Maria Paula Fernandez and Hasenin Al-khersan
Bascom Palmer Eye Institute
The “Complications” session of the 11th Annual Vit-Buckle Society Meeting is a perennial favorite, offering insightful discussion and many surgical pearls for the audience. Moderated by Drs. Maria Berrocal, Jay Chhablani, David S. Chin Yee, and Yannek I. Leiderman, the session included eight interesting cases, several of which are summarized below.
Case 1: The session started with a presentation entitled “Aqueous Misdirection with Silicone Oil Overfill.” This was a case of an aphakic patient who presented with aqueous misdirection after silicone oil insertion. Interestingly, this case was managed in the office by performing ocular palpation with the patient facing down.
The audience and moderators discussed the indications, advantages, and disadvantages of managing this type of complication in the office including avoiding a return trip to the operating room. Recommendations to avoid silicone oil overfill and aqueous misdirection were discussed, which included: performing the instillation of oil under direct visualization, creating an iridotomy at the end of surgery, leaving viscoelastic in the anterior chamber, suturing all wounds, and face down positioning.
Case 2: The second case entitled “Bad Blood” described the case of a choroidal hemorrhage in the setting of a choroidal biopsy for suspected malignancy. The discussion focused on the challenge of controlling bleeding during intraocular surgery. Discussed recommendations to prevent bleeding during a choroidal biopsy included increasing the IOP to 60 mmHg, using the diathermy tip before performing the biopsy, choosing a more anterior location (farther away from the macula), and frequent evaluation and control of the patient’s blood pressure.
Case 3: The third case, “Just Another Mac Hole,” was a case of a massive suprachoroidal hemorrhage with overlying detachment from a 25-gauge needle during air gas exchange. The case prompted an interesting discussion regarding the multiple techniques for venting while performing an air-gas exchange or air-silicone oil exchange in addition to the different risk factors for the development of a suprachoroidal hemorrhage. The panelists also walked the audience through the steps and timing to surgically treat these patients. Recommendations included using the ultrasound to guide the location for cutdowns, avoiding vortex veins, not attempting 100% drainage, and to wait at least 7 to 10 days from diagnosis to intervention.
Case 4: The fourth case, “Management of Inadvertent Suprachoroidal Silicone Oil Injection,” highlighted the case of a ruptured globe with retinal detachment in which silicone oil was inadvertently injected in the suprachoroidal space. The panelists discussed the importance of visualizing the surgical instruments in the eye and verifying the proper placement of the trocars and cannulas. They also highlighted the importance of using longer infusion cannulas in trauma cases and avoiding a bevel during trocar placement.
Case 5: The next case was that of a suture perforation during a scleral buckling procedure with subsequent subretinal hemorrhage into the macula. The techniques to manage this complication suggested by the panelists included conversion to vitrectomy, the injection of PFO to protect the fovea, and the importance of tilting the patients head in order to void bleeding into the fovea. Dr. Berrocal also discussed her “Squeegee technique” to move the blood towards the periphery using PFO with shaking of the globe. Most importantly, the panelists agreed upon urgent decision making to prevent blood from being trapped subfoveally.
The last cases presented included giant retinal tear slippage, bleeding in the setting of a vascular loop during PVD induction, and stress-induced contractions in a pregnant patient during scleral buckle surgery. During this last case, a 36 week multiparous pregnant patient was undergoing primary scleral buckling under MAC anesthesia when she blurted out, “I think it is coming.” The OB team was rushed to the operating room and definitive contractions were noted on fetal monitoring. Fortunately, the contractions subsided, but the patient was admitted to the hospital and delivered several days later. Her retina remained successfully attached and a lasting bond was made between patient and retina surgeon. This last case took home the coveted buckle award for best complication. As always, these complications elicited vigorous discussion with many surgical pearls for the audience.