DIABETIC VITRECTOMY SURGERY SHAWNEE MISSION MEDICAL CENTER MERRIAM, KS September 20, 2007

Transcription

1 DIABETIC VITRECTOMY SURGERY SHAWNEE MISSION MEDICAL CENTER MERRIAM, KS September 20, :00:08 ANNOUNCER: Welcome to Shawnee Mission Medical Center in Shawnee Mission, Kansas. Over the next hour, you'll see a vitrectomy for diabetic retinopathy performed by Dr. David Dyer. During the surgery, Dr. Dyer will make three small openings in the eye, extract the gel from the inside, and remove any scarring. He will then perform a laser treatment to prevent the recurrence of abnormal blood vessels. Often, there are no symptoms or pain with diabetic retinopathy, so it's important for diabetics to get a comprehensive eye exam at least once a year. OR- Live makes it easy for you to learn more. Just click on the "request information" button on your webcast screen and open the door to informed medical care. Now let's go live to the operating room. 00:00:53 BEATTY G. SUITER, MD: Hello and welcome. Today we'll perform a diabetic vitrectomy surgery live from Shawnee Mission Medical Center in Shawnee Mission, Kansas. I'm Dr. Beatty Suiter with Melissa Magwire, who is a registered nurse and certified diabetes educator. 00:01:06 MELISSA MAGWIRE, RN, CDE: Good evening. 00:01:08 BEATTY G. SUITER, MD: Also with me this evening is Dr. David Dyer, who will perform the procedure. Before we get to Dr. Dyer in the operating room, there are a few housekeeping items to discuss. First we will answer any questions you may have during the surgery about diabetes or the surgery. You can these to us by clicking the MDirectAccess button on your screen. Second, an archived presentation of this will be placed on the website later this evening. You can share this with friends or families or watch it again. Now I'll turn it over to Dr. Dyer in the operating room, who's preparing to begin the procedure. Dr. Dyer. 00:01:44 DAVID S. DYER, MD: Thank you, Dr. Suiter. Before we get started, let me introduce the O.R. staff that's going to be working with me tonight. First, the O.R. scrub nurse, it's Kevin. The circulating nurse will be Natasha, and the nurse anesthetist is Lenny. Before we get started doing the surgery, we're going to show you an animation that shows the basic mechanics of the surgery that we're going to be doing today, and then we'll come back and start our surgery here. 00:02:12 BEATTY G. SUITER, MD: This is an image of our needle that helps us gain access to the retina and vitreous. On this needle is a small tube called a trochar. Three of these are placed during surgery. The outer covering of the eye is displaced and the needle is used to penetrate the wall of the eye in a safe area for entry and exit. Here you see the needle pass through the wall of the eye into the vitreous. The needle is withdrawn and the tube stays in place. This is an image of an intraocular forcep,

2 essentially a small tweezer. This instrument passes through the tube, and we use it to remove scar tissue from the retina. Diabetic patients will occasionally grow new blood vessels, which scar, causing bleeding and traction, and we can remove these with these small tweezers. This is an image of the vitrectomy instrument or cutter. It simultaneously aspirates vitreous and cuts it. It cuts up to 1,500 times per minute and is a very effective instrument in removing the vitreous. Diabetic patients will occasionally have blood which needs to be removed from the vitreous cavity. Here you see the fiber-optic light coming from the other tube. After surgery, we can remove these tubes and the incisions will close without suturing. As the tube is removed, the wall of the eye closes and the outside covering covers the incision, thereby preventing any bacteria from entering. Dr. Dyer. 00:04:04 DAVID S. DYER, MD: Okay, we're going to go ahead and get started. The first thing we're going to do is put these little tubes in that you just saw on the animation. These are called cannulas, and they'll allow us to have access inside the eye. We can move the outer coating of the eye, as you see here, to make our initial incision. And these just go right through the eye wall. Infusion on, please,.347. The first incision's on the lower outer part of the eye. There's a lower -- you can turn the infusion off, please. A little cannula that we're going to put in. this brings fluid into the eye to replace the vitreous gel that we're going to take out during the surgery. If we don't replace what we take out, then the eye will lose its integrity and will become soft. Turn the infusion on, please. The next thing I'm going to do is put two more of these cannulas, or tubes, in the upper part of the eye. And this is where I'll use my hand instruments to actually do the surgery. And again, we'll move the outside coating of the eye. One of these cannulas will have a fiber-optic light that I'm going to show you here in just a minute. This is a light we use so that we can see inside the eye, and it's just a very small tube with a fiber in it. We can put it through our cannula and see inside the eye. Let's put our -- we're good here. We can see inside the eye with the aid of -- we may have a bad fiber here, Kevin. As in everything, sometimes our equipment doesn't work exactly as we want to, and we have a fiber optic that looks like it has a break in it, so we're going to exchange this out for a new fiber optic. Fortunately, we have plenty of backup instruments and backup machines in case something like this happens. But as I was saying, while we're waiting for -- we need a new light pipe, yeah. While we're waiting, I'll show you the operating microscope. It hangs down from the ceiling and it has two viewing systems: one for myself and one for the -- the scrub nurse which will assist me during surgery. And hanging below the microscope is a lens system that allows us to get a wide-field view inside the eye. And what we're doing now is we're focusing this system so we can see to operate. We're just going to go dark here for a minute while we change out the light pipe. 00:06:40 BEATTY G. SUITER, MD: Dr. Dyer, I have a few questions that Melissa may be able to help us with. 00:06:42 DAVID S. DYER, MD: Okay. 00:06:43 BEATTY G. SUITER, MD: Melissa, why -- why does diabetes cause damage to the eye? 00:06:48 MELISSA MAGWIRE, RN, CDE: Well, as you know, higher than normal blood-sugar levels can irritate small blood vessels in the back of the eye. And Dr. Dyer's going to talk about that a little bit later, about the disease process and how if you have damage to the eye vessels, you can actually grow smaller, weaker vessels that tend

