Vit-Buckle Society 2021 Meeting: Episode 2

Matthew Starr
Vitreoretinal Fellow
Wills Eye Hospital

VBS The Force Awakens Episode 2 was moderated by Mrinali Gupta, Jorge Fortun, and Avni Finn. The meeting kicked off with an intense debate amongst vitrectomy platforms. Debating in favor of the DORC Eva was Ashely Crane who emphasized the precise vacuum control and focused lighting with the DORC platform. There are some packaging kinks, though, that are currently being worked out with the DORC system, one of which requires flicking the laser probe to remove inadvertent bubbles during the packaging process. The Alcon Constellation needed no introduction and Dr. Adrienne Scott spoke to the wide use of this system and how the majority of fellows are trained on this system. The Constellation also has the widest array of secondary instruments available compared to other platforms. Perhaps most critical to the Constellation is the precise IOP control that surgeons enjoy compared to other platforms. With the new hypervit technology emerging, 20,000 cut speed is now available across the 25 and 27 gauge systems. Lastly, Dr. Scott also mentioned the built in datafusion technology that integrates the heads up NGenuity display with the Constellation. Lastly, the Bausch and Lomb Stellaris was advocated for by Victor Gonzalez who immediately spoke on the bi-blade cutting technology that doubles the cut rate of the Stellaris while increasing the flow efficiency. Dr. Gonzalez is able to use the 27g vitreous cutter as a multipurpose tool without having to introduce many instruments into the eye. Additionally, the new 27g B&L instruments have increased rigidity making them less fragile than previous versions. In the end, most viewers (89%) reported using the Alcon platform while the majority (41%) want to try the DORC Eva at some point in the future.

Next up was an incredible talk by Dr. Caroline Baumal on “Varsity Level OCT” who highlighted a number of high yield OCT findings and their associated retinal diseases. She went over so many findings in such a short time period, including DRIL, ILIM draping, PAMM lesions, AMN lesions, Henle Hemorrhages, laser maculopathy, eclipse retinopathy, bacillary detachment, flying saucer sign, and choroidal excavation. Interestingly, the double layer sign has a new name, Shallow Irregular RPE Elevation (SIRE), and is associated with type 1 choroidal neovascularization and wet AMD. Most importantly, she highlighted the dynamic nature of OCT technology and for retina providers to always adapt to the evolving technology.

Following Dr. Baumal’s presentation was macular hole acrobatics, debating the best technique for the treatment of chronic, large macular holes: ILM flap vs amniotic membrane graft vs submacular BSS. Debating pro ILM flap was Prethy Rao who uses her own “Rug technique” where she starts an ILM flam 1-2 disc diameters inferior to the macular hole and then pulls the flap in a continuous sheet over and just past the hole. She then allows the flap to drape back over the hole during a careful fluid air exchange. She notes to drain along the inferior macula or optic nerve to get the flap to unravel inferiorly. Following this was Jessica Lee who described her retrospective study regarding the use of amniotic membrane grafts. Her pearls for this technique are to use a 2mm corneal punch biopsy to harvest the graft, peel the amniotic membrane using ILM forceps which will fold the graft into a “taco”, the outside of taco shell is the sticky side and lays onto the RRPE. Using the ILM forceps and a soft tip, the graft is placed under the edges of the hole. She notes using a chandelier is key for a bimanual technique to ease the graft placement. Lastly, she mentions that with this technique, gas is an adequate tamponade and there is no need for PFO or SO tamponade as with other grafts. The last debater was Daniela Meiznner, advocating for submacular BSS. She uses a 38g needle to form a subretinal bleb to release the retinal adhesions 360 degrees around the macular hole. She then massages the borders of the hole with a flex loop, but also always makes sure to peel the ILIM. Again with this technique, gas tamponade is adequate and she has great success rates and notes this technique is much easier than grafting.

Following the macular hole battle was an excellent real world presentation by Christine Gonzales on job contracts. She started off discussing that in searching for the right retina practice, the most important consideration is finding the job that fits with your values whether that be financial, teaching, autonomy, business acumen, geographic, or intellectual activities. Private practices allow for more in business management and increased financial gains with less strain on academic productivity. Crucial to these practices is compatibility with future partners. When interviewing for these jobs, try to extend the interview as long as possible, learn as much as you can about the partners, take a 2^nd look, and shadow in the clinic/OR. Also find out how many satellites there are and how often you will go there. Be upfront about private equity and the practices plans for PE if any. When interviewing for academic positions, ask about the track you are interviewing for, is it clinical, scientific, or research. Know the expectations for promotion, whether you will get devoted time for teaching/clinic. Regardless of the setting, ask why the group or university is hiring and if anyone has someone left the setting, why did they leave. It is also important to know how you will be expected to get new patients, are you inheriting a practice or starting from scratch. It is also critical to not focus on the starting salary, focus on compatibility and potential future earnings. In the contract discussions, be professional and direct, hire a healthcare attorney with experience in retina if possible. She did note that somethings are not just worth the battle, very sage advice for young surgeons looking for their first job.

Last but not least, the night ended with the annual complications’ videos moderated by Paula Pecen and David Chin Yee. The first video was a smooth PVR RRD repair until the very last step, the administration of the subconjunctival antibiotics when unexpectedly, the needle jets off the syringe, piercing the cornea and phakic lens. No note of a retinal impact site was mentioned, but the patient re-detached on post-operative day 5, thought to be due to inadequate gas fill, although a retinal impact site could not be ruled out. The next video showed an eloquent lens exchange with the surgeons meticulously threading goretex suture in the vitreous cavity and rescuing a dropped lens. However, during the last step, the surgeons broke the goretex and then broke the haptic, having to abort the lens rescue. The next video was an ACIOL surgery for a patient with Down Syndrome and lens subluxation, when early on in the case, a suprachoroidal detachment is noted. Inadvertently, the infusion line slipped out and into the suprachoroidal space. The surgeons managed the choroidal well, moving the infusion line to a new cannula and finishing the case successfully, however, no lens was placed in an attempt to keep the case as simple as possible. Something the moderators really felt was important whenever a complication is encountered. They noted bad things always happen while doing unnecessary steps. The next video was of a submacular hemorrhage during external drainage of a primary chandelier buckle. The panelists agreed that immediately increasing the IOP to tamponade the hemorrhage with digital pressure or tightening the buckle were critical. Additionally, a gas bubble with face down positioning to prevent migration of the hemorrhage was a great maneuver by the surgeons. As an aside many panelists discussed they won’t drain subretinal fluid during primary buckle repair if able. Astute advice from Dr. Adrienne Scott “trust the process” in primary buckles, the retina will flatten. The last video was of a PPV/PPL with secondary IOL placement that developed a macular hole during the PPL. The surgeons also struggled with converting a smaller gauge sclerotomy to a large gauge to fit the fragmatome, and had difficulty achieving a closed system with this wound continuously leaking. The panelists all noted that when performing a PPL, a separate sclerotomy is crucial and makes the whole case flow much smoother. In the end, the coveted award for best complication video was the penetrating needle injury.