Viva Las Vegas: VBS V

By Safa Rahmani, MD
 

The fifth meeting of the Vit-Buckle Society (VBS V) was stylized with a Roman numeral at the end to refer to the meeting’s location: Caesar’s Palace in Las Vegas. The meeting was full of discussions on the complexities of modern retina surgery by the leading surgeons in United States and abroad.

One such surgeon is Dean Eliott, MD, whose career has influenced a list of mentees comparable to the list of attendees at any major retina meeting. Dr. Eliott achieved a level of mentorship that many retina doctors aspire to, and he is in a position where the effects of his teachings have trickled down to generations of retina surgeons. His ability to teach from beyond the confines of his institution is part of the reason why the VBS chose Dr. Eliott as the recipient of this year’s VBS Lifetime Mentorship Award.

Below, one of Dr. Eliott’s recently graduated second-year retina fellows, Safa Rahmani, MD, profiles his lecture. It seems all too appropriate that one of Dr. Eliott’s fellows would profile him—but then again, in some sense, we are all Dr. Eliott’s fellows.

— R.V. Paul Chan, MD; Anton Orlin, MD; and Aleksandra Rachitskaya, MD

Dean Eliott, MD: Lifetime Mentorship Award

By Safa Rahmani, MD

This year’s VBS Lifetime Mentorship Award was given to Dean Eliott, MD. The award recognizes an individual who has made significant contributions to the field of retina through the education and mentorship of the next generation of retina specialists. Dr. Eliott certainly exemplifies all the qualities that a young retina specialist can aspire toward, and the VBS was proud to recognize this year’s recipient.

Delivering the VBS Lifetime Mentorship Lecture, Dr. Eliott focused on one of his passions: proliferative vitreoretinopathy (PVR). He has spent much of his career treating and attempting to understand this complex disease process.

RETINECTOMY

Dr. Eliott broke his lecture into six sections. In the first section, he discussed the use of retinectomy for treatment of PVR. Retinectomy was first used by Robert Machemer, MD, and the team at the Duke Eye Center, as well as Steve Charles, MD. All retinectomy edges are vulnerable to reproliferation and traction, Dr. Eliott argued. He cautioned that retinectomy edges should be avoided at or near the 6 o’clock position and should ideally span 2 clock hours away at each end from 6 o’clock. Dr. Eliott said that if a 270° retinectomy is needed, then it is usually better to complete a 360° retinectomy. Hemostasis is extremely important for retinectomy success, and use of diathermy and laser to achieve this is key. Reproliferation often occurs at the location of postoperative blood, Dr. Eliott said. A common mistake during retinectomy, he continued, is failure to peel and remove all foreshortened or stiff retina. He advised against performing a small retinectomy.

LENSECTOMY

Dr. Eliott next discussed lensectomy. He emphasized the need for complete vitrectomy and removal of anterior scar tissues in eyes with PVR. He said he believes that leaving the anterior lens capsule for possible future IOL placement is not practical in eyes with severe PVR or proliferative diabetic retinopathy. Lensectomy enables complete removal of anterior traction, and relief of ciliary body traction is critical to prevent future complications. Leaving the capsule can lead to opacification, adhesion to the iris, anterior retinal detachment, and hypotony with proliferation over the ciliary processes. At minimum, these anterior adhesions can cause macular edema that may be recalcitrant to treatment, even if parts of the lens capsule are left for future use. Dr. Eliott demonstrated these principles with discussion of studies and clinical examples from among his patients. He summed up this section of his lecture with an axiom: “No one ever went blind from aphakia.”

BUCKLES

Dr. Eliott next focused on the use of scleral buckles in managing PVR. Scleral buckles can support the edges of a retinectomy, especially 180° retinectomies at the 3 o’clock and 9 o’clock edges. The buckle provides extra support in these difficult cases. Dr. Eliott said that if there is a 360° retinectomy or significant laser anteriorly that effectively moves the new ora posteriorly, then a buckle will not help. Also, meticulous attention must be given to conjunctival closure to prevent buckle erosion or exposure.

