The “battle” is on for the best outcomes in retinal surgery…
Teams from Japan, China and India tested their surgical mettle and battled it out during the second episode of “Repair that Retina,” the world’s first competition-webinar for eyecare professionals. Organized by Alcon (Geneva, Switzerland), the competition was judged by renowned vitreoretinal specialists Dr. David Chow from Canada, Dr. Kourous Rezaei from the United States, and a mystery judge.
When to go bimanual
During the basic surgery round, Dr. Hemanth Murthy from Team India presented a video on bimanual surgery. To begin, he entered the cleavage plane by redefining the secondary membrane. As he started clearing the secondary membrane, he saw a dense and broad-base addition at the macula. “That’s the time when I switch over to bimanual surgery. I used the scissors and the forceps for the bimanual surgery, because the scissors provide an elegant tool to safely dissect the membrane from the retina.
“As you can see, there are major vessels that are adherent to this membrane. The scissors dissection is a good way to separate these vessels from the fibrovascular tissue. By doing so, I’m able to save major blood vessels and prevent bleeding, which is very important in diabetic TRD (tractional retinal detachment) surgeries,” said Dr. Murthy.
Once he was able to dissect the membrane, he cleared it off using a cutter before doing an ILM (internal limiting membrane) peel, endolaser treatment, followed by a fluid exchange. All the major vessels were intact and there were no tears.
“A preoperative OCT (optical coherence tomography) can help you decide which cases need bimanual surgery. If you see a densely adherent membrane at the retina, this should alert you to the possibility of a bimanual surgery,” he suggested.
Suprachoroidal hemorrhage
During the complex surgery round, Dr. Xiaorong Li from Team China presented a case involving a 50-year-old woman with high myopia. Suprachoroidal hemorrhage occurred during surgery. The posterior chamber pressure increased, while the anterior chamber was shallow. The vitreous cavity was filled with blood. He tried to remove the blood as much as possible. Silicone oil was also injected into the eye and removed in order to drain the blood. This was repeated eight times. One month after the surgery, OCT images showed that the suprachoroidal hemorrhage was totally absorbed.
Residential judge Dr. David Chow commented that he would first check the blood pressure of the patient if he were to perform vitrectomy on a high myope.
He also noticed that in the video, the trocar cannula was used to stabilize the contact lens holder on the eye. “The trocar cannula is made for internal clearance of a certain length, and by putting it through the wing of the contact lens holder then through the sclera, I would be worried whether the cannula has a higher risk of going suprachoroidal in its location. So, if the cannula goes suprachoroidal in a high myope with high blood pressure, those are risk factors for a choroidal hemorrhage,” he commented.
Summing it up, residential judge Dr. Kourous Rezaei said: “The key is to pay attention to where the choroidal hemorrhage is coming from. You need to pay attention to the IOP, maybe use perfluorocarbon as the mystery judge pointed out, or make sure the eye is pressurized. Get things done quickly and get out of the eye. You don’t want to mess around too much. Generally, it’s not a great idea to drain it as it may cause more bleeding.”
Endoscopy versus keratoprosthesis
Meanwhile, Dr. Mihori Kita from Team Japan shared a case of proliferative vitreoretinopathy (PVR) with severe corneal opacity, for which she decided to perform endoscopic-guided vitrectomy with a 25-gauge endoscope. This was opposed to the temporary keratoprosthesis followed by keratoplasty, as this option can possibly cause corneal graft failure. A few months later, after silicone oil removal, the patient was referred to the corneal surgeon for cornea transplantation.
The mystery judge commented that he would prefer to do the keratoprosthesis instead of the endoscopic-guided vitrectomy as it offers better visualization, which would lead to better outcomes.
Dr. Chow said that the mystery judge’s comments resonated with him, as in his experience he had been limited by the visualization of the endoscope. Nevertheless, he applauded the fact that Dr. Kita’s video provided a clear visualization of the vitreous. “You can see that when she was pulling up those membranes and the vitreous was lit up and was visualized way better than what we normally see with a microscope or NGENUITY. So, even though the resolution is not great, the technology itself may allow us to visualize the vitreous membrane and PVR membrane better as what we saw in her video,” he concluded.
Editor’s Note: The second episode of Repair that Retina was held on 14 August 2021. Reporting for this story took place during the event.
