This video was part of a roundtable discussion involving surgeons Christina Y. Weng, MD, MBA; Mrinali Gupta, MD, FASRS; Nimesh A. “Nemo” Patel, MD; and Frank Brodie, MD, MBA. An edited transcript of the case presentation and discussion follows below:

Christina Y. Weng, MD, MBA: We’re back again this summer for another Retinal Physician Surgical Roundtable, which we’ve done for several years now. It’s always a treat being able to showcase our techniques to one another and really just sit back and have an open discussion.

Because of the nature of this segment, it's really important to include the most skilled and innovative surgeons out there, and this year really is no exception. Today we welcome 3 amazing vitreoretinal surgeons: Mrinali Gupta, MD, FASRS; Nimesh A. “Nemo” Patel, MD; and Frank Brodie, MD, MBA.

Our lineup this year includes a variety of complex cases, and I’m certain that not only will our audience learn a lot from your videos and comments, but the 4 of us will do the same. We do that every single year, and I always learn from everyone at the roundtable. I say this a lot, but I'm going to say it again here about the importance of sharing not just our slam-dunk cases, but also ones that are complex or complicated because that's how we as a subspecialty continue to improve care for our patients.

So thanks again for being part of this roundtable. I'm really excited to hear how you all handled some really complex situations, and we'll start off first with Mrinali, who's going to show a case of a giant retinal tear (GRT). I’ll hand it over to you, Mrinali.

Mrinali Gupta, MD, FASRS: So I'm presenting a straightforward giant retinal tear detachment. This was a 50-year-old tennis instructor who got struck in the eye, phakic GRT. I did a buckle—I always buckle these patients first. I like a low-lying buckle, especially in phakic GRTs. I'm just doing a complete vitrectomy. I always use Kenalog in all detachments, but especially complex ones like this. Just shaving the anterior vitreous or the anterior retinal skirt here. I like to get all the shaving and skirt removal done before the perfluorocarbon (PFO) goes in, because I have scrub techs assisting me and when they depress, we get some turbulence sometimes and I want to avoid subretinal PFO in these eyes. I’m placing the PFO to drain the fluid subretinally and just applying laser here to the edges of the tear.

I had a buckle and I try to use a low-lying buckle, but in this case I still ended up deciding to laser at the posterior edge of the buckle almost 360°. And then I know some people like oil, some people go PFO oil tamponade, but I try to use gas whenever possible and just drain the subretinal fluid and the fluid meniscus very carefully before I remove the PFO. And I just try to go really insanely slow—way slower than I would be inclined—to just reduce the risk of slippage. Just getting the last bits of PFO. You can see it's a pretty low-lying buckle there and the patient ended up doing well postoperatively. It’s a pretty straightforward type of surgery, but I thought it could lend itself to a discussion of different ways that we handle GRTs and complications that may arise and how we handle that.

Dr. Weng: That's a really beautiful case and a beautiful outcome, Mrinali. Always amazed by your awesome surgical prowess. You brought up a lot of really important topics and I'd love to hear everyone sort of chime in on this, but I'll start. You mentioned that you always place a buckle for GRTs and I certainly do the same. I like a low-lying buckle on every GRT that I do. I even do them honestly for pseudophakes as well, but I've had some pushback and people have said you really don't need a buckle as long as you really do a depressed shave like you did there. Can you talk more about that and your reasoning behind it? And then I'd love to hear, Frank and Nemo, how you feel about putting a buckle on for these types of cases.

Dr. Gupta: Yeah, a lot of these patients have an abnormal vitreous space and I think supporting that as much as possible is valuable. Also, with all that exposed retinal pigment epithelium(RPE) and the nature of this detachment, it’s much higher risk of proliferative vitreoretinopathy (PVR). And I’ve had cases where I see some PVR developing and having a buckle in place can just help counteract that and help maybe keep us out of the operating room. Mostly it’s just a belt-and-suspenders approach. I usually wait to tighten it until after I've drained the subretinal fluid internally. But if I have a scrub tech who's less experienced, then I sometimes will tighten it at the beginning so I have a depression for my shave without needing the assistant so much and then I loosen it back up so it's a low-lying buckle towards the end of the case.

