In this roundtable discussion, expert vitreoretinal surgeons discuss management of cases where complications occurred. Below are transcripts of the four case presentations; scan the QR code that accompanies each case to view the surgical video presentation as well as the discussion of the case management and outcomes.
Christina Y. Weng, MD, MBA: We’ve hosted this Retinal Physician surgical roundtable now for several years running, and it is always a lot of fun to exchange and learn from amazing surgeons like the panelists we have here today: John B. Miller, MD; Raymond Iezzi Jr, MD; and Suzie A. Gasparian, MD.
The catalyst for this roundtable stemmed from the fact that we all have a natural inclination to showcase our very best cases, but it is equally, if not more, important to be comfortable discussing cases that might not have gone so smoothly or may have taken an unexpected turn.
I’m always amazed by the shared experiences we have as surgeons—as they say, if you do enough cases, complications are inevitable. My favorite part about forums like this is that not only do we get the opportunity to learn from one another, but that these gains will be multiplied within our community through the Retinal Physician readership and their patients.
Case 1: Technique for Removing Subretinal Perfluoro-Octane (PFO) Bubbles
John B. Miller, MD: Thanks a lot for the invitation to show a case today. I’ll be showing how we’ve managed a complication that we all dread and hate to see after retinal detachment surgery. This is a 52-year-old male who presented after having a successful repair of a giant retinal tear (GRT) retinal detachment. It was a superotemporal tear and you can see in this OCT a tremendous number of subretinal perfluoro-octane(PFO) bubbles, including some right at the fovea. We’ll talk later in the discussion about how to avoid subretinal PFO. With that, I'll play the video.
This patient at this point was post-vitrectomy a few months out . He had a significant cataract that was going to obscure our view for these delicate macular procedures, so we removed the cataract and placed the regular standard IOL. We can see this diffuse collection of PFO bubbles. We used the VFC injector and a subretinal cannula here to create a subretinal bleb. It’s important to have nice settings on your VFC, you want to try to have about 4 to 6 on the pressure, much lower than we use for oil, just to get a nice steady stream.
Here you can see us making a nice bleb. We're kind of starting in the superior macula. We don't want to be too close to the fovea, this is thin tissue. We tried to balloon the bleb up high enough to encompass all the subretinal PFO bubbles. I’m intentionally trying to create a lot of turbulence in the eye by running the vacuum at full throttle with the cutter. We saw a few bubbles come out, but not much. We’re now just aspirating here with the soft tip through a new retinotomy that we made. We've kind of dislodged them a little bit with that infusion washing, and we go through this cycle a few times: we get a few out, we re-bleb, the bleb keeps collapsing when we do that that aspiration with the extrusion. You can see a few of them actually coming out as we're re-blebing. The pressure of the re-bleb can push some of the PFO out here through it as well. Then we’re going to re-aspirate it and try to vacuum more out. After 2 or 3 of those rinses, we then use the surface tension of a larger PFO bubble to sort of squeegee the smaller PFO bubbles over towards the larger retinotomy. We also take advantage of that bigger bubble; hopefully, it would absorb the smaller bubbles if it could come in contact with it. We then went to a fluid-air exchange.
This is the postop OCT, where we can see good improvement in the number of PFO bubbles, but we certainly didn't get all the PFO bubbles. Some of that has to do with the time from the retinal detachment period to the time of our surgery. We did make a significant improvement for the patient. You can see some photoreceptor loss, but the patient did have an improvement in their visual acuity and they reported improved vision. This was a complex macula-off detachment, so a relatively good result for this surgical complication.
At this time, we can open it up to discussion with the group. Any thoughts on how to avoid subretinal PFO, and how to manage, and which PFO bubbles to go after? I think those are the 3 main questions that a retina fellow or a new faculty member would want to think about if they encountered this situation.
Dr. Weng: John, that was such a beautiful case, I appreciate you sharing that. I told you earlier that I had a similar nightmare situation with a superotemporal GRT in a young patient who suddenly bucked while he was under general anesthesia and ended up having a ton of these subretinal PFO bubbles creep in through the GRT and find their way to the macula as they tend to do. I personally don't use PFO all that much, for this very reason, but I do for GRTs. Because PFO has such a low surface tension, is optically clear, and has a low viscosity, it really is kind of the perfect storm for retention; some of the papers out there have cited up to 10% to 11% retention rate.
I would offer 1 tip to start off, which is something I always teach fellows and trainees about PFO: when you’re injecting PFO, you want to inject right into the bubble itself to help avoid creating fish eggs. I usually start right over the nerve and then I make sure that the tip of the cannula remains in that PFO bubble as it continues to grow. I’d love to hear tips from Ray and Suzie as well.
Dr. Iezzi: John, I think your outcome was fantastic. I really like your technique—I thought you were highly effective in getting those pesky bubbles out from under the retina. I think the secondary use of PFO to help coalesce them and to manipulate them was a great thought. A lot of times some form of external manipulation through the retina, either through a soft-tip cannula or perhaps even through a finesse loop, would allow you to coalesce those. I’ve found that there's a 40-gauge needle that has a beveled tip [MicroTip Beveled Cannula; MedOne Surgical]. It’s got a sharp tip, and we can insert it into these tiny little holes. So, I have a tendency of literally poking these individual bubbles. Of course, in this case there were a lot, and I don't know if it would have been possible to coalesce them, but I typically will insert this microneedle, which is sharp and beveled, into each of the cysts and aspirate and it does a really good job.
