This video demonstrates Vitreous surgery with foveal sparing ILM peeling in a 75-year-old woman, who presented with decreased vision due to Myopic Retinoschisis.
Surgeon: Dr. Makoto Inoue, Kyorin Eye Centre, Japan
DR INOUE: Vitrectomy with foveal sparing ILM peeling and cataract surgery for myopic retinoschisis. I have no financial disclosure related to this talk. Myopic traction maculopathy is caused by the elongation of axial length. Elongation of axial length increases vitreous traction. Treatment for myopic traction maculopathy is based on removing of vitreous traction or reduction of posterior curvature of the eyeball. Progression of myopic traction maculopathy is initiated from retinoschisis. At the second stage, the fovea has been elevated, and developed a foveal detachment. At the third stage, macular hole or macular hole retinal detachment develops. Depression with foveal detachment is a good candidate to recommend vitreous surgery, because usually vision decreased. Combination vitrectomy and ILM peeling is an effective treatment for myopic traction maculopathy. In contrast, ILM peeling may increase the risk of postoperative macular hole. Postoperative macular hole and macular hole retinal detachment causes decreased vision. Once the postoperative macular hole develops, the macular hole usually enlarges. Because the retina is more stretched for retinal reattachment in highly myopic eyes. Additionally, retinal arteriolar traction makes it difficult to reattach the retina. To decrease the risk of postoperative macular hole or macular hole retinal detachment, fovea-sparing ILM peeling has been reported. In this technique, the ILM is peeled around the fovea like a doughnut shape, but the ILM at the fovea is not peeled, to avoid fovea dehiscence. This technique is also called foveal ILM non-peeling technique. This 75-year-old woman noted a decrease of vision in the left eye, due to myopic retinoschisis. The fovea appeared to be very thin, so we planned a vitrectomy and foveal sparing ILM peeling. Following anesthesia, the patient was instructed to look out and upwards, and the conjunctiva was bisected. A bent needle was inserted, and 2 to 3 milliliters of lidocaine was injected into the muscle cone. Povidone-iodine was rinsed just before the surgery started. Paracentesis was created at 10:00 and 2:00. Anterior chamber was filled with dispersion-type and condensed-type viscoelastic materials. One-plane corneal-scleral incision was made with a slit knife. The conjunctiva was cut to avoid chemosis. CCC was created with a bent needle, like a circumflexion. Initially, a triangle flap was created. The lens capsule flap was inverted, then pushed or pulled to entry to precede the capsulotomy. For this patient, we plan to implant an IOL with a 6.5 millimeter optical diameter. So the size of this CCC was slightly larger than the conventional cataract surgery. Hydrodissection was performed by injecting balanced salt solution beneath the edge of the anterior dense capsule. It is better to make sure that the nucleus can be rotated by the tip of the needle, like a needle dissection. For the phaco, the anterior cortex was aspirated by the phaco tip. The phaco tip was pulled up into the nucleus, then the nucleus divided with the hook. The divided nucleus is further segmented, like a pie piece. The residual cortex was aspirated with I/A tip. The opening port of the I/A tip was set upwards to avoid aspiration of the posterior capsule. Residual cortex at the entry site of the I/A tip was aspirated very carefully. Before IOL was inserted, anterior chamber was filled with a viscoelastic material. The intraocular lens was implanted into the lens capsule. The following haptic was inserted into the lens capsule by the rotating technique with a hook. The viscoelastic material was aspirated with the I/A tip. The viscoelastic material behind the oil should be removed more carefully. The 27-gauge cannulas were inserted in the oblique fashion. The distance from the corneal limbus is set at 3.0 millimeters for phacovitrectomy. With a distance of 3.5 millimeters for lens-sparing vitrectomy. Before the infusion was turned on, it should be taken care whether the tip of the cannula was inserted in the vitreous cavity. Core vitrectomy was initiated, with a wide angle view system. You can see the chorioretinal atrophy at the inferior vascular arcade. Core vitrectomy was relatively slow, because we are using a 27 vitreous cutter. A PVD appeared to be present. However, we had to make sure after visualization of (inaudible). Peripheral vitreous is removed as much as we can see with a