ASRS 2018: Neovascular AMD


Sarwar Zahid, MD Vitreoretinal Surgery Fellow University of Illinois Chicago The Surgical Case Conference was a tour de force of complex surgical cases and surgical techniques presented by surgeons at various levels of training. Dr. Carl Awh and Dr. Carl Regillo expertly moderated the session. [caption id="attachment_2215" align="alignnone" width="4032"]IMG_5746 Moderators Carl Awh, MD, and Carl Regillo, MD[/caption] Dr. AlBahati kicked off the session describing the repair of a chronic (1-year) macular hole with an autologous retinal graft in a patient with DM with moderate retinopathy. He showed a beautiful surgical video showing retinal grafting under PFO and implanting silicone oil. OCT showed integration of the edematous graft into the area of retinal defect. One month after SO removal, the patient developed CME localized to the graft, which was treated with intravitreal aflibercept and dexamethasone injections. Despite no improvement on OCT, the patient reported subjective improvement. Discussion points included whether the edema was exudative or degenerative, for which he planned to further evaluate with FA. Dr. Regillo also suggested using gas instead of oil for tamponade. [caption id="attachment_2212" align="alignnone" width="4032"]IMG_5741 Mohamed AlBahiti, MBBS, FRCSC[/caption] From Duke, Dr. Ali presented an interesting case of unilateral anterior uveitis treated with topical steroids. At presentation, the patient had HM vision with anterior uveitis and suspected exudative RD without breaks. Treatment with difluprednate did improve the inflammation but revealed an RD with grade C PVR with subretinal bands of PVR. This eye was treated surgically and was attached at three months, though vision was limited by a pre-existing APD. [caption id="attachment_2213" align="alignnone" width="4032"]IMG_5743 Mohsin Ali, MD[/caption] Dr. Borse reported an interesting progressively worsening BRAO which was treated surgically. Low infusion pressure during vitrectomy revealed the plaque which was gently massaged radially with forceps to dislodge the embolus distally. Discussion points included the importance of time course to intervention, which in this case was within 72 hours of symptom onset. Dr. Borse mentioned that peeling fibrous preretinal bands with gentle massage can help with dislodging emboli. [caption id="attachment_2214" align="alignnone" width="4032"]IMG_5745 Nishikant Borse, MS, FMRF[/caption] Next, Dr. Chang reported a case of vitrectomy for aqueous misdirection, during which a bleb of corneal epithelium developed during synechiolysis. Interestingly, there was no evidence of any false passages created with needles. During discussion, it was hypothesized that the fluid may have been forced through unhealed stroma of 2-week-old cataract surgery wounds into the subepithelial space. [caption id="attachment_2216" align="alignnone" width="4032"]IMG_5748 Jonathan Chang, MD[/caption] Dr. Li from St. Louis described an eye with suprachoroidal hemorrhage in a patient on anticoagulation 6 months after trabeculectomy. He described the use of a one-port 23-gauge valved cannula directed towards the dome of the choroidal hemorrhage 4 mm from the limbus. Maintaining the IOP with injection of BSS and concomitant external massage with a cotton-tip applicator successfully drained hemorrhage. Important pearls from Dr. Regillo included the use of an anterior chamber maintainer, which may provide more controlled IOP control. Importantly, the goal is not to completely resolve all choroidal hemorrhage, but more so to reduce the apposition. [caption id="attachment_2217" align="alignnone" width="4032"]IMG_5749 Albert Li, MD[/caption] Dr. Michalewska from Poland then described a case of traumatic macular hole which required multiple surgeries. The initial surgery included hyaloid and ILM peeling, which were tightly adherent in a young patient. An ILM transplant was performed and resulted in successful closure. Discussion points included the point that surgery is not always necessary, as traumatic macular holes often close spontaneously. Further, during ILM implantation, turning off the infusion can help prevent the flap being blown away until a layer of overlying OVD is placed. [caption id="attachment_2218" align="alignnone" width="4032"]IMG_5750 Zofia Michalewska, MD, PhD[/caption] Dr. Nagpal from India described a case of ERM peeling, which was complicated by visualization of blood at the start of the case. He realized that it had resulted from inadvertant globe perforation at two sites from administration of a peribulbar block by the anesthesia team. It is a case that reminds us of the importance of taking care during administration of blocks. Others mentioned that most people currently do their own retro- or peribulbar blocks, while some surgeons prefer a limited cutdown with sub-Tenon’s administration; other surgeons have anesthesiologists perform their blocks. [caption id="attachment_2219" align="alignnone" width="4032"]IMG_5755 Manish Nagpal, MD, FRCS (UK)[/caption] Dr. Ozkan from Turkey described a giant traumatic macular hole and retinal detachment noted 1 month after vitrectomy with IOFB removal and silicone oil implantation. During the following surgery, she created a retinal graft under PFCL and grafted this over the macular hole. This technique resulted in successful closure of macular hole. Interestingly, she suggested that the retinal graft acted more like an ILM flap and ultimately resulted in closure of the hole via gliosis, with gradual atrophy of the graft. [caption id="attachment_2220" align="alignnone" width="4032"]IMG_5757 Berna Ozkan, MD[/caption] Dr. Rubin next described a new method to sclerally fixate 1-piece IOLs (SN60WF). He described performing 2-point fixation using Gore-tex suture around the haptic-optic junction. However, the suture eroded through the haptic, possibly given that the needle was passed through the IOL. Others suggested using a clove-hitch around the haptic as a technique to avoid this problem. Dr. Regillo also suggested 25- or 27-gauge systems to reduce the risk of hypotony post-operatively. [caption id="attachment_2221" align="alignnone" width="4032"]IMG_5758 Uriel Rubin, MD[/caption]
Dr. Sridhar from Bascom Palmer then presented a case of dense vitreous hemorrhage in a patient with a history of treated metastatic cutaneous melanoma of the earlobe in remission. During vitrectomy there were noted to be dense pigmented membranes over the surface of the retina and complete pigmentation of the retinal vessels. There was concern for malignancy and thus a vitrectomy sample was sent to pathology and triple freeze-thaw cryotherapy was applied to the sclerotomy sites at the end of the case. Pathology confirmed metastatic cutaneous melanoma .
[caption id="attachment_2222" align="alignnone" width="4032"]IMG_5760 Jayanth Sridhar, MD[/caption] Dr. Villegas described a case of pediatric Terson’s Syndrome 3 months after an MVA requiring a craniotomy. After peeling the tightly adherent hyaloid, an area of subhyaloid fibrosis was peeled using ILM forceps. Other pearls included using the vitreous cutter to peel an already elevated ILM flap. Pathology revealed that this sub-ILM hemorrhage was likely consistent with prior hemorrhage into this space. [caption id="attachment_2223" align="alignnone" width="4032"]IMG_5763 Victor Villegas, MD[/caption] Finally, Dr. Christina Weng from Baylor presented a 24-year-old with a chronic combined tractional-rhegmatogenous retinal detachment associated with a retinal capillary hemangioma. She described using sutures to ligate the three feeder vessels, after which endodiathermy was applied distal to these vessels, allowing en bloc excision of the capillary hemangioma. Interestingly, in contrast to most detachments caused by capillary hemangiomas, which tend to be exudative, this eye had numerous small retinal breaks nearby. [caption id="attachment_2347" align="alignnone" width="1000"]KC2_1455.jpg Christina Weng, MD, MBA[/caption]