RETINAL SURGERY COLE EYE INSTITUTE, CLEVELAND, OHIO Broadcast April 29, 2005 NARRATOR During the next hour, surgeons at the Cleveland Clinic Cole Eye Institute will demonstrate the latest in retinal surgery techniques in a live internet broadcast. Today s live surgery features one of the many procedures that participants attending the 2-day Fifth Retina Summit at the Institute are also viewing. You may participate in the program by sending questions to the operating room at any time by clicking the MDirectAccess button on this screen. The Cole Eye Institute is a leader in ophthalmic treatment and research. Many procedures developed here have been adopted by ophthalmologists around the world. Dr. Hilel Lewis, the Chairman of the Cole Eye Institute, is operating on a patient and I d like to present that patient both to the audience here at the Retina Summit as well as to the internet. I also would note that on the internet there will be a little button for you to press that allows you to ask questions to me that I can relay on to Dr. Lewis, as well as the audience here, if you have a question, just press the little key pad so I can also get the question to Dr. Lewis as well as our distinguished panel. So why don t we have the presentation of the patient Dr. Lewis is working on today. She s a 46-year-old female that has had a very, very unfortunate course. We ll start with her left eye. In her left eye, she had a vitrectomy for floaters, then cataract surgery for a cataract that formed after the vitrectomy and developed a retinal detachment, which was repaired by a scleral buckle vitrectomy gas injection. Developed PVR and had a PVR surgery with again gas injection. Dr. Lewis actually operated at this point in April with the vitrectomy gas and again PVR surgery and stripping of membranes, etc. In the right eye, patient fortunately did not have a vitrectomy for floaters, but did have a cataract surgery. That cataract surgery led to a retinal detachment, which was repaired by a primary vitrectomy and gas injection, then a vitrectomy with silicone oil a month later, and then four months after that, the silicone oil was removed. Silicone was replaced because the patient developed PVR once again. Now we have a patient who has a visual acuity of hand motion in that right eye. Fortunately, the vision in the operated eye that Dr. Lewis just operated on was 20/70, but here you can see the problem in the right eye is that she has an intraocular pressure of 2 in that eye. The pressure of 2 has been there for quite a long time, since probably October or November.
So here is what the patient looks like now. She has band keratopathy. Patient is aphagic. You can see what Dr. Lewis is looking at now in the operating room is considerable epiretinal proliferation and bands. You can see maybe an old retinotomy site here with extensive proliferation from there toward what we hope is somewhere there, the optic nerve, in the posterior pole. Peripherally, you can see dramatic anterior membranes. Again, this is under silicone oil. You can see this is extending all around, almost 360 o around this unfortunate patient s eye, with extensive preretinal and subretinal membranes. You can see how the vascularity is pulled toward the retinotomy site. This is a UVM showing ciliary body detachment. You can see the pulling of the iris from the membranes, so there s anterior PVR, again ciliary body detachment, extensive membranes, almost clumps along the ciliary body on the UVM. You can see on one side, I think this is temporal or supratemporal, you can see the silicone oil bubble and almost complete loss of the ciliary body. Then you can see it supranasally, there s reasonable ciliary body there, but again the epiciliary membrane and epiciliary proliferation is present. So you can see why this patient has hypoteny. You can see why this needs surgery. You may not want to be doing the surgery, but fortunately for us, we have Dr. Lewis, who is performing the surgery. Why don t we go live to Dr. Lewis and we ll say hi to him and see how things are going. Dr. Lewis, can you hear us? Yes, I can hear you, Peter. Basically, when we started on this case, the patient had very severe band keratopathy that prevented visualization, so we placed an EDPA on the cornea and then chelated the band keratopathy. Following that, we removed the silicone oil and I found out it was 5,000 silicone oil. Now you can see the view here. The patient has massive perisilicone proliferation with a detached retina. There might be some subretinal silicone oil here, in this area, and there is massive anterior proliferation with PVR. We might be able to see it here, in this area. The proliferation extends all the way to the anterior retinal pars plana and you cannot even see the pars plicata. The anterior retina is detached. Also, interestingly, here you can see some of the membranes here. Some of them appear to be vascularized. I don t know if you can see this area here or how well you can see it, but this here is vascularized tissue, right here. All this is detached, detached. Posteriorly she is detached. So we re working right now on trying to remove some of this membrane. Now, with your approach for the cornea, how often do you find EDPA works to clear your view? If it doesn t work, what do you do? What we do is, you know, if it s not too bad, then EDPA will work. If it s very severe, then we always try EDPA work, but then we re ready to do a temporary keratoprosthesis and TPK. So that s what we do. We were ready here to do a keratoprosthesis if it was required.
