RETINAWESOME 007: Searching for the Next Challenge in Retina Surgery

Each day, surgeons around the world battle challenging and intriguing retinal surgery cases — and the heroics of these superstars often go largely unacknowledged. That ends now, thanks to the Retinawesome team who have one primary job: to find the most exciting surgical cases from around the globe and bring them to light.

Pearls in Pediatric Retina

In his keynote session, Dr. Yoshihiro Yonekawa discussed pearls in pediatric surgery. “There is something profoundly satisfying about treating children. For example, saving vision in a child with retinopathy of prematurity is potentially 100 years of vision saved in both eyes,” he noted. 

When examining children, you don’t have much time, so you need to be fast, continued Dr. Yonekawa. “It is what we call a ‘flying retina,’ because sometimes you may have half a second to make a diagnosis,” he explained. The eye examination is relatively more straightforward in children less than a year old.

“However, in 1 to 3-year-olds, it becomes more difficult, and the use of several distraction techniques, such as animated toys, is advised,” he added.

According to Dr. Yonekawa, B-scan ultrasonography is a great tool and is well tolerated in children when indirect examination of the peripheral retina proves difficult. However, when all other techniques fail, examination under anesthesia is advised (after excluding possible risk factors). Because of the genetic origin of many retinal diseases in children, it is important to examine other family members who may show similar traits. Widefield fluorescein angiography (FA) is very useful because many pediatric retinal diseases affect the peripheral retinal vasculature. “For angiography in children, oral formulations of fluorescein can be given when IV administration proves difficult, and when feasible, OCT imaging can be very informative in revealing diagnostic macular pathologies,” said Dr. Yonekawa. 

One of the top four surgical strategies in pediatric retinal surgery is to not make iatrogenic breaks rely on the RPE — this is because these breaks can flatten the retina, and that could be the end of the eye. It is essential to understand that the eye’s anatomical landmarks and dimensions in children are different from adults. For example, the sclera is usually tougher, and thus may require special instruments and surgical approaches. “Scleral buckling is very useful in fixing retinal detachment in children because the vitreous is very well-formed and can never be removed entirely,” said Dr. Yonekawa.

A Case of FEVR, Mask-induced Endophthalmitis and Fetal Vasculature

Prof. S. Natarajan presented an interesting FEVR (familial exudative vitreoretinopathy) case of a 13-year-old girl from Kashmir with a past familial history of low vision. Examination revealed optic disc drag, exudates, and minimal vitreous hemorrhage in both eyes. 

As a treatment modality, Dr. Natarajan explained that he performed a 25-G pars plana vitrectomy with ILM peel for a vitreous hemorrhage, optic disc drag and exudates, with endolaser and fluid air exchange. Dr. Natarajan advised that in such a case, the use of perfluorocarbon liquid (PFCL) and a third hand was vital in stabilizing the vitreous, ensuring careful membrane peeling, and releasing the traction without breaks.

RETINAWESOME 007: Searching for the Next Challenge in Retina Surgery
Foggy glasses are but one annoying eye problem that can be caused by face mask wearing. 

Dr. André Jucá discussed endophthalmitis and face mask use, showing different patient statistics with a focus on intravitreal injections and injection site concerns. With the ongoing COVID-19 pandemic, face masks in public settings have become mandatory in many countries. “With face masks, air from the mouth and nose is funnelled toward the eyes, especially in people who wear glasses; this causes an associated increased risk of contamination at intravitreal injection sites,” explained Dr. Jucá. In most cases, the infections were resolved using injection antibiotics alone, but in more severe cases, management was combined with vitrectomy. 

One particular case of Streptococcus mitis infection was challenging to treat. Commenting on this case, Dr. Yonekawa said: “We see increasing cases of face mask-associated endophthalmitis and now recommend taping the top part of face masks for both the surgeon and patient, during and after injections, to reduce this risk.”

Dr. Wai-Ching Lam presented a case of persistent fetal vasculature in a 2-month-old child, with the ultrasound showing a thin stalk without extensive pathology. Dr. Lam provided useful take home surgical tips. “I recommended the limbal approach instead of a pars plana approach when the posterior view is limited and cauterization of the prominent tunica vascular lentis on the fibrovascular plaque after lensectomy,” he said. “Also, always use scissors to segment the membrane before removal with the vitrectomy cutter and avoid excessive traction of the fibrovascular membrane,” added Dr. Lam.

