Challenging Vitreoretinal Surgery Cases: Highlights from Retinawesome 13, Part 1

The name, Retinawesome, really says it all, and lucky number 13 — Challenging Vitreoretinal Surgery Cases certainly did not disappoint! This virtual event was held on February 26, 2022, and can be viewed on YouTube. It had everything you could want — and things you didn’t know you needed — in a presentation of challenging cases, mysteries, surprises, spirited discussions … and even a musical number.

Dr. Hudson Nakamura opened the session by introducing Brazilian singer Gabriel Diaz, whose guitar stylings and musical talent set the stage for the exciting case presentations.

A Case of a Massive Submacular Hemorrhage

First to present was keynote speaker, Dr. Wai-Ching Lam, who described the surgical management of a massive submacular hemorrhage. Although this is not a new topic for many, especially to our seasoned vitreoretinal experts, it turned out to be a valuable refresher for the audience. Dr. Lam shared the effects of a submacular hemorrhage, starting with the direct damage to photoreceptors cells from clot formation, including iron toxicity from the blood causing oxidative stress, and formation of a physical barrier, blocking the actions of the RPE pumps and nutrient diffusion, starting right on Day 1.  

Over time, this is followed by severe degeneration of the outer retinal layers, photoreceptors and RPE layer, leading to RPE atrophy and scarring within the first couple weeks. Prognosis is very dependent on the size of the hemorrhages, and the duration of time they are allowed to stick around. Like so many things in retina, the earlier the treatment, the better the outcome. As Dr. Lam explains, the goal of treatment is to displace any blood from the fovea, break up the clot, and then treat the underlying reason the hemorrhage occurred.

Dr. Lam explained the mechanism of tissue plasminogen activator (tPA), converting plasminogen to plasmin, which is very useful in causing fibrinolysis which breaks down the offending clot and can be delivered subretinally or intravitreally. Naturally, subretinal delivery is more technically challenging and has greater risks, but it does directly target the hemorrhage. Intravitreal delivery can be done in the office and studies have shown that it does have a high degree of complete displacement of the hemorrhage. Dr. Lam shared a couple of cases, accompanied by very illustrative fundus images, OCTs and spectacular intraoperative OCT, guiding the tPA treatment of severe macular hemorrhage. Like a vitreoretinal magician, he created a retinotomy and allowed the large amount of blood to escape from the subretinal space, which facilitated reattachment without the inferior displacement of blood.  

Dr. Lam highlighted a complication that involved blood escaping through the macula, and he advised if this occurs, not to quit, proceed with the plan, but create the bleb elsewhere (always start outside the area of hemorrhage) and deal with the macular hole in a secondary surgery. He also recommends a gentle touch, avoiding forceful subretinal injection to reduce the risk of RPE rips and macular hole formation. He shared that he uses the foot pedals of the viscous fluid injector to inject; and usually turns down the injection pressure to about 16 to 20, carefully gauging through the outside to see just how fast the fluid is going — avoiding the gush, but rather maintaining a continuous steady flow. Finally, minimize the number of punctures to the retina, push the needle through when the first bleb is created, stay there as long as possible — and always keep a steady injection hand. 

A Challenging ERM Case

Keeping with the “awesome” theme, next was a presentation entitled, Epiretinal Membrane Surgery Pinch & Bleed, from Dr. Vaibhav Sethi from the Arunodaya Deseret Eye Hospital in India. He shared incredible surgical video, starting with a strongly adhered PVD, and then using brilliant blue stain, he proceeded to remove the ERM, but it was coming out in small patchy pieces … not quite the “easy-peasy” surgery he had anticipated. Rather suddenly, when peeling a remaining “island” there was a gush of blood, so Dr. Sethi decided to wait a moment, take a breath, let it clot, increase the pressure slightly and say a prayer that he didn’t have a full thickness break on his hands.  

He described how after getting back to normalizing pressure, he aspirated the fluid around the area. Soon realizing that he should have left the clot in place because it was acting as a natural clog, he let it reform and fortunately, it was parafoveal. Dr. Sethi shared fundus photos and OCT images from one month postoperatively: the fovea was good, everything looked fine and there was a partial thickness break visible where part of the laminar tissue had been pinched while lifting on the island. The patient’s vision was also good. 

