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Ulrich Spandau · Mitrofanis Pavlidis

27-Gauge
Vitrectomy
Minimal Sclerotomies
for Maximal Results

123
27-Gauge Vitrectomy
Ulrich Spandau • Mitrofanis Pavlidis

27-Gauge Vitrectomy
Minimal Sclerotomies
for Maximal Results
Ulrich Spandau Mitrofanis Pavlidis
Department of Ophthalmology Augencentrum Köln
Uppsala University Hospital Cologne
Uppsala Germany
Sweden

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Preface

Vitreoretinal surgery is developing rapidly. 23G technique was until recently the
golden standard and now many surgeons are converting to the 25G technique. And
why not a take a step further to 27G?
But why do we, the authors, operate in 27G?
I (US) started with 20G pars plana vitrectomy. In 2008, I converted to 23G. I was
especially enthusiastic about the trocars in combination with the valves because the
eye was watertight and the ports easier to access.
I converted then to 25G because I needed to operate a newborn with retinopathy
of prematurity and I wanted to operate sutureless. I continued then with macular
peeling and finally with detachment surgery. Macular peeling is more difficult with
25G because the forceps is softer. But detachment surgery with 25G is wonderful.
The sclerotomies are tight and a gas tamponade lasts much longer than with
23G. But I still used sutures in highly myopic eyes.
I converted therefore to 27G in long eyes (AXL >25 mm); the globe was now
watertight and the tamponade lasted even longer than with 25G. I continued with
pediatric eyes because these eyes have a soft sclera and therefore weaker scleroto-
mies. Macular peeling was very similar to 25G but detachment surgery was more
difficult because the vitreous base was hard to access with the soft vitreous cutters.
The beginnings of 27G were similar to the beginnings of 25G. Today the vitreous
cutters and most instruments are much stiffer so that 27G feels more and more com-
fortable. Another main disadvantage of 27G was the slow speed. This obstacle has
been overcome with the revolutionary double-cut vitrector making 27G as fast as
23G. Today I operate 40 % of all cases with 25G and 60 % with 27G. I will increase
with 27G if all required instruments are available in 27G.
I (MP) am using 27G for all cases except for heavy silicone oil extraction.
In cooperation with DORC I developed the TDC cutter (Two Dimension Cutter)
which is a double cutting, permanent aspiration vitrectome. The TDC cutter
increases dramatically the fluid flow, which has been the major limitation of 27G.
With the flow problems solved, rigidity of the very thin 27G instruments is almost
the last limitation of 27G. New materials and instruments designs are in develop-
ment and in my opinion 27G will replace 23G and 25G vitrectomy procedures in the
next years.

v
vi Preface

The surgical techniques described in this book are not the only possible treat-
ment for the described pathology. They are only recommendations, not guidelines
or rules.
In our quest for smaller sclerotomies and a less traumatic surgical procedure, the
journey goes on. If you wish to visit our surgical units, you are more than welcome.
One visit is more worth than ten conferences.
We wish every reader, may he or she be a beginner or an advanced surgeon, to
enjoy reading this book and watching the surgical videos. Included are a huge
amount of commented surgical videos. Our endeavour is to inspire more people to
master this amazing surgical technique.

Uppsala, Sweden Ulrich Spandau


Köln, Germany Fanis Pavlidis
April 2015
Acknowledgements

I would like to thank my wife Katrin for her patience and moral support and my
children Maximilian and Moritz for being less naughty than usual during my work
on this book.

Ulrich Spandau
Department of Ophthalmology
Uppsala University Hospital
75185, Uppsala, Sweden

vii
Contents

Part I 27G

1 Introduction to 27G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Does Size Matter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 The Dilemma of the Law of Hagen–Poiseuille . . . . . . . . . . . . . . . . . 6
1.3 Differences Between 23G, 25G and 27G. . . . . . . . . . . . . . . . . . . . . . 6
1.4 Double-Cut Vitreous Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.1 History of 27G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.2 History of Double-Cut Vitrector . . . . . . . . . . . . . . . . . . . . . . 7
1.4.3 The New TDC Cutter Is Much Faster Than
the Regular Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Part II Optimal Tools for 27G

2 Optimal Visualization, Optimal Instruments


and Optimal Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 Optimal Visualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2 Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.1 Red Lights in the Operating Room . . . . . . . . . . . . . . . . . . . . 19
2.2.2 Inflatable Pillow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.3 Location of the Patient, Surgeon, Vitrectomy
Machine and Scrub Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.4 Carboband . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3 Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3.1 Light Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3.2 Binocular Indirect Ophthalmo Microscope
(BIOM) Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4 Instruments for Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4.1 Vitrectomy Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4.2 Trocars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4.3 Trocar Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.4.4 Scleral Marker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.4.5 Scleral Depressor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

ix
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2.5 27G Standard Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26


2.5.1 Vitreous Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.5.2 Endoillumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.5.3 Peeling Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.6 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.1 Backflush Instrument (=Charles Flute Needle) . . . . . . . . . . 36
2.6.2 Endodiathermy Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.6.3 Laser Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.6.4 Fragmatome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.6.5 Foreign Body Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.6.6 Instruments for Gas Tamponade . . . . . . . . . . . . . . . . . . . . . . 39
2.6.7 Instruments for Silicone Oil Tamponade . . . . . . . . . . . . . . . 40
2.6.8 Dyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.6.9 Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Part III Optimal Techniques for 27G

3 Usage of 27G Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43


3.1 Insertion of Trocars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.2 Valve Removal and Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.3 Removal of Trocar Cannulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.4 Endoillumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.4.1 Usage of a Light Fibre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.4.2 Insertion of Chandelier Light in Sclera or Trocar . . . . . . . . . 50
3.4.3 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.5 Usage of a Double-Cut Vitreous Cutter . . . . . . . . . . . . . . . . . . . . . . 56
3.6 Usage of a Charles Flute Instrument . . . . . . . . . . . . . . . . . . . . . . . . . 57
4 Important Vitreoretinal Techniques with 27G . . . . . . . . . . . . . . . . . . . . 59
4.1 Induction of Posterior Vitreous Detachment . . . . . . . . . . . . . . . . . . . 59
4.2 Trimming of Vitreous Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2.1 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.3 Staining of Membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
4.4 Peeling of Membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.5 Endodiathermy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.6 Laser Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5 Intraoperative Tamponade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
5.1 Basics of Intraoperative Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . 75
5.1.1 Air < = > PFCL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
5.2 Air Tamponade (Exchange of Water Against Air) . . . . . . . . . . . . . . . 77
5.2.1 BSS Tamponade (Exchange of Air Against BSS) . . . . . . . . . 78
5.3 PFCL Tamponade (Exchange of Fluid Against PFCL) . . . . . . . . . . . 78
5.3.1 Removal of PFCL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
5.3.2 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Contents xi

6 Postoperative Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.1 Basics of Postoperative Tamponades . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.1.1 Gases and Liquids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.1.2 Physiologic Characteristics of Gases and Liquids:
Specific Gravity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.1.3 Surface Tension Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.1.4 Expanding Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.1.5 Air Tamponade (Exchange of Water Against Air). . . . . . . . . 84
6.2 Gas Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.2.1 Basics of a Gas Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.2.2 Physics of a Gas Tamponade (Exchange of Air
Against Gas). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.2.3 Practical Approach for a Gas Tamponade . . . . . . . . . . . . . . . 85
6.2.4 Gas Tamponade (Exchange of Air Against Gas) . . . . . . . . . 86
6.3 Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.3.1 Basics of a Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . 87
6.3.2 Physics of a Silicone Oil Tamponade (Exchange of Air
Against Silicone Oil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.3.3 Light Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . . . . . . 87
6.3.4 Heavy Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . . . . . 88
6.3.5 Practical Approach for a Silicone Oil Tamponade. . . . . . . . . 88

Part IV Surgeries for 27G

7 Vitrectomy for Floaters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97


7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
8 VMTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8.2 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
8.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
8.4 Complication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
9 Macular Peeling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.2 Epiretinal Membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
9.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
9.2.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
9.2.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
9.2.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
xii Contents

9.3 Macular Holes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113


9.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
9.3.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
9.3.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
9.3.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
10 Membrane Peeling with Intraoperative OCT . . . . . . . . . . . . . . . . . . . . 123
11 Dislocated IOL: Extraction of IOL and Implantation
of Iris-Fixated IOL with 27G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
11.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
11.2 Special Instruments for Iris-Claw IOL Implantation . . . . . . . . . . . . 131
11.2.1 Instruments for Iris-Fixated IOL . . . . . . . . . . . . . . . . . . . . . 131
11.2.2 Enclavation Spatula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
11.2.3 Caliper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
11.2.4 Serrated Jaw Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
11.2.5 Endgripping Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
11.3 Iris-Claw IOL Implantation Surgery . . . . . . . . . . . . . . . . . . . . . . . . 133
11.3.1 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
11.3.2 Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
11.3.3 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 133
11.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
11.5 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
12 Endophthalmitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
12.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
12.2 Antibiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
12.2.1 Preparation of Antibiotic Therapy . . . . . . . . . . . . . . . . . . . . 148
12.2.2 Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
12.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
12.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
13 Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
13.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
13.2 Pneumatic Retinopexy with BIOM . . . . . . . . . . . . . . . . . . . . . . . . . 163
13.2.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
13.2.2 Practical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
13.2.3 The Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
13.2.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
13.2.5 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
13.3 Episcleral Buckling for Detachment Surgery with BIOM . . . . . . . . 167
13.3.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
13.3.2 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
13.3.3 Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
13.3.4 The Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
13.3.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
13.3.6 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Contents xiii

13.4 Vitrectomy for Detachment Surgery . . . . . . . . . . . . . . . . . . . . . . . . 181


13.4.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
13.4.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
13.4.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
13.4.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
14 Diabetic Retinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
14.1 Combined Phacoemulsification and Anti-VEGF Treatment . . . . . . 207
14.2 Easy PDR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
14.2.1 The Surgery Step-by-Step . . . . . . . . . . . . . . . . . . . . . . . . . . 210
14.2.2 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
14.2.3 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
14.3 Difficult PDR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
14.3.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
14.3.2 The Surgery Step-by-Step . . . . . . . . . . . . . . . . . . . . . . . . . . 214
14.3.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
14.3.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
15 Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
15.1 Different Indications, Different Methods. . . . . . . . . . . . . . . . . . . . . 240
15.1.1 Primary Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . 240
15.1.2 PVR Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
15.1.3 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
15.1.4 Macular Hole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
15.2 Duration of Silicone Oil Tamponade . . . . . . . . . . . . . . . . . . . . . . . . 240
15.3 Air Against Light and Heavy Silicone Oil Exchange . . . . . . . . . . . 241
15.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
15.3.2 Exchange of Air Against Silicone Oil
with Chandelier Illumination (Under BIOM View). . . . . . . 242
15.3.3 Exchange of Air Against Silicone Oil Without
Chandelier Illumination (Without BIOM View) . . . . . . . . . 244
15.4 PFCL Against Light and Heavy Silicone Oil Exchange
with DORC Infusion Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
15.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
15.4.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
16 Silicone Oil Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
16.1 Light Silicone Oil (1000, 1300 and 5000 cSt) Removal . . . . . . . . . 253
16.2 Heavy Silicone Oil (Densiron 68®) Removal. . . . . . . . . . . . . . . . . . 253
16.2.1 Active Removal of Heavy Silicone
Oil (e.g. Densiron 68®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
16.2.2 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
17 Paediatric Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
17.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
17.2 Physiology of a Neonate Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
xiv Contents

17.3 Retinal Detachment Secondary to ROP . . . . . . . . . . . . . . . . . . . . . . 256


17.4 Timing of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
17.5 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
17.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
17.7 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
18 Vitrectomy of Myopic Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Part V Hybrid Procedures

19 Dropped Nucleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273


19.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
19.2 Extraction of a Posteriorly Dislocated Nucleus
with Fragmatome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
19.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
19.2.2 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 276
19.3 Extraction of a Posteriorly Dislocated Nucleus with PFCL . . . . . . 280
19.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
19.3.2 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 281
19.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
19.5 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
20 Retinal Detachment Complicated by Proliferative
Vitreoretinopathy (PVR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
20.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
20.1.1 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 288
20.2 Inferior Redetachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
20.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
20.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
21 Neovascular Glaucoma Treated Under View of a BIOM . . . . . . . . . . . 309
21.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
21.1.1 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 310
22 Submacular Haemorrhage Secondary to CNV . . . . . . . . . . . . . . . . . . . 313
22.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
22.2 Surgery of a Small Submacular Haemorrhage. . . . . . . . . . . . . . . . . 316
22.2.1 Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
22.2.2 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 316
22.2.3 Postoperative Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
22.2.4 Follow-Ups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
22.3 Surgery of a Large Submacular Haemorrhage . . . . . . . . . . . . . . . . . 317
22.3.1 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 317
22.3.2 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
22.4 Surgery of a Massive Submacular Haemorrhage . . . . . . . . . . . . . . . 322
22.4.1 The Surgery Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . 323
22.4.2 In Case of Residual Submacular Haemorrhage . . . . . . . . . . 328
Contents xv

22.4.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335


22.4.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
23 Submacular Haemorrhage Secondary to Arterial
Macroaneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
23.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
24 Suprachoroidal Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
24.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
24.2 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
24.3 Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
24.4 The Surgery Step By Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
24.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
24.6 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352

Part VI Ocular Trauma

25 Penetrating Eye Injury by Metal Intraocular Foreign


Bodies (IOFB); Delayed, Stepwise Surgery . . . . . . . . . . . . . . . . . . . . . . 357
25.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
25.2 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
25.3 Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
25.4 The Surgery Step By Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
25.4.1 The Surgery Step By Step . . . . . . . . . . . . . . . . . . . . . . . . . . 370
25.5 IOFB Extraction, Immediate Surgery . . . . . . . . . . . . . . . . . . . . . . . 374
25.5.1 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
25.5.2 Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
25.5.3 The Surgery Step By Step . . . . . . . . . . . . . . . . . . . . . . . . . . 375
25.5.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
25.5.5 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
26 Case Reports of Penetrating and Blunt Ocular Trauma . . . . . . . . . . . . 381
26.1 General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
26.2 Surgical Management of a Corneal Perforation. . . . . . . . . . . . . . . . 382
26.3 Surgical Management of a Traumatic Cataract . . . . . . . . . . . . . . . . 387
26.4 Surgical Management of a Scleral Wound at Pars Plana . . . . . . . . . 392
26.5 Surgical Management of Aphakia and Distorted Pupil . . . . . . . . . . 394
26.6 Surgical Management of a Traumatic Mydriasis
with Suture Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
26.7 Surgical Management of a Traumatic Aniridia
and Aphakia with Iris and IOL Prosthesis . . . . . . . . . . . . . . . . . . . . 399
26.7.1 Implantation of a Foldable Iris Prosthesis
(Human Optics®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
26.7.2 Scleral Fixation of a Combo Iris–IOL Prosthesis . . . . . . . . 405
26.7.3 Implantation of an Iris Prosthesis in the Sulcus . . . . . . . . . . 408
26.7.4 Implantation of an Iris Prosthesis in the Lens Capsule . . . . 410
26.7.5 Non-foldable Iris–IOL Prosthesis (Ophtec®) . . . . . . . . . . . . 415
xvi Contents

26.8 Surgical Management of a Traumatic Mydriasis with Suture


(Iridoplasty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
26.9 Surgical Management of an Iridodialysis . . . . . . . . . . . . . . . . . . . . 420
26.10 Surgical Management of a Cyclodialysis. . . . . . . . . . . . . . . . . . . . . 422
26.11 Surgical Management of a Traumatic Retinal Detachment . . . . . . . 425

Part VII Miscellaneous

27 Frequently Asked Questions (FAQ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445


28 Materials (in Alphabetical Order). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
28.1 Dyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
28.2 Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
28.3 Knives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
28.4 Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
28.5 Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
28.6 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
29 Company Addresses (in Alphabetical Order) . . . . . . . . . . . . . . . . . . . . 455

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Abbreviations

BIOM Binocular indirect ophthalmo microscope


C2F6 Perfluoroethane, gas for retinal tamponade
CF Counting fingers
cSt Kinematic viscosity of a fluid (unit = centiStoke)
HM Hand movement
ILM Internal limiting membrane
IOFB Intraocular foreign body
IOL Intraocular lens
IOP Intraocular pressure
LE Left eye
LIO Laser indirect ophthalmoscopy
MICVIT MicroIncisional Cataract Vitrectomy
MIVS Micro-incision Vitrectomy Surgery
OD Oculus dexter, right eye
OS Oculus sinister, left eye
OU Oculus uterque, both eyes
PDR Proliferative diabetic retinopathy
PDVR Proliferative diabetic vitreoretinopathy
PFCL Perfluorocarbon liquid
PPV Pars plana vitrectomy
PRP Pan-retinal photocoagulation
PVD Posterior vitreous detachment
RE Right eye
rPA r(t)PA recombinant (tissue) Plasminogen Activator
SF6 Sulphahexafluoride, gas for retinal tamponade
TDC Two Dimensions Cutter (=double cut vitreous cutter)
TRD Tractional retinal detachment

xvii
Video List

Videos are accessible online at http://extras.springer.com/ by searching via the ISBN

Video 1.1 Flow regular cutter


Video 1.2 Flow TDC cutter
Video 1.3 TDC cutter without fluid
Video 1.4 Left regular cutter Right TDC cutter 6000 cpm_450 mmHg
Video 1.5 Comparison_23G regular cutter vs 25G TDC cutter
Video 3.1 Insertion of a chandelier light (audio)
Video 3.2 Regular cutter
Video 3.3 TDC cutter
Video 4.1 PVD with Atkinson cannula (no audio)
Video 4.2 27G difficult PVD (audio)
Video 4.3 Diabetic peeling
Video 4.4 PFCL bubble and membrane peeling 27G retinal scraper (Atkinson
cannula)
Video 7.1 Vitreous floaters-27G_old cutter
Video 7.2 27G-asteroid hyalosis_TDC cutter
Video 7.3 Vitreous floaters
Video 8.1 27G-Difficult PVD
Video 8.2 VMTS with many complications_no audio
Video 9.1 27G-peeling surgery
Video 9.2 27G macular peeling
Video 9.3 Macular hole 27G
Video 9.4 Anterior dislocated IOL and macular hole with 27G
Video 10.1 Intraoperative OCT
Video 11.1 Anterior dislocated IOL and macular hole with 27G
Video 11.2 Bimanual extraction of anterior dislocated IOL
Video 11.3 27G posterior dislocated IOL
Video 12.1 Candida endophthalmitis
Video 12.2 Endophthalmitis
Video 12.3 Endophthalmitis and subchoroidal haemorrhage
Video 13.1 Pneumatic retinopexy with Biom
Video 13.2 Episcleral buckling with BIOM 1
Video 13.3 Episcleral buckling with BIOM 2

xix
xx Video List

Video 13.4 27G retinal detachment without PFCL


Video 13.5 Retinal detachment high myopia with PFCL
Video 13.6 27G retinal detachment
Video 13.7 27G Retinal detachment Constellation
Video 13.8 27G redetachment
Video 14.1 Phaco and Avastin (no audio)
Video 14.2 27G lens-sparing vitrectomy of a type I diabetic
Video 14.3 27G lens-sparing vitrectomy PDR easy-difficult
Video 14.4 Difficult PDR with 27G monomanual vitrectomy
Video 14.5 Difficult PDR—Constellation 27G
Video 14.6 27G-CRVO
Video 14.7 PVD induction (audio)
Video 14.8 PVD no blood (audio)
Video 14.9 PVD with blood (audio)
Video 14.10 Delamination of membranes with 25G blunt cannula (Atkinson)
(no audio)
Video 14.11 Bimanual peeling with vacuum cleaner and forceps (audio)
Video 14.12 Bimanual peeling with knob spatula audio
Video 14.13 Diabetic peeling with scissors 1 (audio)
Video 14.14 Bimanual peeling with scissors 2 (no audio)
Video 14.15 Bimanual peeling with scissors_3_no audio
Video 14.16 Bimanual peeling with cutter (audio)
Video 14.17 Hemostasis
Video 14.18 Knob spatula
Video 14.19 PFCL laser audio
Video 14.20 Tamponade air (audio)
Video 14.21 Tamponade silicone oil (audio)
Video 15.1 27G silicone oil injection
Video 16.1 27G silicone oil removal
Video 16.2 Densiron 68 removal with 25G
Video 17.1 ROP_RE
Video 17.2 ROP_LE
Video 17.3 Neurofibromatosis 2
Video 17.4 Intraoperative OCT
Video 17.5 Pediatric cataract with 27G
Video 17.6 PHPV with 27G
Video 18.1 27G IOL exchange high myopia
Video 18.2 Retinal detachment high myopia
Video 18.3 27G lens sparing vitrectomy of a type I diabetic
Video 19.1 Extraction of dropped nucleus with fragmatome and sulcus IOL
Video 19.2 Extraction of dropped nucleus with ICCE and retropupillar
Verisyse IOL
Video 19.3 ICCE and iris-claw IOL
Video 20.1 PVR detachment
Video 20.2 Peeling techniques for PVR detachment
Video 20.3 PVR peeling
Video List xxi

Video 20.4 PVR-detachment secondary to trauma


Video 20.5 Traumatic detachment
Video 21.1 Retinal cryopexy (no audio)
Video 22.1 Submacular rtPA
Video 22.2 Traumatic submacular hemorrhage
Video 23.1 Submacular hemorrhage secondary to macroaneurysm
Video 24.1 Endophthalmitis and subchoroidal hemorrhage
Video 24.2 Open globe
Video 24.3 Globe rupture
Video 25.1 IOFB case 1—stepwise surgery
Video 25.2 IOFB case 2
Video 25.3 IOFB case 3
Video 26.1a Lens injury after intravitreal injection
Video 26.1b Traumatic cataract
Video 26.2 Iridoplasty and iris-claw IOL
Video 26.3 Combo IOL-iris prosthesis (long version)
Video 26.4 Foldable iris and IOL prosthesis (very short version)
Video 26.5 Extraction and reimplantation of iris prosthesis
Video 26.6 Old traumatic mydriasis
Video 26.7 Iridoplasty for traumatic mydriasis
Video 26.8a Explosive trauma (no audio)
Video 26.8b Explosive trauma (audio)
Video 26.8c Cyclodialysis
Video 26.9 Trauma with kick scooter
Video 26.10a Intraocular nail—part 1
Video 26.10b Intraocular nail—part 2
Video 26.11 Trauma with snow blower
Video 27.1 PFCL bubble and membrane peeling 27G retinal scraper_Atkinson
cannula
List of All Surgical Pearls

1. Insertion of a Synergetics chandelier light............................................... 55


2. PVD.......................................................................................................... 60
3. PVD and dye ............................................................................................ 61
4. Difficult PVD ........................................................................................... 62
5. 27G........................................................................................................... 65
6. Iatrogenic break ....................................................................................... 73
7. Laser therapy ............................................................................................ 73
8. BIOM and air ........................................................................................... 76
9. Posterior capsular defect during anterior vitrectomy ............................... 78
10. PFCL injection ......................................................................................... 79
11. Gas tamponade ......................................................................................... 87
12. Gas filling with 27G ................................................................................. 87
13. Infusion line and silicone oil .................................................................... 91
14. Instrument trocars towards 12 o’clock ..................................................... 98
15. Trypan blue .............................................................................................. 111
16. PVD.......................................................................................................... 111
17. Membrane and dye ................................................................................... 112
18. Peeling of ERM and ILM ........................................................................ 112
19. PVD.......................................................................................................... 115
20. Staining in air-filled eye ........................................................................... 118
21. ILM peeling and dot haemorrhages ......................................................... 119
22. Peeling with chandelier light ................................................................... 119
23. Backflush instrument ............................................................................... 119
24. Tamponade for macular hole.................................................................... 119
25. Posterior dislocated IOL .......................................................................... 141
26. Difficult IOL extraction from posterior pole............................................ 141
27. Enclavation of iris-claw IOL .................................................................... 142
28. Do not enclavate too much iris tissue ...................................................... 142
29. Pus and fibrin in the anterior chamber ..................................................... 149
30. Pars plana infusion ................................................................................... 152
31. Treat the retinal tears and not the detachment ......................................... 162
32. Retinal tear under a muscle ...................................................................... 179
33. Corneal suture .......................................................................................... 192

xxiii
xxiv List of All Surgical Pearls

34. Capsular tension ring ............................................................................... 192


35. Corneal lubrication................................................................................... 192
36. PVD in RRD ............................................................................................ 193
37. Triamcinolone and RRD .......................................................................... 193
38. Unseen breaks and Schlieren phenomenon.............................................. 194
39. PFCL ........................................................................................................ 194
40. Iatrogenic break ....................................................................................... 195
41. Laser......................................................................................................... 195
42. Laser cerclage .......................................................................................... 195
43. Laser necrosis........................................................................................... 196
44. Trimming of vitreous base ....................................................................... 196
45. Active aspiration ...................................................................................... 198
46. Removal of PFCL .................................................................................... 198
47. Air as tamponade ..................................................................................... 199
48. Air test for detachment............................................................................. 201
49. Gas vs silicone oil .................................................................................... 201
50. Bilateral PDR ........................................................................................... 208
51. B-scan ...................................................................................................... 209
52. Blocked infusion ...................................................................................... 210
53. Removal of anterior hyaloid..................................................................... 210
54. How should epiretinal blood be removed?............................................... 211
55. Small pupil ............................................................................................... 211
56. Recurrent vitreous haemorrhage .............................................................. 212
57. BSS damages the phakic lens .................................................................. 213
58. Corneal lubrication................................................................................... 232
59. Peeling and choroidal haemorrhage ......................................................... 234
60. Intraoperative haemorrhage and adrenaline ............................................. 235
61. Postoperative vitreous haemorrhages....................................................... 236
62. Lens-sparing vitrectomy .......................................................................... 237
63. 6 o’clock iridectomy for light silicone oils .............................................. 242
64. 12 o’clock iridectomy for heavy silicone oils .......................................... 242
65. Methylcellulose in anterior chamber ....................................................... 243
66. Silicone oil in the anterior chamber ......................................................... 244
67. Infusion line and silicone oil .................................................................... 248
68. PFCL against silicone oil exchange 1 ...................................................... 248
69. PFCL against silicone oil exchange 2 ...................................................... 248
70. PFCL against silicone oil exchange with 20G ......................................... 249
71. Clogged infusion line ............................................................................... 253
72. Removing Densiron 68® .......................................................................... 254
73. Location of infusion cannula in paediatric vitrectomy ............................ 261
74. Anti-VEGF dose for ROP ........................................................................ 262
75. Complicated cataract surgery ................................................................... 274
76. Dropped nucleus ...................................................................................... 279
77. Residual nuclear fragment ....................................................................... 279
78. One-piece IOL vs three-piece IOL .......................................................... 279
List of All Surgical Pearls xxv

79. Posterior synechiae ................................................................................ 288


80. Removal of PVR membranes ................................................................. 300
81. Eckardt ILM forceps .............................................................................. 300
82. Air bubbles behind IOL ......................................................................... 301
83. Doughnut shape of the anterior retina .................................................... 302
84. Laser cerclage ≠ encircling band ........................................................... 302
85. Laser cerclage ........................................................................................ 302
86. Cyclocryopexy ....................................................................................... 312
87. Anterior chamber maintainer ................................................................. 346
88. 6 mm trauma trocars .............................................................................. 347
89. Difficult removal of suprachoroidal blood ............................................. 350
90. Subepithelial location of trocars ............................................................ 350
91. Chandelier light...................................................................................... 351
92. Hypotony with phthisis bulbi ................................................................. 352
93. Cyclitic membranes ............................................................................... 353
94. Inflamed or vascularly active eye ........................................................... 363
95. Seidel test ............................................................................................... 379
96. Anterior chamber haemorrhage ............................................................. 379
97. Scleral defect .......................................................................................... 392
98. Scleral defect and silicone sponge ......................................................... 392
99. Open globe injury .................................................................................. 392
100. Combo iris–IOL prosthesis .................................................................... 405
101. IOL–iris prosthesis and Scharioth.......................................................... 405
List of All Case Reports

Case Report No. 1: VMTS......................................................................... 104


Case Report No. 2: Neurofibromatosis Type 2 .......................................... 123
Case Report No. 3: Endophthalmitis and Choroidal Haemorrhage ........... 153
Case Report No. 4: Ozurdex Endophthalmitis........................................... 154
Case Report No. 5: A pseudo-endophthalmitis ......................................... 156
Case Report No. 6: ROP Stage 4 ............................................................... 262
Case Report No. 7: Neurofibromatosis Type 2 .......................................... 263
Case Report No. 8: Traumatic Cataract ..................................................... 264
Case Report No. 9: PHPV.......................................................................... 266
Case Report No. 10: Traumatic PVR Detachment ...................................... 304
Case Report No. 11: Large Submacular Haemorrhage................................ 322
Case Report No. 12: Massive Submacular Haemorrhage 1 ......................... 328
Case Report No. 13: Massive Submacular Haemorrhage 2 ......................... 329
Case Report No. 14: Traumatic Choroidal Haemorrhage ............................ 332
Case Report No. 15: Retinal Macroaneurysm 1 .......................................... 338
Case Report No. 16: Retinal Macroaneurysm 2 .......................................... 343
Case Report No. 17: Corneal Perforation and Large Iris Defect ................. 382
Case Report No. 18: Corneal Perforation in a Child ................................... 385
Case Report No. 19: Traumatic Cataract ..................................................... 387
Case Report No. 20: Traumatic Cataract ..................................................... 390
Case Report No. 21: Scleral Wound at Pars Plana Secondary to IOFB ...... 392
Case Report No. 22: Aphakia and Distorted Pupil ...................................... 394
Case Report No. 23: Suture Net................................................................... 397
Case Report No. 24: Traumatic Mydriasis and Aphakia ............................. 405
Case Report No. 25: Traumatic Mydriasis and Aphakia ............................. 405
Case Report No. 26: Iris Defect ................................................................... 408
Case Report No. 27: Traumatic Mydriasis and Cataract ............................. 410
Case Report No. 28: Traumatic Mydriasis .................................................. 415
Case Report No. 29: Traumatic Mydriasis and Sulcus Implantation........... 415
Case Report No. 30: Dislocated Nucleus and Traumatic Mydriasis ........... 418
Case Report No. 31: Iridodialysis ................................................................ 420
Case Report No. 32: Dislocated Nucleus, Traumatic Mydriasis and
Cyclodialysis .............................................................. 422

xxvii
xxviii List of All Case Reports

Case Report No. 33: Globe Rupture, Traumatic Cataract and Incarcerated
Retina with Total Detachment .................................... 425
Case Report No. 34: Corneal Perforation with IOFB, Traumatic Cataract
and Retinal Perforation .............................................. 431
Case Report No. 35: Corneal Perforation, Traumatic Mydriasis,
Dislocated Nucleus and Retinal Detachment ............. 437
Part I
27G
Introduction to 27G
1

Contents
1.1 Does Size Matter? ............................................................................................................... 4
1.2 The Dilemma of the Law of Hagen–Poiseuille................................................................... 6
1.3 Differences Between 23G, 25G and 27G............................................................................ 6
1.4 Double-Cut Vitreous Cutter ................................................................................................ 7
1.4.1 History of 27G 7
1.4.2 History of Double-Cut Vitrector 7
1.4.3 The New TDC Cutter Is Much Faster Than the Regular Cutter 7

Trocar Against No Trocar The most essential development of small-gauge vitrec-


tomy was the introduction of a trocar which rests inside the sclera. Instruments are
much easier introduced, the trocar protects the sclera against injury through the
instruments and a trocar is easier to find than a usual sclerotomy. The disadvantage
of the trocar compared to the usual sclerotomy is the excessive leakage of fluid
through the trocars.

Valve Against No Valve The valve on the trocar solves this problem. The valve
keeps the globe watertight. You can remove the infusion and the globe is still nor-
motensive. Valves have more advantages. Valves prevent incarceration of vitreous
into the trocars; less fluid is infused; valves build up a higher intraocular pressure,
which is useful during a fluid–air exchange or removal of a preretinal oil bubble;
and you do not need to work with plugs.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 3


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_1
4 1 Introduction to 27G

1.1 Does Size Matter?

We are convinced that size does matter. See Table 1.1. Size was the major motiva-
tor to switch from ECCE to phacoemulsification. The small incisions of phaco-
emulsification are better in almost all aspects than the gaping wound of ECCE:
faster postoperative recovery, improved visual results, less astigmatism and a
closed and safe globe.
The same principle applies for vitrectomy. Small sclerotomies and small instru-
ments induce less intraoperative trauma, improved postoperative gas filling, less
leakage and faster postoperative recovery. The principle “the smaller the gauge, the
better” is evident.
The main disadvantage of 23G is that the sclerotomies are not as tight as 20G
sclerotomies with sutures. The use of 23G is thought to be a sutureless technique but
requires quite often sutures in order to avoid postoperative hypotony.

Don’t Forget A 27G trocar creates a 25G sclerotomy. A 25G trocar has a 23G
sclerotomy. And a 23G trocar has a 22G sclerotomy. It is obvious, that a 25G scle-
rotomy is superior to a 22G sclerotomy.
27G, in contrast, has no leakage, the globe is watertight without sutures, and the
tiny instruments cause less intraoperative trauma (Figs. 1.1, 1.2, 1.3, and 1.4). The
major advantages are as follows:

• No sutures, no suture granuloma


• No postoperative irritation and foreign body sensation
– Fast healing
• Less leakage
– Less postoperative hypotony
– Improved gas tamponade
• Small instruments
– Atraumatic surgery

Table 1.1 Outer diameter Gauge External diameter in mm


of a needle in gauge and mm
17 1.4
19 1.07
20 0.9
23 0.64
25 0.51
27 0.41
29 0.34
30 0.30
1.1 Does Size Matter? 5

Fig. 1.1 The inner diameter of a 23G trocar is 23G but the outer diameter is 22G. A 23G trocar
has therefore a 22G sclerotomy. The outer diameter of a 27G trocar is 25G. It is obvious that a 25G
sclerotomy is water-tighter than a 22G sclerotomy

Fig. 1.2 27G MVR blade


(DORC)

1.2 The Dilemma of the Law of Hagen–Poiseuille

But physics are against small-gauge vitrectomy. The Hagen–Poiseuille equation


states that the flow is proportional to the fourth power of the internal diameter of a
lumen. See Table 1.2. The flow in 23G is 3.65 times slower than in 20G. The flow in
27G is 12.5 times slower than in 23G. This physical obstacle has been overcome
with powerful vitrectomy machines and novel vitreous cutters with double cutting
frequency and permanent flow. The novel double-cut vitrector has made 27G to a
fierce competitor of 23G.
6 1 Introduction to 27G

Fig. 1.3 Section through


the sclera after insertion
and extraction of a 27G
trocar (DORC). Excellent
sealing of sclerotomy

Fig. 1.4 Begin of


vitrectomy. The high
pressure infusion line is in
place. On the left side, you
see the light pipe and on
the right side the vitreous
cutter

Table 1.2 Hagen–Poiseuille equation (Flow ≈ diameter4) and its relevance for vitrectomy
Gauge Internal diameter in mm Flow ≈ diameter4
20 0.52 0.073
23 0.39 0.02 3.65 × less flow than 20 G
25 0.29 0.007 2.8 × less flow than 23 G
27 0.20 0.0016 12.5 × less flow than 23 G
4.3 × less flow than 25 G

1.3 Differences Between 23G, 25G and 27G

If the performance of a 23G cutter is 100 %, then a 25G cutter has approximately
30 % less performance and a 27G cutter approximately 30 % less performance
(Fig. 1.5).
1.4 Double-Cut Vitreous Cutter 7

Performance comparison

23G 25G 27G

100 % 70 % 30 %

–30 % –30 %

Fig. 1.5 Performance comparison of a regular and TDC cutter in relation to the gauge. Measured
is the aspiration time of artificial vitreous (Courtesy DORC)

The disadvantages of a smaller lumen have been overcome through the introduc-
tion of powerful vitrectomy machines and novel vitreous cutters which make 27G
vitrectomy almost as fast as 25G vitrectomy.

1.4 Double-Cut Vitreous Cutter

1.4.1 History of 27G

27G vitrectomy was developed in 2010 from Oshima and colleagues in Japan. The
old 27G cutter had lower fluid dynamics and less cutting efficiency than a 25G cut-
ter. The same applied also for aspiration and infusion rates. These obvious disad-
vantages of 27G became obsolete after a novel type of vitreous cutter was introduced.
The companies DORC (Netherlands) and Geuder (Germany) developed this novel
double-cut citreous cutter.

1.4.2 History of Double-Cut Vitrector

Video 1.1: Flow regular cutter


Video 1.2: Flow TDC cutter
Video 1.3: TDC cutter without fluid

The initial idea for the novel vitreous cutter came from Hayafuji and colleagues
from Japan in 1992 (see Fig. 1.6). After a journey of trial and errors, the final vitrec-
tor was developed in 2013 from DORC in contribution with Dr. Parlidis. This new
vitreous cutter has two open cutting ports and a second cutting blade. See Fig. 1.7. It
is named Two Dimensions Cutter (TDC). This new invention comprises two new
features/dimensions: (1) a permanent flow and (2) two cutting blades.

1.4.3 The New TDC Cutter Is Much Faster


Than the Regular Cutter

Video 1.4: Left regular cutter Right TDC cutter 6000 cpm_450 mmHg
Video 1.5: Comparison_23G regular cutter vs. 25G TDC cutter
8 1 Introduction to 27G

Year Description Image

First idea M. Hayafuji


(1992) Y. Hanamura
S.Niimura

DORC Vitreous Shaver with 3 adjustable


(1996) (slit) aspiration ports

Luiz Lima New dual port cutter system


(2010)

Rizzo Extra aspiration port in internal


(2011) capillary

Parlidis Two dimensions Cutter


(2013)

Fig. 1.6 Historical development of TDC cutter (Photo courtesy DORC)

Second cutting port


First blade (old)

Second blade (new)

Fig. 1.7 The novel twin


duty cycle (TDC) cutter.
The cutter has two open
cutting ports and a
second cutting blade
1.4 Double-Cut Vitreous Cutter 9

The two cutting blades have the result that the cutter cuts two times during one
movement, effectively doubling the cutting speed. The vitreous cutter has a cutting
rate of 8000 cuts/min. But the actual cutting rate with two cutting blades is
8000 × 2 = 16,000 cuts/min, which reaches new dimensions. The second novelty is
continuous and even flow due to the two open cutting ports. This novel technology
reduces vitreous traction, decreases the surgical time and increases the safety of
surgery (Figs. 1.8 and 1.9).
Figure 1.10 shows that the TDC cutter has 1.5× to 1.75× higher performance
than a regular cutter. This results in a fast core vitrectomy.

First blade (old) Second blade (new)

Second opening (new)

First opening
(old)

Fig. 1.8 Illustration of a TDC cutter in action. One movement (forwards and backwards) results
in two cuts. In old cutters one movement (forwards and backwards) results in one cut. The novel
two blade cutters have therefore the same movement frequency like old cutters but a double cutting
frequency: 5000 × 2 = 10,000 cuts/min
10 1 Introduction to 27G

Aspiration 23G vitrectome @ 500 mmHg


30.0
EVA 23G regular vitrectome EVA 25G TDC vitrectome
25.0

20.0
Aspiration [ml/min]

15.0

10.0

5.0

0.0
0 2000 4000 6000 8000
Cut rate [cpm]

Fig. 1.9 Comparison of an old 23G cutter vs a new TDC 27G cutter. The new cutter has a stable
flow in the complete cutting range from 0 to 8000 cuts/min. The old cutter has a high aspiration at
1000 cuts/min and a low aspiration at 8000 cuts/min

TDC Regular Comparison


cutter cutter

23G TDC 23G regular 164 %


25G TDC 25G regular 176 %
27G TDC 27G regular 150 %

27G TDC 23G regular 48 %


27G TDC 25G regular 71 %
27G TDC 27G regular 150 %

Fig. 1.10 Performance comparison of TDC cutter vs regular cutter (Courtesy DORC)

27G Is Very Useful for Following Pathologies (Figs. 1.11 and 1.12)
The following eyes and indications tend to have a postoperative hypotony and
make them therefore to excellent candidates for 27G.

1. Children eyes: No sutures necessary


2. Long eyes: No sutures necessary, excellent tamponade
3. Uveitis eyes: 27G causes minimal postoperative inflammation
4. Silicone oil removal: Less hypotony compared with 23G
1.4 Double-Cut Vitreous Cutter 11

Fig. 1.11 Removal of a


vitreous with synchysis
scintillans

Fig. 1.12 After removal


of the trocars. The
sclerotomies are watertight,
require no suture and no
hypotony is present the day
after. This is an excellent
feature for long eyes and
pediatric eyes

5. Retinal detachment: Tight globe, less leakage resulting in better tamponade


6. Lens exchange: Less hypotony compared with 23G

27G Is Less Useful for the Following Pathologies


These indications have a low risk of postoperative hypotony. There is not really a
difference between 23G and 25G regarding this important feature.

1. Macular pucker: No advantage to 23G except of faster postoperative recovery


2. Macular hole: Better tamponade with 27G but clinically no difference

If you, however, wish a white eye after a 1-week follow-up like after phacoemul-
sification, then you should again choose 27G.
Part II
Optimal Tools for 27G
Optimal Visualization, Optimal
Instruments and Optimal Technique 2

Contents
2.1 Optimal Visualization 16
2.2 Operating Room 19
2.2.1 Red Lights in the Operating Room 19
2.2.2 Inflatable Pillow 19
2.2.3 Location of the Patient, Surgeon, Vitrectomy Machine and Scrub Nurse 19
2.2.4 Carboband 19
2.3 Devices 19
2.3.1 Light Source 19
2.3.2 Binocular Indirect Ophthalmo Microscope (BIOM) Systems 21
2.4 Instruments for Vitrectomy 21
2.4.1 Vitrectomy Set 22
2.4.2 Trocars 23
2.4.3 Trocar Forceps 25
2.4.4 Scleral Marker 25
2.4.5 Scleral Depressor 26
2.5 27G Standard Instruments 26
2.5.1 Vitreous Cutter 27
2.5.2 Endoillumination 28
2.5.3 Peeling Instruments 30
2.6 Miscellaneous 36
2.6.1 Backflush Instrument (=Charles Flute Needle) 36
2.6.2 Endodiathermy Probe 38
2.6.3 Laser Probe 38
2.6.4 Fragmatome 39
2.6.5 Foreign Body Forceps 39
2.6.6 Instruments for Gas Tamponade 39
2.6.7 Instruments for Silicone Oil Tamponade 40
2.6.8 Dyes 40
2.6.9 Sutures 40

© Springer International Publishing Switzerland 2015 15


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_2
16 2 Optimal Visualization, Optimal Instruments and Optimal Technique

The A and O of a successful vitreoretinal surgery are optimal visualization, opti-


mal instruments and optimal technique. This is different to phacoemulsification
surgery. Visualization is also very important in cataract surgery as well as a good
phaco machine, but instruments and the technique are of minor importance.
Regarding instruments, even for an experienced surgeon, there is a significant dif-
ference when using different peeling forceps. Test all available forceps and find the
one which is most suitable for you. The vast pathological spectrum from PVR
detachment to dislocated IOL requires different instruments, the optimal instru-
ment for the specific indication. The same applies to technique. Every pathology
requires an optimal technique. You can operate a dark-brown nucleus with phaco-
emulsification. But the likelihood that you will encounter a posterior capsular rup-
ture, zonular lysis or decompensated cornea is high. This is not the case, if you use
the SICS (modified ECCE) technique. If you operate a difficult PDR with trac-
tional membranes with monomanual vitrectomy, you will likely run into problems
such as retinal tears or incomplete removal of the membranes. Insert a chandelier
light and things are easy. If you operate an ora serrata dialysis with vitrectomy
instead of episcleral buckling, then you made a risky choice because the success
rate with buckling surgery is 100 %.

2.1 Optimal Visualization (Figs. 2.1, 2.2 and 2.3)

An essential condition for successful surgery is optimal visualization. Do every-


thing to optimize visualization. Even an excellent surgeon cannot unfold his skills,
if he does not see well. The main factors for optimal visualization are the BIOM and
the endoillumination. The quality of microscopes is high with all manufacturers.
Important is moreover the choice of BIOM. Test all available BIOMs in order to
find the best suitable BIOM for you. It will directly translate into better surgical
quality. Of importance are also the lens and an easy lens change. Many surgeons
operate with a 90D lens, which is an excellent compromise lens. But you cannot
visualize the periphery well with a 90D lens, which makes it a bad candidate for
retinal detachment surgery. We prefer therefore 120D lenses in order to visualize the
complete retina and then change to a 60D lens. A good alternative to a 60D lens is
a one-way contact lens.
The next important factor for optimal visualization is endoillumination. Three
points here are essential: (1) The resterilization of light pipes reduces their quality.
Use new light pipes. (2) The usage of an external light source. An external light
source such as Brightstar (Fig. 2.3) (DORC) or Photon (Alcon) provides more
brightness than an internal light source. An alternative to an external light source is
the internal light source of the newest generation of vitrectomy machines such as
EVA (DORC), Stellaris PC (B&L) and Constellation (Alcon). The EVA machine
has an integrated LED light (Fig. 2.1). Their internal light source is as powerful as
an external light source. (3) Choice of chandelier light. The brightness of chandelier
lights varies a lot. Test many different chandelier lights until you have found a
satisfying solution.
2.1 Optimal Visualization 17

Fig. 2.1 The EVA


vitrectomy machine from
DORC. A laser device is
integrated and a LED light
for illumination. This
vitrectomy together with
the powerful TDC cutter
enables a fast 27G surgery

One author (US) uses a Zeiss microscope with a Resight visualization system
(Zeiss) (Fig. 2.2). The Resight is simple to use; two different lenses can be rotated
into the light beam and the view under air is excellent. Regarding endoillumination
he uses an external light source (Photon, Synergetics) or the internal light source
from the vitrectomy machine (Constellation and EVA). He uses predominantly the
25G chandelier light Awh from Synergetics for eyes with vitreous body and 25G
chandelier lights from DORC and Synergetics for eyes without vitreous body. The
latter light probes are inserted with a trocar and are therefore suitable for soft globes.
The second author (MP) uses a Zeiss microscope with a Resight visualization sys-
tem (Zeiss). Regarding endoillumination he uses the internal light source from EVA
with a twin light chandelier from DORC or the 29G twin light from Synergetics.
18 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.2 The Resight


system from Zeiss can be
only used with Zeiss
microscopes. It is easy to
use, two lenses (120D and
60D) can be rotated in and
the view under air is
excellent

Fig. 2.3 An external light


source (Brightstar, DORC)
gives much more light than
an internal light source
from a vitrectomy
machine. This is especially
the case for chandelier
lights.
2.3 Devices 19

And again: It is worthwhile to set high standards regarding visualization because


it influences the surgical quality and outcome directly.

2.2 Operating Room (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 2.10
and 2.11)

2.2.1 Red Lights in the Operating Room

We painted our neon tubes with a red colour like in submarines so that we have a
good room illumination without disturbing the surgeon (Fig. 2.4).

2.2.2 Inflatable Pillow

We use an inflatable pillow which can be formed around the patients head by pump-
ing out the air (Figs. 2.5 and 2.6).

2.2.3 Location of the Patient, Surgeon, Vitrectomy Machine


and Scrub Nurse

There are many different set-ups of the patient’s bed, vitrectomy machine and surgi-
cal table. Figures 2.7 and 2.8 shows our specific set-up. The disadvantage of this
set-up is that the touch screen of the vitrectomy machine is far to be reached for the
scrub nurse.
Another possible set-up (Fig. 2.9) is the location of a second surgical table over
the breast of the patient. Light pipe and vitreous cutter are placed here constantly, so
that these instruments can be accessed by the surgeon.

2.2.4 Carboband

We use also several carbobands which we use to attach plastic tubes. We attach it to
the scrub table to fixate the plastic tubing and attach two carbobands at 12 o’clock
for the light pipe and at 4 o’clock for the chandelier light (Figs. 2.10 and 2.11).

2.3 Devices

2.3.1 Light Source

The light source is either external or is integrated into the vitrectomy machine. The
recent generation of vitrectomy machines (Constellation, Stellaris PC, EVA) has a
stronger internal light source which suffices for use of a chandelier light (Fig. 2.1).
20 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.4 We painted our neon tubes with red colour like in submarines. The red light gives suffi-
cient light and causes much less glare than white light
2.4 Instruments for Vitrectomy 21

Fig. 2.5 We use a vacuum


pillow which provides a
customized positioning and
fixation of the patients
head

A good alternative is an external light source such as a photon light source


(Synergetics) or a xenon light source (DORC and Alcon) (Fig. 2.3).

2.3.2 Binocular Indirect Ophthalmo Microscope (BIOM) Systems

We use a wide-angle lens (120D) for peripheral vitrectomy and scatter laser photocoagu-
lation (Fig. 2.2). We use a 90D or 60D for peeling of fibrovascular membranes. If you do
not have a 60D lens for your BIOM system, then use a plano concave contact lens (1284.
DD, DORC). The contact lens provides an excellent zoom and depth perception.

2.4 Instruments for Vitrectomy (Figs. 2.12, 2.13, 2.14, 2.15,


2.16, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23, 2.24, 2.25, 2.26,
2.27, 2.28, 2.29, 2.30, 2.31, 2.32, 2.33, 2.34, 2.35, 2.36, 2.37,
2.38, 2.39, 2.40, 2.41, 2.42, 2.43, 2.44, 2.45, 2.46 and 2.47)

Retinal surgery is a very “instrumental” operating area. This means that a surgeon
requires many different instruments (Fig. 2.12), significantly more than during
phacoemulsification. Therefore, the surgeon should be familiar with all the different
22 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.6 A foot pump is


required to pump up the
pillow. The complete
procedure takes a few
seconds (German, Sweden
GE22393300000
55 × 30 cm)

instruments, because high surgical quality will only be obtained by their applica-
tion. The individual surgical instruments are introduced below.
The main limitation for 27G vitrectomy is the limited amount of available instru-
ments. But this is changing quickly. Until now there is a backflush instrument, an
endodiathermy, a laser probe, a peeling forceps and very recently intravitreal scis-
sors available. As a retinal scraper, we use a blunt 27G retrobulbar cannula
(Atkinson, Beaver-Visitec, USA). The 27G vitreous cutter can be used more exten-
sively than a 23G vitreous cutter. The today equipment is therefore sufficient for
approximately 80 % of all cases.

2.4.1 Vitrectomy Set

Here you will find all the details of our vitrectomy instrument set, which we use at
the University Hospital of Uppsala (Fig. 2.12). The instruments vary, of course,
from hospital to hospital.

1. 1× lid speculum Lieberman. Geuder G-15960


2. 1× irrigating cannula. Geuder G-15180 (for irrigation of the eye)
3. 1× dressing forceps, serrated. Geuder G-18781
4. 1× tissue forceps, 1 × 2 teeth. Geuder G-18791
2.4 Instruments for Vitrectomy 23

Fig. 2.7 The set-up in our Small TV


OR. We have no assistant
and the surgeon indents on
his own. There is a large
TV screen behind the
surgeon for visitors and
scrub nurse. The surgeon
has a view to a small TV
screen on the other side

Patient
Vitrectomy
machine

Surgical table
Micro-
Scope
Scrub nurse

Surgeon

Large TV

5. 1× Castroviejo suturing forceps, straight. Geuder G-19023


6. 1× Barraquer Cilia forceps. Geuder G-18750 (for suturing)
7. 1× trocar forceps. DORC 1276.2 (for removal of the trocars)
8. 1× eye scissors, straight pointed/pointed 9 cm. Geuder G-19350
9. 1× Vannas scissors. Geuder G-19760
10. 1× Halsted mosquito forceps, curved serrated. Geuder G-18181
11. 1× Hartman mosquito forceps, straight serrated. Geuder G-18170 (for disinfec-
tion of the eye)
12. 1× Barraquer needle holder, curved, without lock. Geuder G-17500
13. 1× sclera depressor, double ended. Geuder G-32715
14. 1× Braunstein fixed caliper. Bausch & Lomb E2402 (scleral marker 3.5 and
4.0 mm)

2.4.2 Trocars (Fig. 2.13)

Almost all ophthalmic companies have trocars with valves in their product portfolio
(Alcon, DORC, Bausch & Lomb, Geuder) (Fig. 2.13). The valve prevents the out-
flow of intraocular water. We recommend trocars with valves. They are especially
pleasant for beginners, because the eye is always normotensive. The valves maintain
24 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.8 A photograph of our OR. There is usually no assistant present

Fig. 2.9 The position of Small TV


the vitrectomy machine,
surgical table and scrub
nurse varies from OR to
OR. This is an alternative
set-up with a separate
surgical table in front of
the surgeon. A vitreous
cutter and light pipe are
placed on this table. The Patient
tubes are fixated with a Vitrectomy
Small surgical table
Velcro fibre tape. The machine
with vitreous cutter
advantage is that the and light pipe Surgical table
surgeon can access these
main instruments on his
Scrub nurse
own

Surgeon

Large TV

a closed system, i.e. when removing the instruments or even when stopping the infu-
sion, the eye remains normotensive. They prevent vitreous incarceration into the
sclerotomies and reduce therefore the risk of sclerotomy related tears. They reduce
the intraocular flow of fluids and cause less damage to the photoreceptors.
Trocars without valves have disadvantages: In cases of a PFCL-filled eye, they
easily cause PFCL bubbles. This is hardly the case in trocars with valves. Trocars
without valves need to be closed with plugs, and a fluid–air exchange without closed
trocars can lead to a dangerous hypotony. All these problems can be avoided if tro-
cars with valves are used.
2.4 Instruments for Vitrectomy 25

Fig. 2.10 We use a Velcro


fibre tape to fasten the
tubes of the instruments on
the surgical table and on
the surgical drape

Important The closed valve trocar system has the disadvantage that no open
“drain” is present as in conventional 20G vitrectomy. If a fluid or gas is injected into
the eye, the intraocular pressure increases. This problem can be avoided by the use
of a special infusion cannula, which simultaneously injects and removes fluid
(double-barrelled cannula).

2.4.3 Trocar Forceps (Figs. 2.14a, b and 2.15)

Indication: For manipulation of trocars. A very useful forceps for any kind of
manipulation of trocars. DORC 1276.2

2.4.4 Scleral Marker (Figs. 2.16 and 2.17)

Indication: To mark the position of the sclerotomy on the sclera—3.5 mm for pseu-
dophakic and 4 mm for phakic eyes. Many manufacturers incorporate a marker in
the handle of the trocar inserter.
26 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.11 Package with


details of a Velcro fibre
tape

2.4.5 Scleral Depressor (Fig. 2.18)

A scleral depressor indents the retina. It is a standard instrument for pars plana vit-
rectomy. It is used for trimming of the vitreous base, in particular in retinal detach-
ment surgery. With a 3-port vitrectomy and chandelier endoillumination, one can
use the scleral depressor for bimanual trimming of the vitreous base using the vitre-
ous cutter or for panretinal photocoagulation up to the ora serrata. Remember: No
one can indent as well as your second hand.

2.5 27G Standard Instruments

In the following, all available 27G standard instruments are listed. The companies
with the biggest 27G portfolio are DORC, Synergetics, Alcon and Medilens. The
27G standard instruments (light pipe and vitreous cutter) are softer than their 25G
counterparts. They bend more easily when working in the periphery.
2.5 27G Standard Instruments 27

Fig. 2.12 The vitrectomy instrument set at the University Hospital in Uppsala

Fig. 2.13 A 27G trocar


(DORC)

2.5.1 Vitreous Cutter (Figs. 2.19a, b and 2.20)

High-speed vitreous cutters have a cut rate of 5000–7500 cuts/min. The newest gen-
eration of vitreous cutters has a double cut rate of 10,000–15,000 cuts/min (Two
Dimensions Cutter, DORC). They enable a much faster removal of the vitreous and
keep a detached retina very stable. The 27G vitreous cutter has a port which is located
close to the end of the tip. This feature allows to place and manoeuvre the vitreous cut-
ter very close to the retina, e.g. for induction of PVD and manipulation of membranes.
28 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.14 (a) Trocar a


forceps. DORC 1276. (b)
A very useful instrument
for manipulation of trocars

Fig. 2.15 The trocar


forceps fixates a trocar
during insertion of the
infusion line

Fig. 2.16 Scleral marker. Braunstein fixed caliper. Bausch & Lomb, Storz instruments: E2402

2.5.2 Endoillumination

2.5.2.1 Hand-Held Light Probes (Fig. 2.21a–c)


In 27G the following hand-held light probes are available:

1. TotalView Endoillumination Probe, 27 gauge/0.4 mm, length 15 DORC 3269.


B04
2. Shielded TotalView Endoillumination Probe DORC 3269.SBS04
2.5 27G Standard Instruments 29

Fig. 2.17 The scleral


marker in action. We use it
for every vitrectomy

Fig. 2.18 A scleral depressor for indentation of the retina. Geuder. G-32 715

Fig. 2.19 (a) A novel a


vitreous cutter with two
blades and permanent flow.
In one stroke (up and
down), two cuts are
performed, effectively
doubling the cutting b
frequency:
8000 × 2 = 16,000 cuts/min
(DORC, TDC cutter). (b)
Note the second cutting
port, which enables a
permanent and stable flow

2.5.2.2 Chandelier Light Fibre (Figs. 2.22, 2.23 and 2.24)


A chandelier light provides a panoramic light source and illuminates the entire fun-
dus. A chandelier light is either fixated directly in the sclera (Figs. 2.22 and 2.24) or
in a trocar (Fig. 2.23). This enables bimanual surgery and allows the surgeon to use
a second active instrument in addition to the vitreous cutter. In 27G an Eckhardt
twin light chandelier (DORC 3269.MBD27) is available.
For optimal illumination of a chandelier light, an external light source (Photon,
Xenon) or a modern vitrectomy machine (Stellaris PC, Constellation, Eva) is required.
30 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.20 A typical view


on a 27G trocar set-up with
high infusion line. Note the
same size of a 27G grey
cannula and a 27G vitreous
cutter

Fig. 2.21 (a–c) A 27G a


light fibre (a) with an open
light tip (b) (DORC 3269.
B04) and a shielded light
tip (c) (DORC, 3269.
SBS05) b c

Fig. 2.22 Chandelier


lights. An Eckhardt twin
light chandelier (DORC,
3269.MBD27)

2.5.3 Peeling Instruments

2.5.3.1 Delamination of Membranes

Membrane Pic (Figs. 2.25a, b)


Indication: To elevate a membrane, which is firmly attached to the retina. DORC
1292.EO4

Retinal Scraper (27G Retrobulbar Cannula Atkinson, Figs. 2.26a, b and 2.27)
This blunt cannula is suitable for opening of the posterior hyaloid or delamination
of flat membranes. The membrane can be lifted up with the blunt cannula and then
2.5 27G Standard Instruments 31

Fig. 2.23 A DORC


chandelier light which is
fixated with a trocar
(DORC, 3269.EB06)

Fig. 2.24 We use the 25G


wide-field Awh chandelier
from Synergetics with the
Photon light source from
Synergetics

Fig. 2.25 (a, b) A 27G membrane pic (a) and tip (b). Indication: delamination of membranes.
DORC, 1292.E04
32 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.26 (a, b) The 27G


retrobulbar cannula a
(Atkinson) (a) is very
useful for manipulation of
membranes. The blunt tip
(b) may be used for
delamination of a
membrane or opening of
the posterior hyaloid or
b
ILM

Fig. 2.27 The package of


the retrobulbar cannula
(Atkinson), Beaver Visitec

b
Fig. 2.28 (a) 27G
disposable intravitreal
forceps. DORC. (b)
Eckhardt endgripping
forceps. Indication:
removal of membranes and
ILM. DORC, 1286.WD04
2.5 27G Standard Instruments 33

Eckardt Tano asymmetrical

Fig. 2.29 Eckardt and Tano forceps (Synergetics forceps, 27G)

Fig. 2.30 Power


endgripping forceps.
Indication: removal of
PVR membranes. DORC,
1286.WPD04

Fig. 2.31 27G disposable


curved intravitreal scissors.
Indication: cutting of PVR
or diabetic membranes.
DORC, 2286.PD04

be removed with the microforceps. Beaver-Visitec, 27G retrobulbar cannula


Atkinson.

