Terry Hsieh, MD, PhD
University of California, Irvine
Drs. Maria D. Berrocal and Carl D. Regillo moderated the surgical case conference consisting of fourteen cases on Day 1 of ASRS. Here are the highlights of cases and the relevant discussion.
Dr. Jennifer O. Adeghate, MD, showed a video of treating a tractional retinal detachment (TRD) secondary to a vasoproliferative tumor (VPT). The VPT itself was treated with direct laser.
Dr. Vishal Agrawal, MD, FRCS, FACS, FASRS, presented a case of closure of a coloboma and optic nerve head (ONH) pit with two separate ILM flaps subsequently complicated by retinal detachment. Dr. Regillo suggested doing a double flap in ONH pits to put one over the pit and another over the fovea to prevent macular hole formation. Dr. Berrocal states she goes to air prior to lasering coloboma or ONH pit as the gas will push fluid out and improve laser uptake..
Dr. Abdulaziz A. Alshamrani, MD, presented a surgical case of ocular trauma with intraocular foreign body (IOFB) in a young child presenting with light perception (LP) vision. A heroic surgical effort that included pars plana vitrectomy (PPV) and lensectomy (PPL) with internal limiting membrane peel, endolaser, IOFB removal, and pupilloplasty was performed. At most recent follow up, this child was 20/100. The discussion focused on the timing of IOFB removal in real world situations versus the military trauma data with delayed IOFB removal after closure. There may be some benefit in delay to allow for propagation of the posterior vitreous detachment, but that must be weighed against the risk of endophthalmitis. In either case, it is important to start systemic and/or intravitreal antibiotics.
Dr. J. Fernando Arevalo, MD, PhD, FACS, FASRS, presented a video of a combined cataract extraction (CE) and intraocular lens (IOL) implantation with scleral buckle (SB) and vitrectomy (PPV) to repair degenerative retinoschisis with retinal detachment. A retinectomy had to be performed to allow the cavity to flatten despite PPV/SB. Dr. Berrocal added she often combines the inner and outer breaks and, since they have an absolute scotoma, a generous endolaser barricade is well tolerated.
With more reports of intraocular lens (IOL) tilt in scleral fixation of CT Lucia 602 lenses, Dr. David Doobin, MD, PhD, demonstrated a technique to correct tilt. In this case, they were able to use the light pipe to position the IOL and a 23G laser (due to bending with the 25G) to laser the optic-haptic junction in the desired position.
Dr. Mallika Goyal, MD, showed a series of cases using fibrin glue to close retinal breaks in combined tractional (TRD) and rhegmatogenous retinal detachments (RRD). In this series, iatrogenic breaks occurred while repairing the TRD. After fluid-air exchange (FAX), fibrin glue (Tisseel) was placed over each of the breaks – thick then thin followed by silicone oil. Post-operative OCT demonstrated resorption of the fibrin glue after <7 days. In her hands, so far, there have been no issues with inflammation at 10 months postoperatively.
Dr. Tahreem A. Mir, MD, demonstrated drainage of appositional choroidals one month after glaucoma drainage device implantation. A scleral buckle sleeve was cut to act as a guard, exposing only 2 mm of a 25g hypodermic needle. This needle was attached to the extrusion line, and under direct visualization via chandelier, the surgeon can observe that the needle is not penetrating the retina and perform direct drainage of the choroidals.
Dr. Jennifer Nadelmann, MD, presented a chronic case of subretinal abscess with vitritis that was located nasally. Given the chronicity, a vitrectomy was performed to biopsy the lesion. A 23G system was used with the surgeon sitting temporal to access the lesion better. Diathermy was performed followed by biopsy using scissors and forceps. The patient developed progressive proliferative vitreoretinopathy in this eye and nothing grew from the lesion. However, a new sinus lesion that was biopsied by Otolaryngology identified a non-tuberculosis mycobacterium, and the patient was started on treatment.
Dr. Zofia A. Nawrocka, MD, PhD, presented a case of spontaneous closure and reopening of a macular hole…twice. Due to this, Dr. Nawrocka planned an ILM flap from the temporal side, but the flap creation was difficult and did not fold over as usual. The same stain was applied and an epiretinal membrane (ERM) was identified. After removal of the ERM, an inverted ILM flap technique was utilized to cover the hole. There was significant discussion after this case as to flap size and when to use an ILM flap. Dr. Nawrocka employs an ILM flap in all full-thickness macular hole cases.
Dr. Geovanni J. Rios, MD, described a case involving an elderly man who suffered blunt trauma that resulted in a dense cataract being dislocated posteriorly. A vitrectomy was performed followed by creation of a corneal wound. This wound was then used to insert a phacoemulsification probe. Using forceps to grab the nucleus, the phacoemulsification probe was used to quickly remove the nucleus in the vitreous cavity.
Dr. Veer Singh, MS, FVRS, FMRF, FICO (Retina), presented a very interesting case of a young female with a live subfoveal cyst from cysticercosis. The cyst was noted to be live with subtle movement on exposure to the light pipe. An ILM peel was performed followed by a 41g cannula into the subretinal space to induce macular detachment, but the cyst popped up through the fovea and landed on the optic nerve where it was then removed by the vitreous cutter. Unfortunately, a macular hole developed postoperatively that was subsequently repaired with an ILM flap. A pearl from the moderators was to make sure that patients with cysticercosis get further imaging to identify if there are other areas of systemic spread.
Dr. Karen M. Wai, MD, demonstrated macular fold repair after prior RRD repair. She detached the macula with balanced salt solution (BSS) using a 41g cannula by injecting from the periphery followed by PFO to flatten the area. Intraoperative OCT confirmed flattening with improvement of the fold. The panel discussed the main key is the prevention of macular folds, especially with gas tamponade. Dr. Berrocal will keep patients prone until they go home if she suspects fluid while others consider posterior retinotomy versus an incomplete fluid-air exchange to treat it like a “super” pneumatic.
Dr. Srinivas Joshi, MD, FASRS, showed a case of a very large subfoveal PFO bubble. Direct aspiration was performed. However, due to the size, a fold was noted and a subretinal cannula was used to make a macular detachment followed by gas tamponade. A high yield point was that subfoveal PFO, even in eyes with poor vision, can be very symptomatic and should be removed within a few weeks. Subretinal PFO outside fovea is generally well-tolerated and can be observed.
Dr. Christina Y. Weng, MD, MBA, FASRS, showed an elegant creation of silicone oil retention sutures described by Dean Elliot for an aphakic patient with recurrent RRD and missing iris. First, 5 equidistant points are marked around the limbus. Entry is 1.5mm posterior to limbus with 10-0 prolene and tight hairpin loops are made with care to cross the prior path while going above and below previous passes. This will create 11 compartments with 5 passes of one continuous suture.