Danny A. Mammo MD
Vitreoretinal Surgery Fellow
Cole Eye Institute, Cleveland Clinic
For the final session to wrap up a wonderful VBS 2022 meeting, the much-anticipated surgical complications session “It Takes Two to Make an Accident” was moderated by Michael Klufas MD and Paula Pecen MD with panelists David Chin Yee MD, Yannek Leiderman MD PhD, and Aleksandra Rachitskaya MD.
Every surgeon encounters surgical complications and they can be humbling to experience and show to our peers, so we thank all of the excellent surgeons for their submissions.
The session began with a Yamane’s Surprise by Dr. Isabela Melo from University of Toronto where an MA60 IOL was inserted and secured with the Yamane technique but a scratch on center of the optic led to IOL explantation and reinsertion of another MA60 secured with the Yamane technique. This led to a discussion on the various secondary IOL techniques, suggesting that all the options have their benefits. It was widely accepted that everyone should still keep ACIOL implantation in their armamentarium.
Dr. Chris Fuller then entertained the audience with an exciting and well-edited video of a Yamane secondary IOL insertion in a patient on Eliquis anticoagulation. He encountered heavy intraoperative bleeding requiring a second operation. This led to a discussion on the risks and benefits to holding anticoagulation and also the necessity of a peripheral iridotomy during secondary IOL techniques.
Dr. Wei Wei Lee from the University of Toronto presented a very interesting case of chronic retinal detachment in a patient with Ehlers Danlos. She encountered leaking sclerotomies that proved difficult to close due to the scleromalacia as well as intraoperative bleeding. This led to an educational discussion with pearls on the use smaller gauge instrumentation, opening the conjunctiva at the beginning of the case to better examine the sclera, and avoiding tight suturing to avoid cheesewiring of the sclera. Lastly, a comment from the audience reminded us that Ehlers Danlos patients are prone to bleeding which may warrant preoperative hematologic evaluation.
Dr. Brian Do presented a case of perforation during creation of a scleral buckle belt loop, leading to subretinal hemorrhage and retinal incarceration. This required inferior retinectomy to relieve incarceration and remove the clotted blood. The video led to a discussion on ways to reduce scleral perforation and whether subretinal bleed outside of the macula can be observed. Nonetheless, the panel acknowledged that the subretinal clot in this case was too large to observe and a retinectomy was the most appropriate management.
Dr. John Hinkle’s video demonstrated pars plana vitrectomy for retinal detachment repair after failed pneumatic retinopexy complicated by a large pocket of subretinal gas. Early fluid air exchange combined with posterior scleral depression were used to remove the subretinal gas via the existing retinal break. Dr. Yee mentioned sometimes subretinal gas can be expressed with face down positioning and scleral depression in clinic before deeming it a failure. One commenter described a similar case where subretinal gas had expanded pushing the retina directly behind the lens. In his case, the gas was evacuated via external drainage.
The next video by Dr. Michael Klufas was a case of unexpected subretinal silicone oil seen during routine silicone oil removal. The subretinal oil was brought into the vitreous cavity via an inferior retinectomy and then removed. This case led to an interesting discussion from the audience about silicone oil in cases with optic nerve pit. Avoiding oil in these in these cases was recommended as oil can sometimes get into the pit and end up in the subretinal space or cerebrospinal fluid!
The following cases focused on pediatric retina. Dr. Edward Wood’s video highlighted a child with persistent fetal vasculature (PFV) who was being operated on by a pediatric ophthalmologist leading to an iatrogenic retinal break. The case was handled well with scleral buckle, pars plana vitrectomy and short-term PFO placement and a secondary operation to remove PFO, further elevate the hyaloid and reattach the retina. A pediatric retina specialist in the audience highlighted that appropriate parent counseling is needed for these cases since the PFV eye may require multiple surgeries and may have cosmetic and functional asymmetry to the other eye.
The next case was an excellently performed surgery by Mariam Al-Feky MD on a retinal dialysis with a falciform fold. She utilized PFO and external drainage along with membrane peeling to manage this case. This video won the audience voted award for best video of the session! Congratulations to Dr. Al-Feky.
The last pediatric retina case was a video by Dr. Robert Sisk of a tough case of an eye with PFV and coloboma with a retinal detachment, where the retina appeared to be sucked into the large coloboma. Some commented that retinal detachment with colobomas in younger patients are also usually exudative so initial observation (+/- diamox) could be considered.
The last surgical complications video of the session was a case presented by Dr. Klufas where an inferior retinectomy was needed. As the retinectomy edge was being treated with diathermy, the diathermy probe created an iatrogenic break posterior to the retinectomy edge. The retinal break and retinectomy edge were treated with laser and the case proceeded as usual. This led to a discussion on efficiency and safety with Dr. Liederman recounting a quote he likes to use from another surgeon: “You don’t go fast by rushing, you go fast by not wasting time.”
The session concluded by addressing a question from the audience on the important topic of medicolegal implications of surgical complications. This led a discussion on pearls for documentation and honesty with patients.
This session is often one of the most favorite by attendees and there was great discussion among the panelists, moderators, and audience. We again thank all the submitters for being brave enough to share their toughest cases with us for continued learning.