2.5.3.2 Removal of Membranes

Eckhardt Endgripping Forceps (Figs. 2.28a, b and 2.29)


The 27G endgripping forceps from DORC is a mix of ILM forceps and endgrip-
ping forceps. It functions well for ILM, membranes or grasping of luxated
IOL. DORC, 27G disposable microforceps.1286.WD04 and Synergetics 27G,
39.08.27PIN
34 2 Optimal Visualization, Optimal Instruments and Optimal Technique

b c

Fig. 2.32 (a–c) A 27G Charles flute instrument (backflush instrument). Two indications: (1) aspi-
ration of fluid (blunt and brush needle, b). (2) Non-traumatic work on the retinal surface and
delamination of epiretinal membranes (brush needle, c) (DORC 2281.AD04)

Fig. 2.33 27G backflush cannula. Indication: (1) can be attached to a backflush handpiece. (2)
Can be attached to a 3 cc syringe to inject dye (Medilens)

Fig. 2.34 Active aspiration: A flute instrument is attached to an infusion tube which is inserted
into the vitrectomy machine. Then the active aspiration mode is activated. Close the opening of the
tubing with your index finger and press the foot pedal. The intraocular fluid is aspirated into the
vitrectomy machine. Active aspiration is required for 25G and 27G

Power Endgripping Forceps (Fig. 2.30)


The power endgripping forceps is useful for firmly attached membranes such
as in PVR retinal detachment. DORC, 27G disposable microforceps. 1286.
WPD04
2.5 27G Standard Instruments 35

Fig. 2.35 When removing a dropped nucleus, the Charles flute needle gets easily clogged. Eject
the clogging particles with forceful injection of BSS

Fig. 2.36 27G endodiathermy handpiece. Indication: cauterizing of bleeding vessels or marking
of retinal tears. DORC, 1120.04

Fig. 2.37 (a, b) 27G laser probe (a) with a curved tip (b) (DORC, 7527)

Fig. 2.38 Fragmatome handpiece. Indication: removal of a dropped nucleus. Alcon Accurus frag-
matome. In addition you need the fragmatome accessory pack (REF 1021HP)

Tano Asymmetrical Forceps (Fig. 2.29)


For fine membranes and useful for diabetic membranes. Synergetics, 27G. 0904A

Curved Microscissors (Fig. 2.31)


The microscissors are a useful instrument for cutting of membranes and a retinec-
tomy. DORC, 27G disposable microscissors. 2286.PD04
36 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.39 Foreign body


forceps: (1) 17G
microforceps—Avci
Foreign Body. DORC.
2286.H; (2) 20G
intravitreal foreign body
forceps: Geuder 36264

Fig. 2.40 A 60 cc syringe filled with gas is attached to the three-way crane and then instilled into
the eye

2.6 Miscellaneous

2.6.1 Backflush Instrument (=Charles Flute Needle) (Figs. 2.32


a–c, 2.33, 2.34 and 2.35)

Indication: For aspiration of fluid and pressure control. It aspirates in fluid by capil-
lary force and pressure difference. Use active suction when working with 27G
2.6 Miscellaneous 37

Fig. 2.41 A 10 ml silicone oil syringe which is filled with silicone oil. DORC

Fig. 2.42 A 27G cannula


is attached to the syringe
for silicone oil injection.
DORC, 1272.VFI04

Fig. 2.43 Silicone oil


removal with plastic pipe
for 20G–27G (DORC)

Fig. 2.44 Vicryl 8-0


suture for suturing of
conjunctiva and
sclerotomies
38 2 Optimal Visualization, Optimal Instruments and Optimal Technique

Fig. 2.45 Mersilene 5-0


(Ethicon): suturing of a
cerclage

Fig. 2.46 Supramid 5-0


(Serag Wiessner): suturing
of a silicone sponge

(Fig. 2.34). The backflush handpiece and the backflush cannula are available as one
instrument or as two separate instruments (DORC, MedOne).

2.6.2 Endodiathermy Probe (Fig. 2.36)

An endodiathermy probe is useful for (1) marking of retinal breaks in detachment


surgery and (2) cauterizing bleeding retinal vessels such as those present in diabetic
retinopathy. When treating an acute intraocular haemorrhage, the surgeon must
work bimanually. One hand should hold the endodiathermy probe while the other
hand holds the backflush instrument.

2.6.3 Laser Probe (Fig. 2.37a, b)

Curved and straight laser probes are available in 27G (DORC, Synergetics).
Extendable/retractable laser probes are not yet available in 27G. The curved laser
2.6 Miscellaneous 39

Fig. 2.47 Polypropylene


10-0 with 1 curved and 1
straight needle: for scleral
fixation of IOL (Alcon)

is particularly suitable for the peripheral retina. If a peripheral laser treatment


is applied (break, peripheral ischemic retina), the use of a scleral depressor is
recommended, which makes the break more accessible and avoids touching the
lens. This can be performed either using a chandelier light and a scleral depressor
or using the light pipe as a scleral depressor with transscleral illumination. An
alternative are laser probes combined with endoillumination. These are until now
not available for 27G.

2.6.4 Fragmatome (Fig. 2.38)

The fragmatome can be used to emulsify a dropped nucleus in the vitreous cavity. It
is available in 23G but is used without a trocar cannula. A fragmatome is difficult to
use. On the one hand, it is less powerful than a normal phaco handpiece. On the
other hand, it can exert high levels of suction in the posterior segment. Aspiration of
the vitreous or the retina into the handpiece must be avoided. Lens fragments tend
to jump away from the needle tip. In such cases, one must aspirate the fragments in
the needle tip before emulsification.

2.6.5 Foreign Body Forceps (Fig. 2.39)

The foreign body forceps are executed by a 20G sclerotomy (without trocar) in the
eye. Available are 17G, 19G and 20G foreign body forceps. The sclerotomy must of
course be enlarged if necessary. I recommend forceps with a roughened surface grip
(diamond dusted).

2.6.6 Instruments for Gas Tamponade

Figure 2.40
40 2 Optimal Visualization, Optimal Instruments and Optimal Technique

2.6.7 Instruments for Silicone Oil Tamponade (Figs. 2.41, 2.42


and 2.43)

The 27G cannula for silicone oil injection requires a long injection time. If you want
to speed up this procedure, a 25G cannula is advisable.

2.6.7.1 Silicone Oil Injection and Extraction Set (Fig. 2.41)


Indication: For injection and removal of silicone oil

1. 27G plastic cannula (DORC) (Fig. 2.42)

Indication: For injection of light silicone oil

2. 27G silicone oil removal plastic pipe (DORC) (Fig. 2.43)

Indication: For removal of silicone oil. This plastic pipe is attached to the trocar
and can be used for 23G, 25G and 27G.

2.6.8 Dyes

2.6.8.1 Backflush Cannula (=Flute Needle) (Fig. 2.33)


The 27G backflush flute needle can also be used for injection of fluids (e.g. PFC or
dye) into the eye. We use to inject dye with a normal 3 cc syringe which enables a
smooth injection of dye. (27G cannula MedOne 3257)

2.6.8.2 Triamcinolone
Kenalog (Squibb): Indication: For staining of the vitreous and membranes

2.6.8.3 Trypan Blue and Brilliant Blue G


Contains two dyes (trypan blue and brilliant blue G) (Membrane Dual®, DORC):
Indication: For staining of the vitreous, epiretinal membranes and ILM

2.6.9 Sutures

2.6.9.1 Vicryl 8-0 (Fig. 2.44)


Indication: Suture of a sclerotomy or conjunctiva (Ethicon)

2.6.9.2 Mersilene 5-0 (Fig. 2.45)


Indication: Suturing of an encircling band (cerclage) (Ethicon)

2.6.9.3 Supramid 4-0 (Fig. 2.46)


Indication: Suturing of an episcleral sponge (Serag - Wiessner)

2.6.9.4 Polypropylene 10-0 (Fig. 2.47)


Indication: Scleral fixation of a three-piece IOL (Alcon)
Part III
Optimal Techniques for 27G
Usage of 27G Instruments
3

Contents
3.1 Insertion of Trocars .......................................................................................................... 43
3.2 Valve Removal and Replacement...................................................................................... 44
3.3 Removal of Trocar Cannulas............................................................................................. 45
3.4 Endoillumination............................................................................................................... 47
3.4.1 Usage of a Light Fibre .......................................................................................... 48
3.4.2 Insertion of Chandelier Light in Sclera or Trocar ................................................. 50
3.4.3 FAQ 56
3.5 Usage of a Double-Cut Vitreous Cutter ............................................................................ 56
3.6 Usage of a Charles Flute Instrument ................................................................................. 57

All 27G instruments allow to operate more delicate and atraumatic than 25G or 23G
instruments. This results in less trauma and faster postoperative recovery.

3.1 Insertion of Trocars (Figs. 3.1, 3.2 and 3.3)

27G instruments are softer than their 25G counterparts. A vitreous base shaving
is rather difficult because the vitreous cutter is soft and bends when working in the
periphery. A peripheral vitrectomy can be nonetheless performed without problems
with exception of the superior pole from 11 o’clock to 1 o’clock. To overcome this
problem, insert the superotemporal trocar towards 12 o’clock (instead towards 6
o’clock). Now the vitreous cutter bends less and you can reach easily the 12 o’clock
position.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 43


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_3
44 3 Usage of 27G Instruments

Fig. 3.1 Insertion of 27G


trocars (DORC). Insert the
infusion trocar as usual

Fig. 3.2 Insert the


instrument trocars towards
12 o’clock

This problem only exists if you do not indent, e.g. if you do not work with chan-
delier light. If you insert a chandelier light, you can indent the vitreous base and
remove it easily.

3.2 Valve Removal and Replacement (Figs. 3.4, 3.5 and 3.6)

Fixate the trocar with the trocar forceps (DORC). Then remove the valve with an
anatomic forceps. If you reattach the valve: Fixate the trocar with the trocar forceps,
place the valve on your index finger and place the valve onto the trocar.
3.3 Removal of Trocar Cannulas 45

6 o’ clock 6 o’ clock

Infusion

Yes
No

12 o’ clock 12 o’ clock

Fig. 3.3 27G instruments are softer than 25G instruments. An insertion of trocars towards 12
o’clock facilitates the trimming of the vitreous base at the superior pole

Fig. 3.4 The valve has


been removed

3.3 Removal of Trocar Cannulas (Figs. 3.7 and 3.8)

It is useful to remove the trocars in the following order: first the instrument trocars,
then the chandelier light and finally the infusion cannula. The infusion cannula
remains in place until the end to avoid hypotension when removing the trocars. The
infusion should therefore remain open until removal of the infusion cannulas.
To remove the trocars, pull out the trocar with the trocar forceps, and then press
the edges of the sclerotomy together with a forceps and massage the sclerotomy
with a cotton swab. Lastly the infusion cannula is removed. Before you do this,
check the intraocular pressure manually.
46 3 Usage of 27G Instruments

Fig. 3.5 Fixate the trocar


with the trocar forceps.
Place the valve on the tip
of the index finger

Fig. 3.6 Then place the


valve on the trocar

If the globe is hypotensive after trocar removal, refill the eye with gas, until the
eye is normotensive. Refill the eye before removing the infusion line and infusion
trocar. In case of silicone oil, the eye should be rather hypotensive (approx.
8–10 mmHg). Then the infusion cannula with running infusion (BSS, air or oil) is
removed. The sclerotomies are usually not sutured. Exceptions are silicone oil tam-
ponades, because the oil may cause subconjunctival cysts.
A major advantage of not suturing a gas-filled eye is that the eyes are rarely
hypertensive, as the expanding gas can escape postoperatively through the
3.4 Endoillumination 47

Fig. 3.7 Trocar removal.


Remove the 27G trocar
with a trocar forceps
(DORC)

Fig. 3.8 Press against the


sclerotomy with an
anatomic forceps

non-sutured sclerotomies. There is of course less leakage present with 27G com-
pared with 23G. If you observe uveal tissue or even a vitreous prolapse out of the
sclerotomy you should remove it with the vitreous cutter because otherwise there is
a possible wicking and endophthalmitis risk. 27G sclerotomies require no suture.

3.4 Endoillumination

Endoillumination is essential for optimal visualization. Test different light sources,


light probes and chandelier lights to achieve an optimal view to fundus.
48 3 Usage of 27G Instruments

3.4.1 Usage of a Light Fibre (Figs. 3.9, 3.10, 3.11, 3.12, 3.13, 3.14,
3.15 and 3.16)

The 27G light fibres bend easier than their 25G counterparts. This is especially evi-
dent when working at the vitreous base. The superior vitreous base is difficult to
access especially because the nose of the patient is in the way. We recommend
therefore to insert the trocars towards 12 o’clock and/or to insert a chandelier light
and indent the vitreous base.

Fig. 3.9 Conventional


monomanual vitrectomy

Fig. 3.10 Monomanual


vitrectomy. One hand is
occupied with the light
probe and only one hand is
free to operate
3.4 Endoillumination 49

Fig. 3.11 4-port


vitrectomy with chandelier
light for bimanual
vitrectomy

Fig. 3.12 Bimanual


vitrectomy. Both hands are
free and allow the usage of
two instruments. Even
scleral indentation is
performed by the surgeon
himself

Chandelier
illumination

There are two different fixation methods for a chandelier light: One is
inserted directly into the sclera (e.g. Eckardt twin light (DORC) or Awh
(Synergetics)) and the other one is inserted into a trocar (e.g. DORC or Vivid
Synergetics). We use the scleral-based chandelier light for eyes which are not
vitrectomized and the trocar-based chandelier light for eyes which are vitrecto-
mized and have a soft globe.
50 3 Usage of 27G Instruments

Fig. 3.13 Panoramic


illumination of the fundus
with a chandelier light

Fig. 3.14 There are two


different ways to fasten the
chandelier light. This one
is fastened into the sclera
(25G Awh, Synergetics)

3.4.2 Insertion of Chandelier Light in Sclera or Trocar (Figs. 3.17,


3.18, 3.19, 3.20, 3.21, 3.22, 3.23, 3.24, 3.25 and 3.26)

Video 3.1: Insertion of a chandelier light (audio)

The chandelier light is best positioned inferonasally, because this location does
not affect the rotation of the eye. The 12 o’clock or 6 o’clock insertion sites disturb
the rotation of the globe, and the light fibre is easily dislocated when the globe is
rotated upwards or downwards. Some chandelier lights (Synergetics, Alcon) have a
rigid cable which allows bending of the light fibre and henceforth the ability to
manoeuvre the light to different directions in the vitreous cavity.
3.4 Endoillumination 51

Fig. 3.15 This chandelier


light is fastened into a
trocar (DORC). We use
always the inferonasal
position because it is the
only free quadrant

Fig. 3.16 This chandelier


light is also trocar based
(25G Vivid, Synergetics).
In vitrectomized eyes a
trocar-based chandelier
light is easier to insert than
a scleral-based chandelier
light because the eyes are
soft

The scleral-fixated chandelier light from Synergetics is trickier to place but pro-
vides, on the other hand, an excellent panoramic illumination of the vitreous cavity.
Rotate the globe with a swab in a superotemporal direction so that there is space for
the insertion of the chandelier light inferonasally. With the sclerotomy needle sup-
plied by the manufacturer, the surgeon first performs a transconjunctival sclerotomy
3.5 mm posterior to the limbus with a perpendicular (not lamellar) path. The chan-
delier light is then inserted into the sclerotomy. This procedure requires some prac-
tice (Figs. 3.17, 3.18, 3.19 and 3.20). The Synergetics chandelier light requires an
external Photon light source or a new-generation vitrectomy machine. By bending
the rigid cable of the chandelier light, the surgeon can manoeuvre the light fibre.
Sometimes it is necessary to tape the cable to the drape.
52 3 Usage of 27G Instruments

Fig. 3.17 Insertion of a


scleral-based chandelier
light. Rotate the eye with
the cotton wool swab and
mark the sclerotomy with a
scleral marker

Fig. 3.18 Pierce the 25G


needle perpendicular
through conjunctiva and
sclera

Fig. 3.19 And insert the


chandelier light. If you are
not able to insert the light,
then widen the sclerotomy
with a normal 23G cannula
3.4 Endoillumination 53

Fig. 3.20 The Synergetics


light contains a rigid cable
which allows steering the
light

Fig. 3.21 The DORC light


is simply inserted into a
trocar

Fig. 3.22 Any 25G trocar


may be used
54 3 Usage of 27G Instruments

Fig. 3.23 Insertion of a


trocar (Synergetics) for a
25G Vivid, Synergetics
light

Fig. 3.24 Fixate the trocar


with a trocar forceps
(DORC)

If a surgeon has never used a chandelier light before, then he or she should start
with one which can be easily inserted. The 23G chandelier light from DORC
(Figs. 3.21 and 3.22) and the 25G chandelier light from Synergetics (Figs. 3.23,
3.24, 3.25 and 3.26) are simple to use as the light fibre can be placed inside a normal
one-step trocar.
3.4 Endoillumination 55

Fig. 3.25 Insert the light


fibre and fixate the plastic
stopper into the trocar

Fig. 3.26 This light has


no rigid cable and cannot
be steered

Surgical Pearls No. 1


Insertion of a Synergetics chandelier light:
1. The insertion of the chandelier light is easier using hands rather than with the
trocar forceps. But the surgeon must exert a relatively strong pressure to
insert the tip of the chandelier through the sclera. If this does not succeed, the
surgeon can expand the sclerotomy with a 23G cannula. The insertion is now
easier, but the chandelier sits a little loose in the sclerotomy.
2. Conjunctival chemosis or haemorrhage may make it difficult to identify the scle-
rotomy. In such cases, use a pressure plate (DORC, no 2117) or open the con-
junctiva focally with scissors and forceps in order to visualize the sclerotomy.
56 3 Usage of 27G Instruments

3.4.3 FAQ

1. Why is the inferonasal quadrant the optimal place for insertion of the chandelier
light? We insert our trocars in three quadrants, it is therefore logical to use the
fourth empty quadrant for the chandelier light.
2. Why is the inferonasal quadrant better than the 12 o’clock? Because there is no
space at 12 o’clock. You would not insert a trocar at 12 o’clock, so why insert a
chandelier light at 12 o’clock? If you rotate the globe, you do not affect the chan-
delier light in the inferonasal quadrant: In contrary you affect the chandelier light
at 12 o’clock if you rotate the globe,
3. What features should a chandelier light have? First of all is good panoramic
illumination of the complete retina. Then it would be appreciated if you can steer
the light, e.g. through a soft wire. Thirdly an easy insertion is important; the easi-
est insertion is via a trocar.

3.5 Usage of a Double-Cut Vitreous Cutter (Figs. 3.27, 3.28,


3.29 and 3.30)

Video 3.2: Regular cutter


Video 3.3: TDC cutter

The newest generation of vitreous cutters has a double cut rate of 10,000–
15,000 cuts/min (Two Dimensions Cutter, DORC). This vitreous cutter has two
blades instead of the usual one and a constant flow. This innovation enables a much
faster removal of the vitreous and keeps a detached retina very stable.

Fig. 3.27 A novel TDC vitreous cutter (DORC)

Fig. 3.28 This cutter has a


second cutting port
allowing a permanent and
stable flow
3.6 Usage of a Charles Flute Instrument 57

Fig. 3.29 The cutter has


two blades

Forward cut, cut 1 Backward cut, cut 2

Fig. 3.30 And cuts twice in one stroke (forwards and backwards)

Fig. 3.31 Active


aspiration. The 27G
lumen is so small that
you need to perform a
fluid–air exchange with
active aspiration

3.6 Usage of a Charles Flute Instrument (Fig. 3.31)

The Hagen–Poiseuille law is very evident when aspirating passively with a 27G
backflush instrument. It is very slow. It is therefore advisable to use active aspira-
tion. You can also use a 27G vitreous cutter. For fluid–air exchange is a backflush
instrument with active aspiration faster than a vitreous cutter.
Important Vitreoretinal Techniques
with 27G 4

Contents
4.1 Induction of Posterior Vitreous Detachment ..................................................................... 59
4.2 Trimming of Vitreous Base ............................................................................................... 63
4.2.1 Complications 65
4.3 Staining of Membranes ..................................................................................................... 66
4.4 Peeling of Membranes ...................................................................................................... 67
4.5 Endodiathermy .................................................................................................................. 70
4.6 Laser Treatment ................................................................................................................ 70

27G instruments are more delicate than their 23G and 25G counterparts. In addi-
tion, the dilemma of the Hagen–Poiseuille law reduces the flow significantly. These
different features require specific adjustments for vitreoretinal techniques.

4.1 Induction of Posterior Vitreous Detachment (Fig. 4.1)

Video 4.1: PVD with Atkinson cannula (no audio)


Video 4.2: 27G difficult PVD (audio)

A PVD induction is easier to perform with a 27G vitreous cutter because it can
be placed very close to the retina. For this step, we routinely use a 90D front lens.
To induce a posterior vitreous detachment is a difficult procedure in the learning
phase. We therefore recommend staining the vitreous first with triamcinolone or

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 59


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_4
60 4 Important Vitreoretinal Techniques with 27G

Fig. 4.1 Induction of PVD


with vitreous cutter. Note
the silky appearance of the
posterior vitreous

trypan blue. The vitreous body is then much easier to identify and the induction of
posterior vitreous detachment significantly easier.
For induction of PVD, position the vitreous cutter just in front of the optic disc,
and then increase suction (foot pedal to bottom position) to a maximum. In the suc-
tion phase, the cortex and especially the posterior hyaloid will be engaged in the
aspiration port. Then draw the vitreous cutter slowly with maximal suction towards
the lens. Perform this manoeuvre in all directions. If the manoeuvre is successful,
you will see a kind of fine silk screen that moves forward together with the vitreous
cutter. Sometimes, this whole manoeuvre must be repeated several times until it
succeeds. Before you repeat the manoeuvre, cut the aspirated vitreous in the vitre-
ous cutter to prevent traction and tractional tears and then place the vitreous cutter
in front of the optic disc again.

Surgical Pearls No. 2


PVD:
1. The correct assessment of the relationship between the posterior vitreous
face and the retina/optic disc is one of the key steps to master pars plana
vitrectomy. Always check if a PVD is present or not. Even in cases when
you expect a PVD to be present (e.g. retinal detachments), you will some-
times be surprised by an attached vitreous face.
2. The freshly detached posterior vitreous face has a “beaten metal” appear-
ance. You know that you have induced a PVD if you see this appear on the
posterior surface of the vitreous. When a PVD is induced, suddenly, a lot
more vitreous, which must be removed, will appear in the vitreous cavity.
4.1 Induction of Posterior Vitreous Detachment 61

Surgical Pearls No. 3


PVD and dye:
1. We recommend beginners to stain the vitreous at the beginning of vitrec-
tomy for the first 10–20 vitrectomies. The vitreous is much easier to recog-
nize, and vitrectomy and especially the induction of a posterior vitreous
detachment become considerably easier.
2. To stain the posterior vitreous face with triamcinolone: Perform a core
vitrectomy and a peripheral vitrectomy in front of your ports. Induce the
cannula into the mid vitreous (be careful not to inject peripherally, or you
will inject in to the vitreous base and exert traction). Inject a small amount
of triamcinolone that will drop down onto the posterior pole. This will very
nicely stain the bursa praemacularis of the vitreous. Do not inject too much
triamcinolone for vitreous staining. It will only obscure your view and will
be cumbersome to remove later on during the surgery. Few drops are suf-
ficient for staining the posterior vitreous.
3. Once the bursa praemacularis is stained with triamcinolone, try to engage
the posterior vitreous face at the optic disc. Try to cut a small break in the
posterior vitreous face nasal to the disc, then “pick up” the posterior vitre-
ous phase with the cutter and suction only. Pull anterior towards the lens.
Try to keep an eye on the advancing posterior vitreous face in the mid-
periphery. This looks like a tidal wave. It is where breaks will develop
during induction of a PVD.

Surgical Pearls No. 4 (Figs. 4.2, 4.3 and 4.4)

Fig. 4.2 Induction of PVD


with instruments. A PVD
was not successful. Note
the attached posterior
vitreous

Attached
posterior hyaloid
62 4 Important Vitreoretinal Techniques with 27G

Fig. 4.3 With help of a


27G cannula (Atkinson,
Beaver-Visitec), the
posterior hyaloid is opened

Opening in
posterior hyaloid

Atkinson
cannula

Fig. 4.4 The edge of the


posterior hyaloid is
grabbed with an
intravitreal forceps

ILM forceps

Opening of
posterior hyaloid

Difficult PVD: If you are not able to induce a PVD, try the following: (1)
Increase the vacuum to 600 mmHg and try again. (2) Stain the vitreous with
trypan blue or triamcinolone and try again. (3) Insert a 60D lens and mobilize
the posterior hyaloid membrane with an Eckardt forceps. If you have created
a hole, try to aspirate this part with a vitreous cutter and provoke a PVD. (4)
Create a hole in the posterior hyaloid with a 27G Atkinson cannula (Beaver-
Visitec). Then mobilize the hole edges with a forceps (Figs. 4.2, 4.3 and 4.4).
4.2 Trimming of Vitreous Base 63

4.2 Trimming of Vitreous Base (Figs. 4.5, 4.6 and 4.7)

After successful PVD, continue with trimming of the vitreous base. We usually use
a 120D or comparable wide-angle lens. Regarding the settings of the vitrectomy
machine, decrease the vacuum and increase the cutting frequency the closer you
work with the vitrector at the retina (Table 4.1).
When performing vitrectomy, hold the instruments almost vertically towards the
orbital apex. Make calm and slow movements, in contrast to irrigation/aspiration
during phacoemulsification. Another important difference is that you hardly move
the irrigation handpiece during phacoemulsification, but the light pipe in PPV is in
constant motion. Light pipe and vitreous cutter move simultaneously, the light pipe
illuminating the path of the vitreous cutter. You point the beam of the light pipe to
the tip of the vitreous cutter. The vitreous is often difficult to detect. You recognize
the vitreous best in the light cone. Move both instruments in a half circle in the vitre-
ous cavity as if peeling an onion from inside to outside. Remove the left half of the
vitreous body and then change the instruments to remove the right half.
In detachment surgery, the vitreous base must be removed as completely as pos-
sible, because vitreous traction is causatively responsible for the retinal break and
residual vitreous may continue to exert traction on the retina and cause postopera-
tive new breaks. For surgeries such as macular hole or macular epiretinal mem-
branes, it is not necessary to remove the vitreous base completely, because the
pathological changes are located here in the macula and not in the retinal periphery.
In contrast, working too aggressively in this area may cause more harm by inducing
retinal breaks or lens touch. The presence of the natural lens makes working in the
area of the vitreous base challenging. Firstly, there is a risk of lens touch, and sec-
ondly, access to the vitreous base is more difficult as the lens is in the way, in

Fig. 4.5 The best set-up


for a 27G vitrectomy. The
trocars (DORC) are
inserted towards 12
o’clock
64 4 Important Vitreoretinal Techniques with 27G

Fig. 4.6 An eye with


synchysis scintillans

Fig. 4.7 The novel 27G


vitreous cutter works as
fast as a regular 23G cutter.
The second cutting port
enables a stable and
permanent fluid flow
4.2 Trimming of Vitreous Base 65

Table 4.1 Approximate settings for 27G with double-cut vitrector


New-generation vitrectomy machines with
8000 x 2 = 16,000 cuts/min
Core vitrectomy 4000 400
PVD 0 400–600
Vitreous base shaving 8000 200
Opening of posterior capsule 400 400
Retinotomy 300 200
Cutting speed cuts/min Vacuum mm Hg

particular in elderly patients with a thicker lens. Finally, a vitrectomy will induce
cataract development in each and every case of phakic patients.
The trimming of the vitreous base is more difficult with 27G than with 25G or
23G because the vitreous cutter and the light pipe are softer and bend easier. This
problem is evident at the superior pole from 11 o’clock to 1 o’clock. You need to
bend the instruments to reach this area but the softness of the instruments make it
difficult. This is especially the case in the learning phase.

Surgical Pearls No. 5


When working with 27G, insert the superotemporal trocar towards the supe-
rior pole. This upward position of the trocar reduces the bending of the instru-
ments and allows in the most eyes a complete trimming of the vitreous at the
superior pole.

4.2.1 Complications

1. Scleral folds or soft globe during vitrectomy: If you view scleral folds during
vitrectomy or if the globe is soft, then stop PPV at once. The most likely cause
is a dislocated infusion line. Reinsert the infusion line and check if the globe is
normotensive and if the scleral folds have vanished.
2. Choroidal detachment due to dislocated infusion line: Relocate the infusion
line to an instrument trocar. Remove the old infusion trocar and suture the
sclerotomy. Insert a new trocar in an area away from the choroidal
detachment.
66 4 Important Vitreoretinal Techniques with 27G

4.3 Staining of Membranes (Figs. 4.8, 4.9, 4.10, 4.11 and 4.12)

Staining may become difficult if you use the syringe of the company. If too much
force is applied during injection, a sudden jet of dye can be injected into the eye
which will obscure the view and is cumbersome to remove. We recommend there-
fore to change the syringes. We use a regular 3 cc syringe instead, which is predict-
able in its behaviour (Figs. 4.8 and 4.9).
The next step is the staining of the ERM with triamcinolone or trypan blue. Stop
the infusion. Then take the syringe with the dye in one hand and eject a few drops
of the dye outside the eye in order to avoid blockage of the cannula and injection of
air (Fig. 4.10). Then insert the syringe until the tip is placed above the macula and
slowly inject a little dye to fall on the macula. After a period of about 15–30 s, turn
on the infusion and aspirate the dye with a flute needle or a vitreous cutter.
Some PVR membranes cannot be easily detected; we recommend therefore to
stain the membranes with trypan blue. In case of centrally located membranes, you
can stain in a BSS-filled eye. But in case of peripherally located membranes, this
method does not work because the dye falls onto the posterior pole. You need to
perform therefore a fluid–air exchange and drop the dye directly on the membranes
(Figs. 4.11 and 4.12). Wait 30 s, aspirate the dye from the posterior pole and per-
form an air–fluid exchange. With this method, a higher concentration of the dye is
reached and therefore a better staining of the membranes.

Fig. 4.8 A 27G flute


needle cannula (Medilens)

Fig. 4.9 We refill the dye


into a regular 3 cc syringe
and attach the 27G flute
needle. The regular syringe
allows a controlled release
of the dye

Fig. 4.10 Dye injection in


a BSS-filled eye: the dye is
heavier than BSS and falls
onto the posterior pole
4.4 Peeling of Membranes 67

Fig. 4.11 What to do if


the membrane is located in
the periphery? Inject dye in
e
an air-filled eye. In blu
n
addition, you achieve a ypa
high concentration of dye Tr

Air

Starfold

Fig. 4.12 Peripheral


staining of a PVR
membrane is only possible
in an air-filled eye. Then
change to BSS and start
peeling

4.4 Peeling of Membranes (Figs. 4.13, 4.14, 4.15, 4.16, 4.17,


4.18 and 4.19)

Video 4.3: Diabetic peeling


Video 4.4: PFCL bubble and membrane peeling 27G retinal scraper (Atkinson
cannula)

The difficulty of peeling depends to a large amount on the instrument, even if


you are an experienced vitreoretinal surgeon. Test therefore many different peeling
forceps to find the one which suits you best.
68 4 Important Vitreoretinal Techniques with 27G

The limitation of 27G instruments is very much evident regarding the removal of
membranes. But only in the last half year, several new 27G instruments have been
produced. For delamination of the membrane, we use a 27G blunt retrobulbar can-
nula (Atkinson, Beaver-Visitec) (Figs. 4.13, 4.14 and 4.15). Alternatively you can
use a membrane pic (DORC). For dissection of membranes, three different forceps
from DORC are available. In my experience, the 27G endgripping forceps (DORC)
is suitable for every tissue from ILM to IOL (Figs. 4.16, 4.17 and 4.18). Vitreoretinal
tractions can be cut with curved 27G microscissors (DORC) (Fig. 4.19).

Fig. 4.13 Delamination of


a diabetic membrane with
27G instruments

Fig. 4.14 There is no 27G


retinal scraper available

Fig. 4.15 The 27G blunt


cannula (Atkinson, Beaver
and Visitec) works
excellent as scraper
4.4 Peeling of Membranes 69

Fig. 4.16 The ILM can


also be opened easily with
a 27G Atkinson cannula

Fig. 4.17 ILM peeling


with a 27G endgripping
forceps (DORC)
70 4 Important Vitreoretinal Techniques with 27G

Fig. 4.18 The 27G


endgripping forceps can be
used for membranes and
ILM (DORC)

Fig. 4.19 A difficult


diabetic case. The
tractional membrane is cut
with a 27G curved scissors
(DORC)

4.5 Endodiathermy (Figs. 4.20, 4.21, 4.22 and 4.23)

There is a reusable 27G endodiathermy available from DORC and a disposable 27G
endodiathermy from Alcon.

4.6 Laser Treatment (Figs. 4.24 and 4.25)

If the break is so peripheral that you need a scleral depressor to see it, you must now
either insert a chandelier light in order to have a free hand for the scleral depressor,
or indent the eye with your light pipe. Surround the break with one to three rows of
laser burns (e.g. using the 532 nm diode laser OcuLight GL Company Iridex, we use
the laser parameters: power, 150 mW; duration, 200 ms; interval, 300 ms).
4.6 Laser Treatment 71

Fig. 4.20 Usage of


endodiathermy: the retinal
tears cannot be visualized
now

Fig. 4.21 After marking


with endodiathermy, the
tear is easily visualized

Fig. 4.22 Usage of


endodiathermy: cauterize
bleeding vessels in a
difficult PDR case
72 4 Important Vitreoretinal Techniques with 27G

Fig. 4.23 We use laser


within the arcades and
endodiathermy outside the
arcades

Fig. 4.24 Usage of a laser


probe: all 27G laser probes
are curved and not
retractable

Fig. 4.25 The eye is


illuminated with a
chandelier light. Indent the
sclera and treat up to the
ora serrata
4.6 Laser Treatment 73

Surgical Pearls No. 6


Iatrogenic break: When a small break is located within the vascular arcades,
a laser treatment is not necessary as the pigment epithelium in the central area
has sufficient pumping function so that no detachment occurs. If the break is
large, however, we recommend lasering the break with one row of laser burns.
Even if you create a peripheral break this is not a problem as long as you also
recognize the break. Surround the tear with three rows of laser burns and per-
form a gas tamponade.

Surgical Pearls No. 7


Laser therapy:
1. A laser treatment can be carried out in a water (BSS)-filled, silicone oil-
filled and PFCL-filled eye. In an air-filled eye, it is difficult to laser due to
a poor visibility.
2. It is easiest to laser breaks under heavy liquid, as you have a good apposi-
tion of retina and retinal pigment epithelium. One of the disadvantages of
this technique is that the margins of the break are more difficult to see.
Mark the location of breaks with endodiathermy or laser spots before cov-
ering it with heavy liquid. This way it is easy to identify them under heavy
liquid.
3. Beware of the “continuous” function of the laser. You can easily overtreat.
This may result in mini-explosions, choroidal haemorrhage or retinal
breaks or predispose to postoperative tears. Pigmentation increases towards
the periphery. Less energy is needed for peripheral laser spots.
4. The further you move the laser probe away from the retina, the larger the
resulting spot size on the retina (and the more energy you need to create a
burn). This can be quite useful if you want to treat larger areas as the result-
ing burns have softer edges, and do not cut the retina like a knife.
5. Use 360° prophylactic laser with caution. It may not be necessary, may
result in anterior segment ischemia and will make it very difficult to iden-
tify small breaks in cases of postoperative retinal detachments. Treat only
the visible tears instead.
Intraoperative Tamponade
5

Contents
5.1 Basics of Intraoperative Tamponade 75
5.1.1 Air < = > PFCL 75
5.2 Air Tamponade (Exchange of Water Against Air) 77
5.2.1 BSS Tamponade (Exchange of Air Against BSS) 78
5.3 PFCL Tamponade (Exchange of Fluid Against PFCL) 78
5.3.1 Removal of PFCL 78
5.3.2 Complications 79

5.1 Basics of Intraoperative Tamponade

Intraoperative tamponades have several indications. A fluid/air (fluid against air)


exchange may be necessary to stain peripheral located PVR membranes. A fluid/air
exchange removes the subretinal fluid in detachment surgery. Further, an air tam-
ponade is a test for a successful detachment surgery. A PFCL (heavy liquid) tam-
ponade is important in detachment surgery to attach the retina.

Question Which intraoperative tamponades work opposite ways?

Answer Air and PFCL. See Fig. 5.1.

5.1.1 Air < = > PFCL

In the supine position, air exerts the most pressure on the anterior retina (ora
serrata) and less on the posterior retina (Fig. 5.1). Because air is lighter than
water or PFCL, the eye will be filled with air from the ora serrata and then down
to the optic disc. To fill the eye completely with air, the surgeon must aspirate

© Springer International Publishing Switzerland 2015 75


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_5
76 5 Intraoperative Tamponade

Fig. 5.1 Opposite


mechanisms of action of
PFCL and air in a
BSS-filled eye. Air fills the
globe anteroposteriorly.
PFC fills the globe
posteroanteriorly

Air

BSS

PFC

the liquid behind the air bubble with a flute needle. This is most easily done by
holding the flute needle just above the optic disc until the liquid is completely
removed.
Air is important in detachment surgery for the fluid/air exchange manoeuvre,
in which a detached retina can be flattened with air. This is possible due to the
high surface tension pressure of air. In addition, in eyes with vitreous haemor-
rhage, air can be used as a tamponade to prevent possible postoperative
bleeding.
Another indication for an air-filled eye is a better sealing of the sclerotomies. The
air exerts pressure on the wedges of the tunnel sclerotomies and induces an improved
closure of the sclerotomies.
A disadvantage of air and gases in general is the greater distortion of the optical
image. One advantage is the wide-angle view up to the pars plana in an air-filled eye
(Figs. 5.2 and 5.3).

Surgical Pearls No. 8


BIOM and air: When filling air into the vitreous cavity, the image is out of
focus due to the different refractive index. If you move the BIOM lens up a
little, the image becomes focussed again.
5.2 Air Tamponade (Exchange of Water Against Air) 77

Fig. 5.2 View under BSS:


the equator can be
visualized

Fig. 5.3 View under air:


the ora serrata can be
visualized

5.2 Air Tamponade (Exchange of Water Against Air)

To perform an air tamponade, hold the flute needle in front of the optic disc of the
water-filled (BSS-filled) eye. The scrub nurse switches from water to air. The air
streams anteriorly in the eye, and the water is aspirated by holding the tip of the flute
needle in the water. During air insufflation, the visibility worsens, as air has a
78 5 Intraoperative Tamponade

different refractive index to water. This problem can be solved by turning the front
lens of the BIOM with the focus wheel up a little bit until the image is sharp.
Continue with aspiration and after a while, a water level at the posterior pole can be
recognized. Continue to hold the flute needle in front of the optic disc and aspirate
the remaining water. If in doubt, it is better to leave a little water at the posterior pole
than to risk a retinal or optic disc touch.

5.2.1 BSS Tamponade (Exchange of Air Against BSS)

Hold the flute needle directly behind the IOL. Then the scrub nurse switches from
air to water and the eye fills up quickly with water. If small air bubbles remain at the
end behind the IOL, then there is still (anterior) vitreous behind the IOL. If you plan
to perform macular surgery now, you have to remove these irritating air bubbles. In
order to do so, perform an anterior vitrectomy.

Surgical Pearls No. 9


Posterior capsular defect during anterior vitrectomy: This is no catastrophe. If
the defect is circular, you don’t need to do anything. Otherwise, cut a round
capsular rhexis with the vitreous cutter (e.g. 500 cuts/min). The rhexis will not
go out and the IOL remains stable in the bag.

5.3 PFCL Tamponade (Exchange of Fluid Against PFCL)

Inject PFCL always in a fluid-filled eye and not in an air-filled eye. The PFCL must
be injected slowly. PFCL injected too quickly can induce retinal damage. PFCL
should never be injected in the direction of the macula. Start with the injection
nasally to the optic disc and then move the cannula slowly towards the lens, leaving
the tip of the cannula in the apex of the PFCL bubble. Leaving the tip of the cannula
in the big bubble prevents the formation of small PFCL bubbles (fish eggs).
When injecting PFCL, simultaneously decompress the globe with a backflush
instrument. Alternatively, you can use a dual-bore cannula which allows simultane-
ous injection and decompression.

5.3.1 Removal of PFCL

Hold the flute needle in front of the optic disc and aspirate the complete PFCL
bubble. If a small bubble remains and you do not succeed with the flute needle, then
do not insist but aspirate the residual bubble with a silicone-tip flute needle in order
not to damage the retina or the optic disc.
5.3 PFCL Tamponade (Exchange of Fluid Against PFCL) 79

Surgical Pearls No. 10


PFCL injection: Try to inject one bubble only. Start very slowly and then
always keep the tip of your cannula in touch with the bubble. This avoids
splitting the stream into multiple bubbles, which can then displace into the
subretinal space.

5.3.2 Complications

Subretinal PFCL: (1) Do not inject PFCL in the direction of a retinal break; the
PFCL may flow subretinally. (2) Use trocars with valves to avoid/reduce PFCL
bubbles.
Postoperative Tamponade
6

Contents
6.1 Basics of Postoperative Tamponades 81
6.1.1 Gases and Liquids 82
6.1.2 Physiologic Characteristics of Gases and Liquids: Specific Gravity 82
6.1.3 Surface Tension Pressure 83
6.1.4 Expanding Gases 84
6.1.5 Air Tamponade (Exchange of Water Against Air) 84
6.2 Gas Tamponade 84
6.2.1 Basics of a Gas Tamponade 84
6.2.2 Physics of a Gas Tamponade (Exchange of Air Against Gas) 85
6.2.3 Practical Approach for a Gas Tamponade 85
6.2.4 Gas Tamponade (Exchange of Air Against Gas) 86
6.3 Silicone Oil Tamponade 87
6.3.1 Basics of a Silicone Oil Tamponade 87
6.3.2 Physics of a Silicone Oil Tamponade (Exchange of Air Against Silicone Oil) 87
6.3.3 Light Silicone Oil Tamponade 87
6.3.4 Heavy Silicone Oil Tamponade 88
6.3.5 Practical Approach for a Silicone Oil Tamponade 88

6.1 Basics of Postoperative Tamponades

Question What do intraocular gases and fluids have in common?

Answer
• They are both heavier than air (Fig. 6.1a).
• They are both lighter than water (exception: heavy silicone oil); see Fig. 6.1b.

© Springer International Publishing Switzerland 2015 81


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_6
82 6 Postoperative Tamponade

a b
Air Air
oil
ne
ico
Backflush Sil
Backflush
instrument instrument
flute needle

Air
Air Air

Gas

Fig. 6.1 The left eye (a) shows the injection of gas and the right eye (b) shows the injection of
silicone oil

6.1.1 Gases and Liquids

In posterior segment surgery, various gases and liquids are used. It is therefore
important to understand their characteristics and abilities. Four different intraocular
gases are commonly used: air, sulphur hexafluoride (SF6), perfluoroethane (C2F6)
and perfluoropropane (C3F8). In the vitreous cavity, these gases are colourless,
odourless and inert. When injected into the vitreous cavity, air does not expand,
whereas pure SF6, C2F6 and C3F8 gases do. All gases are, however, used in a non-
expanding concentration (see Table 6.1).
Gases are temporary tamponades and are absorbed over several days (air) to
months (C3F8). Air < SF6 < C2F6 < C3F8; see Table 6.1. Silicone oil tamponades, how-
ever, are permanent tamponades and are usually removed between 6 weeks and 6
months after the initial surgery. Perfluorocarbon (PFCL) is a temporary, preopera-
tive tamponade used especially for detachment surgery.

Remark If the term “water-filled eye” is used in this book, it means an eye filled
with “balanced salt solution (BSS)”. The BSS will be replaced postoperatively by
aqueous humour.
In order to understand the function of the gases and liquids, one needs to know
their physiologic abilities.

6.1.2 Physiologic Characteristics of Gases and Liquids:


Specific Gravity

Substances with a specific gravity (SG) of 1 are neutrally buoyant; those with SG
greater than 1 are denser than water and will sink in it; and those with an SG of less
than 1 are less dense than water and so will float. The following figure (see Table 6.2)
gives the location of the fluids and gases depending on their relative weight within
6.1 Basics of Postoperative Tamponades 83

Table 6.1 Our normogram for tamponades in regard to the specific pathology. We use rarely
5000 cSt silicone oil and C3F8
Macular hole Retinal detachment Diabetic retinopathy
Postoperative SF6; in case of SF6, C2F6, 1000 cSt silicone Mild PDR: Air or
tamponade long-standing hole and oil; in case of inferior SF6, difficult PDR,
no posture possible: detachment: Densiron 68 1000 cSt silicone oil
1000 cSt silicone oil
Duration of Silicone oil: 4–6 weeks Silicone oil: 6 weeks; Silicone oil: 2–3
tamponade Densiron 68: 6 weeks months
Postoperative 5 days on the opposite 7 days depending on No posture
posture cheek position of retinal break

Table 6.2 Relative location of liquids, oils and gases in the vitreous cavity
Air/gas; SG = 0.0012 Vitreous space
Conventional silicone oils; SG = 0.97 SG = 1
Water; SG = 1
Heavy silicone oils; SG = 1.06
Perfluorocarbon; SG = 1.75
SG specific gravity

the vitreous cavity. Perfluorocarbon (PFCL) is the heaviest liquid and is always
located on the bottom of the eye. Heavy silicone oils (Densiron 68®, Oxane Hd®)
are heavier than water and tamponade therefore the inferior circumference.
Conventional silicone oils are lighter than water and tamponade the superior cir-
cumference. The lightest tamponades used are gases; they are always located
anteriorly.
In the eye, several gases or liquids may be present at the same time. In this con-
text, the term phase is important. Phase is with regard to physical properties, a spa-
tially homogeneous field. One uses the term, for example, of a gaseous phase or
liquid phase. A gas or liquid “bubble” refers to the spherical shape. Another impor-
tant term is the meniscus: It refers to the curved surface of a liquid.

6.1.3 Surface Tension Pressure

The high surface tension between gas and fluid enables formation of an effective
seal around a retinal break, thus preventing the flow of fluid into the subretinal
space. The remaining subretinal fluid is absorbed by the pigment epithelium and the
retina reattaches. The surface tension pressure of the gas/water interface is the great-
est and therefore is the most effective in closing retinal breaks (70 mN/N). Because
the specific gravity of any gas is lower than that of water, the intraocular gas bubble
has buoyancy that presses the retina against the RPE, and this effect is greatest at the
apex of the gas or fluid bubble. Buoyancy forces can be directed by positioning of
the patient’s head so that the retinal break is placed at the apex of the bubble. Within
5 days, chorioretinal adhesions created by laser photocoagulation or cryotherapy
84 6 Postoperative Tamponade

are established. Less effective are silicone oils because the surface tension pressure
of silicone oil/water is only 50 mN/N.

6.1.4 Expanding Gases

SF6, C2F6 and C3F8 are expanding gases as dissolved nitrogen diffuses along the
concentration gradient from the blood into the gas bubble and accumulates here.
The postoperative extension may lead to strong increases in intraocular pressure
when the gases are injected undiluted into the eye. To avoid this intraocular pressure
rise, expanding gases are used in a concentration in which they do not expand. The
non-expanding concentration of SF6 is 20 %, of C2F6 15 % and of C3F8 14 % (see
Table 6.1). Patients with a gas-filled eye should not undergo anaesthesia with nitrous
oxide, as it diffuses into gas-filled cavities and leads to an increase of volume. In
addition, any air travel or trips to locations at greater heights (e.g. patients living in
mountainous areas) are strictly prohibited.

Important These restrictions also apply for air. Air is a gas and expands also.
Patients with an air tamponade are not allowed to fly because air expands with
increasing altitude. A plane flying at a height of 10,000 m above sea level has an air
cabin pressure of 2400 m.

6.1.5 Air Tamponade (Exchange of Water Against Air)

An air tamponade has several indications: (1) Air in the vitreous cavity that presses
against the wedges of the sclerotomy incision and thereby stabilizes the scleroto-
mies, which results in a reduced postoperative hypotony, (2) postoperative bleeding
(favourable for diabetic eyes) and (3) macular holes.

6.2 Gas Tamponade

6.2.1 Basics of a Gas Tamponade

Question How much heavier is SF6 compared to air?

Answer SF6 is five times heavier than air. C2F6 is five times heavier and C3F8 is 6.5
times heavier than air. In comparison, helium is 10 times lighter than air (see
Fig. 6.2).

Question Why is this important?

Answer The gas flows onto the posterior pole, and the air can be extracted anteri-
orly behind the lens. Otherwise, the air against gas exchange would not function.
6.2 Gas Tamponade 85

Fig. 6.2 Relative location


of gases within the eye
according to their
molecular weight (g/mol).
He = helium (SG = 2.016);
air (SG = 29); C2F6 He
(SG = 138); SF6 (SG = 146);
C3F8 (SG = 188)

Air

C2F6

SF6

C3F8

Question Can SF6, C2F6 and C3F8 be used as an inferior tamponade if they are
heavier than air and located on the bottom of globe?

Answer No, unfortunately not. After a short time, aqueous is secreted into the
posterior chamber and, because it is heavier than gas, it is located on the bottom of
the globe.

6.2.2 Physics of a Gas Tamponade (Exchange of Air


Against Gas)

6.2.3 Practical Approach for a Gas Tamponade

6.2.3.1 Anterior Segment and Tamponade


1. Make sure that all potential anterior segment problems are addressed before
starting a tamponade. The air bubble will push the iris–lens diaphragm forward,
making any manipulations in the anterior chamber extremely difficult. In addi-
tion, fluid injected into the anterior chamber will enter the posterior segment and
displace the tamponade, potentially causing an “underfill”.
2. In cases of large defects within the zonules or the lens capsule, inject Miochol
and an air bubble into the anterior chamber before fluid–air exchange. This pre-
vents the iris–lens diaphragm from moving forward and avoids iris capture or
displacement of the gas tamponade into the anterior chamber. With modern
viewing systems and air in the anterior chamber, there usually is a sufficient view
of the posterior pole to perform a safe fluid–air exchange.
86 6 Postoperative Tamponade

6.2.4 Gas Tamponade (Exchange of Air Against Gas) (Figs. 6.3


and 6.4)

After the fluid to (against) air exchange, you can swing out the BIOM, activate the
inverter and switch on the light of the microscope. The surgical nurse attaches a
50 ml syringe with diluted gas to the three-way tap and injects the gas (about 45 ml)
into the vitreous cavity (Figs. 6.3 and 6.4). Instruct the scrub nurse to stop injecting
immediately if he or she feels an increasing resistance to injection. To avoid an
increased pressure in the eye, you must simultaneously decompress the eye. This
can be achieved by holding the flute needle behind the lens and leaving the side

Fig. 6.3 Gas tamponade.


The surgical gases are 5×
heavier than air and fall
therefore onto the posterior
pole. Place the Charles
Air
flute needle behind the lens
to release the anteriorly Backflush
instrument
located air flute needle

Air Air

Gas

Infusion
line

s
Ga

Backflush
instrument

Air

Fig. 6.4 The intraoperative setup. Gas is infused via the infusion line and the air is released via the
backflush instrument
6.3 Silicone Oil Tamponade 87

opening open. Leave approximately 5 ml of gas in the syringe. Now stop the gas
insufflation and remove both instrument trocar cannulas. Before removing the infu-
sion cannula, check whether the eye is hypotensive. In this case, inject gas to achieve
normotension and then remove the infusion cannula.

Surgical Pearls No. 11


Gas tamponade: Hold the flute needle behind the lens or close to the trocar.
Do not hold the flute needle in the middle of the vitreous body. The injected
gas is heavier than air and flows to the bottom of the globe. You can only
extract the air if you hold the flute needle in the front part of the eye.

Surgical Pearls No. 12


Gas filling with 27G: The main advantage of 27G is the tight sclerotomy. A
27G sclerotomy has less leakage than a 23G sclerotomy, and the gas filling is
therefore much better and longer. This feature is important for detachment
surgery. We use often only an air tamponade in superior detachments.

6.3 Silicone Oil Tamponade

6.3.1 Basics of a Silicone Oil Tamponade

Question How much heavier is BSS compared to light silicone oil?

Answer BSS is only slightly heavier than silicone oil. BSS has an SG = 1 and light
silicone oil an SG = 0.97.

Question How much lighter is BSS compared to heavy silicone oil?

Answer Only a little difference. BSS has an SG = 1 and Densiron 68® has an
SG = 1.06. See Fig. 6.5.

6.3.2 Physics of a Silicone Oil Tamponade (Exchange of Air


Against Silicone Oil)

6.3.3 Light Silicone Oil Tamponade

Silicone oil tamponades can be used with 23G, 25G and 27G technology. It is
straightforward to use 1000 cSt silicone oil. Even if 5000 cSt silicone oil can be
injected with 25G and 27G systems, it only takes longer. You can inject the oil into
a water-filled or an air-filled eye. An injection into a water-filled eye, however, is
88 6 Postoperative Tamponade

Air

Light silicone oil

BSS

Fig. 6.5 Relative location


of fluids within the eye
according to their specific Heavy silicone oil
gravity. Air (SG = 0.001);
light silicone oil
(SG = 0.97); water (SG = 1);
heavy silicone oil PFC
(SG = 1.06); PFC
(SG = 1.75)

difficult because the two liquids are difficult to distinguish. We, therefore, recom-
mend the exchange of air against silicone oil for most routine cases. Use the 27G
plastic cannula from DORC (DORC, 1272.VFI04).

6.3.4 Heavy Silicone Oil Tamponade

Oxane Hd® and Densiron 68® may mix with PFCL and should not come in contact
with pure PFCL for longer periods of time. However, a short contact (e.g. during
direct PFCL-heavy silicone oil exchange) is possible. We, therefore, recommend
the exchange of air against silicone oil for all straightforward cases.

6.3.5 Practical Approach for a Silicone Oil Tamponade

6.3.5.1 Prepare Anterior Chamber for Planned Silicone Oil Injection


Before you perform a fluid–air exchange, prepare the anterior chamber; stabilize the
anterior chamber and perform an iridectomy or inject methylcellulose if necessary.
Cut with the vitreous cutter (low cut rate: about 200 cuts/min) a break in the periph-
eral iris at 6 o’clock (before you inject the silicone oil).

6.3.5.2 Exchange of Air Against Silicone Oil (Light and Heavy)


(Figs. 6.6, 6.7, 6.8, 6.9, 6.10 and 6.11)
The infusion line must remain in place because the air streaming in keeps the eye
normotensive. Silicone oil injection under BIOM view requires a chandelier light
(Figs. 6.6, 6.7 and 6.8). Without chandelier light, there is no view to the fundus
6.3 Silicone Oil Tamponade 89

Fig. 6.6 Air against


silicone oil exchange under
BIOM view. The globe is
air filled via the infusion
line. A chandelier light
illuminates the retina. The
silicone oil is injected via a
syringe on the right side.
On the left side, air is
released with a Charles
flute needle. The BIOM is
flicked in

Fig. 6.7 The same setup


in a drawing. Silicone oil Air infusion

injection under BIOM


Chandelier
view light fiber

Backflush instrument Silicone oil

Air
oil
one
Silic
Backflush
instrument

Fig. 6.8 The eye is air


filled. The silicone oil Air
(light and heavy) sinks
onto the posterior pole and
fills the eye from posterior
to anterior. Note: A
silicone oil injection under
BIOM view can only be
performed with a
chandelier light
90 6 Postoperative Tamponade

Fig. 6.9 Air against


silicone oil exchange
without BIOM view. Note
that no chandelier light is
used

Fig. 6.10 A drawing for a


silicone oil tamponade
without BIOM view. The ion
us
infusion line injects air, the inf
A ir
right hand injects silicone
oil and the left hand
releases air

Si
lic
on
e
oil

Backflush instrument

Air
il
eo
on
lic
Backflush Si
instrument

Air

No view

Fig. 6.11 There is no


view to the retina during
injection of the oil
6.3 Silicone Oil Tamponade 91

Table 6.3 Diagram of the location of Intraoperatively Postoperatively


liquids at an air × silicone oil exchange
Air Silicone oil Vitreous cavity
Silicone oil Water

under silicone oil injection (Figs. 6.9, 6.10 and 6.11). For silicone oil injection, we
use a silicone oil 27G plastic cannula (DORC). The oil falls from the anterior onto
the posterior pole, i.e. the eye is filled from the back to the front with oil. At the
same time, you must drain the air with a backflush instrument from a trocar. After
50 % filling, reduce the infusion pressure of air to 10–20 mmHg. When the last
bubble disappears behind the lens, stop the infusion of air and remove the residual
air bubble. Then inject so much silicone oil until the globe is hypotensive to normo-
tensive. During this procedure, check for a positive venous pulse.
The sclerotomies should be sutured, because otherwise silicone oil can flow
under the conjunctiva.
Table 6.3 shows the location of the fluids in the vitreous chamber during an air/
silicone oil exchange. Air is lighter than silicone oil. During surgery, the silicone oil
is injected into the air-filled vitreous cavity. Depending on the amount of injected
oil, more or less water will be localized at the inferior pole after surgery.

6.3.5.3 Exchange of PFCL Against Silicone Oil (Light and Heavy)


(Figs. 6.12 and 6.13)
Connect an infusion line (DORC) to the silicone oil syringe and then to the infusion
trocar (Figs. 6.12 and 6.13). Table 6.4 shows the location of the fluids in the vitreous
cavity. Silicone oil is lighter than water. Intraoperatively, perfluorocarbon is the
heaviest liquid and lies always on the posterior pole. Anterior to perfluorocarbon is
water and anterior to that is silicone oil. Postoperatively, the perfluorocarbon is
removed, and therefore, water is located at the bottom and silicone oil at the top. See
also Figs. 6.14, 6.15 and 6.16.

Surgical Pearls No. 13


Infusion line and silicone oil: An infusion line with metal cannula (e.g. Alcon)
falls off when injecting silicone oil (Fig. 6.12). Use instead a DORC infusion
line which has a plastic cannula (Fig. 6.13). This infusion will remain stable
in the infusion trocar when injecting silicone oil due to the special shape and
different materials of the DORC trocar cannula.

Caution A hypotony is present if the IOP < 6 mmHg. If a silicone oil-filled eye has
an IOP < 6 mmHg, you cannot remove the silicone oil because the eye would fall
into a hypotony and fall into a phthisis bulbi.