3 to rupture and can cause problems. We also know that higher than normal average blood sugars can change the shape of the lens of the eye when your sugars fluctuate up or down, and by doing so, you put a lot of wear and tear on the lens, and that can lead to problems with cataracts as well. 00:07:17 BEATTY G. SUITER, MD: Thank you. 00:07:18 DAVID S. DYER, MD: We can go back if you want to now to me. 00:07:22 BEATTY G. SUITER, MD: Dr. Dyer? 00:07:23 DAVID S. DYER, MD: Okay, I think we're ready to proceed on here. Here's our fiberoptic light again. You can see, it's a lot brighter than the first one we used. So this will go in this little tube here. There we go. And again, with the operating microscope and the viewing system, we can get a nice view inside the eye. And we're looking from the very front of the eye into the back of the eye. All the way in the back, that dark area that you see -- we'll zoom up here a little bit -- that's a blood spot that's right in the patient's central vision. That's one of the things that we're going to try to operate on today. There's also some abnormal blood vessels from the diabetes, which we'll show you as we do the -- do the surgery. Just to the right on your screen is a little round spot. That's the optic nerve, and all the nerve endings from the retina drain into that nerve to form the nerve, and that goes out the back of the eye to your brain, and that's how you see. The red lines that you see, those are the arteries and veins that are inside the eye. The next instrument that I'm going to put in is something called a vitrector, and that's an instrument that we use to cut the gel out. Here we go. And it's a little metal shaft with a hole down near the end, and it's a guillotine style cutter, so there's a blade inside the shaft that goes up and down, and as Dr. Suiter said earlier, it goes up and down approximately 1,500 times per minute. So what we're doing is we're taking very small bites or cuts of the vitreous gel. In the center of that tube, we have a vacuum hooked up to it, so it'll cut and actually aspirate or suck in the little piece of gel, and we can pull it out of the eye through this -- through this metal shaft. And in a very controlled way, then, we can take all of the gel out of the inside of the eye. As we're operating, you'll see some cloudy-like material that's kind of floating around inside the eye. That's the actual vitreous gel inside the eye, and so I'll be moving this instrument around, cutting out all this vitreous gel. As we scan around inside the eye, you'll see there's some red spots down here and here and here. That's a little bit of hemorrhaging that you can see from diabetes. After having years of high blood sugar, you can damage the blood vessel walls in your eye or actually anywhere else in your body, and sometimes you'll get small hemorrhages that we'll see inside the eye from these damaged blood vessels. Over the course of years, that damage can stop the blood flow into some of these blood vessels. The eye's response to that stopped blood flow is to actually grow new blood vessels, but they're abnormal vessels. And sometimes these abnormal vessels will grow, and they'll cause scar tissue and bleeding inside the eye. And there's a few of these abnormal vessels in here, and it's all hard to see right now, but as we get all of the gel out, we'll be able to zoom in and see some of these vessels, and we'll actually take some of these out tonight. 00:10:33 BEATTY G. SUITER, MD: Dr. Dyer, another question for Melissa: is there anything that can be done to prevent diabetic retinopathy? 00:10:39 MELISSA MAGWIRE, RN, CDE: Well, certainly keeping your diabetes under good control is one of the major things you can do. Some studies have shown that 50-

