Clinical Pearls for Pediatric and Adult Vitreoretinal Surgery: Highlights from Retinawesome 14, Part 1

The wait is over! The latest and greatest in retina was live on March 26, 2022 and as per usual, the cases presented as part of The Recommendations for Pediatric and Adult Vitreoretinal Surgery were nothing short of awe inspiring … or Retinawesome.

Once again, we were dazzled by this virtual gathering of international expertise in vitreoretina. Dr. Subhadra Jalali from India was the keynote speaker, joined by Dr. Hudson Nakamura (Brazil), Dr. Jorge Rocha (Brazil), Dr. Andre Juca (Brazil), Dr. Emmanouil Mavrikakis (Greece), and Dr. Marcelo Murillo Sasamoto (Bolivia), joined by our esteemed panel from Retinawesome 13.  

Scarring Vitrectomies, Macular Holes and Retinal Rupture

Starting things off, we were treated to a presentation by Dr. Jorge Rocha, discussing Scarring Vitrectomies. He shared brilliant surgical video of a case of using perfluoro-n-octane (PFO) for retinal rupture. He demonstrated the use of subretinal PFO, highlighting that the PFO infusion should be slow and recommended using the light-pipe as a retina shield. Next, Dr. Rocha repairs a case of macula rupture, and describes in the initial video clip, “just how bad it was, the accumulation of blood underneath the retina, a terrible complication.”

According to Dr. Rocha, he believes that this type of complication occurred because as he opened the fluid, the jet stream touched the retina, resulting in the large hole in the macular area. Caution: PFO jetstream can become a weapon, damaging the retina! Expert tip:  Always check to ensure infusion pressure is not higher than 30 mmHg at the beginning of the surgery.  

Next, he shared a third case, Weeping Aspiration. He describes finishing a case to remove an intraocular lens, and everything appeared to be fine as he was removing the last PFO bubble with positive aspiration and ‘sucked the retina.’ He finished the case with some laser and gas, but wanted to make other surgeons aware that this is something that should be avoided. Dr. Rocha’s take-home message for this case was to take special care in removing PFO from the retina, especially the small bubbles. He recommended to turn the eye, making the bubbles move away from the optic nerve and proceed cautiously, not aggressively. For the last case, Dr. Rocha shared that the new soft tip instruments could really be helpful to suck the last bubble. 

Dr.  Hudson Nakamura shared that he likes to switch the tip from 23-gauge to 25 and approach the backflush canula towards the perfluorocarbon (PFC) bubble, but not quite to the bubble, then put the lumen toward it and switch to the smaller diameter.  He shared that he always tells the residents and fellows to use the macular lens when removing the bubbles. Some PFO and PFC brands create a lot of bubbles!  

Dr. Rocha responded to a chat comment, asking if the light pipe breaks the PFO into smaller bubbles like fish eggs. He responded that if you inject continuously and position the light pipe as a chute, so if the injection is too hard, the jetstream will not become damaging. He injects over the optic nerve, very slowly and it doesn’t create PFO fish eggs. 

Dr. Ashraya Nayaka added that PFC has a very high specific gravity, so when you have a small bubble you need to stop, so that it moves more towards the disc, because when you aspirate a smaller bubble it is much safer there.  He shared that when using the Constellation platform (a vitrectomy system from Alcon), it has an IOP compensated inclusion, which means that when moving from fluid air exchange to fluid infusion, the pressure in the cavity is zero. The Constellation is pumping the fluid at a much higher rate, which can be very risky. He added that he has had cases where the infusion induced breaks in the retina, so when switching on the fluid, it is always better to hold the light pipe in the anticipated stream path, to reduce the velocity and avoid infusion induced breaks.  

Dr. Marcelo Murillo Sasamoto added that there are cases when the cornea does not allow for good visualization, so he recommends using triamcinolone to recognize the PFO and remove it all.  

Keynote Presentation on Neonatal and Infantile VR Surgeries

Dr. Jalali began her keynote presentation, Principles of Neonatal and Infantile Lens Sparing Vitreoretinal Surgical Techniques, by sharing a fun fact that her talk was 12 minutes long, which is only half a minute for every year of her 24-year career in pediatric retina. She encouraged the fellows in attendance not to be intimidated by pediatric retina surgery, it is a little tougher than in adults ,but the principles are similar. She shared a series of surgical clips, beginning with the basics, transitioning through more involved cases and then showing surgery in a newborn and some of her innovations. 

