Samuel Cohen, MD and David Peprah, MD
Moderated by Drs. Gerardo Garica-Aguirre and Jessica D. Randolph, this surgical case panel featured eight different cases with unique intraoperative complications.
Dr. Sean Adrean described a complication in which a 27G soft tip cannula became dislodged and settled underneath the fovea during an otherwise routine pars plana vitrectomy for retinal detachment repair. This complication was noted on OCT during a post-operative visit and the patient returned to the operating room for soft-tip removal given its subfoveal location. A perfluorocarbon bubble was used to displace the soft tip to a safe location, after which a retinotomy and forceps were ultimately used to carefully retrieve the soft tip. The case emphasized the importance of maintaining a stable intraocular environment while avoiding retinal contact during retrieval. Controlled removal under direct visualization was critical to preventing secondary injury. This case served as a reminder that even routine tools can become intraocular foreign bodies, reinforcing the need for vigilance and instrument checks throughout surgery.
Dr. Arjun Desai followed with a case of epiretinal membrane removal, which was complicated by an iatrogenic macular break followed by a large suprachoroidal hemorrhage. Clinical pearls centered on the importance of constant visualization of the tips of instruments in the eye to prevent iatrogenic breaks as well as different points in the surgery when views of the retina may be limited and iatrogenic injuries more likely. Panelists discussed the utilization of different tamponade agents, including silicone oil or gas tamponade, in suprachoroidal hemorrhage cases. Audience members recommended maintaining elevated eye pressure until the bleed stabilizes and avoiding air-fluid exchange whenever possible during a suprachoroidal hemorrhage.
Dr. Jason Fan then presented a case of severe open globe injury caused by a high-velocity concrete nail. After careful nail removal, vitrectomy, lensectomy, and laser, insertion of silicone oil into the eye was unsuccessful as the eye failed to pressurize and several oil bubbles formed on the surface of the sclera. It was then determined that oil was egressing through a posterior penetrating wound. At post-operative month one, focal traction was present at the strike site and the patient returned to the operating room for a vitrectomy and scleral buckle with a revised retinectomy. Clinical pearls from Dr. Fan included maintaining a high suspicion for posterior penetration when a large IOFB moving at a high velocity is suspected and emphasizing that CT may not be able to accurately determine the presence of posterior penetration.
Dr. Kenneth Fan proceeded to describe a case in which gene therapy delivery for retinitis pigmentosa was complicated by the formation of a retinal hole during subretinal delivery. The hole was identified post-operatively, and given that her already limited central vision was affected, the patient returned to the operating room for repair. After an ILM peel, an amniotic membrane transplant was placed over the hole under oil to facilitate closure. Less than three months later, an unsuccessful attempt was made to peel the amniotic membrane transplant off the hole. In an effort to avoid causing an additional hole, the amniotic membrane was trimmed rather than completely removed. Post-operative evaluation revealed that the hole was closed but vision was limited due to the amniotic membrane transplant effectively integrating into the retina, precluding complete removal. Discussion from the panelists and the audience centered on the importance of standardized guidelines for amniotic membrane use and removal.
Dr. Joaquin Romano was next to present a rare case of consecutive intraoperative instrument failures, illustrating the cumulative risk of mechanical fatigue in vitreoretinal surgery. The case required rapid recognition, careful accounting of all retained fragments, and controlled retrieval under direct visualization. Maintaining intraocular stability while avoiding retinal injury was central to successful management. The discussion emphasized the importance of preparedness, including awareness of instrument lifespan and having contingency strategies readily available.
Dr. Lucas Soares described an intraoperative suprachoroidal hemorrhage in a monocular patient undergoing phacoemulsification and Ahmed valve for phacomorphic glaucoma. Immediate control of intraocular pressure was prioritized to prevent further expansion of the hemorrhage. A pars plana approach to decompression was employed to better address posterior segment pressure dynamics. Key take-home points from Dr. Soares included the importance of stratifying high-risk patients prior to surgery and the need to immediately recognize and control suprachoroidal hemorrhage to preserve globe anatomy.
Dr. Ethan Sobol presented a challenging case of persistent fetal vasculature complicated by rhegmatogenous retinal detachment. Abnormal vitreoretinal adhesions and altered anatomy increase the risk of iatrogenic injury during surgical dissection in these cases. Intraoperatively, a giant retinal dialysis was noted in the nasal periphery, A core vitrectomy with laser and gas tamponade was performed to repair the dialysis. The retina remained completely attached on follow up several months later. Dr. Sobol emphasized the importance of recognizing the retina can be drawn up into ciliary processes in persistent fetal vascular cases, warranting extra caution during dissection. Moreover, he advocated for the use of valved cannulas at the limbus, even in a combined case with an anterior segment surgeon.
Dr. Marcelo Ventura Filho finished the session presenting a case of subretinal migration of perfluorocarbon liquid (PFCL) through a macular hole. A fluid air exchange and accessory retinotomy were performed to address this rare but visually significant complication. At post-operative month two, only small bubble remnants in the subretinal space remained; however, the patient’s macular hole failed to close. The patient deferred further surgery. This case emphasized meticulous PFCL handling as the best preventative strategy. When complications occur, such as subretinal migration, management must be individualized based on location and visual impact.
