CHANDELIER-ASSISTED EXTERNAL DRAINAGE OF SUBRETINAL FLUID Jay Chhablani, MS, DNB, Divya Balakrishnan, FNB
Purpose: External drainage could be indicated for long-standing nonresolving exudative retinal detachment secondary to chronic central serous chorioretinopathy, capillary hemangioma, and Coats disease. The authors report a modified technique of external drainage of subretinal fluid using Chandelier illumination. Methods: Muscles were tagged after conjunctival exposure. After placing the Chandelier illumination at the 12-o’clock position, 26-gauge needle attached with cannula is inserted externally at the equator into the subretinal space. Under direct visualization through surgical microscope, subretinal fluid was slowly removed and the needle was withdrawn. After maintaining the intraocular pressure, retina was examined and was found to be attached. Results: Successful removal of subretinal fluid achieved without any complications. Conclusion: Chandelier-assisted external drainage of subretinal fluid is easier, wellcontrolled, and a convenient technique, which provides continuous direct visualization during external drainage of subretinal fluid to achieve excellent anatomical and visual outcome and prevent complications. RETINAL CASES & BRIEF REPORTS 9:223–225, 2015
step of drainage, sometimes, the fluid gets shifted to the posterior pole and the peripheral retina becomes flat or the detachment becomes very shallow in the periphery, which leads to failure of drainage and complications. Self-retaining 25-gauge Chandelier endoilluminator is used commonly in vitreoretinal surgeries. Scleral buckling using 25-gauge Chandelier illumination is a recently introduced method.8 Here, we describe a modification of the technique for external subretinal fluid drainage, as described by Charles,5 by using Chandelier endoilluminator for direct visualization in a case of chronic exudative retinal detachment secondary to central serous chorioretinopathy.
From the Smt.Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, Hyderabad, India.
E
xternal drainage of subretinal fluid is one of the most complicated step during scleral buckling. External drainage could be indicated for long-standing nonresolving exudative retinal detachment secondary to chronic central serous chorioretinopathy, capillary hemangioma, and Coats disease.1–3 Various methods of external drainage of subretinal fluid have been reported, including conventional scleral cutdown, needle aspiration, external argon endolaser probe, and suture needle.4–7 External drainage can be associated with complications such as retinal incarceration, subretinal hemorrhage, and loss of vitreous. The challenging situation, while performing an external drainage, is the posterior shifting of subretinal fluid. As the patient is in lying down position before the actual
Case Report After administration of local anesthesia, the procedure was performed under a surgical microscope. The sclera was exposed with an inferotemporal conjunctival incision, the extraocular muscles including inferior recti and lateral recti were hooked at the insertion in the left eye, and traction sutures were placed with 4/0 black silk. Conventional external drainage, cutdown technique, was attempted in the inferotemporal quadrant. However, a dry tap was noticed. On indirect examination, the subretinal fluid was found to be accumulated at the posterior pole, with no fluid in the periphery. Subretinal hemorrhage due to previous attempt was noted, without any retinal tear. An oblique incision with a 25-gauge trocar cannula (Chandelier lighting system; Alcon, Fort Worth, TX) was placed 3.5 mm away
None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprint requests: Jay Chhablani, MS, DNB, Smt.Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, L. V. Prasad Marg, Banjara Hills, Hyderabad 500 034, Andhra Pradesh, India; e-mail: [email protected]
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from the limbus at the 12-o’clock position to visualize the inferior retina. A 25-gauge Chandelier light was inserted into the cannula. A wide-field noncontact lens binocular indirect ophthalmoscope (BIOM; Oculus, Lynnwood, WA) along with stereoscopic diagonal inverter was used, and the fundus was observed using a surgical microscope. A 26-gauge needle was attached with the aspiration tube and a 5-mL syringe (Figure 1). The entry site was localized by depressing the sclera with shaft of the 26-gauge needle under visualization through surgical microscope. After careful observation of maximum height of the bullae, 26-gauge needle was inserted just posterior to the equator. After confirming the subretinal location of the needle, the needle was pushed forward in the subretinal spaces under direct visualization and bevel was turned toward choroid. The assistant performed slow aspiration, and slowly the needle was withdrawn. As soon as the needle was out of the eye, hypotony was noted. Ringer lactate solution was injected to achieve the normal intraocular pressure, and the fundus was evaluated. Complete attachment of the retina was achieved (Figure 2). The 25-gauge cannula was removed, and the site was compressed using cotton-tip applicator to confirm that there was no leakage. Surgery was completed by conjunctival closure (see Video, Supplemental Digital Content 1, http://links.lww.com/ICB/A13).