But certainly, I actually gave a lecture to the residents tonight and I said the best way to avoid subretinal PFO is to never use PFO [Laugh]. But of course, I think in GRTs it’s one of our main go-tos for a GRT. In my experience, when I get subretinal PFOs in a GRT, it's very much at the end. I think valved cannulas have been really helpful in reducing the intraocular turbulence that can emulsify this low-surface tension PFO. I kind of wish that PFO had a color so we could see it better, but I feel that a lot of the PFO emulsification happens at the end. I'm wondering if anyone else has any thoughts on that.
Dr. Weng: Those are great points, Ray, and I don't know that I have any additional insights, but I agree that valved cannulae have made a tremendous difference in preventing fish eggs from occurring. The other thing I do is turn down my infusion rate before placing PFO because even moving instruments in and out through valved cannulae can cause turbulence as well. Additionally, I scleral depress every single case before closing, but remember to do that before the PFO goes in if possible. If you must depress after PFO has been placed—which we sometimes need to do for lasering purposes—depress slowly and do not suddenly release as it can otherwise lead to bubbles forming.
I wanted to comment on one more thing, John. In my case, I also had a lot of small bubbles, but I had a large one in the central fovea area, and I was surprised—just as you beautifully showed in your video—that they didn’t just coalesce and come out with a subretinal bleb, which I had anticipated. They're sort of sticky; based on my reading, it seems like that’s even more so the case the closer you get to the fovea. For my patient with the large PFO bubble in the central fovea, I actually had to jostle the eye itself with a scleral depressor to be able to dislodge it and remove it through the retinotomy. That’s just another tip to share.
Dr. Miller: I mean I think the turbulence of the infusion both create but I was trying to use it to help to dislodge and I think that high flow you can try to create a rinse to free them from the undersurface of the retina. I agree with Ray’s point of using direct aspiration for one to three or five. This was certainly the most I’ve ever seen, and I would only go after them if they were in the central macula. I have seen PFO levels outside the arcade or at least in the mid-periphery, and those you can certainly leave. This was kind of the most extreme case and that's why we’re showing it at a rounds like this, because it kind of highlights a challenge that presented a different problem.
Dr. Weng: Beautifully managed. Suzie, you had a comment.
Dr. Gasparian: Just beautiful work. I think the key point in these cases if there is subretinal PFO is, ultimately, it's hard to get all of it out, so the focus should be on clearing the subfoveal area where the PFO is and if there is a little bit retained closer to the arcades, I don't think that’ll be as detrimental in terms of impacting the patient's vision. I like to keep the PFO as one large bubble and try to do as much laser as I can. Then, once I take the entire PFO out, under air I will ensure that the horns or edges of the tear are then lasered with depression so as to avoid any additional turbulence while I'm in the eye with PFO in there.
Dr. Miller: I agree with all those points, Suzie; I think those are well said. I think Christina you said this as Christina you both said trying to do as few steps as possible after the PFO is in is important. It seems that all of us are pretty low users of PFO. I really very rarely use it. I use it for retinectomy and GRTs and pretty much nothing else. I do know of some really big training programs that do use it for primary retinal detachment, but that's like the last resort. Maybe a case I can't find a break and I want to sort of massage the subretinal fluid out to help me identify where the break is—that's one of the primary detachment reasons I would use it. Otherwise just use training through the break or occasionally on posterior retinotomy. I really don't use PFO in standard retinal detachment repair.
Dr. Weng: I'm the same. I would like to ask one more question of the group before we move on to the next case and that is with regards to threshold for intervention. Suzie made the point earlier that we don't necessarily have to go in for subretinal PFO. If you have a small bubble out in the far periphery, for example, that's not affecting the vision at all, I certainly will leave those sometimes. Sometimes they'll actually freeze in place as the retina attaches. But I wanted to ask about threshold —how close does it need to come towards the fovea before you’re inclined to go in? And what about timing? Like John, I waited as well—in my case about 3 weeks for multiple reasons—and my patient ended up having a lot of photoreceptor loss, so it makes me wonder: What is the ideal time frame to intervene when we know that PFO can be toxic to the photoreceptors? Does anyone have any thoughts or opinions on that?
Dr. Miller: I generally would have gone earlier than in my case. I went in [at] 3 months, which is not what I would have chosen if I had my pick. It was a follow-up issue more than anything else and initially not having an OCT until the gas was far enough away it was hard to tell in the early postop period. Became more and as the gas went away but I think there was [no] access to the OR or some sort of patient follow-up that led to the significant delay. I think sooner, like you did, would be better.
Dr. Gasparian: I agree, I think the sooner the better. However, I would want to give the laser a little bit of time to mature when it comes to these retinal detachments just so that once you're removing the tamponade agent, oil for example, the retina isn't re-detaching so I would at least want to make sure that the laser has scarred and matured that way the retina is at least in place. In terms of proximity, I think if it's subfoveal, juxtafoveal—that's when you're really risking the vision-threatening outcome. That's my threshold of when I would decide to intervene and try to take out the subretinal PFO.
