Odd submacular lesion with fibrosis

This right eye was initially treated with a haemorrhagic PED in early 2007, presenting with a vision of 6/24. Three Avastin injections were given at 6 weekly intervals, and things settled nicely with vision varying between 6/18 and 6/12 on subsequent visits. The last injection was September 2007.

Things remained stable till Feb 09, when she came back with a new complain of seeing a 'blob' in her central vision in her right eye.

Vision was still 6/18
Ant Seg - unremarkable, no cells in her vitreous.

This is her colour fundus photo:

Red Free pictures

She has a clear history of Flourescien allergy, so we couldn't do one.

IR photo:

Her early ICG is shown

Late ICG

Early ICG movie

Mid-phase ICG movie

Late ICG movie

Other eye had PDT some years ago for a fibrovascular PED and settled to a vision of 6/36, been stable for 5+ years.

Any idea about diagnosis? Management?

Inducing a PVD

Usually it is easy to induce a posterior vitreous detachment, but some times the posterior hyaloid face can be very resistant to coming off...

Here is one such case, after trying all the usual manouvres which failed, I decided to 'stain' the vitreous with triamcinolone and then mechanically peel the posterior hyaloid face till I could develop the plane of separation. Once tha was achieved, engaging and pulling up the posterior hyaloid face with the ocutome was easy.

Vitreo-macular traction

I used to find diagnosing a Vitreo-macular traction very difficult before the advent of routine OCT. OCT has really enhanced our understanding of the retinl pathology, and 3D rendering can show the pathology even better.

VMT shown clearly on OCT here:

I offerred this patient surgery rather than laser or intravitreal injections and he did very well.

A 3D rendering of VMT -

Drainage of SRF through the tear

Internal drainage of subretinal fluid through the retinal tear in a fresh retinal detachment using a 25g system. As the air comes in the retina flattens nicely. This is a clip from 5 years ago, when the 25g light sourcses were not very bright, but current light sources are both brighter and provide a wide field of illumination.

Completely sutureless combined phaco and pars plana vitrectomy

I'm a great fan of sutureless surgery, and have been using sutureless 25g technology for the majority of my vitrectomy procedures since 2003. Of course the later introduction of 23g & then 20g sutureless systems brought in other possibilities...but let's leave that story for another day.....

When doing combined phaco and vitrectomy surgery, even with a 2.85 mm phaco clear corneal incision, I have routinely put a stitch into the corneal incision before going to the post segment procedure, as otherwise, I would sometimes loose the AC during peripheral indentattion whilst completing the peripheral vitrectomy and internal search.

The introduction of sub 2mm phaco technology has solved this problem. Theoretically, the most secure corneal wound is square, and a 1.6-1.8mm wide corneal incision which is of a similar length gets to this theoretical ideal.

So now, the procedure is:
1. Place an inferotemporal 25G cannula in the pars plana and plug it.
2. Do a bimanual microincision phaco using 2x 1.6 mm incisions
3. Implant a microincision lens using wound assisted technique through a sub 2 mm incision
4. Place the infusion line into the preplaced 25g cannula
5. Place two superior 25g ports
6. Complete pars plana vitrectomy (and associated procedures)
7. Remove 25g cannulas
Voila...done

Here is a video of a combined phaco, vity for mac hole case:

Steps 1 to 5 are as above, then you can see the posterior hyaloid being detached and complete vitrectomy with vitreous base shave using indentation being done. After ILM peel a FAX (Fluid air exchange) is done which finishes with direct drainage from the hole - allowing the hole to close on the table- air is left in as tamponade.

Then 25g ports are removed - and in spite of agressive indentation and peripheral vitrectomy during the posterior segment procedure, the AC remains sealed, deep and well formed.

Oil in AC

Here is someone who I treated for a GRT, pseudophake with an Acrysof len in, so no anticipated ant seg problems. Having sorted his retina out, proceeded to a direct PFCL to OIl exchange, everything went swimmingly, till right at the end - some oil made it's way through the zonules into the AC. You see a sign, the iris is suddenly not sitting on the IOL , but billowed forward!

Should I have done something more at that stage? Who knows, I decided to close up and posture patient face down - hoping to let the oil go back into the posterior chamber...

Did it work - Heck

5 days later patient has an iris plastered to the corneal endothelium, and running pressures over 50 inspite of maximal medication...


What should one do now?

Discuss your surgical techniques

Gentlemen and Ladies,

A lot of the meetings and journals we attend/read concenterate on 'new' treatments and techniques. Basic training in surgical technique is left to a 'apprenticeship' with one's trainer and osmosis from others together with evolution of technique through experience. I propose to discuss the basic surgical tecniques involved in various cases using video clips in this blog and invite others to do so. The format should be a video clip highlighting some problems/difficulties faced, and then to invite others to comment, or give on own views on how these could have been avaoided / better dealt with.

This should not only give those starting out in VR surgery a rich experience, but also cross- fertilise ideas amongst those of us who are more experienced.

I find that the best way of learning surgery, or improving one's technique is by watching your own surgical video. This is an extension of the same principle, by letting others watch your surgery here, you can benefit from others ideas about how to improve your surgery. If you prefer to stay anonymous - send your short write up and video clip to me and I will post it without any identifiable details

You can upload videos directly to the posts (they are hosted on Google Video). If you have any trouble, you can send the video to me, and I can upload it for you. The most practical way of sending across large video files is to use a service such as YouSendIt (free for files under 100 MB). If you are files are larger than this, use a program such as 'Windows Movie Maker' (free in Windows), to compress it for download.

If you still have queries about how to do this, please feel free to email me.

Let's give it a try and see how it pans out.

Best Wishes

Som