Now I notice you have more than one light source in your eye there. What are you using for your light sources? I m using the Alcon Xenon light. This is an infusion-illuminated cannula, right here, infratemporally, because in order to approach the anterior tissue, I am going to induce scleral depression, so I like to do that bimanually, if I can, so that s what I m using. This is a really wonderful light. I don t know if you can see there, but the instrument that I have in my left hand is a relatively new probe, which is the sapphire probe from Alcon that gives you a cone view of about 150 o. Now, you have to understand we have 2 lights now in the eye, but even if we turned off the other light, this will give you a very nice field of vision. We have also some excellent PVR surgeons in the office and Dr. Lewis has asked me, while he s concentrating hard, to ask some of the audience or faculty members some questions. Gene, I don t want to pick on you, but being one of the more experienced retinal surgeons here, when do you think you can go in to treat a hypoteny case and when do you think it s at the point where there s just no way you can fix it? Is there a time point or are there features of the exam that you look for? GENE, M.D. For me, we ve looked at this for a long time. Bert Lazor and Ron Michaels were the first to really begin to treat some of these hypoteny cases specifically, but for me, I treat hypoteny as early as I can. I think it s much better to treat it earlier. The best cases are those that have lid problems or they have a secondary fiberoptic change. In my hands, resection of the ciliary body, removing the membrane peels away the epithelium. In my hands, that really doesn t help that much, so early, aggressive, don t wait for them to come back, lots of steroids, (can t hear speaker clearly). Hilel, are you using anything special in the infusion that you re performing? No. As you know, the study that was done at Morfield s shows no benefit for antiproliferative agents, given in the infusion cannula for patients that already have established PVR, so no, I m not using anything in the infusion cannula.
When you approach these cases, do you start outside in or do you start inside out? Do you like to start posteriorly or do you work on the anterior membranes first? In some cases, I like to remove the posterior membranes. Most of those cases do require retinectomy, so I do like to remove the posterior membranes as much as I can before I go anteriorly, which is what I m trying to do now. One of the things for those of you in the audience, the lighted infusion cannula that he is using here is one of the newest models. It s unique in that the flow through that infusion cannula is almost as good as a regular infusion cannula. The old style infusion cannula with the older light sources had to use a very thick gauge fiberoptic. These new infusion cannulas can use a 25-gauge fiberoptic and almost a bare fiber, so the light is incredibly good, but at the same time, the infusion is incredibly good, so if you re doing a diabetic or a PVR where you re worried about bleeding, you can very rapidly increase intraocular pressure, which is something you really couldn t do with the older lighted infusion cannulas. These new designs are really spectacular for bimanual surgery. You can see how the scar tissue is really fused with the retina. It s amazing how adherent this tissue is to the retina. There s more silicone oil coming in. All that subretinal silicone is now coming into view, so I need to remove it again. You can see that infusion cannula is placed just like a regular infusion cannula. It looks like a regular infusion cannula but really works very nicely. It s a little stiffer, so you can actually aim the light where you want to go. You can see the cornea, how nice the cornea looks now, after the EDPA. I d also like to remind the audience here, if you have any questions, please ask us through the little intercom in front of you. I remind you to press and hold it so we can actually hear the question, but also the internet audience, if you have a question, you can email myself here with the button on the website there. That will be emailed to me and
I ll be able to ask the question of the faculty, if you d like, or to Dr. Lewis. You can choose. The patient has had about 4 surgeries before and has had even retinectomy before. As you can see here, there is retinal corneal anastomosis going into this area right here and a proliferative tissue which really fused. Do you see here? Let me show you. It is completely fused into the retina. Do you see this? We are going all the way anteriorly and here it s completely extending into this area of incarceration. In those cases, you just want to go into that area, but you do not want to completely separate it because you end up ripping the entire retina. Here again, this is what appears to be another retinectomy here, in this area that the tissue is vascularized. SPEAKER (can t hear speaker) It s all laser. This is the first time I m in this eye, but the patient doesn t have any history of histo. You can see how thick these membranes are. They re typical for PVR because many of them are vascularized. Gene, do you think this is a case for 25-gauge? GENE No, especially because of a lot of anterior dissection. You have to do a lot of manipulation. Do you think some of the newer generations? I know Bausch & Lomb and Opcon are working on stiffer instruments. That was one of the knocks in the earlier versions that would make it easier to do some of the peripheral dissection. GENE Yeah, it s getting better every year. 23-gauge, stiffer 25-gauge, so on these cases, the majority are 25-gauge. How about here?
