Rehan M. Hussain, MD
Vitreoretinal Surgery fellow
Bascom Palmer Eye Institute
Session 6 of the VBS 6th annual meeting was a special Retinaws session. A panel of vitreoretinal surgeons shared videos of complex cases and discussed surgical techniques. The session was moderated by Kourous Rezaei, MD of Rush University Medical Center/Illinois Retina Associates.
Steven Houston III, MD (Lake Mary, FL) discussed Gore-Tex scleral fixation of the Akreos A060 lens for eyes with poor capsular support. He uses 25-gauge trocar ports for this surgery. He prefers to bury the Gore-Tex knot in one sclerotomy on each side, while suturing the other one closed. Dr. Houston also described a case of a traumatic cataract associated with ruptured globe, in which he waited 2 weeks after the initial closure to place a sulcus IOL and clear vitreous hemorrhage.
Marco Mura, MD (Baltimore, MD) discussed retinal detachments associated with macular holes. One point of discussion was whether one should be concerned with enlarging the macular hole if they use it as a site for drainage of subretinal fluid. Dr. Mura did not believe this to be a concern, though Dr. Rezaei opined that he prefers to avoid draining from the macular hole because the thickness of the subretinal fluid can cause enlargement of the hole. Other challenges include peeling ILM on a detached retina due to lack of counter-traction, along with using perfluorocarbon liquids to prevent ICG from entering the subretinal space. It was emphasized that one should not miss a peripheral retinal tear by assuming the macular hole was the only break responsible for the retinal detachment. Dr. Rezaei also recommended to complete any part of the surgery that requires a chandlelier before staining with ICG to minimize light toxicity.
John Pitcher, MD (Albuquerque, NM) discussed subretinal hemorrhage pneumatic displacement. He infuses tissue plasminogen activator (TPA) under the subretinal space while under air, then applies laser around the retinotomy site. The patient in his video ended up with 20/20 vision after the procedure. Dr. Rezaei advised to keep in mind that the retinotomy is frequently bigger than you expected.
Sophie Bakri, MD (Mayo Clinic, Rochester, MN) showed a case of a retinal artery macroaneurysm (RAM) that caused submacular hemorrhage and macular hole. The goal of the surgery was to displace the hemorrhage and close the hole. The panel debated whether it was better to inject subretinal TPA first or peel the ILM first in this case. SF6 tamponade was placed after the ILM was peeled. Dr. Harry Flynn chimed in from the fact-checking booth to share a paper regarding nonsurgical management of submacular hemorrhage caused by RAM, which concluded that good visual outcomes can be achieved with observation.
Kasra Rezaei, MD (University of Washington, Seattle, WA) discussed a case of Propionibacterium Acnes chronic endophthalmitis, which required removal of a 3 piece IOL and the capsule. White opacities noted in the vitreous were thought to be fungal elements. He peeled retinal membranes, which were also thought to be fungus. Kourous Rezaei, MD described a case of P. Acnes endophthalmitis in a patient with 20/20 vision, in which he delayed surgery with every 2 month intravitreal injections of vancomycin. He eventually explanted the IOL after the patient presented with a hypopyon. Dr. Harry Flynn suggested to obtain anaerobic cultures for P. Acnes, and to send half of the biopsy sample for special stains and send the other half to microbiology.
Arshad Khanani, MD (Reno, NV) discussed a case of an ERM peel that was complicated by retinal detachment that formed due to subretinal infusion of BSS. This was caused by the infusion nicking the retina during scleral depression.
Bryon Ladd, MD (Midlothian, VA) lastly showed a case of a complicated retinal detachment with proliferative vitreoretinopathy in which he used the backflush from the cutter to spray PFO and silicone oil from the retina and ciliary body. Dr. Kourous Rezaei advised to do multiple fluid-air exchanges to get rid of as much silicone oil as possible. Dr. Bakri suggested to do scleral depression multiple times to “jiggle” away the silicone oil bubbles away from the ciliary body.
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