The Vit-Buckle Society (VBS) meeting provides an open forum to educate vitreoretinal surgeons early in their careers, to nurture innovative surgical technologies and therapeutic approaches to retinal diseases, and to foster best practices. If you’re not a member but are interested in becoming one, find out more at bit.ly/VBSmember.
To continue our coverage of the sixth annual meeting of the Vit-Buckle Society, we chose three talks from session 1 on day 1, which focused on surgical adventures. The fellows selected to summarize these presentations did a great job of highlighting each speaker’s key takeaways. See for yourself below, as Prethy Rao, MD, MPH; Nicholas Farber, MD; and Brian Do, MD, break down presentations by Robert A. Sisk, MD; Jayanth Sridhar, MD; and Lejla Vajzovic, MD, respectively.
In the next issue of Retina Today we will wrap up our coverage of this year’s VBS meeting, so don’t miss it!
—R.V. Paul Chan, MD, MSc; Anton Orlin, MD; and Aleksandra Rachitskaya, MD
Closing the Uncloseable Hole
By Prethy Rao, MD, MPH
No VBS meeting is complete without a thorough discussion of large and complex macular holes. Robert A. Sisk, MD, an ophthalmologist in the Division of Pediatric Ophthalmology at Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, began session 1 with his talk titled “Closing the Uncloseable Hole.” Dr. Sisk described his take on a technique performed by Levent V. Karabas, MD, in holes bigger than 1,000 µm diameter, using perfluoro-N-octane (PFO) to cover the macula, a scraper to migrate retina tissue toward the hole, and a 41-gauge needle to drain the submacular fluid.
A SISK SPIN TO A KARABAS TECHNIQUE
Dr. Sisk shared videos demonstrating this technique in large chronic macular holes and pediatric macular holes (Terson syndrome–related holes and traumatic macular holes). In his experience with traumatic macular holes, Dr. Sisk said, he discovered two modifications that aid in closure: Leave additional temporal internal limiting membrane (ILM) so that it can be reposited back into the hole, and perform a direct PFO-silicone oil (SO) exchange. Narrating a Terson syndrome–related hole, he explained that a simple PFO-SO exchange was not enough to close the hole, so an additional ILM flap was required. Dr. Sisk also noted that use of general anesthesia in pediatric retina cases can be challenging because patients in the initial postoperative recovery phase remain in the supine position. He advocates for opposite-side-down positioning immediately after extubation, followed by prolonged postoperative facedown positioning for these patients.
After reviewing several other techniques for closing holes, Dr. Sisk proposed his own modified surgical technique for challenging macular holes. First, the macula is covered with PFO. Then, a scraper is used to massage the edges of the hole, alternating with aspiration from a 41-gauge subretinal cannula until the hole is dehydrated. Finally, the hole is covered with an ILM flap, and rehydration of the hole is prevented with use of a slow fluid-air exchange or direct PFO-SO exchange.
By Nicholas Farber, MD
Jayanth Sridhar, MD, of Bascom Palmer Eye Institute in Miami, Florida, delivered an excellent talk regarding the lessons he has learned staffing vitreoretinal fellows. He began by offering advice to fellows for enhancing surgical success and decreasing frustration for attending surgeons.
MIND THE PFCL
Dr. Sridhar first emphasized that perfluorocarbon liquid (PFCL) is not magic; it requires the correct technique to be used effectively. Importantly, all traction must be released before PFCL can be used gently to roll out folds. Also, particular and exacting attention must be paid to removing all PFCL at the end of a case. And retina that will not flatten may hold trapped subretinal PFCL or subretinal fluid due to as-yet-unrelieved traction. Dr. Sridhar advised in these situations to remove the PFCL, relieve the traction, and then attempt to flatten the retina again. The bottom line: Understand the limitations of PFCL in order to use it successfully.
THE DEPRESSED EXAMINATION
Dr. Sridhar next underlined the importance of performing examination with scleral depression both in the clinic and in the OR. “You don’t want your elective cases … to come in with unexpected detachments,” he said. Practicing and performing thorough depressed examinations is vital, especially at the end of a case, to find those hidden, possibly uninvolved tears. To find these peripheral breaks, one must also have a clear view. Dr. Sridhar impressed upon the audience that not being able to see is the biggest stressor for attending surgeons and the most common reason for switching with the fellow. “Rather than fighting a bad view … learn to not fight through and understand [how] we can troubleshoot it,” he explained. Top tip: Start troubleshooting anterior to posterior, from indirect system through to retina, for a systematic review of why your view is not working.
BE OPEN TO ALTERNATIVES
The last point Dr. Sridhar had for fellows was to think outside the box. Think about placing ports at the limbus for anterior-to-posterior dissection, or using a viscoelastic substance to temporarily flatten the retina, creating space for further manipulation and careful peeling. His take-home message: Don’t be afraid to use your tools in unconventional, safe ways.
DON’T TRUST EVERYTHING (OR ANYTHING) YOU’RE TOLD
For the second half of his talk, Dr. Sridhar shifted the focus toward attending surgeons. Dr. Sridhar shared what appeared to be a video of a pars plana vitrectomy for a nonclearing vitreous hemorrhage—except the hemorrhage turned out to be metastatic cutaneous melanoma coating the retina. The bottom line: Asking questions and examining patients personally will save time, energy, and grief later on.
