RETINAWS 2010: ASRS A sampling of cases presented and discussed at the ASRS Annual meeting in Vancouver, Canada. BY KOUROUS REZAEI, MD RETINAWS was presented at the American Society of Retina Specialists Meeting on Tuesday afternoon, September 31, 2010, in Vancouver, Canada. Below you will find a brief description of cases presented. RETINAWS was recorded live and can be watched on www.eyetube.net/retinaws. We would like to thank Alcon Laboratories, Inc., for sponsoring the recording. We hope you enjoy this recap of RETINAWS. TIMOTHY G. MURRAY, MD, MBA, FACS Bascom Palmer Eye Institute University of Miami Miller School of Medicine Miami, Florida Malignant Melanoma A man aged 64 years presented with 20/100 visual acuity, a complex retinal detachment, and an intumescent cataract. On ultrasound, the ciliary body mass was atypical with medium to high reflectivity and questionable vascularity. The patient underwent combined torsional phacoemulsification and acrylic intraocular lens (IOL) implantation and a valved 23-gauge, three-port pars plana vitrectomy (PPV). After phacoemulsification and IOL implantation, aspiration of perivascular pigment for cytopathology, removal of posterior hyaloid, air-fluid exchange, and continuous direct tumor ablation with illuminated and curved 23-gauge laser were performed. Histologic examinations revealed malignant melanoma of the epithelioid and mixed cell type. After reviewing the pathology, the eye was enucleated. The patient was alive and free of metastatic and orbital disease at 40 months. Because not all pigment associated with retinal detachment is benign, always look for an unsuspected mass via indirect ophthalmoscopy and, when indicated, via echography. Link to video: retinaws/retinaws-17-/ Assisting Your Anterior Segment Colleague A woman aged 67 years underwent planned phacoemulsification and IOL implantation by an anterior segment surgeon. During the procedure, early posterior capsular compromise and dropped nucleus (large) occurred. A vitreoretinal surgeon in the OR was able to assist. The anterior segment surgeon stabilized the anterior chamber, removed easily accessible nucleus and cortex, placed a three-piece acrylic IOL in the sulcus, and closed the anterior segment wound with 10-0 nylon. At this point, the retina surgeon placed valved 23-gauge trocars, focusing first on placement of an infusion line to stabilize intraocular pressure (IOP). The retina surgeon then directed his attention to vitreous and hyaloid removal, and after vitreoretinal traction was eliminated, removed cortical and nuclear fragments with the 23-gauge vitrector. Remarkably, many cases may be completed without the need for a fragmatome. If a 20- gauge fragmatome is needed, then remove the trocar and use a 20-gauge microvitreoretinal blade to enlarge wound; next, insert the 20-gauge fragmatome and remove nuclear fragments. Pay particular attention to stabilizing fragments in mid-vitreous, and avoid iatrogenic retinal breaks. Evaluate the retinal periphery 360º for retinal tear or detachment, which has a 7% to 14% incidence, and treat if present (laser encerclage with or without intravitreal tamponade). If the IOL is unstable but undamaged, consider using a McCannell-type iris suture. If the IOL is damaged, exchange with an anterior chamber IOL. If it is a sulcusplaced posterior chamber IOL, consider anterior optic capture in the residual anterior capsular bag. Off-label intravitreal placement of triamcinolone acetonide can be used at the conclusion of the case. At 3 weeks, the patient saw WATCH HOW TO HELP YOUR ANTERIOR SEGMENT COLLEAGUE NOW ON WWW.EYETUBE.NET retinaws/retinaws-2-/ 18 IRETINA TODAYIJULY/AUGUST 2011
20/25+, had an IOP of 16 mm Hg, and had no retinal complications. You now have one happy patient and one thrilled anterior segment colleague. DEAN ELIOTT, MD Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts Silicone Oil in an Aphakic Eye Without an Iris A 29-year-old woman experienced a traumatic openglobe injury. She underwent primary repair, at which time she was found to have no iris and lens. She had dense vitreous hemorrhage and retinal incarceration in the wound. Two weeks later, she underwent vitrectomy, scleral buckle, retinectomy, and silicone oil injection. Two 10-0 polypropylene sutures were placed across the anterior chamber, limbus to limbus, to keep the oil posterior and prevent contact with the corneal endothelium. IOP was normal, and the oil was successfully contained posteriorly, despite aphakia and iris loss, until it was removed at 6 months. The cornea remained clear, and the retina remained attached. Link to video: retinaws/retinaws-5-/ Suprachoroidal Gas A woman aged 54 years presented with decreased vision (20/400) and was