Vitreoretinal Surgery

This is the third edition of a highly successful textbook that in many areas has become the preferred book of vitreoretinal surgery. It provides a complete guide to all common vitreoretinal surgical procedures and also covers diagnosis and other aspects of management. The book is designed to allow a trainee or professional vitreoretinal surgeon to determine the best methodology in individual cases. In order to acquaint the reader with different opinions, “surgical pearls” have been contributed by other international experts in vitreoretinal surgery. These have been welcomed in the past as an illustration of alternative methods, without detracting from the overall method described by the main author. Vitreoretinal Surgery, 3rd Edition will continue to prove particularly popular amongst trainees, but will also be of value to practicing professionals who need help in the management of difficult and rare cases. Preface Contents Contributors Surgical Pearls List of Figures List of Tables 1: Anatomy and Clinical Examination of the Eye Introduction Surgical Anatomy of the Retina and Vitreous The Vitreous Embryology The Anatomy Anatomical Attachments of the Vitreous to the Surrounding Structures The Retina Embryology Anatomy Retinal Pigment Epithelium Photoreceptor Layer Outer Segments Inner Segments Outer Limiting Layer Outer Plexiform Layer Intermediary Neurones Inner Nuclear Layer Inner Plexiform Layer Ganglion Cells Ganglion Cell Layer Nerve Fibre Layer Inner Limiting Membrane Retinal Blood Vessels Other Fundal Structures Bruch’s Membrane Choroid The Physiology of the Vitreous Anatomy and Physiology and the Vitreoretinal Surgeon Clinical Examination and Investigation Examination of the Eye Examination Technique Visual Acuity The Slit Lamp Binocular Indirect Ophthalmoscope Using the Indenter Ultrasonography Vitreous Haemorrhage Posterior Vitreous Detachment Subretinal Haemorrhage Optical Coherence Tomography Time-Domain OCT Colour Coding (Fig. 1.29) Scan of Normal Features Frequency-Domain OCT Full-Field OCT Scan Resolution Images and Measurements Performing the Scan Macular Scan Patterns Central Retinal Thickness Inner Segment and Outer Segment Junction and External Limiting Membrane Subjective Tests The Preoperative Assessment Summary References 2: Introduction to Vitreoretinal Surgery 1 Introduction Choice of Anaesthesia Pars Plana Vitrectomy Sclerotomies Where to Place the Trochars? Creating a Self-Sealing Sclerotomy Wounds and Tissue Manipulation Securing the Infusion Cannula Checking the Infusion How to Clear the End of Non-Penetrating Infusion Cannula? Thinking in Compartments The Superior Trochars Where to Place Surgical Tip Checking the View The Independent Viewing System [5] Surgical Pearl Optimising Use of the Wide-Angle Viewing System Removing the Vitreous Hagan Poiseuille Law Vitrectomy Cutters Handling the Light Pipe Intraocular Instruments, Arc of Safety The Internal Search (Figs. 2.73 and 2.74) Thinking in Compartments Light and Laser Properties Types of Laser in Ophthalmology Endolaser (Figs. 2.81, 2.82, 2.83) Yag Laser Using a Contact Lens Closing Surgical Pearl Intrascleral Hydration for 23-Gauge Pars Plana Vitrectomy Sclerotomy Closure Advantages and Disadvantages of 23G, 25G, and 27G Systems Combined Cataract Extraction and PPV Surgical Pearl Avoiding Hypotony How to Decide Whether to Perform Combined Surgery Biometry Complications Chandelier Systems and Bimanual Surgery