Discussion Subretinal fluid drainage is considered as the most dangerous step during the scleral buckle surgery. Complications during subretinal fluid drainage include retinal incarceration, subretinal hemorrhage, and loss of vitreous. Diagnosis of these complications before the significant damage happens is essential. Several techniques have been proposed to perform external drainage of subretinal fluid with direction to reduce complications. Conventional external drainage is performed by making a sclerotomy followed by choroidotomy using diathermy. Raymond et al7 reported a suture needle drainage technique, which helped to reduce the complications, especially retinal incarceration due to small sclerotomy site. Charles5 reported a needle and Fig. 2. A. Exudative retinal detachment with posterior bullae and chandelier illumination at the 12-o’clock position (arrow). Subretinal hemorrhage (black arrow) due to failed external drainage was noted. B. Needle (arrow head) is inserted into the subretinal space in the inferotemporal quadrant, and subretinal fluid is drained under direct visualization. C. Attached retina throughout after removal of subretinal fluid.
Fig. 1. A 26-gauge needle attached with an aspiration tube and a 5-mL syringe.
syringe technique with continuous internal monitoring with indirect ophthalmoscope. Azad et al4 reported a modified needle drainage technique by perforating the sclera perpendicularly with a 26-gauge half-inch disposable needle attached to a 2-mL glass syringe with the plunger removed. Once the bead of fluid is seen in the hub of the needle, the needle is immediately withdrawn to permit spontaneous subretinal fluid
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drainage. Jaffe et al6 reported external drainage by tightening of the buckle before needle drainage. Nevertheless, continuous internal monitoring is necessary during external subretinal fluid drainage to identify imminent complications before the damage occurs and manage them before they endanger the anatomical or visual outcomes. Continuous internal monitoring helps surgeon to control the drainage of fluid under direct visualization, which is considered to be an uncontrolled and dangerous process. In addition, internal monitoring assures complete drainage of subretinal fluid and helps to achieve better anatomical and visual outcome. Traditionally, continuous internal monitoring is performed using indirect ophthalmoscope. However, this requires repeated removal and adjustment for visualizing the fundus. This makes this technique inconvenient, time consuming, and ergonomically uneasy. Advantages of chandelier illumination are to provide continuous monitoring of the procedure. Chandelier illumination can be used using regular surgical microscope and vitrectomy machine; it does not require any special equipment, such as Optic Fiber Free Intravitreal Surgical System (Topcon, Inc, Paramus, NJ). Another advantage of Chandelier illumination is easy placement and removal of the cannula. Chandelier illumination seems to be an excellent teaching tool for residents and fellows for such difficult and dangerous steps of surgery. This technique achieves better ergonomics for the vitreoretinal surgeons. Using an aspiration tube prevented the fluttering of the retina and allowed a slow removal of subretinal fluid. This prevented a sudden decompression of the globe and associated complications as well. In place of the aspiration tube with 26-gauge needle, pediatric
intravenous cannula can be used. In addition, 25-gauge infusion cannula can also be placed to maintain constant pressure during the drainage to avoid the hypotony. In conclusion, Chandelier-assisted external drainage of subretinal fluid is easier, well-controlled, and convenient technique, which provides continuous direct visualization during subretinal fluid drainage to achieve excellent anatomical and visual outcome and prevent complications. Key words: chandelier, SRF drainage, subretinal fluid, retinal detachment. References 1. Han ES, Choung HK, Heo JW, et al. The effects of external subretinal fluid drainage on secondary glaucoma in Coats’ disease. J AAPOS 2006;10:155–158. 2. Tsai FY, Lau LI, Chen SJ, et al. Persistent exudative retinal detachment after photodynamic therapy and intravitreal bevacizumab injection for multiple retinal capillary hemangiomas in a patient with von Hippel-Lindau disease. J Chin Med Assoc 2014;77:52–56. 3. Kang JE, Kim HJ, Boo HD, et al. Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy. Korean J Ophthalmol 2006;20:131– 138. 4. Azad R, Kumar A, Sharma YR, Rajpal. Modified needle drainage. A safe and efficient technique of subretinal fluid drainage in scleral buckling procedure. Indian J Ophthalmol 2004;52:211–214. 5. Charles ST. Controlled drainage of subretinal and choroidal fluid. Retina 1985;5:233–234. 6. Jaffe GJ, Brownlow R, Hines J. Modified external needle drainage procedure for rhegmatogenous retinal detachment. Retina 2003;23:80–85. 7. Raymond GL, Lavin MJ, Dodd CL, McLeod D. Suture needle drainage of subretinal fluid. Br J Ophthalmol 1993;77:428–429. 8. Nam KY, Kim WJ, Jo YJ, Kim JY. Scleral buckling technique using a 25-gauge chandelier endoilluminator. Retina 2013;33:880–882.