4 75% risk reduction in keeping your sugars under control, and so that's the main thing. Also, controlling your blood pressure, your cholesterol. Those issues will help as well, too. 00:10:58 DAVID S. DYER, MD: One thing that I might add to that that I have to deal with many times with patients is that if you've had poor control of your blood sugar and then you start to have good or tight control of the blood sugar, sometimes we'll see patients will continue to have ongoing progression of their diabetic eye disease or their diabetic retinopathy. And it can sometimes take up to two years of good control before you see some of the positive changes developing inside the eye. And so the only thing I would say is that if you've had poor control, don't get disheartened if you still see diabetic changes progressing despite having good control, because it may take a year or two before you start to see things turn around. 00:11:42 BEATTY G. SUITER, MD: Dr. Dyer, I have another question: what type of anesthesia is used and how much pain do patients generally experience? 00:11:49 DAVID S. DYER, MD: We use a local anesthesia. It's called a retrobulbar injection, which is an injection of a numbing agent behind the eye. Before we do that, we start an IV and Lenny gives the patient an IV sedation, so the patient falls asleep for about five minutes. While the patient's asleep, we give this numbing injection behind the eye to deaden the eye, and that will prevent the patient from having pain during surgery. The other thing it does is it paralyzes the eye muscle, so the eye doesn't move while we're operating, which is very important, obviously. As far as the pain after surgery, because we don't put stitches in the eye with this technique, there's very little or no pain. Most of my patients at the most will need Tylenol for a few days after surgery. Many patients don't need to take anything. And the reason is, if you can imagine having stitches on the outside coating of your eye, every time you blink, your eyelid is going to rub on those stitches, and that becomes pretty painful. By having a no-stitch or sutureless method, you can blink your eye naturally and there's no irritation to the eye. 00:12:58 BEATTY G. SUITER, MD: Do these type of surgeries change people's prescriptions and can you wear contacts after a vitrectomy? 00:13:07 DAVID S. DYER, MD: Let me -- that's two questions, so I'll answer the first one, about the prescriptions. The type of surgery we're doing tonight, the vitrectomy surgery with a 25-gauge, or the no-stitch technique, does not change your prescription of glasses. And so if you wear glasses before surgery, more than likely you'll have the same prescription after surgery. If you're wearing contact lenses, you can wear contacts after surgery, but you have to wait till we've stopped all of the eye drops. For a few weeks after surgery, we put you on some steroid eye drops and some antibiotic eye drops, and you can't wear contact lenses while you're instilling eye drops onto your eye. But as soon as we stop the eye drops, you can go back to wearing your normal contact lenses. 00:14:00 BEATTY G. SUITER, MD: Here's another question for Melissa: will most diabetics have problems with their eyes? 00:14:06 MELISSA MAGWIRE, RN, CDE: Not necessarily. We do think that over the course of a lifetime, certainly your length of diabetes puts you more at risk for the eye disease, however the severity and the need for treatment is certainly decreased by keeping it under good control. One of the things we talk about most often is prevention as far

5 as keeping your blood sugars down like Dr. Dyer and I both said, but also not waiting until you have symptoms. Patients need to get into the habit of having dilated eye exams every year before even having symptoms. And the likelihood of having problems then is much lessened. And if they do have problems, to a much smaller degree at that point. 00:14:44 DAVID S. DYER, MD: While Melissa was talking to you, I did something I commonly do, I switched instruments. So I now have the fiber-optic light in my right hand and I have the vitrectomy instrument in my left hand. I've taken all of the gel out of the -- kind of the right side of the eye and now I'm going in and taking out the gel on the left side, or kind of the inside part of the eye. And once we're done taking the gel out, then we're going to take these forceps or tweezers like you saw on the animation and take some of these abnormal blood vessels off the surface of the retina. Before we can do that, though, we have to take all of the gel out. The gel blocks our ability to reach the retina, so we have to get all of the gel out of the eye so that we have easy passage into the eye and to the retina. The other benefit in diabetes of taking all of the gel out is that it increases the oxygen tension going to the retina, which helps to prevent further damage from the diabetes. And so we think that it's actually protective or helpful to have a vitrectomy. That's not a reason to have the surgery done, but it's kind of a bonus if you need to have it done. So we're just about done with the vitrectomy part, and then we're going to switch gears and start to do some of the more intricate parts of our surgery. 00:16:15 BEATTY G. SUITER, MD: Dr. Dyer, another question just came in: what is the biggest risk in this surgery? 00:16:23 DAVID S. DYER, MD: Well, the most significant risk would be loss of vision. One of the most common ways that you could lose vision would be to develop a detached retina as a result of surgery. It's very possible in the process of taking the gel out since the gel is attached to the retina, we could create a tear in the retina and fluid could get underneath the retina and lead to a detached retina. We always check during and then at the end of surgery to see if there's any retinal tears. If there is, that's usually pretty easily treated with some laser treatment at the end of the surgery. Another risk is endophthalmitis, which means bacterial infection inside the eye. And about 1 in 3,000 times, a patient can get a bacterial infection inside the eye. That's one of the reasons why we see you the first day after surgery and a week after surgery, is to look for signs of an infection. And if we can catch the infection early, we can treat it with antibiotics and prevent any significant damage to the eye. 00:17:24 BEATTY G. SUITER, MD: And another one that came in over the internet: what is the extent of epithelial debridement typically seen during the procedure? 00:17:32 DAVID S. DYER, MD: Well, that's something that we don't see as much anymore. Before we did the -- the no-stitch surgeries, we used to make larger incisions into the eye wall, and the surgeries took a lot longer to perform. And sometimes the front of the eye or the epithelium, which is the front coating of the eye over the cornea, would become cloudy, and we'd have to actually remove that front layer so we could get a good clear view inside the eye. Since these surgeries don't take very long, it's very unusual to have to debride the epithelium or to remove the epithelium from the front surface of the eye. It's something we probably only do a few times a year now, where we used to do it a few times a day. Okay, we're going to switch over now to a little higher magnification system using a contact lens on the front surface of the eye. So we're going to swing our wide-field viewing system out and then Kevin's

