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Challenging Retinal Cases in Vitreoretinal Surgery

To provide optimal outcomes for patients, sharing knowledge and experience from challenging cases is of utmost importance for surgeons — especially when it comes to difficult vitreoretinal procedures. Therefore, during the RETINAWESOME III virtual meeting on June 20, retinal specialists congregated (albeit online) to share their valuable insight on treating conditions including macular holes, ocular trauma, retinal detachment, diabetic retinopathy (DR) and more…

Tricky Retinal Detachments

Challenging Retinal Cases in Vitreoretinal Surgery
You have to get everything just right with the Tetris technique.

The first case study presented by Keynote Speaker Dr. Yusuke Oshima (Japan) involved a junior high school student with Coat’s disease and retinal detachment. He explained the procedure, noting that the fibrosis and epiretinal membrane were removed from the retinal surface and an internal limiting membrane peel was performed. Then, using a wide-angle vitrectomy viewing system, Dr. Oshima found an angioma in the posterior pole at the retinal periphery; he inserted a buckle (240 band) around the eye for indentation and to support the retinal periphery. Following, laser and cryotherapy was used to treat the hemangioma. Dr. Oshima added that although perfluorocarbon and intraocular gas were used, silicone oil was not needed during this procedure.

Next, Dr. Marcelo Murillo Sasamoto (Bolivia) presented a case on pediatric retinal detachment which was treated by combining large radial retinotomy and circumferential retinectomy. “Nowadays, I call the technique ‘Tetris Retinectomy’ because it follows the form of the video game,” explained Dr. Sasamoto. “We start the surgery with keratotomy to see what’s going on with the retina. The edge of the retinal detachment is then treated to remain flat and ready to laser.” 

The ‘Tetris’ technique is used to change tangential traction after post inflammatory retinectomy — this multi-distribution of force vectors helps avoid a retinal redetachment. Dr. Sasamoto said that although this was a really tough case, it ended very well: Postoperatively, the patient received three intravitreal injections of methotrexate (1200μm) every 15 days, followed by 400μm every month for 4 months, to avoid proliferative vitreoretinopathy (PVR).

That Slippery Dislocated Lens

Challenging Retinal Cases in Vitreoretinal Surgery
The BBQ technique may not make you salivate.

Dr. Oshima’s second case involved a patient with a dislocated lens and used some newer, fancier techniques. One was called “Barbeque Technique”, where he inserted forceps inside the crystalline lens and then removed the lens with the cutter. (He noted he used a 25-gauge sclerotome at 10,000 cuts per minute during this procedure.) Once the lens was removed, Dr. Oshima used the Yamane technique for the intrascleral fixation of the intraocular lens — a sight that participants agreed was spectacular to see. 

Continuing the topic of dislocated IOLs, Dr. Gustavo Huning (Brazil) discussed the scleral pocket technique, which he learned from Dr.Theodoros Potamitis (Cyprus). He explained that in this technique, “trocars are inserted through these pockets and then I did an anterior vitrectomy. The haptics are released under the pockets because they are safe — and doing so made the haptics more stable. We then suture the pockets to close them.” 

To determine the distance between the limbus and IOL he shared: “I decided that the conjunctiva is the region where I will do the pocket. The inserting plane is 4mm from the limbus and I enter the pars plana 2mm from the limbus. The total length of the pocket is 2mm.” 

On Persistent Fetal Vasculature 

Zeroing in on pediatric eyes was Dr. Yoshihiro Yonekawa (USA). His case detailed a 23-gauge plaque dissection of anterior persistent fetal vasculature in a 2-week old boy (who was referred for leukocoria). When he looked into the eye, there was a massive membrane and fibrotic tissue over the pupillary plane. To cut through the thick membrane, an MBR blade was used to create the initial plane; scissors were later employed when the cutter was not able to penetrate the solid mass. Dr. Yonekawa finished off the case with air and sutures. The patient was fitted with a fake contact lens and did well postoperatively, he reported.

“In children, the most important thing is to rule out retinoblastoma by taking a good B-scan, looking at the family history, and also the other eye,” said Dr. Yonekawa. 

The Future is Now: Bionic Eyes 

Challenging Retinal Cases in Vitreoretinal Surgery
Ever felt like your eyes needed an upgrade?

The artificial retinal implant, Argus II, was then discussed by Dr. Robert Devenyi (Canada) for its merits in treating patients who are blind due to retinitis pigmentosa (RP). To date, he has performed nearly 20 of these procedures, which helps restore functional vision in patients with degenerative eye disease. 