found to have a full thickness, stage 4 macular hole. She underwent vitrectomy, epiretinal membrane (ERM) peel, internal limiting membrane (ILM) peel, and fluid-air exchange. During an attempted air-gas (14% C 3 F 8 ) exchange, a large choroidal elevation was noted in the quadrant of attempted gas injection. The etiology of the choroidal elevation was suprachoroidal gas. The needle was removed and placed in the opposite quadrant to continue the gas injection into the vitreous cavity. On postoperative day 1, there was a large WATCH SUPRACHOROIDAL GAS NOW ON WWW.EYETUBE.NET retinaws/retinaws-16-/ choroidal elevation for 360º, a small vitreous cavity, and a very small gas bubble (several disc diameters in size), which was in contact with the fovea when the patient was lying face-down. No intervention was undertaken. At 1 week postoperatively, the choroidals were resolved, the gas bubble had completely reabsorbed, and the macular hole was closed. Visual acuity ultimately improved to 20/60. Choroidal Effusion A woman aged 37 years with no past medical history complained of decreased vision in both eyes for several weeks. She reportedly had elevated IOP and underwent attempted laser peripheral iridectomy. During this time, she developed shortness of breath and weight gain and was found to have pleural effusions, edema, and lymphadenopathy. Ophthalmologic exam demonstrated visual acuity 20/400 OU, IOP 43 OU, shallow anterior chamber, and peripheral choroidals OU. Systemic workup was consistent with lupus, and immunosuppressive therapy was initiated. Despite medical management, IOP remained in the high 30s mm Hg OU, and scleral windows with drainage of suprachoroidal serous fluid were performed in both eyes. Visual acuity returned to 20/20 OU, IOP normalized, and choroidals resolved. Link to video: retinaws/retinaws-13-/ JERZY NAWROCKI, MD Jasne Blonia Ophthalmic Surgical Center Lodz, Poland Delayed Removal of a Magnetic Intraocular Foreign Body A young man presented with ocular trauma 2 months earlier, but his primary ophthalmologist overlooked a small globe perforation and found a completely healthy eye with 20/20 vision. An x-ray was not performed. Approximately 2 months later, the patient complained of blurry vision in the same eye and was referred to my practice. CT examination showed that an intraocular foreign body was localized in the temporal lower quadrant, approximately 3 mm to 4 mm posterior to the limbus. Careful examination indicated a delicate scleral scar, located nasally in the region of pars plana. Visual acuity was 0.2. External magnet removal of the foreign body was performed. Haziness of the vitreous slowly decreased, and 20/20 vision was achieved. This case exemplifies that an external magnet may be useful in certain cases. JULY/AUGUST 2011 IRETINA TODAYI 19
WATCH DELAYED REMOVAL OF MAGNETIC IOFB NOW ON WWW.EYETUBE.NET retinaws/retinaws-14-/ Iatrogenic Macular Hole During Vitrectomy for ERM Removal A patient aged 75 years with an initial visual acuity of 20/200 and ERM in the center of the fovea underwent PPV. During the standard surgical approach, ERM was removed with ILM, but after their removal iatrogenic macular hole was observed. Fluid-air exchange was performed. Initially, the macular hole was flat open, but after 1 month, it was open. Using another similar approach, vitrectomy with mechanical decrease of macular hole size and gas injection was performed, and, again, the macular hole was initially flat open and subsequently reopened. Final visual acuity was between 20/200 and 20/150. The presence of foveal depression in a patient with ERM may indicate the risk for developing iatrogenic macular hole during the peeling. Link to video: retinaws/retinaws-7-/ Treatment of Macular Hole in a Patient Who Cannot Position Face-Down A woman aged 77 years, who was scheduled for standard macular hole surgery, had previously undergone thyroid removal surgery with recurrent laryngeal nerve damage and tracheostomy. Because of her unique situation, the patient could not breathe when positioned face-down. The patient was treated following the standard method of inverted ILM flap for macular hole closure and air injection. However, the macular hole remained open after this approach was applied. For that reason, we decided to perform the ILM flap technique with silicone oil, which was later removed. After a few months, the macular hole remained closed. Visual acuity improved from 10/200 to 20/150. This case indicates that in a selected group of patients, silicone oil may be considered for treatment of macular hole. Link to video: retinaws/retinaws-11-/ Severe Ocular Trauma with Iris Reconstruction A patient aged 34 years who had severe ocular trauma 6 months earlier was