6 going to hand me a contact lens. It's a little bit bigger than what you would want to wear normally, but you'll see, there's a -- a large contact lens sitting on the eye. And what this contact lens really does, it neutralizes the effect of the natural lens inside the eye so we can focus with the microscope, and it gives us a magnified view inside the eye. So if you remember our initial view, that spot in the back of the eye looked pretty small, and now you're going to see that spot of blood has gotten quite a bit bigger. And I can actually show you the optic nerve here in a little bit more detail. Take the -- I'll take a forcep, too. I'm going to zoom out here just for a second. I want to show you this forcep. This is the forcep that you saw on the animation. And this is a little plastic basket that we can squeeze, and by squeezing this basket, it makes the forcep open and close so that I can get that in focus. There we go. So here's our forcep, and we can go inside the eye with this. And with my fingers, I can squeeze that little basket up at the top that I showed you, and we can grab the abnormal blood vessels and grab scarring and pick things up off the surface of the retina with this. And so we're going to put this inside the eye. And again, it's going to go through these little tubes that we placed at the beginning of the surgery. And here you can see, we can open and close these forceps. This is the optic nerve. Let me zoom up here so we get a little bit better view. This is the optic nerve, this round structure here. And then these are the normal blood vessels that come out of the optic nerve to bring blood flow to the retina. This is some blood that's on the surface within and actually underneath the retina. And that's right in the central vision. And then over here, this little white spot that you see, that's a little blood vessel growth. And it's white because we have the pressure of the eye turned up. And here's another blood vessel growth over here. And so we're obstructing the blood flow. I might need a diamond dusted membrane scraper, we'll see. With these forceps, we can carefully pick up these vessels. These are very fine vessels. And it may not look like they would cause much damage, but there are some vessels on the tip of the forcep here, and if left alone, they can grow and they can cause scarring and bleeding. And they can actually pull the retina off the back of the eye wall. Okay, let's try a membrane scraper here. There's another instrument we're going to use today, actually has a little diamond dust on it, and this is used to run along the surface of the retina, and it's a little bit rough on the edge, so it helps us to pull up the edges of these blood vessels. And so we're just going to very gently kind of tease this across the surface of the retina. There, you can center that for me, Kevin, that'd be great. Take the forcep back again. Forcep. And then we go back in with the forcep and remove some more of these vessels. 00:23:41 BEATTY G. SUITER, MD: Dr. Dyer? DAVID S. DYER, MD: Yeah, Dr. Suiter? 00:23:44 BEATTY G. SUITER, MD: There is another question here: how does removing the vitreous and replacing it with saline affect the intraocular pressure of the eye is the first part of the question. 00:23:54 DAVID S. DYER, MD: Yeah, there's no effect with removing the saline -- I'm sorry, with removing the vitreous and replacing it with saline. It doesn't change the eye -- the eye pressure. There's very little difference in the vitreous. The vitreous is pretty liquid-like anyways, and so it doesn't change the eye pressure. The second part of that question is: why is saline, which seems significantly less viscous than vitreous, suitable as a replacement? 00:24:18 DAVID S. DYER, MD: Well, the eye makes something called aqueous humor, which is very similar to saline. So it's a natural replacement for --

7 00:24:27 BEATTY G. SUITER, MD: Is that saline replaced over time by the aqueous? 00:24:30 DAVID S. DYER, MD: And that saline is replaced over time by the aqueous, over about a week's time or so. These vessels are pretty adherent. As you can see, it's pulling on the retina itself. But you can see how strong they are. Okay. Let's go with the kenalog. The next step we're going to do is put some kenalog on the surface of the retina. 00:25:14 BEATTY G. SUITER, MD: This is a type of steroid, correct? 00:25:16 DAVID S. DYER, MD: Correct. This is a -- a dilute steroid solution that just helps sustain the top surface of the retina. We're going to try to see if we can't release some of this blood that's on the surface. This is our steroid going in, it's white. Forcep and I'll tell you what, let me have a retractor first. I'll take a little bit of this excess out. And then after we take this little membrane off of the center, we're going to do some laser treatment. The laser treatment works by treating the very far peripheral retina where there's poor blood flow. It's the areas that are receiving poor blood flow that actually -- looks like we still have some gel down here. And this is the very back layer of the gel that's still attached to the center. You can see that come up with the steroid now. And we use our cutter to remove all of that. 00:26:39 BEATTY G. SUITER, MD: Is there a chance that patients undergoing this procedure will need to have it done again because of new scarring or more damaged blood vessels? 00:26:47 DAVID S. DYER, MD: It's certainly possible, and that's why we do -- do the laser treatment is we do the laser treatment to try to prevent regrowth of the blood vessels and regrowth of the scarring. I'm going to swing now back out to our widefield viewing system, and we'll see if there's any more gel on the surface of the retina that we can remove. Need the Gonisol. There's a clear gel that we put on the front surface of the eye, and this just keeps the eye moist while we're doing the surgery, and it helps to improve our view inside the eye during surgery. Again, I'm going to swing in our wide-field viewing system. 00:27:53 BEATTY G. SUITER, MD: Dr. Dyer, do patients undergoing this procedure see improvements in vision immediately, or is there a healing process that goes on? 00:28:03 DAVID S. DYER, MD: There is a healing process, and depending on where the scarring is and how severe it is -- you can see here, this is a good example of these vessels that we loosened up on the high-field view. Let's see if we can zoom in on these. I'll answer that in just a second, Dr. Suiter. If I can get this on the monitor. It may be difficult to see from where it's at inside the eye, but these vessels are white. And now that we have them loosened up and have the gel loosened up, I'm able to remove these with the vitrectomy cutter. And we may be able to come back with our forceps and -- and pull these up as well. But there is a healing process, and typically it takes about six weeks before we start to see the vision improve. Many times, if we're just going in and removing blood and the central vision doesn't have any damage from the diabetes, a lot of times you'll have really significant improvements in vision just overnight. And so the speed of recovery depends on how much damage or how much the central vision is involved with the diabetic problems. If it's not terribly involved, than because of -- there's no stitches in the eye and the incisions are so small, the vision tends to recover quickly. If there's damage to the central