Important The performance of a tamponade depends very much if you use a tro-
car system with valves or without valves. This is especially important for a silicone
oil tamponade.
92 6 Postoperative Tamponade

Fig. 6.12 Caution:


Silicone oil injection is not
possible with the Alcon
infusion line

Fig. 6.13 For silicone oil


injection, use instead a
DORC infusion line. It will
remain stable

Table 6.4 Diagram of the Intraoperatively Postoperatively


location of the fluids in the
Silicone oil Silicone oil Vitreous cavity
vitreous cavity
Water
Perfluorocarbon Water
6.3 Silicone Oil Tamponade 93

Fig. 6.14 A PFCL against Infusion


line
silicone oil exchange under
BIOM view. A chandelier oil
light is not necessary one
Silic

Backflush
instrument

Light fiber
PFCL

Fig. 6.15 The infusion BSS


line injects silicone oil via
the active injection modus
Backflush
and the foot pedal. The instrument
silicone oil is located
anteriorly because it is
lighter than PFC and
BSS. Remove first the BSS Silicone oil
phase
BSS

PFC

If you use a trocar system with valves and inject too much silicone oil, you can
create a dangerous excess pressure that can lead to the closure of the central artery.
In cases of water or gas, you can easily release excess pressure with the backflush
instrument. This is not possible with silicone oil. You must therefore learn to control
a possible hypertension. DORC’s trocar system has the advantage that the valve can
be removed in case of high intraocular pressure. This is not possible for other
94 6 Postoperative Tamponade

Fig. 6.16 Remove then


the PFC. For the final PFC
bubble: Compress the PFC
globe with the index finger
to increase the intraocular
pressure and aspirate the Backflush
instrument
final bubble

Silicone oil

PFC

Fig. 6.17 In case of


silicone oil overfill, cut the
infusion line to release
silicone oil

manufacturers (Alcon, Oertli, Geuder). Alcon includes a metal cannula in the trocar
valve pack, which is inserted into the valve trocar in order to release excess pressure
(Fig. 6.17). An alternative is to cut the infusion line so that excess silicone oil can
flow out. An intraocular hypertension cannot arise with a trocar system without
valves. Here you must deal with a possible hypotension.
Part IV
Surgeries for 27G
Vitrectomy for Floaters
7

Contents
7.1 Introduction 97
7.2 Surgery 97
7.3 Complications 99
7.4 FAQ 99

Video 7.1 Vitreous floaters-27G_old cutter


Video 7.2 27G-asteroid hyalosis_TDC cutter
Video 7.3 Vitreous floaters

7.1 Introduction

Small-gauge vitrectomy and especially 27G enabled a paradigm shift concerning


the indication for surgery of vitreous floaters. A patient who has severe visual symp-
toms such as disturbing floaters in the visual axis with reduced contrast vision and
dyschromatopsia should be offered a vitrectomy and not a psychologist.

7.2 Surgery Figs. 7.1 and 7.2

In phakic eyes, you can cross the midline only when working at the posterior pole to
mid-periphery. To reach the vitreous base, you are not allowed to cross the midline.
The vitreous base can be removed from the opposite site by indenting the vitreous
base or from the same side with the “backhand” and wide-angle viewing systems.

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com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 97


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_7
98 7 Vitrectomy for Floaters

Fig. 7.1 Insert the


instrument trocars towards
12 o’clock to facilitate
vitreous removal at the
superior pole

Fig. 7.2 The 27G TDC


cutter works as fast as a
regular 23G cutter

Don’t perform an extensive vitreous base shaving (Fig. 7.2). You may create
retinal tears and it does not improve the visual symptoms.

Surgical Pearls No. 14


Insert the instrument trocars towards 12 o’clock and not towards 6 o’clock
(Fig. 7.1). In the first case the vitreous cutter will be less bent when working
at 12 o’clock and you can remove the superior vitreous without problems.
7.4 FAQ 99

7.3 Complications

Lens touch: Vitrectomy for floaters is often performed in phakic eyes.


Retinal detachment: This risk is very low. With 23G–27G trocar-based vitrec-
tomy, our department has 0.7 detachment per year secondary to peeling surgery
(unpublished results).

7.4 FAQ

What are the most common symptoms?


The main symptom is floaters in the visual axis. Further disturbing symptoms are
impaired colour vision and contrast vision.

What is the typical patient?


The most typical patients have jobs in the lab and work a lot with the microscope or
photographers working a lot with a camera or with the computer screen.
VMTS
8

Contents
8.1 Introduction................................................................................................................. 101
8.2 Instruments ................................................................................................................. 102
8.3 Surgery ........................................................................................................................ 102
8.4 Complication............................................................................................................... 104

8.1 Introduction

Video 8.1: 27G-Difficult PVD


Video 8.2: VMTS with many complications_no audio

In VMTS a PVD is always necessary. PVD can be performed in most cases with
the vitreous cutter, but in a few cases the usage of a forceps is advisable because you
may create otherwise a macular hole. The 27G vitreous cutter is superior to the 25G
and 23G regarding PVD because you can place the tip of the cutter very close to the
retina. We recommend a 90D lens for PVD or a good zoom on the optic disc when
using a widefield lens.
Be careful in cases with a detached macula and a vitreofoveal adhesion (Fig. 8.1);
you may create a macular hole when inducing a forceful PVD with the vitreous cut-
ter. Stain in these cases the vitreous with trypan blue or triamcinolone and peel the
posterior vitreous membrane with a forceps from the macula. If you do not succeed
with the forceps, then create a hole with a retinal scraper (e.g. 27G retrobulbar can-
nula, Atkinson, Beaver-Visitec).

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com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 101


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_8
102 8 VMTS

Fig. 8.1 Vitreomacular traction syndrome with a retinal schisis and subfoveal fluid. Avoid
damaging the fovea when removing the posterior hyaloid

After successful PVD, examine or stain the macula to exclude a membrane. In


most cases a peeling is not necessary. Exclude finally retinal breaks induced by the
PVD. An air tamponade can be performed according to the preference of the sur-
geon to reattach the macula.

8.2 Instruments

1. 3-port trocar
2. 120D lens
3. Vitreous cutter
4. For induction of PVD: 27G forceps (DORC), 27G Atkinson cannula, and 90D
lens

8.3 Surgery

1. 27G 3-port system


2. Core vitrectomy
3. Induction of PVD with the vitreous cutter
Insert the trocars. If the patient is older than 60 years, consider a combined
phaco/IOL before the vitrectomy. Perform a core vitrectomy and induce a
PVD. Position the vitreous cutter at the edge of the optic disc, with the aspiration
port almost touching the optic disc – induce maximal suction. Meanwhile, the
8.3 Surgery 103

Fig. 8.2 Stain the


posterior vitreous with
Membrane Dual® (DORC)

Fig. 8.3 Open the


posterior hyaloid with a
retinal scraper (e.g.
Atkinson cannula, Beaver
Visitec). A PVD induction
with the vitreous cutter
may cause a macular hole
Opening in
posterior hyaloid

Atkinson
cannula

cortex and posterior hyaloid will be engaged in the aspiration port and pull the
vitreous cutter slowly towards the lens. The posterior hyaloid membrane can be
seen as a fine silky parachute structure (see Chap. 4 on induction of a PVD). If
you are not sure whether you induced a posterior vitreous detachment success-
fully, stain the vitreous with triamcinolone or trypan blue. If the posterior vitre-
ous detachment has not been successful, you will now recognize the stained
vitreous cortex (bursa praemacularis) adjacent to the posterior pole.
4. Induction of PVD with peeling instruments
Stain the posterior hyaloid with trypan blue (e.g. Membrane Dual, DORC) or
triamcinolone (Fig. 8.2). Then create a break in the posterior hyaloid with the
27G Atkinson cannula (Fig. 8.3). If you are successful, you can grab an edge of
104 8 VMTS

Fig. 8.4 Elevate the


posterior hyaloid with an
intravitreal forceps

the break with a 27G endgripping forceps (DORC) and induce a PVD (Fig. 8.4).
You can also try to induce a PVD only with the forceps; it is however difficult to
grab the posterior hyaloid.

8.4 Complication

Macular hole when inducing PVD. In order to avoid this event, remove the central
posterior hyaloid with a forceps instead.

Case Report No. 1: VMTS


Figures 8.5 and 8.6
A 67 y/o male patient was admitted for macular surgery secondary to VMTS. OCT
showed an extensive dragging and deformation of the fovea (Fig. 8.5). Visual acuity
was measured with 0.4. Three days prior to surgery, the patient called and cancelled
the surgery because visual acuity had improved overnight. He was examined 1 week
later. The OCT showed a completely restored foveal anatomy and visual acuity was
1.3 (Fig. 8.6).
8.4 Complication 105

Fig. 8.5 Case report 1: The OCT of a VMTS 1 month prior to scheduled surgery

Fig. 8.6 Case report 1: The OCT 1 week after scheduled surgery. No surgery was performed
Macular Peeling
9

Contents
9.1 General Introduction ................................................................................................... 107
9.2 Epiretinal Membranes................................................................................................. 108
9.2.1 Introduction..................................................................................................... 108
9.2.2 Surgery ............................................................................................................ 108
9.2.3 Complications ................................................................................................. 112
9.2.4 FAQ ................................................................................................................. 112
9.3 Macular Holes............................................................................................................. 113
9.3.1 Introduction..................................................................................................... 113
9.3.2 Surgery ............................................................................................................ 114
9.3.3 Complications ................................................................................................. 120
9.3.4 FAQ ................................................................................................................. 120

9.1 General Introduction

A combined phacoemulsification/vitrectomy is advisable in all patients above 60


years. Ideally the (nonacute) vitrectomy should be performed in a pseudophakic
eye, i.e. the cataract surgery should be scheduled before the vitrectomy.
The first difficult surgical step (for a beginner) is the induction of a PVD. In
almost all cases of macular holes, a PVD is present. The contrary is the case in
macular puckers; a PVD is seldom present.
The next difficult step for a beginner is the peeling itself which is easier in
membranes and more difficult for macular holes. The best case for a beginner is
a thick macular pucker with uplifted edges. If you feel safe with peeling of
puckers, then proceed with macular holes. The appropriate dye for macular

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© Springer International Publishing Switzerland 2015 107


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_9
108 9 Macular Peeling

puckers is trypan blue, and the appropriate dye for macular holes are Brilliant
Blue G. Today, a combined dye with trypan blue and Brilliant Blue G (Membrane
Dual®, DORC) is available for staining both an epiretinal membrane and the
ILM.
For peeling, only two instruments are required: A good forceps and a retinal
scraper (27G retrobulbar cannula, Atkinson, Beaver-Visitec). The retinal scraper
elevates an edge in membranes and creates a hole in the ILM in macular hole peel-
ing. Many surgeons use only a forceps. One author (US) uses always a retinal
scraper and one author (MP) works only with forceps.
In macular pucker or idiopathic epiretinal membranes (ERM), the epiretinal
membrane, which is usually stained with trypan blue, is peeled. Some surgeons
recommend a subsequent peeling of the ILM, but there is currently no consensus on
this. In a high proportion of cases, the ILM will already be removed together with
the ERM. If you wish to peel the ILM after removal of an ERM, then use the dye
Membrane Dual® (DORC) from the beginning. It stains the vitreous, the membranes
and the ILM.
A gas tamponade is standard for macular holes. There is no standard present for
membranes. We perform in most cases an air tamponade to avoid hypotony and
inject 0.1 ml triamcinolone if a macular oedema is present. We use triamcinolone
without benzalkonium chloride which is possibly toxic for the retina (Vitreal S®,
Sooft Italia).

9.2 Epiretinal Membranes

9.2.1 Introduction

Video 9.1: 27G peeling surgery


Video 9.2: 27G macular peeling

The two most important tools for macular peeling are (1) the peeling lens; use a
contact lens (e.g. plano-concave contact lens, DORC) or a 60D peeling lens on your
BIOM, whichever suits you best, and (2) the peeling forceps. Test different variants
of different companies until you find the forceps that suits you best.

9.2.2 Surgery

9.2.2.1 Instruments
1. 27G 3-port trocar
2. 120D lens, for peeling: 60D lens or plano-concave contact lens
3. Vitreous cutter
4. Backflush instrument
5. 27G ILM forceps (DORC)
6. 27G retrobulbar cannula (Atkinson)
9.2 Epiretinal Membranes 109

9.2.2.2 Dye
Membrane: Triamcinolone acetonide, trypan blue
For injection, use a 3 ml syringe with 27-gauge backflush needle (Fig. 9.1).

9.2.2.3 Tamponade
Possible air tamponade

Individual Steps
1. 27G 3-port system
2. Core and peripheral vitrectomy
3. Staining of the ERM
4. Peeling of epiretinal membrane
5. Inspection of periphery
6. Air tamponade with/without triamcinolone
7. Removal of the trocars

9.2.2.4 The Surgery Step by Step: Figs. 9.2, 9.3 and 9.4
1. 27G 3-port system
2. Core and peripheral vitrectomy

Insert the trocars. If the patient is older than 60 years, consider a combined
phacoemulsification/IOL before the vitrectomy.

Fig. 9.1 We refill the dye


into a regular 3 cc syringe
which is easier to handle
than the original syringe

Fig. 9.2 We use


depending on the surgeon’s
preference a 60D BIOM
lens or plano-concave lens
(1284.DD, DORC)
110 9 Macular Peeling

Fig. 9.3 As a retinal


scraper, we use a 27G
Atkinson cannula

Fig. 9.4 As an intravitreal


forceps, we use a 27G
endgripping forceps
(DORC)

Perform a core vitrectomy and induce if necessary a PVD. If you are not sure
whether a posterior vitreous detachment is present, stain the vitreous with triam-
cinolone or trypan blue. If the posterior vitreous detachment has not been success-
ful, you will now recognize the stained premacular vitreous cortex (bursa
praemacularis). Continue with a peripheral vitrectomy which has not to be as thor-
ough as in macular holes because no gas tamponade is used.
PVD: If you plan to stain with trypan blue, then use it also for PVD. It makes
surgery so much easier. But if you stain the vitreous, you need to restain for the
membrane.

3. Staining of the ERM (epiretinal membrane)

The next step is the staining of the ERM with triamcinolone or trypan blue.
Stop the infusion. Then take the syringe with the dye in one hand and eject a few
9.2 Epiretinal Membranes 111

drops of the dye outside the eye in order to avoid blockage of the cannula and
injection of air. Then insert the syringe until the tip is placed above the macula
and slowly inject a little dye to fall on the macula. After a period of about
15–30 s, turn on the infusion and aspirate the dye with a flute needle or a vitre-
ous cutter.

Surgical Pearls No. 15


Trypan blue: Staining may become difficult if you use the syringe of the com-
pany. If too much force is applied during injection, a sudden jet of dye can be
injected into the eye which will obscure the view and is cumbersome to
remove. We recommend therefore to change the syringes. We use a regular
3 cc syringe instead, which is predictable in its behaviour (Fig. 9.1).

Surgical Pearls No. 16


PVD: If you plan to stain with trypan blue, then use it also for PVD instead of
triamcinolone. It makes surgery so much easier. But if you stain the vitreous,
you need to restain for the membrane.

4. Peeling of epiretinal membrane


Before you start with the peeling, you need to change to a higher-resolution lens.
You may take a macular lens (60D) or a plano-concave contact lens (DORC, 1284.
DD), which is placed with contact gel on the cornea (Fig. 9.2).

Caution
1. If you work with a contact lens, you only have a small visual field. And the risk
of ramming an instrument into the retina is pretty high. Insert, therefore, an
instrument only under minimal zoom.
2. The eye is a sphere. Follow during peeling the spherical shape of the eye, i.e.
move the forceps obliquely upwards. If you move the forceps at the posterior
pole horizontally, you will ram the instrument into the retina.

Try to mobilize the membrane with a 27G membrane pic or scrape the membrane
with the 27G Atkinson scraper (temporal, superior or inferior to the macula), until
a small defect is created. Once an edge is mobilized, it can be grasped with an
Eckardt forceps (Figs. 9.3 and 9.4). Pull parallel to the retina until the complete
membrane is removed. If the membrane is strongly attached to the retina, do not
insist—you might create a retinal defect. If the edges of the membrane tear off and
you no longer recognize them, stain again instead and avoid poking around in the
retina with the forceps.
112 9 Macular Peeling

Surgical Pearls No. 17


Membrane and dye: Stain the membrane repeatedly, as there are often several
membranes present. You can only exclude a residual membrane, if staining
was negative. And the better the membrane is made visible, the easier it can
be peeled.

Surgical Pearls No. 18


In cases of ERM, you can try a “two in one” peeling of ERM and ILM by start-
ing your peeling more peripheral than usual (e.g. at the major vessel arcades).
If you manage to grasp the ILM, continue your peeling towards the centre.
The ERM should sit on top of the ILM, and both layers can be removed with
one peeling.

5. Inspection of the periphery


6. Air tamponade and triamcinolone injection
7. Removal of the trocars

Inspect the periphery for retinal tears and perform laser treatment if necessary.
The best laser probe in this case is a combined laser probe with endoillumination.
Alternatively the scrub nurse or your assistant can indent.
Continue with a fluid against air exchange. If a macular oedema is present, inject
0.1 ml washed triamcinolone (Vitreal S®, Sooft Italia) and close the case.

9.2.3 Complications

1. Retinal defect. A retinal defect temporal to the macula is less serious. It will
appear as a retinal hole in OCT and does not need to be laser treated. A retinal
defect in the papillomacular bundle is, however, serious because it causes a deep
visual field defect.
2. Retinal vessel defect: A defect of an artery may cause occlusion of the vessel and
appear as an arterial branch occlusion with visual field defect.

9.2.4 FAQ

Question I removed the membrane completely. Do I need to restain?

Answer Yes, restain. You will be surprised how much membrane or wrinkled ILM
is left which you did not recognize prior.
9.3 Macular Holes 113

In case of epiretinal membrane, do you always remove the ILM at the same
time?
No. If the ILM is wrinkled and deforms the macula, I remove it; if it is smoothly
attached, I leave it. A recurrence of epiretinal membranes is very rare. I had one case
in 2 years.

9.3 Macular Holes

9.3.1 Introduction

Video 9.3: Macular hole 27G


Video 9.4: Anterior dislocated IOL and macular hole with 27G

Macular holes are surgically more demanding than epiretinal membranes because
a PVD has to be induced and the ILM is more difficult to remove (Figs. 9.5 and 9.6).
The ILM is a thin layer and more difficult to elevate from the retina compared to a
membrane.
We use to perform a combined vitrectomy with PVD, peeling and gas. We use
always 20 % SF6.
If the macular hole is long standing, consider 1000/1300 cSt silicone oil. If the
patient cannot sleep on his/her back, consider heavy silicone oil.
We position the patients the first night face down and then 5 days face down or
to the opposite side. For example, if the right eye was operated, the patient shall
position with face down or on the left cheek for 5 days.

Fig. 9.5 Full-thickness macular hole


114 9 Macular Peeling

Fig. 9.6 A closed macular hole 1 month after surgery

9.3.2 Surgery

9.3.2.1 Instruments
1. 27G 3-port trocar
2. 120D lens, for peeling: 60D lens or plano-concave contact lens
3. Vitreous cutter
4. Backflush instrument
5. 27G ILM forceps (DORC)
6. Retinal scraper: 27G retrobulbar cannula (Atkinson) or Tano diamond dusted
scraper

9.3.2.2 Dye
Brilliant Blue G (several companies) or Membrane Dual® (DORC)
For injection, use a 3 ml syringe with 27-gauge backflush needle.

9.3.2.3 Tamponade
Twenty percent SF6, silicone oil (with macular holes in which no postoperative head
positioning is possible)

Individual Steps
1. 27G 3-port system
2. Core vitrectomy
9.3 Macular Holes 115

3. Induction of PVD
4. Staining of ILM
5. Peeling of ILM
6. Gas tamponade
7. Removal of trocars

9.3.2.4 The Surgery Step by Step: Figs. 9.7, 9.8, 9.9, 9.10, 9.11, 9.12
and 9.13
1. 27G 3-port system
2. Core vitrectomy
3. PVD

Insert the trocars. If the patient is older than 60 years, consider a combined
phacoemulsification/IOL before the vitrectomy.
Perform a core vitrectomy and induce a PVD. Position the vitreous cutter in front
of the optic disc, the aspiration port almost touching the optic disc—induce maxi-
mal suction. Meanwhile, the cortex and posterior hyaloid will be engaged in the
aspiration port and pull the vitreous cutter slowly towards the lens. Perform this
manoeuvre in all directions.

Surgical Pearls No. 19


PVD: If you plan to stain with Membrane Dual®, then use it also for PVD. It
makes surgery so much easier. But if you stain the vitreous, you need to
restain for the membrane.

Fig. 9.7 The dye can be


injected in a more
controlled fashion in an
air-filled eye because the
dye only accumulates in
the posterior pole
116 9 Macular Peeling

Fig. 9.8 The dye puddle


can also be easily removed.
Continue with an air–fluid
exchange

Fig. 9.9 We use a 27G


Atkinson cannula for ILM
opening (Beaver-Visitec)

Fig. 9.10 It is advisable to


open the ILM in the
blue-marked area. When
performing a downward
scraping movement, a
retinal defect is less likely
in this area
9.3 Macular Holes 117

Fig. 9.11 Start with


macular rhexis temporal to
the macula. Avoid starting
in the papillomacular
bundle

Fig. 9.12 Start with the


rhexis temporal to the
macula and perform a
clockwise or anticlockwise
rhexis

Fig. 9.13 Remove the


ILM up to the temporal
vessel arcade. The retinal
hemorrhages are a proof
that the ILM is removed
118 9 Macular Peeling

4. Staining of the ILM


The internal limiting membrane (ILM) stains with Brilliant Blue G particularly
well. The new dyes are heavier than BSS. They can therefore be injected in a BSS-
filled vitreous cavity.

Surgical Pearls No. 20


Staining in air-filled eye
This method achieves a much higher concentration of the dye; you need
less dye and staining is faster. Perform a water–air exchange and leave a small
puddle of water on the central pole. Use a 3 cc syringe with a backflush needle
for injection. Inject 2–3 drops of Brilliant Blue G into the puddle, wait 15 s
(Fig. 9.7), position the flute tip in the puddle and remove the dye (Fig. 9.8).
Then perform an air–water exchange. The advantage here is: The dye acts
only in the water puddle, and the surgeon can remove it more quickly than if
the dye is distributed throughout the vitreous cavity.

5. Peeling of ILM
Before you start with the peeling, you need to change to a higher-resolution lens.
You may take a macular lens (60D) or a plano-concave contact lens, which is placed
with contact gel on the cornea (Fig. 9.2).
To mobilize the ILM, brush the retinal surface with the Tano diamond dusted
membrane scraper or scrape it with the 27G Atkinson blunt cannula attached to a
backflush handpiece (temporal, superior or inferior to the macula), until a small
defect is created (Figs. 9.9 and 9.10). You can also pinch the ILM with the ILM
forceps, but the risk of retinal bleeding is higher with this technique. Grasp the
edge with Eckardt forceps and pull the ILM parallel to the retina. Perform a cir-
cular rhexis of the ILM (Figs. 9.11 and 9.12). Always perform the ILM peeling in
a circular fashion pulling around and towards the macular hole (just like a capsu-
lorhexis in phacoemulsification). Do not just pull the ILM in one sheet across the
macular hole. The pathology is that there are usually strong adhesions between
the posterior vitreous face and the edge of the macular hole. Therefore, by simply
pulling a sheet across, you may enlarge the macular hole. If you do not recognize
the edges, stain again. Remove the complete ILM up the vascular arcade
(Fig. 9.13).
You (as a beginner) should work very carefully within the papillomacular bun-
dle. You might create irreversible visual field defects. Therefore, you should never
start the ILM rhexis in the papillomacular bundle, but in an area with a good stain-
ing superior, inferior or temporal to the macula (Fig. 9.12). Small retinal bleeding
may occur during peeling. They will cause no harm and vanish within 1 month.
When the removal of the epiretinal membrane has succeeded, change to the
120D lens and, with the help of scleral indentation, examine the retinal periphery
for breaks.
9.3 Macular Holes 119

Surgical Pearls No. 21


ILM peeling and dot haemorrhages: Small dot haemorrhages occur only dur-
ing ILM peeling and do not appear with ERM peeling (Fig. 9.13).

Surgical Pearls No. 22


Peeling with chandelier light: Insert a chandelier light. Assist the dominant
hand under peeling; you will be surprised how calm your hand is and without
tremor. If you have a hand without tremor, take a Charles flute needle in the
nondominant hand and aspirate the pieces of membrane or ILM. If you use a
vacuum cleaner, you evenly lift up the edges of the membrane and then
remove them with the forceps.

6. Tamponade for macular hole


To carry out the gas tamponade, position the flute tip above the optic disc and
then switch to fluid–air exchange. The air streaming in has a different refractive
index than water; therefore, the image becomes blurred but more wide angled. You
can focus the image by turning the focus wheel of the BIOM so that the front lens
moves up. The image will come into focus again. Since a complete aspiration of
BSS is not necessary, avoid an optic disc touch (optic neuropathy). Inject 20 % SF6
into the vitreous cavity and decompress the eye by holding the flute needle in a
trocar. Open and close the side opening of the backflush instrument with your index
finger depending on the tension of the globe. The intraocular pressure is checked
with the index finger of the other hand.

Surgical Pearls No. 23


Backflush instrument: When working with 27G, you should perform an active
fluid aspiration. Use the backflush instrument with active suction or alterna-
tively the vitrector. Be cautious when coming close to the retina. It is not pos-
sible to aspirate the water completely with the vitrector due to the position of
the opening.

Surgical Pearls No. 24


Most vitreoretinal clinics use 20 % SF6 as tamponade for macular hole.
However, some clinics prefer 15 % C2F6, 14 % C3F8 or even 1000 cSt silicone
oil. Silicone oil is also a good choice for patients who are unable to position
themselves in prone position.
120 9 Macular Peeling

7. Removal of the trocars


The sclerotomies need not be sutured. The big advantage of not suturing is that a
postoperative hypertension due to the expanding gas, though rare, allows the gas to
escape through the unsutured sclerotomies.

8. Postoperative posture

We recommend face down posture for 5 days. Some clinics do not position their
patients and have excellent results. There is unfortunately no randomized study
published.

9.3.3 Complications

What complications may happen during peeling?


Retinal defects and even a worse defect of a retinal artery. Do not peel a membrane
above a retinal vessel and always observe the tip of the forceps during peeling (and
not the membrane). The posterior pole is concave, and you may ram the forceps into
the retina.

What do you do in case of recurrence?


If the macular hole is not closed after 4 weeks, we repeat the gas tamponade with
20 % SF6. If the macular remains open, we use silicone oil (1000 cSt or Densiron
68). We achieve an almost 100 % hole closure using this procedure.

9.3.4 FAQ

Which magnification do you use for peeling?


I use a 60D plano-concave lens from DORC. It provides an excellent magnification
and depth feeling. The disadvantage of contact lenses compared to 60D BIOM
lenses is the small visual field. Be careful when inserting an instrument.

Which instruments are important for peeling?


A retinal scraper and a forceps. We use the blunt cannula from Atkinson as retinal
scraper. It is available in 25G and 27G. It can be used for opening of the ILM and
delamination of a membrane. Then we use a 25G or 27G ILM forceps from DORC.

How important is the forceps?


The peeling is very different with the different forceps. Test all available (ILM)
forceps and use that one you are comfortable with.
9.3 Macular Holes 121

Is it possible to peel with the 90D or widefield lens?


Yes, it is. But it depends. If it is a membrane with elevated edges, you can use these
lenses with a high zoom. But if you are a beginner and if you peel macular holes,
then a 60D lens or contact lens is recommended.

How is the follow-up done?


We have one regular follow-up after 1 day. After 1 week, we measure only the
IOP. After 1 month, we perform again a regular follow-up with OCT. In case of
persistent open macular hole, we repeat a gas injection with SF6. Approximately
95 % of holes close after one surgery and the residual 5 % after the second
surgery.

What do you do in case of small holes?


We do not peel the ILM if small holes are present. After PVD, we perform a fluid–
air exchange, inject gas and close the case. In our experience, almost all small holes
close with this procedure without peeling.
Membrane Peeling with
Intraoperative OCT 10

The intraoperative visualization of the retina opens new surgical and diagnostic pos-
sibilities. The anterior segment surgeon can assess the anterior segment (Fig. 10.1),
the posterior segment surgeon can assess the retina and pathologic structures during
surgery (Fig. 10.2) and the paediatric ophthalmologist can perform an OCT of chil-
dren in general anaesthesia (Fig. 10.3). The companies Zeiss (Germany) and Haag-
Streit (Switzerland) have developed a surgical microscope with integrated
OCT. These microscopes are only available as floor microscopes.
How does the OCT help the surgeon?
The OCT can visualize the cornea (e.g. lamellar keratoplasty) and the anterior
segment during anterior segment surgery (Fig. 10.1). The OCT can guide the sur-
geon during surgery, i.e. during removal of the membrane. The OCT may help you
assess the question whether the complete membrane has been removed or if residual
membrane is present (Figs. 10.4 and 10.5). In macular hole surgery the OCT can
assess whether the macular hole is closed or open (Figs. 10.6, 10.7 and 10.8). In
diabetic retinopathy the OCT can help differentiate tractive membranes from large
vessels when peeling membranes from the arcades.

Case Report No. 2: Neurofibromatosis Type 2

Video 10.1: Intraoperative OCT

A 5 y/o boy with known neurofibromatosis type 2 was admitted to us for assess-
ment of a macular pucker. Visual acuity was measured with 0.8 bilateral. A preop-
erative OCT showed thickening of the macula and an epiretinal membrane
(Fig. 10.3). Before starting surgery, we performed an intraoperative OCT. We placed

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 123


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_10
124 10 Membrane Peeling with Intraoperative OCT

a contact lens (DORC) on the cornea and performed an OCT (Fig. 10.9). Then the
membrane was successfully removed with 27G vitrectomy (Fig. 10.10). A follow-
up half a year later showed no improvement of the visual function.

Fig. 10.1 Intraoperative OCT of the anterior segment with the Zeiss Callisto microscope. Note
the IOL viewed by the OCT

Fig. 10.2 Intraoperative OCT with the Zeiss Callisto microscope during macular peeling. Note
the vitreous cutter on the OCT image
10 Membrane Peeling with Intraoperative OCT 125

Fig. 10.3 An examination of a child with plano concave lens for an epiretinal membrane

Fig. 10.4 The OCT screen provides an excellent fundus photograph with OCT
126 10 Membrane Peeling with Intraoperative OCT

Fig. 10.5 A fundus


photograph of a macular
pucker

Fig. 10.6 A macular hole before peeling


10 Membrane Peeling with Intraoperative OCT 127

Fig. 10.7 A macular hole during peeling. The OCT improves the view and facilitates delicate
peeling

Fig. 10.8 An OCT image after ILM peeling


128 10 Membrane Peeling with Intraoperative OCT

Fig. 10.9 Case report 2: A child with epiretinal membrane secondary to neurofibromatosis type 2

Fig. 10.10 Case report 2:


Peeling of the membrane
Dislocated IOL: Extraction of IOL
and Implantation of Iris-Fixated IOL 11
with 27G

Contents
11.1 General Introduction 129
11.2 Special Instruments for Iris-Claw IOL Implantation 131
11.2.1 Instruments for Iris-Fixated IOL 131
11.2.2 Enclavation Spatula 131
11.2.3 Caliper 132
11.2.4 Serrated Jaw Forceps 132
11.2.5 Endgripping Forceps 132
11.3 Iris-Claw IOL Implantation Surgery 133
11.3.1 Instruments 133
11.3.2 Material 133
11.3.3 The Surgery Step by Step 133
11.4 Complications 143
11.5 FAQ 144

Video 11.1: Anterior dislocated IOL and macular hole with 27G
Video 11.2: Bimanual extraction of anterior dislocated IOL
Video 11.3: 27G posterior dislocated IOL

11.1 General Introduction

The first part of the surgery is the extraction of the dislocated IOL. In most cases,
the IOL is only subluxated because the vitreous body is present. The extraction is
simple with a serrated jaw forceps. In a few cases when the eye has been

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 129


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_11
130 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

vitrectomized, the IOL will luxate to the posterior pole. Now the extraction is trick-
ier and requires often a chandelier light for bimanual extraction.
The benefits of an iris-claw IOL implantation are a short surgical time,
sutureless implantation, excellent centration without risk of tilting and fast
learning curve (approximately five surgeries). The surgical time is approxi-
mately 20 min. A redislocation such as in scleral fixated IOLs does not occur
with iris-claw IOLs. The disadvantage is that the IOL is fixated into the iris tis-
sue, and a too traumatic implantation may lead to an inflammation. This postop-
erative inflammation with cellular proliferation of the IOL is induced by
macrophages. This occurs, however, only in the learning curve. In addition,
sufficient iris tissue is required for implantation, e.g. an implantation in case of
aniridia is not possible.
We will demonstrate the implantation of an iris-claw IOL (Verisyse®,
Abbott and Artisan®, Ophtec) (Fig. 11.1). The iris-claw IOL can be implanted
before the pupil or behind the pupil. If you implant the IOL retropupillary, then
it has to be done “upside down” (= on the back) because the haptics are bent
upwards.
We will demonstrate the retropupillary method, which is quite easy to learn. We
recommend starting with an aphakic eye which underwent an anterior vitrectomy.
The pupil should be constricted before surgery. We recommend retrobulbar
anaesthesia.
The A-constants for antepupillar and retropupillar IOL implantations differ; con-
tact the companies for further information.
The most difficult part of the surgery is the dissection of a scleral tunnel, which
is the same as for the SICS technique (modified ECCE). We prefer a scleral tunnel
to a corneal tunnel in order to reduce astigmatism; this tunnel is 6 mm wide. Why?
Because the iris-claw IOL is 6 mm wide. What may happen if the tunnel is 8 mm
wide? The wider the tunnel, the more you risk a choroidal detachment.
Which gauge?
We prefer 27G in order to avoid hypotony after surgery which may occur due to
the 6 mm scleral tunnel.

Fig. 11.1 An iris-claw


IOL (Artisan®, Ophtec,
and Verisyse®, AMO)
11.2 Special Instruments for Iris-Claw IOL Implantation 131

11.2 Special Instruments for Iris-Claw IOL Implantation

11.2.1 Instruments for Iris-Fixated IOL

The instruments needed for the implantation of an iris-fixated IOL can be acquired
from Abbott (Verisyse®) and Ophtec (Artisan®). The most important instrument is
the IOL implantation forceps (Fig. 11.2). In addition you need the following
instruments.

11.2.2 Enclavation Spatula (Fig. 11.2)

Indication Retropupillar fixation of IOL claws in iris tissue. This spatula is thin so
that only a little iris tissue is enclavated. Sekundo enclavation spatula, Geuder
32724.

Fig. 11.2 Two instruments


are required for
Implantation of an
iris-fixated IOL. (1) An
IOL implantation forceps
(AMO), (2) an enclavation
spatula (Geuder) for
implantation of an
iris-claw IOL
132 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

11.2.3 Caliper (Fig. 11.3)

Indication Marking of main incision and sclerotomy. The main incision for the
implantation of an iris-fixated PMMA IOL is 6 mm wide. Caliper by Castroviejo,
Geuder 19135

11.2.4 Serrated Jaw Forceps (Fig. 11.4)

Indication Extraction of IOL with lens capsule. 20G or 23G. DORC. 1286. C06

11.2.5 Endgripping Forceps

Indication Luxation of IOL from posterior pole into anterior chamber. 27G. DORC
1286.WD04

Fig. 11.3 A 23G


intravitreal serrated jaw
forceps (DORC).
Indication: extraction of
the subluxated IOL from
the anterior chamber

Fig. 11.4 Useful is also a


caliper. Indication: frown
incision (Geuder)
11.3 Iris-Claw IOL Implantation Surgery 133

11.3 Iris-Claw IOL Implantation Surgery

11.3.1 Instruments

1. Crescent bevel up knife


2. 15° knife
3. 2.4 mm tunnel knife
4. Caliper
5. IOL implantation forceps (AMO)
6. Enclavation spatula
7. 20G or 23G serrated jaw forceps
8. In case of IOL luxation: 27G ILM forceps

11.3.2 Material

Acetylcholine (Miochol)
Iris-claw IOL (Artisan®, Verisyse®)
Maybe: Triamcinolone

11.3.3 The Surgery Step by Step: Figures 11.5, 11.6,


11.7, 11.8, 11.9, 11.10, 11.11, 11.12, 11.13, 11.14,
11.15, 11.16, 11.17, 11.18, 11.19, 11.20, 11.21, 11.22, 11.23
and 11.24

1. 27G 3-port trocar system


2. Paracentesis at 3 and 9 o’clock
3. Scleral tunnel/frown incision
4a. Extraction of an anterior dislocated IOL
4b. Extraction of a posterior dislocated IOL
5. Anterior vitrectomy
6. Injection of Miochol
7. Implantation of iris-fixated IOL
8. Closure of the frown incision and conjunctiva

1. 27G 3-port trocar system


2. Paracentesis at 3 and 9 o’clock
134 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

Fig. 11.5 An anterior


dislocated bag–IOL
complex secondary to
zonular lysis

Fig. 11.6 Open the


conjunctiva along the
limbus from 11 o’clock to
1 o’clock with the Vannas
scissors (limbal peritomy)

Fig. 11.7 Mark a 6 mm


broad scleral incision with
the caliper. The incision is
approximately 1.5 mm
behind the limbus
11.3 Iris-Claw IOL Implantation Surgery 135

Fig. 11.8 Mark the frown


incision with a marker pen

Fig. 11.9 A 50 %
scleral-thickness incision
with the 15° knife is
performed

Fig. 11.10 Dissect a


scleral flap with the bevel
up crescent knife. If the
knife is visible through the
sclera, then you have the
correct depth
136 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

Fig. 11.11 Then open the


anterior chamber with a
2.4 mm blade

Fig. 11.12 Luxate the


IOL at 12 o’clock up to the
pupillary plane in order to
access it with the forceps

Fig. 11.13 Then remove


the IOL with the serrated
jaw forceps
11.3 Iris-Claw IOL Implantation Surgery 137

Fig. 11.14 A different


approach is required in
case of a posterior
dislocated IOL

Fig. 11.15 Grasp the


fibrotic capsular bag with
an intravitreal forceps. In
some cases, the capsular
bag gives no hold: remove
the capsular bag in order to
free the haptics and grab
them. It may be advisable
to inject PFCL in order to
protect the posterior pole

Fig. 11.16 Then lift the


IOL forward to the pupil
138 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

Fig. 11.17 And extract


the IOL with a second
intravitreal forceps

Fig. 11.18 Perform an


anterior vitrectomy

Fig. 11.19 Turn the


iris-claw IOL upside down
for implantation and
implant it with the IOL
implantation forceps
(AMO)
11.3 Iris-Claw IOL Implantation Surgery 139

Fig. 11.20 Centrate the


IOL and fixate it with the
IOL implantation forceps
(AMO)

Fig. 11.21 Tilt the IOL


behind the iris on one side

Fig. 11.22 Tilt the IOL


behind the iris on the other
side and then press the iris
tissue with an enclavation
spatula (Geuder) behind
the claws
140 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

Fig. 11.23 Switch hands


and perform the same
manoeuvre on
the other side

Fig. 11.24 Note the


enclavated iris tissue at 3
and 9 o’clock

3. Scleral tunnel/frown incision


Begin with a paracentesis incision at 3 o’clock and 9 o’clock.
Note: The location of the IOL is determined by the position of the frown
incision. If the claws are located at 3 o’clock and 9 o’clock, then the frown inci-
sion must be located at 12 o’clock. In case of an iris defect at 3 o’clock or a
filtration bleb at 12 o’clock, you have to choose the position of the IOL and
frown incision accordingly.
Continue with the frown incision. Perform a limbal peritomy from 11 to 1
o’clock with Westcott scissors and cauterize the bleeding vessels (Figs. 11.5
and 11.6). Then mark a 6 mm wide incision (not wider!) with a caliper
(Figs. 11.7 and 11.8). The incision should be 1–1.5 mm behind the limbus.
Dissect a 50 % scleral-thickness deep limbus parallel incision with a 15° knife
(Fig. 11.9). Then dissect a scleral tunnel with the crescent angled bevel up knife
(Fig. 11.10) and open finally the anterior chamber with a 2.4 mm blade
(Fig. 11.11).
11.3 Iris-Claw IOL Implantation Surgery 141

4a. Extraction of an anterior dislocated IOL


The extraction is easier, if the eye is not vitrectomized and the IOL is located
behind the iris. Close the infusion line during extraction. Inject viscoelastics
into the anterior chamber and then behind the IOL and lift the IOL a little bit up
at 12 o’clock so that the optic edge or a haptic is visible (Fig. 11.12). Grasp the
IOL optic or haptic with the serrated jaw forceps and extract the IOL with the
lens capsule (Fig. 11.13). Often some fibrotic parts of the lens capsule remain
in the anterior chamber. Remove them with viscoexpression, e.g. inject visco-
elastics behind them into the anterior chamber and then press on the sclera of
the scleral tunnel.
Reopen the infusion line and continue with an anterior vitrectomy from pars
plana.
4b. Extraction of a posterior dislocated IOL
If the eye is vitrectomized and the IOL is located on the posterior pole,
then you have to lift it up now (Fig. 11.14). You need two intravitreal for-
ceps, one 27G endgripping forceps and one 20G or 23G serrated jaw for-
ceps. Grasp the edge of the optic or haptic with the first 27G endgripping
forceps and lift the IOL up (Fig. 11.15). Lift the IOL into the anterior cham-
ber/pupillary plane, insert the serrated jaw forceps through a paracentesis
and grab the IOL (Fig. 11.16). Withdraw the first intravitreal forceps and
reinsert it through the main incision. Grab the IOL with the endgripping
forceps, withdraw the serrated jaw forceps (from the paracentesis) and
extract the IOL (Fig. 11.17).

Surgical Pearls No. 25


Posterior dislocated IOL: An IOL located on the posterior pole is not easy to
grasp. It is usually enclosed inside the lens capsule. The lens capsule, how-
ever, is difficult to grasp. Try therefore to grasp the edge of the IOL or haptic.
As forceps we prefer a 27G endgripping forceps (DORC) with sharp edges.

Surgical Pearls No. 26


Difficult IOL extraction from posterior pole: Try the following manoeuvres:
(1) Grab the haptic or rhexis edge with an intravitreal forceps. (2) Insert a
chandelier light and work bimanual with one intravitreal forceps and one 27G
membrane pic (DORC) to elevate the IOL. (3) Inject a small bubble of PFCL
to elevate the IOL and to protect the macula. Grab the IOL. (4) Inject a small
bubble of PFCL to elevate the IOL. Then remove the lens capsule around the
haptic with the vitreous cutter (Fig. 11.15). If the haptic is freed from the lens
capsule, it is easy to grasp with a forceps. Remark: The fourth method is
always successful.
142 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

5. Anterior vitrectomy
6. Injection of Miochol
Continue with an anterior vitrectomy (Fig. 11.18). Inspect then the periphery
for retinal tears. The next step is pupil constriction. Before implantation of an
iris-claw IOL, the pupil must be constricted. Inject acetylcholine (Miochol®)
and then viscoelastics into the anterior chamber.
7. Implantation of iris-fixated IOL
Instrumentation
Dominant hand: IOL implantation forceps (Abbott)
Non-dominant hand: Enclavation spatula
Close the infusion line during IOL implantation (Fig. 11.19). Centrate the IOL with
a manipulator (e.g. push–pull) inside the anterior chamber. Grasp the IOL at the
edge with the IOL implantation forceps (Abbott) (Fig. 11.20). Flip the IOL to the
right (Fig. 11.21) so that the IOL is behind the iris and then flip it to the left so
that the IOL is completely behind the iris. Hold the IOL now in the middle of the
pupil. Do not move it to the left or right.
Take then the enclavation spatula in your left hand. Lift the IOL a little bit up, so
that the iris claws are visible behind the iris tissue. Then insert the spatula in
the 3 o’clock paracentesis and clamp the iris tissue between the iris claws
(Fig. 11.22). Then the hand of the implantation forceps has to be changed. This
manoeuvre should be thoroughly practiced preoperatively. Then take the encla-
vation spatula in your right hand and perform the same manoeuvre at 9 o’clock
(Fig. 11.23). Remove finally the implantation forceps and open the infusion
line to achieve normotension. A retropupillary implantation requires no
iridectomy.

Surgical Pearls No. 27


Enclavation of iris-claw IOL: Instead of enclavating the IOL from both para-
centesis, you can enclavate the IOL from one paracentesis. The tip of the
enclavation spatula is long enough to reach both iris claws.

Surgical Pearls No. 28


Do not enclavate too much iris tissue. It may cause ocular pain. In order to
avoid this side effect, use the thin Sekundo enclavation spatula from Geuder.
11.4 Complications 143

8. Closure of the frown incision and conjunctiva


Suture the frown incision with a Vicryl 8-0 cross stitch and the conjunctiva
with a Vicryl 8-0 interrupted stitch (Fig. 11.24).

11.4 Complications

Complete iris-claw IOL dislocation: The dislocation of an iris-claw IOL is very


unusual. It may happen postoperatively secondary to a trauma.
Partial dislocation of an iris-claw IOL: Insert two iris hooks at 1 and 11 o’clock.
Insert two trocars at 10:30 and 1:30 o’clock. Lift the IOL up from the trocars. Grasp
the IOL with the IOL implantation forceps and then fixate the loose side.
Postoperative inflammation due to traumatic surgery, which occurs only in the learn-
ing phase. Do not enclavate too much iris tissue. It may cause ocular pain. In order to
avoid this side effect, use the thin enclavation spatula from Sekundo from Geuder.
Choroidal detachment (Figs. 11.25 and 11.26): The main reason is an open main
incision. Make the main incision not wider than 6 mm and perform an even cut so
that the scleral lips are attached. The reason is the big main incision and pressure
fluctuations during manipulations at the main incision. A shallow choroidal detach-
ment will resorb on its own after 2–3 months. In case of a highly bullous choroidal
detachment, inject PFCL and then perform a PFCL × 1000 cSt silicone oil exchange.

Fig. 11.25 A dreaded


complication: choroidal
detachment. The reason is
the big main incision and
pressure fluctuations
during manipulations at the
main incision. It is
therefore important to (1)
perform a 6 mm incision
(not wider) and (2) close
the infusion and fill the
anterior chamber with
viscoelastics when
working in the anterior
chamber
144 11 Dislocated IOL: Extraction of IOL and Implantation of Iris-Fixated IOL with 27G

Fig. 11.26 In case of a


shallow choroidal
detachment, nothing has to
be done. In case of a highly
bullous choroidal
detachment, it is advisable
to inject PFCL and then
perform a PFCL × 1000 cSt
silicone oil exchange

11.5 FAQ

Is an iris-claw implantation after trauma possible?


If the eye underwent a traumatic surgery due to a difficult cataract surgery with loss
of the lens capsule, we would prefer a delayed implantation. We would implant the
iris-claw IOL after approximately 1 month in order to obtain an uninflamed iris.

Is a core vitrectomy necessary?


This depends on the retinal school. I prefer to perform as little surgery as possible
and as much surgery as necessary. In my experience, an anterior vitrectomy is suf-
ficient. But an inspection of the retinal periphery for retinal tears is surely advisable.
Other retinal schools perform a core vitrectomy; continue with induction of PVD
and peeling of ILM and end with a 360° laser cerclage.

Are three ports necessary?


In case of a subluxated IOL, you can use two temporal ports only.

Is a BIOM necessary?
In most cases, the IOL is only subluxated because the vitreous body is present. In
this case, you may use only two trocars. An anterior vitrectomy is sufficient and a
BIOM is not required.

Pupil dilatation before surgery?


Only 1–2 drops tropicamide. Do not dilate maximally because you need a small
pupil for implantation.

Is it possible to perform this surgery in two sessions?


Yes, of course. You may in one session extract the IOL and perform an anterior
vitrectomy and then in a second session implant a Verisyse IOL. The advantage of
two sessions is that the pupil can be constricted preoperatively with pilocarpine.
11.5 FAQ 145

I am a beginner what is the best eye to start with?


An aphakic eye with small pupil and removed anterior vitreous.

How do you treat a macular edema secondary to pseudophakia?


With topical eyedrops or with intravitreal triamcinolone.

Is treatment with Ozurdex possible?


No. The Ozurdex pellet will enter the anterior chamber and cause a corneal damage.
See case reports.
Endophthalmitis
12

Contents
12.1 General Introduction .................................................................................................. 147
12.2 Antibiosis ................................................................................................................... 148
12.2.1 Preparation of Antibiotic Therapy ................................................................ 148
12.2.2 Surgery Step by Step..................................................................................... 149
12.3 Complications ............................................................................................................ 158
12.4 FAQ ............................................................................................................................ 158
Reference ................................................................................................................................. 158

12.1 General Introduction

Video 12.1: Candida endophthalmitis


Video 12.3: Endophthalmitis
Video 12.3: Endophthalmitis and subchoroidal haemorrhage

The Endophthalmitis Vitrectomy Study recommends intravitreal antibiotics if


the visual acuity is > hand motion and vitrectomy and if visual acuity = light percep-
tion. In practice, most vitreoretinal clinics tend to perform a vitrectomy at earlier
stages with a better visual acuity. Due to the increasing number of intravitreal injec-
tions, the incidence of endophthalmitis is rising. In every tertiary vitreoretinal cen-
tre, clear treatment guidelines should be established; all necessary antibiotics and an
examination of the microbiological specimens should be available at all times.
In recent years, there is a significant increase of endophthalmitis in patients
following intravitreal injections of anti-VEGF agents. In contrast to the previ-
ously more common endophthalmitis following cataract surgery, the majority of
these patients are still phakic and the lens or opacified vitreous adjacent to the lens

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 147


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_12
148 12 Endophthalmitis

might impair the view of the posterior segment for vitrectomy. If you perform a
phacoemulsification, then open the posterior capsule and do not insert an IOL in
order to improve the outflow of aqueous and reduce bacterial growth in the capsu-
lar bag.
If you are contacted from a peripheral institution regarding a patient with pre-
sumed endophthalmitis and a delay of several hours before the patient can be seen
in your institution is to be expected, it is advisable to ask the referring Ophthalmologist
to perform an intravitreal injection of antibiotics before sending the patient. Time is
of paramount importance in treating endophthalmitis, and the benefit of earlier anti-
biotic injection overrides the disadvantages of a short delay in the referral and pos-
sibly the failure to obtain a specimen for microbiology.

12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis


and Treatment of Endophthalmitis) [1]

1. 1 mg/0.1 cc vancomycin and


2. 2.25 mg/0.1 cc ceftazidime (Fortum)

12.2.1 Preparation of Antibiotic Therapy

12.2.1.1 Vancomycin
You need: 1× vancomycin 500 mg and 2× plastic ampoules 10 ml NaCl 9 mg/ml
(9 %)

1. Dissolve 500 mg of vancomycin in 10 cc NaCl 9 mg/ml (first ampoule).


2. Aspirate 2 cc of the second NaCl 9 mg/ml ampoule and discard it.
3. Add 2 cc of the dissolved vancomycin (first ampoule) into 8 cc of NaCl 9 mg/ml
(second ampoule). The ampoule contains now 10 cc of vancomycin 10 mg/ml
4. Inject 0,1 cc (=1 mg) vancomycin into the vitreous cavity.

(Remark: cc = ml)

12.2.1.2 Ceftazidime
You need: 1× Fortum 500 mg and 2× plastic ampoules 10 ml NaCl 9 mg/ml (9 %).

1. Dissolve 500 mg of Fortum in 10 cc NaCl 9 mg/ml (first ampoule).


2. Aspirate 8.8 cc of the second NaCl 9 mg/ml ampoule and discard it. The second
ampoule contains now 1.2 cc NaCl 9 mg/ml.
3. Draw 1 cc of the dissolved Fortum and inject it into the second ampoule. The
second ampoule contains now 2.2 cc Fortum 22.7 mg/ml.
4. Inject 0.1 cc (=2.27 mg) Fortum into the vitreous cavity.
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment) 149

12.2.1.3 Instruments
1. 3-port or 4-port trocar system
2. Insulin syringe for sampling

12.2.1.4 Potential tamponade


Silicone oil

12.2.1.5 Individual Steps


1. 27G three ports with chandelier light
2. Specimen from the anterior chamber
3a. Pseudophakic eye: Flushing of the anterior chamber and the capsular bag
3b. Phakic eye: Phacoemulsification without IOL
4. Specimen from the vitreous cavity
5. Vitrectomy
6. Induction of posterior vitreous detachment
7. Intravitreal antibiotics
8. Tamponade with silicone oil

12.2.2 Surgery Step by Step (Figs. 12.1, 12.2, 12.3, 12.4, 12.5
and 12.6)

1. 27G 3-port system with chandelier light


If you use a silicone oil tamponade, a chandelier light is advisable.
2. Specimen from the anterior chamber
3a. Pseudophakic eye: Flushing of the anterior chamber and the capsular bag
After performing a paracentesis, perform an anterior chamber tap. Then
rinse the anterior chamber and the capsular bag thoroughly with BSS and irriga-
tion/aspiration (I/A). With foudroyant endophthalmitis, it is appropriate to
explant the IOL with the capsular bag.
3b. Phakic eye: Phacoemulsification without IOL
Perform a phacoemulsification and cut a round hole in the posterior capsule
with the vitreous cutter from pars plana.

Surgical Pearls No. 29


Pus and fibrin in the anterior chamber can be extracted easily with Eckhardt
forceps via a paracentesis.

4. Specimen from the vitreous cavity


Take a sample from the central vitreous with an insulin syringe (Figs. 12.1 and
12.2). You can either connect the syringe to the vitreous cutter or aspirate manu-
ally (dry vitrectomy) or you can send the vitrectomy cassette to microbiology.
150 12 Endophthalmitis

Fig. 12.1 A bacterial


endophthalmitis with
opacified vitreous and no
view to fundus

Fig. 12.2 A 3 cc syringe is connected to the vitreous cutter in order to perform a vitreous biopsy
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment) 151

Fig. 12.3 The fundus


before PVD

Fig. 12.4 The fundus after


PVD and removal of the
vitreous

Fig. 12.5 A bacterial


endophthalmitis after PVD
and vitrectomy. Do not
remove the preretinal pus;
the retina is fragile
152 12 Endophthalmitis

Fig. 12.6 1000 cSt


silicone oil tamponade and
injection of antibiotics

5. Vitrectomy
Follow the usual steps of vitrectomy. Be very careful not to induce iatrogenic retinal
breaks, as these will necessitate a silicone oil tamponade in endophthalmitis
cases.
In cases of severe endophthalmitis, it is sometimes impossible to identify all struc-
tures correctly. It is therefore very easy to cut through the retina. In such cases,
work your way very carefully from “top to bottom”, e.g. from the space behind
the lens to the posterior pole. Try to identify retinal vessels in order to identify
the correct working plane. If you are unsure and you only see a yellowish mass
behind the lens, start cutting in the periphery—the retina might be detached and
pulled anteriorly; it is then better to cut through the peripheral retina. Focus on
identifying retinal vessels as your guideline as early as possible.

Surgical Pearls No. 30


Do not open the pars plana infusion without visualizing it first (see Chap. 4).
If you are unable to see the internal opening of the infusions port, start the
vitrectomy using an infusion via an anterior chamber maintainer.

6. Induction of posterior vitreous detachment


An induction of the posterior vitreous detachment is an important step in endo-
phthalmitis surgery in order to remove the basis of bacterial growth (Figs. 12.3
and 12.4). This step is difficult because pus reduces the visualization of the pos-
terior vitreous. Next a vitrectomy is performed. The retina often shows panreti-
nal haemorrhages and epiretinal pus. Caution: The retina in endophthalmitis is
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment) 153

Fig. 12.7 Case report 3.


After complicated cataract
surgery: reduced view to
fundus due to an
endophthalmitis with
opacified vitreous and a
haemorrhagic choroidal
detachment

very fragile (Fig. 12.5). It is easy to induce breaks. It is not necessary to perform
a thorough trimming of the vitreous base. The possible harm is greater than the
possible benefit.
7. Intravitreal antibiotics
Now vancomycin and ceftazidime are injected into the eye (Fig. 12.6).
8. Potential tamponade: Silicone oil
Some surgeons suggest silicone oil as tamponade, because it is attributed with bac-
teriostatic properties. Others use no tamponade. In the latter, one has no or only
a reduced view of the fundus during the first postoperative days; after about 3
days, the eye will clear up. If you have identified or created a retinal break, we
recommend silicone oil tamponade. The antibiotics can be injected into the ante-
rior chamber or into the silicone oil. There is no place for a gas tamponade in
endophthalmitis cases.

Case Report No. 3: Endophthalmitis and Choroidal Haemorrhage


Figures 12.7, 12.8 and 12.9
A 72-year-old male patient was admitted to us due to suspicion of an endophthal-
mitis. He was operated 2 weeks ago for phacoemulsification + IOL. A posterior cap-
sular defect occurred; an anterior vitrectomy was performed when a subchoroidal
haemorrhage developed. The eye was closed; the eye was pseudophakic. The patient
experienced first a visual acuity increase but after 10 days the vision got worse. He
visited the out-patient clinic and an endophthalmitis was diagnosed. Visual acuity
was light perception, no hypopyon was present and the view to fundus was bad due
to the choroidal haemorrhage. The patient complained of ocular discomfort. It was
not really clear that an endophthalmitis was present. There are several options now:
If only a subchoroidal haemorrhage was present, we could simply wait. If we sus-
pected an endophthalmitis, we could inject antibiotics. This option was tricky due
154 12 Endophthalmitis

Fig. 12.8 Case report 3.


Insert an anterior chamber
maintained and drain
suprachoroidal blood from
4 mm sclerotomies

Fig. 12.9 Case report 3.


View to fundus after partial
drainage, vitrectomy and
injection of PFCL

to the large choroidal detachment. And of course we had the option of vitrectomy
which was a difficult option due to the subchoroidal detachment. I decided for the
last option. Unfortunately there was no anaesthesia available on this day so that the
surgery had to be performed in general anaesthesia. A removal of subchoroidal
blood + vitrectomy + injection of antibiotics + 1000 cSt silicone oil was performed.
An endophthalmitis was present.

Case Report No. 4: Ozurdex Endophthalmitis


Figures 12.10, 12.11 and 12.12
A 73-year-old female patient was treated two times with Ozurdex secondary to
macular oedema secondary to CRVO. The visual acuity was 0.2. Five days after the
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment) 155

Fig. 12.10 Case report 4.


A bacterial
endophthalmitis with
severe pars planitis after
Ozurdex injection

Fig. 12.11 Case report 4.


Removal of the Ozurdex
pellet

second injection, the visual acuity decreased and the eye became painful. She vis-
ited the out-patient department and an endophthalmitis was diagnosed. A vitrec-
tomy with PVD + 1000 cSt silicone oil + antibiotics was performed. The Ozurdex
pellet was located in the periphery at pars plana and the retinal changes were
advanced. The silicone oil was removed after 3 months. The postoperative visual
acuity was 0.15.
156 12 Endophthalmitis

Fig. 12.12 Case report 4.


1000 cSt silicone oil
tamponade and injection of
Fortum and Vancomycin
antibiotics

Fig. 12.13 Case report 5.