Dr. Iezzi: That’s a great point, Suzie. I've actually taken these out in the presence of oil, just going in with a microneedle through the oil and then going directly into the bubble and just aspirating, and leaving the oil in as a longer-term tamponade. It actually helps as well by compartmentalizing the fluid posteriorly. I found that I could aspirate without having BSS as an issue and I could get into the retina. Of course, when you go to pierce the retina with these microneedles in the setting of a PFO bubble, you find that sometimes the bubble wants to escape from you. Sometimes you have to use another instrument to kind of trap it a little bit to try to keep it adjacent to the tip of the microneedle. But you can go in without taking out the oil, which is kind of nice; this allows you to get in a little bit earlier. I agree with the idea that we just want to get these things in. I have to admit, in some cases I've directed the patient to sleep in a certain position with the hope that gravity would draw the bubble away from where I don't want it to go. Sometimes that's really quite helpful.
Dr. Weng: Thanks. Great commentary and discussion on that case, I really appreciate you sharing that complex case with us, John.
Case 2: Management of Complex Dislocated In-the-Bag Intraocular Lenses
Suzie A. Gasparian, MD: Thank you for the opportunity to present regarding the management of complex dislocation of in-the-bag intraocular lenses. This is a middle-aged male with a history of combined scleral buckle and pars plana vitrectomy with gas for repair of a rhegmatogenous retinal detachment. He presented with dislocation of a single-piece intraocular lens.
During surgery, I initially mark then utilize 27-gauge trocars to create the scleral tunnels through which I will externalize the haptics. I like to use a 23-gauge platform for all lens cases. The patient had a previous thorough vitrectomy for retinal detachment repair. There, you can see the dislocated intraocular lens in the vitreous cavity. Here, I am removing any capsular remnants, and then aspirating the dislocated lens to visualize it anteriorly. Here, I’ll grab the lens with the 23-gauge MaxGrip forceps and use the vitrector to remove Soemmering’s ring and any capsular remnants, and then bring the intraocular lens into the anterior chamber. Then, I'll remove any remnants of the Soemmering’s ring that fell posteriorly. We have to be very cautious aspirating small remnants so as not to touch the retina. I create the clear corneal incision superiorly, inject viscoelastic agent into the anterior chamber, and remove the intraocular lens through a Pac-man technique. I then inject the 3-piece intraocular lens, and use 27-gauge MaxGrip forceps to externalize the first haptic. I burn the tip of the haptic with low-temp cautery creating a small bulb. I'll repeat the same maneuver superiorly here. We have to be very cautious while externalizing haptics, as you can actually dislocate the haptic through the scleral tunnel if you pull too hard. Lastly, I create a small inferior peripheral iridectomy with the cutter, and go ahead and close up the corneal wound and all ports. I like to suture all of these cases just to ensure there’s no hypotony to ensure that the intraocular lens remains stable.
A couple of surgical pearls and how to avoid pitfalls in these cases - I’d love to talk a little bit about the utility of 23-gauge platform for these cases, how you approach these dislocated intraocular lens cases, and how to avoid IOL tilt and slippage of haptics through sclerotomy tunnels in these cases. Some people like to work more anteriorly versus posteriorly in lens cases, so it would be nice to see what everyone thinks.
Dr. Weng: First of all, a beautiful job, Suzie. You make that look effortless and you are seriously one of the best at these types of cases, so thank you for sharing. I’d love to hear from John and Ray—is the modified Yamane your go-to technique, as it has become for many of us in the retina community in the past few years, or do you prefer other secondary IOL techniques?
Dr. Miller: I also use the modified Yamane, as you showed really beautifully here. I also teach with the MaxGrip forceps because I think it’s the most reproducible as we’re learning these new techniques. I try to learn lots of different ways and I still consider other lenses to try just because we have had that rotisserie issue with these types of lenses.
As far as gauge, I do not typically use 23 unless I’m doing a PPL [pars plana lensectomy]. I think of these cases as either 3-port or 5-port. In this eye, I might have done a 3-port 27-gauge because you’ve already done a thorough vitrectomy for the retinal detachment, so I shouldn’t have too much intraocular vitrectomy to do. So ideally, I could just put the ports superonasal/inferotemporal and use the infusion line as one of my externalization haptic locations and then just grab the lens with the working supertemporal normal port (it looked like this was a right eye). I think that you did a beautiful job and I think the 5 ports [approach is] very reproducible. You maintain good view, you have a little bit more flexibility if you have trouble grasping one of the haptics because you still have your access to your lights when you’re going for that second haptic. It’s a beautiful surgery.
Dr. Gasparian: Especially with IOL explantation, I’ll often err on the side of using 23-gauge just because when it comes to explanting the lens itself, often times I feel as though I have more stability while grasping IOLs with 23-gauge MaxGrip forceps as opposed to a 25-gauge or a 27-gauge. That's just something I’ve picked up during training and have continued using in practice and have seen successful results with them.