8 vision, then typically it takes about six weeks before we start to see things turn around. Okay, I went in and I released the gel that was on the center part of the vision and on the back of the eye, and so now I've gone back in with our cutter and I'm removing the rest of the gel. I don't know if you can see. I think you can see on the monitor that this cloudy-like area that's swirling around, that's the vitreous gel. It's a little bit easier to see now that we've put some kenalog or steroid inside the eye. And so initially when we went in, we cored out all the center gel, and there was still a gel attached to the back of the eye. And so with the steroid and the forceps and the vitrectomy system, I was able to release that off the back of the eye. And so now we're back in with our cutting instrument, removing the remaining gel that's been freed up from the back of the eye. 00:30:34 BEATTY G. SUITER, MD: Dr. Dyer, I have a question for Melissa: does the type of diabetes you have affect your chances of developing diabetic retinopathy? 00:30:41 MELISSA MAGWIRE, RN, CDE: Well, certainly, both type-1 and type-2 diabetics are - - can be prone to retinopathy, however we think maybe type-1s are a little bit more prone to it just because of the longevity of the disease. Often type-1 diabetics develop disease early on in childhood, and therefore 20 years down the line, they've had time for that damage to happen. 00:31:02 BEATTY G. SUITER, MD: They've had it longer. 00:31:03 MELISSA MAGWIRE, RN, CDE: They've had it longer. 00:31:08 DAVID S. DYER, MD: Here's a good example. Let's see if we can see this on the picture here. That little white spot floating in your view here, that's a little blood vessel growth that we were loosening up with the forceps earlier. You kind of see it moving around down here. And that's -- that's pulled up now with the gel, and we're going to cut this out. You'll see it kind of bounce around, and we'll cut it out with the vitrector. And there's a larger vessel here that we were working on with the diamond-dusted membrane scraper and with our forceps that we'll also come back in and take out. 00:31:58 BEATTY G. SUITER, MD: Dr. Dyer, who is not a candidate for this procedure? 00:32:04 DAVID S. DYER, MD: Well, there's a couple different ways you can look at that. One is your systemic health. If you're not healthy enough and if you have severe medical problems, you may be at risk for -- with the anesthetic and just the stress of having the surgery, so that's something we always check with the medical doctor that's been taking care of the patient's diabetes. Also, the only time that you really benefit from this is if you have abnormal blood vessels that are bleeding or if you have scarring from the abnormal blood vessels that's pulling on the retina that is leading to a detached retina. So if you don't have abnormal vessels and you don't have scarring, there's very little benefit to having a vitrectomy surgery. The only other time that we do vitrectomy surgery is in patients who have chronic macular edema. And what macular edema is is you can develop swelling in the central vision that makes your vision blurry. Many times we'll treat that with laser treatment or steroid injections into the eye or sometimes there are some newer medications we use that work on the leaking blood vessels. But if those don't work, sometimes we'll do a vitrectomy surgery to relieve the mechanical pulling of the vitreous gel on the central vision. But most of the time we're doing vitrectomy surgery for bleeding or scarring inside the eye. And again, I'm just working on the vitreous gel here. We're working

9 in the very far peripheral retina, which may be difficult to see on the computer screen, but this is the very, very edge of the vitreous gel. I'm just working my way all the way around. And once we get all of this gel cleaned off again, we'll go back in with our forceps and take out this one last blood vessel growth that's still inside the eye. 00:34:01 BEATTY G. SUITER, MD: Dr. Dyer, another question came over the internet -- we may have already answered this, although we could ask it in a different fashion: do the abnormal blood vessels grow back? I guess you could ask, do the same ones grow back or do we have new ones that develop? 00:34:16 DAVID S. DYER, MD: They're actually new ones that develop, and once they're removed, and if you do laser treatment, the laser will usually prevent them from growing back. But sometimes in severe cases where there's very poor blood flow, despite having surgery, you can develop new vessels growing. And that's one of the things we have to monitor after surgery. And so that -- even though you've had a vitrectomy surgery, it doesn't necessarily guarantee that you won't have future problems, it just makes it less likely. And now I've gone back in with our forcep again. And there's a little blood vessel growth back here that we were working on earlier. You can see here, it's much more mobile. And I'm going to try to pull that off. The blood vessel growth is attached to the regular vessel. This -- this large red vessel coming up here is a vein, and this blood vessel growth is growing off of this vein. So I'm going to try to grab the edge of this vessel growth, and it's just attached in two different areas here. Many times, we can just kind of tease it off the retina. I'm going to need some curved scissors. Now, this is a case where this vessel's pretty adherent to this blood vessel, and so what I'm going to do is I'm going to take a pair of scissors, and we'll actually cut the vessel off from the normal vessel. And it'll take just a second. Kevin is feverishly working here to take out our curved scissors so we can use those. I'm going to swing our wide-angle system out, and I'll show you a picture from the microscope of our scissors. Here's our scissors. Get them in view here. These are really -- everything we work with is pretty tiny, so it's very difficult to get the microscope to get perfect focus, but we do the best we can here. You can kind of see these scissors opening and closing. You'll be able to see them inside the eye a little bit easier. 00:36:50 BEATTY G. SUITER, MD: Dr. Dyer, I have another question that Melissa may help us with: how would you define good diabetes control? We keep talking about "control your diabetes, control your diabetes." Well, what is that? 00:37:01 MELISSA MAGWIRE, RN, CDE: Well, typically, we look at the hemoglobin A1c, which is a three-month average blood sugar, and that test is done every three months on patients. Currently the standard is anything less than 7%, which equals a blood sugar roughly of less than 150. That's 24 hours a day, seven days a week for 90 days. And there is some theory out there and some thinking that we need to even lower that to about 6.5%. So on average, we ask patients to keep their glucose between about 80 and 140 to ensure proper diabetic control. 00:37:35 DAVID S. DYER, MD: I'm going to go ahead and use these scissors, and we'll cut this vessel off. We can kind of sneak underneath this blood vessel, and with these scissors, just slightly cut this off from the underlying vessel. There we go. Now you can see, here's this blood vessel that's been freed up that's on the tip of my scissors. It's still attached. There's some gel here that's still attached here, so I'm going to let

