So having not succeeded in controlling his intraocular pressure medically and the iris still being up against the endothelium, there was little choice but to go back to the operation theatre... Making two paracentecis, the AC was reformed using a Rycroft cannula on BSS, an inferior PI was created - see video-
I resisted the temptation to remove oil from the AC, as in the past when I have tried to do so, the oil from the post segment keeps coming forward, and I didn't want to loose tamponade, as the patient was still in the first week of a Giant Retinal Tear repair. He postured face down for 24 hours after this, and the oil in the AC went back to the posterior segment, and his intraocular pressure remained normal and his anterior chamber remained deep. 8 weeks later, I removed his silicon oil via a pars plana approach and his retina remains attached - mission accomplished!
Question: Should I have made an inferior PI at his primary surgery? This is always done for an aphakic eye, but in phakic/pseudophakic/combined IOL vity sil oil cases I have not done this usually?
Thoughts?
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Hi
ReplyDeletewhat helps me to decide on making a inferior pi during primary surgery is:in pseudophakic eyes,in case i find air entering the AC after FGE,indicating some zonular dehiscence or loss,i usually make a primary inferior pi, which maintains the AC depth and prevents oil migration to the AC, as in an aphakic eye.
works well .
regards.
Thanks Sumita, good tip.
ReplyDeleteAny idea of what one should do when doing direct PFCL to silicon oil exchange?
Because one is looking through the BIOM/EIBOS during direct heavy liquid to oil exchange, one is not visualising the anterior chamber during oil fill, and so more prone to get oil in AC.
If one goes to air and then oil fill, then, essentially the oili s being dropped into an air filled cavity, and I find that as I am viewing the AC, as soon as the oil appears just behind the IOL/lens, I can ease off the injection pressure and generally avoid oil getting into the AC.
Regards
Som
Sir, I was wondering if air was injected into the anterior chamber after making inferior iridotomy with the vit cutter, would it have helped? I too have tried to remove oil from AC and had recurrence of RD post op after a few weeks in one case.
ReplyDeleteDr Sai Giridhar Kamath MS, FRCS(Ed)
Kasturba Medical College
Manipal University
Good idea, Sai,
ReplyDeleteNot sure whether air would be enough to push the oil back, but may have been worth trying.
Best wishes
Som
Nothing can be more frustrating for a VR surgeon to confront a oil-in-the-AC scenario after accomplishing a successful reattachment of retina on the table.
ReplyDeleteWe know that in direct PFCL /silicone oil exchange , the oil fills the eye from anterior to posterior direction. During the initial part of the fill surface tension of the oil partially seals the AC preventing escape of fluid and if AC remains formed ,there are less chances of oil moving into the anterior chamber during the exchange process.. I almost always perform a direct PFCL/ oil exchange and try to maintain AC depth by minimal manipulation and assuring smooth introduction of instruments through the ports. Performing air exchange prior to injecting silicone oil gives a good view but carries a risk of posterior slippage of the retina especially in GRTs.
If the oil comes in to anterior chamber in a phakic /pseudophakic eye as an isolated detached bubble , it can be removed easily through paracentesis after inserting an AC maintainer and keeping the fluid pressure high. In a communicating oil migration in to AC with persistently raised IOP I remove all the oil and do a refill procedure. If IOP is controlled I prefer to wait through a safe period allowing the retina to become firmly attached with laser scars before removing the oil completely.
Regards
Dr.Nadeem Qureshi
Dr Qureshi,
ReplyDeleteThanks - good review of the situation.
Best Wishes
Som