. This way you get rid of the indirect way of surgery. You are sitting comfortably like your vitrectomy, looking through a microphone and doing these surgeries.
December 15, 2017