1134hrs: Surgical Retina PANEL DISCUSSION

Discussion held after the lunch break instead of before. Here are some notes.

1134_Panel_Discussion

Q: Any pearls from ancillary testing and also sub RPE membranes. Thoughts on Anti-VEGF

A: Dr Maberley, size and duration of macular hole important. Chronicity and macular RPE changes might lead to poorer prognosis. Still a role for removing sub RPE membranes. Pre-op avastin not good for these cases.

Q: Dr Napier, as a cataract surgeon, do you have any advice if high myope and had prior vitrectomy…how to handle this very deep anterior chamber.

A: Dr Merkur, suggests keeping bottle height as low as possible yet trying to keep stable chamber. However, that missing vitreous scaffold makes this tough. If have access to 25-G system, infuse posteriorly or put gas into vitreous cavity. Also suggests hanging a bag to infuse more fluid from behind rather than setting up a second (vitrectomy) machine.

Q: Dr Maberley, asks more about longterm data of sutureless scleral fixated IOLs.

A: Dr Merkur, don’t have more data on longterm follow-up. Says one study from a group in Germany reported no complications but limited to one study. 

1118hrs: Macular Surgery (David Maberley)

Dr Maberley is also local faculty from UBC.

1118_Maberley

ERM, MH, SMH our most common elective retinal surgeries. OCT has been pivotable in defining our approach to these diseases from identifying the condition to confirming the surgical goals post-op.

Caveats of OCT and Visual Acuity related to diabetes. VA does not correlate well with OCT retinal thickness. 

Thickening of inner retinal layer with corrugations along stress lines. CME often a factor too. Prior vascular conditions such as macular venous occlusion may have occurred. Chronicity difficult to identify. Key to talking with patient as those presenting with metamorphopsia tend to have a better prognosis. 

OCT and cataract assessment before consider surgery. Often best to do the cataract/IOL first if cataract present to avoid additional surgeries. If not convinced of peripheral retina tear, could have RPE disruption that may only be found with IVFA.

If peel ILM, need to make sure get broad area. If membrane the only problem, best to not peel the ILM off. Head positioning sometimes an issue post-op. Patient can notice horizontal line from the air/fluid level. 100% risk cataract within 2 years if >50 yo.

Macular Hole well defined by OCT to confirm the diagnosis, measure diameter and perifoveal changes, and confirm proper closure post-op. IVFA may still be needed in some patients.

Goes through Don Gass’s original description of macular hole when thought to be tangential but now know more perifoveal and more vertical.

Over 90% holes should close with overage vision improved to 6/15 or so with surgery. Goes through other stats for success rates under different macular hole causes.

Next deals with subretinal haemmhrage. Difficult to tell if subfoveal especially by angiogram but OCT able to show sub-foveal. Therefore suggests management different with need to displace the blood.

1102hrs: Vitreoretinal Surgery in the Third World (Anthony Hall)

Dr Albiani introduces Dr Hall, trained in Zimbabwe then in England. Has since moved to Tanzania at the Christian Medical Centre.

1102_Hall

What do retinal surgeons in Africa do. Patients tend to present rather late. Often see trauma cases, also presenting late. Lots of paediatric cataract surgery as well that generates retinal detachments later. Also complications of HIV to deal with.

KCMC directly serves 2.5 million people. Referrals from much broader area. Dr Hall has a program that has trained 7 others across africa. All of this just scratches the surface of all those in need of retinal care.

Almost all patients present rather late. Also, very often the only eye at time of presentation.  Frequently subretinal fibrosis. Goal to try to restore some navigation vision. Huge range of very interesting patients. Everyday is a grand rounds.  Deal with lots of infections and vascular problems.

Trauma also a big problem, often children presenting late after lacerations.

Case of “unusual Bests’ disease.” In fact, Cysticercosis as could be seen when examine fellow eye. 

Another case of damage from VKH with serous detachment, sunset glow, and subretinal membranes. Steroids initiated but still lots of traction bands. Ultimately did remove the traction bands and has navigation vision.

1046hrs: Retinal Detachment (William Ross)

Full Professor here at UBC who has run the retina fellowship program for many years.

1046_Ross

Starts with discussion of Gonin’s Principle; recognition that retinal break was the cause of the detachment. Closure of the break cures the detachment.

Pathogenesis of detachment reviewed. Liquid vitreous getting through the tear with RP pump trying to drain it and traction of vitreous on the retina opposes this.

Pneumatic retinopexy: if superior break. Gas bubble occludes the break and the RP pump draws out the subretinal fluid. Cryo done around tear which can scar later; sometimes supplement with laser. If however too much vitreous traction, this can still pull retina off later. This technique is least invasive of all but does also require proper patient positioning. Fluid can shift and lead to new breaks however.

