Asad Durrani, MD
Prashanth Iyer, MD
Linnet Rodriguez, MD
Wills Eye Hospital, Philadelphia, PA
The 14th session, “What if it’s the Demogorgon?!” focused on complications and was moderated by Paula Pecen, MD. Panelists included Kyle D. Kovacs, Carlos A. Medina, Katherine E. Talcott, and Scott D. Walter. A total of 10 videos were presented and they are summarized below.
RRD during IOL exchange: The first video showcased a patient who developed endophthalmitis following cataract surgery. After pars plana vitrectomy, the visual acuity improved from LP to 20/50. The patient, however, subsequently developed a dislocated intraocular lens. During repeat vitrectomy for IOL exchange and placement of an Akreos lens, the patient was found to have a retinal detachment. The retina was repaired without complication, but the decision was made to avoid an Akreos IOL given the risk of potential opacification with tamponade. The panelists discussed surgical options including MX60 at the time of RD repair versus a staged surgery.
Retinal patch graft: Next, Iuri Golubev MD from Eye Associates of New Mexico presented a surgical video entitled “Central macula repositioning after iatrogenic separation”. Dr. Golubev described a patient who had been receiving intravitreal injections for AMD who developed an RRD with PVR. During removal of the PVR membranes, the fovea and localized surrounding tissue lifted with the membranes and was torn entirely from the macula leaving a hole at the fovea, likely due to integration of pre-retinal membranes with the CNV complex. The surgeon was able to peel the membranes and salvage the retinal operculum. Perfluorocarbon liquid (PFCL) was injected and the operculum was placed back at the fovea to patch the iatrogenic hole. The posterior breaks were lasered and Dr. Golubev performed a direct PFCL to silicone oil exchange to minimize dislocation of the patch.
Silicone oil overfill: Next up was a case describing a closed funnel RD repair in an aphakic patient where silicone oil entered the anterior chamber at the conclusion of the case after the trocars had been removed and the sclerotomies were sutured. Viscoelastic was placed in the anterior chamber to increase pressure and BSS on a cannula was then used to burp the oil out of the anterior chamber. The panel suggested an alternative approach where the cannulas were left in place to have more control over the IOP, and they also discussed the possibility of tolerating some oil in the anterior chamber.
Light pipe strikes again: During an ERM peel, the light pipe touched down on the temporal macula resulting in hemorrhage – a complication which many have seen before. The panel discussed how to handle the subsequent conversation with the patient and how to teach trainees instrument positioning during peeling where the field of view is narrow.
Unrepaired scleral laceration in patient with RRD: Dr. Mohsin Ali, MD presented a case of a post-trauma RD. At the start of the case, a 13 mm laceration was discovered behind the rectus muscles that had been missed during the primary globe repair. There was significant scarring due to the delay in repair, making isolation of all 4 rectus muscles impossible prior to scleral buckle placement. Dr. Ali used a sponge instead of an encircling band which is a reasonable option when all four muscles cannot be isolated. After the initial surprise, the case proceeded smoothly.
Frag burn: Next up was Dr. Tavish Nanda, MD, who described a patient with a macula-threatening RRD and cataract was brought to the OR. While using the fragmatome, the lens was not being removed efficiently, and soon a scleral burn was noted at the sclerotomy site. The scleral burn was closed with a figure-of-eight vicryl suture as well as an interrupted nylon suture. The cause of the burn was incorrect machine settings: the aspiration rate was set to 50 instead of 150-200. The case was performed after hours, and the panelists discussed the importance of double-checking surgical setup when working with unfamiliar teams or infrequently used instruments.
Subretinal PFO: A case of retained sub-foveal PFO was presented. The surgeon utilized a 41-gauge subretinal cannula to remove the PFO from under the retina. The panelists noted that knowing when to stop is key, as all of the PFO does not need to be removed for surgical success. More harm may come from attempting to remove every last bubble of PFO.
GORE-TEX suture rescue: During an intraocular lens exchange utilizing the GORE-TEX sutured method of scleral fixation, the sutures on one side of the lens were removed from the eye accidentally without tying a knot. The surgeons utilized a handshake technique to re-thread the GORE-TEX suture while the lens was in the eye in order to save the day.
PVR, ERM, RRD: This case involved a patient that previously had a primary RD repair with PPV/SO and 4 months later was undergoing silicone oil removal and ERM membrane peeling. During repeat air-fluid and fluid-air exchanges to wash residual oil, an aggressive fluid gush hit the inferonasal retina and caused a hole. The ERM was peeled as planned and the detachment was repaired with oil. To decrease the chance of an aggressive fluid gush during exchange of air with fluid, some suggested quick bursts of the vitrector, not aspirating the air too fast and lowering the IOP during fluid refilling.
Glass IOFB: Everything was going smoothly during IOFB removal in this case until air-fluid exchange when there was noted to be hypotony and collapse of the eye. Upon further inspection, there was a scleral laceration under the rectus muscle that was missed at the start of the case. While suturing this scleral laceration, a second glass IOFB was discovered in the suprachoroidal space! This case highlighted the importance of always performing a careful examination of the sclera in all cases of IOFB as there may be multiple entry sites.
Photos courtesy of Kevin Caldwell