Dr. Weng: I think along those same lines. Frank, do you put a buckle on all of your GRT cases as well? 

Frank Brodie, MD, MBA: I do. And certainly in any kind of phakic detachment that's not like totally bread and butter superior, we'll always get a buckle. I think the Primary Retinal Detachment Outcomes (PRO) study was pretty convincing to me that these buckles do a lot in these cases, these phakic detachments.

Watching it, I’m not sure if I would’ve done gas or oil in this case. I think it obviously turned out beautifully with gas. I worry about a giant retinal tear, especially one that's going below the meridian and that they're at a pretty high risk for PVR. But you're right, there's a lot more surface tension with gas that's going to hold that retina better in place. And I think it would be a judgment call and obviously yours was spot on here. You got a beautiful outcome.

Dr. Weng: So Frank, let me dig into that a little more. You said that you might consider oil in a case like this. I also use oil a lot, but I also like gas when I can get away with it. So I see both sides of it. One of the areas where people always get nervous with GRTs—especially if you have a buckle on—is slippage, especially at that drainage step. Do you use PFO? And if you do and you place oil, do you do a direct PFO-oil exchange or how do you go about that to make sure that doesn’t happen?

Dr. Brodie: I’ve done it both ways. I probably more routinely go to air and then to oil. If I think I'm at really high risk of slippage and things have been moving around on me, then I will go direct. It always feels like a bit of a hassle, at least in my OR. And I've got the resident holding the light pipe and I'm kind of praying everything's getting pumped and pulled and your view kind of goes to pot. And as one of my attendings always used to say, it's a “high sphincter tone moment.” So that I try to go to air if I can first.

Dr. Weng: Nemo, how about you? Do you like using oil vs gas? Do you have a preference of putting a scleral buckle on most of the time for these? Tell us what you do for these GRT types of cases. 

Nimesh A. Patel, MD: Yeah, no hard rule. I'm also very pro-buckle in the phakic GRT patients. I think in terms of the gas and oil, I really think about it in macula-on and macula-off. I think the longer I've gone on, you really do think that oil toxicity is a real thing and you've seen it in the macula-on patients where they end up 20/100 for no good reason. So I think in the macula-ons, I really try to give them gas no matter what on the first surgery and then think about oil at a later time.

In terms of the buckle, especially in gas, if the GRT is anterior and you think the tear can lie on the buckle, I think you have a really good chance with gas in most cases. So if you have a really funny posterior tear that splits in many different ways, your buckle may not be helping you as much, I find, for the anterior ones that lie on the buckle. And that's why sometimes in these cases, I put the buckle a little bit more posterior, because if you can catch the tear on the buckle, I think you win almost every time.

One other tip from the pediatric retina surgery world is that a lot of these are Stickler syndrome, and a lot of patients now don't look like they have Stickler and we've been testing them and it's kind of surprising now. You see a lot of people without any other systemic sequelae of Stickler and if they're 9 to 10 years old, even if they have some trauma history, we'll usually test them and you'll occasionally get a positive Stickler patient and a Stickler parent. So it's kind of funny now with genetic testing, I think we're redefining some of the phenotypes and the expression of some of these systemic comorbidities.

Dr. Gupta: Nemo, will that lead you to put in a lot more laser? If you suspect Stickler syndrome, and are tested for Stickler, will you do the full Stickler protocol laser when you're repairing these?

Dr. Patel: Yeah, and it would really push me to laser the other eye. I think there are people who laser the other eye on the GRTs anyway, but I think that's kind of a bigger push for that. And sometimes patients don't really want treatment in their asymptomatic eye, but then if you have the genetic test to back you up, then that really puts it more in that direction.