Scleral buckling: some people think no longer needed. However, scleral buckle has been the benchmark for RD repair. Position buckle to close the tear; rarely need to drain subretinal fluid at time of surgery as long as buckle on the tear. The explant (buckle) helps relieve the vitreous traction forces. No use of gas to cause cataracts, no travel restriction as no gas to expand, no cataract formation as eye not invaded internally. 

Retinal dialysis: usually in young people from trauma. Circumferential band often needed. Usually takes 2-4 years for this to occur as vitreous liquifies. Must close the dialysis with the buckle. Unfortunately, as often such a slow progression to detach, the prognosis is guarded. However, totally preventible if caught early.

Combined scleral buckle and vitrectomy: RD with superior and inferior breaks. Dr Ross prefers encircling bands to provide additional support. Worth the extra 15 minutes; then proceed with the vitrectomy now that traction is relieved. Shows video. 360 degrees of laser to prevent future detachment. If phakic, patient will get a cataract for sure. Don’t like primary vitrectomy for people under 50 if possible.

Giant retinal tear: peripheral break extending >90 degrees. Need to infuse “heavies” to posterior pole starting at optic nerve to push the retina flat. In the end, replace with fluid then C3F8. Shows movie of this.

PVR: total RD with PVR, retina is getting foreshortened. Trouble is that membranes forming not just on top but also underneath the retina. Silicone Oil needed and stays in place for 3-4 months. Unfortunately, sometimes retina so foreshortened that you have to cut it to release the subretinal traction. Another video shown.

Quiz: 40 yo male with breaks post and inferiorly. People respond with scleral buckle.

Next quiz: massive PVR; need to cut the retinal breaks.

Another: total detachment but just one break superiorly. Definitely try pneumatic first.

Last case: toxo in the eye, macula still on, break below inferior arcade. 13 yo male. Sponge is the way to go on this one.

1030hrs: Retained Lens/Surgical Management of Aphakia (Andrew Merkur)

Dr Merkur is on faculty at UBC. His residency training was at University of Ottawa, and fellowship at UBC.

1030_Merkur

This talk is on surgical management of aphakia. We’ve come along way since the early days of couching lenses.

Starts reviewing option for lens implantation when no capsular support including aphakic glasses, AC/iris fixated IOLs, next generation foldable AC IOLs, iris-sutured PC IOL, sulcus-fixated lenses and new techniques. These were all discussed.

AC IOLs seem to be showing a trend to better vision and fewer complications than even posterior fixated IOLs. People often concerned of potential chaffing issues but not outweighing its benefits.

If have complicated case, do not put something like an SA60 into the sulcus; leave aphakic if don’t have appropriate sulcus 3-piece lens.

AC IOL (non-folding ones) less technically demanding but no sutures to erode or break. They do require large incisions and could effect the angle which is of concern with glaucoma patients. Risk pupillary block and UGH. Newer open-loop designs are quite good. Still glaucoma docs shy away from this out of glaucoma concerns. 

Iris-fixated claw lenses discussed. Some potential concerns with inability to dilate patient afterwards as pinch onto iris with claws.

Iris-sutured IOL. Still better than a one-piece lens in the sulcus in terms of rubbing. These patients do end up with a cat-eye pupil (which patients not always happy with) and mydriasis is restricted. Fairly stable surgery. 

Sutured sulcus IOL is commonly done here in Vancouver. Rather large incision and shows off your surgical prowess. Prolene does breakdown eventually, and those are the sutures used to fixate these lenses. When these start to break down, extra trauma to the eye to re-suture them. Also risk of chaffing with iris if too anterior and of tilting the IOL. However, can get great dilation of the pupil afterwards. Surgery is long and there can be significant light toxicity with this surgery. As this is the standard technique here, he goes into greater detail showing drawings. Scleral flaps at each end where the suture will be fixated. Tie sutures to the haptics then internalize the lens. Newer lenses now that can allow 4-point fixation instead of just 2 which can help minimize decentration or tilt.

Foldable IOLs when sutured are like gummy bears in that the suture tightening can distort the lens.

New sutureless small incision sutureless scleral IOL. Technically a bit challenging but over time will be easier. Pass the haptic through avascular tissue. Broad fixation of the haptic with this technique. Shows video starting with 24-G scleretomies 180 degrees apart after a complete vitrectomy done. With bent needle, create needle tracks. Corneal incision inject IOL and leave trailing haptic out corneal wound.With end-grasping forceps, pull each prolene haptic of the IOL into the sclerotomy then bury into the needle tracks sclerotomy incision. (The video shown during the talk was presumed to be that performed by the speaker but was in fact copied from EyeTube.net without appropriate credit. He has performed the procedure and will provide me with this to post.) Minimal incision, foldable small incision, no exposed sutures.

Updating video clip first week of May so that actually surgery the speaker has performed then will re-post.