Vitrectomy to the Rescue

RETINAWESOME 007: Searching for the Next Challenge in Retina Surgery

Dr. Saad Waheeb described a case of vitrectomy in a patient with diabetic retinopathy who also had a dislocated intraocular lens (IOL). According to Dr. Waheeb, the whole IOL complex was freely mobile and was moving into the anterior vitreous. A scleral fixation was performed accordingly with the Yamane secondary IOL fixation technique, ensuring good IOL centration by adjusting the haptics. A residual iris defect was also corrected with a prolene suture. The surgery was very successful, and vision improved from counting fingers to 20/400 within 1 week. 

Next, Dr. Francyne Cyrino presented a cool case involving a giant retinal tear vitrectomy in a 40-year-old male where the retina was attached under perfluorocarbon liquid and endolaser, switched by air and gas after an air-fluid exchange. The second case was also a giant retinal tear, managed by phacovitrectomy surgery; perfluorocarbon liquid was also used and switched to silicone oil to give a good outcome. Dr. Cyrino mentioned Dr. Yusuke Oshima’s teaching on giant retinal tears, where it’s advised to perform direct perfluorocarbon exchange for silicone oil to prevent retinal slippage in the case with a giant retinal tear over 90 degrees.

Dr. Emmanouil Mavrikakis reported on vitrectomy in a case of an intraocular foreign body. “The patient had metal inside the eye after hammering work. Interestingly, the patient had a clear lens, average/good visual acuity (20/80), and a temporal corneal-scleral wound with mild leakage,” noted Dr. Mavrikakis. “The intraocular foreign body was visible on a skull X-ray and CT scan. There was a vitreous hemorrhage sparing the macula, and the foreign body was stuck in the temporal area,” he added. 

How was this treated? “With vitrectomy, it was possible to remove it with the appropriate forceps. The first attempt to dislodge the foreign body with the pic was successful, and part of the foreign body was removed. However, it was necessary to use a magnet to attempt to detach most of the stuck foreign body from within the retina,” explained Dr. Mavrikakis.

ROPs, Macular Holes and Retinal Detachment 

Further in the session, Dr. Marcelo Murillo Sasamoto described a case of retinopathy of prematurity (ROP) stage 4B pre-plus disease with macular dragging. “The patient underwent a lensectomy, vitrectomy, posterior hyaloid removal, endolaser and silicone oil. The very young patient (3-months-old) developed a posterior hyaloid contracture 15 days after the first surgery and went back to the operating room to remove the posterior hyaloid,” Dr. Sasamoto explained. The case ended up with the retina attached and the visual acuity improved. The same patient had a transscleral intraocular lens fixation a month later, and today the patient has regained his visual acuity.

Dr. Jorge Mitre, during his presentation, outlined current techniques for closing a macular hole. “There have been studies on using an amniotic membrane, using an internal limiting membrane (ILM), and gas buffering,” he noted. “These procedures are associated with varying degrees of success and complications, and currently, we don’t have a perfect technique,” added Dr. Mitre. He then presented a novel technique representing a different way to approach the ILM and remove it in macular hole cases. He used indocyanine green (ICG) as the dye for staining the membrane. “ICG has unique characteristics of dehydrating and contracting the ILM. The idea is to use a small amount of ICG to stain the ILM over a very short period to avoid any retinal toxicity,” explained Dr. Mitre.

Last but not least, Dr. Hudson Nakamura shared an interesting diabetic vitrectomy case: a severe diabetic retinopathy tractional retinal detachment managed with an efficient fibrovascular tissue peel technique. There was a severe combined rhegmatogenous and tractional retinal detachment over the macular area, and with the bimanual technique, the retina was freed from the fibrovascular tissue attached to it. “We had to go toward the retinal periphery and do a retinotomy because of such enormous traction. But the patient remained phakic, and the lens was not touched,” concluded Dr. Nakamura. 

Editor’s Note: Retinawesome 007 was held on December 5, 2021. Reporting for this story took place during the event. 

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