PFCL

His talk then focused on the use of perfluorocarbon liquid (PFCL) in PVR. One of the main complications of PFCL use is inadvertent subretinal migration of the heavy liquid. The risk of this is especially prevalent in eyes with large tears and retinectomies. Dr. Eliott said studies have shown that PFCL can migrate even after surgery, and it usually heads toward the fovea. Most subretinal PFCL occurs during the first 24 hours of the postsurgical period as the patient moves and small anterior bubbles find their way under the retina.

Patients are left with an absolute scotoma wherever the PFCL is located and a relative scotoma where the PFCL used to be, so, after PFCL migration, there can be areas of both types of scotomas. Depending on the location of the PFCL, attempts can be made to remove the retained bubble. Dr. Eliott said he does not attempt to remove subretinal PFCL unless it is in the fovea and of substantial size. In order to prevent this complication, it is best to decrease the intraoperative turbulence of fluid shifts by lowering infusion pressure. A few drops of balanced salt solution wash after fluid-air exchange may be helpful in removing remaining PFCL bubbles on top of the retina, he said. These bubbles may be difficult to remove from the subretinal space, although some authors have reported success using small-gauge cannulas with pinpoint focal holes.

SILICONE OIL

Dr. Eliott next discussed silicone oil complications in PVR and how to minimize issues associated with its use. Dr. Eliott warned against overfill, as it usually results in a repeat visit to the OR. He discussed his method of using a 25-gauge needle with tuberculin syringe. By placing the needle at the anatomic pupil plane and gauging the distance as the oil is injected, Dr. Eliott said that oil placement becomes much more precise.

Dr. Eliott also discussed problems related to oil emulsification and the retina, optic nerve head, and trabecular meshwork. Even after removal of silicone oil, retained particles may remain attached to an intraocular lens or may cause chronic intraocular pressure issues. Scleral depression over the ciliary processes and iris root to dislodge particles can be particularly helpful in getting out as many oil particles as possible.

Dr. Eliott also discussed techniques to address oil placement in patients with distorted iris anatomy and aniridia with use of silicone oil retention sutures. These sutures are effective in holding the oil back from migrating to the anterior chamber, he said.

PATHOGENESIS

Dr. Eliott finished his talk with discussion of the pathogenesis of PVR. The biggest problem with PVR is recurrence, and there is no effective treatment for it. Dr. Eliott cited a number of studies that showed an association between genetic polymorphisms and PVR. There are also some ocular factors that we are all familiar with. In addition, there are behavioral factors that are associated with PVR, such as smoking.

Dr. Eliott delineated the four steps in the PVR formation pathway: inflammation, which causes blood-ocular barrier breakdown; release of growth factors, predominately basic fibroblast growth factor and platelet-derived growth factor; proliferation of cells, including retinal pigment epithelial cells, glial cells, fibroblasts, and macrophages; and membrane contraction with extracellular matrix and collagen deposition. Extensive research into blocking each of these steps has met with variable success.

CONCLUSION

In short, Dr. Eliott said, retinectomy is effective for managing contracted retina, and, when in doubt, making it larger. The complexity of the lecture reflected the multifaceted nature of the disease—a reflection not lost on Dr. Eliott.

Safa Rahmani, MD
• second-year vitreoretinal fellow, Massachusetts Eye and Ear Infirmary, Boston, MA.
safa.rahmani@gmail.com

 

Contact Info

Bryn Mawr Communications LLC
1008 Upper Gulph Road, Suite 200
Wayne, PA 19087

Phone: 484-581-1800
Fax: 484-581-1818

Michael Jones
Senior Editor
484-581-1821
mjones@bmctoday.com

Janet Burk
Publisher
214-394-3551
jburk@bmctoday.com

About New Retina MD

New Retina MD delivers cutting-edge content to retina specialists in their first 15 years of practice. Each issue provides fresh insight from younger physicians plus established mentors on clinical and nonclinical issues affecting ophthalmologists in the earlier stages of their careers. NRMD features surgical pearls, clinical research endeavors, practice management, medical reimbursement and policy, continuing educational requirements, financial planning, innovations, and more.