referred for surgery. His visual acuity was hand motions. Remnants of iris and vitreous hemorrhage were present at the pupillary plane. The first surgical approach was vitrectomy. After the removal of blood, complete retinal reattachment was performed, and in some areas old subretinal hemorrhage was observed. Iris reconstruction was performed. Two months later, the patient returned to the clinic with complete retinal detachment. Vitrectomy with retinotomy and removal of subretinal membranes and ERM was performed. The eye was filled with silicone oil. Three months later, retinal redetachment occurred. Newly formed epiretinal and subretinal membranes were removed, and the eye was filled with silicone oil. Finally, the retina remained attached, and 4 months later the silicone oil was removed and a scleral-fixated foldable IOL was implanted. Final visual acuity was 5/200. It appears that removal of the subretinal blood during the first surgery with ILM peeling might have increased the success of the initial procedure. Link to video: retinaws/retinaws-18-/ JOHN POLLACK, MD In-the-Bag IOL Dislocation, With a Twist Capsular tension rings add a twist to the management of a dislocated IOL-capsular bag complex. This video describes one way to manage this situation. Link to video: retinaws/retinaws-3-/ Device Decompensation When one is using relatively new devices, it is always a good idea to expect the unexpected. These videos describe some unexpected equipment malfunctions and how they could possibly be prevented in the future. Link to video: retinaws/retinaws-9-/ 360º Subconjunctival Gas Dissection Three-hundred sixty-degree subconjunctival dissection of gas after cannula removal is an indication of leaking sclerotomies and can make identification of leak sites difficult. This video illustrates a technique for managing this scenario and potentially closing the sclerotomy sites without the need for suture. 20 IRETINA TODAYIJULY/AUGUST 2011
WATCH 360º SUBCONJUNCTIVAL GAS DISSECTION NOW ON WWW.EYETUBE.NET retinaws/retinaws-19-/ MAHESH SHANMUGAM, DO, PHD Sankara Eye Hospital Bangalore, India Intraocular Cysticercosis Intraocular cysticercosis is best managed by surgical removal of the cyst. These videos illustrate two different techniques of removal of the cysts. A woman aged 58 years presented with gradual loss of the temporal field of vision in her left eye. Her best corrected visual acuity was 6/6 OU. Fundus examination showed subretinal cysticercosis in the nasal quadrant, which was confirmed on B-scan and CT. Systemic examination was normal. The peripheral subretinal location prompted transscleral removal of the cyst, shown in this video. The cyst was localized on the sclera (similar to break localization during scleral buckling procedure) and removed through sclerotomy and choroidotomy. She maintained her preoperative vision after the surgery. Link to video: retinaws/retinaws-10-/ Second Membrane in Diabetic Vitrectomy Operating in the correct plane is essential to avoid complications in diabetic vitrectomy. There is vitreoschisis in diabetic proliferation with a second membrane (Figure 1) proliferating on the surface of the retina, anterior to the visible fibrovascular proliferation. Identifying and dissecting this membrane allows easy removal of the large fibrovascular proliferation with the cutter and provides access to the vascular nails with minimal risk of iatrogenic break. The videos illustrate the dissection of the second membrane, followed by dissection of the fibrovascular proliferation. This video shows that the fibrovascular proliferation does not roll in to the vitreous cutter. Identifying the Figure 1. The second hidden membrane. anterior second membrane and peeling it with a needle and forceps allows it to be removed with the cutter easily. This video also shows removal of the second membrane with the vitreous cutter, allowing complete removal of the fibrovascular tissue in a young female patient with complicated combined retinal detachment. A significant amount of bleeding was encountered despite the use of preoperative intravitreal bevacizumab. Link to video: retinaws/retinaws-12-/ Sutureless Scleral Buckling Sutureless buckle surgery is easy to perform and can be used to close retinal breaks 1 to 2 clock hours in circumferential extent. The encerclage is secured using scleral tunnels two tunnels straddling the retinal break are placed in the quadrant of the retinal break. The solid silicone explant is slipped beneath the encerclage between the two tunnels. The solid silicone explant is held in position by the tunnels on both sides and the encerclage, as shown in Figure 2, and it is not necessary to use a mattress suture. The buckle effect achieved with this technique is effective with adequate tightening of the encerclage. The advantages of this technique are its ease, speed, and decreased risk of buckle infection in the absence of sutures. Link to video: retinaws/retinaws-20-/ Figure 2. Sutureless scleral buckle. JULY/AUGUST 2011 IRETINA TODAYI 21