Dyes Intracameral Antibiotics Intravitreal Injections Injection Medications Complications Slow Release Preparations Summary References 3: Introduction to Vitreoretinal Surgery 2 Maintaining a View Microscope IVS Cornea Blood in the Anterior Chamber Condensation on an Intraocular Lens Implant Cataract Formation Pupillary Dilation Perioperative Complications Iatrogenic Breaks Causes Choroidal Haemorrhage Avoiding SCH at Surgery What to Do if Choroidal Haemorrhage Occurs? Haemorrhage from Retinal or Other Blood Vessels Sources of Bleeding Lens Touch What to do Hypotony Postoperative Complications Cataract Post-Vitrectomy Phacoemulsification Endophthalmitis Corneal Changes Choroidal Haemorrhage Finite Element Analysis of Choroidal Haemorrhage Mahmut Dogramaci Histopathology Dynamics of choroidal haemorrhage Phase 1: Ciliary Artery Rupture Phase 2 Dissemination of Blood into the Extravascular Space Bruch’s Membrane and Sclera Scattered Focal Adhesions Between Eyewall Layers Linear Adhesions at Ora Serrata Subsequent Management of SCH Raised Intraocular Pressure Retinal Breaks and RRD Hypotony Scleritis Sympathetic Uveitis Adjustments for Small Gauge Vitrectomy Instrumentation Surgical Technique Vitrectomy Technique Flexibility Indentation Flow Rates Trochar Internal Protrusion Silicone Oil Complications Extrusion of the Trochar on Removal of Instrumentation Conjunctival Chemosis Hypotony Endophthalmitis Postoperative Retinal Break Formation 20 Gauge Self-Sealing Sclerotomies References 4: Principles of Internal Tamponade Gases Principles (also see Appendix 1: Useful Formulae and Rules) Properties A Safe Method for Drawing Up Gas Physical Properties Surgical Pearl An Inexpensive Option for Air–Gas Exchange Complications Vision Cataract IOP Loss of the Gas Bubble Gas in the Wrong Place Important Postoperative Information Flying or Travel to High Altitude General Anaesthesia Silicone Oil Properties Silicone Oil in the Anterior Chamber During Surgery Complications of Silicone Oil Refractive Changes Cataract Capsule Opacification IOP Cornea Macular Toxicity Oil in the Wrong Place Surgical Pearl How to Reduce the Chance of Silicon Oil Coming into Anterior Chamber (AC) at the End of Surgery in an Eye with Zonular Dehiscence Emulsion Intraocular Lenses Surgical Pearl Silicone Oil and Inflammation The Surfactants Inflammation The Mechanical Energy Perfluorocarbon Liquid Toxicity and Interactions Interaction Between Heavy Liquid and Silicone Oil Can Lead the Sticky Oil Formation Silicone Oil Removal (Table 4.5) Alternative Methods Retinal Redetachment Rates After Oil Removal Heavy Silicone Oils Heavy Liquids “Light” Heavy Liquids Removal of Emulsified Silicone Oil Summary References 5: Posterior Vitreous Detachment Introduction Symptoms Floaters Flashes Introduction Clinical Characteristics Signs Detection of PVD Shafer’s Sign Vitreous Haemorrhage Ophthalmoscopy Retinal Breaks U Tears Atrophic Round Holes Other Breaks Progression to Retinal Detachment Peripheral Retinal Degenerations Summary References 6: Vitreous Haemorrhage Introduction Aetiology Aetiology [4–10] Natural History Erythroclastic Glaucoma Investigation Ultrasound Management Surgery Vitrectomy Summary References 7: Rhegmatogenous Retinal Detachment 1 Introduction Natural History Tears with Posterior Vitreous Detachment Breaks without Posterior Vitreous Detachment Natural History Chronic RRD Risk to the Other Eye Clinical Features Anterior Segment Signs