I wouldn t say I do the majority. I would say I m starting to do it. I think one of my big reasons I didn t adopt 25-gauge was the light source. To me, especially since I use wide angles so much, using that 25-gauge, the older 25-gauge light sources were at a very coned down view of what I was doing. I didn t like that, especially since I teach fellows. I didn t know where they were in the eye and I didn t know where I was in the eye and I was having a very difficult time. Now, with these newer wide angle prismatic 25-gauge light sources, I think that knock has really been eliminated and makes the surgery much easier and much more performable. The other thing is, the instruments I really felt weren t there. Several manufacturers now have come out with very good instruments. You know, if you didn t have a cautery, for instance, how are you going to do a diabetic? So the instruments weren t caught up to the surgery. I think now that has gotten to the point where I ve started to do more than I had in the past. I wouldn t say the majority just yet, though. Next year. But I think it s exciting. I like 25-gauge. It dramatically speeds surgery up for us. You can see here the subretinal membrane and this, I think it s an area where the subretinal membrane is connected to the epiretinal membrane. You see this epicenter here? That s again where a chorioretinal scar was present, so I think if I continued to pull in here, I would just rip the retina. You see here, like this star-shaped membrane, I m going to try and remove the membranes anterior to that and then eventually we will probably have to do a retinectomy there. You can see here the subretinal silicone oil that s remaining in the eye. There s a little bit more over there. This is really fused. We could use some perfluorocarbon to try to stabilize the retina, but the retina is really thin. As you can see, it s paper thin here, so I don t think that would help much. We ll end up creating a lot of breaks in the retina, so at some point it might be just better for the patient to have a controlled retinectomy. I want to see how much I can get without that. In this case, it s pretty obvious where the membranes are, but if you re doing some PVR cases, it s often difficult to see the membranes. Do you use any types of stains or anything to help you visualize pre-retinal membranes in PVR? No, not really, I don t. That s more of a European thing. In Europe they use vision blue to try to visualize some of the epiretinal proliferation, especially in PVR cases, but since that s not available in the U.S., we don t use it as much and have not found it that beneficial for these types of surgeries.
Again here you can see the incarceration and the progression of the membrane into that chorioretinal scar there and also right here. SPEAKER (can t hear speaker) No. I never leave any proliferation in the eye because I don t like to leave any residual traction here, so what I do in cases like this, I just do a retinectomy and then I just disconnect the retina, but I normally try to remove as much as I can. I take my time trying to remove as much as I can of the epiretinal membrane. This is not a diabetic case, but in diabetics I would use that technique that we were just talking about, in some cases, but not here. You see again the tissue goes into the area where the retinectomy was made and that s where it gets stuck. All the way here. So this entire area is just, again, subretinal membranes here, pre-existing break there, and very, very adherent membrane. It looks like, Hilel, that removing all that anterior membranes is going to be impossible, so is your goal now to remove all the preretinal membranes up to the point where you re planning to do your retinectomy? Yeah. I m going to just remove as much as I can so I can do my retinectomy as anterior as I can, so that s the goal. Again, here there is a chorioretinal scar with a small subretinal membrane with a pre-existing break and perisilicone proliferation going to the area. I ll just show you again. You can see how it s connected to the subretinal tissue right here, so again, if I keep pulling in here, I m going to pull the retina away, so I m just going to try and limit the...you can see it here from the pre-existing retinal break, what s happening. Now can I get the vitreous cutter, please? Can you ask Susan, the nurse, what setting the light is on? It s on 100 because we wanted to have it for the video here, so people can see very well.
