Ординатура / Офтальмология / Английские материалы / Retinal and Vitreoretinal Diseases and Surgery_Boyd, Cortez, Sabates_2010

The FILMS® Technique

The appeal of this technique is that it avoids lifting the retina while the ILM is separated from the rest of the retina. The viscoelastic fluid is injected underneath the ILM through a special 36 g microcannula whose proper placement is the most crucial element in the procedure; the microcannula is held in this plane while the surgeon momentarily (i.e., low pressure/flow) injects the viscoelastic (Figures 20 and 21); the injection force is controlled by the foot of the surgeon, thereby avoiding to much pressure that would disrupt the ILM. (Author's Note: The injection force controlled by the foot of the surgeon, requires proportional pressure, with the maximum set at a low level for

this maneuver). Following the creation of the initial bubble, the surgeon withdraws the microcannula to have visual confirmation of being in the correct plane (i.e., under the ILM and not under the retina). The microcannula is then reinserted and its slow advancement is coordinated with further viscoelastic injection. Finally, with an adequate size of ILM separation, the ILM is grasped with forceps and is removed.

Prognosis: A previously incurable disease, most macular holes are successfully closed today, and vision improves in all but the very chronic cases. Most clinicians routinely remove the ILM today, achieving macular hole closure rates of ~95%, 10% to 15% greater than without ILM removal (p<0.0001).2

In summary, traction maculopathies, which used to interfere with the patients‘ visual performance, have now a high cure rate if timely vitreoretinal surgery is carried out. Removal of the ILM, either as part of the actual treatment or as a prophylaxis against recurrence, is usually performed for these pathologies today, and the list of indications is growing. (Author's Note: With our understanding of the pathophysiology of various maculopathies improving, (tangential) traction is increasingly identified as part of

the problem in many diseases; one obvious example is diabetic maculopathy). The surgical techniques are evolving, improving the results and reducing the associated risks.

References

1.Morris, R., Kuhn, F., Witherspoon, C.D. Retinal folds and hemorrhagic macular cysts in Terson’s syndrome. Ophthalmology 101:1, 1994.

2.Mester, V., Kuhn, F. Internal limiting membrane removal in the management of full-thickness macular holes. Am. J. Ophthalmol. 129: 769-777, 2000.

Retinal detachment was first described in the 1700s; however, it was not until the invention of the ophthalmoscope in the mid 1800s when significant advances were made in its diagnosis. At the beginning of the last century, Jules Gonin described the role of the retinal tear in the development of rhegmatogenous retinal detachment, which dramatically changed the treatment.

Characteristics - Relation to Procedure of Choice

Retinal detachments are some of the most time-critical emergencies encountered by ophthalmologists. There are several techniques available for uncomplicated rhegmatogenous retinal detachment surgery, such as the scleral buckle technique, scleral implants, pneumatic retinopexy, the Lincoff balloon technique, or a pars plana vitrectomy. The decision to use one of these therapeutic options is usually

based on various factors, such as the number, location and size of the retinal breaks, the condition of the crystalline lens, individual patient factors, such as the expected compliance with bodily positioning after the surgical procedure, the availability of the operating room, and the surgeon’s preferences.

THE SCLERA BUCKLING PROCEDURE

This procedure, introduced in 1949 and subsequentlymodified,gainedenormouspopularity with the introduction of the binocular indirect ophthalmoscope in the 1950’s. Besides being generally indicated in rhegmatogenous retinal detachment, this procedure is preferred in patients who have any of the following presentations: multiple tears that are distant from one another, grade “C” proliferative vitreoretinopathy(PVR,)greater inferiorretinal breaks and questionable retinal breaks.

First Steps in Scleral Buckling

Precise location of the retinal breaks and a meticulous drawing of the fundus should be done before surgery (Figure 1). The pupil must be adequately dilated. Many retinal surgeons use local anesthesia, which in most cases is quite effective. A mix adds 150 units of hyaluronidase to a combination of 5 cc of 2% lidocaine and 5 cc of 0.75% bupivacaine. A total of 6 cc of this mixture is injected. This combination without hyaluronidase is also effective. Parabulbar or flush local anesthesia method may be used.

During the procedure more anesthesia may be added with the use of a blunt cannula in the sub-Tenon’s space. The anesthesiologist monitors the procedure closely and uses intravenous medication as needed.

3). If only one or two quadrants are to be buckled, the extension of the peritomy is limited (Figure. 2). Tenon’s capsule is separated from the sclera by blunt dissection, and two

Figure 1: Color Diagram of a Retinal Detachment Chart. The retinal detachment characteristics are drawn in a specific chart using a well known color key among ophthalmologists. This chart includes the patient ́s name, date and the affected eye. The detached retina is colored in blue, the attached retina is colored in red and the causative retinal tears or degenerations are colored in red outlined with blue. (Art from Jaypee Highlights Medical Publisher).