10 that go, and we'll go back in with our vitrectomy cutter and we'll cut that vessel up and take it out. 00:38:15 BEATTY G. SUITER, MD: Dr. Dyer, I have another question. 00:38:17 DAVID S. DYER, MD: Okay. Here's our cutter cutting up that blood vessel. 00:38:22 BEATTY G. SUITER, MD: If you need surgery in one eye, is it more likely that you will also need it in the other? 00:38:27 DAVID S. DYER, MD: Yeah, I think in general, that's true. And the reason is that the amount of diabetic disease in one eye tends to be mirrored in the other eye except in special circumstances. So if you have severe problems in one eye that need surgery, it's very likely you may have the same issue with -- with the other eye, so it does make it more likely. Okay, and again, I'm going to switch hands because we need to get to the gel in the other side of the eye. 00:39:13 BEATTY G. SUITER, MD: Dr. Dyer, if you are diabetic and having cataract surgery, will you also need a vitrectomy surgery? 00:39:19 DAVID S. DYER, MD: Usually not, and cataract surgery these days is also done with very small incisions, and it's much less stressful on the eyes than what used to be done 10, 20 years ago. And so most people who have diabetes, if their diabetic retinopathy is in good control and there's no abnormal vessels that are bleeding -- you know, there's no significant swelling or edema in the back of the eye, it's very safe to have cataract surgery without the need to have anything else done. Okay, that completes the vitrectomy part of the surgery. The next thing we're going to do now is to put a fiber-optic laser probe inside the eye and do laser treatment to try to prevent these vessels from growing back. And I'll show you what this looks like. This is a fiber-optic tube that we can extend the laser on the tip. There's a little button on the end that if I pull back with my finger on this button, it actually extends the laser out of the tip and it curves the laser. And then we're able to rotate the handle to get the laser to fire in all different areas inside the eye. The laser has an aiming beam, that's what this bright red light is. Let's see. It's not showing on the video as well. Can we boost the power? There, you can see the red light there a little bit. You'll see it inside the eye. But there's a little red aiming beam that helps us to -- to know where the laser's going to fire at. Okay, we'll swing our wide-field system back in and we'll get back in focus. 00:41:30 BEATTY G. SUITER, MD: Melissa, a question not really related to the eyes with diabetes: how do I know that I may have -- or how may I know that I have diabetes? 00:41:39 MELISSA MAGWIRE, RN, CDE: Unfortunately, a lot of times patients have type-2 diabetes without having any signs and symptoms, and so preventative health care, your yearly physicals, exams. Symptoms of high blood sugar would include blurry vision, thirst, urination. Often patients don't assimilate that with anything wrong; it could be summertime. So just vigilance with yearly exams. If you have a family history and you have some of the risk factors: obesity, high blood pressure, like I said, the family history, and cholesterol problems, that should maybe spark a visit to the physician to get that checked out. 00:42:17

