Akshay Thomas, MD
Vitreoretinal Surgery Fellow
Duke Eye Center
The 7th session of the 6th annual VBS meeting was titled, “Surgical Adventures, Bridging the Gap.” The session was moderated by Jonathan S. Chang, MD, Theodore Leng, MD, Andrew Moshfeghi, MD, MBA, and Cynthia Qian, MD. The session focused on pearls for difficult surgical situations and new technologies.
The session commenced with Yasha Modi, MD of NYU, who discussed the predisposing factors, prevention and management of retinal folds following retinal detachment surgery. He discussed that common risk factors include the presence of a fovea splitting detachment, a bullous detachment, use of high buckles or elements and incomplete drainage of subretinal fluid.
Dr. Modi discussed that in cases where there is residual subretinal fluid following vitrectomy, he positions his patients temporal side down for 30 minutes followed by face down positioning for 30 minutes. Consistent with the literature, he advocated for observation of partial thickness folds.
With regards to symptomatic full-thickness folds, Dr. Modi discussed the surgical options. The retina is first detached using BSS through a 41G subretinal cannula, and the folds are then flattened with perfluorocarbon. Risk factors for poor visual outcomes include poor presenting acuity, retinal folds which have been present for a long time and foveal ectopia.
Dr. Modi also showed an illustrative case of a patient with a peripheral retinal fold. The visual acuity was fantastic, but the patient was very symptomatic with binocular diplopia and metamorphopsia. Imaging with near-infrared reflectance showed nicely an ectopic fovea, which was being dragged towards the peripheral fold. He raised an intriguing question of whether we should be more aggressive about surgically redetaching these folds to flatten them out, even in the setting of partial thickness macular folds or extramacular folds. We look forward to further studies.
Diabetic TRD Pearls
Dimitra Skondra, MD from University of Chicago then discussed her tips and tricks for managing diabetic TRDs including optimizing the surgical view, preoperative use of bevacizumab 2-4 days prior to surgery, meticulous removal of all posterior hyaloid and segmentation of all significant membranes (but not necessarily needing to remove all the tissue, as long as the pegs are separated), and removal of all plaques around retinal breaks (including performing a limited retinectomy if necessary), leaving subretinal hemorrhage, performing good PRP to the ora with depression, postoperative local and systemic steroids and long-acting gas tamponade with prolonged face-down positioning.
A very nice pearl was the re-stain at the end of the case with triamcinolone, as often times the hyaloidal face is still attached. Re-staining assures that the hyaloid is completely removed, as this is one of the main causes of re-detachment in diabetic TRDs.
With regards to maintaining the surgical view, Dr. Skondra recommends using a layer of 50% dextrose on the corneal surface to dry up the cornea and a layer of Viscoat over this. Dr. Flynn mentioned that he prefers avoiding the routine use of preoperative bevacizumab as it may cause significant worsening of the TRD and create breaks.
Dr. Skondra illustrated that using her sequence of surgical techniques, she has had a 98.9% reattachment rate for TRDs with a single surgery with >72% patients achieving 20/200 or better vision. Dr. Maria Berrocal reinforced the use of long-acting gas rather than silicone oil given the risk of severe perisilicone oil proliferation in the presence of preretinal hemorrhage.
Trauma Without The Drama
Yewlin Chee, MD from University of Washington, a large quaternary trauma center, discussed her tips for secondary vitrectomy following open globe injury. She reinforced the importance of knowing the details of the initial injury and how it was repaired.
Indications for secondary vitrectomy include persistent media opacity, endophthalmitis, progressive vitreous and/or retinal traction, and retinal detachment.. She advocated for intervention within 1-2 weeks of the initial open globe repair.
Her steps for surgery are drainage of choroidals (if needed), placement of a scleral buckle (if there were no choroidals), lensectomy if necessary, careful vitrectomy with identification of the retina, identification of the nerve with use of perfluorocarbon if there is a funnel detachment, peeling preretinal membranes, careful retinectomy around areas of incarceration, flattening the retina with perfluorocarbon, endolaser and silicone oil tamponade with placement of silicone oil retention sutures if there is not significant residual iris tissue.
Autologous Platelet-Rich Plasma
Scott Walter, MD from Retina Consultants, Connecticut, discussed the use of autologous platelet-rich plasma as an adjunct for closure of large myopic macular holes. Platelet-rich plasma is acquired by centrifuging a tube of the patient’s blood acquired intraoperatively. A portion of the supernatant which is rich in growth factors and platelets is then collected in a special dual-chamber syringe.
Dr. Walter discussed how platelet-rich plasma had been used in the 1990s for macular holes and how Dr. Marta Figueroa recently published on resurgence of this technique for challenging macular holes. In the series of patients with myopic macular holes included in Walter’s study, all patients underwent vitrectomy with ILM peeling. Some patients had an inverted ILM flap or free ILM flap.
Next, following a fluid-air exchange with drying of the hole, a few drops of platelet-rich plasma were instilled over the hole. The investigators used intraoperative OCT to appreciate the formation of a hyper-reflective coagulum plugging the hole, following which silicone oil tamponade was used.
Using this technique, 6/7 patients achieved hole closure though vision did not improve. The one case of failure was attributed to residual fluid at the macular hole which diluted the platelet-rich plasma, and caused it to contract in an irregular fashion. Dr. Flynn, from the fact checking booth, reinforced that gas is superior to silicone oil as a tamponade agent for macular holes and this may have been an additional factor for the one case of non-closure from this series.
3D Digitally-Assisted Vitrectomy
Finally, Rishi Singh, MD from Cole Eye Institute, discussed tips for optimizing our experience in digitally-assisted vitrectomy (DAV). He discussed that the advantages of DAV include HDR imaging, ultrawide field of view, high resolution for operating/recording/feedback, the depth of focus, the ability to integrate OCT, its excellence as a teaching tool, its cost-effectiveness and the immersive appearance for the entire operative team.
Dr. Singh discussed the importance of adjusting the aperture distance from the eye and aperture size for depth of focus, positioning of the viewing screen at the patient’s calf height and 1 meter from the surgeon, initially focusing on the limbus under high magnification to ensure parfocality and continued practice to get used to the minimal lag appreciated during gross movements outside of the eye.
RETINA Roundup VBS VI Coverage:
3/27/2018 VBS VI: Historic Delivery of Gene Therapy for LCA
3/27/2018 VBS VI: Surgical Adventures – Curing One Eye at a Time
3/26/2018 VBS VI: Retinaws
3/26/2018 VBS VI: Complications Session
3/26/2018 VBS VI: Women of VBS Breakfast
3/26/2018 VBS VI: Endophthalmitis Session
3/25/2018 VBS VI: Retina Caliente
3/25/2018 VBS VI: Lifetime Mentorship Award: Jay Duker
3/24/2018 VBS VI: Surgical Adventures – Bridging the Gap
3/24/2018 VBS VI: Real World Retina – Practice Management, Private Equity, Advice for Young Retina Specialists
3/24/2018 VBS VI: Medical Retina
3/24/2018 VBS VI: Live Surgery Session
3/23/2018 VBS VI: Fellows’ Forray
3/24/2018 VBS VI: Welcome to Miami