A suspected
endophthalmitis with
pseudohypopyon: an
Ozurdex pellet in the
anterior chamber
mimicking a hypopyon

Case Report No. 5: A Pseudo-endophthalmitis


Figures 12.13, 12.14, 12.15 and 12.16
A 76-year-old female patient was admitted to our surgical ward with the suspi-
cion of an endophthalmitis with hypopyon. The examination revealed that the eye
was painful, the visual acuity was decreased to HM, the cornea was oedematous and
a “hypopyon” was present. The hypopyon was, however, an Ozurdex pellet which
was lying horizontal in the inferior cornea mimicking a hypopyon.
The patient underwent a complicated phacoemulsification 2 months prior. An
iris-claw IOL (Verisyse®) was implanted, and then, 6 weeks later, an Irvine–Gass
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment) 157

Fig. 12.14 Case report 5.


An iris-claw IOL was
implanted and the Ozurdex
pellet migrated into the
anterior chamber

Fig. 12.15 Case report 5.


Easy removal of the
Ozurdex pellet

Fig. 12.16 Case report 5.


The cornea was severely
affected for several months
after removal
158 12 Endophthalmitis

macular oedema occurred. The macular oedema was treated with Ozurdex. Ten
days after injection, the patient presented with the above-mentioned symptoms. The
Ozurdex pellet was immediately removed, but the recovery of the cornea was very
slow and the last visual acuity was measured with 0.3. Remark: Do not inject an
Ozurdex pellet in an eye with posterior capsular defect or aphakia.

12.3 Complications

Retinal detachment: The retina is very fragile when inflamed. It is easy to create a
hole during PVD (central hole!). Do not perform a thorough trimming of the vitre-
ous base. The vitreous cutter causes much dragging to the peripheral retina which
may result later into a retinal detachment. Conclusion: It is important to perform a
PVD, but do not insist to remove every leukocyte in the vitreous base.

12.4 FAQ

Intravitreal antibiotics vs vitrectomy: If you are a retina clinic, then pursue the com-
plete way and perform a vitrectomy. If you are an anterior segment clinic or do not
have immediate access to vitrectomy, then inject intravitreal antibiotics. Important:
Treat the patient immediately after arrival at the ward with intravenous antibiotics
(e.g. 1.5 g Zinacef® ×3/day). There is always a considerable delay between the time
point of arrival of the patient and the time point of injection. Add also subconjunc-
tival cortisone (e.g. 1 ampoule Betapred®) to reduce the inflammation.

Reference
1. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study.
A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of
postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479–96.
Retinal Detachment
13

Contents
13.1 General Introduction ..................................................................................................... 160
13.2 Pneumatic Retinopexy with BIOM ............................................................................... 163
13.2.1 General Introduction ........................................................................................ 163
13.2.2 Practical Procedure .......................................................................................... 164
13.2.3 The Surgery ..................................................................................................... 164
13.2.4 Complications .................................................................................................. 166
13.2.5 FAQ .................................................................................................................. 166
13.3 Episcleral Buckling for Detachment Surgery with BIOM ............................................ 167
13.3.1 General Introduction ........................................................................................ 167
13.3.2 Instruments ...................................................................................................... 168
13.3.3 Material............................................................................................................ 170
13.3.4 The Surgery ..................................................................................................... 171
13.3.5 Complications .................................................................................................. 180
13.3.6 FAQ 180
13.4 Vitrectomy for Detachment Surgery ............................................................................. 181
13.4.1 General Introduction 181
13.4.2 Surgery 182
13.4.3 Complications 200
13.4.4 FAQ 200
References ................................................................................................................................ 202

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 159


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_13
160 13 Retinal Detachment

13.1 General Introduction

The key for the understanding of a rhegmatogenous detachment are the four Lincoff
rules (Figs. 13.1, 13.2, 13.3 and 13.4). They indicate where the primary break is
located with a very high probability [1]. More and more surgeons do not assess
longer the retina before surgery because the assessment is much better under the
microscope than before the slit lamp. This argument is absolutely true, but I highly
recommend taking your time to assess only which type of detachment is present.
There are only four types present and the first two types make 70 % of all cases. You
do not need to assess the tears.

Fig. 13.1 Superotemporal 1,5 clockhours from


or superonasal retinal the upper edge
detachment. The primary
break is located within 1½
clock hours of the
superior border of the
detachment. Lincoff rule 1

Fig. 13.2 Superior or


total detachment that
crosses the 12 o’ clock
meridian. The primary
break is located within a
triangle with the apex at
12 o’ clock and the sides
between 10:30 (temporal
side) and 1:30 (nasal
side). Lincoff rule 2
13.1 General Introduction 161

Fig. 13.3 Inferior


detachment. The primary
break is located between
the highest border of the
detachment and 6:30.
Lincoff rule 3

Tear can occur between


upper edge and 6:30

Fig. 13.4 Highly


bullous inferior
detachment. The
primary break is
located at 11 or 1 o’
clock. Lincoff rule 4

Why?
If you know which type of detachment is present, you know where the (primary)
tear must be present.
But I will find this tear under the microscope.
Possibly not, if it is a minihole. A few examples, right eye:
1. Detached retina from 6 o’clock to 11 o’clock. This is called a “superotemporal
detachment”. The tear must be present 1.5 clock hours from the superior edge of
detachment, i.e. in this case between 9:30 and 11:00 (Fig. 13.1).
2. A detached retina between 8 o’clock over 12 o’clock to 3 o’clock. This is termed
a “superior detachment” and the tear must be located within a triangle at 12
o’clock, in this case between 10:30 and 1:30 (Fig. 13.2).
Now you may argue that this was not difficult and you would solve these
cases without preoperative assessment. Okay, probably, but the following case
would be a hard nut if you did not assess the eye preoperatively:
162 13 Retinal Detachment

3. Initial assessment: Highly bullous inferior detachment from 4 o’clock to 8


o’clock. If you would start surgery now, you would search after a tear within this
area. But there is no tear present there. Why? Because you missed that the detach-
ment is highly bullous and inferior detachments are never highly bullous. So a
different kind of detachment must be present. This is a Lincoff-type four detach-
ment with a highly bullous inferior detachment and a very small tear at 11
o’clock. If you examine the fundus thoroughly, you will find a sinus in the
periphery to a tiny hole at 11 o’clock (Figs. 13.3 and 13.4).
Conclusion: Make a short assessment of the detached retina before surgery so
that you know which type of Lincoff-type 1–4 detachment is present.

Surgical Pearls No. 31


Treat the retinal tears and not the detachment. This sounds simple but often
an overtreatment is performed. If you mend a hole in a bicycle tire then you
only mend the hole and not the complete tire. The same principle applies to a
hole in the retina. Treat only the hole edges and not the complete retina.

The next important question is: Which type of surgery for which
type of detachment?
This depends from vitreoretinal clinic to vitreoretinal clinic. The aim is to attach the
retina with as little surgery as possible. Our treatment algorithm is as follows:

# A detachment with retinal breaks between 7 o’clock over 12 o’clock to 5 o’clock


and macula engagement we would operate with a vitrectomy (Fig. 13.5).
# An inferior detachment with a retinal break between 5 o’clock and 7 o’clock, we
would preferably operate with an episcleral buckling (Fig. 13.5).

Pneumatic retinopexy
12
11 1

10 2
my
Vitrecto

9 3
my
Vitrecto

8 4

Fig. 13.5 Our treatment 7 5


algorithm for retinal 6
surgery depending on the Episcleral bucking
location of the retinal
breaks
13.2 Pneumatic Retinopexy with BIOM 163

Fig. 13.6 Ora dialysis Limbus


is often located in the
inferotemporal
8 o’clock 5:30 o’clock
quadrant. The silicone
sponge has to be placed Silicone sponge
on the ora dialysis and Ora dialysis
under the inferior rectus
muscle

Muscle

Special cases are as follows:

# Children: Episcleral buckling. Children have excellent optical media allowing an


easy assessment of the retina. The typical case is an ora dialysis.
# Young myopes: Episcleral buckling. Also these patients have excellent optical
media which allow an easy retinal assessment. It may be advisable to use a
microscope for suturing because the sclera is thin.
# Ora dialysis: Episcleral buckling. The surgical success rate for ora dialysis with
episcleral buckling is 100 %. And surgery is simple. Place the sponge just below
the muscle insertions and you will succeed (Fig. 13.6).
# Detachment Lincoff rule 4: Episcleral buckling. This very special case which can
be seen with approximately every 20th detachment is very easy to fix with an
episcleral buckling and much less time-consuming than vitrectomy. Place a
sponge on the minihole at 11 o’clock or at 1 o’clock. No drainage is necessary.
The retina will be completely dry the next day demonstrating nicely the excellent
pump function of the pigment epithelium (Fig. 13.4).

13.2 Pneumatic Retinopexy with BIOM

13.2.1 General Introduction

Video 13.1: Pneumatic retinopexy with BIOM

A focal detachment with a retinal break between 10 o’clock and 2 o’clock and
attached superior arcade, we would operate with a pneumatic retinopexy (Fig. 13.8).
There are two possible techniques: (1) binocular ophthalmoscopy with helmet or (2)
the microscope with BIOM and insertion of a chandelier light. We describe the
second method.
164 13 Retinal Detachment

13.2.2 Practical Procedure

1. Perform a cryopexy of the tear.


2. Paracentesis and drainage of anterior chamber fluid.
3. Inject 0.5 ml 100 % SF6.

OR

1. Paracentesis and drainage of anterior chamber fluid.


2. Inject 0.5 ml 100 % SF6.
3. Perform laser coagulation 1 day later.

13.2.3 The Surgery: Figs. 13.7, 13.8, 13.9, 13.10 and 13.11

1. Insertion of a chandelier light


2. Flick in the BIOM
3. Cryopexy of the break
4. Removal of the chandelier light
5. Paracentesis
6. Injection of air or gas

Insert the chandelier light on the opposite side of the break. Flick in the BIOM,
localize the break and freeze the break edges with cryopexy. Remove the chandelier
light. A suture (Vicryl 8-0) of the sclerotomy may be necessary. Perform a paracen-
tesis and drain aqueous from the anterior chamber. Inject 0.5 ml 100 % SF6 into the
vitreous cavity.

Fig. 13.7 Pneumatic


retinopexy: insert a
chandelier light
13.2 Pneumatic Retinopexy with BIOM 165

Fig. 13.8 Pneumatic


retinopexy: the chandelier
light is located on the
opposite of the break

Fig. 13.9 Pneumatic


retinopexy: flick in the
BIOM

Fig. 13.10 Pneumatic


retinopexy: freeze the
retinal break
166 13 Retinal Detachment

Fig. 13.11 Pneumatic


retinopexy: perform a
paracentesis and inject
0.5 ml 100 % SF6

Fig. 13.12 Pneumatic Compression of


retinopexy: the gas vitreous body
bubble displaces the
superior vitreous body
and may cause an
inferior retinal traction
gas
resulting in a detachment

Traction of
vitreous body
=> Retinal traction

13.2.4 Complications

Infero(temporal) detachment, see Figs. 13.12 and 13.13; in most cases a tractive
detachment. In this case, we would perform a 25G or even better 27G vitrec-
tomy + laser + C2F6. In case of a rhegmatogenous detachment, we would prefer an
episcleral buckling. This complication occurs mainly in young patients.

13.2.5 FAQ

It only occurs in the eyes with attached posterior vitreous. The gas bubble pushes
the superior vitreous against the retina and pulls the inferior posterior vitreous
resulting in an inferior detachment.
13.3 Episcleral Buckling for Detachment Surgery with BIOM 167

Fig. 13.13 Pneumatic


retinopexy: the inferior
detachment is often
located in the
inferotemporal quadrant Gasbubble

Inferior
detachment

Remember: Pneumatic displacement in old patients secondary to submacular


haemorrhage never results in a retinal detachment because the posterior vitreous is
detached.

How high is your success rate? 100 %, but remember: We use a very restricted
indication with breaks only from 10 o’clock to 2 o’clock.

13.3 Episcleral Buckling for Detachment Surgery with BIOM

13.3.1 General Introduction

Video 13.2: Episcleral buckling with BIOM 1


Video 13.3: Episcleral buckling with BIOM 2

The complete surgery is performed with a microscope. We use the microscope


with BIOM instead of a helmet with binocular ophthalmoscopy. For endoillumina-
tion a chandelier light is inserted.
Why? Today vitreoretinal surgeons are more used to the microscope. It is easier
for a vitreoretinal surgeon to inspect the retina with a microscope than with binocu-
lar ophthalmoscopy. In addition, suturing of the silicone sponge is easier under a
microscope than with a helmet. This is especially the case for long myopic eyes.
The episcleral buckling technique we apply is the minimal buckling technique
according to Kreissig/Lincoff [1]. In short: (1) Cryopexy of the tear. (2) Application
of a segmental buckle. Finish. No drainage necessary. No encircling band necessary.

Which silicone sponge? There are many silicone sponges on the market. My
department uses in almost all cases only two types of sponges:
168 13 Retinal Detachment

Fig. 13.14 Instrument set


for retinal detachment from
the University of Uppsala

1. A normal sized (3.77 × 5 mm) silicone sponge. Our most common used silicone
sponge. Indication: Ora dialysis, all normal size breaks. This sponge requires a
7 mm marking.
2. A large (3.66 × 7.5 mm) silicone sponge. Less common used silicone sponge.
Indication: Big breaks. This sponge requires a 9.5 mm marking.

13.3.2 Instruments

Here you will find all the details of our episcleral buckling instrument set, which we
use at the University Hospital of Uppsala (Fig. 13.14). The instruments vary, of course,
from hospital to hospital. The instruments in italic are absolutely necessary.

Blepharostat
1× Williams open adult

Cannulas
1× rough curved

Forceps
2× anatomical forceps
2× forceps claw 1 × 2
1× forceps Bonn

Scissors
1 scissors eyes straight sharp
1 scissors eyes bent sharp
1 scissors Westcott Geuder 19750 (Fig. 13.15)
1 scissors straight Vannas Geuder 19760
13.3 Episcleral Buckling for Detachment Surgery with BIOM 169

Fig. 13.15 Westcott


scissors 12 cm, Geuder
19750

Fig. 13.16 Orbital spatula


Sautter, Geuder 15740

Fig. 13.17 Caliper


Castroviejo 20 mm,
Geuder 19135

Fig. 13.18 Strabismus hook


Bonn 1 mm hole, Geuder 15821

Clamping scissors
2 clamping scissors bent Halsted
2 clamping scissors Hartman straight
1 clamping scissors Crile straight 14 cm

Needle holders
1 needle holder Barraquer without lock
1 needle holder Snowden–Pencer with lock

Orbital spatula
1 orbital spatula Helvestone
1 orbital spatula Sautter Geuder 15740 (Fig. 13.16)

Knot holder
2 knot holder Rapp

Other
1 caliper Castroviejo straight 1–20 mm Geuder 19135, (Fig. 13.17)
1 ruler
4 clamp Diefenbach 2
1 depressor scleral with or without marker
1 strabismus hook Bonn 1 mm hole, Geuder 15821, (Fig. 13.18)
170 13 Retinal Detachment

Fig. 13.19 Two different


silicone sponges
(Labtician, Canada)

Fig. 13.20 Supramid 4-0


suture for silicone sponge,
Serag Wiessner, Germany

13.3.3 Material

1. Silicone sponge: (Fig. 13.19)


1. 5 × 3.77 mm partial-thickness sponge (Labtician, Canada) OR
2 7.5 × 3.66 mm partial-thickness sponge (Labtician, Canada)
2. Surgical skin marker with ultrafine tip (many companies, e.g.: 1456XL SR-100,
Viscot Medical LLC, USA)
3. Supramid suture 4-0 (REF SP151399, Serag Wiessner, Germany), alternative:
polyester 5-0 (Alcon) (Fig. 13.20)
4. Silk suture 3-0 (Ethicon)
13.3 Episcleral Buckling for Detachment Surgery with BIOM 171

13.3.4 The Surgery

1. 180° limbal peritomy.


2. 3 traction sutures.
3. Insertion of a chandelier light.
4. Search for the retinal break with scleral depressor.
5. Cryopexy of the break.
6. Scleral marking of the break.
7. Apply the sutures.
8. Paracentesis, release aqueous from anterior chamber.
9. Fasten the sponge temporarily.
10. Inspect the retina.
11. If sponge covers the break, fasten the sponge permanently. If sponge does not
cover the break, then replace the sponge.
12. Remove the chandelier light and suture the sclerotomy with a Vicryl 8-0
suture.
13. Remove the traction sutures and close the conjunctiva with Vicryl 6-0.

13.3.4.1 The Surgery Step by Step: Figs. 13.21, 13.22, 13.23, 13.24,
13.25, 13.26, 13.27, 13.28, 13.29, 13.30, 13.31, 13.32, 13.33,
13.34, 13.35, 13.36, 13.37 and 13.38
1. 180° limbal peritomy.
2. 3 traction sutures.

The limbal peritomy and the three traction sutures are placed according to the
location of the break. If the break is located at 12 o’clock, then the lateral rectus, the
medial rectus and the superior rectus require traction sutures, and the limbal perit-
omy is located from 8 o’clock over 12 o’clock to 4 o’clock.
Perform a limbal peritomy and place a strabismus hook with hole behind a
straight muscle. Confirm that you grabbed the whole muscle because you may place
a sponge beneath the muscle. Insert the silk suture into the hole and retract the hook
with the suture (Fig. 13.21). Tie a knot into the suture. Repeat this procedure with
the two other straight muscles.

3. Insertion of a chandelier light.

Continue with insertion of the chandelier light (Fig. 13.22). The best location is
opposite to the break. If the break is located superiorly, then insert the chandelier
light inferiorly.
172 13 Retinal Detachment

Fig. 13.21 Insert the


strabismus hook with hole
under a straight muscle and
insert a silk 3-0 suture

Fig. 13.22 Insertion of a


chandelier light opposite to
the break

Fig. 13.23 Search for a


retinal break
13.3 Episcleral Buckling for Detachment Surgery with BIOM 173

Fig. 13.24 Cryopexy of


the retinal break

Fig. 13.25 Mark the


sclera: 9 mm for a big
sponge and 7 mm for a
small sponge

Fig. 13.26 Mark the


sclera
174 13 Retinal Detachment

7mm

break

Fig. 13.27 Scleral marking for a radial sponge

2mm

break
7mm
5mm

Fig. 13.28 Scleral marking for a limbus parallel sponge


13.3 Episcleral Buckling for Detachment Surgery with BIOM 175

Limbus

Muscle
2mm

rupture
7mm
5mm

Fig. 13.29 Scleral marking for a limbus parallel sponge with muscle

Fig. 13.30 Scleral suture


under microscope view
176 13 Retinal Detachment

limbus

First suture

Second suture

Fig. 13.31 Drawing of a suture for a radial sponge

Limbus

First suture Second suture

Fig. 13.32 Drawing of a suture for a limbus parallel sponge


13.3 Episcleral Buckling for Detachment Surgery with BIOM 177

Fig. 13.33 Be careful


when suturing especially in
myopic patients

Fig. 13.34 Suture the


anterior and then the
posterior marking

Fig. 13.35 Insert the


sponge under the suture
loop and under the
complete muscle
178 13 Retinal Detachment

Fig. 13.36 Place two


throws on top of the
sponge (2–1–2)

Fig. 13.37 Then inspect


the retina. If the sponge is
not correctly located then
replace the sponge

Fig. 13.38 Note that the


sponge lies under the
complete muscle
13.3 Episcleral Buckling for Detachment Surgery with BIOM 179

4. Search for the break with scleral depressor.

Flick in the BIOM and break for the break (Fig. 13.23). This manoeuvre is a bit
more difficult compared to vitrectomy because the globe is more difficult to rotate.

5. Cryopexy of the break.


6. Scleral marking of the break.

Freeze now the break, keep the cryopexy handpiece in place, flick out the BIOM
and rotate the globe; the assistant inserts an orbital spatula between tenon/conjunc-
tiva and sclera to identify the freezing spot (Fig. 13.24). Dry the freezing spot with
a cotton swab and mark it with the surgical marker pen (Fig. 13.25). Dry the spot
again with the cotton swab. The sclera must be absolutely dry that you can mark it.

7. Apply the sutures.

Decide now whether you want to apply a radial sponge or a limbus parallel
sponge (Figs. 13.25, 13.26, 13.27, 13.28 and 13.29). If the break is located under a
muscle, a limbus parallel approach is advisable because it is difficult to suture under
the muscle. Paint the tips of the caliper with the surgical skin marker pen. Mark the
sclera with the caliper (Geuder). How wide? Two millimetres more than the width
of the sponge. If the sponge is 5 mm wide, then mark 7 mm. Where to mark? In case
of a radial sponge, mark approximately 2 mm above the break and 2 mm below the
break (Fig. 13.27). In case of a limbus parallel sponge, mark approximately 2 mm
left and right to the break (Figs. 13.28 and 13.29). If the break is next to a muscle,
then mark left and right to the muscle and place the sponge under the muscle. The
muscle force will help to indent the sponge (Fig. 13.29, 13.30).
How to suture? (Figs. 13.30, 13.31, 13.32, 13.33, 13.34, 13.35, 13.36, 13.37 and
13.38). The suture is the most dangerous manoeuvre in the complete surgery because
you can perforate the sclera. Place therefore a less deep but long stitch. You need one
suture with one needle for two markings, i.e. cut the suture in two halves so that you
have two sutures with one needle each. Place a 3–4 mm long stitch under microscope
view at one marking and a second stitch at the second marking (Fig. 13.31 and 13.32).

Surgical Pearls No. 32


Retinal tear under a muscle. Alternatively to a limbal sponge, you can apply
a radial sponge. If you want to apply a radial sponge under the muscle, then
remove the muscle, suture the sponge and suture the muscle back to place or
suture the sponge onto the muscle. If the patient experiences diplopia after
surgery, you can remove the sponge after approximately 2 weeks.

8. Paracentesis, release aqueous from anterior chamber.

You need a soft globe to achieve a proper indentation of the sponge. Perform a
paracentesis and release aqueous from the anterior chamber.
180 13 Retinal Detachment

9. Fasten the sponge temporarily.

Place the silicone sponge under the sutures, make two throws (Figs. 13.35 and
13.36), tighten the suture a little bit, release tension on the traction sutures and then
tighten the suture again. Perform the same manoeuvre with the second suture. Do
not complete the tying and do not cut the suture because we will examine the retina
first and may have to replace the sponge. If you use a supramid suture, then the knot
will remain stable. You may also complete tying and then use new sutures, if you
have to replace the sponge (Figs. 13.37 and 13.38).

10. Inspect the retina.

Flick in the BIOM and inspect the retina. If the sponge covers the break, fasten
the sponge permanently. If the sponge does not cover the break, then replace the
sponge.

11. Remove the chandelier light.


12. Remove the traction sutures and close the conjunctiva with Vicryl 6-0.

Remove the chandelier light and suture the sclerotomy with a Vicryl 8-0 suture.
Continue with cutting the traction sutures and remove them. Replace the conjunc-
tiva and sew it with Vicryl 6-0 or 8-0.

13.3.5 Complications

Scleral perforation: A scleral perforation can be seen by leakage of intraocular


fluid. Redraw the needle, freeze the leakage site with cryopexy and repeat the
suture.
Bulbar hypotony: Especially in vitrectomized eyes, the globe may be very
hypotonous with scleral folds. Inject BSS with a 30G needle via pars plana until the
globe is normotensive.

13.3.6 FAQ

Can I place a silicone sponge during vitrectomy?


Yes. If you want to buckle, for example, a break at 6 o’clock, then place a limbus
parallel silicone sponge under the inferior rectus.

What about episcleral buckling in a vitrectomized eye?


This is no problem. It is actually easier because the impression of the sponge is
more pronounced due to the absent vitreous body. In case of a focal redetachment
without PVR, I often do episcleral buckling. The tear is difficult to find and often it
is a laser necrosis which causes a tiny break. Place a sponge on this laser-treated
break and the retina will be attached the next day.
13.4 Vitrectomy for Detachment Surgery 181

13.4 Vitrectomy for Detachment Surgery

13.4.1 General Introduction

Video 13.4: 27G retinal detachment without PFCL


Video 13.5: Retinal detachment high myopia with PFCL
Video 13.6: 27G retinal detachment
Video 13.7: 27G Retinal detachment Constellation
Video 13.8: 27G redetachment

A rhegmatogenous retinal detachment (RRD) with multiple breaks is a surgery


for experienced surgeons, as there is a significant complication profile. The begin-
ner should start with a localized detachment (one to two quadrant detachment and a
single break), as this is usually easier to manage. See Flow chart 13.1.
Regarding surgery we recommend two things which simplify vitrectomy very
much: phacoemulsification and usage of a chandelier light. We recommend per-
forming a phacoemulsification in all patients older than 50 years because the ante-
rior vitreous and the vitreous base can be removed completely. Secondly we
recommend the usage of a chandelier light because it facilitates every step of the
vitrectomy. The tears are located in the periphery and need to be indented with the
scleral depressor: Nobody indents as well as your second hand.
PFCL or No PFCL?

primary retinal detachment

Phakic Pseudophakic

> 50 yrs < 50 yrs

Phaco No phaco

PPV

Small Large
detachment detachment

BSS × air njection of


exchange PFCL + laser

Laser PFCL × air


treatment exchange

Flow chart 13.1 Our


treatment algorithm for Tamponade
retinal detachment surgery
182 13 Retinal Detachment

Some vitreoretinal clinics use PFCL as a routine; others hate it. PFCL is an
excellent tool for vitreoretinal surgery and I recommend to use it, if necessary. We
use PFCL in large, macula-off detachments, and we work without PFCL in focal,
macula-on detachments. In giant tears, we always use PFCL due to the risk of
slippage.

13.4.2 Surgery

Instruments
1. 27G 3-port trocar system
2. Chandelier light
3. 120D lens
4. Endodiathermy
5. Endolaser
6. Backflush instrument
7. Scleral depressor

Dye
Possibly: Triamcinolone to stain the vitreous

Tamponade
Intraoperative: PFCL
Postoperative: Primary detachment—20 % SF6, 15 % C2F6. Secondary detachment—14 %
C3F6, 1000 cSts silicone oil

Individual Steps
1. 27G 3-port system with chandelier light
2. Phacoemulsification with IOL
3. Core vitrectomy and posterior vitreous detachment
4. Marking of breaks with endodiathermy
5. Injection of PFCL up to the posterior edge of the break and drainage of subreti-
nal fluid
6. Vitrectomy of the break flap and the peripheral vitreous
7. PFCL injection up to ora serrata or continue with 10.
8. Laser photocoagulation around breaks
9. Trimming of the vitreous base (Shaving)
10. Fluid–air exchange
11. Drainage of subretinal fluid
12. Complete laser coagulation
13. Gas tamponade
14. Removal of trocars
15. Postoperative posture
13.4 Vitrectomy for Detachment Surgery 183

13.4.2.1 The Surgery Step by Step: Figs. 13.39, 13.40, 13.41, 13.42,
13.43, 13.44, 13.45, 13.46, 13.47, 13.48, 13.49, 13.50, 13.51,
13.52, 13.53, 13.54, 13.55, 13.56, 13.57, 13.58 and 13.59

Fig. 13.39 This is the


best set-up for a vitrectomy
for retinal detachment:
trocars with valves, if
possible 27G, a
pseudophakic eye and a
chandelier light

Fig. 13.40 A highly


bullous superior
detachment. First a
phacoemulsification + IOL
implantation was
performed. A chandelier
light illuminates this eye.
Now a vitrectomy is being
performed
184 13 Retinal Detachment

Fig. 13.41 Search for the


break: move the scleral
depressor from the ora
serrata towards the
posterior pole and look for
break flaps

Fig. 13.42 Now you do


not see the break

Fig. 13.43 This picture


shows very nicely that
sometimes it is almost
impossible to visualize the
rupture
13.4 Vitrectomy for Detachment Surgery 185

Fig. 13.44 The


endodiathermy highlights
the rupture for laser
therapy and drainage

Backflush
instrument

Trapped
fluid

PFC

Fig. 13.45 A drawing showing the drainage of subretinal fluid through the break after injection
of PFCL
186 13 Retinal Detachment

Fig. 13.46 Due to the


chandelier light, the
surgeon has two free
hands. With your left
hand, you indent the
retina and the tear. The
right hand holds the
vitreous cutter

Fig. 13.47 The flap of the


tear has been removed with
the vitreous cutter. This is
necessary in order to
remove the vitreous
traction, which caused the
retinal detachment
13.4 Vitrectomy for Detachment Surgery 187

Fig. 13.48 The “left


hand” injects PFCL and
the “right hand” drains
subretinal fluid from the
break

Trapped fluid

break
PFC
Fig. 13.49 Intraoperative
situation before fluid
against air exchange. The
eye is filled with PFCL up
to the ora serrata, and
subretinal fluid is trapped
between the break and ora
serrata
188 13 Retinal Detachment

Fig. 13.50 Intraoperative


photograph of trapped fluid
with a doughnut shape

Fig. 13.51 Three rows of


laser burns are applied
around the break, which
was marked with
endodiathermy. Next to the
break, you recognize an
old cryoscar

Fig. 13.52 Situation


before shaving. PFCL is
injected up to the ora
serrata. The transparent
space between retina and
PFCL is filled with
vitreous
13.4 Vitrectomy for Detachment Surgery 189

Fig. 13.53 Situation


after shaving. The
vitreous and henceforth
the transparent space
have been removed with
the vitreous cutter

Fig. 13.54 Drawing of


the situation in the eye
during a PFCL against air
exchange. The BSS phase,
which is located between
the air and PFCL phase, is
Backflush
being aspirated instrument

Air

BSS

PFC

Fig. 13.55 The tip of the


flute needle is held just
above the PFCL bubble in
order to remove the water
phase
190 13 Retinal Detachment

Fig. 13.56 Hold the tip


of the flute needle in the
middle of the break and
drain the subretinal fluid
and residual intravitreal
fluid. Do not aspirate
more PFCL before you
completely removed the
subretinal fluid

Fig. 13.57 Drawing of a Backflush


sandwich technique. The instrument
air pushes the subretinal Air
fluid towards the posterior
pole. PFCL prevents that
the subretinal fluid
proceeds to the posterior
pole. Both meniscus of
air and PFCL must meet
at the break in order to PFC
drain the subretinal fluid
from here. Remember:
Air pushes trapped fluid
to the centre and PFCL
pushes trapped fluid to
the periphery
13.4 Vitrectomy for Detachment Surgery 191

Fig. 13.58 Drawing of a


detachment with several
breaks. Begin the fluid x
air exchange and hold the
Charles flute cannula in the
first break (1). Then
proceed to break 2 and
finally to break 3

Fig. 13.59 Completion


of laser therapy in an
air-filled eye. Now the
break is easy to laser
because the edges are
attached after a
successful sandwich
technique
192 13 Retinal Detachment

1. 27G 3-port system with chandelier light.

Insert the trocars at the usual locations 3.5 mm behind the limbus. Visualize the
location of the infusion cannula in order to avoid a choroidal detachment. Then
insert the chandelier light inferonasally 3.5 mm behind the limbus (Fig. 13.39).

2. Phacoemulsification.

The IOL can be implanted in this step or later when all the breaks are treated
(step 10). The advantage of early IOL implantation is that one works with a stable
anterior segment and the IOL implantation is usually easier at this stage compared
to the end of the surgery. The disadvantage is that the edge of the IOL may interfere
with the view of the retinal periphery and the vitreous base.

Surgical Pearls No. 33


Corneal suture: In case of an unstable anterior chamber, place a single 10-0
nylon suture at the end of the phacoemulsification and IOL. This avoids acci-
dental opening of the corneal wound during indentation, which may lead to
flattening of the anterior chamber and even dislocation of the IOL. The suture
can be removed once the vitrectomy has been completed.

Surgical Pearls No. 34


Capsular tension ring: A good idea is the insertion of a capsular tension ring
after aspiration of the cortex. The capsular tension ring stretches the capsular
bag so that the posterior capsule does not sag or dip. This reduces the risk of
injury to the lens capsule during vitrectomy. If you are using a capsular ten-
sion ring, make sure that it is in the right place, as removing a capsular tension
ring from the vitreous base is not an easy task.

Surgical Pearls No. 35


Corneal lubrication: A major problem during vitrectomy, especially in com-
bined surgeries with duration of over 1 h, is corneal epithelial oedema. With
generous application of methylcellulose (Celoftal, Alcon), the cornea remains
clear for the complete surgery.
13.4 Vitrectomy for Detachment Surgery 193

3. Core vitrectomy and posterior vitreous detachment.

Perform a core vitrectomy and identify the posterior vitreous face to verify that
a PVD is present. If the vitreous is still attached, perform induction of a PVD. Then
continue with vitrectomy, and search for retinal breaks. Carefully remove the vitre-
ous close to the retina in the area of detached, fluttering retina (Fig. 13.40).

Surgical Pearls No. 36


PVD in RRD: In about 15 % of patients with RRD, the vitreous is still attached
at the posterior pole. One group at risk is myopic patients below the age of 50
years with multiple small round breaks. The vitreous may be very adherent to
the retina in such cases and trying to induce a PVD can lead to multiple iatro-
genic breaks. These cases usually do very well with scleral buckling surgery.
If in doubt, check the status of vitreous attachment/detachment with preopera-
tive ultrasound before deciding to perform a vitrectomy.

Surgical Pearls No. 37


Triamcinolone and RRD: Many cases of RRD are caused by strong vitreoreti-
nal adhesion. It may not be possible to separate vitreous and retina simply by
engaging the vitreous with the vitreous cutter and pulling it off the retina—
you may enlarge pre-existing breaks or induce iatrogenic breaks in some
cases. If you find very strong vitreoretinal adhesions, it is advisable to “stop
pulling” and start “shaving” the vitreous of the retina. This is facilitated by
staining the adherent vitreous with triamcinolone. When staining the vitreous
with triamcinolone, use minimal amounts and direct the injection to the area
of interest. Injecting too much triamcinolone may interfere with your view,
and it can be cumbersome to remove this later on in the procedure.

4. Mark the breaks with endodiathermy.

The key concept of all retinal detachment surgeries is to identify and treat all reti-
nal breaks (Figs. 13.41 and 13.42). Perform a thorough internal search for breaks
following Lincoff rules that point to the most likely areas of retinal breaks. If you
fail to identify and treat a retinal break in detached retina, failure and retinal rede-
tachment following vitrectomy are guaranteed. Mark the edges of the break with
endodiathermy. A break, which is not marked, is hard to identify when it is attached
to the underlying retinal pigment epithelium (Figs. 13.43 and 13.44).
194 13 Retinal Detachment

Surgical Pearls No. 38


Unseen breaks and Schlieren phenomenon: Inject PFCL slowly and watch for
the “Schlieren phenomenon”. In particular in long-standing RRD, the subreti-
nal fluid appears like a muddy stream when entering the vitreous cavity. This
“Schlieren phenomenon” may point to the location of the retinal break at the
entry site of the Schlieren in cases of “unseen breaks”.

5. Injection of PFCL to posterior edge of break and drainage of subretinal fluid.


The PFCL has three tasks in detachment surgery:
1. Stabilization of the mobile retina
2. Removal of the subretinal fluid
3. Elevation of the vitreous base

The PFCL pushes the subretinal fluid from the central pole towards the periphery
and presses it through the retinal break into the vitreous cavity. First, the PFCL is
injected up to the posterior edge of the most central break, while we observe how
the subretinal fluid is forced through the break into the vitreous cavity. You can
accelerate this step by aspirating subretinal fluid actively with the Charles flute nee-
dle (Fig. 13.45). The PFCL also has the effect that the mobile retina is attached, and
a vitrectomy in the vicinity of the detached retina is less dangerous.

Surgical Pearls No. 39


PFCL is quite expensive. In more complicated cases, it may be necessary to
perform multiple manipulations under PFCL, occasionally removing and then
again adding PFCL at a later stage. If PFCL needs to be removed, one can
easily aspirate it back into the injection syringe for reinjection at a later stage
of the procedure.

6. Vitrectomy of the tear flap and the peripheral vitreous.

After ensuring the presence and completion of a PVD, the next step is to perform
a trimming of the vitreous base. Start within the area of the break(s) and also remove
the flap, as the vitreous traction on the flap caused the detachment. The scleral
depressor in the second hand is a great help when indenting the retina (Figs. 13.46
and 13.47).

7. PFCL injection up to ora serrata or continue with 10.

Depending on the anterior/posterior location of the break, there is more or less


subretinal fluid anterior to the break (trapped fluid) (Fig. 13.48). If a break is
located at the ora serrata, you can drain the residual subretinal fluid with a com-
plete PFCL fill. However, if the break is however located at the equator, then a
complete drainage is not possible with a complete PFCL fill. The subretinal fluid is
13.4 Vitrectomy for Detachment Surgery 195

trapped between the break and the ora serrata (Figs. 13.49 and 13.50). In the first
case, you can proceed with laser photocoagulation, and in the latter case, you can
perform a partial laser photocoagulation and complete the laser after the fluid–air
exchange in step 10.
If you want to remove the trapped fluid in this step, there are two possibilities: (1)
Cut an iatrogenic break close to the ora serrata and drain the fluid from there. (2)
More elegant but technically more demanding is a sandwich technique as described
in detail in step 11.

Surgical Pearls No. 40


Iatrogenic break: If the break and the bullous detachment are far apart from
each other, it is difficult to drain the subretinal fluid from the break. In the first
case, one can try to massage the subretinal fluid with a scleral depressor to the
break or perform an iatrogenic break in the area of trapped fluid. Mark the
inferior retina close to the ora serrata with endodiathermy. Then cut a hole
with the vitreous cutter (setting: approx. 300 cuts/min) by suctioning the ret-
ina and then cutting it cautiously. Drain the subretinal fluid from this break.

8. Laser therapy of breaks.

Apply three rows of laser burns around the breaks (Fig. 13.51). The settings
depend on the laser device.
It is possible that subretinal fluid has accumulated now anterior to the break (so-
called trapped fluid) which makes it difficult to apply a laser onto the anterior part
of the break. Try to indent the break with the scleral depressor, so that the subretinal
fluid is pushed away. Apply white laser burns. A good alternative is to freeze the
break with a cryoprobe. If you do not succeed due to excess trapped fluid, then
complete the laser treatment in a later step.

Surgical Pearls No. 41


Laser: Be careful with your laser energy. Only a mild whitening of the RPE is
necessary. Burns which are too strong will weaken the retina and are a predi-
lection site for the formation of new retinal breaks. They may also cause con-
traction of the choroid or even choroidal haemorrhages. A typical beginner’s
mistake is to perform too much laser or cryotherapy as an extra safety mea-
sure that then may turn out to have exactly the opposite effect.

Surgical Pearls No. 42


Laser cerclage: A circumferential 360° laser is not recommended. It is essen-
tial to identify and treat all retinal breaks. A circumferential laser has the big
disadvantage that in case of a redetachment, the breaks are difficult to find
within the patches of chorioretinal atrophy.
196 13 Retinal Detachment

Surgical Pearls No. 43


Laser necrosis: Another complication of laser is a retinal necrosis. Too high
laser intensity may cause a necrosis of the retina and small, difficult to find
holes. These tears occur often at the outer edge of the laser treatment. The
same applies for cryopexy.

9. Trimming of vitreous base (shaving).

If it has not been performed before, drainage of all subretinal fluid should be car-
ried out (see above); a thorough vitrectomy of the vitreous base has to be performed
at this stage using the scleral depressor. This procedure is also called “shaving”. PFCL
lifts the vitreous up and enables a secure and thorough trimming of the vitreous base.
In those areas, where PFCL does not rest on the retina, there is vitreous which has to
be removed (Figs. 13.52 and 13.53). Indent the sclera and move the vitreous cutter
along the meniscus of the PFCL. Hereby you can manoeuvre the vitreous cutter very
close to the retina because the heavy liquid presses against the retina.

Surgical Pearls No. 44


Trimming of vitreous base: There are various ways to trim the vitreous base:
(a) bimanual technique using a scleral indentor, (b) removal under coaxial
light (only with microscope illumination) by using a cotton wool swab or a
scleral depressor to indent the sclera or (c) using the light fibre as an external
scleral depressor (this gives you a focussed beam of light transsclerally to
illuminate the vitreous base).

10. Fluid against air exchange.

If the shaving is finished, a PFCL–air exchange is performed. Before we perform


this procedure, we have a look at Diagram 13.2, to get a better sense of the situation
in the vitreous cavity. Before the PFCL–air exchange, the vitreous cavity is filled
with PFCL and on top of it is a layer of water. During the PFCL–air exchange, there
is an anterior phase of air, a middle phase of water and a posterior phase of
PFCL. After the PFCL–air exchange, only air is in the eye, which is then replaced
by gas. Postoperatively, water will accumulate again under the gas phase.
Consequently, the gas does not effectively tamponade the lower pole.
The PFCL–air exchange is certainly the most difficult and most important
manoeuvre in the whole detachment surgery, mainly because visibility under air is
bad (Figs. 13.54 and 13.56). Therefore, it is essential to understand the characteris-
tics of PFCL and air. PFCL and air “work” as antagonists. Air exerts a pressure in
the eye from peripheral (anterior) to central (posterior) but PFCL vice versa from
posterior to anterior.
13.4 Vitrectomy for Detachment Surgery 197

Intraoperatively Postoperatively
PFCL / air exchange
Before During after
Water Air air / gas gas
Water
PFCL PFCL water

Diagram 13.2 Diagram of the location of fluids during the PFCL–air exchange

PFCL presses most of the subretinal fluid from the central pole to the periphery
through the retinal break into the vitreous cavity, but a part of it flows beyond the
break-up to the ora serrata, where it cannot be aspirated (“trapped fluid”) (Figs. 13.49
and 13.50). This “trapped fluid” can, however, be removed with air: The air attaches
the retina beginning in the periphery and ending at the central pole and thereby
pushes the “trapped fluid” in the direction of the break (Fig. 13.57).

11. Drainage of subretinal fluid.

How do we proceed in practice? Before you switch to air, hold the flute tip in the
middle of the break. If necessary, take the scleral depressor to help. If several breaks
are present, start with the most peripherally located break and then move to the next
more central break (Fig. 13.58). Now, the scrub nurse switches the three-way tap
from water to air. In the beginning, disturbing air bubbles arise and the view deterio-
rates. Remain calm and turn the front lens with the BIOM-focus wheel up. The
visibility will gradually improve.
In the beginning, the break is covered with PFCL. After a short time, the PFCL
is suctioned to the posterior edge of the break. Now the air presses the subretinal
fluid in the direction of the break (Fig. 13.55). The subretinal fluid is trapped
between anterior-located air and posterior-located PFCL, so-called sandwich tam-
ponade. Now you aspirate the subretinal fluid through the break and at the same
time the water phase between air and PFCL (Fig. 13.56).
Only when the “trapped fluid” and the water phase in the vitreous cavity are
completely aspirated can you continue to aspirate PFCL beyond the posterior edge
of the break. This is very important because the subretinal fluid, which you do not
aspirate, will continue to flow beyond the break in the direction of the optic disc.
If the “trapped fluid” is completely removed, you switch with the flute needle
alternately between the PFCL bubble in order to reduce it and the break in order to
aspirate fluid here. Try to aspirate without indenting the break. But sometimes you
can only reach the break with the flute needle if you indent it with the scleral depres-
sor. But you should not indent the break itself but the retina on either side of the
break. By indenting the break, you close it and prevent the aspiration of subretinal
fluid. This procedure is usually not easy and requires patience.
198 13 Retinal Detachment

The remaining PFCL is aspirated by holding the flute tip directly in front of the
optic disc. Make sure that the PFCL is completely removed and that neither the
retina nor the optic disc is affected.
If after complete removal of PFCL, residual subretinal fluid remains in the cen-
tral pole, then you may either inject PFCL again up to the break and aspirate the
fluid or —if it is only a small amount—leave it. With a postoperative prone position
(face down), the subretinal fluid will be absorbed on the first postoperative day.

Surgical Pearls No. 45


Active aspiration: In 27G the aspiration of subretinal fluid is easier and more
effective with active (than passive) aspiration. If you do not want to use PFCL,
e.g. because only a focal retinal detachment is present, then you should abso-
lutely aspirate subretinal fluid with active aspiration.

Surgical Pearls No. 46


Removal of PFCL: Two pearls for PFCL removal: (1) When using a silicone
tip-flute needle, the risk of retinal or optic disc touch is much lower. (2) If you
are not sure whether you aspirated the entire PFCL, instil a little water into the
air-filled vitreous cavity (with a brief water–air exchange) and then com-
pletely remove the residual PFCL–water puddle.

12. Complete laser coagulation.

If necessary, complete now the laser therapy in the air-filled eye (Fig. 13.59).

13. Tamponade (Diagram 13.3).

Sitting up 1 Sitting up

SF6

9 3
C2F6 C2F6

Buckling
Densiron 68
Left cheek to Right cheek to
Diagram 13.3 Tamponade pillow 7 5 pillow
and posture for retinal Silicone oil
detachment depending on Flat on the back
the location of the break
13.4 Vitrectomy for Detachment Surgery 199

Concerning the use of tamponade, there are significant differences between vit-
reoretinal units at the national and international levels. The trend nowadays is to use
SF6 in a primary detachment and longer-acting gases and silicone oils for
redetachments.
We differentiate between detached breaks and attached breaks. The choice of
tamponade depends only on the detached breaks. See Diagram 13.3. If all detached
breaks are located above the 3 o’clock–9 o’clock meridian, we use SF6. If one
detached hole is located below the 3 o’clock–9 o’clock meridian, we use C2F6. If the
detached break is located at 6 o’clock, we would use Densiron 68 or perform epi-
scleral buckling.

Surgical Pearls No. 47


Air as tamponade: In case of a superior detachment with a break between 11
o’clock and 1 o ’ clock, we use often only air as tamponade. 27G sclerotomies
leak very little. There is an excellent tamponade present for 7–10 days, and
laser treatment is effective after 3–4 days.
Why does it matter? Especially professionally active patients will appreci-
ate to regain their visual acuity after 1 week. In comparison, C3F8 makes an
eye blind and the patient earthbound for 2 months.
Gas tamponade: air against gas exchange
If the retina and the breaks are fully attached, you can flick the BIOM out
and insufflate the diluted gas. The gas container is connected to the three-way
tap, the scrub nurse injects the gas and the surgeon decompresses the globe
with the use of a flute instrument. The globe should remain normotensive.
Silicone oil tamponade: exchange of air against silicone oil
In a 4-port vitrectomy, the following method is easiest: Attach an injection
cannula (plastic cannula, MedOne or metal cannula, Alcon) onto the silicone
oil-filled syringe, and inject the silicone oil through an instrument trocar.
Reduce after a while the air inflow to 10–20 mmHg. When the last air bubble
vanishes behind the IOL, switch the air infusion off.

14. Removal of the trocar cannulas.

Finally, the trocars are removed. Remove first the instrument trocars and at
the end the infusion trocar. In case of a gas tamponade, add some gas until the
globe is normotensive. No suture is needed neither for gas nor for silicone oil.

15. Postoperative posture.

See Diagram 13.3.


For day 1, we recommend a face down posture in order to have a good tam-
ponade of the posterior pole.
200 13 Retinal Detachment

From day 2 to day 7, we recommend “sitting up” if all breaks are above the
horizontal meridian. If inferior breaks are present, the posture should support
the breaks, for example, “left cheek to pillow” in a break in the nasal inferior
quadrant of the left eye. If breaks in the superior and inferior periphery are pres-
ent, a supine position “flat on the back” or “alternating sides, left and then right
cheek to pillow” are recommended. Posture should be carried out for a week,
day and night, for a minimum of 50 min on the hour.

13.4.3 Complications

1. Posterior capsular defect:


This is a stupid complication during detachment surgery because the tampon-
ade will press the IOL forwards and gas or silicone oil will flow into the anterior
chamber. In case of a gas tamponade, I would inject air into the anterior chamber
to counterpress, and in case of a silicone oil tamponade, I would perform an iri-
dectomy and fill the anterior chamber with Healon GV.
2. Slippage:
A. In cases of giant tears, the retina in the area of the break may slip/glide post-
operatively towards the posterior pole (slippage). This is associated with the
risk of developing retinal folds postoperatively which, in the worst of cases,
may involve the macula. This phenomenon is caused by inadequate drainage
of subretinal fluid during fluid–air exchange. To avoid slippage, perform a
direct PFCL x silicone oil exchange.
B. In some cases, you will not succeed in removing all subretinal fluid despite
several attempts. In this case, you can follow two different methods: (a) If only
a small amount of subretinal fluid is present, instruct the patient and nursing
staff to ensure a face down position for about 4–6 h immediately after the sur-
gery. By this time, the subretinal fluid should be reabsorbed without causing a
retinal fold. (b) If a substantial amount of subretinal fluid persists and cannot
be removed, leave a puddle of preretinal fluid behind and instruct the patient to
keep a supine position (flat on the back) for the first hours after the surgery. The
latter manoeuvre is only possible if you do not use PFCL intraoperatively.

13.4.4 FAQ

How do you deal with what type of detachment?


The general recommendations are that in phakic patients, one should perform a
buckling surgery if possible. In pseudophakic patients, a PPV is recommended [2].
In pseudophakia with multiple breaks, we always perform a PPV; this is often
named “primary vitrectomy for retinal detachment”.
There is a strong tendency towards a combined phacoemulsification/vitrectomy
for RRD in all phakic patients of 50 years or above. This greatly facilitates the trim-
ming of the vitreous base that is necessary in retinal detachment.
13.4 Vitrectomy for Detachment Surgery 201

Must I change the position of the trocars according to the location of the
detachment?
No. The trocars are always located at the same positions. You can however make
small deviations according to the location of the break, i.e. to reach the break
more easily.

What do you do if a macular hole is present?


Always check for the presence of a macular hole. This is present in 0.5 % of all reti-
nal detachments, and if you don’t consider it, chances are that you will miss it.
Check either during the preoperative examination or during the surgery. This is
important for prognostication and your surgery, as you may be able to perform an
ILM peeling during the vitrectomy in order to increase the chances of a postopera-
tive hole closure. To correctly identify a macular hole in cases of macula-off, RRD
is difficult as the thinned retina at the fovea may be mistaken for a macular hole by
the inexperienced examiner.

Should I perform an ILM peeling under PFCL?


If the retina at the posterior pole is attached, then perform an ILM peeling in a
water-filled eye. If it is detached, then perform an ILM peeling under a PFCL bub-
ble. Stain the ILM before you inject PFCL.

Surgical Pearls No. 48


Air test for detachment: When the retina is completely attached under air, you
have drained the subretinal fluid completely. Air presses the entire subretinal
fluid from the periphery to the optic disc, where it is easy to spot. This is only
partly true for PFCL because PFCL pushes the subretinal fluid from the pos-
terior pole to the periphery, where the “trapped fluid” is hard to detect.
Remark: PFCL attaches the retina by its specific gravity. (Specific gravity of
PFCL = 1.75, Densiron 68 = 1.06) Air, in contrast, attaches the retina due to its
high surface tension pressure.

Surgical Pearls No. 49


Gas vs silicone oil: If the retina is attached under air in detachment surgery,
then it will also be attached under gas but that’s not necessarily the case for
silicone oil. Why? The surface tension pressure of the gas/water interface is
the greatest and therefore is the most effective in closing retinal breaks (70
mN/N). So when the retina is attached under air, then it is also attached
under gas. The same statement is not true for silicone oil. Why? Because the
surface tension of silicone oil/water with 50 mN/N is less than that of air/
water. So when the retina is attached under air, it might not be attached
under silicone oil.
202 13 Retinal Detachment

References
1. Ingrid Kreissig. Minimal surgery for retinal detachment. Thieme. ISBN 3131110619.
2. Heimann H, Bartz-Schmidt KU, et al. Scleral buckling versus primary vitrectomy in rheg-
matogenous retinal detachment: a prospective randomized multicenter clinical study.
Ophthalmology. 2007;114(12):2142–54.
Diabetic Retinopathy
14

Contents
14.1 Combined Phacoemulsification and Anti-VEGF Treatment ...................................... 207
14.2 Easy PDR .................................................................................................................... 208
14.2.1 The Surgery Step-by-Step ............................................................................. 210
14.2.2 Complications ............................................................................................... 212
14.2.3 FAQ ............................................................................................................... 212
14.3 Difficult PDR .............................................................................................................. 212
14.3.1 General Introduction ..................................................................................... 212
14.3.2 The Surgery Step-by-Step ............................................................................. 214
14.3.3 Complications ............................................................................................... 237
14.3.4 FAQ ............................................................................................................... 238

General Introduction
The surgical planning of the diabetic eye is very important; this is especially the
case in active proliferative diabetic retinopathies. What is the right timing for a vit-
rectomy? Do not operate too early; if the eye is not pretreated with PRP or anti-
VEGF injections and the diabetes is badly regulated, then the vitrectomy becomes
very difficult. But do not operate too late either; if an active PDR progresses to a
tractional detachment with macular involvement, then the vitrectomy will be diffi-
cult and visual prognosis poor.
The main rule is not to perform a vitrectomy in an untreated eye. Pretreat the eye
first with PRP and anti-VEGF (Fig. 14.1), keep a tight follow-up until the retinopa-
thy is inactive and then schedule surgery.
For surgery of diabetic eyes, we favour a stepwise procedure, i.e. we operate in
several sessions depending on the severity of the PDR (see Table 14.1). Why a step-
wise procedure? The difficulty of the vitrectomy depends on the severity of the
PDR. A severe diabetic retinopathy requires a long traumatic surgery. The surgical
trauma however aggravates the diabetic retinopathy, resulting in a vicious cycle.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 203


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_14
204 14 Diabetic Retinopathy

Fig. 14.1 Our treatment


Proliferative diabetic retinopathy
algorithm for surgical
planning of a PDR

pretreated
not pretreated
with PRP

< 50 yrs PRP

> 50 yrs < 50 yrs

Avastin Phaco + Avastin Avastin

1-4 weeks later

Vitrectomy + peeling + laser + anti-VEGF

The surgical planning is, however, also determined by local factors such as reim-
bursement of the surgery or the travel distance to the hospital. If the costs of the
surgery are covered by the national health system and the patient lives close by, then
the surgeon has much more freedom in surgical planning. If the patients pay the cost
for surgery on his own and the travel distance is long, then the surgical planning is
limited; the surgeon may be forced to perform the complete surgery in one
session.
The grade of surgical difficulty depends on the severity of the diabetic retinopa-
thy. The grades of difficulty are differentiated below:

Easy diabetic retinopathy 1. Mild PDR: A complete PVD with vitreous haemor-
rhage is present. The retina is treated with scatter laser (Fig. 14.2).

Difficult diabetic retinopathy 2. Severe PDR: A partial PVD is present.


Fibrovascular membranes are located at the posterior pole and the eye is scatter
laser treated (Fig. 14.3).
3. Advanced PDR: A PVD is not present. No laser treatment has been performed.
A tractional retinal detachment may be present (Fig. 14.4).

The more active the retinopathy, the more stepwise we operate:

• # In an easy PDR, we operate in one session if the nucleus is soft and in two ses-
sions if the nucleus is hard, the latter, of course, in combination with an intravit-
real anti-VEGF injection (Fig. 14.2).
• # In a difficult PDR, we operate in two sessions: (1) phacoemulsification and
intravitreal anti-VEGF and 1–4 weeks later (2) vitrectomy (Figs. 14.3 and 14.4).
14 Diabetic Retinopathy 205

Fig. 14.2 A mild (surgically


easy) PDR with vitreous
haemorrhage. Note that a
complete PVD is present. It is
unlikely that fibrovascular
membranes are present
because the posterior hyaloid
is detached

Fig. 14.3 Illustration of a severe (surgically difficult) PDR. The retina is laser treated. Many reti-
nal proliferations and vitreoretinal adhesions are present. The posterior hyaloid is attached in the
posterior pole and partially detached in the periphery; the nasal posterior hyaloid is often attached
206 14 Diabetic Retinopathy

Retinal proliferaton
Vitreoretinal
adhesion Attached posterior hyaloid

d
aloi
r hy
o
teri
pos
Fibrovascular membranes
d
che

id
Atta

t lo
en hya
m r
ch io
e ta ter
d s
al po
t in ed
Re ach
t
at
ith
w

Vitreoretinal
adhesion

Fig. 14.4 A tractional retinal detachment (surgically very difficult). The retina is not laser treated.
Many retinal proliferations and vitreoretinal adhesions are present. A tractional detachment is
present. The posterior hyaloid is completely attached

Surgical trauma triggers the diabetic retinopathy and consequently the


postoperative healing. It increases also the risk of recurrence of fibrovascular
membranes. If you only operate on the cataract of an eye with active prolifera-
tive diabetic retinopathy, then the retinopathy will progress in the most cases
and an iris rubeosis may occur. Therefore, combine a phacoemulsification
always with an intravitreal anti-VEGF treatment in order to prevent a progres-
sion of the retinopathy and to quieten the retinopathy for the following
vitrectomy.
We perform a stepwise procedure: First phacoemulsification combined with
an anti-VEGF injection and 4 weeks later a vitrectomy. The vitrectomy is much
easier, if the eye is pretreated with phacoemulsification and Avastin. The poste-
rior hyaloid is easier to open, less intraoperatively bleeding will occur, the mem-
branes are easier to remove and so forth. And the postoperative healing is of
course faster.
A cautionary note regarding the timing of phaco and Avastin treatment: The
effect of Avastin lasts 6 weeks. After 4–6 weeks, a laser treatment with/without
vitrectomy should be scheduled. Alternatively, repeat an Avastin injection.
Otherwise the PDR will reoccur after 3 months.
14.1 Combined Phacoemulsification and Anti-VEGF Treatment 207

In the case of a lens-sparing vitrectomy (i.e. a young diabetes type I patient), we


perform in a first step an intravitreal anti-VEGF injection. And 1–4 weeks later, we
perform a lens-sparing vitrectomy.
Do not operate on an eye with advanced diabetic retinopathy that is not pre-
treated with anti-VEGF or PRP. If the retina is attached, then perform a PRP
and inject anti-VEGF medication. If the retina is partially detached, then laser
treat the attached retina. These advanced eyes are like a VEGF forest fire. A
vitrectomy will add extra fuel to the fire. Extinguish the fire with PRP and anti-
VEGF and perform a vitrectomy at a later time point when the PDR is
inactive.

14.1 Combined Phacoemulsification


and Anti-VEGF Treatment

Video 14.1: Phaco and Avastin (no audio)

A diabetic vitrectomy is easier if the eye is pretreated with anti-VEGF 1–4


weeks prior to the vitrectomy. If you have an opacified lens and the patient is older
than 50 years, then perform also a cataract operation before the vitrectomy. It only
takes 10 min of extra surgical time. Especially in advanced diabetic retinopathy
cases, avoid anterior segment inflammation with iris rubeosis. A diabetic eye,
which is pretreated with anti-VEGF and cataract surgery, is much easier to
vitrectomize.
Perform a phacoemulsification as usual. Inject the IOL and place it into the cap-
sular bag. Before removing the viscoelastics, perform an intravitreal injection with
an anti-VEGF medication. Inject 0.1–0.2 ml. Then remove the viscoelastics and
hydrate the incisions (Figs. 14.5 and 14.6).

