Fig. 5.2 Viscodissector. Viscodissector (BD Visitec¨ 20-gauge×1-in. cannula with 30-gauge×3/16- in. tip extension) can be used to separate the posterior hyaloid face and Þbrovascular tissue from the underlying retina with a viscous solution such as Healon¨, which contains 10 mg/ml of sodium hyaluronate dissolved in physiological sodium chloride phosphate buffer; it is transparent with relatively high viscosity. Healon¨ can be injected between the Þbrovascular proliferation and the retina using the viscodissector cannula attached to a syringe held by the surgical assistant

In addition, the rates of retinal reattachment and visual acuity improvement were similar among the viscodissection and conventional membrane dissection cohorts. Viscodissection (using Healon¨) was associated with a greater incidence of elevated postoperative intraocular pressure despite the fact that active aspiration was used to remove intraocular Healon¨ at the end of the case. Viscodissection can be particularly helpful when there is a traction-rhegmatogenous retinal detachment with no or only limited preexisting separation of the hyaloid from the underlying detached retina and atrophic retina and relatively Þrm attachment of the posterior hyaloid to the retina. In circumstances where delamination is difÞcult for small-gauge surgery, viscodissection can be a particularly useful tool to initiate the delamination dissection.

Conclusion

Surgical intervention with PPV has been the mainstay of treatment for eyes with active PDR. With the availability of pharmacologic agents, including anti-VEGF drugs and ocriplasmin, the future management of active PDR will change. A combination treatment may be the best option. However, the type, dose, timing, frequency, and order of use of various pharmacologic drugs as adjuvant therapy to PPV should be evaluated in prospective randomized clinical trials.

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