Dr. Miller: Absolutely, great setup. I guess I'm cheating because I do use bigger instruments from our cataract colleagues throughout the corneal wound, so you can use the MST forceps or other things.
Dr. Iezzi: I thought it was a great job. I actually suture my lenses in with Gor-Tex. I use CZ-70, so it's a little different of a technique, and I do it with 27 gauge.
What I have found is that there are Soemmering’s rings and there are Soemmering’s rings. Sometimes you get these calcific bones that are encircling your lens. I try to avoid getting into vitrectomy removal of such rings. I’ll try to take it along with the IOL, if I can. I’ve even had situations where I’ll take the optic and then I'll kind of reserve the Soemmering’s ring in the angle to then take out as a separate entity. I really try to avoid vitrectomy in the Soemmering’s ring just because of the calcium that I’ve encountered in the past. I just don’t like getting surprised by the toughness of some of those things.
Dr. Miller: It can take longer to get that out than the IOL.
Dr. Iezzi: That's so true, and once you’re in that position, you just wish you weren't. I do use viscoelastic as a third hand. So when I bring up the IOL from the back with aspiration, I usually have visco in the AC and I sort of apply the lens to the visco. It's sort of like gluing it to the cornea, in a sense. Not that it’s touching the cornea, I just use it to give me a little bit of time to let go of the lens and then reformat, get the haptic into the AC. I find that to be a very helpful trick, using visco as sort of a glue to give me some stability as I position the haptics into the AC.
Dr. Gasparian: I’ve definitely been in that situation where the Soemmering’s rings can be very calcified. In those cases, I’ll take what I can get. If there are any remnants of it in the anterior chamber, I'll use the MaxGrip forceps to just gently pull it through the main corneal wound.
Dr. Weng: It’s really interesting that you mentioned that, Ray. I remember one I encountered a couple years ago that was so dense that I tried using the fragmatome to remove it and it still wouldn’t eat. It was like stone, just as you said. You're absolutely right that turning to the approach of removing these in a similar way to how you would an IOFB is very appropriate in certain cases.
Dr. Miller: I think if you can get it up towards your corneal wound, then you can use the fluidics of the infusion from the back to just to depress the back edge of your corneal incision and sort of burp everything out. That is the easiest way. I think along these lines, because of what Ray said, I do sometimes think about rescue. Could you talk a little bit, Suzie, around what are the parameters in which you would consider rescuing this lens, or a 3-piece, and what are your techniques for those different IOL situations?
Dr. Gasparian: I'll typically only rescue 3-piece IOLs. If it’s a single-piece IOL that's been dislocated, I'll explant those lenses and then insert a new 3-piece lens and fixate those haptics. Recently, I had a case of a dislocated lens—it was an MA60AC (Alcon) actually—and so that one, the haptics were intact, the lens was in good condition, so I was able to salvage that lens and was able to fixate the haptics nicely. That case went very well.
Dr. Miller: Did you clean off the capsule from that MA60? Are you pretty meticulous? Do you take some, or just clear the tip? What are your thoughts?
Dr. Gasparian: Actually, the lens itself didn't have any capsular remnants, no Soemmering’s rings, no issues there. However, for all cases I'll do a sulcus depression and make sure that I remove all of the capsular remnants because often if that stays there and fibroses down, you can see lens tilt. So, I always remove the capsular remnants even if it’s not actually encircling the lens itself. Any PMMA lens, of course, will be removed through a scleral tunnel, but any acrylic lens I’ll cut and remove.
Dr. Miller: I agree with your points. I just rescue sometimes, so if it’s a tough capsule and it’s a one-piece you can suture a proline through there like a belt loop technique if the capsule is sturdy around the haptic. That gives you enough to make sort of a radial 1 mm-2mm back prolene scleral suture lens.
Dr. Weng: A couple of really subtle points, Suzie, that you showcased nicely. I love that you emphasized cleaning up the capsule remnants at the sulcus. I think that’s an underappreciated maneuver that really does help with the final position of the IOL and avoiding some of the tilt that you can see. Another thing, too, is really where you’re starting. So not just making sure that you're exactly 180° apart when you mark the cornea through the limbus, but also the approach that you take with those cannulae. They really have to be as symmetric as possible, and that includes that approaching angle. So if you’re approaching one side at 30° and the other side at 45°, even if you tunnel the same length and are exactly 180° apart, you will end up with IOL rotation. It's not always the IOL’s fault! Appreciate you teaching us that subtle point—just a beautiful case, and we really appreciate you showing it.
Case 3: A Technique for Removing an Intraocular Foreign Body
Raymond Iezzi Jr, MD: I’d really like to thank everybody for the opportunity to be here and present. This is a really interesting case. It's a technique that was sort of a MacGyver move to figure out how to get an IOFB out of the eye. This is a gentleman who was hammering metal and had a metallic foreign body enter his eye through his pars plana. The patient is phakic and has really good vision. It’s a technique that I had used a long, long time ago and the video got deleted—I'm talking like 6 years ago—it was a gentleman that was walking through a field, and somebody shot a shotgun, and one of the pellets from the shotgun entered his eye. It was very large—looked like a musket ball because it was so big—and it was very, very heavy. I used this technique to encircle this sphere, which I couldn’t grab with forceps because it was just physically too large. I was really surprised that this technique encircled the sphere and was firmly holding it. I could even shake the instrument, and the sphere, when I got it out of the eye, would not come off of the instrument.
