This video demonstrates a chandelier-based scleral buckling surgery in a case of retinal detachment. It is the same classic technique of scleral buckling but enhanced by using a vitrectomy lens with chandelier.
Surgeon: Dr. Manish Nagpal, Retina Foundation & Eye Research Centre, Ahmedabad, India
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DR NAGPAL: This is a case of a chandelier-based buckling surgery. After isolating the muscles, the viewing lens is placed, and after that, we get a view of the retina. The inferior detachment is seen along with multiple inferior breaks. Indentation is carried out to assess the size and extent of the breaks. After that, a cryoprobe is placed on the posterior surface of the tears and applied. You can see the white reaction of the cryo coming in on the edges of the breaks. The white reaction encompasses the whole edge of the retina, next to the break, and slowly it thaws and disappears. So step by step, we do it to the whole surface of the tear, and go to the edges of the tear, and also do the cryo to those areas. Once the cryo is done, we choose the drainage site. In this case, it’s inferiorly. You can see that we have done a needle puncher, and after that, we are depressing the posterior lip of the medial puncher, and the viscous fluid is coming out. We keep pressing so that more and more fluid comes out, and it drains out totally. Now you can see a few pigments coming, with the fluid flow reducing. This usually indicates that most of the fluid is drained out. At this stage, we want to localize the break, so we are indenting, using an indenter, and assessing the posterior edge of the break. Since it’s a peripheral tear, you can actually view it directly under the microscope. Once we have localized, we are passing the suture. You can see that this suture is passed a bit posterior to the localized site, and the next one is passed anterior. These sutures are being taken to place a 5-millimeter oval sponge that we would place. Once the suture is placed, the plomb is inserted under the muscle and then passed through below the loop of the suture, and then passed through the other muscle. After this, the suture that is passed is tightened over the plomb. Normally, we pass one suture in each quadrant, after localizing the break, but in this case, since the tear extends a lot of clock hours, it’s a large tear, here we have decided to pass three sutures in the same quadrant, so that the whole extent of the tear can be well indented. All of them are taken at the same level. So all the three sutures have been passed, and now we’re just passing the plomb through the other vessels, so as to give a 360-degree effect of the buckle effect. Normally for smaller tears, we would do a segmental buckle, but for a large expanse of a tear like this, we prefer doing a 360, so that the indentation is better. Now we are viewing inside to look at the indentation effect, and you can see that the tear — or the multiple tears with thin margins in between — are well indented by the buckle effect. The rest of the retina looks flat now. Now that we have assessed that the retina is flat and the buckle effect is good, we are taking sutures to the other quadrants where the plomb is passed, to stabilize it. While taking the sutures, we usually take out the chandelier from the cannula, because otherwise the chandelier’s fiber-optic comes in the way of suturing. At this stage, you could sometimes plug in the cannula, if you feel that the pressure is high. Otherwise, you could just let it be. Now, the end to end sutures for the plomb are being taken. Once again, we are testing the buckle effect, and you can see that the breaks are on the buckle, and the retina is well flattened after the drainage. At the end, we take off the cannula, and then take sutures on it, so as not to have any sort of leak from that site. Chandelier-based buckling allows us to view the retina just like the way we are used to seeing with the vitrectomy procedure, so you would use the same procedure of classic buckling, but enhance the visualization by using a vitrectomy lens with the chandelier. This becomes an excellent tool for teaching, and have people seeing the same thing that you are seeing, while performing the surgery.
May 4, 2018