Purpose: External drainage could be indicated for long-standing nonresolving exudative retinal detachment secondary to chronic central serous chorioretinopathy, capillary hemangioma, and Coats disease. The authors report a modified technique of external drainage of subretinal fluid using Chandelier illumination. Methods: Muscles were tagged after conjunctival exposure. After placing the Chandelier illumination at the 12-o’clock position, 26-gauge needle attached with cannula is inserted externally at the equator into the subretinal space. Under direct visualization through surgical microscope, subretinal fluid was slowly removed and the needle was withdrawn. After maintaining the intraocular pressure, retina was examined and was found to be attached. Results: Successful removal of subretinal fluid achieved without any complications. Conclusion: Chandelier-assisted external drainage of subretinal fluid is easier, wellcontrolled, and a convenient technique, which provides continuous direct visualization during external drainage of subretinal fluid to achieve excellent anatomical and visual outcome and prevent complications. RETINAL CASES & BRIEF REPORTS 9:223–225, 2015
step of drainage, sometimes, the fluid gets shifted to the posterior pole and the peripheral retina becomes flat or the detachment becomes very shallow in the periphery, which leads to failure of drainage and complications. Self-retaining 25-gauge Chandelier endoilluminator is used commonly in vitreoretinal surgeries. Scleral buckling using 25-gauge Chandelier illumination is a recently introduced method.8 Here, we describe a modification of the technique for external subretinal fluid drainage, as described by Charles,5 by using Chandelier endoilluminator for direct visualization in a case of chronic exudative retinal detachment secondary to central serous chorioretinopathy.
From the Smt.Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, Hyderabad, India.
E
xternal drainage of subretinal fluid is one of the most complicated step during scleral buckling. External drainage could be indicated for long-standing nonresolving exudative retinal detachment secondary to chronic central serous chorioretinopathy, capillary hemangioma, and Coats disease.1–3 Various methods of external drainage of subretinal fluid have been reported, including conventional scleral cutdown, needle aspiration, external argon endolaser probe, and suture needle.4–7 External drainage can be associated with complications such as retinal incarceration, subretinal hemorrhage, and loss of vitreous. The challenging situation, while performing an external drainage, is the posterior shifting of subretinal fluid. As the patient is in lying down position before the actual
Case Report After administration of local anesthesia, the procedure was performed under a surgical microscope. The sclera was exposed with an inferotemporal conjunctival incision, the extraocular muscles including inferior recti and lateral recti were hooked at the insertion in the left eye, and traction sutures were placed with 4/0 black silk. Conventional external drainage, cutdown technique, was attempted in the inferotemporal quadrant. However, a dry tap was noticed. On indirect examination, the subretinal fluid was found to be accumulated at the posterior pole, with no fluid in the periphery. Subretinal hemorrhage due to previous attempt was noted, without any retinal tear. An oblique incision with a 25-gauge trocar cannula (Chandelier lighting system; Alcon, Fort Worth, TX) was placed 3.5 mm away
None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprint requests: Jay Chhablani, MS, DNB, Smt.Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, L. V. Prasad Marg, Banjara Hills, Hyderabad 500 034, Andhra Pradesh, India; e-mail: [email protected]
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from the limbus at the 12-o’clock position to visualize the inferior retina. A 25-gauge Chandelier light was inserted into the cannula. A wide-field noncontact lens binocular indirect ophthalmoscope (BIOM; Oculus, Lynnwood, WA) along with stereoscopic diagonal inverter was used, and the fundus was observed using a surgical microscope. A 26-gauge needle was attached with the aspiration tube and a 5-mL syringe (Figure 1). The entry site was localized by depressing the sclera with shaft of the 26-gauge needle under visualization through surgical microscope. After careful observation of maximum height of the bullae, 26-gauge needle was inserted just posterior to the equator. After confirming the subretinal location of the needle, the needle was pushed forward in the subretinal spaces under direct visualization and bevel was turned toward choroid. The assistant performed slow aspiration, and slowly the needle was withdrawn. As soon as the needle was out of the eye, hypotony was noted. Ringer lactate solution was injected to achieve the normal intraocular pressure, and the fundus was evaluated. Complete attachment of the retina was achieved (Figure 2). The 25-gauge cannula was removed, and the site was compressed using cotton-tip applicator to confirm that there was no leakage. Surgery was completed by conjunctival closure (see Video, Supplemental Digital Content 1, http://links.lww.com/ICB/A13).