Fig. 14.5 A diabetic eye


with vitreous haemorrhage.
We apply a stepwise
technique: First a combined
phacoemulsification with
intravitreal Avastin and 1
month later, if still necessary,
a vitrectomy
208 14 Diabetic Retinopathy

Fig. 14.6 After implantation


of the IOL and before
removal of the viscoelastics,
an intravitreal injection of
Avastin (0.1 ml) is performed

Surgical Pearls No. 50


If a patient has a bilateral PDR and you decide to vitrectomize one eye, then
do not forget the other eye. Treat the other eye in the same session (or shortly
after) with phaco + IOL + Avastin or at least only Avastin. It easily happens
that the clinical focus lies on the vitrectomized eye and the other eye (often
the better eye) gets worse.

14.2 Easy PDR

Video 14.2: 27G lens-sparing vitrectomy of a type I diabetic

A vitreous haemorrhage with attached retina and no associated major vitreoreti-


nal pathology is suitable for the beginner. In most cases, a PVD is present and the
haemorrhage fills out the vitreous gel behind the lens (Fig. 14.2). In the presence of
vitreous haemorrhage, a previous history of panretinal photocoagulation usually
facilitates the surgery, because it is associated with a higher rate of posterior vitre-
ous detachment and promotes retinal adhesion to the RPE and choroid. He/she
learns to work with the vitreous cutter and apply a PRP but does not need to perform
any significant manipulations of the retina.
The main problem with this procedure is that there is no view of the fundus
(Fig. 14.7). The procedure is even harder when the natural lens is still present, due
to the risk of injuring the posterior capsule. In the learning phase, perform only
PPVs in pseudophakic eyes.
Practice the application of panretinal laser photocoagulation (PRP) very well
using a chandelier light. In one hand, hold the scleral depressor and indent the sclera
and retina, and in the other hand, hold the laser probe and apply a PRP up to the ora
serrata (Fig. 14.8). This surgery can be performed under local anaesthesia. We use
mostly 27G for these cases.
14.2 Easy PDR 209

Fig. 14.7 A dense vitreous


haemorrhage with attached
retina behind the vitreous

Fig. 14.8 Perform a PRP up


to the ora serrata

Surgical Pearls No. 51


B-scan: In cases with vitreous haemorrhage, always perform a detailed
preoperative ultrasound examination. Try to determine the state of the pos-
terior vitreous face (attached, partially attached or detached) and the
retina.

Instruments
1. 27G three-port trocar system with or without chandelier illumination
2. 120D lens
3. Vitreous cutter
4. Backflush instrument
5. Scleral depressor
210 14 Diabetic Retinopathy

Tamponade
Air, SF6

Individual Steps
1. Three-port trocar system with or without chandelier illumination
2. Core vitrectomy
3. Peripheral vitrectomy
4. PRP
5. Tamponade and intravitreal anti-VEGF treatment
6. Removal of the trocar cannulas

14.2.1 The Surgery Step-by-Step: Figs. 14.7 and 14.8

1. Three-port trocar system with or without chandelier illumination


2. Core vitrectomy

The vitreous haemorrhage reduces the illumination of the light fibre, because the
light cone is hidden by blood. Therefore, the surgeon should first make a core vit-
rectomy. Keep the vitreous cutter behind the IOL and remove all vitreous gel. It
might be easier to work first without BIOM and use the microscope only as you
would in cataract surgery. If the visibility is not improved, then try only to aspirate
the liquefied blood. Try next to cut a break in the posterior hyaloid in order to obtain
a view of the fundus (Fig. 14.7). It is important to identify the retinal vessels to
make sure that the surgeon is in the right plane (and not in the subretinal space). If
successful, continue the vitrectomy from the break into the posterior hyaloid.

Surgical Pearls No. 52


Blocked infusion: The haemorrhagic vitreous blocks sometimes the infusion.
Check the infusion trocar before vitrectomy, and if in doubt, then cut the
haemorrhagic vitreous around the infusion trocar.

Surgical Pearls No. 53


Removal of anterior hyaloid: In case of a haemorrhage directly behind the
lens, it may be necessary to remove the anterior hyaloid. This is an easy pro-
cedure in pseudophakic patients but a lens-threatening procedure in phakic
patients. We perform two techniques: Work at the edge of the lens (i.e. behind
the zonules) in order to avoid a lens touch. (1) With help of a serrated jaws
forceps, grab the anterior hyaloid/vitreous and pull it towards the centre of the
globe. Work from both sides. (2) With help of a vitreous cutter, suck the ante-
rior hyaloid/vitreous (only aspiration) and pull the vitreous cutter towards the
centre of the globe. Cut the vitreous there. Work from both sides.
14.2 Easy PDR 211

3. Peripheral vitrectomy
Proceed to trim the vitreous base. Do not trim the vitreous base completely
because the risk of causing damage to the retina is higher than the benefits. If the
posterior vitreous body is not detached, then a PVD should be performed now. If the
aetiology of the bleeding is, for example, a bleeding vessel, treat it now with laser,
diathermy or cryo.

Surgical Pearls No. 54


How should epiretinal blood be removed? (1) Aspirate epiretinal blood by
sweeping with a silicone tip flute needle over the retina. (2) By pressing sev-
eral times on the side opening/tubing of the backflush instrument, water is
ejected from the tip of the flute needle and blows the epiretinal blood upwards.
The blood can then be easily aspirated at the same time with the vitreous cut-
ter. (3) Clotted blood can be grasped with an ILM forceps and be removed
with the vitreous cutter.

4. Panretinal photocoagulation (PRP)


We recommend completing a PRP intraoperatively in all cases of vitrectomy for
proliferative diabetic retinopathy. This is the best opportunity to complete the PRP,
as rebleeding into the vitreous cavity is a common problem following vitrectomy,
which will have a negative influence on performing additional PRP after the vitrec-
tomy. Use the scleral depressor and apply a dense PRP up to the ora serrata
(Fig. 14.8). For PRP we recommend the following laser parameters: power, 100–
150 mw; duration, 200 ms; and interval, 200–300 ms at an OcularLight GL Company
Iridex. These values are dependent on the device and the pigmentation of the
fundus.
After endolaser photocoagulation, check if a new haemorrhage occurred at the
central pole, and treat it before you move on to the tamponade.

Surgical Pearls No. 55


Small pupil: If the pupil constricts during surgery, inject 0.01 % Adrenalin
into the anterior chamber. The pupil should enlarge within seconds. If the
small pupil is caused by posterior synechiae, use stretching instruments such
as a push–pull or insert iris hooks to enlarge the pupil.

5. Tamponade and intravitreal anti-VEGF treatment


An air or gas tamponade is recommended to avoid a rebleeding into the vitreous cav-
ity. Inject 0.2 ml bevacizumab at the end of the procedure to inhibit proliferative vessels.

6. Removal of trocar cannulas


The trocars are removed, as described above. In cases of a 25G trocar and sili-
cone oil tamponade, suture the sclerotomy.
212 14 Diabetic Retinopathy

Postoperative Tamponade and Posture


For a mild PDR, we use in the most cases air and sometimes SF6.

14.2.2 Complications

1. Important: Air does not expand at sea level. But patients with an air tamponade
are not allowed to fly because air expands with increasing altitude. The air pres-
sure in the plane corresponds to an air pressure at 2500 m above sea level. Travel
to higher elevations should also be avoided.

Surgical Pearls No. 56


Recurrent vitreous haemorrhage: After a vitrectomy for a vitreous haemor-
rhage, bleeding may reoccur after surgery. If the recurrence is associated with
a hyphema, then check if the patient takes anticoagulants, i.e. aspirin. The
patient should stop taking blood thinning medication for approximately 1
month. In most cases, the hyphema resolves. Do not reoperate on the patient
before the hyphema has resolved.

14.2.3 FAQ

Do you peel the ILM in diabetic retinopathy?


No, never. The only exception would be a very difficult case complicated by
PVR. There are no double-blind studies published which justify the prophylactic
removal of physiologic tissue such as ILM.

14.3 Difficult PDR

Video 14.3: 27G lens-sparing vitrectomy PDR easy–difficult


Video 14.4: Difficult PDR with 27G monomanual vitrectomy
Video 14.5: Difficult PDR—Constellation 27G
Video 14.6: 27G-CRVO

14.3.1 General Introduction

The main surgical steps in a severe PDR are:

1. Posterior hyaloid rhexis


2. Bimanual removal of membranes
14.3 Difficult PDR 213

In the most cases of severe PDR, you can use the periphery to disc (outside-in)
technique. Start therefore with a posterior hyaloid rhexis.
The surgical time is approximately 90–150 min.
The eye should be pseudophakic, an exception is the young type I diabetic
patient. In the latter case, we perform a lens-sparing vitrectomy. We usually work
with a 27G trocar system. If extensive membranes are present, we use a hybrid
25G/27G system because the whole range of 25G peeling instruments is required.
In case of a long eye, we use 27G.

Surgical Pearls No. 57


BSS damages the phakic lens: In pseudophakic eyes, BSS is used as irrigation
fluid and in phakic eyes BSS Plus® (Alcon). BSS Plus® also contains gluta-
thione, glucose and sodium bicarbonate.

Instruments
1. 27G three-port trocar system with chandelier illumination
2. 120D lens, for peeling: 60D lens
3. Vitreous cutter
4. Backflush instrument
5. 27G endgripping forceps (DORC)
6. 27G curved scissors (DORC)
7. Silicone tip Charles flute needle/vacuum cleaner
8. Endodiathermy (DORC, Alcon)
9. Laser probe
10. Scleral depressor

Maybe
25G straight scissors
25G knob spatula

Dye
Triamcinolone or trypan blue

Tamponade
20 % SF6, 1000 cSt silicone oil

Individual Steps
1. Three-port trocar system with chandelier illumination
2. Posterior hyaloid rhexis
3. Removal of tractional membranes
4. Instruments for removal of membranes
• Delamination of membranes with membrane pic, knob spatula and vacuum
cleaner
214 14 Diabetic Retinopathy

• Dissection of membranes with curved scissors


• Removal of dissected membranes with vitreous cutter
5. Haemostasis
• Slight bleeding
• Moderate bleeding
• Strong bleeding
6. Removal of attached posterior hyaloid in the periphery
7. PRP under BSS
8. Fluid against air exchange
9. Internal tamponade
• Gas tamponade
• Silicone oil tamponade
10. Removal of trocars

14.3.2 The Surgery Step-by-Step: Figs. 14.9, 14.10, 14.11, 14.12,


14.13, 14.14, 14.15, 14.16, 14.17, 14.18, 14.19, 14.20, 14.21,
14.22, 14.23, 14.24, 14.25, 14.26, 14.27, 14.28, 14.29, 14.30,
14.31, 14.32, 14.33, 14.34, 14.35, 14.36, 14.37, 14.38, 14.39,
14.40, 14.41, 14.42, 14.43, 14.44, 14.45, 14.46, 14.47, 14.48,
and 14.49

Fig. 14.9 A three-port


vitrectomy with chandelier
light is the best surgical
set-up for a difficult PDR; a
chandelier light allows
bimanual surgery and
bimanual removal of
membranes
14.3 Difficult PDR 215

vitreous cutter

peripheral
detached
posterior
hyaloid

Fig. 14.10 The first important step of diabetic vitrectomy: the posterior hyaloid rhexis

vitreous cutter

Rhexis of
posterior
hyaloid

Fig. 14.11 Perform a rhexis of the detached posterior hyaloid on the height of the equator
216 14 Diabetic Retinopathy

vitreous cutter

Rhexis of
posterior
hyaloid

Fig. 14.12 Then continue with the removal of the vitreous to the nasal and temporal arcades

Fig. 14.13 Posterior hyaloid


rhexis without subhyaloidal
haemorrhage
14.3 Difficult PDR 217

Fig. 14.14 Be careful not to


damage the retina

Fig. 14.15 Perform a


posterior hyaloid rhexis of
the detached hyaloid. A
rhexis of the attached hyaloid
is not possible
218 14 Diabetic Retinopathy

Attached posterior hyaloid

Rhex
is

Fig. 14.16 A different view. Open first the posterior hyaloid


Detached
d,

outside-in technique
ible hyaloi

posterior h
is p sterior
oss
o
no r ched p

yaloid, rhex
hex
Atta

is possible

outside-in technique

Fig. 14.17 Perform then a posterior hyaloid rhexis on the height of the equator
14.3 Difficult PDR 219

Detached
d,
ible hyaloi

posterior h
is p sterior
oss
o
no r ched p

ya
hex

loid, rhexis
Atta

possible
Fig. 14.18 And then remove the vitreous to the temporal and nasal arcades. The attached (nasal)
hyaloid cannot be removed in this stage

Fig. 14.19 An opening of


the posterior hyaloid with
presence of subhyaloidal
haemorrhage
220 14 Diabetic Retinopathy

Fig. 14.20 Use the vitreous


cutter with a low cutting
frequency such as 1000 cuts/
min

Fig. 14.21 Open the


posterior hyaloid as far as
possible, i.e. try to perform a
round rhexis as far as
possible
14.3 Difficult PDR 221

Fig. 14.22 The next and


most difficult step is the
bimanual removal of
fibrovascular membranes

Fig. 14.23 Create an


opening in the posterior
hyaloid with the 27G blunt
cannula (Atkinson)

Fig. 14.24 Enlarge the


opening in the posterior
hyaloid
222 14 Diabetic Retinopathy

Fig. 14.25 The blunt


cannula (25G and 27G) is a
very convenient instrument
for opening of the posterior
hyaloid and for delamination
of membranes

Fig. 14.26 Delaminate the


membrane with a knob
spatula or a vacuum cleaner

Fig. 14.27 If necessary,


stain the posterior hyaloid
with trypan blue and
delaminate it from the retina
14.3 Difficult PDR 223

Fig. 14.28 Use a knob


spatula or vacuum cleaner or
membrane pic for delamina-
tion. Use an endgripping
forceps or a Charles flute
needle to lift up the
membrane

Fig. 14.29 The forceps


fixates the membrane, and the
silicone tip flute needle
delaminates the membrane
from the retina
224 14 Diabetic Retinopathy

Fig. 14.30 Always pull the


membrane parallel to the
retina. Pulling vertically may
Silicone tip flute needle
cause a choroidal bleeding

Endgripping
forceps

Fig. 14.31 The surgeon’s


right hand pulls the mem-
brane parallel to the retina
and the left hand cuts the
tissue bridges with the
straight scissors
14.3 Difficult PDR 225

Fig. 14.32 We use straight


scissors often for diabetic
retinopathy. The long straight
blades allow a precise and
controlled cutting of tissue
bridges

Fig. 14.33 The 27G curved


microscissors allows precise
cutting of vitreoretinal
adhesions
226 14 Diabetic Retinopathy

Fig. 14.34 Hold the


membrane in the middle of
the vitreous cavity and
remove the membrane with
the vitreous cutter

Fig. 14.35 The membrane is


completely removed
14.3 Difficult PDR 227

Fig. 14.36 Perform a


meticulous haemostasis. We
use endodiathermy outside
the temporal arcades and
laser inside the temporal
arcades

Fig. 14.37 Also haemostasis


is performed bimanually. The
surgeon’s left hand holds the
Charles flute needle and
aspirates the blood. The right
hand cauterizes the bleeding
source

Fig. 14.38 Compress the


bleeding source for 1 min
with the instrument
228 14 Diabetic Retinopathy

loid
hya
ior
ter
pos
ed
ach
Att

Fig. 14.39 In the initial steps, a vitreous rhexis was performed and the vitreous was removed to the
arcades. Then the fibrovascular membranes together with the central posterior were removed. The
next step is the removal of the attached posterior hyaloid in the periphery—here on the nasal side

Fig. 14.40 Using bimanual


technique—with an
endgripping forceps and a
knob spatula—the residual
posterior hyaloid is removed
from the disc to the ora
serrata
14.3 Difficult PDR 229

Fig. 14.41 Delaminate the


posterior hyaloid up to the
vitreous base

Fig. 14.42 Now a complete PVD has been performed. The most difficult part of the surgery has
been completed
230 14 Diabetic Retinopathy

Fig. 14.43 Perform a dense


PRP from the arcades to the
ora serrata

Fig. 14.44 Use preferably a


curved laser probe in order to
perform a laser treatment up
to the ora serrata

Fig. 14.45 We perform in


almost all cases a fluid
against air exchange. If the
vitreous cavity is filled with
PFCL, we perform a PFCL
against air exchange and then
the tamponade. In this case,
with a detached retina we
would use 1000 cSt silicone
oil
14.3 Difficult PDR 231

Fig. 14.46 For 23G we use a


Charles flute needle with
passive aspiration. For 25G
and 27G, we use Charles flute
needle with active aspiration

Fig. 14.47 Injection of 1000


cSt silicone oil into an
air-filled vitreous cavity. If
possible try to perform an air
against silicone oil exchange.
It is technically much easier
than a PFCL against silicone
oil exchange
232 14 Diabetic Retinopathy

Fig. 14.48 Cut the infusion


line. The excessive silicone
oil can escape and overfill is
avoided. Then 0.2 ml Avastin
is injected into the silicone
oil bubble

Fig. 14.49 The sclerotomies


are sutured with Vicryl 8-0

1. Three-port trocar system with chandelier illumination


Insert first three trocars and then inferonasally the chandelier light. Continue
with a core vitrectomy. We recommend 27G trocars (Fig. 14.9); an alternative is a
hybrid system.
2. Posterior hyaloid rhexis (Figs. 14.10, 14.11, 14.12, 14.13, 14.14, 14.15, 14.16,
14.17, 14.18, 14.19, 14.20, and 14.21)
Surgical Pearls No. 58
Video 14.7: PVD induction (audio)
Corneal lubrication: A major problem during vitrectomy, especially in combined
Video 14.8: PVD no blood (audio)
surgeries with a duration of over 1 h, is corneal epithelial oedema. With the appli-
Video 14.9: PVD with blood (audio)
cation of methylcellulose (Celoftal®, Alcon or Ocucoat®, Bausch & Lomb) on
The posterior vitreous is usually attached in eyes with fibrovascular membranes.
the cornea, the cornea can remain clear for many hours. A debridement of the
An important aim of surgery is the induction of PVD. The induction of PVD is
epithelium is rarely necessary, but if needed use a broad blade (crescent knife).
14.3 Difficult PDR 233

extremely challenging in the eyes with ischemic retina because the posterior hyaloid
is firmly attached to the retina. When inducing a PVD, the surgeon can easily make
tears in the retina.
To avoid this damage, the surgeon should begin with a peripheral vitreous
detachment. In most cases of proliferative diabetic retinopathy, a partial vitre-
ous detachment is present. This means that the vitreous is still attached centrally
but partially detached in the mid-periphery. Try to find where the peripheral
vitreous is detached. Here, create an opening of the posterior hyaloid on the
height of the equator. Then remove the vitreous along the posterior vitreous face
(Figs. 14.10, 14.11, 14.12, 14.13, 14.14, 14.15, 14.16, 14.17, 14.18, 14.19,
14.20, and 14.21) on a constant level in a circular fashion (posterior hyaloid
rhexis). Do not perform a posterior hyaloid rhexis in the area where the poste-
rior hyaloid is attached.
Then carefully vitrectomize further from the periphery towards the beginning
of the tractional membranes (Figs. 14.12 and 14.18). Be careful that you do not
exert any strain on the membranes. If the surgeon succeeds with the posterior
hyaloid rhexis, he or she can continue removing the tractional membranes
bimanually.

3. Removal of tractional membranes


The fibrovascular membranes are usually located along the vascular arcades. The
membranes are removed together with the posterior hyaloid. The way to success is
bimanual delamination (Fig. 14.22).

4. Instruments for removal of proliferations


For lifting the membranes, both the 27G endgripping forceps and the backflush
instrument are suitable. The forceps grasps the membrane and the flute needle ele-
vates the membrane through aspiration force. For manipulation of the membrane,
use the vacuum cleaner, the 27G retrobulbar cannula (Atkinson, Beaver-Visitec),
the curved scissors and the vitreous cutter.

• Delamination of membranes with 27G Atkinson cannula and 27G vacuum


cleaner or 25G knob spatula

Video 14.10: Delamination of membranes with 25G blunt cannula (Atkinson)


(no audio)

This instrument is suitable for opening of the posterior hyaloid or delamination


of flat membranes. The membrane can be lifted up with the blunt cannula and then
removed with the microforceps (Figs. 14.23, 14.24, and 14.25).

Video 14.11: Bimanual peeling with vacuum cleaner and forceps (audio)
Video 14.12: Bimanual peeling with knob spatula audio
234 14 Diabetic Retinopathy

Grasp the peripheral portion of the membrane with the Eckardt forceps or a
backflush instrument in one hand, and delaminate the membrane with the knob
spatula (Figs. 14.26 and 14.27) or the vacuum cleaner in the other hand
(Figs. 14.28, 14.29, and 14.30).

• Dissection of membranes with 27G curved or 25G straight scissors

Video 14.13: Bimanual peeling with scissors 1 (audio)


Video 14.14: Bimanual peeling with scissors 2 (no audio)
Video 14.15: Bimanual peeling with scissors_3_no audio

The membranes are partially attached by “tissue bridges” to the retina. These
bridges have to be identified by careful delamination and then be cut with the
straight or curved scissors (Figs. 11.31, 11.32, and 11.33). The vertical scissors can
be used for horizontal tissue bridges. The tractional membranes are dissected and
removed through a constant change of instruments between delamination and cau-
terization. If a bleeding occurs during this step, then perform a haemostasis.

• Removal of dissected membranes with vitreous cutter

Video 14.16: Bimanual peeling with cutter (audio)

Grasp the membrane with an intravitreal forceps and hold it in the middle of the
vitreous cavity. Then cut it with the vitreous cutter (1000–2000 cuts/min) (Figs. 11.34
and 11.35).

Surgical Pearls No. 59


Peeling and choroidal haemorrhage: Do not pull a membrane forwards to the
lens—you may cause a choroidal haemorrhage. Pull the membrane parallel to
the retina.

5. Haemostasis
There are different methods to stop intraoperative bleeding, depending on its
severity:

• Slight bleeding:

Increase the intraocular pressure to approximately 40 mmHg.


Aspirate the blood with the left hand and cauterize the bleeding source with
endodiathermy or the laser probe in the right hand. Inside the arcades, we cauterize
the bleeding sites with laser. Outside the arcades, we cauterize retinal bleeding sites
with endodiathermy (Figs. 14.36 and 14.38). Start with relatively low energy, as too
vigorous endodiathermy may create breaks in ischemic retinal tissue. Avoid
14.3 Difficult PDR 235

diathermy on the disc; this may cause destruction of nerve fibre bundles. If the
bleeding occurs within the temporal vascular arcades, then use a laser probe to cau-
terize the bleeding instead. Often you have to work bimanually.

• Moderate bleeding and bleeding at the optic disc:

In the case of a strong bleeding source, hold the knob spatula or the vitreous cut-
ter for about 1 min onto the bleeding source (1 min is longer than most people think)
(Fig. 14.38).

• Severe bleeding:

If the bleeding is so severe that there is no view of the fundus, and despite aspira-
tion with the flute needle it does not clear up, then you should perform a fluid x air
exchange. The bleeding will stop. Now try to cauterize the bleeding source with
endodiathermy or compress it mechanically with the knob spatula. The vitrectomy
can also be continued in an air-filled vitreous cavity. Another alternative is silicone
oil. One can either work under silicone oil or end surgery with a silicone oil tampon-
ade with Avastin.
Watch following short videos for haemostasis:

• Endodiathermy

Video 14.17: Haemostasis

• Compression of vessels with knob spatula

Video 14.18: Knob spatula

Surgical Pearls No. 60


Intraoperative haemorrhage and adrenaline: If there is constant bleeding
from several vessels under surgery, then add adrenaline to the BSS bottle.
Adrenaline will constrict the vessels and reduce the bleeding.

6. Removal of attached posterior hyaloid in the periphery (Figs. 14.39, 14.40,


14.41, and 14.42)
Trim the peripheral vitreous and the vitreous base with a bimanual technique. Indent
the sclera with the sclera depressor, and cut the vitreous with the vitreous cutter.
After removal of the posterior hyaloid from the posterior pole, remove the residual
attached posterior hyaloid in the periphery. Remember: The posterior hyaloid in the
periphery is in the most cases only partially detached. The detached part with a poste-
rior hyaloid rhexis was opened in the beginning. Now the attached part must be
236 14 Diabetic Retinopathy

removed. This part is firmly attached to the retina (Fig. 14.39). Simply inducing a
PVD with the vitreous cutter does not work because this creates retinal tears. The
surgeon must delaminate the posterior hyaloid with a bimanual technique (Figs. 14.40
and 14.41). The posterior hyaloid has to be removed up to the vitreous base (Fig. 14.42).

7. Panretinal photocoagulation (PRP) under BSS


Video 14.19: PFCL laser audio
The next step is a PRP (Fig. 14.43). Perform a dense PRP from the arcades up to
the ora serrata. By using the scleral depressor, the surgeon can laser treat up to the
ora serrata (Fig. 14.44).
After endolaser photocoagulation, check if a new haemorrhage has occurred at
the central pole and treat it before moving on to the tamponade.

Surgical Pearls No. 61


Postoperative vitreous haemorrhages are the number one problem follow-
ing vitrectomy for proliferative diabetic retinopathy. In order to lower the
rate of this complication, be meticulous with haemostasis. Watch out for
small oozing bleeding sites after PRP has been performed. Even small col-
lections of blood point at continuous bleeding sites that should be treated
before closing up.

8. Fluid against air exchange


Video 14.20: Tamponade air (audio)

Perform a fluid against air exchange (Figs. 14.45 and 14.46). In case of 25G or
27G, use active aspiration with backflush instrument or use the vitreous cutter.
Air bubbles behind IOL: During a fluid–air exchange, the water condenses at the
posterior surface of the IOL in the area of the capsulotomy, thereby greatly impair-
ing the view of the fundus. It can either be removed with a flute instrument or injec-
tion of viscoelastics onto the posterior surface of the IOL.

9. Internal tamponade
In most cases, we use air or 20 % SF6 and sometimes 1000cSt silicone oil. Use
silicone oil in difficult cases, in extensive retinal bleeding and in functionally
only eyes.

• Gas tamponade

We use in the most cases 20 % SF6. For injection of gas, a view of the fundus is
not necessary. See Chap. 6.2 “Gas tamponade”.
14.3 Difficult PDR 237

• Silicone oil tamponade

Video 14.21: Tamponade silicone oil (audio)

In case of a silicone oil, we use in most cases 1000/1300cSt silicone oil. Inject
the silicone oil under BIOM view (Fig. 14.47). In case of overfill, cut the infusion
line and excessive silicone oil will escape (Fig. 14.48). Inject a 0.1–0.2 ml Avastin
bubble into the silicone oil bubble.

Surgical Pearls No. 62


Lens-sparing vitrectomy: In young diabetic patients, we experienced good
results with a lens-sparing vitrectomy and then a SF6 gas or 1000 cSt silicone
oil tamponade. Even after 10–20 years, the lens hardly opacifies.

10. Removal of trocars


If silicone oil is used, one should suture the sclerotomies, otherwise oil might
flow under the conjunctiva. Suture 25G sclerotomies with Vicryl 8-0 (Fig. 14.49);
27G sclerotomies require usually no suture.

11. Postoperative tamponade and posture


For postoperative tamponade, we use 1000 csts silicone oil, which we remove
after 2–3 months. There is no posture necessary.

14.3.3 Complications

1. Injury of a retinal artery during peeling. Fibrovascular membranes may hide the
temporal arcade. Be careful with delamination here. Begin with blunt instru-
ments such as a knob spatula or a vacuum cleaner. Prefer a curved scissors
(27G curved scissors, DORC).
2. Extensive bleeding: (1) Try to cauterize the bleeding vessel. (2) Place the tip of
the vitreous cutter or the knob spatula onto the bleeding vessel for 1 min. (3)
Perform a BSS against air exchange and try to cauterize the vessel. (4) Inject
silicone oil and anti-VEGF and close the case; reoperate when the bleeding has
subsided.
238 14 Diabetic Retinopathy

14.3.4 FAQ

Which type of silicone oil you use?


We use routinely 1000/1300 cSt silicone oil. We remove the oil after 3 months. We
see no advantage of using 5000 cSt oil in diabetic cases, even with tractional
detachment.
Silicone Oil Tamponade
15

Contents
15.1 Different Indications, Different Methods...................................................................... 240
15.1.1 Primary Retinal Detachment ........................................................................... 240
15.1.2 PVR Detachment ............................................................................................. 240
15.1.3 Diabetes ........................................................................................................... 240
15.1.4 Macular Hole ................................................................................................... 240
15.2 Duration of Silicone Oil Tamponade ............................................................................ 240
15.3 Air Against Light and Heavy Silicone Oil Exchange.................................................... 241
15.3.1 Introduction ..................................................................................................... 241
15.3.2 Exchange of Air Against Silicone Oil with Chandelier Illumination
(Under BIOM View) ........................................................................................ 242
15.3.3 Exchange of Air Against Silicone Oil Without Chandelier Illumination
(Without BIOM View) ..................................................................................... 244
15.4 PFCL Against Light and Heavy Silicone Oil Exchange with DORC Infusion Line.............. 245
15.4.1 Introduction ..................................................................................................... 245
15.4.2 Surgery............................................................................................................. 246

The surgical method of choice regarding silicone oil exchange is the injection of
silicone oil into an air-filled eye. This applies for light and heavy silicone oil. The
injection of silicone oil into a PFC-filled eye is also possible but technically more
difficult. This applies for light and heavy silicone oil. Also heavy silicone oil can be
exchanged with PFC. The risk that heavy silicone oil and PFCL will blend during
the short exchange time is low, and both fluid phases can be well distinguished.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 239


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_15
240 15 Silicone Oil Tamponade

15.1 Different Indications, Different Methods

Each pathology requires a different approach to inject the silicone oil.

15.1.1 Primary Retinal Detachment

1. Air against light silicone oil exchange

15.1.2 PVR Detachment

1. Air against light silicone oil exchange


2. PFCL against light silicone oil exchange
3. Air against Densiron 68 exchange
4. PFCL against Densiron 68 exchange

15.1.3 Diabetes

1. Air against light silicone oil exchange

15.1.4 Macular Hole

1. Air against light silicone oil exchange

15.2 Duration of Silicone Oil Tamponade

Duration of light silicone oil tamponade:

Retinal detachment: 6 weeks


Diabetic retinopathy: 2–3 months
Macular hole: 4–6 weeks

Duration of heavy silicone oil tamponade:

Inferior detachment: 6 weeks


Macular hole: 4–6 weeks
15.3 Air Against Light and Heavy Silicone Oil Exchange 241

15.3 Air Against Light and Heavy Silicone Oil Exchange

Video 15.1: 27G silicone oil injection

15.3.1 Introduction

We use predominantly 1000 or 1300 cSt silicone oil. Earlier on, we used 5000 cSt sili-
cone oil, but we switched almost completely to 1000/1300 cSt silicone oil. We reserve
5000 cSt silicone oil for cases which require silicone oil for a long time such as recur-
rent detachments or hypotony eyes. Apart of these rare cases, we use 1000/1300 cSt
silicone oil for all pathologies. We remove the oil after 6 weeks in detachments and
after 3 months in diabetics. There are no problems with emulsification.
Silicone oil injection with 27G is technically no problem. A 27G polyamide
cannula (DORC) is available (Fig. 15.1a). The injection, however, takes approxi-
mately 10–15 min. It may therefore be advisable to use a 25G cannula instead
(Fig. 15.1b).

Fig. 15.1 (a) A 27G


polyamide cannula for
silicone oil injection
(DORC, 272_
VFI04_27G). (b) A novel
25G metal cannula for
silicone oil injection
(DORC)
242 15 Silicone Oil Tamponade

Fig. 15.2 A basal


iridectomy. Place the
vitreous cutter behind the
iris and create an
iridectomy with
approximately 100 cuts/
min. If the pupil is dilated,
then pull at the same time
at the inferior pupil edge
with an intravitreal forceps

15.3.2 Exchange of Air Against Silicone Oil with Chandelier


Illumination (Under BIOM View)

15.3.2.1 Prepare Anterior Chamber Before Silicone Oil Injection


Before you perform a fluid x–air exchange, prepare the anterior chamber; stabilize
the anterior chamber and perform an iridectomy or inject methylcellulose if neces-
sary (Fig. 15.2).

Surgical Pearls No. 63


6 o’clock iridectomy for light silicone oils: If aphakia or zonular lysis is pres-
ent, create an Ando iridectomy (6 o’clock) to prevent an increase in intraocu-
lar pressure. An Ando iridectomy prevents a secondary angle closure, because
the aqueous can flow through the iridectomy at 6 o’clock into the anterior
chamber and press the oil bubble back into the vitreous cavity. Work bimanu-
ally: Draw the pupillary edge at 6 o’clock with an intravitreal forceps. Place
the vitreous cutter (low cut rate: about 200 cuts/min) with the opening for-
wards behind the iris at 6 o’clock, aspirate the iris and then cut a hole.

Surgical Pearls No. 64


12 o’clock iridectomy for heavy silicone oils: Densiron 68® (Geuder) is a
heavy silicone oil and will tamponade the inferior retina. If an iridectomy is
needed, it must be performed at 12 o’clock. Perform the iridectomy optimally
in a perfluorocarbon liquid (PFCL) or water-filled eye, i.e. before silicone oil
injection.
15.3 Air Against Light and Heavy Silicone Oil Exchange 243

Surgical Pearls No. 65


Methylcellulose in anterior chamber: If a large zonular lysis is present, inject
now methyl cellulose into the anterior chamber; it can be left there postopera-
tively. It holds the anterior chamber silicone oil free. There will be only a
slight postoperative rise of IOP.

The infusion line must remain in place during the complete surgery because the
air streaming in keeps the eye normotensive (Figs. 15.3, 15.4, and 15.5). Attach a
silicone oil 27G plastic cannula (DORC) or a metal cannula (Alcon, all gauges) to
a silicone oil syringe. The oil falls from the anterior onto the posterior pole, i.e. the
eye is filled from the back to the front. At the same time, the surgeon must release
the air with a backflush instrument from a trocar. Reduce the air infusion pressure
after 50 % filling with silicone oil to 15–20 mmHg. When the last air bubble disap-
pears behind the lens, stop the air infusion and remove the residual air bubble. Then
inject silicone oil until the globe is hypo- to normotensive. During this procedure,
check for a positive venous pulse. If the globe is hypertensive, then release oil by
removing a valve or by simply cutting the infusion line.

Fig. 15.3 Injection of


silicone oil with a 27G
polyamide cannula
(DORC)

Fig. 15.4 Note the


Eckardt twin light
244 15 Silicone Oil Tamponade

Fig. 15.5 A chandelier


light is required if you
want to inject under BIOM
view

15.3.3 Exchange of Air Against Silicone Oil Without


Chandelier Illumination (Without BIOM View)

The surgery is performed without BIOM. The infusion line must remain in place
during the entire surgery because the air streaming in keeps the eye normotensive.
Attach a silicone oil 27G plastic cannula (DORC) or metal cannula (Alcon, all
gauges) to a silicone oil syringe. Insert a backflush instrument into one trocar to
release the air and the silicone oil cannula into the other trocar. Wait until the last air
bubble disappears behind the lens. Then close the infusion line and remove the final
air bubble. Then inject silicone oil until the globe is hypo- till normotensive. We
prefer an intraocular pressure of 10 mmHg, so rather less oil than too much oil.

Surgical Pearls No. 66


Silicone oil in the anterior chamber: Remove the silicone oil bubble with I/A
handpieces (Figs. 15.6 and 15.7). The removal is simple if the vitreous cavity
is filled with BSS. Usually the vitreous cavity is filled with silicone oil, and
the risk is that after removal of the silicone oil bubble, a new bubble comes
into the anterior chamber. The reasons for this is an overfill of silicone oil in
the vitreous cavity and a zonular defect. If a new bubble comes into the ante-
rior chamber, then remove first the silicone oil bubble with I/A. Then remove
the aspiration handpiece but leave the irrigation in the anterior chamber. Then
inject with the second-hand methylcellulose into the anterior chamber and
slowly retrace the irrigation handpiece. The methylcellulose causes no ocular
hypertension.
15.4 PFCL Against Light and Heavy Silicone Oil Exchange with DORC Infusion Line 245

Fig. 15.6 A silicone


oil bubble in the
anterior chamber
due to zonular lysis

Fig. 15.7 Remove


the bubble with I/A,
extract the
aspiration
handpiece, inject
methylcellulose and
then extract the
infusion handpiece

15.4 PFCL Against Light and Heavy Silicone Oil Exchange


with DORC Infusion Line

15.4.1 Introduction

This situation is very different than the situation explained above. Why? The eye is
filled with PFCL and is therefore stable, i.e. you can remove the infusion line and
the eye will not collapse.
246 15 Silicone Oil Tamponade

Fig. 15.8 PFCL x


silicone oil exchange. An
Alcon infusion line
cannot be used for
injection of silicone oil
because the infusion
cannula detaches
Alcon
infusion line

Fig. 15.9 PFCL x silicone


oil exchange. Use instead a
DORC infusion line with
plastic cannula (not high
infusion line). The infusion
line remains stable under
injection of silicone oil

DORC
infusion line

15.4.2 Surgery

Instrument: (Figs. 15.8 and 15.9)

1. 23G or 25G DORC infusion line with plastic cannula

Remark: A high infusion line (DORC) does not work.


The surgeon must work with the BIOM in order to remove the PFCL when
injecting the silicone oil. There is only one method to inject the silicone oil:
15.4 PFCL Against Light and Heavy Silicone Oil Exchange with DORC Infusion Line 247

Fig. 15.10 PFCL x BSS


silicone oil exchange:
three fluid phases are
present—PFCL on the
posterior pole, silicone Backflush
oil in the anterior pole instrument
and BSS in-between.
Remove first BSS Silicone oil

BSS

PFC

Fig. 15.11 Then remove


the PFCL
PFC

Backflush
instrument

Silicone oil

PFC

Disconnect the infusion line from the BSS infusion and connect the infusion line
to the silicone oil syringe. It is important to use a DORC infusion line (Fig. 15.10).
Hold the light probe in one hand and the backflush instrument in the other hand.
Inject the silicone oil with active injection modus into the vitreous cavity. Hold the
flute needle in the beginning above the PFCL bubble in order to aspirate the residual
water (BSS) (Fig. 15.11). Then hold the flute needle into the PFCL phase (Fig. 15.11).
At the end of the aspiration, you recognize clearly the PFCL meniscus and also the
final PFCL puddle at the posterior pole. If subretinal fluid is present, remove it by
248 15 Silicone Oil Tamponade

holding the tip of the flute needle in the break. Aspirate the subretinal fluid under the
pressure of the incoming oil and increase the pressure in the eye by injecting more
oil. If the break is fully attached, you can complete the photocoagulation.
Check the pressure of the eye a few times with an index finger. If the pressure is
too high, stop the injection of oil and aspirate more PFCL. If the globe is hard (no
venous pulse), remove a valve at once and let excess silicone oil flow out. The final
PFCL bubble may be tricky to remove. It requires sufficient intraocular pressure.
This can be achieved by injecting more silicone oil. Or alternatively, compress the
globe with one finger in order to increase the intraocular pressure.

Surgical Pearls No. 67


Infusion line and silicone oil: An Alcon infusion line may fall off when inject-
ing silicone oil (Fig. 15.8). Use instead a DORC infusion line which has a
plastic cannula (Fig. 15.9). This infusion will remain stable in the infusion
trocar when injecting silicone oil due to its special shape and different mate-
rial of the DORC trocar cannula.

Surgical Pearls No. 68


PFCL against silicone oil exchange 1: Do not confuse this method with air
against silicone oil exchange. If you disconnect the infusion line with air and
connect it to the silicone oil syringe, then the eye will collapse. An air-filled
eye needs constant air infusion in order not to collapse. This is not the case in
a PFCL-filled eye. The eye is stable even if you disconnect the infusion line.

Surgical Pearls No. 69


PFCL against silicone oil exchange 2:
1. If unsure whether there still is some heavy liquid left behind, pause and
wait. The heavy liquid will collect and the interface will be clearly visible
after approximately 20 s.
2. Removing the final puddle of heavy liquid is not an easy step. The danger is
to aspirate retina into the flute needle at the posterior pole or to damage the
optic disc. Either try to remove the final bubble “in one go” or let it collect
over the optic disc. Then increase the pressure with the silicone oil injection,
and touch the bubble with the opening of the backflush instrument. For small
remnant bubbles, indent the eye with your ring finger. This will give you a
much better pressure control than the injection of silicone oil with the foot
pedal. Aspirate the heavy liquid bubble and immediately cover the opening
of your backflush instrument before withdrawing it from the eye; otherwise,
the heavy liquid bubble will drop back onto the posterior pole.
15.4 PFCL Against Light and Heavy Silicone Oil Exchange with DORC Infusion Line 249

Surgical Pearls No. 70


PFCL against silicone oil exchange with 20G: This manoeuvre takes much
more time with 20G without trocars because you work in an open system
which leads to a much lower counterpressure. In contrary, a trocar system
with valve creates a much higher counterpressure.
Silicone Oil Removal
16

Contents
16.1 Light Silicone Oil (1000, 1300 and 5000 cSt) Removal............................................... 253
16.2 Heavy Silicone Oil (Densiron 68®) Removal ............................................................... 253
16.2.1 Active Removal of Heavy Silicone Oil (e.g. Densiron 68®) ........................... 253
16.2.2 FAQ ................................................................................................................. 254

Video 16.1: 27G silicone oil removal

27G is an excellent choice for silicone oil removal because the risk of postopera-
tive hypotony is significantly reduced. 1000 cSt and 5000cSt silicone oil can be
easily removed with 27G. Remove a valve from an infusion trocar and attach the
silicone oil infusion line (VFE, DORC) (Figs. 16.1 and 16.2). 1000cSt oil can be
removed within 5 min and 5000 cSt oil within 10 min. An alternative is the novel
25G metal cannula for silicone oil injection and removal (Fig. 16.3).
Heavy silicone oil (1300 cSt, Densiron 68) can be removed with the 25G metal
cannula (DORC, Fig. 16.3) or a novel 23G metal cannula (10 mm, DORC)
(Fig. 16.4).

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 251


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_16
252 16 Silicone Oil Removal

Fig. 16.1 The silicone oil


high infusion line (VFE,
DORC) for removal of
silicone oil. It can be used for
23G to 27G

Fig. 16.2 Remove a valve


and attach the infusion line

Fig. 16.3 An alternative is


the novel 25G metal cannula
(DORC) for silicone oil
injection and removal

Fig. 16.4 A novel 23G


metal cannula (DORC) for
extraction of Densiron 68®
16.2 Heavy Silicone Oil (Densiron 68®) Removal 253

16.1 Light Silicone Oil (1000, 1300 and 5000 cSt) Removal

Silicone oil removal with the Eva vitrectomy machine is simple and fast. Insert three
trocars. Attach the high infusion to the trocar (VFE, DORC) and actively aspirate
the silicone oil (Figs. 16.1 and 16.2). When extracting the silicone oil, make sure
that the tip of the aspiration cannula is always located in the silicone oil bubble and
not in the water phase.

16.2 Heavy Silicone Oil (Densiron 68®) Removal

Video 16.2: Densiron 68 removal with 25G

Heavy silicone oil removal cannot be performed with 27G. Heavy silicone oil
removal can be performed with 23G and 25G. We use always 25G because the eye
has less hypotony after surgery due to the small sclerotomies. Alternatively, use 23G
and perform a fluid x air exchange at the end.

16.2.1 Active Removal of Heavy Silicone Oil (e.g. Densiron 68®)

There are two extraction cannulas available:

1. Short 25G metal cannula (Fig. 16.3 DORC or Alcon) or 23G metal 10 mm can-
nula (Fig. 16.4, DORC): Both cannulas can be used with all modern vitrectomy
machines (EVA, Constellation or Stellaris). The removal is simple and fast. Use
again the Alcon silicone oil extraction cannula and aspirate actively the silicone
oil. Remove the silicone oil bubble as one would with conventional silicone oil,
always staying in touch with the bubble with active suction (Fig. 16.5). The
residual bubble will stay connected to the short cannula through the “siphoning”
effect, will move upwards towards the cannula and can easily be removed this
way. Small remnant bubbles at the posterior pole can then be collected with the
backflush instrument. The removal time is approximately 2–3 min.
2. A good and safe alternative is a long 19G metal cannula (Alcon): With this long
metal cannula, you cannot lose the final bubble. Pull the final heavy oil bubble
forwards to the centre of the vitreous cavity and remove it safely there.

Surgical Pearls No. 71


Clogged infusion line in the beginning of the procedure: The reason of the
clogged infusion line is silicone oil within the infusion. (1) Do not press with
the syringe onto the globe. You press otherwise the silicone oil into the infu-
sion line. (2) Increase the IOP to 40–50 mmHg until the BSS comes. Then
reduce again to 25 mmHg.
254 16 Silicone Oil Removal

Fig. 16.5 Extraction of


Densiron 68®. The long
cannula prevents the loss of
the heavy silicone oil bubble

Surgical Pearls No. 72


When removing Densiron 68® with a short cannula, it is important not to lose
contact with the bubble before it starts “floating up” towards the cannula. In
order to guarantee uninterrupted suction, check the residual volume that is left
to be aspirated in your suction line just before you are about to “pick up” the
residual bubble. If only a few millimetres are left in your syringe, remove the
oil from the syringe by switching to injection mode outside the eye and then
go back in to remove the residual bubble with uninterrupted suction. If you
lose contact with the bubble and it is too small to be reached with the short
cannula, you either need to proceed with a backflush cannula (which takes a
long time) or switch to the method using the 19G cannula outlined above.

16.2.2 FAQ

Is it possible to remove heavy silicone oil with 25G?


Yes, this is no problem.

Why do you prefer 25G to 23G for silicone oil removal?


I experienced quite a few cases of hypotony with choroidals after silicone removal
with 23G. I never experienced choroidals with 25G. The disadvantage of 25G is that
the silicone oil removal takes longer. Conclusion: 25G is intraoperatively slower but
postoperatively safer.

Gas or silicone oil tamponade?


Try to use less silicone oil and more gas. Try to use more SF6 and less C3F8. Try to
use more 1000 cst and less 5000 cst silicone oil.

PFCL or air?
As a beginner use PFCL, it is much easier. The view is much better, PFCL expresses
the subretinal fluid, and the holes are attached during laser treatment. If you are an
experienced surgeon, use air.

Surgical pearls no. 47:


Residual PFCL? Perform a short air x water exchange and remove the PFCL
together with the residual water.
Paediatric Vitrectomy
17

Contents
17.1 General Introduction ................................................................................................... 255
17.2 Physiology of a Neonate Eye....................................................................................... 256
17.3 Retinal Detachment Secondary to ROP....................................................................... 256
17.4 Timing of Surgery ........................................................................................................ 256
17.5 Surgery ......................................................................................................................... 257
17.6 Complications .............................................................................................................. 262
17.7 FAQ ............................................................................................................................. 263

17.1 General Introduction

We operate all children eyes with 27G. The reason for this is that the sclera of young
eyes is soft and leaks more easily than an adult eye. In addition, we perform a per-
pendicular and not a lamellar insertion of trocars due to the risk of damaging the
lens. If you perform a perpendicular insertion with 23G or 25G trocars, you need to
suture the sclerotomies. In 27G a suture is not necessary and the sutureless vitrec-
tomy allows a fast postoperative recovery.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 255


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_17
256 17 Paediatric Vitrectomy

17.2 Physiology of a Neonate Eye

In the neonatal eye, the pars plana region is incompletely developed and almost not
existent. The axial length of a newborn eye is 16 mm in the 34th gestational week
and 17 mm in the 40th gestational week. The anterior retina lies just behind the pars
plicata. The site of sclerotomy is therefore much closer to the limbus. The sclerot-
omy should be performed 1.0 mm behind the limbus. See Table 17.1. The newborn
eye has a huge lens compared to the globe. A big lens and a short sclerotomy site
allow only a small canal to insert and manoeuvre the instruments. Utmost care is
needed in inserting a vitreoretinal instrument or in administering an injection,
because it may cause inadvertent lens touching, traction on the vitreous base and
retinal damage. The vitreous body is completely intact; there is no degeneration of
the vitreous body present. The vitreous body is very firmly attached to the retina; a
PVD is virtually not possible. If you try to induce a PVD, you risk creating a retinal
tear.

17.3 Retinal Detachment Secondary to ROP

ROP is a tractive retinal detachment and not a rhegmatogenous retinal detachment.


Due to the fact that a retinal break is not present, there is no need for a tamponade
or even postoperative posture. The aim of surgery is to remove the vitreous body in
order to relieve retinal traction. The retina will reattach in a few days after surgery.
In addition, an anti-VEGF injection is needed to reduce the vascular activity and
remove the pathologic reason of the tractive detachment. We use ranibizumab
(Lucentis®) because the half-life in serum is lower compared to bevacizumab
(Avastin®).
In a 4A and 4B detachment, the state-of-the-art method may be to use the suture-
less 27G technique, to perform a lens-sparing vitrectomy and to inject intravitreal
Lucentis.

17.4 Timing of Surgery

Timing of surgery is of utmost importance. We only operate ROP stage 4A (retinal


detachment and attached macula) and 4B (retinal detachment and detached mac-
ula). See Fig. 17.1. We do not operate stage 5 ROP. Do not operate too late. The risk

Table 17.1 Site of sclerotomy in relation to the age


Age 0 1–6 6–12 1–3 3–6 6–18 Adult Adult
months months years years years phakic pseudophakic
Site of sclerotomy 1.0 1.5 2.0 2.5 3.0 3.5 4.0 3.5
(mm)
17.5 Surgery 257

ROP 3+

Zone 1 Zone 2

Intravitreal Lucentis Laser treatment

Long follow-up for a Short follow-up for


few years a few months

Recurrence

Retinal detachment

27G lenssparing core vitrectomy and intravitreal Lucentis

Fig. 17.1 Our treatment algorithm for treatment of ROP

that you will not succeed is high, and the risk that you will have complications is
even higher. Try to operate in stage 4A.

17.5 Surgery

Video 17.1: ROP_RE


Video 17.2: ROP_LE

The surgery is easy but you have to operate absolutely without complications:
No lens touch, no retina touch and no retinal tear. A lens touch will result in a
lensectomy and amblyopia. A retinal touch with retinal tear will result in retinal
258 17 Paediatric Vitrectomy

detachment and blindness. Be careful when inserting the trocars and instruments.
Aim towards the optic nerve. Perform a central and peripheral vitrectomy. Do not
induce a PVD; it is almost impossible in newborn. Do not remove membranes; you
may induce a retinal tear. A tamponade is not necessary.

17.5.1 Surgery Step by Step

Instruments

1. 3-port 27G trocar system


2. 120D lens

Medication

Lucentis®, alternatively Avastin®

Tamponade

None

Individual Steps

1. 3-port 27G trocar system


2. Core vitrectomy
3. Peripheral vitrectomy
4. Injection of 0.05 ml Lucentis
5. Removal of trocar cannulas

17.5.1.1 The Surgery Step by Step: Figs. 17.2, 17.3, 17.4, 17.5, 17.6, 17.7,
17.8, 17.9 and 17.10

Fig. 17.2 Case report 6.


A 27G lens-sparing
vitrectomy (DORC) in a
newborn eye in 34th
gestational week (right eye)
17.5 Surgery 259

Fig. 17.3 Case report 6.


A stage 4B-5 detachment

Fig. 17.4 Case report 6.


Core vitrectomy and then
injection of Avastin

Fig. 17.5 Case report 6.


First postoperative day. The
retina is almost completely
reattached
260 17 Paediatric Vitrectomy

Fig. 17.6 Case report 6.


14-day follow-up. The retina
is reattached. Note the
exudates at the posterior pole

Fig. 17.7 Case report 6.


A 27G lens-sparing
vitrectomy (DORC) in a
newborn eye in 34th
gestational week. Note the
tunica vasculosa lentis
(left eye)

Fig. 17.8 Case report 6.


A stage 4B detachment
17.5 Surgery 261

Fig. 17.9 Case report 6.


First postoperative day. The
retina is already reattached

Fig. 17.10 Case report 6.


14-day follow-up. The retina
is reattached

1. 3-port 27G trocar system

Insert the trocar cannulas 1.0 mm behind the limbus. Aim with the trocar can-
nulas towards the optic nerve. We insert the trocars straight (perpendicular) into the
eye due to the risk to damage of the eye (Figs. 17.2 and 17.7). The sclerotomies will
remain watertight. Then attach the infusion line to the infusion trocar and double-
check that the infusion trocar is located inside the vitreous body.

Surgical Pearls No. 73


Location of infusion cannula in paediatric vitrectomy: The infusion cannula
tends to turn towards the lens resulting in a blockage of the infusion. The
dangerous consequence of this event is a bulbar hypotony with choroidal
detachment. Observe therefore constantly the position of the infusion trocar
during surgery.
262 17 Paediatric Vitrectomy

2. Core vitrectomy
3. Peripheral vitrectomy

Insert the instruments carefully by aiming them towards the optic nerve.
Remember: The lens of a newborn is much larger than the lens of an adult (ratio
lens/globe). Begin with a core vitrectomy and continue then with a peripheral vit-
rectomy (Figs. 17.3 and 17.8). Hold a secure distance to the retina. Caution: Avoid
a retinal touch. If you induce an iatrogenic hole, you can close the case.

4. Injection of 0.05 ml Lucentis

Attach a 27G backflush cannula to the Lucentis syringe. After completion of


vitrectomy, inject 0.05 ml Lucentis into the vitreous cavity.

Surgical Pearls No. 74


Anti-VEGF dose for ROP: We inject the adult dose of Lucentis. The reason
for this is that a medication in an eye without vitreous body has a shorter half-
life than in an eye with vitreous body.

5. Removal of trocar cannulas

Remove first the instrument trocars and press a surgical instrument against the
incision. Remove in the end the infusion trocar. A suture is not necessary even if you
performed a perpendicular incision!

17.6 Complications

1. The infusion trocar may rotate towards the lens and block the infusion resulting
in a choroidal detachment.
2. A retinal tear will lead inevitably to a retinal detachment which cannot be cured.
3. A lens touch will result in lensectomy and consequently amblyopia.

Case Report No. 6: ROP Stage 4

Video 17.1: ROP RE


Video 17.2: ROP LE

Figs. 17.2, 17.3, 17.4, 17.5, 17.6, 17.7 and 17.8


The neonate was laser treated in the 36th gestational week because of ROP stage 3+.
One week later, the retina on both eyes was detached. The right eye showed a begin-
ning stage 5 detachment and the left eye a stage 4B detachment (Figs. 17.3 and 17.8).
Both eyes had extensive preretinal and subretinal haemorrhages.
17.7 FAQ 263

Three 27G trocars with a lumen of 0.4 mm were inserted 1 mm behind the lim-
bus. The insertion was performed perpendicularly (not lamellar) (Figs. 17.2 and
17.7). A central and peripheral vitrectomy was performed. The vitrectomy was per-
formed with an EVA vitrectomy machine (DORC), a cutting speed of 7000 cuts/min
and a vacuum of 500 mmHg (Fig. 17.4). At the end, 0.4 mg ranibizumab was
injected into the vitreous cavity. No PVD, no peeling and no tamponade were per-
formed. The trocars were removed and the sclerotomies were not sutured. The sur-
gical time of each eye was less than 20 min.
On the first postoperative day, the conjunctiva was white and the globe normo-
tensive. The retina was completely attached on the LE and almost completely
attached on the LE (Figs. 17.5 and 17.9). After 14 days follow-up, the retina was
peripherally and centrally attached in both eyes (Figs. 17.6 and 17.10).

17.7 FAQ

Does the retina reattach after removal of the vitreous?


Yes. The vitreous body in newborns is completely intact. An inflammatory contraction
of the vitreous will result in retinal traction and detachment. If you remove the vitre-
ous body and reduce the vascular activity, the retina will reattach within a few days.

What about ROP stage 5?


The surgical success in stage 5 is low. If the funnel is closed anteriorly, you cannot
access the vitreous cavity without causing a tear into the retina. If the funnel is
closed posteriorly, a surgical approach may be successful.

Case Report No. 7: Neurofibromatosis Type 2


Figs. 17.11 and 17.12

Fig. 17.11 Case report 7. Intraoperative OCT of a boy with an epiretinal membrane secondary to
neurofibromatosis type 2
264 17 Paediatric Vitrectomy

Fig. 17.12 Case report 7.


Photograph of the epiretinal
membrane

Video 17.3: Neurofibromatosis 2


Video 17.4: Intraoperative OCT

A 5-year-old boy was admitted to us for surgery of an epiretinal membrane in the


right eye. He was diagnosed with neurofibromatosis type 2. In December 2012, a large
tumour in the brain was surgically removed. He has a remaining tumour affecting bal-
ance and hearing and, furthermore, a tumour intraspinally. He is treated for epilepsy.
Visual acuity was measured with 0.8 on both eyes; it was not possible to measure
each eye. A fundus examination showed a whitish epiretinal membrane on the mac-
ula (Fig. 17.11).
Three months later, a 27G lens-sparing vitrectomy was performed (Fig. 17.12).
The membrane was delaminated with the 27G Atkinson cannula and removed with
the 27G endgripping forceps (DORC).
An examination 9 months later showed a visual acuity of 0.2 on the right eye, 1.0
on the left eye and OCT revealed a thickening of the macula. The surgery achieved
no functional improvement.

Case Report No. 8: Traumatic Cataract


Figs. 17.13, 17.14 and 17.15

Video 17.5: Paediatric cataract with 27G

A 9-year-old male patient was admitted to us for surgery of a traumatic cataract.


He was hit by a plastic ball during an indoor hockey game. Visual acuity was
17.7 FAQ 265

Fig. 17.13 Case report 8.


Large zonular lysis. A
traumatic cataract of a young
boy. A capsular tension ring
(Croma, Austria) will be
implanted

Fig. 17.14 Case report 8.


Insertion of a one-piece IOL
(Tecnis, ZCB00) in the bag.
Then posterior capsular
rhexis with the 27G vitreous
cutter. From pars plana

Fig. 17.15 Case report 8.


The lens capsule is fully
inflated. The IOL is in the
bag. A posterior capsular
rhexis is present and the
anterior vitreous is removed
266 17 Paediatric Vitrectomy

measured with 0.13. The slit-lamp examination revealed a clear cornea and a hori-
zontal white scar on the anterior lens capsule. The posterior lens capsule was regu-
lar. Vitreous floaters were present and the retina was normal.
Three months later, a phacoemulsification was performed. A large inferior zonu-
lar lysis was visible and treated with implantation of a capsular tension ring
(Fig. 17.13). Then a one-piece IOL was implanted into the lens capsule. Then two
27G trocars were inserted, the anterior vitreous removed and a round aperture in the
posterior capsule cut (Figs. 17.14 and 17.15). An intraoperative fundus examination
showed pigmentary changes of the macula. A postoperative follow-up 3 months
later showed no improvement; the visual acuity was measured with 0.1–0.2. A trau-
matic maculopathy is most likely responsible for the vision loss,

Case Report No. 9: PHPV


Figs. 17.16, 17.17 and 17.18

Video 17.6: PHPV and 27G

A 23-day-old newborn was admitted to us for surgery of a retinal detachment of


the right eye. At birth he had a large right pupil which did not react to light. There
was a clear red reflex. An examination in general anaesthesia was scheduled. The
axial length on the right eye was measured with 14.60 mm and white-to-white with
10 mm. An anterior segment examination showed a strong iris hyperaemia,

Fig. 17.16 Case report 9.