Signs in the Vitreous Subretinal Fluid Accumulation Retinal Break Patterns in RRD Macula Off or On References 8: Rhegmatogenous Retinal Detachment Surgery Flat Retinal Breaks Retinopexy Cryotherapy Cryotherapy in the Clinic Setting Laser (Fig. 8.2) Laser in the Clinic Setting Retinal Detachment (Figs. 8.6, 8.7, 8.8, 8.9, and 8.10) Principles Break Closure Relief of Traction Alteration of Fluid Currents (Figs. 8.13 and 8.14) Retinopexy Pars Plana Vitrectomy (Table 8.2) Introduction Finding the Breaks Advantages and Disadvantages of Retinopexy under Air Draining Subretinal Fluid Surgical Pearl Draining Subretinal Fluid in RRD When to Use Heavy Liquids Removal of Heavy Liquid Choice of Tamponade Avoiding Retinal Folds (Figs. 8.24 and 8.25) Mathematical Modelling of Retinal Displacement after PPV and Gas Tamponade for Retinal Detachment Repair Mahmut Dogramaci Inferior Breaks (Figs. 8.28 and 8.29) Posterior Breaks Multiple Breaks Medial Opacities Complications Surgery for Eyes with no Breaks Found Use of 360° Laser or Routine 360° Encirclage Posturing Surgical Pearl Surgery for Rhegmatogenous Retinal Detachment The Non-Drain Procedure Operative Stages Postoperative Care Complications Peroperative Explant Postoperative Extra Manoeuvres Subretinal Fluid (SRF) Drainage Air Insertion (Figs. 8.91, 8.92, 8.93, 8.94, 8.95, and 8.96) Complications Drainage Air Injection Pneumatic Retinopexy (Table 8.4) Surgical Steps Complications Success Rates of RRD Surgery Causes of Failure Surgery for Redetachment Redo Vitreous Attached RRD Surgery Redo Vitreous Detached RRD Secondary Macular Holes Detachment with Choroidal Effusions Removal of Explant Diplopia Erosion through Conjunctiva Infection Cosmesis Irritation Surgery for Removal of the Explant Summary References 9: Different Presentations of Rhegmatogenous Retinal Detachments Age-Related RRD from PVD Atrophic Hole RRD with Attached Vitreous Pseudophakic RRD Aphakic RRD Retinal Dialysis Clinical Features Surgery for Retinal Dialysis (Table 9.2) Search Cryotherapy Marking the Break Plombage Checking the Indent Complications Giant Retinal Dialysis Dialysis and PVR Par Ciliaris Tear Giant Retinal Tear Clinical Features Stickler’s Syndrome Surgery for Giant Retinal Tear (Table 9.3) Heavy Liquids Retinopexy Trans-Scleral Illumination Technique Silicone Oil or Long-Acting Gas Insertion Surgical Pearl How to Avoid and Tackle Slippage during Air/Perfluorocarbon Exchange in Giant Retinal Tear Success Rates Removal of the Silicone Oil The Other Eye Retinal Detachment in High Myopes Retinoschisis Related Retinal Detachment Clinical Features (Figs. 9.26, 9.27, 9.28, 9.29, 9.30, 9.31, 9.32, and 9.33) Infantile Retinoschisis Senile Retinoschisis Differentiation of Retinoschisis from Chronic Rhegmatogenous Retinal Detachment Retinal Detachment in Retinoschisis Surgery (Table 9.5) Surgical Pearl Check the Relatives’ Retinas Juvenile Retinal Detachment Atopic Dermatitis Refractive Surgery Congenital Cataract Others Summary References 10: Proliferative Vitreoretinopathy Introduction Pathogenesis Clinical Features Introduction Grading (Figs. 10.2, 10.3, 10.4, and 10.5) Risk of PVR (Figs. 10.18, 10.19, and 10.20) Surgery Mild PVR Moderate PVR Severe PVR The Relieving Retinectomy Surgical Pearl Tips for Large Retinectomies Radial Retinotomy Silicone Oil Injection Surgical Pearl Avoiding Retinal Slippage during Vitrectomy Surgery for Retinal Detachment Applying laser ROSO Plus Very Severe PVR