Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment

312 Color Atlas of Ophthalm ology

Fig . 10.21 When placing a radial sponge for a large tear, the size of the sponge should be 1 to 2 mm wider than the tear (e.g., 5-mm sponge for a 3-mm tear). The horizontal distance bet ween the t wo radial bites of the double -armed suture should be 2 to 3 mm beyond the width of the sponge (e.g., 7 to 8 mm for a 5-mm sponge). The lat ter distance equals the half circumference of the sponge and can be calculated with the

Radial placem en t of a 5-m m sponge requires a su t ure distan ce of 7.85 or 8.0 m m . In gen eral, th e h orizon tal distan ce bet w een th e radial bites of th e doublearm ed su t u re sh ould be 2 to 3 m m beyon d th e w idth of th e sponge (e.g., 7 to 8 m m for a 5-m m sponge). Th e precise calcu lat ion is h alf circu m feren ce of th e

For proper sup por t of a ret in al tear w ith a radial sponge, th e m at t ress sut ures n eed to be placed from 1 to 2 m m an terior to th e an terior h orn s of th e tear an d 3 to 4 m m posterior to th e apex of th e tear. To ach ieve p roper su t u re ten sion , th e assist an t h olds th e su t ure kn ot after th e surgeon m akes th e first double th row of th e sut ure kn ot (Fig. 10.22).

For a large ret in al tear, a 12-m m sponge or t w o 5-m m sponges are placed side by side. Th e proper h orizon tal dist an ce bet w een th e t w o radial su t ure bites in th e lat ter sit u at ion is calcu lated w ith th e follow ing form ula: 7.85 m m + 5 m m

– com pression factor = 11.5 m m (Fig. 10.23).

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Fig . 10.24 If a large staphyloma is present along the course of an encircling band, it can be covered by a wider silicone groove -piece or tire under the band, which is then sutured on the thicker sclera outside of the staphyloma. (Courtesy of Retina Consultants Ltd.,

St. Louis, MO.)

Anterior Shifting of Suture Tying for a Posterior Buckle

To ease t ying of th e sut u re kn ot for a radial bu ckle, th e su t u re kn ot can be sh ifted from th e p osterior to th e an terior por t ion of th e m at t ress su t u re for t ying (Fig. 10.24).

Drainage of Subretinal Fluid

Drain age of su bret in al flu id can be accom plish ed (1) via a radial scleral in cision or

(2) un der a p ar t ial-th ickn ess t riangular-sh aped scleral flap . Th e scleral cut-dow n is m ade by a n o. 64 or 69 Beaver blade. Diath erm y m ay be used to ach ieve h em o-

Fig. 10.25 A radial scleral drainage site is made with a 3- to 5-mm incision with a no. 64 or 69 Beaver blade. A 5–0 suture may be preplaced on the scleral edges and the edges may be diathermized. A tapered suture needle, a sharp diathermy electrode, a 27or 30gauge needle may be used for the transchoroidal penetration during drainage.

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Fig . 10.26 A triangular scleral flap may also be made for a drainage site. A 5–0 nonabsorbable suture is preplaced on the apex of the scleral flap and the corresponding corner of the scleral bed. A minimal radial cut-down through the rem aining thin scleral fibers of the drainage bed allows a quick exposure of the choroid for drainage.

stasis. Th e ch oroid is p en et rated w ith a tapered n eedle (e.g., 6–0 silk C-1 n eedle), sh arp diath erm y t ip, 27or 30-gauge n eedle, or sh arp kn ife. Th e altern at ive is th e use of laser delivered by an en dolaser probe or a laser in direct oph th alm oscope (Figs. 10.25 an d 10.26).

Cot ton applicators are used to gen tly com press th e sclera adjacen t to th e drain - age site (especially an terior to it) to en h an ce drain age of su bret in al flu id . Th e ap - pearan ce of sm all pigm en t clum ps in th e exit ing flu id in dicates th e elim in at ion of m ost of th e su bret in al fluid . In direct oph th alm oscopy is perform ed to in spect th e com pleten ess of th e fluid drain age an d detect any com plicat ion s associated w ith th e drain age site (Fig. 10.27).

Fig . 10.27 Gentle traction of the edges of the sclerotomy and mild indentation of the sclera with a cot- ton-tipped applicator allow further drainage of the residual subretinal fluid.

