Darius D. Bordbar, MD
Mass Eye and Ear, Boston, MA
Moderators: Yoshihiro Yonekawa, MD Panelists: Maria H. Berrocal, MD; Dean Eliott, MD; Ajay E. Kuriyan, MD; Phoebe L. Mellen, MD
Moderated by Dr. Yoshihiro Yonekawa, this surgical case panel featured four videos of complex surgical techniques including subretinal silicone oil removal, autologous retinal transplantation, retinectomy under air for diabetic TRD/RRD, and submacular hemorrhage displacement.
Dr. Phoebe Mellen opened with a case of bullous inferior retinal redetachment under silicone oil. After preretinal oil removal, an inferior break and subretinal oil was identified. She performed inferior retinectomy to access the subretinal oil, however the oil could not be mobilized initially. After peripheral extension of the retinectomy, the subretinal bubble finally shifted forward and was removed using viscous fluid extraction. The retina was flattened with perfluorocarbon liquid, the retinectomy edge was lasered, and a PFCL-air exchange was performed followed by silicone oil refill under direct visualization. The panel discussed mechanisms for how oil may enter the subretinal space (including persistent traction at a break or inadvertent passage during oil infusion) and strategies to manage it.
Dr. Ajay Kuriyan followed with a large macular hole refractory to closure despite multiple prior surgical attempts, classified aptly by Dr. Yonekawa as an “extra extra extra large” hole. Dr. Kuriyan presented his autologous retinal transplantation technique. He created an inferior subretinal bleb then used vertical scissors to fashion a graft, with a pearl to oversize the graft to account for contraction. The graft was dragged over the hole under PFCL, and silicone oil was used as a tamponade. The hole closed with improved vision by postoperative month 6. Panel discussion consisted of preferences in dyes (ICG, BBG), tamponades (gas, oil, short-term PFCL), graft harvest sites (favoring healthy attached retina), and caution in patients with PVR history.
Dr. Maria Berrocal shared a challenging case in a young patient with a total combined diabetic TRD/RRD with extensive traction and subretinal membranes. Following phacoemulsification with IOL implantation, Dr. Berrocal demonstrated careful posterior hyaloid dissection and chandelier-assisted bimanual subretinal membrane removal. For peripheral dissection, she demonstrated visualization under air to identify residual traction and guide the extent of retinectomy, achieving retinal flattening without the use of PFCL. Dr. Berrocal gave multiple pearls including the importance of meticulous hemostasis in such repairs.
Finally, Dr. Dean Eliott presented a monocular patient with proliferative diabetic retinopathy status post PRP who developed a new fovea-involving subretinal hemorrhage. The panel discussed limitations of displacement in heavily lasered eyes and potential drainage in these cases. Dr. Eliott demonstrated a technique of 23-gauge PPV, PVD induction, subretinal tPA injection via a 38-gauge cannula into the superior macula, followed by 70% fluid-air exchange and 10% SF6. Pearls included slow injection to avoid iatrogenic macular holes and “prayer positioning”: a 45-degree angle to keep the bubble superior and posterior, promoting inferior displacement of the hemorrhage. Postoperatively, the hemorrhage displaced inferiorly and temporally without inducing new breaks despite the dense PRP scars.