VBS 2023: Surgical Debates

Malini Pasricha, MD
West Coast Retina Medical Group
San Francisco, CA

The Surgical Debates section “I could do this all day” of the 11th Annual Vit-Buckle Society Meeting was an exciting and insightful session. The session was moderated by Drs. Joseph Coney, Chirag Jhaveri, and Katherine Talcott. It highlighted the past, present, and future of surgical techniques and tools that are an integral part in the dynamic landscape of vitreoretinal surgery.

The first debate was on 3D heads up surgery. On the “This Rocks” side, Dr. Jaya Kumar from the Florida Retina Institute brought up several key advantages of this surgical system:

  • Safer illumination of the retina, as it requires lower levels of light intensity
  • Enhanced visualization, specifically greater magnification and greater depth of field
  • Improved stereopsis from color boost and filters
  • Ergonomic posturing, adding years to one’s surgical career. She also mentioned the ability to operate comfortably while pregnant compared to a standard scope!
  • Immersive experience for everyone in the room and superior teaching tool for trainees

The biggest limitation is cost. Dr. Kumar ended on an inspiring note, citing the countless possibilities for technology integration (including intraoperative OCT, ultrasound B scan, and endoscopy) and artificial intelligence-driven assistance during surgeries (such as collision avoidance).

On the “This Sucks” side, Dr. Katherine Talcott from Cole Eye Institute admitted that while 3D heads up surgery has great potential, we cannot reliably replace our standard scopes at this time. She mentioned several challenges of the system, including:

  • The need for headgear
  • Difficulty in optimal machine positioning given crowded OR room
  • The false “necessity” of color filters
  • Lag time with anterior segment work
  • Compromise in the quality of digitized images with confusion from oversaturated colors
  • Difficulty in using the system for challenging cases involving the peripheral retina and secondary intraocular lenses
  • Difficulty in visualizing the laser beam

The future remains to be determined!

The second debate was on macular displacement following repair of retinal detachments. On the “Does Matter” side, Dr. Rajeev Muni from the University of Toronto highlighted his important contributions to the field. Macular displacement after vitrectomy surgery has been reported to be as high as 75%, and studies have shown that the amplitude of displacement is directly associated with distortion. The highest risk of macular displacement is after pars plana vitrectomy, followed by scleral buckle, and then by pneumatic retinopexy. With his chemical engineering colleagues, Dr. Muni was able to show that pneumatic retinopexy causes a 97% reduction in macular displacement. Though many use fundus autofluoroscence overlays to determine the degree of misalignment, Dr. Muni pointed out that the sensitivity of this technique is only 46%. He proposed an alternative technique called homography that involves overlaying the RPE, choroid, and optic nerve to measure displacement using color channels. The key point during his presentation was that anatomic reattachment does not equate to success, and that we must pay scrupulous attention to minimizing macular displacement to avoid metamorphopsia and anisekonia in patients after retinal detachment repair.

On the contrary side, Dr. Michael Cohen from Wills Eye Hospital reported on a single center, comparative case series that he helped perform at his institution. Among 200 patients evaluated, 25 demonstrated some degree of displacement. He noted that their rate of displacement in pars plana vitrectomy cases was 15%, comparable to the rate of displacement in pneumatic retinopexy cases in studies mentioned by Dr. Muni. The Wills study also evaluated several factors that may predispose to macular displacmenet, such as macula on/off status, location of retinotomy, use of perfluorocarbon liquid, and choice of tamponade agent, but none were found to be correlated. Though aneisokonia measurement was not part of the study, Dr. Cohen emphasized that the retinal displacement did not have any measurable effect on the best corrected visual acuity and therefore was not significant.

Nonetheless, it may be that future discussion will shift from “is there macular displacement?” to “how much macular displacement is there, is it visually significant, and is it reversible over time?” There is still lots to learn!

The third debate was on indocyanine green vs. brilliant blue for internal limiting membrane (ILM) staining. On Team Green, Dr. Ferhina Ali from Advanced Eye Specialty Services in New York and New York Medical College argued about the historical success and safety of ICG. She argued that it allows better visualization, enhanced rigidity of the tissue, and more efficient surgery. She mentioned few reports on the toxicity of ICG and pointed out a report of potential toxicity from brilliant blue as well. On Team Blue, Dr. Prethy Rao from Retina & Vitreous of Texas was quick to state that Tissue Blue is the first and only FDA approved dye for ILM staining. Furthermore, the mixing of ICG that is required is cumbersome and leaves room for multiple errors, while Tissue Blue comes in a pre-filled syringe. She also emphasized the potential harmful effects of ICG that have been shown in the literature, including reduced visual acuity, visual field defects, and RPE atrophy.