VBS 2022 – Session 1: Surgical Pearls

Grant Justin, MD
Vitreoretinal Fellow
Duke University Eye Center

Session 1: “Oh, Hello Old Sport” Moderated by Lisa C Olmos de Koo, MD, MBA and Dante J. Pieramici, MD

Dr. David Xu opened the Vit-Buckle Society (VBS) 10th Annual Meeting with a fantastic talk titled “Diabetic Tractional Retinal Detachment (TRD) is Not Your Friend.” He presented a number of critical points on his approach to these difficult cases. When he begins peeling, he uses his forceps to “pluck” along the membrane to dynamically assess and look for space for segmentation. Next, he gave three key pearls when dealing with TRDs: look for stretch retinal holes, peel the internal-limiting membrane (ILM) and don’t ignore the retinal periphery. Regarding stretch retinal holes, they usually occur under the proliferative membranes and finding these breaks is key for the case. Further when he encounters a retinal break, he peels the ILM to the break to remove associated traction. Finally, he uses triamcinolone routinely in his TRD cases as there is frequently vitreoschisis or residual proliferative membranes in the periphery that can contract postoperatively. Regarding preoperative management, anti-VEGF is beneficial. Additionally, pre-operative panretinal photocoagulation (PRP) can be considered.

Dr. Gabriela Lopezcarasa then presented a scleral buckling device in her talk “The Tornambe Legacy.” The talk began with a moving video tribute to Dr. Paul Tornambe – a pioneer of vitreoretinal surgery. As one of the innovators of pneumatic retinopexy, he published studies demonstrating similar efficacy of pneumatic retinopexy and scleral buckling. For scleral buckling procedures, Dr. Tornambe sought a less invasive surgical technique. Dr. Lopezcarasa presented his device for a removable temporary buckling element. The technique of placement is similar to that of a scleral buckle procedure and the device covers one quadrant. However, critically the device can be removed in office after approximately four weeks giving time for the chorioretinal scarring to form from cryoretinopexy. This device would prevent the complications of scleral buckling such as myopia and diplopia. Further, it would be ideal for young phakic detachments or in patients with multifocal intraocular lenses (IOLs).

Dr. Adrienne Scott gave a wonderful talk titled “Mission Possible: Surgical Management of Proliferative Sickle Cell Retinopathy.” She started her presentation by presenting two patients with sickle cell HbSC and proliferative sickle cell retinopathy (PSR). She showed key findings on ultrawide field fluorescein angiography (FA) such as leakage from seafan retinal neovascularization and peripheral nonperfusion. Also, on OCT there was classic temporal macular retinal thinning. She also presented how she manages TRDs in PSR: segmenting the FVP using a bimanual technique with lighted pick and forceps, laser to barricade seafans and to peripheral poorly perfused retina and using silicone oil or intraocular gas for longer tamponade. She then spoke more broadly on the complications of PSR/TRD surgical management including iatrogenic breaks, intraocular bleeding with secondary glaucoma, systemic vaso-occlusive crises, and anterior segment ischemia after high scleral buckles. She emphasized that scatter laser is first line treatment for the patients as it reduced vitreous hemorrhage. Perioperative anti-VEGF injections can be helpful, and she showed FA imaging demonstrating that after one bevacizumab injection peripheral leakage decreased. Overall, her goal is to keep these patients out of the operating room by appropriate use of scatter laser, considering anti-VEGF injection prior to vitrectomy, avoiding high scleral buckles and paying attention to pain and systemic management.

Next Dr. Christina Weng spoke on “Pitfalls of SFIOL and How to Avoid Them.” Recently trocar-based scleral fixation has gained popularity for secondary intraocular lenses, but there are four common pitfalls that put this elegant surgery at risk for failure.

Pitfall 1- Failing to set yourself up for the win. It is critical to have pre-operative calculations of multiple IOLs. She usually targets -0.5D to plano if measuring 2.5 mm back from the limbus. Further, it is critical not to balloon the conjunctiva with the block and to be strategic with trocar cannula placement.

Pitfall 2- Marking is the most important step of the surgery. Currently, she prefers a 12-point corneal ray marker. Also, to prevent lens tilt she will depress and remove any capsule remanent, and she ensures that trocar entry is symmetrical on both sides with identical angle and length of the sclerotomies.

Pitfall 3- Use a hand-to-hand technique. With a bimanual forceps technique using the multiple available cannulas, it is possible to walk the tip of the haptic to yourself. Importantly, grab the tip of the haptic very tightly and if you are not at the tip you can kink the haptic.

Pitfall 4- Make a good bulb. You don’t need to contact the haptic with the cautery, and it is important to dry and elevate the haptic from the surface during cautery. If the lens is not centered, you can trim the haptic as long as there is not tension. The bulb should sit just inside the sclerotomy tunnel and consider Miochol or Miostat at the end of the case.

The last presentation of this session was by Dr. Vaidehi Dedania on “Finding the Hidden Door: Identifying the Retinal Breaks and Repairing Schisis Detachments.” She began by mentioning a few key components of schisis-detachment surgery: PVD induction, identification of outer retinal breaks and drainage of subretinal fluid (SRF). Often even older patients with retinoschisis are less likely to have spontaneous PVD and there is generally very tight adherence of the vitreous to the area of schisis requiring a careful close shave. Second, the outer retinal breaks can be difficult to find and are often at the posterior margin of the area of schisis. It is important to apply laser retinopexy to the outer retinal break, and in discussion after the presentation members of audience deliberated applying laser broadly over the area of schisis. Finally, the schisis fluid can be thick and a drainage retinotomy can be required in order to drain the fluid. Post-operatively fluid can recur in the area of schisis or be pushed inferiorly by tamponade. But, usually the fluid resolves on its own and should be monitored.