11 DAVID S. DYER, MD: What I'm doing now is laser treatment to the peripheral retina. These white spots that you're seeing is where the laser's treated the retina and makes the retina swell and turn white so we know we have good laser reaction to the retina. And this is called PRP or pan-retinal photocoagulation. Another term for this is called scatter treatment, where we kind of scatter laser treatment in the peripheral retina. The idea here is that there's widespread areas where there's poor blood flow in the peripheral retina, and so the laser treatment actually kills off a large number of these cells that are releasing a protein that makes the abnormal blood vessels grow. And by doing this, we can prevent the abnormal blood vessels from growing back. The downside is that you lose some peripheral vision, you have some loss of night vision. You may actually have some glare on a bright, sunny day after having this done. But if you don't do this, you might lose your good central vision. You still have peripheral vision. There is still vision in between where these spots are, and so you don't lose all of the vision. But there is -- there is some vision loss related to the laser, but the idea it's better to lose some peripheral vision and save the good central vision than to lose everything. So what I'm doing is I'm going to go around the peripheral retina and put laser spots throughout these -- these areas. And hopefully that'll prevent any further bleeding down the road and prevent any new blood vessels from regrowing after we've removed them tonight. 00:44:24 BEATTY G. SUITER, MD: What -- what is this patient's postoperative period entail? 00:44:31 DAVID S. DYER, MD: Well, the one thing we haven't done yet is that we have some blood here that's underneath the retina still, and we're going to put an air bubble in the eye, and that -- and then lay him face-down overnight. And being face-down, it's going to push a large part if not all of that blood out of his central vision. And so for the first night, he'll be face-down. After that, he most likely can be in any position he wants to be in after surgery. He'll also be started tomorrow morning on two different drops, an antibiotic drop that he'll take four times a day and a steroid drop that he'll take four times a day. He'll be instructed not to lift more than 20 or 25 pounds for the next week or two. He'll also have to wear a metal shield at nighttime to prevent him from rubbing his eye while he's sleeping. Because there's no stitches in the incisions that we made, the incisions can open up relatively easily. So if you rub your eye by mistake, you can open up one of these incisions and lose some fluid from the eye, which can cause bleeding or other major problems inside the eye, so at nighttime, we usually have patients wear a shield for about a week after surgery. And after that time, the incisions are fairly strong and we think there's less risk of them spontaneously opening or opening with -- with light pressure. But the drops that you're on, you're usually on for a few weeks after surgery. We try to take you off the drops as soon as the eye's quieted down. But usually within a week's time, you're kind of up and about doing things again, you can be back to work, depending on how much work we do, either within a few days to a week or two after surgery. 00:46:14 BEATTY G. SUITER, MD: Melissa, from the onset of diabetes, how long does it take for these blood vessels to grow? 00:46:20 MELISSA MAGWIRE, RN, CDE: Well, it really depends on the type of diabetes. We generally think of type-1 as juvenile diabetes, and that's certainly -- we don't see that very prevalent in adolescents or even within the first five years of diabetes. Here again, it does go back to control, but as we said in the opening, it seems to be the longer you've had diabetes and related to the control, that you're more likely to see this onset. 00:46:43

12 BEATTY G. SUITER, MD: So in 10, 15 years, generally we will see some change from diabetes in almost everybody. 00:46:47 MELISSA MAGWIRE, RN, CDE: Exactly. Exactly. But you can control the extent of that with the good diabetic control. 00:47:00 DAVID S. DYER, MD: Many people who have diabetes who develop these abnormal blood vessels or proliferative diabetic retinopathy, they'll get this exact same type of laser treatment done in the office, but we can do it in the office without making an incision in the eye. And we have a laser that we can fire through a contact lens system through the cornea and through the lens and do this same type of treatment in the office without having to go to the operating room. And many times by doing that, by doing this same type of pan-retinal photocoagulation or scatter treatment, we can prevent the blood vessels from growing to the point where you need to have surgery. Usually that type of treatment's broken up into two or three treatment sessions. In surgery, though, we can do the whole treatment in one session. And one of the reasons is that there's enough fluid flow through the eye that you don't generate as much inflammation as you would in the office, and so the eyes can tolerate much more laser treatment in surgery than what we could normally do in the office. And so we can do a whole scatter or PRP laser treatment in one setting in the operating room. But again, if we catch this early enough, a lot of times we can take care of this in the office and prevent the need for the vitrectomy surgery. These white spots that I'm putting in over the course of a few weeks' time will fade away, and then they'll develop a dark brown, black pigment to them. And so if you see a patient that's had laser done previously, it doesn't stay white forever, it actually turns a brown, dark color. And that's just part of the healing process from the laser treatment. And so all we're seeing right now with the white coloration change is just swelling in the retina as a response to the heat generated from the laser. 00:49:14 BEATTY G. SUITER, MD: Dr. Dyer, is this a common cause of vision loss? 00:49:19 DAVID S. DYER, MD: This is a very common cause of vision loss in diabetic patients as far as having proliferative diabetic retinopathy. 00:49:28 BEATTY G. SUITER, MD: Are there other issues that can cause vision loss? 00:49:35 DAVID S. DYER, MD: Yeah. You can develop a detached retina from more severe proliferative disease by these abnormal vessels causing great big bands of scarring. You can also have vision loss from swelling in the central vision called macular edema. Another way that you can have vision loss is from just loss of blood flow. And sometimes that's called macular ischemia, where you just lose blood flow to your central vision. And that's the one thing that we can't treat. We have pretty good treatment for proliferative disease, where you get these abnormal blood vessels growing. We have pretty good treatment for diabetic macular edema. But there's no treatment so far if you lose blood flow. We don't have a way to restore lost blood flow. Okay, so that's our laser treatment. We're going to put an air bubble in the eye. I need a soft tip. And the main purpose of the air is to try to push as much of this blood out of the central vision as possible. 00:50:39 BEATTY G. SUITER, MD: Do all patients get an air bubble? 00:50:40 DAVID S. DYER, MD: Not all patients. If there -- if there wasn't the blood in the central vision, we would stop here and we wouldn't put an air bubble in. The other

