RETINAWS 2010: ASRS
A sampling of cases presented and discussed at the ASRS Annual meeting in Vancouver, Canada.
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
United States
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.
Video: RETINAWS: My Eye Is Killing Me
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 360° 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 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
United States
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.
Video: RETINAWS: Silicone Oil in Aphakic Eyes with Traumatic Iris Loss
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% C3F8) 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
choroidal elevation for 360°, 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.
Video: RETINAWS: Choroidal Effusion
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.
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.
Video: RETINAWS: Iatrogenic Macular Hole During ERM Peel
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.
Video: RETINAWS: Vitrectomy for Macular Hole in a Patient who cannot Do Face Down Positioning
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.
Video: RETINAWS: Severe Trauma
JOHN POLLACK, MD
Illinois Retina Associates
Rush University Medical Center
Chicago, Illinois
United States
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.
Video: RETINAWS: Dislocated ITB IOL With a Twist
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.
Video: RETINAWS: Device Decompensation
360° 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.
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.
Video: RETINAWS: Intraocular Cysticercosis
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
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.
Video: RETINAWS: Second Membrane in Retinal Proliferative Disease
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.
Video: RETINAWS: Sutureless Scleral Buckle Surgery
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.
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.
Video: RETINAWS: Iatrogenic Breaks in PDR Surgery
KOUROUS REZAEI, MD
Illinois Retina Associates
Rush University Medical Center
Chicago, Illinois
United States
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.