Persistent hyperplastic
primary vitreous (PHPV). A
closed funnel from the optic
head to the lens
17.7 FAQ 267

Fig. 17.17 Case report 9.


A newborn with unilateral
PHPV. Note the retrolental
mass

Fig. 17.18 Case report 9.


The retrolental tissue

posterior synechiae at 6 o’clock and a zonular lysis from to 11 to 1 o’clock. A white


vascularized tissue behind the lens was present (Fig. 17.17). B-scan revealed a
funnel-shaped hyperfluorescence from the optic nerve to the lens. The retina seemed
to be attached. The examination of the left eye revealed an axial length of 16.81 mm
and a W-t-W of 11 mm. Anterior segment and posterior segments were regular.
The parents were informed about the findings and consented into an operation. A
27G lens-sparing vitrectomy was performed and the retrolental tissue was removed
(Figs. 17.17 and 17.18). The view to fundus was poor, and it seemed that retinal
vessels were visible.
An ERG is scheduled in 6 months.
Vitrectomy of Myopic Eyes
18

Video 18.1: 27G IOL exchange high myopia


Video 18.2: Retinal detachment high myopia
Video 18.3: 27G lens-sparing vitrectomy of a type I diabetic

A very good indication for 27G vitrectomy is a long eye. Independent on the
indication, we use 27G vitrectomy for all eyes with an axial length > 25 mm or a
myopia > −5D. The main advantage of 27G is that the sclerotomies are watertight
after surgery without sutures. Remember: A 25G trocar creates a 23G sclerotomy
and a 27G trocar induces a 25G sclerotomy (Figs. 18.1 and 18.2). That’s why 27G
is of advantage for long eyes. The risk of hypotony (0–6 mmHg) is very low and

Fig. 18.1 The trocars fit precisely into each other

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 269


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_18
270 18 Vitrectomy of Myopic Eyes

Fig. 18.2 A 27G trocar has a 25G sclerotomy compared to a 23G trocar which has a 22G
sclerotomy. It is clear that 27G is superior to 23G regarding the sclerotomies

happens very seldom. We never experienced choroidals. This advantage applies also
for a gas tamponade. A 27G sclerotomy has less leakage than a 23G sclerotomy, and
the gas filling is therefore much better and longer.
Part V
Hybrid Procedures

In order to combine the advantages of small sclerotomies and the lack of instru-
ments for 27G a hybrid procedure is recommended. The infusion trocar is 27G and
the instrument trocars are 25G (Fig. 19.1). The high infusion line enables a suffi-
cient flow into the vitreous cavity.
Dropped Nucleus
19

Contents
19.1 General Introduction ..................................................................................................... 273
19.2 Extraction of a Posteriorly Dislocated Nucleus with Fragmatome ............................... 275
19.2.1 Introduction ..................................................................................................... 275
19.2.2 The Surgery Step by Step ................................................................................ 276
19.3 Extraction of a Posteriorly Dislocated Nucleus with PFCL ......................................... 280
19.3.1 Introduction ..................................................................................................... 280
19.3.2 The Surgery Step by Step ................................................................................ 281
19.4 Complications ............................................................................................................... 284
19.5 FAQ ............................................................................................................................... 284

19.1 General Introduction

Necessity of surgery: If nuclear fragments drop, we always operate in order to prevent


intraocular inflammation and hypertension. In case of dropped soft cortical fragments,
it is possible to wait and not to operate if the eye remains quiet (Fig. 19.2).
Timing of surgery: The surgery is not acute. Normally a dropped nucleus occurs
under drop anaesthesia. To proceed with vitrectomy under drop anaesthesia will
inflict much unnecessary pain to the patient. It is therefore advisable to stop surgery
when a dropped nucleus occurs and to schedule a planned surgery within 1 week.
During this time, the eye can be treated against corneal oedema and ocular
hypertension.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 273


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_19
274 19 Dropped Nucleus

Fig. 19.1 A hybrid set-up.


One 27G infusion trocar
and two 25G instrument
trocars

27G

25G

25G

Surgical Pearls No. 75


The most patients who underwent a complicated cataract surgery do not com-
plain about the complication but about the painful procedure. Why? The cata-
ract surgery was started with drop anaesthesia, and when the complication
occurred, the surgery was continued with the same anaesthesia. Our recom-
mendation: If you experience a complication, decide if you continue at once
or delay the surgery. If you decide to continue at once, then add a subtenonal
or retrobulbar anaesthesia. You will have a happy patient.

Determine preoperatively with a maximally dilated pupil whether the anterior


capsule is intact or not. If it is intact, implant a three-piece IOL in the sulcus. If the
anterior capsule is defective, implant a scleral-fixated three-piece IOL (suture or
Scharioth technique) or an iris-claw IOL.
The most difficult part of this surgery is the removal of the nucleus. There are
two methods (Fig. 19.2).

1. You can remove the nucleus with a fragmatome inside the vitreous cavity. In case
of soft to medium-hard nuclei, I recommend working with the fragmatome. See
Sect. 19.2.
2. You can lift the nucleus with PFCL to the pupillary plane and remove it there
with a conventional phaco handpiece or the SICS technique. This technique is
very elegant and easy in case of a rock-hard nucleus. For details of SICS
technique, see my book Complications During and After Cataract Surgery
(Springer). See Sect. 19.4.
19.2 Extraction of a Posteriorly Dislocated Nucleus with Fragmatome 275

soft nucleus hard nucleus

Flute needle Vitreous cutter

PFCL

Fig. 19.2 Treatment algorithm for removal of soft or hard dropped nucleus

19.2 Extraction of a Posteriorly Dislocated Nucleus


with Fragmatome

Video 19.1: Extraction of dropped nucleus with fragmatome and sulcus IOL

19.2.1 Introduction

Do you know which tissue you can remove with a vitreous cutter and the fragmatome?
This is an important knowledge for this case. With the vitreous cutter, you can remove
the cortex, epinucleus, a soft nucleus and iris tissue. You cannot remove a dense nucleus
or a thick capsular fibrosis. With the fragmatome you can remove a dense nucleus and a
thick capsular fibrosis. A rock-hard nucleus is hard to remove by a fragmatome. The
fragmatome is less powerful than a normal phaco handpiece. To remove a rock-hard
nucleus, you need to perform phacoemulsification at the pupillary plane or a SICS.
276 19 Dropped Nucleus

Instruments

1. 23G or 25G 3-port trocar system with chandelier light fibre


2. 120D lens
3. Fragmatome
4. 1.3 mm V-lance for 20G sclerotomy

Individual Steps

1. Hybrid 3-port system with chandelier light fibre


2. Anterior vitrectomy via pars plana
3. Removal of residual cortex from the lens capsule via paracentesis
4. Vitrectomy, if necessary PVD
5. 20G sclerotomy at 9 o’clock
6. Emulsification of the nucleus with fragmatome and flute needle
7. Closure of 20G sclerotomy
8. Trimming of vitreous base
9. Implantation of an intraocular lens
10. Removal of trocar cannulas

19.2.2 The Surgery Step by Step: Figs. 19.3, 19.4, 19.5, 19.6, 19.11,
19.12 and 19.13

1. 3-port system with chandelier light fibre.

After insertion of three trocars, we insert a chandelier light fibre, because we


work bimanually in step 6.

2. Anterior vitrectomy via pars plana.


3. Removal of residual cortex from the lens capsule via paracentesis.
4. Vitrectomy, if necessary PVD.

The anterior vitreous is cut with the vitreous cutter via pars plana. Make circular
movements with the vitreous cutter. The vitreous cutter port points backwards
towards the posterior pole in order to avoid a damage of the lens capsule. Aspirate
then the residual cortex with the vitreous cutter via a paracentesis. It is important
that you switch the vitreous cutter to aspiration and not to cutting. Otherwise you
risk destroying the anterior capsule. If the lens capsule is free from the cortex, con-
tinue with a core vitrectomy from pars plana.

5. 20G sclerotomy at 9 o’clock.


6. Emulsification of the nucleus with fragmatome and flute needle.

Then open the conjunctiva at 9 o’clock in the area of the sclerotomy and perform
a non-lamellar (perpendicular) 20G sclerotomy with the V-lance. This sclerotomy is
19.2 Extraction of a Posteriorly Dislocated Nucleus with Fragmatome 277

Fig. 19.3 A luxated white


nucleus secondary to
trauma for 20 years ago

Fig. 19.4 Emulsification


of a nucleus with
fragmatome. A PFCL
bubble was injected to
protect the posterior pole
278 19 Dropped Nucleus

Fig. 19.5 Many small


nuclear fragments. Every
fragment has to be
removed

Fig. 19.6 The left hand


fixates the fragment with a
backflush instrument and
the right hand removes it
with the fragmatome. The
fragmatome is a dangerous
instrument which can
cause severe retinal and
choroidal damage

used for the fragmatome and closed as soon as the nucleus is removed, in order to
avoid leakage from the sclerotomy.
Soft lens material can be removed first with the vitreous cutter (approximately
400 cuts/min). For hard lens fragments, you can use the flute needle in your left
hand and the fragmatome in the right hand. Aspirate the lens fragments with the
flute needle, move the needle to the central vitreous cavity and emulsify them there
safely with the fragmatome. This procedure is performed repeatedly until all the
lens fragments are removed (Figs. 19.4, 19.5 and 19.6).
If you perform this procedure without flute needle (only with the fragmatome),
there is a risk that during the frequent aspiration of the lens fragments with the frag-
matome you may injure the retina (retinal break) or the choroid (choroidal haemor-
rhage). In addition, the frequent aspiration of the lens fragments clogs the vitreous
cutter. If the suction is not working properly, the risk is increased to induce damage
to the retina or choroid. In this case, it is advisable to inject a PFCL bubble in order
to protect the posterior pole.
19.2 Extraction of a Posteriorly Dislocated Nucleus with Fragmatome 279

Surgical Pearls No. 76


Dropped nucleus: The difficulty of this step is that the nucleus is located on
the posterior pole so that a damage of the retina is easily induced. Three
advices: (1) Inject a PFCL bubble to (a) protect the macula and (b) elevate the
nucleus. (2) Work bimanual so that one hand can fixate the nucleus and the
other hand can remove it. (3) If the posterior vitreous is attached, then
the vitreous cortex is like a cushion for the nucleus making its removal
difficult. In this case, induce a PVD to free the access to the nucleus.

7. Closure of 20G sclerotomy

The 20G sclerotomy must be sutured with a Vicryl 6-0 interrupted stitch or a
Vicryl 8-0 cross-stitch.

8. Trimming of vitreous base

The fragmatome breaks the nucleus in many small pieces which are dispersed all
over the posterior segment. These fragments must be removed meticulously, because
every nucleus fragment which remains may cause a postoperative sterile uveitis.
The most lens fragments are located in the vitreous base at 6 o’clock. In order to
visualize and remove them, you need to indent the vitreous with the scleral depres-
sor. Use for this procedure a chandelier light.

Surgical Pearls No. 77


The trimming of the vitreous base is an important step because a residual
nuclear fragment will cause a postoperative sterile uveitis. Conclusion: Do
not be satisfied after removal of the large nucleus but after complete removal
of all small fragments.

9. Implantation of the IOL


10. Removal of trocar cannulas

If more than two third of the anterior capsule are intact, the lens can be implanted
into the sulcus (“haptic out, optic in”) (Figs. 19.11 and 19.12). If not, fixate a three-
piece IOL to the sclera or implant an iris-fixated IOL (Verisyse®) (Fig. 19.13).

Surgical Pearls No. 78


One-piece IOL vs three-piece IOL: Do not implant a one-piece IOL into the sulcus
because the haptics cause a focal depigmentation of the iris resulting in a secondary
pigment glaucoma. This does not happen with a three-piece IOL. The reason for
this is that a one-piece haptic has sharp edges and a three-piece is round.
280 19 Dropped Nucleus

19.3 Extraction of a Posteriorly Dislocated Nucleus


with PFCL

Video 19.2: Extraction of dropped nucleus with ICCE and retropupillar Verisyse
IOL
Video 19.3: ICCE and iris-claw IOL

19.3.1 Introduction

The advantages of a SICS technique are fast and complete removal of the dropped
nucleus. The disadvantage is sometimes the destruction of the anterior lens capsule
when luxating the nucleus into the anterior chamber. The advantage of phacoemul-
sification is that we are more used to this technique. The disadvantage is an injury
of the endothelium with the phaco energy, which may result in a decompensated
cornea.

Instruments

1. Hybrid 3-port trocar system with chandelier light


2. 120D lens
3. 15° knife (Alcon)
4. Crescent angled bevel up knife
5. Tunnel knife, 2.4 mm
6. Double-barrelled infusion cannula

Tamponade

Intraoperative: PFCL
Postoperative: None

Individual Steps

1. 3-port trocar system with chandelier light


2. Vitrectomy
3. Injection of PFCL and dislocation of the nucleus to the pupillary plane
4. Phacoemulsification of the nucleus
OR
5. Extraction of the nucleus with the SICS method
6. Implantation of an intraocular lens
7. Removal of trocars
19.3 Extraction of a Posteriorly Dislocated Nucleus with PFCL 281

19.3.2 The Surgery Step by Step: Figs. 19.7, 19.8, 19.9, 19.10, 19.11,
19.12 and 19.13

1. 3-port trocar system with chandelier light


2. Vitrectomy
3. Injection of PFCL and dislocation of the nucleus to the pupillary plane

The anterior vitreous is removed with the vitreous cutter via pars plana. Then
the residual cortex is aspirated from the lens capsule with the vitreous cutter via a
paracentesis. It is important that you switch the vitreous cutter to aspiration and
not to cutting. Otherwise there is a risk of destroying the anterior capsule. If the
lens capsule is free from the cortex, continue with vitrectomy from pars plana.
Instil a PFCL bubble; if necessary luxate the nucleus with the flute instrument
onto the PFCL bubble (Fig. 19.7). Then inject PFCL up to the sclerotomies; the
nucleus is then pushed up to the level of the pupil (Fig. 19.8).

4. Phacoemulsification of the nucleus

Emulsify next the nucleus with a normal phaco handpiece. The phacoemulsifica-
tion disintegrates the nucleus into small pieces which may slide away on the PFCL
bubble in the retinal periphery and must be retrieved from there. Viscoelastics
behind the nucleus can help to hold the lens fragments in the pupil.
OR

Fig. 19.7 A different


nucleus removal method.
PFCL is injected to lift up
the nucleus
282 19 Dropped Nucleus

Fig. 19.8 The nucleus is


now located behind the
pupil

Fig. 19.9 Then the


nucleus is luxated into the
anterior chamber. This
manoeuvre is not so easy
because the lens capsule is
slippery. Now an 8 mm
frown incision is
performed

Fig. 19.10 The nucleus is


removed with a so-called
fish hook. Use alternatively
a serrated lens loop
19.3 Extraction of a Posteriorly Dislocated Nucleus with PFCL 283

Fig. 19.11 Insert a


three-piece IOL with
haptics in the sulcus and
the optic behind the rhexis

Fig. 19.12 An illustration


of “haptic out, optic in”.
The IOL is centrated and a
barrier between posterior
and anterior segment is
created

5. Extraction of the nucleus with the SICS method

If the nucleus is too hard for the phacoemulsification, you can extract the nucleus
faster and with a lower risk of complications in toto (Figs. 19.9 and 19.10). I recom-
mend the so-called SICS technique (small incision cataract surgery), which is a
modified form of ECCE. In short: limbal peritomy from 11 to 1 o’clock with Vannas
scissors, mark then with the caliper an 8 mm wide frown incision, dissect the frown
incision with a crescent bevel up knife and open the anterior chamber with a 2.4 mm
tunnel knife. The next steps are the luxation of the nucleus into the anterior cham-
ber, injection of viscoelastics below and above the nucleus and finally extraction of
284 19 Dropped Nucleus

Fig. 19.13 If the lens


capsule is absent, then
implant a scleral-fixated
IOL or an iris-fixated IOL
(Verisyse, AMO)

the nucleus with loop, fish hook or viscoelastics. The incision may be sutured with
a Vicryl 8-0 cross-stitch.

6. Implantation of the intraocular lens


7. Removal of trocars

If more than two thirds of the anterior capsule are intact, the lens is implanted
into the sulcus (“haptic out, optic in”) (Figs. 19.11 and 19.12). If not, fixate a lens to
the sclera or to the iris (e.g., iris-fixated IOL) (Fig. 19.13).

19.4 Complications

Retinal break, choroidal haemorrhage These are the most common complications
and can be avoided, when you use a Chandelier light and work bimanually.

19.5 FAQ

Which Method Do You Prefer, SICS or Fragmatome?


In case of a hard nucleus, I prefer SICS because this technique is faster and smoother.
You can remove the complete nucleus; with the fragmatome you need to remove all
these small pieces. In case of a medium-hard nucleus, I would prefer the fragmatome.
I dislike about the fragmatome technique that it breaks the nucleus in many small
pieces. And all pieces must be meticulously removed. Only one remaining nuclear
fragment can cause a sterile endophthalmitis. This problem does not exist with the
SICS technique.
Retinal Detachment Complicated
by Proliferative Vitreoretinopathy (PVR) 20

Contents
20.1 General Introduction ..................................................................................................... 285
20.1.1 The Surgery Step by Step ................................................................................ 288
20.2 Inferior Redetachment .................................................................................................. 304
20.3 Complications ............................................................................................................... 305
20.4 FAQ ............................................................................................................................... 307

20.1 General Introduction

Video 20.1: PVR detachment


Video 20.2: Peeling techniques for PVR detachment
Video 20.3: PVR peeling
Video 20.4: PVR detachment secondary to trauma
Video 20.5: Traumatic detachment

The correct assessment and practical management of PVR retinal detachment is


one of the biggest challenges in vitreoretinal surgery. The usage of an encircling
band for PVR detachment was standard only 10 years ago. Today, the usage of an
encircling band has drastically reduced (in our department) to approximately 2–5
cases per year. There are many causes for this development: the surgery today is less
traumatic, the primary detachment surgery is more successful resulting in less
severe PVR cases and, not last but least, the advent of new agents such as heavy sili-
cone oil. Heavy silicone oil is an excellent instrument for the difficult inferior
detachments.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 285


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_20
286 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Flow chart 20.1 Our


treatment algorithm for
PVR detachments. If you PVR detachment
use an encircling band,
you can use often a gas
tamponade. If you
perform a retinectomy,
you need in most cases Mobilize retina through removal
silicone oil. If you do not of posterior vitreous and peeling
perform encircling band of membranes
and not retinectomy, then
you need in the most
cases light silicone oil for
the superior detachment Test: Does retina reattach under air?
and 2–4 weeks later
heavy silicone oil for the
inferior detachment NO

Encircling band
YES or
Retinectomy

Laser and silicone oil

PVR consists of epiretinal PVR, subretinal PVR and intraretinal PVR. Subretinal
PVR and epiretinal PVR can be removed with peeling. Intraretinal PVR results in
shortening of the retina and can only be treated with retinectomy or encircling band
or the usage of silicone oil (see Flow chart 20.1).
There are two typical cases for PVR detachment:

1. Old and total PVR detachment


2. PVR redetachment

Our surgical approach for an old detachment is removal of vitreous with poste-
rior vitreous + membrane peeling + cerclage or retinectomy + laser + silicone oil (in
most cases light 1000 cSt silicone oil). If you do not use cerclage or retinectomy,
then quite a few cases develop an inferior detachment. In this case, we extract the
light silicone oil and inject heavy silicone oil.
Our surgical approach for a PVR redetachment is removal of condensated poste-
rior vitreous (if present) + membrane peeling + laser + silicone oil (in most cases
light 1000 cSt silicone oil). In case of an inferior redetachment, we extract the light
silicone oil and inject heavy silicone oil.
20.1 General Introduction 287

The first surgical step in PVR retinal detachment is the removal of membranes.
This means peeling, peeling and peeling. In order to perform a good peeling, we like
to stain the membranes. Because many membranes are located in the periphery, the
usual method does not work well. We therefore make a fluid–air exchange and then
drop the dye on the PVR membranes in an air-filled eye. The dye is very concen-
trated on these areas, and you always get a good staining of the membranes. Return
to a fluid-filled eye and start with the peeling on the posterior pole and work from
there to the ora serrata.
The next main step is the treatment of intraretinal PVR. There are three tools
against intraretinal PVR with shortening of the retina:

1. Cerclage
2. Retinectomy
3. Light and heavy silicone oil

This surgery can be performed with hybrid technique (one 27G infusion trocar
and two 25G instrument trocars) or only with 27G.

Instruments

1. Hybrid 3-port trocar with chandelier light


2. 120D lens, for peeling: 90D lens
3. Vitreous cutter
4. Endodiathermy
5. Endolaser
6. Backflush instrument
7. Scleral depressor
8. Membrane pic
9. Eckardt endgripping forceps or serrated jaw forceps
10. Intravitreal scissors (curved or straight)

If available

11. 25G knob spatula


12. 23G serrated jaw forceps
13. 27G Atkinson cannula

Dye

Trypan blue

Tamponade

Intraoperative: PFCL
Postoperative: light and heavy silicone oils and occasionally long-acting gases
288 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Individual Steps

1. Hybrid 3-port system with chandelier light


2. Phacoemulsification
3. Vitrectomy
4. Staining of the membranes with trypan blue
5. Peeling of PVR membranes
6. Assess if the retina attaches under air or PFCL
7a. Encircling band
7b. Retinectomy
8. Photocoagulation of breaks
9. Prepare anterior chamber for tamponade
10a. PFCL × silicone oil exchange
10b. PFCL × air exchange
11. Tamponade
12. Removal of the trocars

20.1.1 The Surgery Step by Step: Figs. 20.1, 20.2, 20.3, 20.4, 20.5,
20.6, 20.7, 20.8, 20.9, 20.10, 20.11, 20.12, 20.13, 20.14, 20.15,
20.16, 20.17, 20.18, 20.19, 20.20, 20.21, 20.22, 20.23, 20.24,
20.25 and 20.26

1. Hybrid 3-port system with chandelier light


2. Phacoemulsification
3. Vitrectomy

A chandelier light facilitates the surgery very much; use one if available; begin
with a vitrectomy and cautious PVD, i.e. cautious removal of the posterior vitreous.
This step is difficult because the retina is detached (Figs. 20.1 and 20.2).

Surgical Pearls No. 79


Posterior synechiae: How do you remove posterior synechiae? (1)
Simultaneous injection of viscoelastics and delamination with the viscoelas-
tics cannula. (2) If the adhesions are too strong, you can cut them with a
(curved) vitreous scissors.

4. Staining of the membranes with trypan blue

Some PVR membranes cannot be easily detected; we recommend therefore to


stain the membranes with trypan blue. In case of centrally located membranes, you
can stain in a BSS-filled eye. But in the case of peripherally located membranes, this
method does not work because the dye falls onto the posterior pole. You need to
20.1 General Introduction 289

Fig. 20.1 A posteriorly


closed funnel. Remove the
attached posterior vitreous
in order to relax the retina

Fig. 20.2 Remove the


posterior hyaloid up to the
ora serrata in order to
mobilize the retina

perform therefore a fluid–air exchange and drop the dye directly on the membranes
(Figs. 20.3, 20.4, 20.5, 20.6, and 20.7). Wait 30 s, aspirate the dye from the posterior
pole and perform an air–fluid exchange. With this method, a higher concentration of
the dye is reached and therefore a better staining of the membranes.

5. Peeling of PVR membranes

The peeling of PVR membranes is very laborious and time consuming. Begin at
the posterior pole and work your way up to the periphery (Fig. 20.8). When you peel
the PVR membranes, you have to work two handed and dissect bluntly without scis-
sors. Start with elevating the membrane. Depending on the strength of the
290 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

e
blu
n
y pa
Tr

AIR

starfold

Fig. 20.3 An air-filled eye. Stain membranes in the centre and periphery with trypan blue

Fig. 20.4 Drop the dye


onto the membranes to
achieve maximal
concentration
20.1 General Introduction 291

Fig. 20.5 Even peripheral


membranes can be stained
with this technique. This is
not possible in a BSS-filled
eye

Fig. 20.6 An eye with a


tractive PVR detachment

Fig. 20.7 The membranes


are well stained with
trypan blue
292 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Fig. 20.8 Peeling of


membranes: Start in the
centre and continue in the
periphery

Fig. 20.9 The same eye as


in Fig. 20.6 after removal
of all membranes

Fig. 20.10 Bimanual


removal of cyclitic
membranes at the vitreous
base with intravitreal
forceps and straight
scissors (Dorc)
20.1 General Introduction 293

Fig. 20.11 Condensated


air bubbles on the backside
of the IOL

Fig. 20.12 Wipe the air


bubbles away with the
vitrector or inject
viscoelastics onto the
backside of the IOL

Fig. 20.13 Mersilene 5.0


for suturing of encircling
band
294 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Fig. 20.14 Place a silk


3-0 traction suture under
all straight muscles. Place
the encircling band under
the muscles with the help
of the strabismus hook
with big hole

Fig. 20.15 Retinectomy:


start with an
endodiathermy of the
peripheral retina

membrane, in one hand you hold an Eckardt forceps or a serrated jaw forceps and
in the other hand a membrane pic or a retinal scraper (Atkinson blunt cannula).
Grasp the membrane with the forceps and pull it up a little bit with help of the mem-
brane pic or scraper.
Then you switch the membrane pic for the knob spatula and delaminate the mem-
brane of the retina with its blunt tip. It is important to identify the correct plane; this is
20.1 General Introduction 295

Fig. 20.16 Retinectomy:


cut the retina with a
vitreous cutter (100 cuts/
min) or vertical scissors

Fig. 20.17 Cut slowly and


be careful not to damage
the underlying choroid

the key to successful membrane peeling. Find the gap between the membrane and the
retina, and work your way along this gap with Eckardt forceps and the knob spatula.
If you fail to mobilize the membrane, although you have identified the gap, you
can take the straight scissors and cut the membrane off the retina while pulling it
296 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Fig. 20.18 Fold the retina


over and inspect the
subretinal space

Fig. 20.19 Remove


subretinal membranes if
present
20.1 General Introduction 297

Fig. 20.20 Remove all


membranes posterior to the
retinectomy

Fig. 20.21 Otherwise, a


PVR redetachment will
occur posterior to the
retinectomy
298 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

360 deg laser-


cerclage

Silicone oil

No tamponade =>
High detachment risk

Fig. 20.22 360-degree laser cerclage. If you will perform a 360-degree laser cerclage in a totally
detached retina and inject light silicone oil as tamponade, then the inferior retina may detach. The
inferiorly located laser effects will cause a retinal necrosis and create a long break

Fig. 20.23 Prepare the


anterior chamber before
injecting silicone oil. In the
case of light silicone oil,
perform an iridectomy at 6
o’clock. In the case of
heavy silicone oil, perform
an iridectomy at 12 o’clock
with the vitreous cutter.
You can inject viscoelastics
into the anterior chamber
to prevent a silicone oil
prolapse
20.1 General Introduction 299

Fig. 20.24 Continue with


a PFCL against air
exchange

Backflush
instruments

Air

BSS retinectomy

PFC

Fig. 20.25 Aspirate meticulously at the edges of the retinectomy in order to avoid slippage
300 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Fig. 20.26 Inject silicone


oil or a long-lasting gas
into the eye

(Fig. 20.9). The straight scissors are especially needed for the circular membranes
in the periphery. Do not use scissors for the central membranes in order to avoid
breaks.

Surgical Pearls No. 80


Removal of PVR membranes: After silicone oil tamponade, peripherally
located membranes in particular are very difficult to mobilize from the retina.
A retinal scraper such as a 25G/27G Atkinson blunt cannula can be very help-
ful. With its help, you can elevate the membrane of the retina, and with coun-
ter-traction of the forceps in the second hand, you can pull/draw it from the
retina (Fig. 20.10).

Surgical Pearls No. 81


The conventional Eckardt ILM forceps is often not sufficient for removal of
PVR membranes. Try more powerful forceps such as a serrated jaw forceps or
an Eckardt power forceps.

6. Assess if the retina attaches under air or PFCL.

The goal is to mobilize the retina. To check whether the retina is sufficiently
mobile, inject air, drain the subretinal fluid and examine whether the retina attaches.
If the retina does not attach, perform an fluid–air exchange and continue working
and that means in concrete terms: encircling band or retinectomy. Again, a retina
that does not flatten under PFCL or air will not flatten under any other tamponade.
20.1 General Introduction 301

Surgical Pearls No. 82


Air bubbles behind IOL: Beware of a posterior capsulotomy and a fluid–air
exchange in pseudophakic patients. During a fluid–air exchange, the water
condenses at the posterior surface of the IOL in the area of the capsulotomy,
thereby greatly impairing the view of the posterior pole. It can either be
removed with a flute instrument or injection of viscoelastics onto the posterior
surface of the IOL (Figs. 20.11 and 20.12).

7a. Encircling band

Perform a 360° limbal peritomy, delaminate the subtenon tissue and place trac-
tion sutures (silk 3-0) under all straight muscles (see episcleral buckling surgery).
Then place the encircling band behind all four straight muscles and close the belt
with the lock. The lock is located in the inferotemporal quadrant. Then mark the
place of the suture which is the equator or more exact 50 % of the axial length. Place
a suture (Mersilene 5-0, S14 Ethicon) in all quadrants between two straight muscles
(Figs. 20.13 and 20.14). Then constrict the belt and check the effect by looking into
the eye.

7b. Retinectomy

Before performing a retinectomy, you need to remove all membranes between


the optic disc and the posterior edge of the retinectomy because residual membranes
will result in new traction. The main steps for a retinectomy are:

1. Peeling of all membranes from posterior pole to retinectomy edge


2. Peripheral diathermy
3. Retinectomy along the cauterized retina
4. Removal of the anterior retina up to the ora serrata
5. Laser
6. Silicone oil

The main indication for a retinectomy is a shortened retina. When performing a


retinectomy, two golden rules apply: (1) Place the retinectomy as peripheral as pos-
sible, ideally at the ora serrata. (2) Make it larger than you think. As a rule of thumb,
use the area of the contracted retina as your guide and add at least one clock hour on
each side. If the retinectomy is placed at the ora serrata, diathermy is usually not
necessary, as the first bit of the retina is almost avascular. If you have to go more
central than this, we recommend that you perform diathermy first in order to mini-
mize the risk for haemorrhages that are both cumbersome to remove and may also
trigger more PVR postoperatively (Fig. 20.15).
After removal of all posterior membranes, cut the retina with the vertical scissors
or the vitreous cutter (Figs. 20.16 and 20.17). If you have to place the retinectomy
302 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

more centrally, remove all the retina anterior to the retinectomy edge with the vitre-
ous cutter; otherwise, this ischemic retina may cause rubeosis iridis. Use a PFCL fill
to check if the retina flattens completely. If not, start again either with more mem-
brane peeling or extend the retinectomy (Figs. 20.19, 20.20, and 20.21).

Surgical Pearls No. 83


Doughnut shape of the anterior retina: One of the major risks of a retinec-
tomy is cutting into the choroid. This will cause a significant haemorrhage
and may be difficult to control. It usually happens if the retina is too close to
the choroid in the area of the retinectomy. To detach it from the choroid, fill
the eye with PFCL. The subretinal fluid will be pushed anteriorly in a dough-
nut shape and will detach the anterior retina. It is now easier to perform a reti-
nectomy and the anterior edge of the retina is easily identified.

8. Lasertherapy of breaks and apply a circular laser cerclage

If the retina is sufficiently mobilized, it can be photocoagulated under PFCL. Treat


all breaks. If you performed a retinectomy, laser treat along the edges (Fig. 20.26).A
circumferential laser (360°) is usually not recommended. It is only essential to treat
all breaks and retinotomies. You cannot “fix” an area of retinal fold with laser scars—
you either have to perform more membrane peeling or extend the retinectomy.

Surgical Pearls No. 84


Laser cerclage ≠ encircling band. Both, an encircling band and a laser cerclage,
create a barrier for tears located anterior to the barrier. In addition, an encir-
cling band creates an indentation of the retina which results in a relaxation of
the shortened retina. A laser cerclage, however, does not create an indentation
and can therefore not help in relaxing a shortened retina. This is important for
PVR detachments with intraretinal PVR and a shortened retina.

Surgical Pearls No. 85


Avoid if possible an inferior laser cerclage (Fig. 20.22). Why? There is always
more traction on the inferior pole because the gas or silicone oil presses
against the superior pole. In the case of an inferior laser cerclage, the laser
weakens the retina and may cause a detachment along the laser cerclage.
Exception to this is heavy silicone oil as tamponade or an encircling band.

9. Prepare the anterior chamber for tamponade.

Make sure that all potential anterior segment problems are addressed before
starting a tamponade. The air bubble will push the iris–lens diaphragm forward,
20.1 General Introduction 303

making any manipulations in the anterior chamber extremely difficult. In addition,


silicone oil injected into the posterior chamber may enter the anterior chamber.

1. Gas tamponade: In cases of large defects within the zonules or the lens capsule,
inject Miochol and an air bubble into the anterior chamber before fluid–air
exchange. This prevents the iris–lens diaphragm from moving forward and
avoids iris capture or displacement of the gas tamponade into the anterior cham-
ber. With modern viewing systems and air in the anterior chamber, there usually
is a sufficient view of the posterior pole to perform a safe fluid–air exchange.
2. Silicone oil tamponade: If you plan a silicone tamponade, you can inject some
viscoelastics in the anterior chamber or even better Healon GV. If an iridectomy
is needed, it must be performed at 6 o’clock. Light silicone oil will tamponade
the superior retina. Perform the iridectomy optimally in a PFCL or water-filled
eye. Settings are 100 cuts/min. Place the vitreous cutter through a paracentesis at
the 6 0’clock position, and aspirate iris tissue into the vitrector port. Then cut
until a complete hole is created (Fig. 20.23).

10a. PFCL × silicone oil exchange

For details, see Sect. 15.4. In short: For a PFCL × silicone oil exchange, you need
a DORC infusion line because it has a plastic cannula and a special shape which
prevents that the cannula detaches under oil. Attach the DORC infusion line to the
silicone oil syringe and to the infusion trocar. Place the Charles flute needle into the
superior BSS phase and inject the silicone oil. When the BSS is removed, place
the Charles flute needle into the PFCL phase. When a small PFCL puddle is present
at the posterior pole, inject less silicone oil and indent the globe with the ring finger.
After removal of the final PFCL bubble, remove the ring finger.

10b. PFCL × air exchange

The difficult step is the retinectomy edges. Remove the PFCL until the posterior edge
of the retinectomy edges, and then aspirate thoroughly the residual fluid along the reti-
nectomy edges. All water (BSS) needs to be removed from the edge of the retinectomy
(Figs. 20.24 and 20.25). Otherwise you will have “slippage”, i.e. the posterior retina
slides towards the posterior pole. Then continue with complete aspiration of PFCL.

11. Tamponade

A simple rule of thumb is for superior PVR, use light silicone oils and occasion-
ally long-acting gas (15 % C2F6, 14 % C3F8), and for an inferior PVR, use heavy sili-
cone oils (Densiron 68®) (Fig. 20.26).

(a) Light silicone oil tamponade


You can perform a PFCL against silicone oil or an air against silicone oil
tamponade. If possible, perform an air–silicone oil or Densiron 68 exchange
because it is technically easier than the PFC × silicone oil exchange.
304 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

(b) Heavy silicone oil tamponade (Densiron 68®, Oxane Hd®)


We prefer an air against Densiron 68 exchange. Perform a heavy fluid to air
exchange and then an air to heavy silicone oil exchange.

12. Removal of the trocars

If you use silicone oil as tamponade, all sclerotomies should be sutured up to


prevent a spill of oil under the conjunctiva. The conjunctiva can be sutured with 8-0
Vicryl.

20.2 Inferior Redetachment

An inferior redetachment may occur in an eye filled with LIGHT silicone oil.
Extract the light silicone oil and perform a peeling if membranes are present. Then
laser treat the tears and use HEAVY silicone oil as tamponade. Remove the heavy
silicone oil after 6–8 weeks. If an inferior tear is responsible for the detachment,
then you can perform an episcleral buckling as an alternative. Perform surgery
under microscope view and BIOM view with the help of a chandelier light. Leave
the silicone oil inside the eye.

Case Report No. 10: Traumatic PVR Detachment


Figures 20.27, 20.28, 20.29, 20.30 and 20.31

Video 20.5: Traumatic detachment

A 27-y/o-female patient was admitted to us due to a traumatic cataract and


traumatic retinal detachment. She suffered several closed globe injuries second-
ary to fist punches and a severe visual acuity decrease for 1 year. The visual
acuity was measured with light perception. The patient was informed about the
bad prognosis and consented into surgery. A phacoemulsification + IOL + vitrec-
tomy + peeling + retinectomy + laser + 1000 cSt silicone oil was performed
(Figs. 20.28 and 20.29). The retina was attached during the 1-week follow-up
but at the 4-week follow-up, a total redetachment was found (Fig. 20.30). A
surgery with removal of silicone oil + radial retinectomy + membrane peel-
ing + laser + 1000 cSt silicone oil was performed (Fig. 20.31). The retina
remained attached, but after 8 weeks, a shallow redetachment with membrane
formation was detected. A surgery with silicone oil removal + membrane peel-
ing + laser + 1000 cSt silicone oil was performed. Since then, the retina is
attached. The patient is subjectively happy about the “successful” surgery
although she states that visual acuity has not significantly improved. Visual acu-
ity is light perception with a little projection.
20.3 Complications 305

Fig. 20.27 Case report


10: a traumatic mature
cataract

Fig. 20.28 Case report


10: a total detachment with
closed posterior funnel

20.3 Complications

# In PVR grade D (massive), consider a cerclage or a 360° retinectomy.


# Retinectomy: the retinectomy edges contract more or less after surgery. In the case
of retinal folds and detached edges, try to revise otherwise nothing can be done.
306 20 Retinal Detachment Complicated by Proliferative Vitreoretinopathy (PVR)

Fig. 20.29 Case report


10: a 270-degree
retinectomy with oil
tamponade was performed

Fig. 20.30 Case report


10: After 4 weeks, the
retina was again totally
detached
20.4 FAQ 307

Fig. 20.31 Case report


10: four radial
retinectomies were
performed until the retina
was reattached

20.4 FAQ

An old (more than 1 year) superotemporal detachment with PVR membranes


in the inferior pole. Which approach?
If you choose vitrectomy, surgery will become challenging with peeling, retinec-
tomy, encircling band and silicone oil. If there is a clear break of 1.5 clock hours
from the superior edge of the detachment, you could choose episcleral buckling, and
things could become easy. If after 1 week a small residual inferior detachment per-
sists, so what? Nothing. If the same happens with vitrectomy, it is not so good.

A focal redetachment after a primary vitrectomy. Which approach?


If I find a clear break, I would perform a second vitrectomy with gas. If I cannot—
and this is more common—find the break, then the break is usually at the edge of a
laser- or cryopexy-treated break (necrosis). You can either perform a new laser bar-
rier around the old laser barrier and inject gas or, which I prefer, place a sponge on
the laser-treated break.
Neovascular Glaucoma Treated Under
View of a BIOM 21

Contents
21.1 General Introduction ..................................................................................................... 309
21.1.1 The Surgery Step by Step ................................................................................ 310

21.1 General Introduction

Video 21.1: Retinal cryopexy (no audio)

We perform a retinal cryopexy under BIOM view. In contrast to binocular ophthal-


moscopy with the helmet, the view is much better with BIOM. Even if the cornea
becomes cloudy, there is a sufficient view to the retina. We perform a 360 degree limbal
peritomy because a cryopexy damages the goblet cells and induces a significant con-
junctival chemosis. A retrobulbar anaesthesia is required. Prescribe pain medication for
two postoperative weeks because this surgery causes significant postoperative pain.

Instruments
1. Chandelier light fibre
2. BIOM with 120D lens
3. Cryopexy handpiece

Individual Steps
1. Limbal peritomy
2. Insertion of chandelier light fibre

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 309


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_21
310 21 Neovascular Glaucoma Treated Under View of a BIOM

3. Retinal cryopexy under BIOM view


4. Cryopexy of ciliary body under microscope view
5. Reposition of conjunctiva

21.1.1 The Surgery Step by Step: Figs. 21.1, 21.2, 21.3, 21.4 and 21.5

1. Limbal peritomy
2. Insertion of the chandelier light fibre

Begin with a 360 degree limbal peritomy. Dissect the tenon tissue from the
sclera. Then insert a chandelier light at the inferotemporal position (Fig. 21.1).

Fig. 21.1 360 degree limbal


peritomy and insertion of a
chandelier light

Fig. 21.2 Flick in the BIOM


21.1 General Introduction 311

Fig. 21.3 Start with


peripheral cryopexy under
BIOM view

Fig. 21.4 Continue with a


central cryopexy until the
temporal arcades

3. Retinal cryopexy under BIOM view

Flick in the BIOM and perform a circular cryopexy (Fig. 21.2). We first freeze
the retina between the ora serrata and the equator and then continue to freeze the
retina between the equator and the temporal arcades (Figs. 21.3 and 21.4). The
freezing time depends on the cryo device being used, approximately 5–10 s. Wait
until a white bleaching of the retina occurs.
312 21 Neovascular Glaucoma Treated Under View of a BIOM

Fig. 21.5 And finalize


surgery with a cryopexy of
the ciliary body. We do 5 cryo
effects with 30 s duration at
the lower half. This depends
on the cryo device

4. Cryopexy of ciliary body under microscope view

Proceed with cryopexy of the ciliary body. We freeze the inferior half of the cili-
ary body and spare the superior half in order to avoid hypotony. We freeze for 30 s.
This depends again on the cryopexy device. We use an Erbe device (Erbe, Germany).
Depending on the tip size of the cryopexy handpiece, 2–3 freezings are required per
quadrant (Fig. 21.5). The cryopexy areas should be adjacent to each other.

5. Reposition of conjunctiva

Remove the chandelier light fibre. Close the sclerotomy with a Vicryl 8-0 suture.
Then close the conjunctiva at 3 and 9 o’clock with a Vicryl 8-0 suture.

Surgical Pearls No. 86


Cyclocryopexy: 5 cryopexy effects on the inferior half with approximately
30 s duration. Be careful with the dosage of cryopexy because too much
may result in an irreversible hypotony. It is preferable to perform one cryo-
pexy treatment, wait 4 weeks for the effect and then repeat the cryopexy if
necessary.
Submacular Haemorrhage Secondary
to CNV 22

Contents
22.1 General Introduction ..................................................................................................... 313
22.2 Surgery of a Small Submacular Haemorrhage.............................................................. 316
22.2.1 Medication....................................................................................................... 316
22.2.2 The Surgery Step by Step ................................................................................ 316
22.2.3 Postoperative Therapy ..................................................................................... 317
22.2.4 Follow-Ups ...................................................................................................... 317
22.3 Surgery of a Large Submacular Haemorrhage .............................................................. 317
22.3.1 The Surgery Step by Step ................................................................................ 317
22.3.2 FAQ ................................................................................................................. 321
22.4 Surgery of a Massive Submacular Haemorrhage .......................................................... 322
22.4.1 The Surgery Step by Step ................................................................................ 323
22.4.2 In Case of Residual Submacular Haemorrhage .............................................. 328
22.4.3 Complications ................................................................................................. 335
22.4.4 FAQ ................................................................................................................. 336

22.1 General Introduction

Video 22.1: Submacular rtPA


Video 22.2: Traumatic submacular haemorrhage

Timing and procedure are important for this pathology. Try to treat a submacular
haemorrhage within 1–2 weeks. The medication is called recombinant (tissue) plas-
minogen activator (rPA = rtPA, Actilyse®) and acts as a fibrinolytic agent.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 313


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_22
314 22 Submacular Haemorrhage Secondary to CNV

There are two methods present: (1) pneumatic displacement, which comprises
the intravitreal injection of rTPA, anti-VEGF and gas, and (2) vitrectomy which
comprises a vitrectomy, subretinal injection of rtPA, intravitreal injection of anti-
VEGF and gas.
There is an ongoing debate which method (intravitreal or subretinal rtPA) for
which size of haemorrhage (small, large, massive) is superior. The actual data indi-
cates that pneumatic displacement is superior for small haemorrhages, but it is
unclear which method is the best for a large and a massive haemorrhage.
Regarding small and large haemorrhages, both methods are effective in remov-
ing the subretinal haemorrhage but only partially effective in removing the sub-RPE
haemorrhage. The consequence is that an anti-VEGF therapy has to be continued
after surgery. Eylea® is especially effective for a sub-RPE haemorrhage.
Note regarding a massive haemorrhage that the blood clot is attached to the
underlying pigment epithelium. If you remove the blood clot with surgical extrac-
tion, you will at the same time remove the underlying pigment epithelium resulting
in a geographic atrophy. The next problem is that for removal of a large blood clot,
a peripheral retinectomy is required, which may result in a PVR detachment.

The definition of the size of a submacular haemorrhage varies. Our definition


is as follows:
Small haemorrhage: Haemorrhage inside temporal arcades
Large haemorrhage: Haemorrhage including temporal arcades
Massive haemorrhage: Haemorrhage outside temporal arcades and haemorrhagic
retinal detachment

There are several different surgical approaches available. Our procedure is as


follows:
Small bleedings: Pneumatic displacement with rtPA and anti-VEGF; head down
posture for 1 week. See Flow chart 22.1.
Exception: Patients who cannot perform a head down posture. Procedure: rtPA
and anti-VEGF without gas.
Large bleedings: Vitrectomy with subretinal injection of rtPA and gas tamponade
and anti-VEGF; head down posture for 1 week. See Flow chart 22.2.
Massive haemorrhage: (1) 1–7 days preoperatively, rtPA. (2) Vitrectomy + iat-
rogenic hole + drainage of subretinal blood + laser + anti-VEGF + silicone oil. (3)
Add rtPA in case of residual thick blood and repeat surgery 1 week later. See
Flow chart 22.3.
22.1 General Introduction 315

Flow chart 22.1 Our


treatment algorithm for Small submacular hemorraghe
treatment of small
haemorrhages

Intravitreal injection of
SF6, rPA, anti-VEGF

Control 1 month

Large submacular hemorraghe

Vitrectomy + submacular
injection of rPA + gas

Inject anti-VEGF until


CNV is inactive

Flow chart 22.2 Our


treatment algorithm for
large submacular Control 1 month
haemorrhages
316 22 Submacular Haemorrhage Secondary to CNV

Flow chart 22.3 Our


treatment algorithm for Massive submacular hemorraghe
massive submacular
haemorrhages
within 7 days

Intravitreal injection
of rPA

within 7 days

Vitrectomy + retinectomy +
drainage of subretinal blood +
laser + silicone oil

Residual
blood clot

Other surgical options:


Small and large bleedings; submacular rtPA (25micogramm in 0.2 ml) + and aspira-
tion of blood.
Massive haemorrhage: 180–360° retinectomy + removal of haemorrhage + reat-
tachment of retina with PFCL + laser + silicone oil; the latter surgery may cause
large RPE defects because the haemorrhage is attached to the RPE.

22.2 Surgery of a Small Submacular Haemorrhage

22.2.1 Medication

1. rtPA (Actilyse®) dose: 50 microgram/0.1 ml


2. Anti-VEGF: 0.1 ml Avastin, Lucentis, Eylea
3. Gas: 100 % Sf6, use alternatively air

22.2.2 The Surgery Step by Step

Inject anti-VEGF (regular dose) into the vitreous cavity. Perform a paracentesis.
Inject 0.1 ml rtPA into the vitreous cavity. Then inject 0.4 ml 100 % SF6 into the
vitreous cavity.
22.3 Surgery of a Large Submacular Haemorrhage 317

22.2.3 Postoperative Therapy

Two tablets of acetazelomide 250 mg


Head down posture for 1 week

22.2.4 Follow-Ups

Continue with Actilyse® and anti-VEGF until the haemorrhage is absorbed.

22.3 Surgery of a Large Submacular Haemorrhage

Video 22.1: Submacular Actilyse


Video 22.2: Traumatic submacular haemorrhage

22.3.1 The Surgery Step by Step

Instruments
1. Hybrid 27G and 23G 3-port trocar system
2. 120D lens
3. Laser probe
4. 41G subretinal injection needle (23G), DORC 1270.EXT

Usage of the 41G Subretinal Injection Needle (Figs. 22.1 and 22.2)

Fig. 22.1 (a) A 41G


cannula. The handpiece
continues with a plastic
pipe. A syringe filled with
rtPA is connected to this
plastic pipe (DORC, 1290
BTD23). (b) The metal
cannula is 23G. The 41G
cannula is retractable
318 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.2 The syringe


with rtPA is connected to
the 41G cannula

Attach the syringe with rtPA to the end of the handpiece of the 41G needle
(Fig. 22.2). The surgeon holds the handpiece of the needle, and the assistant or
scrub nurse holds the syringe and injects slowly the rtPA.

Remark: A 27G cannula is now available from MedOne: Poly Tip cannula 27G/38G;
Indication: 38G tip for subretinal injection (MedOne, 3259)

Medication
rtPA (Actilyse®) dose: 25 microgram/0.1 ml
Anti-VEGF: 0.1 ml Avastin, Lucentis, Eylea

Tamponade:
Gas: 20 % SF6
22.3 Surgery of a Large Submacular Haemorrhage 319

Fig. 22.3 A large


submacular haemorrhage
secondary to a CNV. Case
report 11

Fig. 22.4 Eject first air


bubbles from the cannula,
pierce the retina and inject
slowly 0.2 ml rtPA. Case
report 11

Individual Steps
1. Vitrectomy with PVD
2. Subretinal injection of 0.2 ml rtPA
3. Fluid–air exchange
4. Tamponade with 20 % SF6
5. Intravitreal injection of anti-VEGF

22.3.1.1 The Surgery Step by Step: Figs. 22.3, 22.4, 22.5, 22.6, 22.7
and 22.8
1. Vitrectomy with PVD
2. Subretinal injection of 0.2 ml rtPA
320 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.5 Note the


subretinal rtPA bubble.
Case report 11

Fig. 22.6 Four-week


follow-up. The subretinal
haemorrhage is displaced.
Case report 11

Fig. 22.7 The


haemorrhage is displaced
to the inferior periphery.
Case report 11
22.3 Surgery of a Large Submacular Haemorrhage 321

Fig. 22.8 The sub-RPE haemorrhage can only partially be displaced and requires further
anti-VEGF injections (e.g. Eylea®). Case report 11

Insert one 27G infusion trocar, one 27G instrument trocar and one 23G instru-
ment trocar for the dominant hand. Continue with a vitrectomy (Fig. 22.3). Insert
then the 41G cannula into the 23G trocar. Test that the cannula is free from air. Then
pierce the haemorrhage close to the inferior arcade (Fig. 22.4). Be careful not to
injure the pigment epithelium. Inject slowly 0.2 ml rtPA. The subretinal bubble
grows slowly (Fig. 22.5). Do not inject too fast because you may create a macular
hole.

3. Fluid–air exchange
4. Tamponade with 20 % SF6
5. Intravitreal injection of anti-VEGF

Perform a fluid–air exchange. Leave 25–33 % residual fluid. Then add 0.1–0.2 ml
Avastin and flush the vitreous cavity with 20 % SF6. Remove finally the trocars.

22.3.1.2 Postoperative Posture


First 2 h on the back so that the blood can liquefy and then head down posture for 1
week so that the blood can drain downwards.

22.3.1.3 One-Month Follow-Up: Figs. 22.6, 22.7 and 22.8


Continue with anti-VEGF injections until CNV is inactive.

22.3.2 FAQ

Do you aspirate the submacular blood through a iatrogenic hole?


No. The only induced hole is a 41G hole for subretinal injection.
322 22 Submacular Haemorrhage Secondary to CNV

Do you recommend to aspirate the subretinal blood?


No. For a central located haemorrhage, you need a central hole. If the blood is not
completely liquefied, then the extraction may become difficult. The tear will enlarge
intraoperatively and even more postoperatively. The gas bubble and the rtPA will do
its job and displace the blood into the periphery.

Case Report No. 11: Large Submacular Haemorrhage


Figures 22.3, 22.4, 22.5, 22.6, 22.7 and 22.8
A 93-year-old male patient was admitted to us for surgical management of a
large submacular haemorrhage. The left had a macular scar after 15 Lucentis injec-
tions and the VA was 0.01. The right eye was his best eye and had a visual acuity of
HM. Fundoscopy showed a bullous haemorrhage from the lower to the upper arcade
(Fig. 22.3).
The same day, a vitrectomy + injection of subretinal rtPA + 20 % SF6 was
performed.
At the 1-month follow-up, the patient reported a significant vision improvement
(Figs. 22.6, 22.7, and 22.8). Visual acuity was measured with 0.02 and fundoscopy
showed a thin macular haemorrhage and displaced blood at the inferior pole. Further
anti-VEGF injections were scheduled.

22.4 Surgery of a Massive Submacular Haemorrhage

Inject rtPA 1–7 days before vitrectomy.

Instruments
1. 27G 3-port trocar system with chandelier light
2. 120D lens
3. Laser probe

Medication
50 microgram/0.1 ml rtPA and anti-VEGF

Tamponade
1000 cSt silicone oil

Individual Steps
1. Vitrectomy with PVD.
2. Injection of PFCL.
3. Iatrogenic hole.
4. Aspiration of subretinal blood.
5. Laser treatment.
6. PFCL–air exchange.
7. 1000 cSt silicone oil tamponade.
8. Inject anti-VEGF and if necessary rtPA.
22.4 Surgery of a Massive Submacular Haemorrhage 323

22.4.1 The Surgery Step by Step: Figs. 22.9, 22.10, 22.11, 22.12,
22.13, 22.14, 22.15, 22.16, 22.17, 22.18 and 22.19

1. Vitrectomy with PVD.


2. Injection of PFCL.

Insert three 27G trocars and then a chandelier light. Begin with a core vitrectomy
and continue with a PVD and then trimming of the vitreous base (Fig. 22.9). Inject
PFCL onto the posterior pole in order to press the submacular blood towards the
periphery (Fig. 22.10).

Fig. 22.9 A massive


subretinal haemorrhage
secondary to CNV. The
retina was treated earlier
on with a scatter laser due
to a diabetic retinopathy.
Case report 12

Fig. 22.10 One day


before the first vitrectomy,
a rTPA injection was
performed. Now PFCL is
injected to displace the
blood from the posterior
pole. Case report 12
324 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.11 The blood is


displaced into the
periphery. In the area of
the bullous detachment,
choose a site for
retinotomy and cauterize it.
Case report 12

Fig. 22.12 A small


retinotomy is performed.
Case report 12

3. Iatrogenic hole.

Search for a good place for the iatrogenic hole. It should be outside the tem-
poral arcades and ideally inside the bullous detachment. Cut then an iatrogenic
hole with the following settings: 400 mmHg vacuum and 100–200 cuts/min
(Fig. 22.11).
22.4 Surgery of a Massive Submacular Haemorrhage 325

Fig. 22.13 The subretinal


blood is aspirated with the
vitreous cutter. This
manoeuvre can take
approximately 15 min.
Case report 12

Fig. 22.14 The liquefied


blood is removed.
It remains a clotted
haemorrhage at the
posterior pole.
Case report 12

4. Aspiration of subretinal blood.

Aspirate then the subretinal blood. This procedure is time-consuming; it may


take 15–30 min (Figs. 22.12 and 22.13). Do not enlarge the hole or create a retinec-
tomy because these procedures will increase the PVR risk. In some cases, there is
326 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.15 A fluid–air


exchange is performed and
the break is laser treated.
Case report 12

Fig. 22.16 1000 cSt


silicone oil is injected and
then a 0.1 ml rtPA bubble
to liquefy the residual
haemorrhage.
Case report 12

residual thick blood which cannot be aspirated. This blood clot can be removed in a
second surgery 1 week later (Fig. 22.14).

5. Laser treatment.
6. PFCL–air exchange.
7. 1000 cSt silicone oil tamponade.
8. Inject anti-VEGF and if necessary rtPA.

Inject PFCL anterior to the tear and continue with laser treating the iatrogenic
tear. The next step is a PFCL against air exchange and injection of 1000 cSt silicone
22.4 Surgery of a Massive Submacular Haemorrhage 327

Fig. 22.17 Five days


later: second vitrectomy.
The silicone oil is
removed. Case report 12

Fig. 22.18 PFCL is


injected to displace the
liquefied blood, the break
is reopened and the blood
is aspirated. Case report 12

oil (Fig. 22.15). Inject anti-VEGF medication into the silicone oil bubble to stop the
bleeding source. If a residual blood clot is present, then inject also 0.1 ml rtPA
(Fig. 22.16). Then remove the trocars.

22.4.1.1 Postoperative Posture


We recommend a head down posture for 1 week.
328 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.19 After


reinjection of 1000 cSt
silicone oil. Note the
submacular CNV which
caused all the trouble.
Case report 12

22.4.2 In Case of Residual Submacular Haemorrhage

Schedule the next surgery within 7 days:

Individual Steps
1. Removal of silicone oil.
2. Reopen the iatrogenic hole.
3. Injection of PFCL.
4. Aspiration of subretinal blood.
5. Laser treatment.
6. 1000 cSt silicone oil tamponade.
7. Inject anti-VEGF.

22.4.2.1 The Surgery Step by Step: Figs. 22.17, 22.18 and 22.19
Remove the silicone oil and reopen the iatrogenic hole (Fig. 22.17). Then inject
PFCL to push the blood towards the iatrogenic hole. Then aspirate the residual
blood (Fig. 22.18). Continue with a fluid–air exchange and remove the PFCL. Laser
treat the break and inject 1000 cSt silicone oil. Do not forget to add 0.2 ml Avastin
because the CNV is still active (Fig. 22.19).
We recommend again head down posture for 1 week and removal of the silicone
oil after 3 months. If the CNV remains active, continue with anti-VEGF injections
every month.

Case Report No. 12: Massive Submacular Haemorrhage 1


Figures 22.9, 22.10, 22.11, 22.12, 22.13, 22.14, 22.15, 22.16, 22.17, 22.18 and 22.19
22.4 Surgery of a Massive Submacular Haemorrhage 329

Fig. 22.20 Case report


13: a submacular
haemorrhage in 2009 was
treated with Lucentis
injections

A 67-year-old female patient was admitted to us due to a massive submacular


haemorrhage secondary to CNV. She lost her left eye due to diabetic retinopathy
and maculopathy. The right eye received earlier on a scatter laser treatment second-
ary to diabetic retinopathy. The eye was treated with rtPA and gas and 1 day later
with vitrectomy + aspiration of subretinal blood + silicone oil. The blood in the mac-
ular region could not be completely removed because it was not liquefied. Therefore,
an injection with rtPA was added at the end of surgery (Figs. 22.9, 22.10, 22.11,
22.12, 22.13, 22.14, 22.15 and 22.16). One week later, the silicone oil was removed,
the residual blood was aspirated and silicone oil was reinjected (Figs. 22.17, 22.18
and 22.19). Three months later, the silicone oil was removed.

