The fourth meeting of the Vit-Buckle Society (VBS) took place in Miami Beach in March 2016. The meeting’s surgical focus—and the range of surgical topics presented—is best illustrated by talks from Lisa C. Olmos de Koo, MD, MBA, and Robert A. Sisk, MD. Fellows’ Foray travel grant winners Natàlia Vilà, MD, MSc, FEBO, and Yewlin Chee, MD, respectively, summarize those presentations below.
Dr. Olmos de Koo’s presentation offers pearls for chorioretinal biopsy in an 80-year-old patient with poor vision and bilateral serous retinal detachment. Dr. Olmos de Koo’s approach of building on others’ experiences and sharing her own expertise epitomizes the VBS’s philosophy that surgical techniques are improved through open discussions with colleagues and exchange of new ideas.
Dr. Sisk’s presentation focuses on mastering a more common procedure: the epiretinal membrane peel. Just as the process itself recalls some surgeons’ earlier procedures performed in fellowship, the pearls Dr. Sisk offers remind us of the most fundamental surgical principles: to manage expectations, to keep the goal of a particular procedure in mind, and to remember that in some cases “perfect can be the enemy of good.”
—R.V. Paul Chan, MD; Anton Orlin, MD; and Aleksandra Rachitskaya, MD
Piecing It Together: Planning and Executing Chorioretinal Biopsy in an Eye with Detached Retina
By Natàlia Vilà, MD, MSc, FEBO
Lisa C. Olmos de Koo MD, MBA, shared her experience with a challenging case involving chorioretinal biopsy in an eye with a detached retina.
When intraocular lymphoma must be investigated as a possible diagnosis, the vitreoretinal surgeon may perform a diagnostic vitrectomy and chorioretinal biopsy. Dr. Olmos de Koo performed such a procedure on an 80-year-old woman who presented with bilateral serous retinal detachment. Visual acuity (VA) in the patient’s better eye was hand motions (HM); in the fellow eye, VA was light perception (LP). Extensive workup including vitreous taps had been performed and was unrevealing. Suspicion remained high for an occult diagnosis of lymphoma.
Dr. Olmos de Koo performed a biopsy on the eye with poorer VA, which was found to have a subtotal serous retinal detachment with part of the retina plastered against an intraocular lens. After consulting colleagues for advice (see Diving for Pearls), she initiated surgery.
DIVING FOR PEARLS
Dr. Olmos de Koo consulted colleagues for pearls before initiating surgery in this case. Here are a few of the pearls she applied when planning surgery:
Phoebe Lin, MD, PhD
Remember that you have different hemostasistechniques at your disposal, including deep diathermy, laser around biopsy sites, and raising the irrigation solution bottle.
Thomas Albini, MD, and Janet Davis, MD
Use of a 19-gauge cannula can help the surgeon avoid losing the specimen.
Dean Eliott, MD
A goal of this surgery should be to extract an adequately sized tissue sample for pathologic examination, which may prove challenging.
One of the goals of the procedure, Dr. Olmos de Koo said, was to gather three tissue samples for biopsy: undiluted vitreous, undiluted subretinal fluid, and chorioretinal tissue. She began with a conjunctival peritomy, followed by placement of an anterior chamber maintainer. She took an undiluted vitreous sample and performed a retinotomy as superiorly as possible to get a sample of undiluted subretinal fluid. Having flattened the retina sufficiently, she then moved the infusion line to the vitreous chamber and added a fourth port for chandelier illumination, which allowed her to use a bimanual technique. She injected perfluoro-n-octane (PFO) to stabilize and flatten the retina, and prepared the site for chorioretinal tissue extraction by performing deep diathermy. Intraocular pressure (IOP) was kept in the range of 25 mm Hg to 35 mm Hg, and the balanced salt solution bottle was adjusted if bleeding was observed. Dr. Olmos de Koo applied endoscopic laser around the tissue extraction site. She used vertical scissors to cut the chorioretinal flap of tissue, enlarged the sclerotomy to externalize the biopsy, and finished the procedure with a direct PFO–silicone oil exchange.
The pathology results were nondiagnostic, as no inflammatory, atypical, or malignant cells were observed. At 9 months postoperative, the retina remained attached and the patient’s VA had improved to 20/60. The fellow eye underwent surgery for a serous retinal detachment at a different institution, and postoperative VA in that eye was HM.
THE VBS AUDIENCE COMMENTS
The VBS audience had plenty to say about Dr. Olmos de Koo’s surgical approach. The use of gas tamponade versus silicone oil was discussed. Postoperatively, patients such as the one in this case may develop fibrosis around the scar, which is a reason why silicone oil could be recommended. Tara McCannel, MD, PhD, noted that there is risk of pulmonary embolism when the choroid is exposed during air-fluid exchange. Silicone oil may minimize this risk, she said. Flavio Rezende, MD, PhD, also emphasized the risk of pulmonary embolism, but he said he considered air-fluid exchange a viable option as long as it is performed under low IOP. The audience agreed that there were good visual outcomes in this specific case, suggesting that when a serous detachment is bilateral with poor VA there is still a role for surgery, particularly when other medical options have been exhausted.