Choice of Endotamponade Silicone Oil or Perfluoro Propane Gas Heavy Oils Removal of Subretinal Bands Adjunctive Therapies Success Rates Postoperative Complications Summary References 11: Macular Hole Introduction Idiopathic Macular Hole Clinical Features Introduction Watzke Allen Test Grading Natural History (Figs. 11.14, 11.15, 11.16, and 11.17) Optical Coherence Tomography FEA Mathematical Modelling of Full-Thickness Macular Hole Mahmut Dogramaci Surgery (Table 11.1) Peeling the Posterior Hyaloid Membrane (Figs. 11.34, 11.35, 11.36, and 11.37) ILM Peel FEA Mathematical Modelling of ILM Pinch Peeling Mahmut Dogramaci Surgical Pearl A Little PFCL Bubble Injection to Protect RPE and Prevent the Dye under the Retina during Macular Hole Surgery: The Roll over Technique ILM Flap Surgical Pearl The Inverted Internal Limiting Membrane Flap Technique Other Adjunctive Methods Choice of Tamponade PostOperative Posturing of the Patient Combined PhacoEmulsification and IOL Posturing Specific Complications Visual Field Loss Success Rates Reoperation Surgical Pearl Repeat Surgery for Macular Hole Using the Inverted ILM Flap Technique or Human Amniotic Membrane Secondary Macular Holes Lamellar and Partial Thickness Holes Micro Plasmin Summary References 12: Macular Pucker and Vitreomacular Traction Clinical Features (Figs. 12.1 and 12.2) Other Conditions Secondary Macular ERM Surgical Pearl Intraretinal Changes Surgery (Table 12.1) Success Rates Specific Complications Membrane Recurrence Summary References 13: Choroidal Neovascular Membrane Age-Related Macular Degeneration Clinical Features (Figs. 13.1, 13.2, and 13.3) Vitreous Haemorrhage and CNV Pneumatic Displacement of Subretinal Haemorrhage Surgery for Failed Anti-VEGF Therapy Introduction (Fig. 13.16) 360° Macular Translocation (Table 13.2) Specific Complications Success Rates (Figs. 13.24, 13.25, 13.26, and 13.27) Choroidal Neovascular Membrane Not from ARMD Introduction Surgery (Table 13.3) Surgical Pearl Nano Subretinal Gateway Device for Subretinal Delivery without Vitrectomy Summary References 14: Diabetic Retinopathy 1 Introduction Diabetic Retinopathy Introduction Diabetic Retinopathy Grading (Table 14.1, Figs. 14.1 and 14.2) Diabetic Vitreous Haemorrhage (Figs. 14.8, 14.9, 14.10, 14.11, and 14.12) Progression to Vitreous Haemorrhage and Tractional Retinal Detachment Clinical Features Indicators for Early Surgical Intervention Surgery (Table 14.2) Detaching the Posterior Hyaloid Membrane Preoperative Anti-VEGF Surgical Pearl When to Operate in Diabetic Vitreous Haemorrhage? Specific Complications References 15: Diabetic Retinopathy 2 Diabetic Retinal Detachment Clinical Features (Figs. 15.1, 15.2, and 15.3) Surgery Tractional Retinal Detachment (Table 15.1) Peroperative Panretinal Photocoagulation Anti-VEGF Pre-Treatment Bimanual Surgery Dealing with Bleeding Vessels Iatrogenic Breaks Silicone Oil Surgical Pearl Operating on Tractional Retinal Detachment Combined TRD and RRD (Table 15.2). Postoperative Complications Cataract Vitreous Cavity Haemorrhage VCH Rhegmatogenous Retinal Detachment Iris Neovascularisation Phthisis Bulbi Maculopathy Survival after Surgery Success Rates Diabetic Maculopathy Surgical Pearl Tangential Endo-Photocoagulation to Microaneurysms in Diabetic Macular Oedema References 16: Other Vascular Disorders Introduction Retinal Vein Occlusion Chorioretinal Anastomosis Arteriovenous Decompression (Table 16.1) Radial Optic Neurotomy (Table 16.2 