Case Report No. 13: Massive Submacular Haemorrhage 2


Figures 22.20, 22.21, 22.22, 22.23, 22.24, 22.25, 22.26, 22.27, 22.28 and 22.29
A 77-year-old female patient lost her left eye due to a wet AMD. The right eye
was treated eight times with Lucentis due to wet AMD, and the eye was stable since
March 2011 (Fig. 22.20). She visited in April 2014 our out-patient department
because of an acute vision loss. Visual acuity was 0.02 and a massive submacular
haemorrhage secondary to a CNV was diagnosed (Fig. 22.21). She was treated the
same day with rtPA and gas. Two days later, a combined vitrectomy with aspiration
of subretinal blood + Avastin + heavy silicone oil (Densiron 68) was performed
(Figs. 22.21, 22.22, 22.23, 22.24 and 22.25). I chose heavy silicone oil because she
was unable to lie with face down posture. Two months later, a Lucentis injection
was repeated because the CNV membrane was still bleeding (Fig. 22.26). Six weeks
later, the silicone oil was removed. The visual acuity was for 2 years stable with
0.4–0.5 (Fig. 22.27). Recently she complained about a slight visual acuity decrease.
A visual acuity of 0.3–0.4 was measured and a recurrent subretinal haemorrhage
was diagnosed (Figs. 22.28 and 22.29). An intravitreal injection of Avastin was
immediately performed. One month later, the bleeding had resorbed significantly
and a CNV could be visualized.
330 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.21 Case report


13: a massive submacular
haemorrhage secondary to
CNV. The eye is first
treated with rTPA

Fig. 22.22 Case report


13: a PFCL bubble is
injected onto the posterior
pole
22.4 Surgery of a Massive Submacular Haemorrhage 331

Fig. 22.23 Case report


13: a bullous ring is
formed in the periphery

Fig. 22.24 Case report


13: an iatrogenic break is
created and the liquefied
haemorrhage is aspirated
332 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.25 Case report


13: the subretinal blood
could be completely
removed. Note the bloody
membrane temporal to the
macula

Fig. 22.26 Case report


13: 1-month follow-up

Case Report No. 14: Traumatic Choroidal Haemorrhage Video 22.2: Traumatic
submacular haemorrhage

Figures 22.30, 22.31, 22.32 and 22.33


A 39-year-old male patient presented to our out-patient department with a closed
globe trauma secondary to a fist punch. Visual acuity was measured with 0.2 with-
out correction and 0.4 with + 1.5 sph. A slit-lamp examination revealed a subretinal
bleeding at the lower temporal vascular arcade that thinned out towards the macula.
There was no sign of a globe rupture.
22.4 Surgery of a Massive Submacular Haemorrhage 333

Fig. 22.27 Case report


13: 6-month follow-up.
The membrane has formed
to a scar

Fig. 22.28 Case report


13: 2-year follow-up. A
new haemorrhagic CNV
has formed next to the old
scar

Fig. 22.29 Case report


13: 2-year follow-up. The
haemorrhagic CNV was
treated two times with
0.2 ml Avastin, and VA
was measured with 0.4
after a 3-month follow-up
334 22 Submacular Haemorrhage Secondary to CNV

Fig. 22.30 Case report


14: a 4-week-old traumatic
subretinal haemorrhage:
old and fresh blood is
located under the inferior
arcade. VA = 0.02. A
vitrectomy was performed,
rTPA and 20 % SF6
injected

Fig. 22.31 Case report


14: 1-month follow-up.
The subretinal
haemorrhage is
significantly reduced. Note
the choroidal defect

At the 2-week follow-up, the visual acuity decreased to 0.02 due to a vitreous
haemorrhage in the visual axis. At the 3-week follow-up, the VA was stable with
0.02, and the decision was made to perform a vitrectomy + rtPA + gas. I chose vitrec-
tomy because the patient is young and I feared a retinal detachment from a gas
injection without vitrectomy.
Two days later, 3 ½ weeks after trauma, a lens-sparing vitrectomy with rtPA and
gas was performed. No subretinal blood was removed (Fig. 22.30).
The 1-month follow-up showed a visual acuity increase to 0,4–0,5 and a signifi-
cant decrease of the subretinal blood clot. We decided to repeat the treatment
(Figs. 22.31 and 22.32).
22.4 Surgery of a Massive Submacular Haemorrhage 335

Fig. 22.32 Case report


14: 1-month follow-up.
The macula is freed from
blood and VA improved to
0.4. A rTPA and gas
injection is repeated

Fig. 22.33 Case report


14: 1-month follow-up.
The large amount of
subretinal blood is
removed and resorbed. The
VA increased to 0.8

Ten days later, a rtPA + gas injection was repeated. At the 1-month follow-up, the
visual acuity was 0.6 uncorrected and +1.0sph = 0.8 (Fig. 22.33). The patient was
not satisfied; he claimed that the visual acuity hardly improved after the last gas
injection and that he had severe 3-D problems and difficulties to coordinate the
eyes. His latent diplopia disappeared with a +1.5 glass.

22.4.3 Complications

1. Avoid extraction of thick clotted blood within the temporal arcades. You will
induce RPE defects with subsequent visual field defects. To prevent this compli-
cation, inject rtPA and aspirate the unclotted blood.
336 22 Submacular Haemorrhage Secondary to CNV

2. The surgery is simple but time-consuming. The above described method has a
low complication profile. There is a PVR risk due to the iatrogenic hole. The
PVR risk is low if you only aspirate the liquefied blood.
3. Do not attempt to cut a central hole and extract subretinal clotted blood with
active aspiration or a forceps. The hole will enlarge intra- and postoperatively.

22.4.4 FAQ

Which procedure is better, intravitreal OR subretinal Actilyse (rtPA)?


The actual data suggests that a minimal invasive method such as pneumatic dis-
placement is superior to an invasive method such as vitrectomy and subretinal rtPA
for small haemorrhages. For large and massive subretinal hemorrhages a minimal
invasive surgery is likely superior to a maximal invasive surgery because the macula
is severely damaged and has a poor prognosis.

What about the follow-up?


The CNV is not inactive after the primary surgery. It is important to continue with
anti-VEGF injections until the membrane is completely dry.
Submacular Haemorrhage Secondary
to Arterial Macroaneurysm 23

Contents
23.1 General Introduction 337

Video 23.1: Submacular hemorrhage secondary to macroaneurysm

23.1 General Introduction

A retinal macroaneurysm has a better prognosis and is usually caused by high blood
pressure. It results into a subretinal, sub-ILM, subhyaloidal and preretinal haemor-
rhage. The latter may break into the vitreous body. It is tempting to perform a vit-
rectomy, inject rtPA into the subretinal space and aspirate the blood. It is however
difficult to treat the macroaneurysm because it may easily bleed destroying all the
surgical progress you made. We perform only a treatment with rTPA and gas and
Avastin. First, the preretinal and intravitreal haemorrhage subsides. Then a subhya-
loidal haemorrhage persists. The retinal macroaneurysm is still open. You can treat
now with gas and Avastin. If the subhyaloidal and the sub-ILM haemorrhage do not
resorb, you can remove it with a vitrectomy. Conclusion: Be cautious with a vitrec-
tomy and be generous with intravitreal treatments. See Flow chart 23.1.

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 337


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_23
338 23 Submacular Haemorrhage Secondary to Arterial Macroaneurysm

Flow chart 23.1 Our


Pre-and submacular hemorrhage secondary to
treatment algorithm for
a retinal macroaneurysm
retinal macroaneurysm
Intravitreal rTPA and 20% SF6

1-month later

Submascular hemorrhage Subhyaloidal hemorrhage and


active macroaneurysm

Intravitreal Avastin and gas

1-month later

Subhyaloidal hemorrhage and


closed macroaneurysm

Vitrectomy

Fig. 23.1 Case report 15:


a small preretinal and large
subretinal haemorrhage
secondary to a retinal
macroaneurysm. rTPA and
gas are injected

Case Report No. 15: Retinal Macroaneurysm 1


Figs. 23.1, 23.2, 23.3, 23.4, 23.5, 23.6, 23.7 and 23.8

Video 23.1: Submacular haemorrhage secondary to macroaneurysm

This 93-year-old female patient presented with an acute vision loss of light per-
ception. A fundus examination showed a large pre- and subretinal haemorrhage
with suspicion of a retinal macroaneurysm (Fig. 23.1). Six days later, an intravitreal
rtPA + gas injection was performed. The 1-month follow-up showed a visual acuity
of HM. The fundus examination showed a reduction of the preretinal haemorrhage
23.1 General Introduction 339

Fig. 23.2 Case report 15: 1-month follow-up. A subhyaloidal haemorrhage. A gas injection is
repeated

Fig. 23.3 Case report 15: 1-month follow-up after the second gas injection. No difference.
A vitrectomy is scheduled

and subhyaloidal blood (Fig. 23.2). One day later, a second injection with rtPA +
Avastin + gas was performed. The 1-month follow-up showed a visual acuity of CF
and an unchanged fundus (Fig. 23.3). A vitrectomy was scheduled. At six weeks, a
vitrectomy with peeling was performed. The residual blood was located between
ILM and the retina (Figs. 23.4 and 23.5). After an ILM peeling, this residual blood
could be aspirated (Figs. 23.6 and 23.7). At the 1-month follow-up, the visual acuity
was measured with 0.2. The haemorrhage was resorbed, and macular function was
limited due to a focal pigment epithelium atrophy (Fig. 23.8).
340 23 Submacular Haemorrhage Secondary to Arterial Macroaneurysm

Fig. 23.4 Case report 15:


intraoperative photograph.
The subretinal
haemorrhage is displaced.
Note the preretinal
haemorrhage

Fig. 23.5 Case report 15: an OCT reveals that the subhyaloidal haemorrhage is almost completely
resorbed
23.1 General Introduction 341

Fig. 23.6 Case report 15:


intraoperative photograph:
a preretinal haemorrhage.
Note the ILM defect at 11
o’clock which was created
with a 27G Atkinson
needle

Fig. 23.7 Case report 15:


after ILM peeling and
aspiration of blood the
macula is free
342 23 Submacular Haemorrhage Secondary to Arterial Macroaneurysm

Fig. 23.8 Case report 15: 1-month follow-up. The macula can be visualized with a residual
thickening

Fig. 23.9 Case report 16:


1-month follow-up after
rTPA and gas. OCT:
bullous subhyaloidal
haemorrhage
23.1 General Introduction 343

Case Report No. 16: Retinal Macroaneurysm 2


Figs. 23.9, 23.10, 23.11 and 23.12

Fig. 23.10 Case report 16: 1-month follow-up. OCT: bullous subhyaloidal haemorrhage

Fig. 23.11 Case report 16: 2-month follow-up. OCT: residual haemorrhage. Free macula
344 23 Submacular Haemorrhage Secondary to Arterial Macroaneurysm

Fig. 23.12 Case report 16: 2-month follow-up. OCT: residual subhyaloidal haemorrhage close to
the macula

An 83-year-old male patient visited the outpatient department because of a sud-


den vision loss on the right eye. The visual acuity was measured with 0,02, and a
sub- and preretinal haemorrhage in the macula and a retinal macroaneurysm at the
inferior arcade were detected. The systemic blood pressure was elevated.
In the next day, an intravitreal injection with rtPA and 0,4 ml 20 % SF6 was
performed.
The 1-month follow-up showed a VA = CF and a bullous subhyaloidal haemor-
rhage. The retinal macroaneurysm was still bleeding (Figs. 23.9 and 23.10).
Four days later, an intravitreal injection of 0,2 ml Avastin and 0,4 ml 20 % SF6
was performed.
The 1-month follow-up showed a VA of 0,1, and a residual subhyaloidal haemor-
rhage temporal to the macula was detected. This haemorrhage was in contact with
the retinal macroaneurysm. The fovea showed a thin bleeding (Figs. 23.11 and
23.12).
Suprachoroidal Haemorrhage
24

Contents
24.1 General Introduction ..................................................................................................... 345
24.2 Instruments.................................................................................................................... 346
24.3 Tamponade .................................................................................................................... 347
24.4 The Surgery Step By Step ............................................................................................. 347
24.5 Complications ............................................................................................................... 352
24.6 FAQ ............................................................................................................................... 352

24.1 General Introduction

Video 24.1: Endophthalmitis and subchoroidal haemorrhage


Video 24.2: Open globe
Video 24.3: Globe rupture

The expulsive haemorrhage is a haemorrhage in the suprachoroidal space (Fig. 24.1).


Sometimes the term “suprachoroidal” is used synonymously to “subchoroidal”. As a
basic rule, these haemorrhages are removed from the scleral side, and not transretinal.
A choroidal detachment may have different causes. (1) It may arise after a cyclode-
structive surgery with hypotony and choroidal detachment. In this case, the subchoroi-
dal fluid consists of a transparent fluid. If you remove the fluid and inject silicone oil,
you may lift the pressure to a normotensive level of 6–8 mmHg. (2) A different cause
is a trauma with an open globe injury and suprachoroidal haemorrhage. (3) Another
common cause is an intra- or postoperative suprachoroidal haemorrhage, for example,
during a complicated cataract surgery or glaucoma surgery.

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U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_24
346 24 Suprachoroidal Haemorrhage

Fig. 24.1 Anatomy of a Sclera


suprachoroidal
haemorrhage Hemorrhage in the suprachoroidal space

Choroid

Retina

Vitreous

Wait about 1–2 weeks with the vitrectomy until the blood liquefies; always moni-
tor for a retinal detachment that may develop which should be treated immediately.
The surgery should be performed under general anaesthesia. Preoperative ultra-
sound is necessary to determine the shape and location of the choroidal haemor-
rhage. You have to perform a sclerotomy in the area of the highest choroidal
detachment. We describe the surgical procedure of a suprachoroidal haemorrhage
without expulsion of intraocular tissue.

Caution It is highly recommended to use long trocars because the pars plana epi-
thelium is detached. A detached pars plana epithelium will result in subepithelial-
located trocars, subepithelial flow of the infusion and a choroidal detachment. Until
now only 6 mm long trocars in 23G (Alcon) are available. If long trocars are avail-
able in 27G, it will be no problem to employ them instead.

24.2 Instruments

1. 23G 3-port trocar system with chandelier light


2. BIOM
3. Anterior chamber maintainer
4. Vitreous cutter
5. 23G trauma trocars (6 mm, Alcon)

You need a retinal detachment set and a PPV set. The anterior chamber main-
tainer is an infusion cannula for the anterior chamber.

Surgical Pearls No. 87


An anterior chamber maintainer can be used for a vitrectomy instead of a
pars plana infusion, if there is sufficient flow between anterior and posterior
chamber, e.g. aphakia. It cannot be used in a phakic eye because there is no
sufficient flow from the anterior to the posterior chamber.
24.4 The Surgery Step By Step 347

24.3 Tamponade

PFCL, 1000 cSt silicone oil

24.4 The Surgery Step By Step

1. Limbal peritomy.
2. Place traction sutures beneath all four rectus muscles.
3. Insert an anterior chamber maintainer.
4. 3 mm sclerotomies between insertion of the muscle and the equator.
5. Drainage of suprachoroidal blood.
6. Insertion of trocars
7. Core vitrectomy.
8. Injection of PFCL.
9. Trimming of vitreous base.
10. Exchange of PFCL against silicone oil.
11. Suture the sclerotomies.

1. Limbal peritomy.
2. Place traction sutures beneath all four rectus muscles.
Perform a 360° peritomy and place traction sutures underneath all horizontal
muscles.
3. Insert an anterior chamber maintainer.
An inferotemporal paracentesis is performed, the anterior chamber main-
tainer is inserted and the infusion line is opened (Fig. 24.2). Now the eyeball
becomes normotensive. An infusion of the anterior chamber works particularly
well when there is a pseudophakia. If the patient is phakic, try to insert the infu-
sion cannula in an area of the pars plana where there is no choroidal detachment
(ultrasound). When in doubt, place a 20G sclerotomy using a long (6 mm) 20G
infusion port. It is of vital importance that the inner opening of the infusion port
is in the vitreous cavity and not in the subretinal/suprachoroidal space.

Surgical Pearls No. 88


Use 6 mm trauma trocars from Alcon (23G). The risk for a subepithelial loca-
tion is low.

4. 3 mm sclerotomies between insertion of the muscle and the equator.


5. Drainage of suprachoroidal blood/fluid.
Before performing a sclerotomy, you should ascertain the location of the SCH
in the eye. You can confirm your ultrasound examination by inspecting the vitre-
ous cavity with a light pipe (Fig. 24.3). Search for the quadrant with the highest
bullous choroidal detachment.
348 24 Suprachoroidal Haemorrhage

Fig. 24.2 Eye with a perforating trauma from a stick. In the first operation, the temporal limbus
was sutured with Ethilon 10-0. The sclera at 5 o’clock was sutured with Vicryl 8-0 from the limbus
to the insertion of the inferior rectus muscle. Prior to the second operation, a 360° suprachoroidal
haemorrhage was detected. Now four traction sutures were placed beneath the four horizontal
muscles. An anterior chamber maintainer was inserted to stabilize the eye

Fig. 24.3 Due to the


choroidal detachment, it is
really difficult to place
trocar cannulas. With the
help of a light pipe, which
is inserted through a
paracentesis, the situation
in the posterior segment is
explored

The sclerotomy should be 3–4 mm mm in length and extend in a radial direc-


tion (Fig. 24.4). Concerning the location of these sclerotomies, there are differ-
ent preferences. Some surgeons perform the sclerotomies 4 mm posterior the
limbus, other place the sclerotomies equatorial, since there is more suprachoroi-
dal blood. We place the sclerotomies between the insertion of the muscle and
the equator. For example, if a temporal and nasal choroidal detachment is pres-
ent, you should perform a temporal and nasal sclerotomy. Once the sclerotomy
is performed, liquefied blood (Fig. 24.5) and blood clots (Fig. 24.6) will flow
out the sclerotomy.
24.4 The Surgery Step By Step 349

Fig. 24.4 A 3 mm
sclerotomy is performed
between the insertion of
the straight eye muscle and
the equator

Fig. 24.5 Liquefied blood


flows out of the second
sclerotomy on the other
side of the globe. Extract
blood clots by compressing
the globe with a forceps or
cotton swabs

Fig. 24.6 If no blood


clots can be pressed out,
then enlarge the
sclerotomy to a 4 mm
incision. If the sclerotomy
is too small, you cannot
extract thicker blood clots.
This sclerotomy needs to
be sutured with 1–2 Vicryl
8-0 cross sutures
350 24 Suprachoroidal Haemorrhage

If only liquefied blood flows out and no clots, you should gently massage the
eyeball with two cotton swabs or a squint hook in the direction of the scleroto-
mies and enlarge the sclerotomy to 4 mm. With this technique you can often
extract larger blood clots.
Depending on the intraocular pressure, the sclerotomies may or may not be
sutured at the end of the surgery. We suture 4 mm sclerotomies and sometimes
3 mm sclerotomies.

Surgical Pearls No. 89


Difficult removal of suprachoroidal blood: If only little blood can be extracted
although a highly bullous choroidal detachment persists, then you should
enlarge the sclerotomies to 4 mm. The reason is that the subchoroidal blood is
clotted and cannot be extracted through 3 mm large sclerotomies.

6. Insertion of trocars.
When no more blood flows out of the sclerotomy, you should try to insert
the trocars at pars plana if you have not done this before. Due to the detach-
ment of the pars plana epithelium, this is a difficult procedure. Choose an area
with little choroidal detachment and select a long infusion cannula (see
above). We use 6 mm long trauma trocars from Alcon. Check if the trocar is
located in the vitreous cavity. Remove the anterior chamber maintainer and
insert a pars plana infusion line. Then insert a second trocar opposite to the
infusion cannula. If the trocar cannula is not in the vitreous cavity, it can be
freed from the surrounding tissue with a membrane pic from the opposite
trocar cannula. The same procedure can now be performed with the second
trocar cannula.

Surgical Pearls No. 90


Subepithelial location of trocars: Especially in the eyes with choroidal haem-
orrhage, an initially correctly placed trocar cannula may move subepithelially
during a later stage of the operation. Double-check the trocars several times
during surgery.

7. Core vitrectomy.
8. Injection of PFCL.
If the choroidal detachment has regressed, a vitrectomy can be performed.
You may need to insert a chandelier light (Fig. 24.7). Then PFCL is injected,
which pushes the residual suprachoroidal blood through the sclerotomies out-
side. You should now check the sclerotomies (flick the BIOM out and rotate the
globe with the traction sutures). If little or no blood flows out in an area with a
high choroidal detachment, try to expel blood clots with a forceps or cotton
swabs.
24.4 The Surgery Step By Step 351

Fig. 24.7 A small space


for insertion of the trocars
was found at 12 o’clock.
The chandelier light is
placed in one of the trocar
cannulas

Fig. 24.8 Inject PFCL to


flatten the retina and to
extract more blood through
the sclerotomies. Finally
PFCL is exchanged against
silicone oil

Surgical Pearls No. 91


Chandelier light: It is advisable to use a trocar-based chandelier light. Insert a
6 mm trauma trocar and then the light fibre (e.g. DORC).

9. Trimming of vitreous base.


Perform a thorough trimming of the vitreous base in trauma patients, in par-
ticular the anterior part of the vitreous base which extends over the ciliary body.
Otherwise the eye will develop cyclitic membranes which form on the ciliary
body and result in a hypotony.
10. Exchange of PFCL against silicone oil.
11. Suture the sclerotomies.
If there is only a minor residual choroidal detachment, perform a PFCL–
silicone oil exchange. The silicone oil is injected through the infusion cannula
(Fig. 24.8). Suture the sclerotomies with a Vicryl 8-0 stitch.
352 24 Suprachoroidal Haemorrhage

Follow-Up
A silicone oil removal can be performed after approximately 3–6 months if the eye
pressure is normal and the choroidals have completely vanished.

24.5 Complications

Injury of the choroid and retina when performing the scleral sclerotomy. If you
ascertain yourself about the correct position of the choroidal detachment, then this
incidence is quite unlikely.

24.6 FAQ

A patient underwent a complicated cataract surgery with dry vitrectomy.


Postoperative the IOL is 3–4 mmHg and a bullous choroidal detachment is
present. What to do?
The main problem is the hypotony. If there are no kissing choroids present you can
inject triamcinolone intravitreally, which may increase IOP. If there are kissing cho-
roids you have to operate. An operation is the same (but easier) as in suprachoroidal
hemorrhage. In short: Limbal peritomy, insert an anterior chamber maintainer, one
small sclerotomy on the equator at the site of the bullous detachment, drainage of
fluid, then vitrectomy, then injection of PFCL and then PFCL x silicone oil exchange.

The same patient as described above. In addition a rhegmatogenous retinal


detachment is present.
A rhegmatogenous retinal detachment is another clear indication to operate at once.
The same procedure as described above. After vitrectomy the retinal holes should
be marked and then laser treated.

Do you need to remove the complete suprachoroidal haemorrhage?


No. A residual suprachoroidal haemorrhage will resorb on its own within
1–2 months.

Will an underfill of silicone oil occur when the choroidals are flat?
Yes. An underfill of 30–40 % may occur. But this does not matter.

Surgical Pearls No. 92


A hypotony is present if the IOP <6 mmHg. If a silicone oil-filled eye has an
IOP <6 mmHg, you cannot remove the silicone oil because the eye would fall
into a hypotony and finally into a phthisis bulbi.
24.6 FAQ 353

Surgical Pearls No. 93


Cyclitic membranes: If the vitreous base is not removed during vitrectomy
and silicone oil used as a tamponade, then the silicone oil will press the vitre-
ous base against the ciliary body resulting in cyclitic membranes and hypot-
ony. It is almost impossible to remove these membranes. It is therefore
essential to prevent them. This can be done by trimming thoroughly the vitre-
ous base.
Part VI
Ocular Trauma
Penetrating Eye Injury by Metal
Intraocular Foreign Bodies (IOFB); 25
Delayed, Stepwise Surgery

Contents
25.1 General Introduction ..................................................................................................... 357
25.2 Instruments.................................................................................................................... 364
25.3 Tamponade .................................................................................................................... 364
25.4 The Surgery Step By Step ............................................................................................. 365
25.4.1 The Surgery Step By Step 370
25.5 IOFB Extraction, Immediate Surgery ........................................................................... 374
25.5.1 Instruments 375
25.5.2 Tamponade 375
25.5.3 The Surgery Step By Step 375
25.5.4 Complications 378
25.5.5 FAQ 378

25.1 General Introduction

Video 25.1: IOFB case 1—stepwise surgery


Video 25.2: IOFB case 2
Video 25.3: IOFB case 3

Penetrating eye injuries should be treated by experienced surgeons. These cases


are associated with a high complication rate and a guarded prognosis, and the initial
surgical intervention is of vital importance. There has been a long debate about the
timing and the extent of the initial surgical intervention.
We prefer a stepwise approach. See Flow chart 25.1. The first step is the primary
closure of the wound (cornea or sclera). We do not remove an opacified cataract in

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com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 357


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_25
358 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Perforation with metal foreign body

ACUTE
Figs. 25.15-25.16
Closure of corneal
wound

2 weeks after trauma PVD


Figs. 25.17-25.25
Phaco and IOL

4 weeks after trauma

Figs. 25.26-25.36
Vitrectomy + extraction of
foreign body

Flow chart 25.1 Our treatment algorithm for stepwise IOFB surgery. After 4 weeks, a PVD
is present, the eye is quiet and the PVR risk is low when extracting the IOFB. If the retina is
detached, we operate at once

Fig. 25.1 This metal


foreign body flew from the
blade of a lawn mower into
the eye of this male
patient, impacted superior
to the macula and is now
located in the inferior part
of the vitreous. VA = 1.0

the same session. If there is suspicion of a nonsterile penetration, we inject intravit-


real antibiotics. We treat the patient then for 10 days with intravenous antibiotics
(1,5 g Zinacef® three times daily). We examine the posterior segment with ultra-
sound. If the retina is attached, we continue to wait; if the retina is detached, we
operate immediately. After approximately 2 weeks, we perform a cataract surgery
25.1 General Introduction 359

Fig. 25.2 Note the impact


site superior to the macula.
The photograph is taken
1 day after the injury

Fig. 25.3 This photograph is


taken 11 days after the injury.
The retinal swelling is reduced

and implant an IOL. In many cases, the lens capsule is injured. We try to implant the
IOL into the bag or into a stable sulcus position. Then approximately 2 weeks after
phacoemulsification, we perform vitrectomy with foreign body extraction.
Vitrectomy is easy because a PVD is present and the retinal wound has healed. The
risk of bleeding from the retinal/choroidal wound is much less, and the risk of PVR
from the wound edges is highly reduced.
We do not prefer the immediate surgery because (1) the experienced retinal
team is often not present when the trauma case arrives at the clinic, (2) a PVD is
not present, and (3) if retinal wounds are present and if the foreign body sticks in
the retina, then immediate extraction will cause bleeding from the exit wound
and result in PVR from the wound edges. Four weeks of waiting will quieten the
retinal wound, and the foreign body can be extracted without bleeding or PVR
from the wound edges (Figs. 25.1, 25.2, 25.3, 25.4, 25.5, 25.6, 25.7, 25.8, 25.9,
25.10 and 25.11).
360 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.4 An OCT 1 day after injury

Fig. 25.5 An OCT 4 days after injury. A severe swelling of the left side of the impact site can be
observed
25.1 General Introduction 361

Fig. 25.6 An OCT 11 days after injury. The swelling is reduced

Fig. 25.7 An OCT 20 days after injury. The swelling is almost not noticeable
362 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.8 An OCT 1 day after injury. A section through the impact site

Fig. 25.9 An OCT 4 days after injury. A severe swelling of the inner retina can be observed

We prefer to perform phacoemulsification and vitrectomy at different time points


because the posterior capsule is often damaged. Vitrectomy worsens therefore the
result of the phacoemulsification if both are performed at the same time points. If
phacoemulsification and vitrectomy are performed at the same time, then the exten-
sive vitrectomy with gas tamponade will tamper with the IOL. The gas may luxate
the IOL into the anterior chamber, the vitrectomy may cause posterior synechiae
and so on.
25.1 General Introduction 363

Fig. 25.10 An OCT 11 days after injury. The swelling is reduced

Fig. 25.11 An OCT 20 days after injury. A retinal defect remains

Surgical Pearls No. 94


Avoid operating an inflamed or vascularly active eye. If the retina is attached,
wait and treat the inflammation and vascularization; use steroids and anti-
VEGF. If the retina is detached, you have to operate.
364 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

25.2 Instruments

1. 27G trocars with chandelier illumination


2. Endomagnet OR
3. Diamond dust-coated foreign body forceps
4. Laser probe

Foreign Body Forceps


The foreign body forceps are executed by a 20G sclerotomy (without trocar) in the
eye. Available are 17G, 19G and 20G foreign body forceps. The sclerotomy must of
course be enlarged if necessary. I recommend forceps with a roughened surface grip
(diamond dusted) (Fig. 25.12a, b).

Endomagnet
Indication: Extraction of a metal foreign body. Synergetics, USA

25.3 Tamponade

Intraoperative: Maybe PFCL


Postoperatively: Air, SF6

Fig. 25.12 (a) An Avci


foreign body forceps.
Available in 17G and
20G. DORC. 2286.I. (b)
The tip of the foreign body
forceps
25.4 The Surgery Step By Step 365

25.4 The Surgery Step By Step (Figs. 25.13, 25.14, 25.15, 25.16,
25.17, 25.18, 25.19, 25.20, 25.21, 25.22, 25.23, 25.24,
and 25.25)
1. 27G 3-port system with chandelier light.
2. Vitrectomy, PVD.
3. Exposure of IOFB.
4. Prepare the exit sclerotomy.
5. Extraction of IOFB through sclerotomy.
6. Apply laser at the impact site.
7. Tamponade.

Fig. 25.13 This male


patient was mowing the
lawn

Fig. 25.14 The metal


blade hit a stone and a
metal piece of the blade
perforated his eye

Fig. 25.15 The


perforation is site is
located in the inferior
cornea
366 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.16 In the first


surgery, the corneal
perforation was closed
with a nylon 10-0 suture

Fig. 25.17 Two weeks


later: a phacoemulsification
is planned

Fig. 25.18 Circular


rhexis. The anterior
capsule is stained with
trypan blue
25.4 The Surgery Step By Step 367

Fig. 25.19 The posterior


capsule is defective

Fig. 25.20 The


sclerotomy site is marked
with a scleral marker
(Storz)

Fig. 25.21 A 23G trocar


is inserted. The complete
surgery is performed with
an Infiniti phaco machine
368 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.22 The residual


cortex is removed

Fig. 25.23 An anterior


vitrectomy is performed
25.4 The Surgery Step By Step 369

Fig. 25.24 The three-


piece IOL is placed on the
iris for a safe sulcus
implantation

Fig. 25.25 The IOL is


rotated into the sulcus
(optic in, haptic out). An
air bubble is injected to
stabilize the anterior
chamber and the trocar is
removed
370 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

25.4.1 The Surgery Step By Step: (Figs. 25.26, 25.27, 25.28, 25.29,
25.30, 25.31, 25.32, 25.33, 25.34, 25.35 and 25.36)
Fig. 25.26 Two weeks
after phacoemulsification.
The IOL is centred in an
optic-in and haptic-out
position

Fig. 25.27 View to the


fundus: the IOFB is
located at 10 o’clock

Fig. 25.28 A partial PVD


is present after 4 weeks
25.4 The Surgery Step By Step 371

Fig. 25.29 3-port


vitrectomy with chandelier
light. Now a sclerotomy
for IOFB extraction is
prepared

Fig. 25.30 Sclerotomy


with 20G V-lance (Alcon)

Fig. 25.31 The IOFB sits


in a retinal pocket
372 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.32 Removal


of the foreign body

Fig. 25.33 Closure of the


sclerotomy with a Vicryl
8-0 cross suture

Fig. 25.34 Note the


fibrotic wound edges
25.4 The Surgery Step By Step 373

Fig. 25.35 Laser


treatment around the
impact site

Fig. 25.36 Air


tamponade. No further
surgery was necessary

1. 27G 3-port system with chandelier light.


We insert a chandelier light for bimanual surgery.
2. Vitrectomy, PVD.
It is very important to induce a posterior vitreous detachment; otherwise,
there is an increased risk of PVR (Fig. 25.27). Since a metallic IOFB induces a
posterior vitreous detachment itself due to its toxic effect, some surgeons prefer
to operate a few weeks after the trauma (see above). This procedure applies to
metallic IOFB only. Organic IOFB should be operated immediately, as the endo-
phthalmitis risk is high.
3. Exposure of IOFB.
One has to resist the urge to remove the IOFB as soon as you can see it
(25.29). An extensive vitrectomy should be performed first and in particular
around the IOFB. Only remove the IOFB when no more vitreous is attached or
surrounding it and no vitreous is on the way towards the sclerotomy through
which it will be removed.
374 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

4. Prepare the exit sclerotomy.


Before grasping and extracting the IOFB, decide where the exit sclerotomy is
placed. Remove here the conjunctiva and perform a limbus parallel sclerotomy
(Figs. 25.29 and 25.30). The sclerotomy is as wide as the IOFB.
5. Extraction of IOFB through sclerotomy.
The foreign body can be extracted with the forceps (serrated or diamond
dusted) or the endomagnet. Before extraction of the foreign body, it is advisable
to inject a PFCL bubble to protect the macula. Then enlarge the sclerotomy suf-
ficiently. Insert the forceps through this sclerotomy, grasp the IOFB and extract
it through the sclerotomy. In many cases, a bimanual extraction is necessary. One
forceps (e.g. 27G endgripping forceps, DORC) is inserted through a trocar and
extracts the IOFB from the retina. The IOFB forceps is inserted through the large
sclerotomy, takes over the IOFB from the endgripping forceps and extracts it
through the sclerotomy (Figs. 25.31 and 25.32).
Congratulations! The worst part is done. Take a deep breath and continue with
closing the exit sclerotomy with Vicryl 8-0 cross sutures (Fig. 25.33).
6. Apply laser at the impact site.
Then you have to photocoagulate the retina around the impact site (Figs. 25.34
and 25.35). If the retina is detached in the area of laser treatment, you must first
inject PFCL in order to flatten the retina.
7. Tamponade.
We use in most cases an air tamponade (Fig. 25.36).

25.5 IOFB Extraction, Immediate Surgery

In the following, the surgical procedure is presented if you choose to perform an


immediate surgery. See Flow chart 25.2

Perforation with metal foreign body

ACUTE

# Closure of corneal wound


Flow chart 25.2 Our
procedure in case of # Phaco and IOL
immediate surgery. The # Vitrectomy and PVD
main difference is that a
1 mm retinectomy around # Extraction of IOL
the wound edges followed
# 1mm retinectomy and diathermy
by diathermy of the
of choroid
choroid has to be
performed. In case of # laser treatment
posterior capsular defect,
# tamponade
the IOFB can be extracted
through the cornea
25.5 IOFB Extraction, Immediate Surgery 375

25.5.1 Instruments

1. 27G trocars with chandelier illumination


2. Endomagnet OR
3. Diamond dust-coated foreign body forceps
4. Diathermy
5. Laser probe

25.5.2 Tamponade

Intraoperative: Maybe PFCL


Postoperatively: Gas or 1000 cSt silicone oil

25.5.3 The Surgery Step by Step: Figs. 25.37, 25.38, 25.39,


25.40 and 25.41

1. 27G 3-port system with chandelier light.


2. Vitrectomy.
3. Induction of PVD.
4. Exposure of IOFB.
5. Extraction of IOFB through sclerotomy or cornea.
6. 1 mm retinectomy around the impact site and diathermy of the exposed choroid.
7. Apply laser at the impact site.
8. Tamponade.

Fig. 25.37 Immediate


surgery. A limbal
perforation. The IOFB is
extracted through a corneal
incision
376 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

Fig. 25.38 The IOFB is


parked on the iris

Fig. 25.39 The IOFB is


extracted

1. 3-port system with chandelier light.


We use the 3-port trocar system and insert a chandelier light.
2. Vitrectomy.
3. Induction of PVD.
It is very important to induce a posterior vitreous detachment; otherwise,
there is an increased risk of PVR. As it can be difficult to determine a posterior
vitreous detachment in young eyes, you may use dyes such as triamcinolone or
trypan blue.
4. Exposure of IOFB.
One has to resist the urge to remove the IOFB as soon as you can see it. An
extensive vitrectomy should be performed first and in particular around the
IOFB. Only remove the IOFB when no more vitreous is attached or surrounding
it and no vitreous is on the way towards the sclerotomy through which it will be
removed. If the IOFB is stuck in the choroid and sclera, you may apply laser
around it in order to lower the intraocular haemorrhage that will occur when you
pull the IOFB out of the sclera.
25.5 IOFB Extraction, Immediate Surgery 377

Wound site with


1mm diathermy edge

Fig. 25.40 Immediate surgery: perform a 1 mm wide retinectomy around the impact site

Perforation 1mm
site

Fig. 25.41 And then


cauterize the choroid of the
retinectomized area
378 25 Penetrating Eye Injury by Metal Intraocular Foreign Bodies (IOFB)

5. Extraction of IOFB through sclerotomy or cornea (Figs. 25.37, 25.38 and 25.39).
Before extraction of the IOFB, decide whether to extract the IOFB through
the sclera or the cornea. The latter is possible if a posterior capsular defect is
present. Extract then the IOFB through the main incision. In this case, the IOL is
implanted after extraction of the IOFB.
6. 1 mm retinectomy around the impact site and diathermy of the exposed choroid
(Figs. 25.40 and 25.41).
After successful extraction of the IOFB, a 1 mm retinectomy is performed
around the impact site. You should also cauterize the underlying choroid. This is
thought to reduce the rate of postoperative PVR. First, cauterize the retina 1 mm
distant from the edge of the impact, then cut the retina with the 27G vitreous
cutter at a low cutting rate (about 200 cuts/min). Finally, the underlying choroid
is cauterized with diathermy or laser.
7. Apply laser at the impact site.
After successful retinectomy and cauterization of the choroid, you must pho-
tocoagulate the retina around the impact site. If the retina is detached in the area
of laser treatment, you must first inject PFCL in order to flatten the retina.
8. Postoperative tamponade and posture.

If you perform a vitrectomy immediately after surgery, we would use 1000 cSt
silicone oil as tamponade. This is due to the high risk of developing PVR
postoperatively.

25.5.4 Complications

The possible complications of immediate vitrectomy are:

# Choroidal bleeding from exit wound


# PVR from wound edges
# Anterior segment inflammation with posterior synechiae and dislocation of IOL

25.5.5 FAQ

What about the risk of retinal detachment?


In our experience, the retina is often injured but detaches very seldom. If the retina
is attached, there is no reason for an immediate surgery. And the retina is attached
in most cases. If the retina is detached, immediate surgery is necessary. Assess the
retina once a week with ultrasound.
25.5 IOFB Extraction, Immediate Surgery 379

Is the risk of endophthalmitis not increased if you wait 4 weeks for


vitrectomy?
You reduce of course endophthalmitis risk if you remove the vitreous immediately.
But we had only one case of endophthalmitis in 10 years and the foreign body was
wood. In most cases, the foreign body is metal. Most metals are sterile and do not
cause an endophthalmitis. In case of organic material, the risk for an endophthalmi-
tis is higher. If it is uncertain if the foreign body was dirty, then inject intravitreal
antibiotics when you suture the penetrating wound. The preparation of antibiotics
can be found in the chapter endophthalmitis.

What about the timing of surgery?


The penetrating wound has to be sutured acute. When to extract the foreign body?
Two schools: At once. Our treatment algorithm: As long as the retina is attached, we
wait. And the retina is usually attached after a penetration with a foreign body.
Usually we extract the foreign body after 1 month. Advantages: The eye is quiet, the
posterior hyaloid is usually detached and the impact site is usually very quiet result-
ing in a lower risk of PVR from the wound edges.

Surgical Pearls No. 95


Seidel test after closure of corneal wound: In order to test if the globe is water-
tight, perform a Seidel test. Perform a paracentesis and inject BSS into the
anterior chamber. If the globe is normotensive, you can close the case. If the
globe is hypotensive, you must continue.

Surgical Pearls No. 96


Anterior chamber haemorrhage: A fresh ACH is not easy to remove, because
the fibrin is difficult to aspirate. Inject rtPA at the beginning, wait 1 min and
then the blood can be easily removed.
Case Reports of Penetrating and Blunt
Ocular Trauma 26

Contents
26.1 General Introduction 382
26.2 Surgical Management of a Corneal Perforation 382
26.3 Surgical Management of a Traumatic Cataract 387
26.4 Surgical Management of a Scleral Wound at Pars Plana 392
26.5 Surgical Management of Aphakia and Distorted Pupil 394
26.6 Surgical Management of a Traumatic Mydriasis with Suture Net 397
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris
and IOL Prosthesis 399
26.7.1 Implantation of a Foldable Iris Prosthesis (Human Optics®) 401
26.7.2 Scleral Fixation of a Combo Iris–IOL Prosthesis 405
26.7.3 Implantation of an Iris Prosthesis in the Sulcus 408
26.7.4 Implantation of an Iris Prosthesis in the Lens Capsule 410
26.7.5 Non-foldable Iris–IOL Prosthesis (Ophtec®) 415
26.8 Surgical Management of a Traumatic Mydriasis with Suture (Iridoplasty) 418
26.9 Surgical Management of an Iridodialysis 420
26.10 Surgical Management of a Cyclodialysis 422
26.11 Surgical Management of a Traumatic Retinal Detachment 425

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 381


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_26
382 26 Case Reports of Penetrating and Blunt Ocular Trauma

26.1 General Introduction

The case reports are structured according to the ocular anatomy: They begin with
the cornea and end with the retina.

26.2 Surgical Management of a Corneal Perforation

Case Report No. 17: Corneal Perforation and Large Iris Defect

Video: No video available

Figures 26.1, 26.2, 26.3, 26.4, 26.5, 26.6, 26.7 and 26.8
A 29-year-old male patient who perforated his cornea with a screwdriver during
work. Visual acuity was light perception. In a first surgery, only the cornea was
sutured. The visual acuity was HM and a vitreous haemorrhage was present. The
patient was followed up every week, and in the fourth week, a retinal detachment
was detected with B-scan. A second operation with phacoemulsification and vit-
rectomy + silicone oil was performed. The visual acuity was 0.1 and a silicone oil
removal + IOL reposition was performed 1 month later. During the postoperative
follow-up, the patient complained of severe photophobia and visual acuity was
0.1–0.2. Eight months later, an iris prosthesis with 11 mm diameter was implanted
into the sulcus without sutures. In a follow-up after 6 months, the patient has no
complaints. In a follow-up after 12 months, the patient complains of ocular irrita-
tion and the IOL is partially dislocated. Visual acuity is 0.1–0.2.
In hindsight: I would not do anything else. Due to the retinal detachment,
I had to perform a combined phacoemulsification/vitrectomy. If the retina did
not detach, I would only operate the traumatic cataract and perform a vitrec-
tomy 1 month later. The advantage of this stepwise approach is that it is easier
to achieve a stable IOL position and you avoid posterior synechiae. The ocular
irritation may be caused by the iris prosthesis. I prefer today a 10 mm prosthe-
sis size for sulcus implantation and I use a trephine (Ophtec®, NL).

Fig. 26.1 Case report 17:


a handyman injured his eye
with a screw driver
26.2 Surgical Management of a Corneal Perforation 383

Fig. 26.2 Case report 17:


the superior cornea is
perforated

Fig. 26.3 Case report 17:


4 weeks follow-up. A
continuous suture of the
central cornea was
performed. At the limbus, a
single suture is used.
Continuous sutures are
easier to perform and
watertight

Corneal performation

Single suture

Continuous suture

Fig. 26.4 Case report 17: a drawing for corneal sutures. In the centre: continuous suture. At the
limbus: single suture
384 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.5 Case report 17:


second surgery. 1 month
after first surgery: staining
with trypan blue

Fig. 26.6 Case report 17:


removal of the soft nucleus
with I/A

Fig. 26.7 Case report 17:


implantation of a
three-piece IOL. Note the
large iris defect
26.2 Surgical Management of a Corneal Perforation 385

Case Report No. 18: Corneal Perforation in a Child

Video: No video available

Figures 26.9, 26.10, 26.11, 26.12 and 26.13


A 5-year-old female patient with her friends were jumping on a trampoline
and throwing spruce cones at each other. One spruce cone hit her eye and
caused a corneal perforation.
She was first operated with suturing of the corneal wound with nylon 10-0.
A continuous suture was performed in the centre of the cornea and interrupted
stitches at the limbus. One month later, a phacoemulsification + IOL was per-
formed. The visual acuity in the last follow-up after 2 years was 0.9.
In hindsight: This case went very well. I think that a traumatic cataract is
easier to operate after 1 month because the inflammation has subsided and the
lens capsule is partially fibrotic.

Fig. 26.8 Case report 17:


third surgery—
implantation of a
customized artificial iris
prosthesis (Human Optics)

Fig. 26.9 Case report 18:


corneal perforation of a
5-year-old girl with a
spruce cone
386 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.10 Case report


18: 1 month after first
surgery with continuous
corneal suture. Note that
the corneal wound is
fibrotic

Fig. 26.11 Case report


18: staining of anterior
capsule with trypan blue.
The anterior capsule is
partially defective. Try to
make the rhexis as round
as possible

Fig. 26.12 Case report


18: the posterior capsule is
intact
26.3 Surgical Management of a Traumatic Cataract 387

Fig. 26.13 Case report


18: in the bag implantation
and an air bubble to
stabilize the anterior
chamber. The corneal
suture was removed
1 month later

26.3 Surgical Management of a Traumatic Cataract

Bonus video 26.1a: Lens injury after intravitreal injection

Case Report No. 19: Traumatic Cataract

Video 26.1b: Traumatic cataract

Figures 26.14, 26.15, 26.16, 26.17 and 26.18


A 35 y/o female with repeated trauma to the left eye due to physical abuse since
January 2013. She indicates a gradual loss of vision in that eye, no flash phenome-
non, no sudden deterioration indicated, in the past month totally hazy and no vision,
and no pain. The visual acuity was light perception. A white cataract was operated
with phacoemulsification and IOL. The anterior capsule was very fibrotic and could
only be opened with a needle and intravitreal scissors. In addition a total retinal
detachment was present and operated (see PVR detachment). The visual acuity in
the final follow-up was light perception.
In hindsight: Chronic retinal detachments are surgically very demanding
but functionally not rewarding. The patient should be informed about this.
388 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.14 Case report


19: blunt globe injury
secondary to a fist punch

Fig. 26.15 Case report


19: posterior synechiae and
a white nucleus
26.3 Surgical Management of a Traumatic Cataract 389

Fig. 26.16 Case report


19: very thick and fibrotic
anterior capsule which can
only be opened with a
sharp cannula

Fig. 26.17 Case report


19: a straight intravitreal
scissors is very suitable for
cutting a fibrotic lens
capsule (23G, DORC)
390 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.18 Case report


19: the nucleus is soft and
can be removed with I/A

Fig. 26.19 Case report


20: a blunt ocular trauma
secondary to an ice hockey
puck

Case Report No. 20: Traumatic Cataract

Video: No video available

Figures 26.19, 26.20, 26.21, 26.22 and 26.23


A 70 y/o male patient was hit by a hockey puck against the left eye at the
age of 26 years and was since then visually impaired. He has recently been in
contact with an optician for renewal of the driving license when a lens opacity
in the left eye was discovered. The patient was referred to the local eye clinic
where a star-shaped traumatic cataract was detected. The patient was referred
to us for further surgical intervention. Visual acuity was 0.2–0.3. A star-shaped
cataract and a large inferior zonular lysis were present. A phacoemulsification
with implantation of a capsular tension ring + implantation of a one-piece IOL
was performed. In the final follow-up, a visual acuity of 1.0 was measured.
In hindsight: It is important to implant a capsular tension ring in order to inflate
the lens capsule completely. It is also a good barrier for a vitreous prolapse.
26.3 Surgical Management of a Traumatic Cataract 391

Fig. 26.20 Case report


20: a 44-year-old trauma
with star-shaped cataract
and large inferior zonular
lysis

Fig. 26.21 Case report


20: circular rhexis

Fig. 26.22 Case report


20: early implantation of a
capsular tension ring
392 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.23 Case report


20: in the bag implantation
of a three-piece IOL
(ZCB00 Tecnis)

26.4 Surgical Management of a Scleral Wound at Pars Plana

Case Report No. 21: Scleral Wound at Pars Plana Secondary to IOFB

Video: No video available

Figures 26.24, 26.25 and 26.26


A 19 y/o male patient was mowing the lawn when a foreign body hit his
eye. Visual acuity was 1.0 and a scleral defect at 3 o’clock was discovered. A
limbal peritomy was performed, the distance from the limbus to the scleral
defect was 3.0 mm. A retinal damage was therefore not possible. The scleral
defect was sutured with Vicryl 8-0. The foreign body was extracted 1 month
later. See chapter “IOFB”.

Surgical Pearls No. 97


Measure the distance of the scleral defect from the limbus with a caliper. If
the distance is longer than 4.0 mm, then a retinal defect is likely. Add in this
case a retinal cryopexy.

Surgical Pearls No. 98


If the same scleral defect is located >4 mm behind the limbus, then perform a
(blind) retinal cryopexy around the wound edges and, if you want to be abso-
lutely safe, suture a silicone sponge above the scleral defect.

Surgical Pearls No. 99


Open globe injury: In case of a scleral defect posterior to the pars plana, mea-
sure with the caliper if unclear, and then schedule a vitrectomy 2 weeks after
the primary closure; see Flow chart 26.1.
26.4 Surgical Management of a Scleral Wound at Pars Plana 393

Fig. 26.24 Case report


21: again an ocular
perforation when mowing
the lawn

Fig. 26.25 Case report


21: note the scleral
perforation at pars plana
(arrow)

Fig. 26.26 Case report


21: limbal peritomy and
Vicryl 8-0 cross suture on
scleral defect. Caution:
measure the location of the
scleral defect with the
caliper
394 26 Case Reports of Penetrating and Blunt Ocular Trauma

Flow chart 26.1 Our


treatment algorithm for
Open globe rupture
open globe injuries (posterior to pars plana)

ACUTE

Closure of rupture

2 weeks later

Vitrectomy

26.5 Surgical Management of Aphakia and Distorted Pupil

Case Report No. 22: Aphakia and Distorted Pupil

Video 26.2: Iridoplasty and iris-claw IOL

Figures 26.27, 26.28, 26.29, 26.30, 26.31 and 26.32


A 52 y/o male patient who experienced with the age of 17 years an open
globe trauma to the left eye. He was operated with lens extraction and cryo-
pexy. After surgery the pupil was distorted to 12 o’clock. He tried contact
lenses for some time but did not tolerate them.
The eye is aphakic since 35 years and has an exotropia. The preoperative
visual acuity was 0.1 without glasses and + 8.0sph = 0.6. The patient was
admitted to us for a secondary IOL implantation. He was clearly informed
that double vision may occur postoperatively. He was operated with irido-
plasty, implantation of Verisyse IOL and creation of an artificial pupil. The
visual acuity at second last follow-up was 0.3 and no double vision was
present.
26.5 Surgical Management of Aphakia and Distorted Pupil 395

Fig. 26.27 Case report


22: perforating ocular
injury with a tree branch

Fig. 26.28 Case report


22: old trauma which was
operated with scleral suture
and lens removal

Fig. 26.29 Case report


22: staining of vitreous
prolapse with
triamcinolone
396 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.30 Case report


22: retropupillar
implantation of an
iris-claw IOL (Verisyse®)
and creation of a new pupil
with the vitreous cutter

Fig. 26.31 Case report


22: iridoplasty with
Hattenbach iris instruments
(Geuder, Germany) and an
Onatec suture (Geuder,
Germany)

Fig. 26.32 Case report


22: closure of the iris
defect
26.6 Surgical Management of a Traumatic Mydriasis with Suture Net 397

26.6 Surgical Management of a Traumatic Mydriasis


with Suture Net

Case Report No. 23: Suture Net

Video: No video available

Figures 26.33, 26.34, 26.35, 26.36 and 26.37


A 48-year-old male patient played ice hockey without a helmet just for fun.
He stumbled and his eye was hit 20 cm above the ice by a hockey puck. He was
admitted to us with a visual acuity of light perception. A scleral perforation at
the limbus was sutured and 2 weeks later a vitrectomy was performed. The
dislocated nucleus was removed with the vitrector. The vitreous body was still
attached to the retina and also removed. A massive subretinal haemorrhage at
the posterior pole was not removed. Due to the traumatic mydriasis, there was
no natural barrier present to prevent the silicone oil to enter the anterior cham-
ber. Therefore, a suture net with Ethilon 10-0 suture was applied. 5000 cSt sili-
cone oil was used and should be preferred up to 1000 cSt silicone oil.
In the follow-up, the suture net functioned well; there was no silicone oil
in the anterior chamber. After 3 months, the suture net had to be revised
because fibrin distorted the net. After removal of the fibrin, the net regained
its regular pattern.

Fig. 26.33 Case report


23: this patient was playing
ice hockey without
protection when his eye
was hit by the puck
398 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.34 Case report


23: a large scleral defect,
dislocated nucleus and
severe retinal injury

Fig. 26.35 Case report


23: after removal of the
attached vitreous, the nasal
retina could be reattached;
the temporal retina was
however severely damaged
and difficult to distinguish
from the choroid

Fig. 26.36 Case report


23: a suture net with
polypropylene 10-0 and a
straight needle was applied
to prevent a prolapse of the
silicone oil into the
anterior chamber
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 399

3.
6.
2.

8. 7.

9. 10.

12. 11.

13.=knot.
1. 5.
4.

Fig. 26.37 Case report 23: a drawing of the suture. Start with 1 and end with 12; number 13 is the
knot. One continuous suture

26.7 Surgical Management of a Traumatic Aniridia


and Aphakia with Iris and IOL Prosthesis

Figures 26.38 and 26.39


Eyes with mydriasis, aniridia and aphakia secondary to trauma can be provided
with an iris prosthesis and an IOL prosthesis. The company Human Optics produces
a foldable iris prosthesis, which is hand-painted. The companies Morcher and
Ophtec produce iris and IOL prostheses. Morcher offers hand-painted iris prosthesis
and Ophtec offers a range of four colours. Both prostheses from Morcher and
Ophtec are PMMA and not foldable. The Morcher and Ophtec iris and IOL prosthe-
ses require a 9.0 mm broad main incision.
The iris prosthesis from Human Optics can be implanted with an IOL injector
into the sulcus. For aniridia and aphakia, the iris prosthesis from Human Optics can
be combined with a three-piece IOL: The iris prosthesis is fixated into the haptics of
a three-piece IOL (MA60AC, Alcon). I call this a combo iris and IOL prosthesis. It
is implanted through a 2.4 mm main incision with an IOL injector (Alcon).
400 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.38 An IOL–iris


prosthesis from Ophtec,
Netherlands. The diameter
is 9 mm. A large incision is
therefore required. The
colour of the prosthesis
turns out brighter when
inserted in the eye. We use
only the brown iris. The
prize is approximately 500
Euros

Fig. 26.39 A hand-


painted and foldable iris
(without IOL) prosthesis
from Human Optics,
Germany. The diameter is
12 mm. The prize is
approximately 2000 Euros

There are several important features which determine the surgical planning:

1. (Partial) aniridia
2. Traumatic mydriasis
3. Aphakia
4. Intact lens capsule

Our surgical management is as follows:

1. (Partial) Aniridia = > foldable iris prosthesis (Human Optics®)


2a. Old traumatic mydriasis = > foldable iris prosthesis (Human Optics®)
2b. Recent traumatic mydriasis = > iridoplasty with iris instruments (Geuder®,
Germany)
3. Aniridia and aphakia: = > combo iris and IOL prosthesis (Human Optics
iris + three-piece IOL, Alcon)
4. Aniridia and intact lens capsule = > combo iris and IOL prosthesis
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 401

5. Traumatic mydriasis and aphakia = > iridoplasty and iris-claw IOL


6. Traumatic mydriasis and intact lens capsule = > iridoplasty and phacoemulsifi-
cation + IOL OR combo iris and IOL prosthesis in the bag

Implantation Site

The Optec IOL can be implanted in the bag and be scleral fixated with 10-0 poly-
propylene suture.
The artificial iris (Human Optics) can be implanted into the lens capsule or in the
sulcus. The combo IOL–iris prosthesis can be implanted in the bag and be scleral
fixated with 10-0 polypropylene suture. An alternative is a Scharioth intrascleral
fixation with the three-piece IOL.

Prosthesis size for human optic iris prosthesis

Sulcus implantation: 10.0–11.0 mm


In the bag implantation: 9.0–9.5 mm

26.7.1 Implantation of a Foldable Iris Prosthesis (Human Optics®)

Video 26.3: Combo IOL–iris prosthesis (long version)

26.7.1.1 Instruments
1. 10 mm corneal trephine (Ophtec)
2. 23G or 25G endgripping forceps
3. IOL injector

26.7.1.2 Material
Iris prosthesis (Human Optics)
MA60AC IOL (Alcon)

26.7.1.3 Individual Steps


1. Preparation of an iris–IOL prosthesis
2. Insertion of an iris–IOL prosthesis into a cartridge
3. Implantation of an iris–IOL prosthesis
4. Fixation of iris prosthesis

The Surgery Step by Step: Figs. 26.40, 26.41, 26.42, 26.43, 26.44, 26.45, 26.46
and 26.47
1. Preparation of an iris–IOL prosthesis
The size of the iris prosthesis depends on its implantation either in the sulcus
or in the capsular bag. In case of a capsular bag implantation, we use a 9.0 mm
corneal trephine. In case of a sulcus implantation, we use a 10.0 mm corneal
trephine (Fig. 26.42). Place the three-piece IOL on the backside of the foldable
iris and place two incisions at each haptic with a 15 degree knife (Alcon). Tunnel
the 25G endgripping forceps through the two incisions, grab an end of a haptic
402 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.40 A bilateral corneal perforation secondary to an exploding gas truck resulting in bilat-
eral corneal perforation, aphakia, iris defect and PVR detachment. Case report 24

Fig. 26.41 Now: aphakia


and iris defect. Case
report 24

and pull the haptic through the incisions (Figs. 26.43 and 26.44). Repeat the
manoeuvre with the other haptic.
2. Insertion of and iris–IOL prosthesis into a cartridge
3. Implantation of an iris–IOL prosthesis
Fold or roll the combo prosthesis and insert it into an IOL cartridge (Alcon)
and finally into an injector. Continue with a 2.4 mm main incision and implant
then the combo iris prosthesis into the anterior chamber (Fig. 26.45).
4. Fixation of iris prosthesis
Rotate the combo iris–IOL prosthesis into the lens capsule. If a lens capsule is not present,
a scleral fixation has to be performed: (1) intrascleral Scharioth method or (2) scleral
fixation with sutures (Figs. 26.46 and 26.47). For details read the book Complications
During and After Cataract Surgery from Ulrich Spandau and Gabor Scharioth.
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 403

Fig. 26.42 Cutting the


foldable iris with a 10 mm
trephine (Ophtec). Case
report 24

Fig. 26.43 A MA60AC


IOL and the iris prosthesis.
Case report 24

Fig. 26.44 The haptics of


the IOL are inserted into
the iris. Case report 24
404 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.45 The combo


iris–IOL prosthesis is
inserted with an IOL
injector (Alcon). Case
report 24

Fig. 26.46 The haptic is


grasped inside the anterior
chamber and externalized
through the sclerotomy.
Case report 24

Fig. 26.47 The iris–IOL


prosthesis is fixated with
scleral sutures. An
alternative is a sutureless
intrascleral implantation
(Scharioth technique).
Case report 24
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 405

26.7.2 Scleral Fixation of a Combo Iris–IOL Prosthesis

Case Report No. 24: Traumatic Mydriasis and Aphakia

Video 26.4: Foldable iris and IOL prostheses (very short version)

Figures 26.40, 26.41, 26.42, 26.43, 26.44, 26.45, 26.46 and 26.47
A 29-year-old patient who was wounded in his face after the explosion of a
gas cylinder of a gas truck. The patient was surgically assessed at the local hos-
pital. CT scan was done and showed no brain damage, no skull fracture and no
foreign bodies in the orbit. It showed a deformed right globe and signs of perfo-
ration on the left globe. It also showed pronounced damage to the soft tissue of
the face. He had healthy eyes before the injury and the sight was 1.0 in both eyes.
The patient was admitted to us for acute surgery. The preoperative assess-
ment showed a bilateral perforated cornea (left more advanced than right).
But the retina on the right eye was more affected than on the left eye. Visual
acuity was light perception in both eyes. Both eyes were first operated with
suturing of the corneal perforation.
In the last follow-up, the left eye has an opacified cornea and a slight
nuclear sclerosis. Visual acuity was 0.4.
The retina in the right eye detached after 1 week and was operated with a
vitrectomy and 1 month later with fixation of an iridodialysis. Three months
after the retinal detachment, the silicone oil was removed. One month later
and finally, an implantation of a combo iris and IOL prosthesis due to aphakia
and traumatic mydriasis was performed. The visual acuity in the last follow-
up was 0.4 in the left eye.

