Jimmy Chen, MD
Mass Eye and Ear, Boston MA
The Vitreoretinal Surgery session at the 50th Annual Atlantic Coast Retina Club and Macula 2026 in Philadelphia, PA brought together a group of expert vitreoretinal surgeons to address controversial and challenging aspects of modern vitreoretinal surgery. The session was moderated by William Benson MD, Richard Kaiser MD, and Meera Sivalingam, MD.
The session opened with Don D’Amico MD, who discussed surgical decision making for macular hole repair. He first discussed previously published data, which showed no difference in visual acuity (VA) or closure rate for macula holes < 400 um with or without ILM peeling, and primary closure benefit for ILM peeling and flaps in larger holes. Secondary techniques for failed primary hole closure were then discussed, with a surgical video showing his preferred technique, visco-stretching. He also reviewed other techniques including flex loop massage, retinal autograft, amniotic membrane placement, and ILM flap repositioning. He ended his presentation with caution that visual acuity tended to be guarded for those requiring additional macula hole surgery.
John Miller MD then presented his evolving experience with the Removable Amniotic Membrane Patch (RAMP) technique for larger macula holes. RAMP involves placement of a large amniotic membrane graft over the macula with planned removal after 2–3 months. His surgical technique was shown, demonstrating bimanual amniotic membrane placement over the macula using a chandelier, placement of perfluorocarbon (PFO) to flatten the graft, and tamponade with silicone oil after PFO-air exchange and fluid air-exchange. Subsequent graft removal was also shown, and was similar to epiretinal membrane peeling. He gave additional tips including using brilliant blue to ensure chorion side was face-down, adding PFO over the center of the graft to avoid tilt, and a slow careful fluid-air exchange.
John Thompson MD reviewed strategies for managing dislocated intraocular lenses (IOLs), emphasizing that there is no “best” technique. He reviewed the most common techniques including: lens removal followed by insertion of scleral-fixated or anterior chamber IOLs or Yamane technique, and lens rescue techniques with iris or scleral fixation. He then introduced his surgical technique for IOL rescue: Haptic Externalization Scleral Suture (HESS), and showed a surgical video demonstrating scleral fixation of a dislocated one-piece IOL through scleral pockets without IOL exchange. He also highlighted retrospective data for this technique demonstrating VA improvement from 20/250 pre-operatively to 20/60 post-operatively on average for 148 IOL repositioning surgeries, and a 4% rate of secondary repositioning required.
Yash Modi MD then presented on the importance of minimizing retinal displacement after retinal detachment repair, in addition to primary reattachment and visual acuity improvement. He reviewed imaging biomarkers predictive for retinal displacement including vessel printing, ellipsoid zone integrity, and outer retinal folds. He then compared slippage rates across repair techniques, with pneumatic retinopexy and scleral buckling associated with less displacement than pars plana vitrectomy, likely due to more passive subretinal fluid resorption. He concluded his talk with a discussion on how even brief head elevations before face-down positioning can increase retinal displacement risk due to fluid turbulence.
Talia Kaden MD addressed the ongoing debate surrounding subretinal fluid drainage during primary scleral buckle surgery. She first outlined contemporary trends favoring primary buckling in young, phakic patients with inferior breaks and an attached posterior hyaloid. She highlighted that while drainage can facilitate buckle placement, aid in visualizing indention, and potentially accelerate visual recovery, she emphasized its risks, including hemorrhage, hypotony, and retinal incarceration. Her discussion underscored the importance of patient selection, noting that drainage may be most appropriate in macula-off, bullous, highly myopic, or chronic shallow detachments, while detachment with superior breaks and macula-on cases may not require drainage.
Finally, Demetrios Vavvas MD PhD reviewed pharmacologic strategies to prevent proliferative vitreoretinopathy (PVR), a major cause of retinal detachment surgical failure, and reasons why an efficacious therapy remains elusive. He summarized several trials involving corticosteroids, radiation, antiproliferative agents such as 5-fluorouracil, retinoids, and biologics including bevacizumab and infliximab – all of which ultimately demonstrated inconclusive benefits. He also discussed recent trials using intravitreal methotrexate for PVR reduction, including work led by Dean Eliott MD; however, results remain mixed. A central theme of his presentation was that small sample sizes and underpowered studies to date were limiting the ability to identify potential statistically significant benefits for PVR pharmacotherapeutics.