Discussion Subretinal fluid drainage is considered as the most dangerous step during the scleral buckle surgery. Complications during subretinal fluid drainage include retinal incarceration, subretinal hemorrhage, and loss of vitreous. Diagnosis of these complications before the significant damage happens is essential. Several techniques have been proposed to perform external drainage of subretinal fluid with direction to reduce complications. Conventional external drainage is performed by making a sclerotomy followed by choroidotomy using diathermy. Raymond et al7 reported a suture needle drainage technique, which helped to reduce the complications, especially retinal incarceration due to small sclerotomy site. Charles5 reported a needle and Fig. 2. A. Exudative retinal detachment with posterior bullae and chandelier illumination at the 12-o’clock position (arrow). Subretinal hemorrhage (black arrow) due to failed external drainage was noted. B. Needle (arrow head) is inserted into the subretinal space in the inferotemporal quadrant, and subretinal fluid is drained under direct visualization. C. Attached retina throughout after removal of subretinal fluid.
Fig. 1. A 26-gauge needle attached with an aspiration tube and a 5-mL syringe.
syringe technique with continuous internal monitoring with indirect ophthalmoscope. Azad et al4 reported a modified needle drainage technique by perforating the sclera perpendicularly with a 26-gauge half-inch disposable needle attached to a 2-mL glass syringe with the plunger removed. Once the bead of fluid is seen in the hub of the needle, the needle is immediately withdrawn to permit spontaneous subretinal fluid
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drainage. Jaffe et al6 reported external drainage by tightening of the buckle before needle drainage. Nevertheless, continuous internal monitoring is necessary during external subretinal fluid drainage to identify imminent complications before the damage occurs and manage them before they endanger the anatomical or visual outcomes. Continuous internal monitoring helps surgeon to control the drainage of fluid under direct visualization, which is considered to be an uncontrolled and dangerous process. In addition, internal monitoring assures complete drainage of subretinal fluid and helps to achieve better anatomical and visual outcome. Traditionally, continuous internal monitoring is performed using indirect ophthalmoscope. However, this requires repeated removal and adjustment for visualizing the fundus. This makes this technique inconvenient, time consuming, and ergonomically uneasy. Advantages of chandelier illumination are to provide continuous monitoring of the procedure. Chandelier illumination can be used using regular surgical microscope and vitrectomy machine; it does not require any special equipment, such as Optic Fiber Free Intravitreal Surgical System (Topcon, Inc, Paramus, NJ). Another advantage of Chandelier illumination is easy placement and removal of the cannula. Chandelier illumination seems to be an excellent teaching tool for residents and fellows for such difficult and dangerous steps of surgery. This technique achieves better ergonomics for the vitreoretinal surgeons. Using an aspiration tube prevented the fluttering of the retina and allowed a slow removal of subretinal fluid. This prevented a sudden decompression of the globe and associated complications as well. In place of the aspiration tube with 26-gauge needle, pediatric
intravenous cannula can be used. In addition, 25-gauge infusion cannula can also be placed to maintain constant pressure during the drainage to avoid the hypotony. In conclusion, Chandelier-assisted external drainage of subretinal fluid is easier, well-controlled, and convenient technique, which provides continuous direct visualization during subretinal fluid drainage to achieve excellent anatomical and visual outcome and prevent complications. Key words: chandelier, SRF drainage, subretinal fluid, retinal detachment. References 1. Han ES, Choung HK, Heo JW, et al. The effects of external subretinal fluid drainage on secondary glaucoma in Coats’ disease. J AAPOS 2006;10:155–158. 2. Tsai FY, Lau LI, Chen SJ, et al. Persistent exudative retinal detachment after photodynamic therapy and intravitreal bevacizumab injection for multiple retinal capillary hemangiomas in a patient with von Hippel-Lindau disease. J Chin Med Assoc 2014;77:52–56. 3. Kang JE, Kim HJ, Boo HD, et al. Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy. Korean J Ophthalmol 2006;20:131– 138. 4. Azad R, Kumar A, Sharma YR, Rajpal. Modified needle drainage. A safe and efficient technique of subretinal fluid drainage in scleral buckling procedure. Indian J Ophthalmol 2004;52:211–214. 5. Charles ST. Controlled drainage of subretinal and choroidal fluid. Retina 1985;5:233–234. 6. Jaffe GJ, Brownlow R, Hines J. Modified external needle drainage procedure for rhegmatogenous retinal detachment. Retina 2003;23:80–85. 7. Raymond GL, Lavin MJ, Dodd CL, McLeod D. Suture needle drainage of subretinal fluid. Br J Ophthalmol 1993;77:428–429. 8. Nam KY, Kim WJ, Jo YJ, Kim JY. Scleral buckling technique using a 25-gauge chandelier endoilluminator. Retina 2013;33:880–882.