Surgical Pearls No. 100


I think that the implantation of a foldable iris prosthesis and a combo iris–IOL
prosthesis with an IOL injector is the method of choice because it is easy and
because the main incision is only 2.4 mm wide.

Surgical Pearls No. 101


The ultimate surgery would be to fasten the IOL–iris prosthesis with the
Scharioth method.

Case Report No. 25: Traumatic Mydriasis and Aphakia

Video: No video available

Figures 26.48, 26.49, 26.50, 26.51, 26.52 and 26.53


406 26 Case Reports of Penetrating and Blunt Ocular Trauma

This 44-year-old female patient was on vacation in South Africa. She was
resting in a pool chair at the hotel pool and reading in her iPad. The iPad slipped
and hit her eye causing a rupture of the globe. The scleral rupture at the limbus
was sutured and the patient was admitted to us for surgical management.
Visual acuity was LP and a vitreous haemorrhage was present. A vitrectomy
with laser treatment of retinal tears was performed. In a 3-week follow-up, the
visual acuity was measured with +10.0sph = 0.3–0.4. Four months later, in a
second surgery, a combo customized iris with three-piece IOL was implanted
with an IOL forceps and subsequently fixated to the sclera with suturing.
In a 4-month follow-up, visual acuity was measured 0.3 without glasses
and with optimal refraction +0.75/−3.5/105 = 0.65. The patient was not both-
ered by the astigmatism because the eye was amblyopic and visual acuity was
similar before the trauma.
In hindsight: The next time I would insert the combo iris–IOL prosthesis
with an IOL injector through a 2.4 mm main incision. I developed this tech-
nique after this surgery.

Fig. 26.48 Case report


25: bulb rupture secondary
to a falling iPad at the
hotel pool

Fig. 26.49 Case report 25: right eye with traumatic mydriasis and aphakia. The left eye is healthy
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 407

Fig. 26.50 Case report


25: preoperative status.
Maximal traumatic
mydriasis and aphakia

Fig. 26.51 Case report


25: the haptics of an
MA60AC IOL (Alcon)
were inserted into the iris
tissue of the Human Optics
iris prosthesis

Fig. 26.52 Case report


25: the combo IOL–iris
prosthesis is foldable
408 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.53 Case report


25: after insertion and
scleral fixation of the iris
prosthesis

Fig. 26.54 Case report


26: an iris defect secondary
to phacoemulsification

26.7.3 Implantation of an Iris Prosthesis in the Sulcus

Case Report No. 26: Iris Defect

Video 26.5: Extraction and reimplantation of iris prosthesis

Figures 26.54, 26.55, 26.56, 26.57, 26.58 and 26.59


A 78-year-old male patient underwent a complicated phacoemulsification
with a large iris defect. He was admitted to us for surgical management of the iris
defect. Visual acuity was 0.6 and the patient’s eye was very light sensitive. A
customized iris prosthesis (11 mm diameter) was implanted into the sulcus. The
postoperative visual acuity was 0.7 and light sensitivity significantly reduced.
Half a year later, the patient was readmitted due to continuous ocular irrita-
tion. In a second surgery, the iris prosthesis was extracted with an intravitreal
forceps, reduced with a trephine to a diameter of 10 mm and reimplanted. The
ocular irritation was immediately improved.
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 409

Fig. 26.55 Case report


26: the patient was irritated
by an increased light
sensitivity

Fig. 26.56 Case report


26: preoperative status

Fig. 26.57 Case report


26: the hand-painted iris
prosthesis
410 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.58 Case report


26: a 11.0 mm-sized iris
prosthesis was implanted
into the sulcus

Fig. 26.59 Case report


26: postoperative finding.
The patient was satisfied
regarding the decreased
light sensitivity but
complained of a constant
ocular irritation. After
½ year, the prosthesis was
extracted and reduced to a
size of 10.0 mm, and since
then, the eye is without
symptoms

26.7.4 Implantation of an Iris Prosthesis in the Lens Capsule

Case Report No. 27: Traumatic Mydriasis and Cataract

Video 26.6: Old traumatic mydriasis

Figures 26.60, 26.61, 26.62, 26.63, 26.64, 26.65, 26.66, 26.67, 26.68 and 26.69
A 46-year-old man from Turkey. During childhood, the patient was kicked
by a horse and sustained an injury to his right eye. He contacted the university
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 411

clinic in 1985, and it was deemed that no action is indicated. He was admitted
to us due to photophobia and implantation of an iris prosthesis. The visual
acuity was 0.1 and the eye was very light sensitive. He was wearing continu-
ously sunglasses. The eye presented with a large pupil and an opacified lens
with extensive zonular lysis.
The eye was operated with phacoemulsification + implantation of a capsu-
lar tension ring + three-piece IOL. The iris prosthesis could only partially be
implanted into the lens capsule because the lens capsule was so fragile that a
complete zonular lysis was feared.
Two weeks later, the iris prosthesis dislocated from the lens capsule. A
second surgery was performed and the prosthesis was fixated with one nylon
10-0 suture to the sclera at 12 o’clock.
A 3-month follow-up showed a visual acuity of 0.4. The patient is very
satisfied with the increased visual acuity and quite satisfied with the reduced
photophobia so that he wore less his sunglasses.
In hindsight: (1) I considered performing an iridoplasty to create a pupil.
An iris is, however, after such a long time (approximately 30 years) fibrotic
and bleeds strongly when you manipulate it. (2) The next time, I would
implant a combo iris–IOL prosthesis. I developed this technique after having
performed this surgery.

Fig. 26.60 Case report


27: an ocular trauma
secondary to a horse shoe
kick
412 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.61 Case report


27: the trauma happened
almost 30 years ago. The
patient is predominantly
disturbed by photophobia

Fig. 26.62 Case report


27: note the large inferior
zonular lysis

Fig. 26.63 Case report


27: circular rhexis and
implantation of a capsular
tension ring
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 413

Fig. 26.64 Case report


27: the customized iris
prosthesis. The 12 mm size
was reduced with a
trephine to 10 mm

Fig. 26.65 Case report


27: the iris prosthesis was
implanted with an IOL
injector into the lens
capsule

Fig. 26.66 Case report


27: the iris prosthesis could
only partially be inserted
into the lens capsule due to
zonular lysis
414 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.67 Case report


27: 2 weeks later. The iris
prosthesis has dislocated
from the lens capsule

Fig. 26.68 Case report


27: second surgery—
insertion of a 23G trocar
without valve at 6 o’clock.
Fixation of iris prosthesis
with a serrated jaws
forceps at 12 o’clock;
piercing a straight needle
(polypropylene 10-0
suture) through the iris
tissue and through the
sclera 1.5–2 mm behind
the limbus. Same method
as for iridodialysis

Fig. 26.69 Case report


27: final photograph. This
one fixation point kept the
iris stable
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 415

26.7.5 Non-foldable Iris–IOL Prosthesis (Ophtec®)

Case Report No. 28: Traumatic Mydriasis

Video: No video available

Figures 26.70, 26.71, 26.72, 26.73 and 26.74


A 28-year-old male patient was hit in his eye by a plastic hockey ball. He had
recurrent hyphema and vitreous haemorrhage with high intraocular pressure.
The eye had a traumatic mydriasis and a glaucomatous optic disc. Visual acuity
was 0.4. He was operated with phacoemulsification and implantation of a
PMMA iris–IOL prosthesis (Ophtec®, NL). This specific colour was chosen
because the patient has a light blue iris. The advantage of a lens capsule implan-
tation is that a possible irritation of the sulcus and ciliary body can be avoided.
In hindsight: The implantation of an iris–IOL prosthesis into the lens cap-
sule is technically easy, the main advantage is the large 9 mm main incision.
If you want to avoid the main incision, you can insert a foldable combo iris–
IOL prosthesis through a 2.4 mm incision. Another surgical alternative is the
implantation of an IOL into the lens capsule and then an iridoplasty to create
an artificial pupil (see below).

Case Report No. 29: Traumatic Mydriasis and Sulcus Implantation

Figures 26.75, 26.76 and 26.77


No details to these cases are known. The scleral fixation of these IOL’s is
simple because the haptic contains a hole where the suture can be fastened.

Fig. 26.70 Case report 28: blunt ocular trauma secondary to an indoor hockey ball
416 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.71 Case report


28: traumatic mydriasis

Fig. 26.72 Case report


28: implantation of an
iris–IOL prosthesis
(Ophtec) inside the
capsular bag

Fig. 26.73 Case report


28: the main incision is
9 mm large. A surgical
alternative is an iridoplasty
and implantation of a
regular IOL
26.7 Surgical Management of a Traumatic Aniridia and Aphakia with Iris and IOL Prosthesis 417
Fig. 26.74 Case report
28: the colour of the
prosthesis appears much
lighter after implantation.
We prefer therefore a
brown iris for all eyes

Fig. 26.75 Case report


29: aphakia and a large iris
defect. An Ophtec iris–IOL
prosthesis is implanted
with scleral fixation

Fig. 26.76 Case report


29: the suture can be
fixated very easily in the
haptic hole
418 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.77 Case report


29: the prosthesis sits very
stable

26.8 Surgical Management of a Traumatic Mydriasis


with Suture (Iridoplasty)

Case Report No. 30: Dislocated Nucleus and Traumatic Mydriasis

Video 26.7: Iridoplasty for traumatic mydriasis

Figures 26.78, 26.79, 26.80, 26.81 and 26.82


A 66-year-old male patient was hit by a hockey stick in his right eye. In the
local eye clinic, a dislocation of the natural lens was observed. The eye pres-
sure with peaks to 40 mmHg level was treated with acetazolamide tablets. The
patient was admitted to us for surgical management. The preoperative visual
acuity was CF. In the first surgery, the dislocated nucleus was removed and a
vitrectomy performed. In a second surgery, 3 months after the injury, an irido-
plasty with implantation of an iris-claw IOL was performed. For iridoplasty,
instruments from Geuder, Germany, were used. For this iridoplasty I recom-
mend 4 paracenteses: 12 o’clock, 3 o’clock, 6 o’clock, 9 o’clock. With these
paracenteses you reach 360deg of the pupillary margin. The postoperative VA
was 0.8.
In hindsight: An iridoplasty with the instruments from Geuder is techni-
cally quite easy but time-consuming. It is for me the method of choice in such
pathologies. The advantage of an iridoplasty compared to a foldable iris pros-
thesis is the lack of possible ocular irritation.
26.8 Surgical Management of a Traumatic Mydriasis with Suture (Iridoplasty) 419

Fig. 26.78 Case report


30: blunt ocular trauma
from an indoor hockey
stick

Fig. 26.79 Case report


30: maximal traumatic
mydriasis

Fig. 26.80 Case report


30: I am using the
Hattenbach iris instruments
and an Onatec suture with
a tiny needle (both Geuder,
Germany)
420 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.81 Case report


30: perform then a
purse-string suture. The
instruments are easy to
handle

Fig. 26.82 Case report


30: before closing the
purse-string an iris-claw
IOL is implanted. Then the
suture is tied

26.9 Surgical Management of an Iridodialysis

Case Report No. 31: Iridodialysis

Video: No video available

Figures 26.83, 26.84, 26.85, 26.86 and 26.87


A 50-year-old male patient was hit by a plastic ball during a game of indoor
hockey. He was admitted to us for surgical management. An iridodialysis was
present and the lens was dislocated. Visual acuity was measured with 0.05. The
eye was amblyopic and had a VA of maximal 0.3. The patient worked as a den-
tist and was very affected in his daily work. The eye was operated with second-
ary implantation of a three-piece IOL with Scharioth technique and in a second
surgery with iridoplasty. Visual acuity in the final follow-up was 0.1–0.2.
26.9 Surgical Management of an Iridodialysis 421

Fig. 26.83 Case report


31: a blunt ocular trauma
secondary to an indoor
hockey ball

Fig. 26.84 Case report


31: insert a trocar without
valve on the opposite side
of the iridodialysis

Fig. 26.85 Case report


31: insert a straight needle
of a polypropylene 10-0
suture through the trocar
and then insert a 27G
cannula from the other side
422 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.86 Case report


31: then pierce the iris with
the needle and catch the
needle with the 27G
cannula from the other
side. Then repeat the
manoeuvre with the second
polypropylene needle, cut
both needles and make a
knot on the side of the
iridodialysis

Fig. 26.87 Case report


31: a different case. Insert
the trocar without valve on
the other side of the
iridodialysis

26.10 Surgical Management of a Cyclodialysis

Case Report No. 32: Dislocated Nucleus, Traumatic Mydriasis and


Cyclodialysis

Video: 26.8a Explosive trauma (no audio)


Video 26.8b: Explosive trauma_(audio)
Video 26.8c: Cyclodialysis

Figures 26.88, 26.89, 26.90, 26.91, 26.92 and 26.93


26.10 Surgical Management of a Cyclodialysis 423

A 76-year-old male patient worked as an explosive expert and prepared an


underwater explosion in a lake area. The explosive charge exploded, and the
patient was thrown to the ground by the blast and hit by mud cakes straight at
his face and eyes. He was possibly unconscious for a short time but alert,
oriented and stable from the time the emergency services arrived at the scene.
He was first admitted to the Karolinska emergency department and the trauma
CT showed an orbital fracture of the right eye. The patient was also examined
by ophthalmologists from St. Erik’s Eye Hospital who operated him in gen-
eral anaesthesia with removal of mud that had settled subconjunctivally in the
right eye. No surgery was performed in the left eye. In this context, subluxated
lenses were noted in both eyes.
The patient was admitted to our hospital, and in the first surgery, the left
eye was operated with extraction of the dislocated nucleus with fragmatome
and implantation of a Verisyse IOL.
The right eye was very inflamed and B-scan revealed an attached retina.
Surgery was scheduled 1 month later, and the eye was followed-up every
week with B-scan to exclude a retinal detachment. First the luxated nucleus
was extracted with SICS (modified ECCE) technique, when a cyclodialysis
was discovered. I fixated therefore the peripheral iris against the sclera, but
this did not improve the situation significantly. I decided then to reattach the
cyclodialysis with a silicone oil tamponade. A silicone oil tamponade implied
an iridoplasty and an implantation of a Verisyse IOL in order to prevent sili-
cone oil to enter the anterior chamber. The iridoplasty was performed with the
Hattenbach iris instruments from Geuder, Germany, and a special suture with
a small needle (Onatec, Geuder). During the follow-up, the IOP was mea-
sured with 7 mmHg and 6 mmHg. I decided therefore to reoperate the cyclo-
dialysis similar to an iridodialysis surgery. The follow-up pressure was located
between 10 mmHg and 14 mmHg in a silicone oil-filled eye. The silicone oil
was removed, and 2 months after silicone oil removal, the IOP was measured
with 12 mmHg and visual acuity was 0.8.

Fig. 26.88 Case report


32: an explosive expert
with a bilateral blunt
ocular trauma
424 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.89 Case report


32: the first surgery is
scheduled 1 month after
the injury in order to
reduce inflammation.
Disclocated nucleus,
traumatic mydriasis and a
cyclodialysis

Fig. 26.90 Case report


32: first surgery—
extraction of nucleus,
fixation of cyclodialysis,
ppV + silicone oil
tamponade +
iridoplasty + implantation
of Verisyse IOL

Cyclo
dialysis

Fig. 26.91 Case report


32: the cyclodialysis is
present on the temporal
side
26.11 Surgical Management of a Traumatic Retinal Detachment 425

Fig. 26.92 Case report


32: second surgery—
limbal peritomy, marking
of the sclerotomies
1.5−2 mm behind the
limbus. Two sclerotomies
are required for one suture
with two straight needles
(polypropylene 10-0,
Alcon)

Fig. 26.93 Case report


32: insert a trocar without
valve at pars plana
opposite to the
cyclodialysis. Insert a
straight needle through the
trocar, pierce the pars
plana epithelium behind
the iris and catch the
needle with a 27G cannula
from the other side

26.11 Surgical Management of a Traumatic Retinal


Detachment

Case Report No. 33: Globe Rupture, Traumatic Cataract and


Incarcerated Retina with Total Detachment

Video 26.9: Trauma with kick scooter

Figures 26.94, 26.95, 26.96, 26.97, 26.98, 26.99, 26.100, 26.101, 26.102,
26.103, 26.104, 26.105 and 26.106
A 48-year-old male patient drove his kick scooter inside a corridor of a
hospital and Facebooking on his smartphone. He stumbled and fell with his
eye on the handle of the scooter. A CT in the same hospital showed a fracture
of the orbital roof. He was admitted to our hospital for surgery and first oper-
ated by neurosurgery and then by us. A large scleral rupture extended behind
a straight muscle was sutured. The patient had a difficult convalescence
426 26 Case Reports of Penetrating and Blunt Ocular Trauma

because brain water was running through his nose. After 2 weeks, a total reti-
nal detachment was detected, the patient was informed about the poor prog-
nosis and consented into surgery. Visual acuity was measured with minimal
light perception, the nucleus was white and B-scan revealed a total detach-
ment. First, a phacoemulsification was performed, a large zonular lysis
detected and the lens capsule consequently removed. An iris-claw IOL was
implanted. The retina was incarcerated into the scleral wound. The retina was
cut posterior to the wound, and a fibrotic tissue which was surrounding the
complete retina was removed. The retina attached completely with PFCL and
surgery was completed with a 1000 cSt silicone oil tamponade. After 2 months,
PVR membranes developed at the inferior retinal edges. In a second surgery,
the membranes were removed, and the eye is since then stable with a follow-
up of 1 ½ years. The postoperative visual acuity was 0.05 and IOP was
8 mmHg; the patient is even aware that the macula was slightly translocated
and very happy with the visual outcome.
In hindsight: I would never have expected this positive outcome giving a
total detachment and minimal light perception. If you succeed to reattach the
retina, the next long-lasting problem is the low IOP. If the IOP is lower than
6 mmHg, the silicone oil cannot be removed and this is often the case. Trauma
patients are frequent guests in your clinic.

Fig. 26.94 Case report


33: the patient was riding a
kick scooter in a hospital
and Facebooking and fell
on the handle of the
scooter
26.11 Surgical Management of a Traumatic Retinal Detachment 427

Fig. 26.95 Case report


33: the result was a globe
rupture and an incarcerated
retina

Fig. 26.96 Case report


33: note the large zonular
lysis

Fig. 26.97 Case report


33: the nucleus and the
lens capsule are removed
428 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.98 Case report


33: the retina is completely
detached and incarcerated
into the scleral wound

Fig. 26.99 Case report


33: the retina is freed from
the wound

Fig. 26.100 Case report


33: PFCL flattens the
retina
26.11 Surgical Management of a Traumatic Retinal Detachment 429

Fig. 26.101 Case report


33: an iris-claw IOL
(Verisyse) is implanted
behind the pupil

Fig. 26.102 Case report


33: a laser treatment is
performed and 1000 cSt
silicone oil is used as
tamponade

Fig. 26.103 Case report


33: the IOL prevents that
the silicone oil enters the
anterior chamber. Note the
iridectomy at 6 o’clock. It
was performed with the
vitreous cutter
430 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.104 Case report


33: 4-month follow-up.
The retina is attached

Fig. 26.105 Case report


33: 1.5-year follow-up.
The retina is attached

Fig. 26.106 The patient


is happy with visual acuity.
In many trauma cases, the
silicone oil cannot be
removed due to a low IOP
26.11 Surgical Management of a Traumatic Retinal Detachment 431

Case Report No. 34: Corneal Perforation with IOFB, Traumatic


Cataract and Retinal Perforation

Video 26.10a: Intraocular nail—part 1


Video 26.10b: Intraocular nail—part 2

Figures 26.107, 26.108, 26.109, 26.110, 26.111, 26.112, 26.113, 26.114,


26.115, 26.116, 26.117, 26.118, 26.119, 26.120, 26.121 and 26.122
A 24-year-old old male patient was handling a nail pistol during work. At
one moment, he was trying to shoot a nail through a wooden material from
backward with the nail gun aiming towards his face. The nail shot through the
material and penetrated the cornea into his eye. Visual acuity was light
perception.
In the first surgery, the nail was extracted, the corneal wound sutured with
a continuous suture and intravitreal antibiotics injected as an endophthalmitis
prophylaxis. After 1 week, the patient was discharged; there was no sign of an
endophthalmitis. The eye was followed-up weekly with B-scan and the retina
remained attached. After 4 weeks, a second surgery with planned phacoemul-
sification + IOL was performed. An eyelash was extracted from the nucleus.
Due to a large posterior capsular rupture, an anterior vitrectomy was per-
formed, and I decided to continue then with vitrectomy. A retinal defect was
present at the posterior pole, maybe from the eye lash, maybe from the intra-
vitreal injections. The retinal defect was treated with laser. The nail penetrated
the retina at 12 o’clock posterior to the ora serrata. The retina was attached
and the perforation site was treated with cryopexy. Surgery was completed
with an air tamponade. The corneal sutures could be removed after 3 months
when a fibrotic corneal scar was present. The postoperative visual acuity is
0.6.
In hindsight: I would not perform a combined phacoemulsification/vitrec-
tomy. As a result of this, the IOL has a superior iris capture. The vitrectomy
with air tamponade caused posterior synechiae which could be prevented with
a stepwise approach.
432 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.107 Case report


34: ocular perforation
secondary to a nail from a
nail pistol

Fig. 26.108 Case report


34: the nail perforated the
cornea and hit the retina at
12 o’clock

Fig. 26.109 Case report


34: iris retractors were
inserted
26.11 Surgical Management of a Traumatic Retinal Detachment 433

Fig. 26.110 Case report


34: the nail was extracted.
Note the barbed hook
which makes extraction
difficult

Fig. 26.111 Case report


34: the iris hooks were
removed

Fig. 26.112 Case report


34: the corneal wound was
sutured with a continuous
Ethilon 10-0 suture. In
addition, intravitreal
antibiotics were injected
434 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.113 Case report


34: 1 month later. Stable
anterior chamber and
posterior synechiae

Fig. 26.114 Case report


34: insertion of iris hooks

Fig. 26.115 Case report


34: anterior rhexis with
forceps and with 23G
straight scissors (DORC)
26.11 Surgical Management of a Traumatic Retinal Detachment 435

Fig. 26.116 Case report


34: an unknown IOFB was
found inside the nucleus

Fig. 26.117 Case report


34: an eyelash could be
extracted

Fig. 26.118 Case report


34: implantation of a
three-piece IOL into the
sulcus
436 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.119 Case report


34: a retinal perforation at
6 o’clock, maybe from the
eyelash, maybe from the
intravitreal injection

Fig. 26.120 Case report


34: laser treatment around
the impact edges

Fig. 26.121 Case report


34: at 12 o’clock a circular
haemorrhage can be
observed (1 month old).
The retinal damage at 12
o’clock was treated with
cryopexy
26.11 Surgical Management of a Traumatic Retinal Detachment 437

Fig. 26.122 Case report


34: 3-month postoperative.
The corneal sutures are
removed; VA is 0.6

Case Report No. 35: Corneal Perforation, Traumatic Mydriasis,


Dislocated Nucleus and Retinal Detachment

Video 26.10: Trauma with snow blower


Video 26.11: Trauma with snow blower

Figures 26.123 , 26.124 , 26.125 , 26.126 , 26.127, 26.128 , 26.129,


26.130 and 26.131
A 64-year-old male patient was working with his snow blower when a
wheel dislocated from the snow blower and hit the left side of his face causing
several facial fractures and a globe rupture. The corneal and scleral perfora-
tion was sutured. The nucleus dislocated outside the eye. After 10 days a vit-
rectomy was performed. Much intravitreal blood was removed and the retina
without major problems reattached. The main problem was the anterior cham-
ber: Anterior synechiae were present along the corneal suture and a traumatic
mydriasis was present. The anterior synechiae were removed with difficulty
and a polypropylene 10-0 suture net sewn. After 1 year follow-up, the cornea
is a little hazy, the suture net is only partially patent because fibrin distorts the
sutures and a silicone oil bubble is protruding into the anterior chamber but
not touching the cornea. The retina is completely attached. Visual acuity is
HM; the patient is happy with the visual function. IOP is 5 mmHg and the eye
has a beginning phthisis.
In hindsight: I would not do things differently. It is quite surprising that the
retina caused so little problem and that the anterior chamber so many prob-
lems. I considered a few times to revise the suture net, but the silicone oil
bubble is not touching the cornea and the eye is very fragile. This case teaches
us vitreoretinal surgeons how important an intact anterior segment anatomy is
for the outcome of a trauma case.
438 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.123 Case report


35: A globe rupture
secondary to a dislocated
wheel from a snow blower

Fig. 26.124 Case report


35: the corneal and scleral
defects were sutured and
2 weeks later a vitrectomy
is performed. Insertion of
an anterior chamber
maintainer

Fig. 26.125 Case report


35: there is much blood
present in the vitreous
cavity
26.11 Surgical Management of a Traumatic Retinal Detachment 439

Fig. 26.126 Case report


35: now some retina can be
visualized

Fig. 26.127 Case report


35: removal of subretinal
haemorrhage
440 26 Case Reports of Penetrating and Blunt Ocular Trauma

Fig. 26.128 Case report


35: injection of PFCL to
flatten the retina

Fig. 26.129 Case report


35: laser treatment along
the retinectomy edges

Fig. 26.130 Case report


35: suturing of a suture net.
An alternative is a
purse-string suture of the
iris, but the temporal iris
was seriously damaged
26.11 Surgical Management of a Traumatic Retinal Detachment 441

Fig. 26.131 Case report


35: a PFCL against 1000
cSt silicone oil exchange.
During follow-up the retina
remained attached, but the
cornea became quite
opacified and the IOP
remained low
(4–6 mmHg). Visual acuity
was HM inferior and
temporal
Part VII
Miscellaneous
Frequently Asked Questions (FAQ)
27

Question (Q) 1 Gas tamponade in aphakia: How do you keep it out of the AC?
Face down posture? Any other recommendations?

Answer (A) 1 You can inject an air bubble into the anterior chamber and constrict
the pupil with pilocarpine drops. Face down posture for 1 week.

Q 2 Phakic patient with sutured 20G pars plana infusion (inferotemporal quadrant)
that is blocked with ciliary epithelium: How do you clear the tissue covering the tip?
Would you use the cutter or the MVR blade entering from the same side sclerotomy,
i.e. the superotemporal one in order to avoid the lens?

A 2 I use the spatula from the other side. If you work in a phakic eye, it is difficult.
Question: Why is the trocar covered by epithelium? Choroidal detachment? Did the
infusion trocar go out under the operation and you got a choroidal detachment? If
the latter is the case, I recommend following trick: Remove the infusion trocar,
replace the infusion to an instrument trocar, increase the infusion, take a trauma
trocar from Alcon (23G, 6 mm long) and use this as a new infusion trocar, and set
the infusion back. You will have no problems with the epithelium.

Q 3 During removal of the last trocar in a gas-filled eye, the eye becomes extremely
decompressed and soft. A suture is placed to the sclerotomy and the eye is filled
again with gas through a 30G needle. Any useful tips?

A 3 You will not have this problem with 25G and not all with 27G. You have this
problem with 23G. And the reason is the bigger sclerotomy. It is therefore impor-
tant to insert the trocar in a 15° angle before operation. After operation compress

Electronic supplementary material for this chapter is accessible online at http://extras.springer.


com/ by searching via the ISBN.

© Springer International Publishing Switzerland 2015 445


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_27
446 27 Frequently Asked Questions (FAQ)

the sclerotomy with an anatomic forceps or scleral depressor; if it leaks, make a


suture. Remove first both instrument trocars. If the eye is soft, add more gas and
remove as last manoeuvre the infusion trocar, but remove first the infusion and
then the trocar.
If the eye is still soft, your idea with the postoperative injection is excellent.

Q 4 Could the 23G cutter be used during fluid–air exchange to aspirate the subreti-
nal fluid (active aspiration mode) instead of a 23G backflush cannula (passive
aspiration)?

A 4 Yes of course. Even better (easier to manoeuvre) is a flute needle with active
aspiration.

Q 5 When injecting PFCL, do you reduce the infusion pressure or not?

A 5 No. I work bimanual. One hand injects PFCL and the other hand aspirates BSS
with the flute needle. This works only if you use a chandelier light. If you do not
have/use a chandelier light, I recommend a double-barrelled infusion cannula (see
Chap. 28 in my book).

Q 6 Any tips on avoiding slippage during PFCL–silicone oil exchange?

A 6 The danger of slippage from PFCL to silicone oil is low. The danger of slippage
is high from PFCL to air to gas and especially if it is a giant tear. Look in the book:
Retinectomy. The essential surgical step is to aspirate the PFCL until it is just
posterior to the edge of the giant tear (posterior edge of the tear). Now aspirate
thoroughly the residual subretinal fluid from the tear. Only when the tear is
completely dry you can continue with aspiration of PFCL.
In addition strict face down posture for 3–5 days.

Q 7 How would you deal with a retinal incarceration?

A 7 This is difficult. Best is to avoid it in the first place when you suture a trauma
case. The only solution is retinectomy. In detail: Ora parallel diathermy posterior to
the incarceration. Retinectomy along the diathermized retina. I would then cut/
remove the retina from the anterior part of the incarcerated retina. Then PFCL, then
laser and then PFCL against silicone oil exchange.

Q 8 In the case of a very dense vitreous haemorrhage in a phakic eye, when the
infusion cannot be visualized and thus opened, would you start the vitrectomy using
an AC maintainer?
Will the BSS in the AC keep sufficient tone of globe?
Does this BSS pass through the zonules of the phakic eye and into the vitreous
cavity?
27 Frequently Asked Questions (FAQ) 447

A 8 You can do a short vitrectomy with an anterior chamber maintainer. BSS flows
through the zonules to the posterior segment but only slowly. Therefore, no, you
cannot perform a long vitrectomy. An alternative is to check the tension of the globe
constantly with your index finger and then wait until the globe is soft again and
continue again.
If you are sure that the retina is attached (ultrasound), then I would definitely set
the infusion in pars plana. I would double-check the infusion trocar with a light pipe
or even use the long trauma trocar from Alcon.

Q 9 In case of a vitreous haemorrhage of unknown aetiology, would you turn the


infusion on without first being able to verify that it is placed in the vitreous cavity?
In this case, would you start by using an AC maintainer?
Does an AC maintainer work in a phakic eye?

A 9 In my personal experience, the location of the trocars (in vitreous cavity or


subepithelial) is only difficult in the eyes with choroidal detachment (hypotensive
eyes, trauma eyes). In these pathologies, I always check thoroughly if the trocar is
located in the vitreous cavity or under the pars plana epithelium. And in these eyes,
I use now only these long 6 mm trauma trocars from Alcon.
So coming to your question, if the eye has choroidals, I would insert an anterior
chamber maintainer; if the eye has no choroidals, I would insert a pars plana
infusion.
An anterior chamber maintainer works partially in a phakic eye. It depends on
the status of the zonules. I would implant an IOL in these difficult eyes.

Q 10 Dear Ulrich,
Modern retinal surgery =

A: Anti-VEGF
B: BIOM
C: Chandelier light
D: Dye (dual!)
E: Eckardt 23G trocars
F: Fantastic—your book!
PS: This is original from me and I want to thank you for the wonderful book!

You may be able to use this in your new book.


Regards
Yaseer

A 10 Thank you, Yaseer.

Q 11 I would like to ask the following questions regarding your technique for peel-
ing PVD in RRD cases:
448 27 Frequently Asked Questions (FAQ)

1. Following vitrectomy, you perform a fluid–air exchange: Do you drain the SRF
through the retinal break and try to make the retina completely flat?
2. Then, under air, you inject trypan blue on the PVR area, then you perform an
air–fluid and then you peel the PVR. Is the sequence correct?
3. After you have stained, when you go from air back to fluid, does the RRD
become more bullous?

A 11 The procedure for PVR is:

1. Vitrectomy.
2. Staining. In order to perform a good peeling, we like to stain the membranes.
Because the membranes are spread all over the retina, the usual method does not
work well. We therefore make a fluid–air exchange and then drop the dye on the
PVR areas. The dye is very concentrated on these areas and you always get a
good staining of the membranes. Wait 30 s and then aspirate the excessive dye at
the posterior pole and then return to fluid-filled eye. And then perform the
peeling. There are different “ideologies” between peeling and retinectomy. But
in any case, you have to remove the membranes posterior to the retinectomized
retina.
3. Peeling. Start in the centre and continue to the periphery.

No, the retina does not become more bullous. This is only a temporary effect
from air–fluid to fluid–air exchange because you press the subretinal fluid to the
posterior pole under air.

Q 12 How do you avoid PFCL bubbles?

A 12 I simply remove them. But I do not have a major problem with PFCL bubbles.
Do you use trocars with valves or without valves?

Q 13 We use trocars without valves because they are cheaper.

A 13 Now I understand your problems/question with PFCL bubbles.


You will not have these problems if you use trocars with valves. The eye is much
more stable and the IOP is stable. Valves with trocars allow also a much easier air–
fluid exchange or vice versa. Why? Because the intraocular pressure is higher with
valves than without valves.
Test trocars with valves. Retinal surgery is much easier with them.

Q 14 Is there a typical sign for a subretinal PFCL bubble?

A 14 Omega sign of PFCL bubble (Fig. 27.1).


27 Frequently Asked Questions (FAQ) 449

Fig. 27.1 Omega sign: subretinal PFCL (Photo courtesy: Yaseer Byazid)

Fig. 27.2 After removal with 27G Charles flute needle (Photo courtesy: Yaseer Byazid)

Q 15 How do you remove subretinal PFCL?

A 15 Video 27.1: PFCL bubble and membrane peeling 27G retinal scraper_Atkinson
cannula

Use 27G Charles with active aspiration and high bottle and hold tip to the bubble.
Use alternatively an Atkinson needle (Beaver-Visitec). Scratch a hole in the retina
and aspirate the bubble (Fig. 27.2).

Q 16 Do you remove a subretinal PFCL bubble in the periphery?

A 16 Usually not. If the PFCL bubble interferes with PVR changes, I would remove
it; if the PFCL bubble lies in a quiet retinal area, I would leave it.
450 27 Frequently Asked Questions (FAQ)

Q 17 A 45-years-old patient suffered an ocular trauma 29 years ago. Now he has a


traumatic mydriasis and cataract. Would you perform an iridoplasty or implant an
iris prosthesis?

A 17 If the trauma happened such long time ago then the iris is fibrotic and bleeds
when you manipulate it. An iridoplasty is therefore most likely not possible. You
can test by stretching the iris with an intravitreal forceps. I would implant a combo
Human Optics iris prosthesis with a MA60AC IOL.

Q 18 A The same patient as in Q17 except that the trauma happened 1 year ago.
How would you proceed?

A 18 I would definitely perform an iridoplasty; first a phaco + IOL and either at


once or at a later time point an iridoplasty with the Hattenbach iris instruments.
Materials (in Alphabetical Order)
28

Contents
28.1 Dyes .............................................................................................................................. 451
28.2 Forceps .......................................................................................................................... 451
28.3 Knives ........................................................................................................................... 452
28.4 Scissors ......................................................................................................................... 452
28.5 Tamponade .................................................................................................................... 452
28.6 Miscellaneous ............................................................................................................... 452

28.1 Dyes

Brilliant Peel ®: (Brilliant Blue G) Geuder, Heidelberg


ILM-Blue®: (Brilliant Blue G) DORC
Membrane Blue®: (Trypan blue) DORC
Membrane BlueDual®: (Trypan blue + Brilliant Blue G) DORC
Monoblue®: (Trypan blue) Arcadophta, Toulouse, France

28.2 Forceps

Eckardt endgripping forceps. DORC, 27G disposable microforceps. 1286.WD04


Foreign body forceps: (1) 17G Microforceps: Avci Foreign Body. DORC. 2286.H.
(2) 20G intravitreal foreign body forceps: Geuder 36264. (3) 19G foreign body
forceps. Synergetics REF 11.20PIN (single-use instrument)
Power endgripping forceps DORC, 27G disposable microforceps. 1286. WPD04
Serrated jaws forceps, 23G. 1286.C06
Trocar forceps. DORC. 1278

© Springer International Publishing Switzerland 2015 451


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_28
452 28 Materials (in Alphabetical Order)

28.3 Knives

2.4 mm wide main incision knife. Indication: main incision. Slit knife. Alcon.
8065992445
Crescent bevel up knife. Indication: preparation of a frown incision. Crescent angled
bevel up. Alcon. 8065990002
V-lance. Knife for 1.3 mm wide scleral and corneal incisions. Indication: paracen-
tesis and 20G sclerotomy. 20G V-lance. Alcon. 8065912001
15 degrees knife. Indication: paracentesis. Alcon. 8065921501

28.4 Scissors

Scissors, curved microscissors. DORC, 27G disposable microscissors. 2286.PD04

28.5 Tamponade

C2F6: many providers, for example, Alcon


C3F8: many providers, for example, Alcon
Densiron 68®: Fluoron
Oxane Hd®: Bausch & Lomb
Silicone oil 1000 cSts: Fluoron. G-80 710, DORC or Bausch & Lomb
Silicone oil 5000 cSts: Fluoron. G-80 810
SF6: many providers, for example, Alcon

28.6 Miscellaneous

41G aspiration and injection cannula. DORC: disposable dual bore BSS injection
needle (41G). 1270.01.
42G injection cannula. Synergetics REF: 12.03
BSS Plus ®: Alcon
Caliper of CASTROVIEJO Geuder No: 19135
Cannula, silicone oil 23G: MedOne: 3241st PolyTip Cannula 23G 10 mm
(Sanisoglu) or DORC: 1272.VFI06. 23G 7 mm.
Cannula, silicone oil 16G: “High viscosity injector cannula (Peyman)”. Ref No.
585002. Beaver-Visitec International Ltd. Bidford-on-Avon, UK
Cannula, 23G for injection of dye: DORC 1281.A5D06
Cannula, 25G for injection of dye: MedOne. Ref. 3225 or DORC 1272.SD25
Cannula, double-barrelled injection dual bore 23G cannula for injection of
PFCL. DORC: EFD.06.
28.6 Miscellaneous 453

Capsular tension ring: DORC, Corneal


Celoftal® (for cornea): Alcon
Chandelier light in trocar: Alcon: Chandelier Accurus 8065751574 or chandelier
Constellation 8065751577; DORC: 23G chandelier light 3269.EB06 and Synergetics
25G Awh chandelier. 56.51.23P or 56.51.25P
Chandelier light in sclera: 27G twin light from Eckardt 3269.MBD27; Synergetics:
25G Awh chandelier 56.20.25
Contact lens, Plano: DORC: disposable vitrectomy lens, flat. 1284.DD
Endomagnet: Alcon surgical. I.O.M. #352
Fragmatome: Alcon (Accurus Fragmentation Handpiece), DORC
Ocucoat® (for cornea): Bausch & Lomb
Suture for sclera-fixated IOL: Alcon. Polypropylene, blue monofilament, double
armed. 8065307601.
Trephine, 10 mm for customizing of iris prosthesis from HumanOptics. Ophtec,
Netherlands
Triamcinolone acetonide (Volon A®): Pfizer
Valved Trocar System by Alcon for trauma: 23G trocar 6 mm 3 pack, 8065751445
Company Addresses (in Alphabetical
Order) 29

Alcon
Alcon Laboratories (UK) Ltd.
Pentagon Park
Boundary Way
Hemel Hempstead
Herts HP2 7UD, England
Phone: 44+1442.341.234
www.alcon.com

Arcadophta
293, Route de Seysses
F-31100 Toulouse
Phone: 0033/561/405235
Fax: 0033/5617 408 466
info@arcadophta.com
www.arcadophta.com

Bausch & Lomb


United Kingdom
Europe, Middle East and Africa Division European Headquarters
Bausch & Lomb House
106-114 London Road
Kingston-Upon-Thames
Surrey KT2 6QJ, England
Phone: 44-20-8781-5500
Fax: 44-20-8781-2989
www.bausch.com

© Springer International Publishing Switzerland 2016 455


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5_29
456 29 Company Addresses (in Alphabetical Order)

Beaver-Visitec
http://www.beaver-visitec.com/

DORC
Dutch Ophthalmic Research
Center International BV
Scheijdelveweg 2
3214 VN Zuidland
The Netherlands
Phone: +31 181 458080
Fax: +31 181 458090
www.dorc.nl

Eye Technology Ltd.


19 Totman Crescent
Brook Road Industrial Estate
Rayleigh
Essex SS6 7UY
United Kingdom
sales@eye-tech.co.uk

Fluoron GmbH
Magirus-Deutz-Strasse 10
89077 Ulm
Phone: 0731/20,559,970
Fax: 0731/205 599 728
info@fluoron.de
www.fluoron.de

German AB
Box 2127,
SE-291 02 Kristianstad, Sweden
Industrigatan 54–56,
SE-291 36 Kristianstad, Sweden
+46 (0)44 12 30 30
+46 (0)44 10 31 79
info@germa.se
www.germa.se

Geuder AG
Hertzstr. 4
69126 Heidelberg
29 Company Addresses (in Alphabetical Order) 457

Phone: 06221/3066
Fax: 06221/303 122
info@geuder.de
www.geuder.de

IRIDEX Corporation
1212 Terra Bella Avenue
Mountain View, CA 94043, USA
www.iridex.com

Labtician Ophthalmics
2140 Winston Park Drive, Unit 6
Oakville, Ontario LgH 5V5
Canada

Medilens
Medilens Nordic AB
Box 1347
251 13 HELSINGBORG
www.medilens.se

MedOne Surgical Inc.


Sarasota, FL USA 34 243
www.MedOne.com

Oculus, Inc. GmbH


Münchholzhäuser Str., 29
D-35582 Wetzlar
Phone: 0641/20 050
Fax: 0641/2005255
sales@oculus.de
www.oculus.de

Oertli Instrumente AG
Hafnerwisenstr. 4
CH-9442 Berneck,
Tel: 0041/71/74742 2000
Fax 0041/71/74742 90
E-mail: info@oertli-instruments.com
www.oertli-instruments.com
458 29 Company Addresses (in Alphabetical Order)

Ophtec BV
Schweitzerlaan 15
9728 NR Groningen,
Netherlands
www.ophtec.com

Serag-Wiessner GmbH
Zum Kugelfang, 8–12
95119 Naila
Germany

Soft Italia SPA


Contrada Molino, 17
63833 Montegiorgio Fermo
Italy
Phone: +39 0734 964096
www.oogroup.it/sooft/en/gruppo_gruppo.html

Synergetics France GmbH


Synergetics France SARL
6 Place de la Madeleine
75008 Paris
France
Phone: 825 825 250
Fax: 1 64 11 16 99
E-mail: plecharpentier@synergeticsusa.com
www.synergeticsusa.com
Index

A Bimanual vitrectomy, 49
Air 4-port bimanual vitrectomy, 49
bubbles, behind IOL, 236, 301 Binocular indirect ophthalmo microscope
exchange, 3, 4, 57, 66, 75, 76, 85, 86, 88, (BIOM), 16, 21, 76, 78, 86, 88–90, 93,
112, 118, 119, 121, 182, 187, 189, 191, 108, 109, 119, 120, 144, 163–180, 199,
195–198, 200, 214, 230, 235–237, 242, 210, 237, 242–246, 304, 309–312, 346,
253, 287–289, 299–301, 303, 304, 319, 351, 447
321, 322, 326, 328, 446, 448 BIOM. See Binocular indirect ophthalmo
filling, 76, 91, 243 microscope (BIOM)
tamponade, 75, 77–78, 84, 87, 102, 108, BIOM, focus, 197
109, 112, 212, 373, 374, 437 Bleeding, intraoperative, 206, 234
Anaesthesia, 84, 123, 130, 154, 208, 266, 273, Break
274, 309, 346, 423 flap, removal, 182
Ando iridectomy, 242 iatrogenic, 73, 193, 195, 331
Anterior chamber, 85, 88, 132, 136, 140–143, laser coagulation, 164, 182, 198
145, 149, 152, 153, 156, 157, 164, 171, mark, 38, 73, 168, 171, 179, 182,
179, 192, 200, 211, 242–245, 280, 282, 193, 195
283, 288, 298, 302, 303, 346–348, 351, peripheral, 73
362, 369, 379, 387, 397, 398, 402, 404, Brilliant Peel, 451
425, 429, 433, 437, 438, 445, 447 BSS. See Balanced salt solution (BSS)
hemorrhage Bupivakain
silicone oil, 88, 153, 200, 242–245, 298,
303, 397, 398, 425, 429, 437, 438
Anterior chamber maintainer, 152, 346–348, C
351, 438, 447 Cannula, double barrelled, 25, 280,
Anterior vitrectomy, 78, 130, 133, 138, 141, 446, 452
142, 144, 153, 276, 277, 368, 436 Capsular tension ring, 192, 265, 266, 390, 391,
Antibiosis, 148–158 412, 414, 453
Ceftazidime, 148, 153
Chandelier light, 16–19, 29–31, 39, 44, 45,
B 47–56, 70, 72, 88–90, 93, 119, 130,
Backflush instrument, 22, 34, 36, 38, 57, 78, 141, 149, 163–165, 171, 172, 180–183,
86, 91, 93, 108, 114, 119, 182, 209, 186, 192, 208, 214, 232, 244, 276, 277,
211, 213, 233, 234, 236, 243, 244, 247, 279–281, 287, 288, 304, 309, 310, 312,
248, 253, 278, 287 322, 323, 346, 350, 351, 369, 371, 373,
Balanced salt solution (BSS), 35, 46, 66, 67, 375, 376, 446, 447, 453
73, 76–78, 82, 87, 93, 118, 119, 149, Choroidal hemorrhage, expulsive, 345
180, 189, 213, 214, 235–237, 244, 247, sclerotomy, 346
253, 288, 291, 303, 379, 446, 447, 452 Conjunctival suture, 46

© Springer International Publishing Switzerland 2015 459


U. Spandau, M. Pavlidis, 27-Gauge Vitrectomy: Minimal Sclerotomies
for Maximal Results, DOI 10.1007/978-3-319-20236-5
460 Index

Core vitrectomy, 9, 61, 65, 102, 110, 114, 115, G


144, 182, 193, 210, 232, 258, 259, 262, Gas
278, 323, 347, 351 dilution, 86, 199
Crocodile forceps expanding, 46, 82, 84, 120
CRVO knife injection, 82, 121, 237, 334, 335,
Cryotherapy 338, 339
ciliary body, 310, 312 location, vitreous cavity, 82, 83, 86, 211
device, 195 phase, 196
properties, table, 83
tamponade, 4, 39, 73, 84–87, 108, 110,
D 115, 119, 120, 153, 182, 199,
Densiron 68®, 83, 87, 88, 242, 252–254, 303, 200, 211, 214, 237, 269, 286,
304, 452 303, 314, 362, 445
Diabetic retinopathy Giant tear, 182, 200, 446
delamination, 68, 213, 222–224, 229, 233, detachment, 182
234, 236, 237
laser photocoagulation, 208, 211, 236
tractions, 203, 204, 213, 233, 234, 238 H
VEGF-inhibitors, 207 Hemorrhage, intraoperative, 340, 341, 345
Diamond dusted membrane scraper,
Tano, 118
I
ILM. See Internal limiting membrane (ILM)
E ILM-rhexis, 118
Eckardt, Claus Indocyanine green
forceps, 33, 62, 111, 118, 234, 287, 294, Infusion cannula
295, 300, 451 insertion, 192, 347, 351
23G vitrectomy, 447 removal, 25, 45, 46, 87, 351
Encircling band, 40, 167, 285, 286, 288, 293, Internal limiting membrane (ILM)
294, 300–302, 307 peeling, 69, 115, 118–119, 127, 144, 201,
Endodiathermy handpiece, 35 339, 341
Endolaser, 182, 211, 236, 287 staining, 115, 118
coagulation, panretinal, 211, 236 Intraocular lens
Endophthalmitis, 47, 147–158, 284, 345, 373, air bubbles, 78, 199, 236, 293, 301
379, 436 dislocation, 130, 143, 192, 378
Endotamponade, 7–11, 56–57 implantation, 129–145, 183, 192, 208, 276,
indication, 11 279, 280, 284, 369, 384, 390, 392, 394,
396, 401, 402, 404, 405, 414–418,
422–425, 435
F Inverter, 86
Fibrin, anterior chamber, 149, 379, 397, 437 Iridectomy
Fish eggs (PFCL), 78 Ando, 242
Flute needle, 35, 36, 38, 40, 66, 76–78, 86, Oxane, 88, 452
87, 89, 111, 119, 189, 190, 194, Iris prosthesis, 383, 385, 399–405, 407–414,
197, 198, 211, 213, 222–224, 227, 418, 453
231, 233, 235, 247, 248, 276, 278, Ischemic syndrome, anterior, 302
284, 303, 446, 449
Focusing, BIOM, 76, 78, 119, 197
Forceps K
crocodile Knife
Eckardt, 33, 62, 111, 118, 234, 287, 294, CRVO/neurotomy, 154
295, 300, 451 sclerotomy, 452
Foreign body extraction, 359 Knob spatula, 213, 222, 224, 228, 233–235,
Fragmatome, 35, 39, 274–279, 284, 423, 453 237, 287, 294, 295
Index 461

L Pars plana anatomy, 26, 60


Laser coagulation, 164, 182, 198 Pars plana vitrectomy (PPV), 26, 60, 63, 65,
Laser probe, 22, 35, 38–39, 72, 73, 112, 208, 200, 208, 346
213, 230, 235, 317, 322, 364, 375 Patient selection, 19
Leakage, 3, 4, 11, 47, 87, 180, 269, 278 Peeling
Learning steps, 59 internal limiting membrane
Lens luxation, 132, 133, 283 (ILM), 118
Light fiber membrane, epiretinal, 109, 111
combined light and laser hand piece membrane, PVR, 288–291
combined with vitreous cutter Perfluorocarbon (PFCL)
Light source, 16–19, 21, 29, 31, 47, 51 bubbles, 24, 67, 78, 79, 189, 197, 201,
Liquids 247, 248, 277–279, 281, 303, 330,
properties, 82–83 374, 448, 449
tamponade, 75 exchange, 91–94, 347, 352
trapped fluid, 194, 195, 197, 201 injection of, 154, 182, 185, 194, 280,
Lubrication, cornea, 192, 232 281, 322, 323, 328, 347, 351,
440, 452
suction, 197
M Perfluoroethane (C2F6), 82, 84, 85, 119, 166,
Macular hole 182, 199, 303, 452
peeling, 107, 108, 118, 126, 127 Perfluoropropane (C3F8), 82, 84, 85, 119, 199,
staining, 113 303, 452
surgery, 63 Peribulbar anaesthesia
Macular protection, 108 PFCL. See Perfluorocarbon (PFCL)
Membrane Blue®, 451 Phacoemulsification, 4, 5, 11, 16, 21, 63, 107,
Membrane, epiretinal 109, 115, 118, 148, 149, 153, 156,
peeling, 108, 109, 111 181–183, 192, 200, 204, 206–208, 266,
staining, 40, 108, 110–111 275, 280–283, 288, 304, 359, 362, 366,
surgery, 108–112, 123, 264 370, 383, 385, 387, 390, 401, 408, 414,
Membrane, fibrovascular, 21, 204–206, 228, 415, 426, 436
233, 237 Phase, 59–61, 65, 83, 93, 143, 189, 196, 197,
dissection, 234 208, 239, 247, 253, 303
Membrane, PVR Posterior synechiae, 211, 267, 288, 362, 376,
delamination, 68 385, 388, 433, 437
peeling, 67, 288, 289 Posture, postoperative, 83, 120, 182, 199, 256,
staining, 75 321, 327
Mepivakain PPV. See Pars plana vitrectomy (PPV)
Metallic foreign bodies, 357–379 Proliferative vitreoretinopathy (PVR)
Microscope, 16–18, 21, 86, 99, 123, 124, 160, bleeding, 288–300
161, 163, 167, 175, 179, 196, 210, 304, detachment, 16, 34, 240, 285–307,
310, 312 314, 402
Monomanual three-port vitrectomy, 214 membrane, removal, 33, 287, 292, 300
PRP. See Panretinal laser photocoagulation
(PRP)
O PVR. See Proliferative vitreoretinopathy
Ophthalmo microscope, binocular, 21, 167 (PVR)
indirect (see Binocular indirect ophthalmo
microscope (BIOM))
Oxane Hd®, 83, 88, 304, 452 R
Retina, 11, 16, 30, 56, 59, 75, 83, 98, 101,
108, 111, 123, 151, 160, 204, 242, 256,
P 278, 286, 309, 311, 316, 339, 350, 358,
Panretinal laser photocoagulation (PRP), 382, 446
203, 207–211, 214, 230, 236 bleeding, 118, 235, 236
462 Index

Retinal detachment, 11, 34, 60, 73, 83, 99, Silicone tip, flute needle, 78, 198,
158–201, 204, 240, 256, 262, 266, 213, 224
285–307, 314, 334, 346, 378, 383, Slippage, 182, 200, 299, 303, 446
385, 387, 405, 425–441 Staining
surgery, 16, 26, 181 internal limiting membrane, 118
Retinectomy, 35, 286–288, 294, 295, 297, membrane PVR, 66, 67, 289
299–307, 314, 316, 325, 374, 375, vitreous, 40, 193, 395
377, 378, 440, 446, 448 Sulfur hexafluoride (SF6), 82–85, 113, 114,
scissors, 295, 301 119–121, 164, 166, 182, 198, 199, 210,
Retinopathy, diabetic, 38, 83, 123, 203–238, 212, 213, 236, 237, 316, 318, 319, 321,
240, 323, 329 322, 334, 364, 452
laser photocoagulation, 21, 83, 182, Surgery, combined 20, 192, 232
195, 208 Synechiae, posterior, 211, 267, 288, 362, 378,
tractions, 203, 204, 213, 233, 234, 238 385, 388, 433, 437
VEGF inhibitors, 203, 204, 206, 207

T
S Tamponade
Sandwich tamponade, 197 air, 75, 77–78, 84, 87, 102, 108, 109, 112,
Scissors 199, 210, 212, 236, 373, 374, 437
horizontal vitreous scissors, 234 amount, 91
retinectomy, 295 gas, 82–83, 199, 318
vertical vitreous scissors, 234, 295, 301 indication, 84, 240
Scleral depressor, 26, 29, 39, 70, 171, 179, liquid, 75, 82–83
181, 182, 184, 194–197, 208, 209, macular hole, 11, 84, 119
211, 213, 236, 279, 287, 446 sandwich, 197
Scleral suture, 175, 395, 404 silicone oil, 40, 46, 82, 87–94, 149, 152,
Sclerotomy 153, 156, 199, 200, 211, 214, 235, 237,
knife, 140 239–249, 300, 303, 304, 322, 326, 328,
leakage, 3, 4, 47, 87, 180, 269, 278 424, 425, 430
marker, 23, 25, 28, 29, 52, 169, 179, 367 Tano diamond dusted membrane scraper,
suprachoroidal hemorrhage, 346 114, 118
suture, 65, 171, 180, 255, 347, 352 Tears, peripheral, 112, 142, 144, 181, 194
Shaving, 43, 65, 98, 182, 188, 189, 193, 196 Trapped fluid, 188, 190, 194, 195, 197, 201
Silicone oil Triamcinolone, 38, 59, 61, 62, 66, 101, 103,
Ando iridectomy, 242 108–112, 133, 145, 193, 213, 376,
anterior chamber, 88, 242–245, 298, 395, 453
397, 425 Trocar
injection, 37, 40, 88, 89, 91, 92, 237, infusion, 44, 46, 65, 91, 199, 210, 248,
241–244, 248, 251, 252, 298, 303 251, 261, 262, 274, 287, 303, 321,
removal, 10, 37, 40, 244, 251–254, 304, 445–447
352, 383, 425 insertion, 5, 28, 43–45, 50–56. 255,
tamponade, 31, 40, 46, 82, 87–94, 149, 277, 347, 350, 351
152, 153, 156, 199, 200, 211, 214, 235, 4-port, bimanual, 149
237, 239–249, 300, 303, 304, 322, 326, 3-port, monomanual, 102, 149, 258, 280,
328, 424, 425, 430 281, 287, 373, 376
Index 463

removal, 11, 23, 45–47, 109, 112, 115, Vitreous


120, 182, 199, 210, 211, 214, 237, 258, base, vitrectomy, 26, 43–45, 48, 61, 63–65,
262, 276, 279, 280, 284, 288, 304 97, 98, 153, 158, 181, 192, 194, 196,
valve, 25, 46, 94 200, 211, 229, 236, 256, 276, 279, 292,
Trypan blue, 40, 60, 62, 66, 101, 103, 323, 347, 352, 353
108–111, 213, 222, 287, 288, 290, hemorrhage, surgery, 338
291, 366, 376, 384, 386, 448, 451 rhexis, peripheral, 78, 117, 118, 141, 212,
213, 215–220, 228, 233, 236, 265, 366,
386, 391, 412, 434
V Vitreous cutter, light pipe, 6, 19, 24, 26, 39,
Vancomycin, 148, 153, 156 63, 65, 70, 348
VEGF inhibitors, 211 Vitreous detachment, posterior, 59–62, 103,
Vitrectomy 110, 149, 152–153, 182, 193, 208, 233,
anterior, 78, 130, 133, 138, 141, 142, 373, 376
144, 153, 276, 277, 368, 436 induction, 59–62, 102–103, 107, 115, 144,
core, 9, 61, 65, 102, 109, 110, 114, 115, 149, 152–153, 193, 233, 256, 258, 275,
144, 182, 193, 210, 232, 258, 279, 373, 376
259, 262, 278, 347, 351 staining, triamcinolone, 59, 61, 62, 101,
23G, advantages and disadvantages, 103, 110
4, 11, 39, 40, 252, 253
23G, a history, 4
high-speed, 27 Z
pars plana, 26, 60, 63, 65, 200, 208, 346 Zonular lysis, 16, 134, 242, 243, 245,
4-port, bimanual, 49 265–267, 390, 391, 410, 412–414,
3-port, monomanual, 26 427, 430