Christopher Chung, MD, MD
Illinois Eye and Ear Infirmary, Chicago, IL
Tina Felfeli, MD, PhD
University of Tornto, Toronto, Canada
The session moderated by Drs. Ferhina Ali and Donald D’Amico, the International Surgical Retina session offered a fascinating glimpse into the surgical techniques, resourcefulness, and challenges faced by retina specialists across the globe. From pediatric eyes to syndromic conditions and advanced proliferative disease, each speaker demonstrated grit and ingenuity worthy of the “cowboys and cowgirls” theme.
Dr. Danilo Iannetta from Italy presented a case of a retinal detachment in a high myope, entitled “Giving Up Wasn’t an Option.” He shared his case of a 59-year-old highly myopic woman with a macula off retinal detachment with a difficult to identify break. Using 23-gauge pars plana vitrectomy, Dr. Iannetta encountered a challenging posterior vitreous detachment induction for which he converted to a chandelier approach with a bimanual technique (using forceps and Tano scraper). Dr. Iannetta highlighted the value of intraoperative OCT in this case for identifying the posterior break which was subsequently marked with diathermy. A complete air-fluid exchange was performed, followed by the placement of a small amniotic membrane graft over the break, and the eye was filled with silicone oil. This patient had a good outcome after eventual silicone oil removal and remained flat at the 18-month follow-up.
Dr. Susan Teixeira from Portugal presented an inspirational talk on “ROP Stage 5 Surgery, Stretching Limits.” She shared with the audience her approach in a very challenging case of twins with bilateral stage 5C retinopathy of prematurity who had characteristic tent-shaped retinal detachments. She highlighted that in these cases, a stalk-like structure, often representing persistent fibrovascular proliferation or residual vitreoretinal traction, should be carefully dissected. In her surgical video, she showed the meticulous and slow opening of the anterior fibrotic membranes and central stalk, and the careful dissection of the retrolental membranes while avoiding any iatrogenic breaks. With surgery aimed at relieving traction, retinal reattachment was achieved in both cases with perfusion on intravenous fluorescein angiography. Both twins maintained ambulatory vision in the operated eyes. The key takeaway from Dr. Teixeira is that oftentimes less is more to avoid creating iatrogenic breaks once traction has been relieved when operating on pediatric eyes with severe tractional detachments.
Dr. Makoto Inoue of Japan presented his talk titled “The Surgical Management of VHL.” He highlighted a case of a 14-year-old male with a history of cerebellar and spinal cord tumors, a known diagnosis of Von Hippel-Lindau Syndrome (VHL), and peripheral retinal capillary hemangioblastoma. Dr. Inoue demonstrated his approach to the management of this case using a one-handed technique with self-depression with anterior viewing to release peripheral traction. He used a combination of laser photocoagulation and trans-scleral cryotherapy to treat the lesion under air. Additionally, diathermy was applied to the arteries and veins feeding the tumor. This case required another surgery with scleral buckle and pars plana vitrectomy with C3F8 gas for repair of a retinal detachment and remained attached 3 years later with no recurrence of hemangioblastoma. Dr. Inoue also demonstrated a second case of a retinal vasoproliferative tumor in a patient with a history of retinopathy of prematurity who underwent membrane peeling and at one-year follow-up demonstrated minimal exudation.
Dr. Maria A. Martinez-Castellanos from Mexico shared a moving overview of her experiences and the challenges in managing oxygen-associated retinopathy (OAR). She presented the classification and morphological differences of vasculature in oxygen-associated retinopathy compared to retinopathy of prematurity. The staging of OAR consists of Stage 1 with capillary dropout and vascular loops, Stage 2 with avascular “islands” in previously vascularized retina with a clear demarcation line, Stage 3 with visible ridge formation, and pathological neo-vessels, Stage 4 with partial retinal detachment, and Stage 5 with retinal detachment. She advocated for the use of oxygen blenders and strict oxygen monitoring as a management strategy for OAR. She ended the presentation by reminding the audience of the importance of visual rehabilitation and that the most challenging work takes place beyond the operating room.
Dr. Kgao E. Legodi of South Africa provided an update on surgical techniques and practices to avoid intraoperative complications. His talk discussed advancements in vitreoretinal surgery taking place in South Africa. As an example, he highlighted increasing proximity of the vitreous cutter to the retina associated with increased risk of iatrogenic breaks. Chandelier and bimanual surgery are now commonly employed in South Africa to minimize the risks of iatrogenic breaks.
Dr. Gabriela Lopez-Carasa of Mexico gave a talk titled, “Flowers in the Desert: Closing Macular Holes Cowgirl Style.” She demonstrated two separate techniques for the closure of macular holes. In her first case, she demonstrated that operating on chronic traumatic macular holes in children can be beneficial. Performing a flower-like technique with inverted ILM flaps is helpful in traumatic macular holes with fibrosis at the edges of the hole. Her next case presentation was the repair of a diabetic tractional retinal detachment with a full-thickness macular hole with the use of Brilliant Blue G and NGENUITY Blue Boost for visualization. In this case, she showcased that a freeze-dried amniotic membrane graft can be inserted through 25-gauge cannulas. She recommended the use of a MaxGrip or Serrated forceps, partial air-fluid exchange, and unfolding of the amniotic membrane and tucking it under the macular hole edge using a soft tip cannula. Once tucked, the remainder of the subretinal fluid was removed, and the eye was filled with silicone oil. Successful hole closure was maintained 1.5 months later under silicone oil.
Dr. Nur Acar Gocgil from Turkey shared a challenging case of recurrent proliferative vitreoretinopathy detachment and strategies to identify these cases early. She presented a case of a 62-year-old male with a history of PPV and silicone oil for recurrent retinal detachment. Following silicone oil removal, he developed flashes and tractional PVR detachment at 2 weeks. A 23-gauge pars plana vitrectomy (PPV) and scleral buckle (SB), with silicone oil 5000 was performed. She warned the audience to always be cautious with a silicone oil-filled eye when not the primary surgeon, and to review any additional risk factors. She also highlighted that thin lamella of the vitreous in particular in pediatric, myopic, and inflammation-prone eyes can cause traction and re-detachment. She suggested that postoperative inflammation and hypotony can be important signs of PVR, which can be minimized with post-operative intravitreal injection of methotrexate.
This session sparked a lively, and thought-provoking discussion among audience members. From resourceful adaptations to surgical creativity, the presentations showcased the remarkable depth of expertise around the world. The session embodied the spirit of resilience, innovation, and global camaraderie that defines the international retina community.