and Fig. 16.5) Intravitreal Steroid and Anti-VEGF Agents (Table 16.3) Tissue Plasminogen Activator Sickle Cell Disease Introduction Types of Sickle Cell Disease Systemic Investigation Inheritance and Race Systemic Manifestations Ophthalmic Presentation Laser Therapy Surgery Visual Outcome Screening Survival Retinal Vasculitis Central Retinal Artery Occlusion Summary References 17: Complications of Anterior Segment Surgery Introduction Dropped Nucleus Clinical Features Surgery (Table 17.1) Primary Management Vitrectomy Surgery Difficult Situations Concurrent Retinal Detachment and Dropped Nucleus Choroidal Haemorrhage Success Rates Suprachoroidal Haemorrhage What to Do if Choroidal Haemorrhage Occurs During Anterior Segment Surgery Intraocular Lens Dislocations Clinical Presentation Surgery Removal of the IOL Removal of an “In the Bag IOL” from the Anterior Segment Surgical Options for the Aphakic Eye Sutured Posterior Chamber IOLs A Simple Method Hoffman Pocket Complications McCannell Iris Sutured IOL Iris-Clip IOL Haptic Capture Sharioch Trochar Yamane Surgical Pearl Silicone Microtube Assisted Intrascleral IOL Fixation Peroperative Postoperative Peripheral Iridectomy Anterior Chamber IOL Surgical Pearl Secondary IOL Insertion Techniques, Choosing the Right Lens Postoperative Endophthalmitis Clinical Features (Figs. 17.28, 17.29, and 17.30) Surgery (Table 17.2) Vitreous Tap Vitreous Biopsy Infective Organisms Antibiotics The Role of Vitrectomy (Table 17.3 and Figs. 17.34, 17.35, 17.36 and 17.37) Success Rates Chronic Postoperative Endophthalmitis Needle-Stick Injury Clinical Features (Figs. 17.39, 17.40, 17.41, 17.42, and 17.43) Surgery (Table 17.4) Intraocular Haemorrhage Retinal Detachment Chronic Uveitis Postoperative Cystoid Macular Oedema (Figs. 17.52, 17.53 and 17.54) Postoperative Vitreomacular Traction Postoperative Choroidal Effusion External Drainage Summary References 18: Trauma Introduction Classification (Fig. 18.1) Contusion Injuries (Figs. 18.4, 18.5, 18.6, 18.7, 18.8, 18.9, 18.10, 18.11, 18.12, 18.2) Clinical Presentation Types of Retinal Break Dialysis (Fig. 18.27) Par Ciliaris Tears Ragged Tear in Commotion Retinae Giant Retinal Tears Surgery (Table 18.1) Choroidal Haemorrhage Other Presentations Visual Outcome Rupture Clinical Presentation (Figs. 18.51, 18.52, and 18.53) [29] Surgery (Table 18.2, Figs. 18.59 and 18.60) Visual Outcome Penetrating Injury (Figs. 18.62 and 18.63) Clinical Presentation Endophthalmitis Retinal Detachment (Fig. 18.64) Surgery (Table 18.3, Figs. 18.69, 18.70, 18.71, 18.72, and 18.73) Surgical Pearl Corneal Suturing Trauma Scores Intraocular Foreign Bodies Clinical Presentation (Figs. 18.75, 18.76, 18.77, 18.78, 18.79, 18.80, 18.81, 18.82, 18.83, 18.84, 18.85 and 18.86) Diagnostic Imaging IOFB Materials Surgery (Table 18.6) The Primary Procedure PPV, the Anterior Segment The Lens PPV, the Posterior Segment The Magnet Unusual Problems Visual Outcome (Figs. 18.101, 18.102, 18.103, 18.104) Siderosis Perforating Injury Sympathetic Ophthalmia Proliferative Vitreoretinopathy Phthisis bulbi (Fig. 18.113) When Not to Operate At Presentation Postoperatively Summary References 19: Uveitis and Allied Disorders Introduction Non-infectious Uveitis of the Posterior Segment (Fig. 19.1) Vitreous Opacification Retinal Detachment Cystoid Macular Oedema Hypotony (Figs. 19.15, 19.16, 19.17, 19.18 and 19.19) Diagnostic Confirmation The Vitreous Biopsy Sampling at the Beginning of a