Modern small-gauge vitreoretinal surgery allows us to perform complicated cases with better control than in the past. In my practice, I employ small-gauge instruments for vitreous surgery in nearly all cases. The Stellaris PC (Bausch + Lomb) allows me to address even complex cases with excellent control and maneuverability using small-gauge instrumentation. This article describes some complex cases in which I have been able to use the features of the Stellaris to achieve excellent outcomes.
PDR, PVR WITH CATARACT
Frequently, posterior segment pathology is accompanied by concomitant cataract, making the Stellaris PC (PC for procedural choice of anterior or posterior segment functionality) a plus in the OR. In a recent case, the patient had proliferative diabetic retinopathy (PDR) with cataract. There was no posterior vitreous detachment (PVD), and the eye had not received previous laser treatment. Visibility of the retina was poor, and there was a chance of peeling up the retina, causing iatrogenic retinal breaks, in an attempt to create a PVD.
Before entering the vitreous cavity, we removed the cataract (Figure 1) and implanted an intraocular lens. With the cataract out of the way, I could begin carefully creating a PVD without damaging the underlying retina. The dual linear footpedal on the Stellaris PC, controlling both cutting and aspiration, allowed me to do everything with the vitrectomy probe, performing as both forceps and cutter without a second instrument (Figures 2 and 3).
As the surgery progressed, islands of fibrovascular attachment remained between the vitreous and the retina. With the cutter alone, without the help of any additional instrument except the light pipe, I was able to remove these attachments without damaging the retina (Figure 4).
In another case, the patient had cataract with PDR, complicated with tractional and rhegmatogenous retinal detachment with subretinal proliferation, as well as a macular hole. Again, no previous laser treatment had been performed. After cataract surgery and lens implantation, the cutter was used for core vitrectomy, and then the subretinal fluid was aspirated through the macular hole using the cutter probe (Figure 5). Because the tissue was ischemic and there was risk of retinal tear, a bimanual technique was used to delicately delaminate and peel the posterior hyaloid and proliferative tissue (Figure 6A) in order to give the retina the mobility to go back into place. With the epiretinal proliferation and the subretinal fibroses removed (Figure 6B), the retina was flattened around the macular hole, and I was able to perform a controlled retinotomy to drain subretinal fluid (Figure 7).
In another eye with posterior proliferative vitreoretinopathy (PVR), peeling the membrane was not possible, so I decided to remove the internal limiting membrane (ILM). This is a way to be sure all the PVR membranes are removed (Figure 8), and also helps to prevent the re-formation of PVR membranes postoperatively. This approach is especially helpful if immature membranes are present, because in those cases it is difficult to tell whether all membranes have been removed. By removing the ILM up to the equator or even more anteriorly, you can be sure all membranes are gone. After trimming the edge of the retinal tear (Figure 9), laser was applied in the periphery.
A 70-year-old man who had 2 previous surgeries with 5000 centistoke (CS) silicone oil injection due to ocular trauma was referred for surgery (Figure 10). The eye was aniridic. In a trauma case like this and in the presence of silicone oil, I prefer to peel membranes under silicone oil because I think it is easier to perform membrane peeling under silicone oil (Figure 11) than under balanced salt solution. Once posterior peeling was completed, I inserted the infusion line and removed the silicone oil. After I performed bimanual peeling and removal of proliferative membranes with removal of subretinal organized fibrovascular proliferation (Figure 12A), I created a 180º inferior retinotomy with the Stellaris cutter to remove a large subretinal bubble of silicone oil (Figure 12B). When all proliferative membranes had subsequently been removed, the retina was flattened with 5700 cs silicone oil exchange.
A 5-year-old girl was referred to me after multiple surgeries. Her other eye was lost, and she was referred for her highly traumatized right eye. I was confronted with a view of her retina, covered by an inflammatory proliferative membrane (Figure 13). It is vital to have excellent illumination to address a situation like this— to even find a place to start. I began to bimanually separate the thick inflammatory membrane from the retina (Figure 14).
With dual linear foot pedal control, I was able to delaminate the membrane carefully (Figure 15). In general, performance of the Stellaris PC allows surgeons to safely work in close proximity to the retina. After a great deal of work, we were able to flatten the retina, and finally see the optic disc, a welcome sight (Figure 16). At 6 weeks after surgery, some sight has been restored to this little girl's eye, which is of course a gratifying outcome.
Some manufacturers offer instruments that may be compatible with Stellaris PC should the desired instrument not be available from Bausch + Lomb. This is particularly useful when a challenging case demands specific illumination and instrumentation to achieve the best outcome. Complex surgeries are made easier than in the past by using modern vitreoretinal machines such as the Stellaris PC.
Cataract surgery is often necessary before or during surgery in managing complex posterior segment cases. Not only is the Stellaris PC able to facilitate efficient and controlled posterior segment surgery, but it is also designed to accommodate combined phaco and vitrectomy cases where warranted.
Faisal Fayyad, MD, is a Consultant Vitreoretinal Surgeon at Jordan Hospital in Amman. Dr. Fayyad is a consultant for Bausch + Lomb. He may be reached at firstname.lastname@example.org.