Samuel D. Hobbs, MD, CAPT, USAF, MC
Vitreoretinal Surgery Fellow
UCLA/Stein Eye Institute
Dr. Richard McDonald started this surgical session by sharing several pre-operative fundus photos and OCT images and asking the panelists their preferred management for each disease. The first case was mild vitreomacular traction (VMT), and Dr. Houmayoun Tabandeh emphasized the importance of gathering more history, including the duration of traction and presence of symptoms, if any. In long-standing VMT or if asymptomatic, there is no need for surgery, and 30% of cases will resolve spontaneously. The next case was similar, however, with an impending macular hole. Dr. Michael Jumper emphasized that again, this can be observed as VMT with an impending macular hole may also spontaneously resolve.
The next case was a patient with myopic macular schisis and good visual acuity (20/25). After eight years, this patient went on to develop a localized macular detachment with 20/40 vision. Dr. Colin McCannel discussed the importance of following vision in these patients, and he prefers to operate when the vision starts declining to 20/30 or 20/40, as waiting longer can lead to poorer visual outcomes. He prefers to treat these patients with pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling. He tries to leave the ILM intact around the fovea because of the risk of macular hole formation, but he otherwise widely peels to allow for relaxation of the remaining retina. The same macular schisis patient was again presented, this time 4-months after surgery, with residual subretinal fluid (SRF) within the macula. Dr. Guarav Shah noted that it is okay to observe this fluid, as long as there is no associated break.
Next, a high myope with a staphyloma and macular hole-associated rhegmatogenous retinal detachment (RRD) was presented. Dr. Shah discussed his preferred surgical technique with PPV and ILM peeling with flap. He discussed the importance of taking time during this type of surgery and having patience with the peel and not draining as to avoid displacing the flap. He discussed the pitfalls of using smaller gauge instrumentation, where the forceps might not reach the bottom of the staphyloma.
The next case was a 12-year-old with a soccer ball injury to the eye and a traumatic macular hole. Dr. Tabandeh noted that these traumatic holes are okay to watch and that they typically will spontaneously close. The fluorescein angiography (FA) from this patient was shown, which showed a diffuse staining pattern with leakage. Dr. Jumper said that this FA pattern indicates a poor visual prognosis, and the areas of staining and leakage will often become a heavily pigmented scar. Dr. Jumper agreed that these often close spontaneously without any need for surgical intervention.
Next, a series of different retinal detachments were then presented. The first was a macula-sparing RRD with lattice and demarcation line in a phakic patient without a posterior vitreous detachment (PVD). Dr. McCannel said his preferred treatment for this type of detachment is with primary scleral buckling. Next was a patient with a chronic phakic RRD with macrocysts and demarcation line, and Dr. McCannel again said he would treat with a scleral buckle, and there is no need to do anything different despite the presence of a macrocyst. Dr. Tabandeh was shown a patient with a phakic RRD with a PVD and a break adjacent to an area of lattice. He said that he would consider either a pneumatic retinopexy for this patient or a PPV with endolaser and gas. He mentioned briefly that phakic status is less important in his decision making now than it was previously in his career.
Another macula-sparing RRD with a superior horseshoe tear and lattice degeneration was shown, and Dr. Jumper agreed with Dr. Tabandeh that his first preferred treatment was with pneumatic retinopexy. He was shown a photo of “fish eggs” after a pneumatic retinopexy and was asked the best method of preventing this from happening, for which he reinforced the importance of injecting into the bubble, and if fish eggs happen, the eye can be gently (or not so gently!) thumped to allow the bubbles to coalesce.
A patient was shown who had persistent SRF one month after primary scleral buckling. Dr. McCannel said that observation is still appropriate, as long as all the breaks are flat along the buckle. Dr. Shah was shown a photo of abnormal retinal pigmentation after repair for a chronic phakic RRD. Although the reason for the abnormal coloration was not completely known, he hypothesized that the change in pigmentation was related to atrophy from the chronic RRD.
The next patient had a traumatic dialysis, and Dr. Jumper said the preferred treatment is with primary scleral buckling with a broad component in the area of the dialysis. A similar dialysis was then shown with an associated macrocyst, and Dr. McCannel again felt that there is no need to do anything differently with a macrocyst. A phakic macula-involving RRD with a large retinal tear was shown, and Dr. McCannel said that his preferred management was either primary scleral buckling or combining PPV with scleral buckle. The question was raised about when to combine scleral buckle with PPV in order to improve anatomical success with a large tear, and Dr. Shah mentioned that large tears are often associated with vitreous hemorrhage. Whenever there is blood in the eye, a buckle can help improve success in primary reattachment. He also noted that surgeons should do whatever works best in their hands – this could be a PPV alone or PPV combined with a scleral buckle.