PPV Special Situations Acute Retinal Necrosis Clinical Features (Figs. 19.23, 19.24, 19.25, 19.26, 19.27, 19.28, and 19.29) Surgery (Table 19.2) For Diagnosis (Fig. 19.33) For Treatment Visual Outcome (Figs. 19.34 and 19.35) Cytomegalovirus Retinitis Clinical Features (Fig. 19.37) Surgery (Table 19.3) For Diagnosis For Treatment (Figs. 19.38, 19.39 and 19.40) Visual Outcome Fungal Endophthalmitis Clinical Features (Figs. 19.41, 19.42, 19.43, 19.44, 19.45 and 19.46) Surgery (Table 19.4) For Diagnosis For Treatment Visual Outcome Other Infections Ocular Lymphoma Clinical Features (Figs. 19.70, 19.71, 19.72 and 19.73) Surgery (Table 19.6) For Diagnosis (Fig. 19.74) Chorioretinal Biopsy For Treatment Visual Outcome and Survival Paraneoplastic Retinopathy Summary References 20: Pathological High Myopia Introduction Myopic Macular Schisis Myopic Macular Hole Success Rates Surgical Pearl Retracting Door Internal Limiting Membrane Flap for Myopic Macular Holes Rhegmatogenous Retinal Detachment Clinical Features Surgery (Table 20.3) Success Rates Spontaneous Suprachoroidal Haemorrhage References 21: Miscellaneous Conditions Vitrectomy for Vitreous Opacities Vitreous Anomalies Persistent Hyperplastic Primary Vitreous Asteroid Hyalosis (Fig. 21.5) Amyloidosis Retinal Haemangioma and Telangiectasia Coats Disease Von Hippel–Lindau Familial Exudative Vitreoretinopathy Clinical Signs Vitreoretinal Presentations Optic Disc Anomalies Optic Disc Pits and Optic Disc Coloboma (Figs. 21.32, 21.33, 21.34, 21.35, 21.36, 21.37, 21.38, 21.39, 21.40, 21.41 and 21.42) Morning Glory Syndrome (Fig. 21.56) Retinochoroidal Coloboma (Fig. 21.62) Marfan’s Syndrome (Figs. 21.63, 21.64, 21.65 and 21.66) Retinopathy of Prematurity Surgical Pearl Elevating the Hyaloid in Paediatric Rhegmatogenous Retinal Detachment Uveal Effusion Syndrome Clinical Features (Figs. 21.69, 21.70, 21.71, 21.72 and Fig. 21.73) Surgery Terson’s Syndrome Intraocular Tumours Disseminated Intravascular Coagulation (Fig. 21.80) Hypotony and Pre-Phthisis Bulbi Retinal Prosthesis Summary References Glossary of Abbreviations Others Appendix Useful Formulae and Rules Cryotherapy Fluids (i.e. Both Gases and Liquids) Gases (Figs. A.5 and A.6) Liquids Ultrasound (Fig. A.9) Diffusion and Viscosity Visual Acuity Diffusion References This is the second edition of a highly successful textbook that in many areas has become the preferred manual of vitreoretinal surgery. It provides a complete guide to all common vitreoretinal surgical procedures and also covers diagnosis and other aspects of management. Because it is a single-author publication, there is minimal duplication in the text, avoiding the confusion and overlap characteristic of multiauthor publications. The book is designed to allow a trainee or professional vitreoretinal surgeon to determine the best methodology in individual cases. In order to acquaint the reader with different opinions, “surgical pearls” have been contributed by other international experts in vitreoretinal surgery. These have been welcomed in the past as an illustration of alternative methods, without detracting from the overall method described by the main author. Vitreoretinal Surgery will continue to prove particularly popular amongst trainees, but will also be of value to practicing professionals who need help in the management of difficult and rare cases. The text is backed up by the provision of videos that illustrate some aspects of the surgery.