13 reason we put an air bubble or sometimes a gas bubble in the eye is if there's a detached retina or a traction that we're trying to push back into place. We can put air in or a couple different types of gas. One type of gas lasts about 7-10 days. Another gas lasts up to six weeks. Let's turn the air on. And we can also put silicon oil in eyes, and the silicon oil lasts -- stays inside the eye until we come back and take it out. So what I have in the eye now is this little cannula with a little soft silicon-based tip on it. You can kind of see it's flexible. I'm going to use that to aspirate the fluid out of the eye. And as we take the fluid out, you're going to see this air bubble coming in. And we'll replace all the fluid in the back of the eye with air. Now what we've done is that there's a little valve that we have hooked up to our infusion cannula. That's the first line that we put inside the eye that brought the fluid in. And we can switch that so instead of bringing fluid into the eye, we bring air in. And so we switch that valve over so we can instill air -- and this is sterile air -- into the eye. And then we can aspirate the fluid out as the air comes in. There was a little bit of fluid in the retina up here, and so we're able to flatten out this part of the retina. We're going to come back and do some laser treatment here as well. I'll take the laser back again. 00:52:37 BEATTY G. SUITER, MD: So what happens to the air or gas bubble? 00:52:39 DAVID S. DYER, MD: The air gets reabsorbed by the eye, and as the air gets reabsorbed by the eye, the eye makes fluid to replace where the air was. And so the air goes away and then fluid reaccumulates inside the eye. Let's go to 300. If we put a gas bubble, the gas bubble just takes longer to dissolve inside the eye, and so it lasts longer before the air replaces the gas. So now I've flattened out this one area of the retina where this blood vessel was, and so now I can get laser treatments into this area. And that'll hold this area down and also help to prevent this blood vessel from coming back again. 00:53:24 BEATTY G. SUITER, MD: Dr. Dyer, there's a question concerning the replacement that we use for vitreous: what is the difference between a balanced salt solution and thicker ophthalmic agents like Provisc or Viscoat? 00:53:52 DAVID S. DYER, MD: Well, the balanced salt solution is more watery. And it's the same basic specific gravity or weight of the fluid that the eye makes naturally, so the eye can see through the balanced salt just like it would see through the natural fluid. The more viscous fluids that you're talking about are fluids we can use at the time of surgery, mainly used for cataract surgery, are thicker, and they affect the -- the eye's ability to see through it because it's not the same density as the fluid that we normally put into the eye. And so -- and so because of that, we don't typically use that during surgery or we don't usually leave it inside the eye at the end of the surgeries. Okay, we've done all our laser treatment, we have an air bubble inside the eye, and so now what we need to do is take our tubes or cannulas out, these three little areas here. And so we're going to take the first two out. Let's drop our pressure to 20. And then like you saw in the an-- in the animation, as we take them out, the white of the eye will kind of close up and seal off without the need for stitches, and we'll hold the little cotton-tip applicator over there to allow that to happen. Take this one out here. There's air coming out of it, that's why sometimes you get little air bubbles coming out of the end of those. Let me take one of those, Kevin. This is what these tubes look like, just to give you an idea. There's a blue cap and there's just a plastic tube that has a little bit of color to it so we can see it inside the eye. And this is our last one that we'll take out. Turn the air off like so. There's a little bit of blood we'll clean up here from our one incision. But you can see at the end here,

14 it's hard to tell that we've done anything. You can see that there's a few incisions, a little bit of blood here and here, but pretty normal-looking eye after -- after having pretty major eye surgery. And that's the advantage of this no-stitch technique is that you have an eye that essentially looks the same, is going to pretty much feel back to normal tomorrow, and then over time, as this air bubble goes away and the blood reabsorbs, the vision will get better also. This is a little speculum we use for -- 00:56:29 BEATTY G. SUITER, MD: Dr. Dyer? We're almost out of time here. Do you have any final comments concerning the surgery tonight? 00:56:36 DAVID S. DYER, MD: No, I think that this just shows a good example of a diabetic vitrectomy surgery where we can go inside the eye, take out the gel, take out abnormal vessels and scarring, and in many cases dramatically improve patients' vision. The nice thing, again, about this technique is that these are very small incisions, and so they'll heal up without putting in stitches. There's very little or no pain, and the recovery time from the surgery is very, very fast compared to the older techniques. 00:57:07 BEATTY G. SUITER, MD: Thank you. 00:57:08 DAVID S. DYER, MD: Okay. thank you. 00:57:11 BEATTY G. SUITER, MD: Thank you for joining us tonight. You watched a diabetic vitrectomy surgery live here at Shawnee Mission Medical Center in Shawnee Mission, Kansas. This surgery was performed by Dr. David Dyer. I'm Dr. Beatty Suiter. This is Melissa Magwire. Thank you for joining us. You can catch this presentation again archived on our website, shawneemission.org. Thank you. 00:57:32 ANNOUNCER: This has been a diabetic vitrectomy performed from Shawnee Mission Medical Center in Shawnee Mission, Kansas. OR-Live makes it easy for you to learn more. Just click on the "request information" button on your webcast screen and open the door to informed medical care. 00:58:00 [ end of webcast ]