I want to show everybody how I make this. This is an intraocular snare. Basically, I start with—in this case, it was a 23-gauge cannula, but you could do it with a 25-gauge cannula. This is a 23-gauge straight cannula and a 5-0 nylon suture. I’m going to play the video, where basically I'm just threading the 5-0 nylon right into the lumen of the 23-gauge straight cannula, and we just create a loop. I cut the needles of this off, and we just use the suture portion of it. When it's through well enough, I grab both ends and I pull it along and make my loop. We’re basically creating our own loop. Then all you need is a Q-tip, and you just push that into the hub of the cannula. So with 3 items that we pretty much should all have in our operating room almost anywhere, we should be able to make this loop. Getting it into the valved cannula is a little bit of a trick. I use a light pipe or forceps to get it in through the valve and then feed it in this way.
The reason why I like this technique is because it allows us to work with the intraocular foreign body in a closed system, so I don't have leakage from a large sclerotomy. I can adjust the size of the loop according to what I'm going to grab and this actually acts as an instrument. I can physically manipulate the foreign body in position. Now my fellow is depressing, and here I am nudging around it. My fellow is going to pull on the strings for me, and now I’ve grasped it. One of the keys is, as you’re pulling up on the string, that the surgeon has to advance the metal cannula toward the foreign body. Otherwise, it'll just kind of fall off, so you have to advance the instrument toward the foreign body as your assistant pulls up on the 2 strings. And then, this is where you open the eye. I could have diathermized to make this look prettier for the video, but I was just interested in getting it out. So there, we’re done. That’s all there is to it.
At the present time, I’ve done 5 cases, if you include that large heavy metal ball from the shotgun. I’ve also taken out glass and some metal that was embedded. You could actually use the loop to physically manipulate the foreign body, get it at the right angle. The other thing that's really interesting is that it will hold on to very complex shapes. It's sort of as if the nylon physically molds to the foreign body and just simply doesn’t let go.
I’ve found this to be very useful and I really enjoyed the last case. One time I had an IOL back there and both haptics came out sequentially and I literally had an optic laying on the back of the retina. The iris was stuck to the host of a corneal transplant and there was a tube, a Seton tube with a plate, so I didn't have an anterior segment and I couldn't make a scleral tunnel to get it out. So I actually took it out like an IOFB using this technique, where I lassoed the optic with no haptics and I took it out through the sclera. So that’s the case.
Dr. Weng: That is so incredibly genius, Ray. These types of cases tend to come in the middle of the night and there is nothing more frustrating than trying to find your pair of IOFB forceps with a staff that does not know where your instruments are, etc., so I love how this is sort of a makeshift pair of IOFB forceps. You mentioned that you had tried it on a shotgun bullet—is that similar to a heavy BB pellet? Would it work for a very spherical object?
Dr. Iezzi: Perfectly spherical, super heavy, laying down there. It’s like pushing a medicine ball around. I was able to engage it and it wouldn’t come off. I could get it out the same way I got this one out. At the end I was hovering over the cornea and I was shaking it back and forth and it wasn’t coming off. So you get this perspective that somehow the nylon sort of permanently molds to the foreign body.
Dr. Weng: That's amazing. One other point I want to make is that I like that you’re externalizing through the same sclerotomy through which your cannula was placed. That’s just pure elegance.
Dr. Iezzi: One little trick associated with that is as opposed to making our sclerotomy radial, it's actually better if you make it parallel to the limbus so that you can extend the same linear wound. Otherwise, you get a T incision. This was the first case I had done subsequent to the one I had done 7 years ago and I didn't do that, so I had a little T at the end of my sclerotomy that I had to add a couple of extra stitches for. To be really slick, you want to make your sclerotomy parallel to the limbus.
Dr. Miller: This is a beautiful case and a great technique, and thank you for teaching us again as usual. [You’re] always a wizard of new and novel ideas and very practical mechanical thinking, thank you. I was curious how the nylon interacts with a non-vitrectomized eye or more specifically a non-vitrectomized area of the posterior segment where the IOFB is. Sometimes these BBs or musket balls or different things are embedded in thick vitreous. For that reason I have often used a magnet, because the force is pulling it away from the vitreous. What is your experience with the nylon in a case like that? What have you seen?
Dr. Iezzi: That’s a great question. In this particular case, the IOFB hit the juxtafoveal region. It didn't hit the fovea. This gentleman wound up 20/20 and retained his lens. It bounced off of the fovea, as they often do, and it wound up in the vitreous base. When we've vitrectomized, we took the vitreous skirt but it was still encumbered in the vitreous base down there. When I used the loop, I nudged the foreign body out of the V base. So it was working in the quagmire of the vitreous base. We were able to encircle it and then pull it away and we didn’t create a break or anything. I don't know what it would be like to use this in a completely non-vitrectomized eye. It’s conceivable that with the foreign body we might be bringing vitreous along with the loop. Probably I’d want to have some vitrectomy going on there.
