2018 AAO Retina Subday: “My Coolest Surgical Video” Session

Yoshihiro Yonekawa, MD
Eric Nudleman, MD, PhD
RETINA Roundup Co-Editors

The “My Coolest Surgical Video” session was moderated by Masahito (Matt) Ohji, Chair of Ophthalmology at Shiga University in Japan. The esteemed panelists were Jorge Arroyo, Sophie Bakri, Susanne Binder, Allen Ho, and Edwin Ryan Jr.

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The first video was from Yuki Morizane. He presented a patient with massive sub-ILM hemorrhage from a ruptured retinal macroaneurysm (RAM).

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Intravitreal tPA was first injected several hours prior to the surgery. Dr. Morizane performed a vitrectomy and peeled the ILM over the macula, but he kept it hinged, so that he could use the ILM as a flap in case there was an underlying macular hole. Lo and behold, there was an underlying full-thickness macular hole after he aspirated off the sub-ILM hemorrhage. There was a clot at the fovea, which he removed with a backflush cannula.

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The ILM was repositioned over the hole, and stabilized with a viscoelastic. Fluid/air exchange was performed, and the patient was instructed to be in a prone position. The macular hole closed beautifully. Dr. Morizane reminded us that macular holes from RAM have notoriously poor closure rates, thought to be from residual hemorrhage above and below the retina.

Dr. Arroyo asked how old the hemorrhage was. Dr. Morizane responded that the bleed was 1 week old. Dr. Arroyo commented that it was a great idea to keep the ILM hinged in case there is a macular hole that cannot be seen until the blood is removed. Dr. Ryan was curious whether the preoperative tPA was required since the hemorrhage was mostly sub-ILM. Dr. Binder asked how the RAM was addressed. Dr. Morizane indicated that he lasered the lesion intraoperatively.

The second video was from Priya Narang, who presented elegant videos of surgical pupilloplasty for secondary angle closure glaucoma induced by silicone oil tamponade. She first described the proposed pathophysiology: Silicone oil anteriorizes the iris plane and pushes it again the iridocorneal angle, causing anterior synechiae.

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In her videos, she showed pupillolasty at 2 or 3 locations to suture the pupillary margins together, to create a smaller pupil and draw the iris in, to release the anterior synechiae and open up the angle.

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Dr. Narang commented that surgeons should take care to perform atraumatic maneuvers because these eyes are chronically inflamed. She showed that in her series of patients, IOP was much better controlled after this procedure. Dr. Bakri asked about the characteristics of the patients. Dr. Narang indicated that most patients were referred in after silicone oil tamponade, and the oil had been in the eyes for 5-6 months. She also advised that her technique is less likely to work if the anterior synechiae has fibrosed in longer-standing cases.

Young Hee Yoon then presented an Argus II surgery where she demonstrated the utility of intraoperative OCT in 2 key parts of the case. The Argus implant was first positioned externally. Then during the vitrectomy, and important step is the complete removal of the cortical vitreous, which can be relatively adherent in retinal degeneration patients. Intraoperative OCT was instrumental in confirming that the hyaloid was removed from the macula.

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The array was then inserted and positioned over the macula, and tacked into place. At the step, intraoperative OCT was used to confirm optimal contact between the arrays and retinal surface.

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At 3-months, the patient’s vision improved from LP to being able to see the eye chart. One year postoperatively, she is now navigating the busy streets in Korea by herself. Dr. Binder congratulated Dr. Yoon on the great case. Dr. Binder also feels that intraoperative OCT is essential during Argus surgery to maximize the function of the 60 probes. She asked whether Dr. Yoon has needed to reposition the implant after tacking. Dr. Yoon indicated that of the six cases she has performed to date, she thankfully has not needed to reposition the implant. It would be very challenging, so planning the surgery and meticulously measuring the anatomy and incisions are essential, she indicated

Gustavo Matias Huning presented the next intriguing video, which was entitled, “What to do when your fluid/air exchange doesn’t work?” He had an instance where the air infusion malfunctioned during fluid/air exchange, and performing the step using a syringe with air was not maintaining eye pressure. He looked at the OR wall, and saw the wall oxygen source, and started to think! The air pressure from the wall unit is dangerously high, so it needs to be regulated carefully. He discussed the situation with his anesthesiologist, who suggested using the sphygmomanometer. He connected the wall air with the sphygmomanometer with 3-way tubing, attached a sterile air filter, and successfully completed the fluid/air exchange.

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Dr. Ho commented that we take now take the integrated vitrectomy units for granted, but in the earlier days, each component of vitreoretinal sugery was a box, stacked on top of each other, including the fish pump for the air/fluid mechanism. Dr. Binder commented that it’s always nice to look to other fields for inspirational ideas.

Amir Kashani presented the final video, of a foldable subretinal scaffold with stem cell derived RPE cells for geographic atrophy in age-related macular degeneration. The case is from an ongoing phase 1/2a clinical trial. He performed 23-gauge vitrectomy, and first created a subretinal bleb with a 41-gauge cannula. A monolayer of RPE cells on a foldable scaffold was inserted, and it opened up in the subretinal space. He used forceps to adjust the positioning of the sheet. Fluid/air exchange was then performed.

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Dr. Ryan and Dr. Ho asked about the mechanics of the bleb creation, because the geographic atrophy can cause adhesions with the overlying retina. Dr. Kashani indicated that after the bleb is created, he uses a curved subretinal cannula to gently hydrodissect the macula off the area of atrophy using the silicone oil injector. Dr. Ho also asked whether there are enough photoreceptors in the area of atrophy to function after the RPE implantation. Dr. Kashani indicated that patients will have various degrees of photoreceptor loss, and earlier, smaller lesions may potentially benefit more from the intervention.