The first video presentation from Dr. Jalali illustrated the basic aspects of mature retinal surgical techniques in infantile eyes. She advised that the first step is to check for any area of retino-lenticular adhesions, which can be common in neonatal tractional detachments, such as retinopathy of prematurity (ROP), persistent fetal vasculature (PFV) and familial exudative vitreoretinopathy (FEVR). Dr. Jalali described depression of the sclera, just behind the limbus, and any adhesive area will show up as a translucent membrane behind the lens. She warned not to enter from that area, enter either into the lens and remove the lens, or have a nasal entry approach. Peripheral vitreoretinal surgery is not possible in the lens sparing mode in neonates and Dr. Jalali illustrated her approach to a 23-gauge, sutured, lens-sparing vitrectomy and epiretinal membrane peeling in an infant. It is important to be very careful while lifting the edge by releasing the nasal side of the membrane first. The temporal side will usually be very stiff and taut and have a retinal fold behind, due to the elastic stretching of infantile retinas. The traction of the temporal edge should be released to prevent retinal breaks. Once the membrane edge reaches the fovea, she gently moves in a curvy linear fashion to avoid further injury. Do not pull! 

Another video from Dr. Jalali is of a macula off rhegmatogenous retinal detachment one day after an ‘avastin disaster.’  She performs a limited core vitrectomy, just peeling around the break, laser, put in oil, then remove the oil with seven days. If Dr. Jalali was doing this case today, she would use trypan blue assisted, rather than oil. 

Then, Dr. Jalali presented a case of scleral imbrication with a buckle for combined pediatric retinal detachments, which includes any detachment, which has falciform folds with exudation and a rhegmatogenous component. These are very complicated conditions without good solutions for how to tackle them. 

ROP Babies are Better Patients than Adults

The first example is of retinopathy of prematurity or similar disorders that develop retinal detachment years later. The eye has rhegmatogenous and tractional detachment and additional exudation. Dr. Jalali shared her technique, cleaning the sclera, then making horizontal and vertical incisions, dissecting and getting good quality flaps both anterior and posteriorly, usually to the equator, but that depends on the site of traction. She does minimal cautery on the surface, lightly if bleeding occurs. Using a non-absorbable suture, like 5-0 or blue Dacron. Take care when passing the sutures, do not poke the underlying choroid! The sutures may appear not to tighten but one the scleral dissection is done the globe actually becomes very soft. Drainage can also be done, a cut down or needle drainage with a 26-gauge needle. She typically likes to suture, if she has done a cut down because she will put a buckle on, a 42 band, or a 240 band.  The retina was reattached and a small amount of cryo was done in the area of exudation. Dr. Jalali cautioned that you cannot do scleral buckles where there is too much traction right around the break because your buckle will not support it. In this case, she supports the break and also shortened the globe, putting the buckles behind all the breaks and pathologies. 

Dr. Jalali highlighted that one of the babies in her videos was 2 days old and it has become normal practice to deliver the siblings of FEVR children (older sibling is blind) at 35 weeks and she sees them within 24 hours of birth and she has a series of cases that they treat with laser within 24 hours and vitrectomy if they have traction and they all do very well. “If you wait, then they will develop all these folds that develop because we’ve not screened them on time and treated them on time, that is an important message I wanted to give.” 

When asked about promoting ROP screening, Dr. Jalali replied, “Once you start screening babies, you don’t want to look at adults because adults keep on complaining. The baby, he’s under your control, you can move him, you can depress, just enjoy the music of their crying, it means they are alive and healthy and good. If the baby doesn’t cry, my heart stops.  Seeing a ROP baby, it’s not difficult at all, you wrap them up, give them a little sucrose and you just enjoy their cry music.”  She adds that for these advanced cases of Coat’s or FEVR, had you seen them at birth, the surgery would have been so much easier with better outcomes, “The key is to start screening them earlier.”  

Dr. Sasamoto posed a question about performing scleral imbrication in late ROP cases, those 18 or 20 years old.  Dr. Jalali responded that those are the eyes where it works the best. 

Although she did not share a video of her stage 5 ROP surgery, Dr. Jalali shares what joy she gets from seeing these little patients five years later come and stick their tongue out at her, asking if she is going to do this again for the next patient and she replies, “Yes, surely so.”

Dr. Wei Ching Lam and the other panelists agreed, amazing videos of very challenging and demanding cases from keynote speaker, Dr. Subhara Jalali.  All marveled at her extraordinary surgical abilities.  

Please check out Part 2 of this Retinawesome wrap up for more exciting cases!

Editor’s Note: Retinawesome 14 was held on March 26, 2022. Reporting for this story took place during the event. Never miss a Retinawesome event … subscribe to the Retinawesome Retina & Vitreous International channel on YouTube.

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