Chorioretinal biopsy is a surgical technique that can be used to rule out intraocular malignancies. It is crucial to get enough tissue for the pathologist, which can be surgically challenging. Dr. Olmos de Koo collected three tissue samples: undiluted vitreous, undiluted subretinal fluid, and chorioretinal tissue. The importance of hemostasis should be emphasized, which can be achieved by controlling the IOP and performing deep diathermy. When serous retinal detachment is included in the pathology, surgery and drainage of subretinal fluid may increase the likelihood of improved postsurgical visual recovery. When the choroid is exposed, there is a risk of pulmonary embolism with air-fluid exchange. However, surgeons may perform air-fluid exchange safely under lower IOP. Alternatively, surgeons may wish to perform direct PFO–silicone oil exchange, as in this case.
Natàlia Vilà, MD, MSc, FEBO
• third-year vitreoretinal fellow, advanced vitreoretinal surgery and endoscopic vitrectomy fellowship, McGill University, Montreal, Canada
From the BMC Archive
Focus on the Future: Argus II Implant Pearls
By Thomas Berenberg, MD, summarizing a presentation by Lisa Olmos de Koo, MD, MBA, and Ninel Gregori, MD New Retina MD Volume 6, Issue 4 Find online at: bit.ly/berenberg416
Perfecting Your Peeling
By Yewlin Chee, MD
In a presentation largely directed toward retina surgeons in their first 5 years of practice, Robert A. Sisk, MD, offered guidelines to help optimize peeling of macular membranes.
He began by describing the goals of the procedure—namely, to improve metamorphopsia and visual acuity—and highlighted the tools surgeons have at their disposal, such as forceps, scrapers, stains, and, most importantly, sound decision-making and good hands.
Dr. Sisk discussed the pros and cons of various techniques used to peel macular membranes. He noted that scraping for flap initiation can be beneficial for enhancing safety, especially if the patient is moving. Potential disadvantages to scraping include increased cost, potential trauma to the retinal pigment epithelium or retina, and difficulty inserting the instrument through valved cannulas. Dr. Sisk said one can choose to peel only the epiretinal membrane (ERM), to peel the ERM then the internal limiting membrane (ILM) sequentially, or to peel both simultaneously.
Procedure success ultimately depends on proper patient selection and management of expectations for immediate postoperative and long-term recovery, according to Dr. Sisk. Presurgical planning should include careful examination of preoperative optical coherence tomography imaging to identify the status of the posterior vitreous, to locate surgical planes, and to identify any preexisting lamellar or full thickness macular holes.
In his presentation Dr. Sisk described his preferred method of performing a membrane peel. He emphasized the need to optimize surgical conditions with proper table and microscope height, wrist rest placement, taping of the patient’s head, placement of a retrobulbar block for akinesia and to prolapse the globe anteriorly, and placement of ports in a comfortable position. His preferred technique includes 23-gauge vitrectomy, as this platform allows a rapid core vitrectomy and larger instruments with a broader forceps grasping platform.
Dr. Sisk said he uses indocyanine green (ICG) weighted with D5W, which he allows to sit on the macula for 10 to 15 seconds before removal. He then initiates a broad ILM flap along the inferior arcade with a scraper such that there is a long horizontal edge available to grasp. If there is no initial staining with ICG, then there likely is a diffuse ERM that is better suited for flap initiation with a pinch-and-peel technique. Dr. Sisk prefers to grasp the ILM and ERM as a complex and to peel over the nasal macula early. He cautioned against regrasping in the papillomacular bundle or central macula, as damage to that region can cause irreversible vision loss.
To conclude his talk, Dr. Sisk emphasized the need to keep the goals of the procedure in mind. “It is most important to relieve traction over the fovea, and it is not critical to removal all of the ILM,” he said. He counseled surgeons to stop when the goals of the procedure are achieved. In short, he noted that this procedure is one where perfection can be the enemy of good.
Yewlin Chee, MD
• vitreoretinal surgeon, University of Washington Harborview Medical Center, Seattle • firstname.lastname@example.org
• Financial disclosure: Consultant (Alcon, Abbott Medical Optics, Valeant/Bausch + Lomb)
Fromthe BMC Archive
Challenging Surgical Situations: Treatment of Retinal Detachment in Pregnancy
By Yewlin Chee, MD, summarizing a presentation by James C. Major Jr, MD New Retina MD Volume 6, Issue 3 Find online at: bit.ly/chee416