Dr. Miller: I think once you snared it, you basically could then try to vitrectomize if you had a chandelier in here. My fear would be doing too much vitrectomy to get at the foreign body and then subsequently dropping it again onto the macular surface.
Dr. Iezzi: Good point. I have to say, during the retrieval of this one, I could see it coming out of the V base pretty quickly. Too bad you didn’t have the audio of me saying, “Pull…Pull!” [Laughs.] You know, rapidly pull the string. I didn’t want it to fall down, so your point is really well made.
Dr. Weng: Another great learning point, John, that you reminded me of is that IOFBs love to hide in the vitreous base and you want to avoid the temptation of going right after them before your vitrectomy is completed which is a rookie mistake. You really just want to focus on the vitreous and get as much of it out as possible. If you can freely mobilize that IOFB, that’s even better. Because the last thing you want to do, as you said, is to tug at the vitreous surrounding IOFB and create some sort of iatrogenic nightmare that you have to clean up later on. These patients are already susceptible, as we know, to having retinal detachments down the line.
I wanted to ask, Ray: you said this one had missed the lens and the lens was not violated. [Dr. Iezzi: Yes.] Unfortunately, a lot of patients with trauma and IOFBs aren't quite as lucky. One of the big debates that we always have at my institution is whether the lens is taken at the time of IOFB removal or if it’s left. Do you guys have strong thoughts about which approach you prefer?
Dr. Iezzi: I personally would take the lens immediately, only because I don't want to add any sort of anaphylactic reaction. I don’t want uveitis superimposed on a healing open globe. So that lens is gone, I don’t even think twice. We have ways—Suzie showed a wonderful method for getting a lens in. I'd say, get the lens out, get your work done, close the eye, go home, and refer it to your favorite anterior seg doc to go back and do a modified Yamane.
Dr. Weng: I feel the exact same way. John, do you have any different thoughts?
Dr. Miller: Ray, you showed a case where you didn’t need to take the lens because it wasn't violated, but I agree that most of them there's either a clear violation, inflammation, or suspicion of a lens issue. If there’s any question, I take the lens. I like to do a scleral tunnel, because I didn’t have Ray’s technique, but the scleral tunnel basically allows you to have a very stable wound that you can directly visualize the removal of the foreign body out if the lens is gone. It’s a very nice technique and you can sometimes even sit the IOFB in front of the iris, just like Suzie showed on her IOL case. You have more structures, you’ve got better visualization. I always am a little nervous in that few seconds where the IOFB is passing under the dilated pupil and you don't know what's happening—is it going to come out through your sclerotomy or not. This case looks great—you got a snare, it's a different situation—but you never know if it's going to fall off the forceps if you’re coming out through the pars plana.
Dr. Gasparian: If there is any question while preoperatively examining the patient about lens capsule violation, even any cortical material coming forward into the anterior chamber, that’s just a ticking time bomb. In the operating room, the view is going to go bad really quickly, so I think the easiest thing to do is just remove the lens. We can always put a lens in later. So not only when it comes to impeding the view but also dealing with the post-operative inflammation induced by lens particles, in an already hot, angry eye, I'll take the lens, especially if there’s any risk that it’s going to impede the view to do my retina work. Beautifully done case. It makes me think that this is a self-made flex loop, basically, and so I expect to see this in the form of a flex loop in the future to aid in our IOFB removals.
Dr. Iezzi: I have actually used the finesse loop to take out Yutiq implants when the IOP went crazy, so these loops have utility. The benefit of this one is we can make it quite large if we need to. It’s adjustable.
Dr. Miller: One other teaching point before we wrap the case is that these do have a very high rate of retinal detachment. We did a large case series [and found] about 50% of these develop retinal detachment. I teach and really push for everyone to try to pull up PVD as much as possible, to get rid of as much vitreous as you can, before or after you take the IOFB out. I would not leave the hyaloid down if you have a reasonable view. Try to pull a PVD and take the extra time because it's going to be a PVR machine if you have even a strike site, somewhere, it's going to proliferate and contract and you then have a very bad PVR detachment to deal with later with hyaloid down.
Dr. Weng: Truer words have never been said, John, and I never really breathe easily until several months down the line because that’s exactly what you're watching for even if they look beautiful upon closure. To that point, does anyone add prophylactic laser in these types of cases, aside from the impact point of course?
Dr. Iezzi: I’m so glad you asked that question. I think the impact itself is all the destruction needed to get the chorioretinal scar so I don't add laser, especially in the macula region, unless there's an RD that I have to repair. I think the impact itself is all you need.
Dr. Miller: I think you’re asking about extended vitreous base laser. I don't usually do that. If you're thinking about prophylactics of detachment, just blanket laser 360, I don't do. I do apply laser to the strike site, but maybe Ray’s point is correct, I don't have to. I do also diathermze, and occasionally cut in a very neat way, a tiny little red otomy around it because you will find that the edges of the retina already has folds and signs of contraction so you really want to try to release that while you're in there if you can. I would apply laser to that as if it was a drainage retinotomy.
Dr. Weng: It's a great point, John. You almost see it exerting traction on the strike site so I love that point that you made.