Dr. Weng: That's a really great point. Mrinali, I noticed that you put laser almost 360°. Is that something you do typically with your buckles or just your GRTs, or was it this particular patient? Talk a little bit more about that, because that’s another area where there’s always controversy. 

Dr. Gupta: I have to admit, even though there's a buckle there with the GRTs, I still do 360° laser. I do not do 360°laser almost ever for standard primary detachments. There was a short period of time where I did them a few years into my attending life and I definitely saw more cystoid macular edema (CME) and epiretinal membranes (ERMs). So I don't do that routinely except in GRTs, just due to the way the peripheral retina and vitreous base are abnormal.

Dr. Patel: I had a question about the laser too. I usually like continuous laser, especially for GRT. I find it a little bit faster. Maybe it's less pretty and I think it's harder to control, but do you have an explanation of why you'd prefer the spot laser vs the continuous? 

Dr. Gupta: Both are great. I just think it's prettier. Clean rows.

Dr. Brodie: Well, we're going to start to do all sorts of cool patterns once we have the Alcon quad laser spot. We could do all sorts of interesting line drawings.

Dr. Weng: As I've tried to work more efficiently, I love the continuous laser too. And I think if you move it in such a way, it actually can look like intermittent spots. I was told by one of my mentors that continuous laser, the pexy, might not be as good as if you have intermittent spots, because it can create sort of this plane that if something comes loose, that whole sheet can come off. But I don't know if that's true or not. That was something in my mind early on that made me avoid continuous laser, but I use continuous laser more and more now and it can be a lot faster. So I like that you asked that point.

One more point before we move on. I'd like to talk a little bit about the PFO and then drainage. In these types of cases, do we all drain from the GRT itself? Or do you ever make a draining retinotomy to make sure it's really bone dry?

Dr. Gupta: I always drain from the GRT itself. I don’t want to make anything more posterior that can be a source of PVR in the future. And I just go really, really slowly [to the point] where I'm asking myself, why am I going this slowly? And then I remember the one time I didn't and then it slipped. I find that if you march along the edge of the GRT and are really slow, then you can avoid slippage and you don't have posterior puddles of fluid to worry about.

Dr. Weng: Frank, do you do the same or do you have a different approach?

Dr. Brodie: I do the same. I’m already opening up the bottle of PFO to manage the GRT. And so I feel like, why make an extra hole in the eye if I've already opened the PFO; I can drain from the break.

Dr. Weng: Nemo, same? 

Dr. Patel: Yes, I'm the same. I think the ones you’ve got to think about a little bit are the nasal ones that are very anterior and phakic patients. They can be a little bit hard to drain with the nose there. You can try to tip the eye and go for it. I don't routinely make drainage retinotomies. Sometimes, if you do see a little puddle or slippage, I may do that.

The other thing to think about in these cases, if you do have an anteronasal GRT in a phakic patient, is to consider phacovitrectomy (phaco-vit). We don't do them as much in the United States, but there are a couple of surgeons here. Ashley M. Crane, MD, is one of them. When we were in fellowship, she taught that she routinely did phaco-vit for these, because she says the 10 minutes you spend on the phaco, you make that up easily, and it just makes the case so much easier when you can drain in a pseudophakic patient vs a phakic patient. You can cross and drain from the other hand if needed.

Dr. Weng: Yes. And I really love also, Mrinali, how you pointed out the fact that you did the depressed exam and the shave before you put in the PFO. I think that's really important. With these types of tears, especially if they're really anterior and you're not making a draining retinotomy, which I don't either typically, you really want to be careful not to get any bubbles that end up slipping in through the break and underneath the retina. And so that's a great point. Other things that you can do to help avoid that intravitreal turbulence include decreasing the infusion pressure and again, making sure all your scleral depression is done before you put in the PFO and also just avoiding large, sudden movements with the eye. So I think that was a really helpful point as well. RP