wide angle view system. I am right-handed, and this patient is operating in the left eye, so the peripheral vitrectomy at the nasosuperior side needs to be taken care, because the angle of the vitreous cutter is more vertical. Sometimes the vitreous cutter may hit to the front lens or the right hand may hit to the patient’s nose. Brilliant Blue G was injected to stain the ILM. The excess brilliant blue G was aspirated with a vitreous cutter. ILM peeling was initiated with 27-gauge anterior forceps. For creating ILM flap to start ILM peeling, the opposite side from the anterior side of the instrument is selected, because the tip of the instrument is more vertical against the retina. And also the tip is more parallel to the retinal surface. At the retinal surface, the tip of the forceps is closed or open during entry to induce a wrinkling of the ILM and to pick up the ILM flap. When the edge of the ILM flap cannot be seen well, we will inject the BBG to stain the ILM. After injection with BBG, the ILM flap can be visualized more identically. Because the detached ILM was stained at both sides of the membrane and seen more clearly. During the ILM peeling, we have to make sure of the position of the fovea. If the ILM is peeled above the fovea, it is not foveal-sparing ILM peeling. ILM peeling should be not beyond the fovea, and the safety margin at least one disc’s diameter around the fovea should be maintained. And also ILM peeling should be performed at 360 degrees to remove the traction toward the fovea completely. The detached ILM around the preserved ILM was trimmed by a vitreous cutter. Additional ILM peeling in a wider area around the preserved ILM is performed within the vascular arcade. After that, ILM was trimmed again, around the fovea, to the exact symmetrical way, and also to minimize ILM flap around the fovea. Then the triamcinolone crystals were injected to visualize the peripheral vitreous. After injection with triamcinolone crystals, the residual vitreous cortex around the vascular arcade is visualized. By aspiration of the vitreous collar, the vitreous cortex was separated. After ILM peeling, you may see the remaining posterior vitreous cortex more clearly. Sometimes we may not see it before ILM peeling. This is why I started ILM peeling initially. Especially at the edge of the posterior staphyloma, the vitreous cortex is strongly attached. So we need to take care to remove the vitreous cortex without creating any iatrogenic retinal break. Vitreous cortex was aspirated in different directions. To separate vitreous cortex more easily. After creating PVD at the temporal side, I will switch the side to the nasal side. Sometimes it’s difficult to create PVD at the nasal side. But do not worry even in these cases. Creating PVD at the temporal side is more important than the nasal side. In this case, I switched the side of the hole in the vitreous cutter to the left hand to create PVD at the nasal side. Luckily, I can create the PVD at the nasal side. I believe, like in this situation, the small instrument is more effective if we use the left hand. So we need to make sure that all the vitreous traction has been removed. The small fragment of residual vitreous cortex, visualized with triamcinolone crystals, may be removed carefully by aspirating with a small gauge cutter. In highly myopic eyes, we will see the mild pole atrophy at the peripheral area. So the aspiration preset of the vitreous cutter may be better to reduce doing a peripheral vitrectomy to avoid iatrogenic retinal break. After the peripheral vitrectomy, the center of the posterior lens capsule was removed, with a vitreous cutter. To avoid possible posterior capsule opacifications. In highly myopic eyes, we often see the mild pupillary vascular retinal break. So we decide to perform fluid exchange at the end of the surgery. The intraocular fluid is aspirated with the vitreous cutter to semi-complete the exchange. After the cannulas are removed, the wound was rubbed with a cotton swab to close. Steroid was injected subconjunctivally at the site with the vitrectomy port, to prevent vitreous leak. At postop day 1, Optos wide angle image can indicate a retinal image in the air-filled eyes. Swept source OCT can also detect a cross sectional retinal image in air-filled eyes. So we can detect no macular hole. At postop day 1 month, the vision recovered to 1.2. However, resolution of retinoschisis takes more time. From 6 to 12 months. I hope this video is helpful to understand the combined surgery with cataract and vitrectomy in highly myopic eyes. Thank you for your attention.
April 10, 2019