Surgery: Achieving a Posterior Vitreous Detachment (PVD) with a Barbed Needle

Dr. Kitchens: One of the things that can be really tough in certain cases, specifically cases with really adherent vitreous to the macula, such as vitreomacular traction, is achieving a posterior vitreous detachment. Even after 15 years of experience, sometimes I’ll still struggle getting a PVD. You can see the advantage of using Kenalog or other stains to identify the vitreous is really critical whenever you just don’t get a PVD quickly. The second thing is a good technique. And I find that the number one problem that fellows-in-training have with getting a PVD is really not having full occlusion of vitreous cutter and having the 3D system, with the heads up ability to see flow, could really help identify when the vitreous is incarcerated fully in your vitreous cutter.

And the second thing is, is instead of just pulling straight up into the mid-vitreous cavity, having this kind of up and out technique where you pull along the eye wall. In this case, utilizing both of these techniques really wasn’t successful. So I utilized a high magnification flat contact lens, and still had some stain of the Kenalog on the posterior hyaloid. And tried with a forcep, and unfortunately this was not successful.

So finally I moved to this bent 25 gauge needle approach, use a one and a half inch needle attached to a 3cc or 10cc syringe. You barb the needle at the tip and you use it to just snag and cut an opening in the posterior hyaloid. And once you found that you violated that posterior hyaloidal face, you’re actually able to aspirate the vitreous, create an opening in there, and it comes up much, much easier with the cutter.

And so here we can see now that I’ve actually able to get in that plane between the posterior hyaloid and the retina. I’m able to aspirate and elevate the vitreous.

Now, don’t be surprised in these cases if you find that they had very adherent mid-peripheral vitreous. And I’ll take this vitreous elevation out as far as I can get it, but I won’t be super aggressive if I don’t need to be to achieve a full separation of vitreous all the way out to the very peripheral retina. Thank you so much for watching.