For these new light sources, the Xenon light sources, there s one from Alcon and there s one from Synergetics. These light sources are incredibly bright and, for those of you who are using them or demoing them, you could start at almost 25 or 30% brightness and it s already 10 times brighter than your current machine, so it s amazing how bright these lights are. It makes a dramatic difference in the surgeries. It also makes a dramatic difference for lighted instruments. Lighted instruments now can come with very fine bare fibers and get a very wide view with the light, so it s really enhancing our ability to do some of these surgeries. I m just trimming the membranes. I just increased the cutting grid to go close to the retina, where it s detached. We re trying to remove it without...okay, so why don t you give me now a plug, please, and give me a depressor. Can you see how the iris is retracted posteriorly? So why don t we look at the tissue anteriorly. You see all this white tissue here? This is just posterior to the iris and the whole tissue is covering the ciliary processes, it s covering the pars plicata. We cannot see any of the pigmented tissue there. Can I have the depressor now. I ll try to go a little bit more posteriorly, if I can. It s just a continuation here, all the way. Let s explore this tissue here. Here you can even see how the iris is deformed and that s because the iris is adherent to the tissue back here. Can you see that? Then again you see the same thing here and the same thing here. Now, UVM is very helpful to me because it tells me whether or not the ciliary processes are still identifiable somewhere. Based on this UVM, there was still some tissue there that looked like viable ciliary processes, at least anatomically. Okay, give me the angiocath, please. All this is coming from the subretinal space. Again, we have to take the time to remove it. Okay, now can I have the MVR, please? Okay, so we re going to try and remove some of this tissue here. The problem here is that it can bleed very profusely as you do this. Do you do this with the pressure raised or do you do it at normal pressure? I m doing it at a normal pressure now. If it starts bleeding, I will raise it. There s a question, Hilel, if you ve ever used an endoscopic system to perform this maneuver? I think if you tried to do that through an endoscope, it s just too little. It s really very little. You can see here some of the ciliary processes that are still intact. All this tissue is creating a ciliary body and choroidal detachment that you could see on the UVM. Even
with MVR, it s hard to cut this tissue. Here, because the iris is folded, it s even hard to see where we re going. It s hard to identify the plane. We re trying to stay on the plane only where the scar tissue is, where the proliferative tissue is, without going all the way to the pigment epithelial side. I m trying to make some radial cuts as well. We are changing the buckle now. The difficulty Dr. Lewis has in removing all these membranes kind of underscores the importance, as retina surgeons, for us to look very closely at this area for any PVR surgery, even the first surgery, if this had been performed and all the membranes and the vitreous had been shaved very well, this might have been avoided, so it s important for us, as retina specialists, to look very closely at this area if we re completing PVR cases. Here you can see ciliary process is still there, so the undersurface of the scar, you want to see as little pigment as you can on that surface. Is your usual technique, Hilel, to use the MVR for this, or do you just use forceps or scissors? In cases like this, the tissue is so thick and so extensive that I do like to use the MVR. In some cases, I will use scissors, but those are cases that are a lot more limited. Even here, I don t know if you can see, but I m having great difficulty cutting the tissue. SPEAKER (can t hear speaker) It does. I removed the anterior retina, Stan, so I will do that later. I like to first remove the posterior membranes as much as we can. Then I deal with the anterior tissue, removing this epiciliary proliferation as much as I can. Sometimes it bleeds profusely, so you have to stop in some areas or some quadrants. Then, after you do that, then I go and do my retinectomy inferiorly. You see here how the tissue is vascularized? You see the blood vessels there? See, you leave the pigmented epithelium intact here and just try to remove the scar tissue, but it is very tedious and it takes a long time to do this. SPEAKER
