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Fig. 10.25 Drawing of the situation in the eye during a PFCL against air exchange after retinectomy. Perform a thorough drainage of the water at the edge of the retinectomy in order to avoid slippage of the retina
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cmolter
Pits & Pearls
Choroidal bleeding: One of the major risks of a retinotomy is cutting into the choroid. This will cause a significant haemorrhage and may be difficult to control. It usually happens if the retina is too close to the choroid in the area of the retinotomy. To detach it from the choroid, fill the eye with PFCL. The subretinal fluid will be pushed anteriorly in a doughnut shape and will detach the anterior retina. It is now easier to perform a retinotomy, and the anterior edge of the retina is easily identified.
Pits & Pearls No. 59
Air bubbles behind IOL: Beware of a posterior capsulotomy and a fluid-air exchange in pseudophakic patients. During a fluid-air exchange, the water condenses at the posterior surface of the IOL in the area of the capsulotomy, thereby greatly impairing the view of the posterior pole. It can either be removed with a fluid needle or injection of viscoelastics onto the posterior surface of the IOL (Figs. 10.26 and 10.27).
9. Laser therapy of breaks and apply a circular laser cerclage
If the retina is sufficiently mobilized, it can be photocoagulated under PFCL. Treat all breaks. If you performed a retinotomy, laser along the edges (Fig. 10.28). A circumferential laser (360°) is usually not recommended. It is only essential to treat all breaks and retinotomies. You cannot ‘fix’ an area of retinal fold with laser scars – you either have to perform more membrane peeling or extend the retinotomy.
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Fig. 10.26 During a fluid/air exchange, bubbles may form behind the IOL. Wipe them either with a fluid needle or remove them by injecting viscoelastics behind the IOL
Fig. 10.27 After injection of viscoelastics, the visually disturbing bubbles are removed
Fig. 10.28 A PVR detachment secondary to trauma under silicone oil tamponade. The retinectomy edges are laser treated. The strange shape of the edges is caused indirectly by the trauma
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10. Tamponade
A simple rule of thumb is for superior PVR use light silicone oils and occasionally long-acting gas (15% C2F6, 14% C3F8) and for an inferior PVR use heavy silicone oils (Densiron 68®).
Light silicone oil tamponade
You can perform a PFCL against silicone oil or an air against ilicone oil tamponade. For exchange of air with silicone oil: see Fig. 4.10a, b.
Exchange of PFCL with silicone oil
The silicone oil filled syringe is connected to the infusion line. Through active injection, the oil is injected into the eye, while you hold the fluid needle in the PFCL bubble. In the end, you can identify the two different liquid phases – the oil bubble floats in the front and the PFCL on the central pole – aspirate until the last PFCL bubble is gone.
Pits & Pearls
Removal of PFCL: It can sometimes be difficult to remove the final small PFCL bubble because you first have to increase the intraocular pressure by infusing more silicone oil and then you have to get in touch with the small bubble. If the pressure is now too high, there is a substantial risk of aspirating retina into the fluid needle, which usually means retina at the posterior pole. A more gentle and controlled way is to increase the intraocular pressure with one of your fingers, usually a ring finger of one of your hands. Press on the eye to increase the pressure, cover the opening of the fluid needle as soon as the bubble is aspirated (otherwise it will drop back into the eye when you release the finger pressure), and then remove the fluid needle from the eye.
Heavy silicone oil tamponade (Densiron 68®, Oxane Hd®)
Perform a heavy fluid to air exchange and then an air to heavy silicone oil exchange. For details see Sect. 4.2: Postoperative tamponade.
Pits & Pearls No. 60
Iridectomy: If you use heavy silicone oil and an iridectomy is needed, it must be performed at 12 o’clock. Densiron 68® is a heavy silicone oil and will tamponade the inferior retina. Perform the iridectomy optimally in a PFCL or water-filled eye.