Dr. Sethi shared the lessons he learned from this case, notably to visualize what you scratch and pinch, and not do too much. Also, he recommends that minimal tissue handling is key to getting the maximum outcome. His final words of wisdom are that these breaks and bleeders that may be encountered are self limiting, so don’t cause any additional trauma by lasering them. He adds that perhaps even injecting air may have done the trick.  

Visualizing Macular Surgery

Dr. Athanasios Nikolakopoulos from Greece recommended that the use of wide-angle systems to visualize macular surgery would be helpful for better illumination of all the places surgeons need to see while working in the eye. He also added that a few months after these cases, one can expect to see some nerve fiber dystrophies on the OCT, some areas where vision may be dropping down a little bit. He posed the question to the audience, asking if they ever see late atrophies that occur in the area of the macula. 

Dr. Lam responded that you are more likely to see this if an ILM is peeled, and that if only the epiretinal membrane is peeled this is less likely to occur. He also recommends starting to look at the ILM peel itself as not totally benign or atraumatic. Dr. Lam continued that adding a second stain may often help to visualize the ILM better and allow for easier pinching and grabbing and possibly prevent from pinching too deep, causing trauma or a small retinal surface tear. Finally, don’t mess with the clot, it is there for the purpose of stopping the bleeding, and the blood will eventually go away and not cause any secondary complications or negatively affect outcomes. 

Dr. Nikolakopoulos added that he also does not remove or retouch the clot, but he does use the pedals to raise the pressure immediately to help with collateral vessel bleeding, which he says everyone has done when doing macular surgery.  

A Case of Flashes and Floaters … Oh Wait, There’s More!

Challenging Vitreoretinal Surgery Cases: Highlights from Retinawesome 13, Part 1
Unfortunately, not this type of “floater”.

Next up was Dr. Saad Waheeb from Saudi Arabia. He describes a 51-year-old female patient with a complaint of flashes and floaters in her right eye for one week. Twelve years prior, this patient had retinal detachment surgery following a similar attack of PVD in her left eye. On examination, her fundus showed an acute PVD with mild vitreous bleed. Dr. Waheeb observed the patient over the following two weeks, asking her to keep her activity to a minimum, but unfortunately, she returned with vision reduced to hand motion, and a macula-off supero-nasal retinal detachment. He shared an excellent video of the PPV, endolaser and SF6 gas that was performed, and all appeared to be a very straightforward surgery. 

At five weeks postoperatively, she returned with a full thickness macular hole (600 microns) and decreased vision.  Another PPV was performed with fovea-sparing ILM peel and air tamponade. At one week postoperatively, OCT demonstrated a closed macular hole and flat retina. At two weeks post-op, the patient returned with endophthalmitis and intravitreal vancomycin/amikacin and dexamethasone were immediately administered. Three months post-endophthalmitis the eye is quiet, vision is 20/100 with a larger macular hole. 

Dr. Waheeb posed the question to the group as to how they would have managed this patient, and also how often they observed a post-vitrectomy RD macular hole, or what the underlying mechanism might be. Dr. Athanasios Nikolakopoulos responded that the surgery looked perfect, but sometimes these things just cannot be avoided, they just happen. Dr. Ashraya Nayaka shared that he has also had a couple of similar cases and that within the literature, retinal contracture following excessive laser has been described as a possible mechanism, adding that they are very difficult to treat. Dr. Lam added that the macula hole may be attributed to cystoid macular edema that was not managed initially, ruptured, causing a macular hole. It is typically not managed because with the initial gas bubble in the eye for the first two weeks of the postoperative period, the back of the eye cannot be visualized. Dr. Lam provided two excellent tips: First referencing a previous case from Dr. David Chow where a small post-vitrectomy macular hole was treated with steroids, more aggressively than our usual post-op regimen, and it settled the edema associated with the hole. Finally, he suggested a fluorescein angiogram to look for any leakage in the fovea, because parafoveal cystic changes will not leak on fluorescein. 

Challenging surgical cases and presentations of complications are incredibly valuable learning tools and the presenters should be commended for sharing these cases so that we can all learn to manage them. A perfect comment from Dr. Lam: “If you don’t want complications, don’t operate, because the minute you operate, you are going to get a complication. You have to have a big heart to show your errors.”    

Retinawesome 13 was jam packed, so please wait for Part 2 of our coverage for more exciting and challenging cases!

Editor’s Note: Retinawesome 13 was held virtually on February 26, 2022. Reporting for this story took place during the event.

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