Surgical Technique
Edited by George A. Williams
Interface Vitrectomy
I
fluid, retinectomy, or vitreous base truncation in twoport infusion-free reoperations (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A215, demonstrating proliferative vitreoretinopathy membrane removal and other maneuvers under oil in a patient with previous acute retinal necrosis and proliferative vitreoretinopathy membranes overlying numerous retinal breaks). This technique is used, as previously described,3 for recurrent retinal detachment because of proliferative vitreoretinopathy or epimacular membrane under previously placed silicone oil. With oil interface vitrectomy, surface tension management is applied to any patent retinal break, which maintains a stable or decreased amount of subretinal fluid intraoperatively. The presence of subretinal oil is a dynamic intraoperative assessment of the remaining traction, and resolves upon adequate epiretinal membrane removal or retinectomy.
nterface vitrectomy is a technique previously described1–4 for operating at the interface between vitreoretinal tissue and substances immiscible in aqueous media. The authors have routinely used the interface between air, silicone oil, and perfluorocarbons for enhanced visualization of vitreoretinal pathology and stabilization of retinal tissue intraoperatively. This report demonstrates 25-gauge pars plana vitrectomy maneuvers under air and silicone oil. Description of Technique Air
Interface vitrectomy3 is used after a full vitreous cavity air fill for enhanced visualization of the vitreous base. The microvitrector is placed within the vitreous base with the port directed away from the retinal surface, and the vitreous removed (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A215, demonstrating vitreous base truncation under air). We have recently used this technique in 86 consecutive rhegmatogenous retinal detachment repairs using wideangle contact-based visualization without scleral depression, none of which developed iatrogenic retinal breaks or new retinal breaks in the postoperative period. Visualization to the pars plana was possible under air in all cases without scleral depression, using a contactbased method. The technique is routinely used in phakic vitrectomy for enhanced visualization of the vitreous base.
Perfluoro-n-octane Perfluoro-n-octane (PFO) may be used for interface vitrectomy during retinal detachment repair, particularly those involving giant retinal breaks or multiple retinal breaks. For giant retinal breaks, a full PFO fill is performed, and any residual vitreous is highlighted at the vitreous–PFO interface. For total retinal detachments with multiple retinal breaks, PFO is filled to the posterior border of the most posterior retinal break, and peripheral vitrectomy performed.
Oil
Discussion 3,5
Interface vitrectomy is used under silicone oil for membrane peeling, internal drainage of subretinal
Operating at the interface between the vitreous and immiscible media may be advantageous for multiple reasons. Air provides dampening of retinal motion and instantaneous surface tension management of retinal breaks. The air–vitreous interface provides instantaneous visualization of any 3-dimensional structure (Figure 1) of the residual vitreous during vitreous base truncation. This technique is primarily used after internal drainage of subretinal fluid during retinal detachment repair, anterior loop proliferative vitreoretinopathy removal, macular hole surgery, and may eliminate the need for scleral depression during
From the *Hamilton Eye Institute, Division of Vitreoretinal Surgery, Health Sciences Center, University of Tennessee, Memphis, Tennessee; and †Division of Vitreoretinal Surgery, Charles Retina Institute, Memphis, Tennessee. 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 of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Eric J. Sigler, MD, Charles Retina Institute, 6401 Poplar Avenue, Suite 190, Memphis, TN 38119; e-mail: ejsigler@ gmail.com
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SURGICAL TECHNIQUE
removal of emulsification from the anterior chamber and tissue manipulation under the overlying silicone oil, which may include internal drainage of subretinal fluid, epiretinal membrane removal, retinectomy, and endophotocoagulation. The authors do not advocate peeling the epiretinal membrane under PFO because of the very low viscosity of PFO, and the potential entry of PFO into the subretinal space in this context. However, performing vitrectomy over underlying PFO may enhance visualization of peripheral vitreous similar to the appearance under air or oil. The microvitrector is placed within peripheral vitreous and vitrectomy performed to maintain a single indwelling PFO bubble. Visualization of peripheral vitreous may also be enhanced with retroillumination by reflected light from the top of the PFO interface. Fig. 1. Vitreous base morphology under air during interface vitrectomy. A. The vitreous base is highlighted by the air–vitreous interface (arrowheads) and the endoilluminator (arrow) is directed parallel to the inner vitreous contour. B. The microvitrector (asterisk) is placed within the vitreous with the port directed away from the retina, and base truncation performed.