At this point, Dr. McDonald reminded the audience of the need for discretion when choosing to operate on a patient. He cited a case report from 2010 in Retina Today of a monocular patient who had 20/20 visual acuity in his only eye and visually significant floaters. After his floaterectomy, he no longer had floaters, but he also had hand motion vision with a central retinal artery occlusion from the surgery.
The next patient was pseudophakic with early proliferative vitreoretinopathy (PVR) four weeks after his initial repair. Dr. McCannel said that he prefers earlier surgical intervention in these cases, despite the fact that earlier intervention may put these patients at higher risk of re-detachment postoperatively. He mentioned that waiting longer often leads to visual decline that can be avoided with early intervention. Dr. Jumper added that he prefers to stain the ILM in these cases. If the ILM can be peeled, it is easier to find the edge of the epiretinal membrane (ERM) and do a better job of relieving traction. The negative staining effect can also be used to highlight areas of ERM. Another PVR case was then shown, this time inferiorly in a phakic patient. Dr. Tabandeh mentioned that if there is inferior traction and a retinectomy needs to be performed, that he extends the retinectomy at least four clock hours to ensure that it will be completely covered by the tamponade agent.
Dr. Jumper was shown a PVR case with circumferential traction. He described his surgical technique of placing a buckle, peeling, and likely needing to perform a retinotomy or retinectomy. All of these techniques are to relieve traction from whatever retina still remains in the eye. He also described extensive peeling posteriorly and starting a retinectomy where the peeling ends. Dr. Shah was shown a pseudophakic RRD with PVR and a funnel configuration, and he said that his “two P’s” for these types of cases are perfluorocarbon liquid (PFCL) and patience. Dr. McCannel was shown a fundus photo of a retinal detachment with extensive subretinal fibrosis. He said that a focal retinotomy for access is usually sufficient to remove the subretinal bands. These membranes tend to be flexible and only need to be removed within the area of breaks or detachment. If they are away from these areas, they may not need to be removed.
A giant retinal tear (GRT)-related RRD was then shown, and Dr. Tabandeh said the most important way to avoid slippage is to drain all the fluid completely. Dr. Jumper added that it is also important to do things while you can visualize them. He often lasers the break under PFL while there is good visualization, since the view might be lost when an air exchange is performed. He also discussed the importance of tilting the eye so that the break is at the lowest point, and then slowly drying at the interface between the PFL and air to get all the fluid out.
There was discussion of a complex traumatic retinal detachment that had already undergone several surgeries. The most recent surgery made use of intravitreal methotrexate (MTX). The panelists were asked their opinion on the use of intravitreal MTX to treat or prevent PVR in similar cases. Dr. Shah said that he uses intravitreal MTX, while Dr. McCannel said that he does not use MTX for this purpose. Dr. Jumper explained the hurdles and risks associated with intravitreal MTX. The current clinical trial for MTX is very rigorous and includes the need for frequent injections over 13 weeks. MTX is also very toxic to the cornea and can cause severe keratopathy, which should be monitored vigilantly. Additionally, care must be taken to ensure adequate endolaser since MTX can prevent scarring, which is especially important at any retinotomy site.
Several additional cases were then quickly discussed. Dr. Shah was shown a photo of retinitis sclopetaria, including rolled retina and choroid as well as areas of bare sclera. He said that surgery was not indicated. A fourteen-year-old child with leukemia and acute onset of vision loss was found to have premacular hemorrhage (with a double ring sign), and Dr. Tabandeh said that this is something that can be observed. YAG laser can also be considered to break the posterior hyaloid face and allow blood into the vitreous, which allows it to clear faster. Dr. Shah was shown a photo of a combined retinal-RPE hamartoma, and he noted that surgery typically does not improve vision. There was a case of an optic pit with fovea-sparing SRF. Dr. Jumper said there was no need for surgery yet. Dr. McCannel added that, when surgery was needed, he would treat the temporal edge of the disc with laser and put gas in the eye. A similar case was shown but this time associated with a coloboma, and Dr. Shah said that sometimes the entire coloboma needs to be encircled with laser, and these cases are often more challenging.
Dr. McDonald then asked the audience to give the diagnosis for several other cases. An OCT was shown with the “jumping fish” sign, or hyperreflective curvilinear lines projecting above the retinal pigment epithelium (RPE), which represent outer retinal folds after RRD repair. These can be observed. Several photos were shown of possible phototoxicity from ICG for ILM peeling. A branch retinal arterial occlusion was shown in a patient who had surgery for a macular hole, which occurred due to prolonged intraoperative intraocular pressure at 60mmHg. Gentamicin toxicity was shown, as well as the “Omega sign” due to subretinal PFCL (so-called due to the acute angle between the RPE and neurosensory retina). A case of Uveitis-Glaucoma-Hyphema (UGH) syndrome was presented, and finally a fundus photograph of an eye with intraocular penetration from a retrobulbar needle during a block.