Pearls for Pediatric Retina Surgery
Continuing the series on surgical pearls for pediatric patients, the editors of Retina Today are proud to include two surgical pearls from leading pediatric retina surgeons.
Peeling the Posterior Hyaloid
By Audina Berrocal, MD
One of the most challenging techniques in pediatric retina surgery is lifting the posterior hyaloid. In babies and children, the hyaloid is taut and lifting it with high aspiration through smaller gauge instrumentation can be quite difficult and time-consuming.
I do not use any intravitreal enzymatic adjuvants before surgery to alter the vitreoretinal interface. However, I will stain the vitreous for two purposes: (1) to be certain that I have completely removed it at the end of the surgery, and (2) because it is beneficial to demonstrate to fellows who may be present just how much vitreous there can be in the eyes of younger patients.
After staining the vitreous I use a macular lens and, starting at the optic nerve, radially tease the vitreous until I get an edge that is visible. Then I separate the hyaloid using the vitrector with high vacuum. Previously, I used a Tano diamond dusted silicone tip brush for this step. A newer instrument, the Flexi Loop (Alcon), has now become my instrument for this step. This instrument is much less damaging to the retina and you can see through the loop, which is vital for assessing any damage that may have been done to the retina—something that is a bit more difficult to appreciate with a Tano brush.
Using this technique allows me to elevate very taut membranes efficiently while imparting minimal trauma to the retinal surface. This technique can also be used to dissect the vitreous from the peripheral retina in cases where it seems to be strongly attached to the equatorial retina. In either case, if areas where the vitreous cannot be separated remain, I feel it is best to fill the eye with oil and perform a second procedure when I go back in to remove the oil. In such cases I have a low threshold to repeat laser to the areas where I pulled new membranes, and I like to leave these eyes with air or gas. In other words, stop while you are ahead!
Audina Berrocal, MD, is a professor of clinical ophthalmology and medical director of pediatric retina and retinopathy of prematurity at the Bascom Palmer Eye Institute in Miami, Florida. She is a member of the Retina Today editorial board. Dr. Berrocal may be reached at firstname.lastname@example.org.
Anterior Chamber Maintainers
By Michael Trese, MD
Maintaining the ocular structure and consistent fluid flow to the posterior chamber are important and sometimes overlooked aspects of pediatric retinal surgery. One way this can be accomplished in phakic eyes is by using an anterior chamber space maintainer. This will reduce the risk of inciting iatrogenic retinal damage. An anterior chamber maintainer allows surgeons to perform procedures such as scleral external drainage of subretinal material while maintaining the vitreous cavity’s structure.
This tactic can be effectively applied to several scenarios, such as a pediatric patient presenting with Coats disease and a total retinal detachment. Many surgeons do not realize they can drain externally while also maintaining the vitreous cavity with an anterior chamber maintainer.
We all know that the aqueous is created in the ciliary body, enters through the zonules, and exits via the anterior angle, but some retina surgeons forget that they can maintain the vitreous cavity with an anterior fluid infusion. After all, it is just fluid flowing in the other direction. n
Michael T. Trese, MD, is a clinical professor of biomedical sciences at the Eye Research Institute of Oakland University, a clinical associate professor at Wayne State University School of Medicine, and chief of pediatric and adult vitreoretinal surgery at William Beaumont Hospital, all in Michigan. Dr. Trese may be reached at +1-248-288-2280 or at email@example.com.