peripheral vitrectomy. Peripheral vitreous cortex separation from the retinal surface may also be extended in this manner. Theoretically, iatrogenic retinal breaks cannot result in subretinal fluid if there is no overlying infusion fluid present, as in air or oil interface vitrectomy. In addition, a wider field of visualization is possible under air. The vitreous–silicone interface provides excellent visualization of residual vitreous and epiretinal membrane, and oil provides viscous dampening of retinal motion. With the eye in operating position, a meniscus of subretinal fluid, blood, or PFO assumes its gravity-dependant position beneath silicone oil or a drainage retinotomy site, and emulsification droplets migrate to the anterior chamber. This allows the
Key words: interface vitrectomy, pars plana vitrectomy, proliferative vitreoretinopathy, silicone oil. ERIC J. SIGLER, MD*† STEVE CHARLES, MD*† JORGE I. CALZADA, MD*† References 1. Charles S. Techniques and tools for dissection of epiretinal membranes. Graefes Arch Clin Exp Ophthalmol 2003;241: 347–352. 2. Charles S. An engineering approach to vitreoretinal surgery. Retina 2004;24:435–444. 3. Charles S, Randolph JC, Sigler EJ. Pars plana vitrectomy reoperation without removing silicone oil. Retina 2012;32: 1664–1665. 4. Voleti VB, Gee CJ, Devin F, Hubschman JP. Vitrectomy under air. Retina 2012;32:1981–1982. 5. Yang CM, Hsieh YT, Yang CH, Liu KR. Irrigation-free vitreoretinal surgery for recurrent retinal detachment in silicone oilfilled eyes. Eye (Lond) 2006;20:1379–1382.
Edited by George A. Williams
Interface Vitrectomy
I
fluid, retinectomy, or vitreous base truncation in twoport infusion-free reoperations (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A215, demonstrating proliferative vitreoretinopathy membrane removal and other maneuvers under oil in a patient with previous acute retinal necrosis and proliferative vitreoretinopathy membranes overlying numerous retinal breaks). This technique is used, as previously described,3 for recurrent retinal detachment because of proliferative vitreoretinopathy or epimacular membrane under previously placed silicone oil. With oil interface vitrectomy, surface tension management is applied to any patent retinal break, which maintains a stable or decreased amount of subretinal fluid intraoperatively. The presence of subretinal oil is a dynamic intraoperative assessment of the remaining traction, and resolves upon adequate epiretinal membrane removal or retinectomy.
nterface vitrectomy is a technique previously described1–4 for operating at the interface between vitreoretinal tissue and substances immiscible in aqueous media. The authors have routinely used the interface between air, silicone oil, and perfluorocarbons for enhanced visualization of vitreoretinal pathology and stabilization of retinal tissue intraoperatively. This report demonstrates 25-gauge pars plana vitrectomy maneuvers under air and silicone oil. Description of Technique Air
Interface vitrectomy3 is used after a full vitreous cavity air fill for enhanced visualization of the vitreous base. The microvitrector is placed within the vitreous base with the port directed away from the retinal surface, and the vitreous removed (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A215, demonstrating vitreous base truncation under air). We have recently used this technique in 86 consecutive rhegmatogenous retinal detachment repairs using wideangle contact-based visualization without scleral depression, none of which developed iatrogenic retinal breaks or new retinal breaks in the postoperative period. Visualization to the pars plana was possible under air in all cases without scleral depression, using a contactbased method. The technique is routinely used in phakic vitrectomy for enhanced visualization of the vitreous base.