(can t hear speaker) I ll tell you, in this patient, the main reason why I m doing this surgery in this patient is because this is a relatively young patient. She is in her 40s and she has bilateral disease. You know, I just operated for PVR in her other eye a few weeks ago and, you know, that was like her 4 th surgery, the first one I did, but like her 4 th surgery, so she has bilateral disease, so anything that I can get in this eye, I think I will be happy with if I can get any improvement whatsoever, but normally what I get is if the hypoteny...and I agree with Gene, you should try and operate as soon as you can, before these things form, but if the hypoteny has been there for more than 3 months, I normally have not been successful in restoring pressure into the eye. On the other hand, if I do a UVM in every case and if on the UVM there are no identifiable ciliary processes, I would not operate on those patients, independent of how long a hypoteny has been present, because then I think that the likelihood of having any success is none. Now, this is a patient that had silicone oil in the eye, so even with silicone oil, you can see what the results were. The patient had a pressure of 2. In this case, I think she had a pressure of 2 for less than 2 months, okay, less than 5, so that s what we re trying to do. You see the pigment epithelium stays here. You can identify ciliary processes in this area. Then what I m going to do is I m just going to remove the membranes anteriorly, so there is no longer traction on the ciliary body in this area. Here you can see the ciliary processes, one, two, three, all over. Hopefully as you do that, you try not to remove any pigment so there is potential for pressure being produced in the eye. It s very tedious surgery. It takes a long time. You have to be very patient and you see here, there are ciliary processes again, there and there. Now we ve unroofed all of them. I knew that by the UVM, so hopefully I will get some pressure in this eye. Now, you have to try to avoid pulling on this because it s very easy at the beginning to make a cut, go with the forceps, and pull on this. If you do that, I think you can end up with serious problems. Now, this tissue is vascularized. Again, here there is vascularization of the tissue, which is very bothersome. That tells you it s chronic and likely to bleed. Given the likelihood that postoperatively there s going to be some bleeding from those sites, what s your decision about oil versus gas, with maybe even refilling gas in the future? My experience, Peter, is if you do not get bleeding intraoperatively, okay, then you will not get bleeding postoperatively. The major problem that we have is fibrin. There is massive fibrin in these patients postoperatively. What I like to do in those cases is just use some TPA, even if the patient does not have a retinectomy. Otherwise, I will give him a lot of steroids and I will use TPA maybe a week later, just for the fibrin, but really,
I don t think...i have had massive bleeding intraoperatively. I can tell you that. But I have not had patients that did not have bleeding intraoperatively, or minimal bleeding, like this patient, but I haven t had those patients bleed postoperatively. If you did not have an infusing light source, how would you be doing this maneuver? That s a little bit of a problem, but you basically have to ask the assistant to depress for you. But, you know, you cannot control the amount of depression. They frequently move and you have to be fairly precise here, so I do prefer these cases to have an illuminated irrigating cannula. It really helps a lot. SPEAKER (can t hear speaker) Can you see the supratemporal sclerotomy? You see how the fluid is coming out of the sclerotomy? So the pressure is not a problem. Okay, so we ll move to the next area here. Look, it s even hard to cut with the vitreous cutter. It s so thick. If you pull on this, then you have the risk of basically tearing the entire retina, so the goal here is just to unroof the ciliary processes. After you ve unroofed the processes, you plan to leave the scar tissue between that and the anterior retina. Are you going to retinectomize or are you going to try to remove all that? If I can remove it safely, I m going to do that. It is when you become very aggressive and you start trying to remove all this tissue that you create a lot of damage, so you have to remember what is the goal of the surgery. The goal of the surgery is to reattach the retina, to have an attached retina in the long-term and the right pressure so there is potential for some vision in this eye. Like here, there are no ciliary processes. You remove all that and you find out that it s all flat. Here it s all flat. Okay, so let s continue our cut. With MVR, you see the tremendous strength that it requires to remove it.