Photo courtesy of Kevin Caldwell
FELLOWS GET TIRED
The routine steps of surgically repairing a macular hole are not yet routine for most fellows. Many will quickly expend energy and brain power getting the right view, hand placement, flap formation, peeling technique, etc. With fatigue, the smallest moment can lead to the biggest complication. Attendings should be mindful of the excessive energy consumed by concentrating fellows and “don’t let them get to the point where bad things can happen,” Dr. Sridhar advised. He then made a point to note that fellows aren’t always to blame when an issue arises. Indocyanine green improperly mixed by a scrub nurse or a patient’s cough just when a peel is initiated are factors outside of the fellow’s control, and they can occur just as easily when an attending is operating. Top tip: Understanding, and occasionally humility, are fundamental to learning and training the retina surgeons of the future.
IN ORDER TO LEARN, TEACH
Dr. Sridhar concluded his talk with a nod to his podcast, Straight from the Cutter’s Mouth, and with thanks to those who help produce it, listen to it, and contribute to its success. He offered a great parallel of his VBS lecture in Episode 100 of his podcast when he said, “I have learned more as an attending staffing fellows in a year and a half than I learned in 2 years of fellowship … [and] I learned a ton in fellowship. But you learn so much more when you are supervising, … when there is no safety net, … and when situations become more difficult because of the nature of staffing someone who’s training.”
Digitally Assisted Ophthalmic Surgery
By Brian Do, MD
Lejla Vajzovic, MD, of the Duke University Eye Center in Durham, North Carolina, presented arguments in favor of using intraoperative OCT and the Ngenuity 3D Visualization System (Alcon).
Anticipating a not-so-distant future in which surgeon compensation may be directly tied to surgical outcomes, Dr. Vajzovic asserted that the incorporation of intraoperative OCT into existing 3D heads-up interfaces may be beneficial. She briefly reviewed previous iterations of intraoperative OCT technology, including the handheld device pioneered by Cynthia A. Toth, MD, and her team at Duke, and the more recently commercially available EnVisu portable OCT (Bioptigen) and OPMI Lumera (Zeiss). “With versions of this technology built on swept-source imaging, with which 3D volumetric retinal scans can be conducted and rendered in near-real time (15 Hz), intraoperative OCT may become more robust than ever,” Dr. Vajzovic said.
PROS AND CONS
With the integration of 3D volume intraoperative OCT scans into the 3D heads-up Ngenuity interface, surgeons benefit from improved orientation, similar to the street view seen with navigation interfaces such as Google maps, Dr. Vajzovic suggested. This type of visualization may even obviate the need for dye-assisted membrane peeling in complex surgical cases, she said. The overall value of such technology lies in its ability to identify membranes and delineate otherwise difficult-to-visualize surgical planes, such as in the setting of complex diabetic traction detachments.
Photo courtesy of Kevin Caldwell
Dr. Vajzovic shared a clinical scenario in which she felt that intraoperative OCT was instrumental in surgical success: during macular hole surgery in a myopic patient with choroideremia. Due to a lack of fundus pigmentation, visual identification of membranes was difficult, and staining of membranes was challenging because of the presence of a significant macular staphyloma. As she showed a video of the case, the audience saw firsthand how intraoperative OCT assisted in identifying the desired landmarks and indicated to what degree traction was being exerted on the retinal tissue over which membranes were being peeled, ultimately leading to a positive surgical outcome.
Aside from the cost of implementing intraoperative OCT and the Ngenuity 3D Visualization System in the OR, Dr. Vajzovic said, few downsides seem to exist. “With Ngenuity, visualization of the peripheral vitreous can be technically challenging, and endolaser in lightly pigmented individuals can also be a bit difficult to perform,” she said, “but significant upsides, especially in the academic setting, may make it worth considering.” The upsides include improved ergonomics, the educational value of providing all individuals in the OR with the same detailed view, and the adjustability of illumination and light settings, potentially reducing the risk of phototoxicity.
The combination of Ngenuity’s integrated 3D heads-up interface and intraoperative OCT offers the opportunity for both fellows and attending physicians to simultaneously visualize and identify surgical planes and the effects of tissue manipulation in real time, Dr. Vajzovic said, whereas microscope-integrated technology provides these views only to the primary surgeon.
Dr. Vajzovic concluded her discussion with a look at technology being developed at Duke under the direction of Dr. Toth. The technology aims to offer a fully immersive 3D intraoperative OCT experience, in which the information now presented on a large television screen would be channeled through 3D goggles worn by the surgeon.
Brian Do, MD
• Vitreoretinal Surgeon and Uveitis Specialist, Retina Group of Washington, Washington, DC
• Financial disclosure: None
Nicholas Farber, MD
• Vitreoretinal Surgeon, Southern Vitreoretinal Associates, Tallahassee, Florida
• Financial disclosure: None
Prethy Rao, MD, MPH
• Vitreoretinal Surgeon, Emory University, Atlanta, Georgia
• Financial disclosure: None