Perfluoro-n-octane Perfluoro-n-octane (PFO) may be used for interface vitrectomy during retinal detachment repair, particularly those involving giant retinal breaks or multiple retinal breaks. For giant retinal breaks, a full PFO fill is performed, and any residual vitreous is highlighted at the vitreous–PFO interface. For total retinal detachments with multiple retinal breaks, PFO is filled to the posterior border of the most posterior retinal break, and peripheral vitrectomy performed.
Oil
Discussion 3,5
Interface vitrectomy is used under silicone oil for membrane peeling, internal drainage of subretinal
Operating at the interface between the vitreous and immiscible media may be advantageous for multiple reasons. Air provides dampening of retinal motion and instantaneous surface tension management of retinal breaks. The air–vitreous interface provides instantaneous visualization of any 3-dimensional structure (Figure 1) of the residual vitreous during vitreous base truncation. This technique is primarily used after internal drainage of subretinal fluid during retinal detachment repair, anterior loop proliferative vitreoretinopathy removal, macular hole surgery, and may eliminate the need for scleral depression during
From the *Hamilton Eye Institute, Division of Vitreoretinal Surgery, Health Sciences Center, University of Tennessee, Memphis, Tennessee; and †Division of Vitreoretinal Surgery, Charles Retina Institute, Memphis, Tennessee. 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 of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Eric J. Sigler, MD, Charles Retina Institute, 6401 Poplar Avenue, Suite 190, Memphis, TN 38119; e-mail: ejsigler@ gmail.com
616
617
SURGICAL TECHNIQUE
removal of emulsification from the anterior chamber and tissue manipulation under the overlying silicone oil, which may include internal drainage of subretinal fluid, epiretinal membrane removal, retinectomy, and endophotocoagulation. The authors do not advocate peeling the epiretinal membrane under PFO because of the very low viscosity of PFO, and the potential entry of PFO into the subretinal space in this context. However, performing vitrectomy over underlying PFO may enhance visualization of peripheral vitreous similar to the appearance under air or oil. The microvitrector is placed within peripheral vitreous and vitrectomy performed to maintain a single indwelling PFO bubble. Visualization of peripheral vitreous may also be enhanced with retroillumination by reflected light from the top of the PFO interface. Fig. 1. Vitreous base morphology under air during interface vitrectomy. A. The vitreous base is highlighted by the air–vitreous interface (arrowheads) and the endoilluminator (arrow) is directed parallel to the inner vitreous contour. B. The microvitrector (asterisk) is placed within the vitreous with the port directed away from the retina, and base truncation performed.
peripheral vitrectomy. Peripheral vitreous cortex separation from the retinal surface may also be extended in this manner. Theoretically, iatrogenic retinal breaks cannot result in subretinal fluid if there is no overlying infusion fluid present, as in air or oil interface vitrectomy. In addition, a wider field of visualization is possible under air. The vitreous–silicone interface provides excellent visualization of residual vitreous and epiretinal membrane, and oil provides viscous dampening of retinal motion. With the eye in operating position, a meniscus of subretinal fluid, blood, or PFO assumes its gravity-dependant position beneath silicone oil or a drainage retinotomy site, and emulsification droplets migrate to the anterior chamber. This allows the
Key words: interface vitrectomy, pars plana vitrectomy, proliferative vitreoretinopathy, silicone oil. ERIC J. SIGLER, MD*† STEVE CHARLES, MD*† JORGE I. CALZADA, MD*† References 1. Charles S. Techniques and tools for dissection of epiretinal membranes. Graefes Arch Clin Exp Ophthalmol 2003;241: 347–352. 2. Charles S. An engineering approach to vitreoretinal surgery. Retina 2004;24:435–444. 3. Charles S, Randolph JC, Sigler EJ. Pars plana vitrectomy reoperation without removing silicone oil. Retina 2012;32: 1664–1665. 4. Voleti VB, Gee CJ, Devin F, Hubschman JP. Vitrectomy under air. Retina 2012;32:1981–1982. 5. Yang CM, Hsieh YT, Yang CH, Liu KR. Irrigation-free vitreoretinal surgery for recurrent retinal detachment in silicone oilfilled eyes. Eye (Lond) 2006;20:1379–1382.
