Alessandra Scampoli, MD
Gemelli-Isola Hospital, Rome
One of the highlights of the FLORetina meeting are the live surgery sessions. Each day of the meeting has live surgery on the program.
The live surgery session on Saturday was moderated by D.J. D’Amico and C. Eckardt from “Policlinico A. Gemelli” in Rome and by J.Garcia-Arumi, F. Patelli, M. Romano, T. Hassan, C.D. Regillo and G.K. Shah from the congress room.
The first two surgeons were Emilio Rapizzi and Giuseppe Lo Giudice who started the live session with two macular surgeries. Dr. Rapizzi presented a case of epiretinal membrane foveoschisis in a pseudophakic eye that was approached with an ILM-inverted flap and air tamponade. Dr. Rapizzi used a Zeiss-Lumera 700 microscope and an Alcon Constellation 27G 20.000 cpm probe. Dr. Lo Giudice operated on an epiretinal membrane with membrane peeling and air tamponade, sparing the internal limiting membrane (ILM). He used the Zeiss Artevo 3D system and a Bausch + Lomb, Stellaris Elite 25G system with 15.000 cpm vitreous cutter. He indicated that he prefers the wide-angle lens instead of contact lenses during macular surgery to see both the periphery of the retina and the macula.
The next surgeon was Umberto Lorenzi who approached a difficult case of diabetic tractional retinal detachment in a pseudophakic eye, using a Zeiss Lumera 700 microscope and DORC EVA Nexus 23G 20.000 cpm machine. He dissected the fibrovascular tissues with ILM forceps and scissors and raising the intraocular pressure to 40 mm Hg to avoid continuous intraocular bleeding, partially caused by high blood pressure. (Fig. 1) C. Eckardt suggested to manage these diabetic patients under general anaesthesia to have better control of the blood pressure and to reduce intraocular bleeding. Dr. Lorenzi performed small retinotomies to remove subretinal membranes, pan retinal photocoagulation laser, and concluded with injection of 1000 cs silicone oil. Later, the panel discussed the option of cutting the thin subretinal bands instead of removing them.
Thomas Papathomas then showed a case of myopic foveo-schisis in a 29mm-axial length eye managed with an ILM fovea sparing peel after lutein and dual blue injection and 20% SF6. (Fig. 2) Dr. Papathomas recommended the vitreous staining with triamcinolone or lutein dyes in all myopic eyes, due to the presence of vitreoschisis. He also reported to prefer lutein because of its property to enter inside the vitreous and not only on the surface. Eckardt commented that after lutein the view of the retina was unusual and not clear, but Papathomas indicated it was effects of the video. From the auditorium, it was proposed to potentially inject the vital dye under air for a better staining. The microscope used was Haag Streit, Eubos and the machine was B&L Stellaris 25G.
Next, Remzi Avci approached a degenerative lamellar macular hole with lamellar hole associated epiretinal proliferation (LHEP) with a LHEP embedding technique combined with a temporal ILM-inverted flap. He highlighted that the vital dye spared the LHEP unlike the ILM surrounding it. To gently separate the LHEP, Dr. Avci used a 27G membrane pic by DORC and then ILM forceps. Avci recommended trimming the LHEP when it’s too large to fit the foveal cavity. To promote the adhesion of the temporal flap without folds, he injected perfluorocarbon (PFCL) but it was contested by Garcia Arumi, who recommended to perform fluid-air exchange above the optic disc to leave the ILM flap stable. The microscope was HS HI-R NEO 900 with EIBOS 2 and the machine used was the DORC Eva Nexus.
Next, Petros Petrou operated on a complicated case of diabetic tractional retinal detachment starting with delamination of the fibrovascular tissue followed by pan retinal photocoagulation laser and SF620% as endotamponade, that he chose to reduce the risk of postoperative haemorrhage. He used the Zeiss Lumera 700 3D microscope and Alcon Constellation machine.
Francoise Devin then showcased a highly myopic eye affected by macular detachment, which is repaired with a 25G 20000 cpm Alcon Constellation system, and he reported using specific forceps for highly myopic eyes to reach the posterior pole. During the surgery he also experimented with the black and white 3D filters to increase the contrast in eyes with high myopia.