He shared that surgeons need to use care when implanting the device: “There are 600 electrodes on the retinal prosthesis, so one has to be very careful not to use regular instruments as they will damage the electronics — only instruments with silicone tips can be used to handle the electronic components,” he explained, adding that the most stressful part of the surgery is that there is only one chance to affix the titanium tack to the central macula. 

And although this procedure has the potential to advance and provide further visual enhancement for patients (including facial and color recognition), he said that the company was unable to do so at the present time as it was an expensive endeavor, with each implant costing $190,000. 

Diving into Macular Holes

Treating macular holes is often complicated. Indian ophthalmologist Dr. Vaibhav Sethi shared details from one case where he performed a macular ILM peel using triamcinolone to better visualize the posterior pole at the macula. To delineate the vitreomacular traction (VMT), he used diluted triamcinolone to stain the broad VMT. Cortical vitreous was trimmed around the VMT, thus avoiding anterior-posterior traction. Then, a cleavage plane was made around the temporal part of the optic disc to release the VMT, which was stained with brilliant blue under fluid, and the ILM flap was created. 

The next case from Dr. Saad Waheeb (Saudi Arabia) concerned a patient with focal exposure to a handheld laser, which caused a lesion at the macula. During his presentation, he showed how he was able to detach the tough and adherent hyaloid. One month post-operatively, the patient’s vision was 20/40. 

Ouch: Scleral Ruptures 

Brazilian ophthalmologist Dr. André Jucá then relayed his insights from a case of scleral perforation (with chronic severe pain) in an eye with previous scleral buckle surgery. To identify these late and unusual complications of buckle surgery, he said, “This patient had buckle surgery done 10 years ago and was now complaining of pain, so we decided to remove the buckle,” he explained. 

“We didn’t see any sign of infection, but when we removed the buckle, we discovered a big hole at the sclera. We decided to cut it out and suture it. Going through the images, we realized that there was a dark area in the center which I missed. In this area, there’s no sclera, just tendon and conjunctiva blocking everything. This is a sign to take note of that scleral rupture or necrosis may be present,” he concluded. 

You Don’t Belong Here, IOFBs

Challenging Retinal Cases in Vitreoretinal Surgery
Think sand in your eye is bad? Try a gunshot wound…

Intraocular foriegn bodies (IOFBs) can cause all sorts of sight threatening complications.

One such case presented by Dr. Vasco Bravo (Brazil) involved a patient with eye trauma (iron in his eye), as well as associated cataract. This called for team work.

“Performing UBM (ultrasound biomicroscopy), we could see that the intraocular foreign body was very, very close to the wall and pars plana … and anteriorly placed,” he said. Together with a cataract specialist colleague, they removed the cataract and IOFB using phacoemulsification, plus perfluorocarbon-assisted IOFB removal with backflush help. 

Dislocated IOLs can become their own worst nightmare (hello, IOFB). Thankfully, Prof. Dr. Wai Ching Lam (Hong Kong) has been there before. He described one such case where he performed a simple scleral technique to elegantly secure the IOL into the sulcus in a stable manner, using 10-0 prolene sutures.

“This is possible as the whole capsule is very intact and it holds up against the capsular retention ring. This is just one option of securing a dislocated intraocular lens implant — in this case, it happened to have a full capsule with some residual material, and a capsular retention ring,” he said. Dr. Lam added that to keep the IOL in place for suturing, his assistant used a cutter to hold the lens against the iris.

Finally, Dr. Hudson Nakamura (Brazil) showed a case of severe intraocular injury with IOFB from a gunshot wound. He used CT images, B-scans and postoperative retinography to show the foreign bodies and to provide the roadmap for surgery. Special forceps were used to remove the IOFBs, and when a retinal detachment was found, he used PFO to reattach it. Dr. Nakamura then used endolaser at the far periphery (under silicone oil) and noted that the patient had a good postoperative outcome.

As virtual meetings go, this was of course, a fruitful one. These challenging cases inspired discussion and learning, while showcasing the evolution of best practices and techniques … all to help improve and restore sight in these devastating vitreoretinal cases.

Editor’s Note: RETINAWESOME III, Challenging Retinal Cases in Vitreoretinal Surgery, was held on 20th June 2020 and was spearheaded by Dr. Hudson Nakamura of Brazil. Reporting for this story took place during RETINAWESOME III. Visit the RETINAWESOME YouTube Channel for more information and videos. 

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