Just a reminder that we will entertain questions, especially from the internet audience. We ll be moving away from the internet audience in 5-10 minutes or so, so if you have any questions, please email them in. SPEAKER Does high pressure in a case like this develop because there s a lot of peripheral vitreous left in from previous surgeries? I think that really plays a very large role in this, Stanley. Here you can see again the ciliary process looks pretty nice anteriorly. What we re going to do is...here, this is a very nice area because the ciliary processes look great. We re going to be able to remove this tissue. You see I m trying to create a radial cut here. You can see how hard it is. Again, just to release all the traction over the ciliary body without removing any pigment. Again you can see the undersurface, how clean it looks. The dissection on that temporal side went beautifully. Yeah, but it was not as bad as the one on the other side. The nasal side was a lot harder. The tissue was thicker and it was all incorporated, and I presume it was older than this. It had been present there for a long time. Again, if you look at that UVM, if you look at it again, you can see that the ciliary body on this side is much better preserved than on the nasal side, but I like to go 360 o. Why don t we show the UVM one more time so show what he s talking about with UVM, the difference between nasal and temporal aspects. SPEAKER Have you considered using an illuminated MVR blade or perhaps a sleeve over the blade with a fiberoptic source? My vision is actually quite good. Maybe not for you, but my vision is quite good. I have no problem with the visualization. It s just that, you know, with the tissue here, you see
how thick it is? So I cannot really cut it. If I try to do this, I m going to end up causing more problems, but again, I have removed the tissue anteriorly, so I m going to go ahead and try to cut it with a vitreous cutter to trim it. So, Hilel, we will probably not be with you when you re doing your retinectomy. How is your plan to perform that? Do you do that with a vitrector or scissors? Most of the time, what I like to do is use MPC scissors for that so that I can have a very clean cut, but in some cases I will consider using the vitreous cutter, but most of the time I diathermize the tissue and then I use the MPC scissors for that. Again, you have to be patient. You cannot hurry here because if you do that, you create a lot of problems. You see the undersurface, the pigmented epithelium, how nice it looks there? Okay, they are going to change the bottle again, very quickly, please. I m just trimming this. Once I finish unroofing all the ciliary processes for 360, then I will go posteriorly again and I will at that point do my retinectomy. After I do the retinectomy, I will explore the subretinal space, where if there are subretinal membranes, I will remove them. If there is any subretinal silicone oil, I m going to remove that and then I ll just reattach the retina in a normal fashion. I know you re going to be giving a talk on this tomorrow, but for the internet audience, if you had inferior pathology, I know you ve been talking about using PFO and leaving PFO in. What are your indications and how do you use that in a case of PVR? Actually, I have used it so far in patients without PVR because I don t use the perfluorocarbon in the eye long enough. I normally leave it for 7-10 days and I believe in PVR you will require a longer time for that. So far, we don t have enough data for longterm use of perfluorocarbon and also because I only, in those cases I will show tomorrow, I only fill about 40-50% of the vitreous cavity with perfluorocarbon for inferior pathology, so I have not yet used it for this particular case. So the jury s still out. Again you start seeing the iris look more normal.
Unfortunately, we ll be losing our internet audience shortly. I wanted to thank those of you on the world wide web who have joined us here at the Retina Summit for the live surgery. Dr. Lewis obviously is still in the midst of this complicated case and will continue the surgery for the people here in the audience, who will be going to lunch. I believe we have some monitors set up in the lunch area to continue to watch the surgery and we can continue on from there. So I thank all of you for joining us for the live surgery here at the 5 th Retina Summit. NARRATOR This has been a retinal surgery performed live at the Cleveland Clinic Cole Eye Institute in Cleveland, Ohio. For more information about the Cleveland Clinic Cole Eye Institute, please go to www.clevelandclinic.org/eye. The Institute is dedicated to the protection, preservation, and restoration of vision.