Dr. Iezzi: When I trained, we were taught exactly that—where you would do a retinectomy, like a very fine linear cut of the retina, because the presumption was that vitreous had incarcerated from the impact into the retina perhaps into the choroid and sclera. I think the key is to make sure that the hyaloid is up. I do use triamcinolone (Triesence; Harrow) in all of these cases to assure that we don't have residual hyaloid, because I think that's ultimately why we see recurrence of PVR. A point very well made, John. I’ve come away from cutting retina, but in favor of labeling the vitreous using triamcinolone and making sure it's up and there’s no remnants in that site because as you know this this is a PVR machine, as you said.
Dr. Gasparian: I agree with all the points you all are making. I always put dilute Kenalog-40 [Bristol Myers Squibb] down just to make sure again we've induced a full PVD. Same with patients who've had retained cataract lens fragments post–cataract surgery, we work on removing the vitreous first and then remove the foreign body or lens fragments themselves so as not to cause more vitreoretinal traction and have the risk of breaks there. So same with these cases, remove all the vitreous and then go after the foreign body. I would have a lower threshold to laser around the impact site. But I also don't do 360 laser in these cases.
Dr. Weng: Fabulous points. Thanks again for sharing that case, Ray, that was really genius.
Case 4: Managing Hemorrhage During Scleral Buckling
Christina Y. Weng, MD, MBA: I’m going to cap things off by showing a complex case that I encountered a couple of years ago. I think this one cost me a few years of my life, but had a pretty good outcome at the end. This is another surgeon—a 48-year-old male with high myopia. He came to me with vision of 20/400 and a macula-off rhegmatogenous retinal detachment in his right eye with a tear at 7 o’clock and lattice inferiorly. I planned for an encircling primary buckle, but knew there was a chance I probably wouldn’t catch that tear and would have to add an element—and indeed, intraoperatively, I couldn’t catch it with the encircling band. So, I decided to add a radial 503 sponge. Unfortunately, when I was placing the posterior mattress suture, I perforated the sclera and it led to quite a large subretinal hemorrhage involving the macula.
I decided not to convert to a pars plana vitrectomy during that surgery. Instead, I injected 0.3 mL of 100% SF6 and positioned the patient face down for a week.
I’m going to show you that first video here. You’re going to see that he has a bullous detachment with that 7 o’clock tear—this is surgeons’ view—and I am going to first place the encircling 41 band. You can see I tried to place it pretty posteriorly but was not able to catch that tear at 7 o’clock. So I decided to add the sponge, but first I go back and mark the break and apply cryotherapy. You can see that it is quite posterior, and it is challenging to judge position when it’s this bullous. Here I am with the 503 sponge and as I mentioned, I unfortunately perforated the sclera during that posterior mattress suture pass. You can see going back in how large this subretinal hemorrhage is. Unfortunately, this is affecting the macula of this patient’s eye.
As I said, I decided to stop there. I ended up injecting 0.3 mL of 100% SF6 and I asked him to position face down in hopes that that hemorrhage would move out of the way.
Postoperatively, the patient ended up developing a dense vitreous hemorrhage. I was a bit uneasy because I no longer had a view and was not sure what was happening, but on B-scan, he looked completely attached so I fathomed that the hemorrhage was probably due to the subretinal hemorrhage egressing through the original tear at 7 o’clock. So I decided to wait it out while the retina reattached, and then returned to the OR 3 weeks later for pars plana vitrectomy.
This is the second part of his surgery. I’m setting up in 25-gauge platform. Notice a very dense vitreous hemorrhage here. I’m removing the vitreous and you can imagine my happiness when I finally get to the back and I’m able to see that the retina is indeed completely attached. You can see where that element is at 7 o’clock. Remarkably, you can see that there is no longer any hemorrhage under the macula, and only a bit of residual heme along the posterior edge of the buckle. I did end up placing a bit of laser around that area—probably not necessary, but I just wanted to be extra cautious. And then I closed up.
Postoperatively, his vision improved to 20/20 and his retina remained attached. It’s been a couple of years—I actually just saw him for his annual visit—and he’s doing really well and still able to operate, thank goodness. Lots of pressure when operating on other surgeons.
I wanted to use this case to really launch a discussion, because I think when you do surgery long enough, you’re going to experience every complication and that's what really makes roundtables like this so fun. You not only get to commiserate and exchange stories and validate experiences, but we also get tolearn from each other about how to manage these situations that you may not have encountered before and also talk about preventing them from happening in the first place.
The best treatment for subretinal hemorrhage is prevention! There are several susceptible steps during primary scleral buckling where this can happen, including subretinal fluid drainage, suturing of the buckle, belt loop creation—especially in patients who are myopic and have thin scleras. Suturing elements can be a susceptible step, especially if you’re trying to reach really posteriorly, because some orbits are very tight. And with cryotherapy, be sure you do not pull the probe away before it has thawed or else it can lead to a major subretinal hemorrhage. Any other tips from the group on preventing hemorrhage during scleral buckling? And how have you managed these situations in the past?
Dr. Iezzi: Christina, I have a question for you: Was this patient big? Was he obese?
Dr. Weng: He’s not obese but he is a very big guy.