Marco Mura then repaired a post traumatic choroidal detachment in a phakic young woman. He used the B&L SeeLuma 3D system and the B&L Stellaris Elite 25G 15.000 cpm. He suggested using the chandelier light in cataract surgeries without red reflexes as in this case. Then, he performed two posterior sclerotomies to drain the hemorrhagic choroidal detachment with partial success because of the coagulated blood. He subsequently tried using PFCL to push the choroid in place. D.J. D’Amico suggested to inject tPA in this case. At the end, Dr. Mura performed a direct PFCL/silicone oil exchange, and avoiding gas to avoid postoperative embolism, and decided to stage the surgery.
Next, Cesare Mariotti treated a case of recurrent retinal detachment after primary scleral buckle in a phakic young woman. He used a Leica Proveo 8 microscope and Alcon Constellation 25G 20.000 cpm machine. Dr. Mariotti preferred to leave the clear lens, removed the vitreous, performed a small retinotomy to drain the subretinal fluid and used C3F8 12% as endotamponade. Don D’Amico recommended leaving the subretinal fluid by closing only the causative break without performing a retinotomy to drain it.
Thodoros Gianopoulos operated on a traumatic aphakic eye with implantation of a Carlevale lens and selected a 20G vitrectomy platform for improved manipulation. He reported that he has never had postoperative Carlevale lens dislocation in his personal surgical experience. The microscope used was Haag Streit Eubos and the B&L Stelaris vitrectomy machine.
Daniele Tognetto used 27G finesse forceps to carefully perform a ERM/ILM peeling. He presented a new injector for vital dyes by BVI, which allows gentle injection without bubbles. The microscope was Zeiss Lumera 700, and the machine was Alcon Constellation 27G 20.000 cpm.
Peter Stalmans operated on a patient with a neovascular central retinal vein occlusion with vitreous hemorrhage, performing a 23G phaco-vitrectomy to remove peripheral and central fibrovascular tissues with bimanual techniques. He suggested to start with a mid-peripheral vitrectomy to interrupt all the traction in the periphery. Stalmans used a DORC Eva Nexus machine and Zeiss Artevo 800 microscope, and introduced a disposable wide angle Resight lens with a new optical design and visualization system for better quality of the intraoperative OCT.
Lukas Mishev treated dense vitreous hemorrhage in a patient with proliferative diabetic retinopathy, using 25G vitrectomy and intraoperative fluorescein angiography to highlight the neovascularization and retinal ischemia, which allowed selective endolaser. He used a Zeiss Lumera 700 with special filters and an Alcon Constellation machine.
Carl Claes presented a case of aphakic recurrent retinal detachment under silicone oil. In case of proliferative vitreoretinopathy (PVR), he suggested to peel the fibrovascular membranes and use intravitreal methotrexate, rather than performing large retinectomies.
Next, Barbara Parolini showed a new macular buckle with endoilluminator and a new shape, which was designed Dr. Parolini, to make the scleral implantation easier. In addition to the positioning of the buckle, she also performed 25G PPV to treat the macular traction maculopathy with foveoschisis (stage 2), performing only a core vitrectomy without ILM peeling.
Frederic Matonti repaired an eye with proliferative diabetic retinopathy with tractional retinal detachment. He explained the advantages of 27G probes to dissect fibrovascular tissues. Dr. Matonti used an Alcon Constellation machine and Zeiss Lumera 700 microscope.
Rodolfo Mastropasqua presented a case of recurrent retinal detachment with PVR. He peeled the peripheral and posterior pole membranes using the Alcon Constellation 25G, 20000 cpm machine. He preferred gas C3F812% instead of oil, which he feels is more effective for superior retinal breaks.
Francesco Boscia showed a cataract surgery with the injection of a SING IMT lens, an implantable miniature telescope, in a patient affected by neovascular age-related macular degeneration with a disciform scar. He suggested to perform a large capsulorhexis to more easily place the lens.
The last surgeon was Stratos Gotzaridis who showed another case of proliferative diabetic retinopathy with tractional retinal detachment, repaired with 27G PPV to delaminate the fibrovascular tissue, followed by pan retinal photocoagulation and SF620% as endotamponade. The microscope was Zeiss Lumera 700, and the machine was Alcon Constellation 27G.