Meeting Notes from: VBS 2.0 Las Vegas
The Vit-Buckle Society (VBS) describes itself as a forum for “innovative vitreoretinal surgeons to share best practices, to foster the development and use of novel surgical technologies and strategies for retinal diseases, and to demonstrate the value of mentorship of emerging vitreoretinal surgeons.” This mission statement of the VBS was in full display at the society’s second annual meeting, dubbed the VBS 2.0, which took place on March 14 and 15, 2014, in Las Vegas Nevada. The colloquial nature of the meeting sparked much honest and open discussion about novel techniques and management strategies for vitreoretinal diseases.
For those who were unable to attend, New Retina MD is pleased to present an ongoing series of notes from the meeting. Here, in the first installment, Christopher J. Brady, MD, a recent graduate of the vitreoretinal fellowship at Wills Eye Hospital, presents a recap of 2 sessions on the ins-and-outs of peeling during vitreomacular surgery.
Be sure to check back in future issues of New Retina MD for more ongoing coverage of the VBS 2.0.
SCIENTIFIC SESSION NO. 2: PEELING
Moderators: Antonio Capone, MD; Michael Ip, MD; and John Kitchens, MD
Back to Basics: ILM and ERM Peeling
With Tien Wong, MD
In the first talk of this session, Tien Wong, MD, described his techniques during macular cases. In general, he often uses triamcinolone, in a 1:4 dilution, to stain the vitreous if necessary during the core vitrectomy and induction of posterior vitreous detachment. He also said he uses triamcinolone to highlight epiretinal membranes (ERMs)—although the particles do not technically “stain” the membrane, they do aid in visualization. Dr. Wong then discussed the concept of “chromovitrectomy,” or the use of dyes to stain ERM and internal limiting membrane (ILM). A poll of the audience revealed widespread use of dyes for this purpose, primarily indocyanine green (ICG) and brilliant blue. Interesting, surgeons who reported using brilliant blue mostly practice outside of the United States or had access to a compounding pharmacy.
Dr. Wong’s technique for staining with ICG is to dilute 1:1, clamp the infusion, inject a small amount of dye, then remove the endoilluminator. He allows the dye to set for 30 seconds before removing it. He likes to start peeling in the superior macula because he feels any scotoma caused by inadvertent retina contact would be less noticeable. When asked by Dr. Capone if he varies the size of his peel by the diagnosis, Dr. Wong reported that he prefers to peel all cases out to around 1500 μm regardless of the diagnosis.
Dr. Wong also discussed the use of membrane blue to stain ERMs. He said he first performs a sub-total fluid-air exchange, and then injects the membrane blue under the air to avoid staining other structures in the eye like the lens capsule. He likes to leave this dye in place for 90 seconds after having removed the endoilluminator. Dr. Wong revealed an important pearl to using membrane blue: He occasionally notes a slight bluish tint to the underlying retina after peeling, and so it is important keep track of which areas have been peeled.
When discussing macular holes, Dr. Wong expressed his feeling that most holes do just fine with SF6 tamponade, and that he reserves C3F8 only for large and recurrent holes. Although there has been a lot of discussion recently about the possibility of no face-down positioning following macular hole surgery, Dr. Wong recommends his patients assume face-down positioning for 3 days.
The audience was asked about their experience with ICG toxicity. About 10% to 15% reported they have had at least 1 case where ICG toxicity occurred. Steve Charles, MD, stated that he peels ILM in every case, but uses brilliant blue, and has not seen toxicity.
He said, She said: Peeling
With Geeta Lalwani, MD, and Ross Lakhanpal, MD
During a collaborative presentation, Geeta Lalwani, MD, and Ross Lakhanpal, MD, presented several cases to highlight different management options in challenging cases.
The first case was of a progressive ERM following successful pneumatic retinopexy. Because the vision was 20/30 at 1 month after the pneumatic retinopexy procedure, a decision was made to observe the ERM at this time. At 2 months, however, the vision had worsened to 20/60 with increased membrane and localized folds in the macula. Some in the audience wondered if the cryotherapy applied during the pneumatic procedure had contributed to an inflammatory response and that membrane formed as a form of proliferative retinopathy, or PVR. Others felt the proliferative process likely originated from the retinal tear and release of retinal pigment epithelial cells, and, thus, that surgeons should not be afraid to apply 2 to 3 spots of cryotherapy. The suggestion that cryotherapy causes PVR is from old data from Glaser and Campochiaro in which large treatments were performed, for example 180° for giant retinal tears. In this particular case, the patient did well with additional cryotherapy, and the vision was 20/30 at the postop week 1 visit.
The next case was of a small membrane in the setting of dry age-related macular degeneration (AMD) with an underlying pigment epithelial detachment. Several audience members mentioned that it is critical to elicit a good history of symptoms consistent with ERM before peeling in cases with other macular pathologies. Increasing distortion is the main symptom that Dr. Lakhanpal likes to see when implicating the ERM. Several in the audience shared experience with a drusen that seemed to be secondary to traction from the ERM, and which may disappear after membrane peeling.
A more general discussion of membrane peeling ensued. Those surgeons in the audience who regularly use brilliant blue posited that the dye allows them to peel membranes en bloc. There was a sense that ICG causes tearing/shredding of ILM. Michael Ip, MD, said he prefers to start his peel with the ILM around ERM to confirm both the ILM and ERM come up at 1 time. He tries to avoid reusing stain for fear of possible toxicity. He feels ILM peeling may reduce the risk of ERM recurrence, which was supported by recently published case series by Chang.
Some in the audience quoted a recent paper from the Pan-American Study Group that suggested that double staining with ICG is required to consistently peel the ILM. This study showed that residual ILM will be left behind with a single application of ICG. Maria Berrocal, MD, discussed her approach to minimize trauma to the retina while peeling. She likes to lift an edge of ILM with forceps, and then uses the cutter to peel up the membrane. She said she notices fewer hemorrhages with this technique. When available, she prefers to use the 27-gauge cutter rather than 25-gauge because she can get better occlusion of the port and purchase on the membrane.
Christopher Brady, MD, is a recent graduate of the vitreoretinal fellowship at Wills Eye Hospital, and is joining the faculty at the Wilmer Eye Institute in Baltimore, Maryland. Dr. Brady may be reached at firstname.lastname@example.org.