Dr. Iezzi: I have found that reverse Trendelenburg is one of the best ways to minimize the risk for choroidal hemorrhage. I think what's going on is that the positive pressure on the thorax from the abdomen puts pressure on the vena cava, and they have a high venous drainage pressure. I think their choroid engorges. So, by having their feet down relative to their head, all the blood is rushing from their thorax, from their abdomen, and it's decompressing the eye to some extent, and they just hyperextend their head just ever so slightly. It's not uncomfortable. I have seen patients where one patient had a thoracic kyphosis and he was quite heavy up top there and I predicted the high risk of a choroidal hemorrhage. As the fellow was doing the primary vitrectomy, we saw a superior nasal choroidal hemorrhage develop and I took over. But this was one of those cases where we couldn't really effect the reverse Trendelenburg because of the thoracic kyphosis. It’s a technique I use to try to reduce that risk.
Dr. Miller: I think my lessons are just that this is going to happen, regardless of any of the techniques you mentioned—belt loop, scleral suturing, drainage—so I think you have to stick to best surgical techniques. When you're teaching or working with trainees, there are times where the actual pass or the belt loop would just be cut too deep. It will happen even if you do perfect technique—you have thin sclera or the vortex vein just happens to be in the same location where you’re trying to drain. I try to teach “move on to the next case, don't over-adjust your technique too much.”
I do drain every case, even though I have had one or two subretinal hemorrhages from draining. I try to avoid draining directly in the mid-quadrant, just given the predominance of that being a common area for vascular congestion. I try to drain just above or below the rectus muscles. If you do have a hemorrhage, I try to raise the pressure. If you have your buckle on, you tighten the buckle and tighten the sutures if you haven’t sutured them yet. Depending on where the hemorrhage is and how close it is to the macula, I would have potentially done a vitrectomy to try to clear the hemorrhage out of the posterior break.
I think you managed the case well. This is in that twilight zone when they’re 40 to 50 years old where you can really do a variety of procedures. Posterior break to me would usually trigger “more likely to do a vitrectomy,” because I know it's going to be hard to support it with the buckle. I don't do radial sponges, so I would have had trouble with my buckle techniques, getting this on the band.
Dr. Weng: It was definitely a borderline case. I thought it was going to be pretty posterior, but it is always hard to tell when the retina is so bullous. But a crystal-clear lens, no PVD, so I did end up doing a primary buckle, but you’re right he’s in that borderline age category and it is important to consent them for either of those procedures.
Dr. Gasparian: I think you managed the case very well. Some people, if there is concern for subretinal hemorrhage involving the fovea, they would attempt vitrectomy, but I think it’s appropriate to inject the gas bubble and have them position to displace any subfoveal heme, assuming that the patient can position well post-operatively. I think that converting to added vitrectomy may pose additional challenges in these instances.
Dr. Iezzi: I totally agree, Suzie. I think this was very brilliantly handled. I think that when you go in and do a vitrectomy, you’re inviting expansion of choroidal hemorrhage. During our procedure, our removal of vitreous, we’re lowering the intraocular pressure. Instead, what you did was you maintained a closed eye, you added gas—which increased the pressure—and you had a drain retinotomy to allow the blood to get out. So, you literally on a mechanical basis did a displacement of a very fresh hemorrhage through a hole in the retina that was ultimately supported. From a physical perspective, this was literally the ideal way to treat this. Going back and doing a vitrectomy for vitreous hemorrhage is a whole lot safer than a vitrectomy for an acute intraoperative choroidal hemorrhage. I think this was fantastic.
Dr. Weng: Ray and Suzie, thanks for those comments. I'll just make one additional comment. I think the scariest moment is when you’re in the middle of that first surgery and see this large hemorrhage forming. Or maybe you know the exact moment when you have perforated, but I want to add that sometimes these hemorrhages can be small and relatively contained. They don’t necessarily get humongous like this one and involve the macula. So like John said, the immediate thing you want to do is to prevent expulsion. If there’s any sort of full-thickness scleral wound, for example, you want to immediately release traction on those isolation sutures and suture things up. But then you want to raise the pressure to try to stabilize the hemorrhage. The other thing you want to try to do is to tilt the eye away from the macula. If you see bleeding happening, which is usually going to be around the equator where we're working or draining, tilt away from the macula. If it stabilizes and stays fairly contained, you can sometimes get lucky where it will not enter the critical macular territory.
Dr. Miller: I think the other thing to think about is that you rather quickly recognized you had hemorrhage, but in some cases you may not know. If you’re doing a vit-buckle, you may not know until you go in or you may not know until you look in to set the height of the buckle. Teaching folks to pay attention to the resistance that they feel as the needle is passing is important. I look for the speed at which the needle is going and if I see a sudden acceleration, that tells me, “Oh, the resistance is lost.” Either the pass is too shallow or it’s too deep. Depending on visual feedback of the wound, you can tell what’s happening. It’s worth taking a look in. Any time that the suture is too deep you want to try to repass it. You don’t want to leave it there. I would usually go a little bit anterior or posterior, depending on which pass it was, and then re-tie it in different location.
Dr. Weng: I appreciate that pearl. Thank you for the great discussion, and this concludes the case. RP