Trocar insertion in the superonasal quadrant is more difficult than in the temporal quadrants, especially in tight orbits and deep-set eyes. -Kourous Rezaei, MD Removal of Large Subretinal/Suprachoroidal Oil Without Retinotomy Subretinal silicone oil may occur as a complication of proliferative vitreoretinopathy (PVR) in severe retinal detachment and must be removed through a large peripheral retinotomy. Suprachoroidal oil may rarely occur as an iatrogenic complication. The video demonstrates an alternative technique to remove the oil in these situations, obviating the need for a retinotomy. Case 1: A patient aged 15 years presented with iridochoroidal coloboma and total retinal detachment with subretinal oil. Conventional procedure for removal of the oil includes at least 180 relaxing retinotomy with perfluorocarbon liquid. This was avoided by draining the oil through a posteriorly placed sclerotomy overlying the subretinal oil. Case 2: A man aged 45 years underwent vitrectomy for diabetic retinal detachment with silicone oil infusion. Inadvertant hypotony during the silicone oil injection resulted in suprachoroidal silicone oil. Transscleral drainage of oil allowed salvage of the eye. WATCH MANAGEMENT OF SUPRACHOROIDAL/ SUBRETINAL OIL NOW ON WWW.EYETUBE.NET retinaws/retinaws-15-/ Managing Iatrogenic Breaks in PVR Surgery Iatrogenic breaks may complicate vitreoretinal surgery for tractional retinal detachment associated with vascular retinopathy. Once a retinal break occurs, it is important to achieve complete traction relief, or, if this is not possible, at least traction relief around the retinal break. Tamponade with oil or gas is no substitute for traction relief. Once a break occurs, it is preferable to dissect the fibrovascular tissue in other areas, leaving the dissection of fibrous tissue around the break for last. Continuing dissection at the area of the break may convert the tractional detachment into a rhegmatogenous detachment, making further dissection difficult. A 35-year-old woman with retinal detachment secondary to proliferative vascular retinopathy underwent vitrectomy. An iatrogenic break occurred during early stages of the membrane dissection. Complete traction relief with vitreous cutter, peeling, and scissors dissection is demonstrated in this video. Link to video: retinaws/retinaws-8-/ KOUROUS REZAEI, MD Trocar Insertion Trocar insertion in the superonasal quadrant is more difficult than in the temporal quadrants, especially in tight orbits and deep-set eyes. The classical teaching for trocar insertion is to insert the inferotemporal trocar first. After doing this, however, the infusion tubing will further rotate the eye to the opposite direction (superonasally) and make the superonasal trocar insertion more difficult. In eyes that undergo vitrectomy surgery for the first time, it is easier to insert the superonasal trocar first. A plug should be inserted into the trocar immediately after removal of the inserter to avoid hypotony (which is not an issue in valved trocars). This technique is shown in the video. Due to the risk of hypotony, this technique should not be used in previously vitrectomized eyes. WATCH TROCAR INSERTION NOW ON WWW.EYETUBE.NET retinaws/retinaws-6-/ 22 IRETINA TODAYIJULY/AUGUST 2011
When the Going Gets Tough, The Tough Get Going A Comprehensive Course on Retinal Misadventures in the Operating Room Registration is on-site Tuesday August 23rd 1:30-3:30pm Republic Room Sheraton Boston Hotel Boston, MA Agenda Subretinal PFCL Oil trapped in AC Peripheral break during PVD induction Subluxated lens. TRD delamination in PDR Optic nerve pit detachment Subretinal blood. Suprachoroidal hemorrhage Silicone oil Pump and scleral rupture Subretinal air Scelrotomy disasters. Subretinal triamcinolone Fluids matters Hydrogel buckling Subretinal trypan blue and hidden retinal breaks Diplopia treated with opaque IOL I have seen the future Transillumination for Shaving Vitreous Base Subretinal Stem Cell Delivery Submacular hemorrhage TPA Injection OZIL technique for Retained Lens Fragments Course Co-Directors Kourous A. Rezaei, MD Faculty George W. Aylward, MD Moorfields Eye Hospital London, United Kingdom Mathew MacCumber, MD, PhD USA Stanislao Rizzo, MD Eye Surgery Clinic Santa Chiara Hospital Pisa, Italy Kirk H. Packo, MD Allen Ho, MD Wills Eye Institute Thomas Jefferson University Philadelphia, Pennsylvania USA Manish Nagpal, MD Retina Foundation Gujarat, India