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Conclusion

Adh eren ce to th e foregoing proper tech n iqu es for scleral buckling en h an ces th e ch an ce of su ccessful repair of a ret in al det ach m en t . Despite th e in creasing popu - larit y of altern at ive su rgical procedu res, scleral buckling rem ain s a reliable su rgical tech n ique for repairing m ost prim ar y an d cert ain recurren t ret in al detach m en ts. It s vit al role in ach ieving favorable an atom ical an d visu al outcom e for rep airing ret in al detach m en t persist s in th e m odern era of vit reoret in al su rger y.

Choroidal Detachment

Serous Choroidal Detachment

Int raoperat ive or postoperat ive: Woun d leak, perforat ion of th e sclera from a su - perior rect us, bridle su t u re, irit is, cyclodialysis cleft , leakage or excess filt rat ion from a filtering bleb, or after laser ph otocoagu lat ion or cr yoth erapy

Traum at ic: Often associated w ith a rupt ured globe, rh egm atogen ous ret in al detach m en t , or after scleral bu ckling repair or a detach m en t

Presentation

Pat ien ts presen t w ith decreased vision or are asym ptom at ic. Th ere m ay be m oderate to severe pain . Decreased vision m ay occur if th e ch oroidal det ach m en t s (CDs) are tou ch ing (“kissing ch oroidals”) or h em orrh agic. Sm ooth , bu llou s, orangebrow n elevat ion of th e ret in a an d ch oroid usually exten ds 360 degrees aroun d th e periph er y in a lobu lar con figu rat ion . Low in t raocular pressu re (IOP) (often less th an 6 m m Hg), sh allow an terior ch am ber w ith m ild cell an d flare, an d posit ive t ran sillu m in at ion s are associated fin dings.

Differential Diagnosis

Melan om a of th e ciliar y body an d RRD

Management

Check history: Gon ioscopy, fu n du s exam in at ion of both eyes, B-scan , an d absen ce of t ran sillu m in at ion con firm th e diagn osis. Cycloplegic, topical steroid, an d surgical drain age of th e su prach oroidal flu id are th e t reat m en t opt ion s. Repair th e un derlying problem .

W ound leak or leak y filtering bleb: Patch for 24 h ou rs, su t u re th e site, u se cya- n oacr ylate glue, p lace a ban dage con tact len s on th e eye, or a com bin at ion of th ese.

Cyclodialysis cleft: Laser th erapy, diath erm y, cr yoth erapy, or su t ure th e cleft to close it .

Uveit is: Topical cycloplegic an d steroid as discu ssed previou sly

Inflam m atory disease: See th e specific en t it y.

Ret inal detachm ent: Surgical repair. Proliferat ive vit reoret in opathy after repair is com m on .

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Hemorrhagic or Expulsive Choroidal Detachment

In t raoperat ive or postoperat ive (from an terior disp lacem en t of th e ocular con ten ts an d rupt u re of th e sh or t posterior ciliar y ar teries) is th e m ost com m on cau se.

Presentation

Sym ptom s are th e sam e as for serous ch oroidal detach m en t . Pain an d red eye m ay be p resen t m ore often . High IOP (if detach m en t is large), sh allow an terior ch am ber w ith m ild cell an d flare, an d absen ce of t ran sillum in at ion are feat u res in w h ich h em orrh agic CD differs from serous CD.

Differential Diagnosis

Melan om a of th e ciliar y body an d RRD

Management

Ch eck the histor y. Confirm ation of th e diagnosis depen ds on h istor y, gon ioscopy, fundus exam in ation , B-scan , and absen ce of transillum in ation .

An an terior vit rectom y an d drain age of th e ch oroidal det ach m en t is perform ed for severe cases w ith ret in a or vit reous to th e w ou n d . Oth er w ise u se gen eral t reat m en t .

Macular Hole

A m acular h ole is a roun d break involving th e layers of th e ret in a, eith er in a par- t ialor fu ll-th ickn ess m an n er, in th e m acu lar region . Th e lesion is fou n d m ore com m on ly in w om en an d is predom in an t in th e fifth to seven th decades (Fig. 10.28 an d 10.29).

A B

Fig . 10.28 (A) Color fundus photograph showing a well-circumscribed full-thickness macular hole with minimal surrounding fluid cuff. (B) Fundus fluorescein angiography of the sam e patient showing a fading fluorescence in the late phase indicating the window defect, the most com mon FFA finding in macular holes.

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A B

Fig. 10.29 Optical coherence tomography showing (A) a full-thickness and (B) lamellar macular hole.

Presentation

Slit-lam p biom icroscopy of a full-th ickn ess m acu lar h ole sh ow s a w ell-circum - scribed pu n ch ed -ou t lesion th at predom in an tly involves th e fovea. A par t ial-th ick- n ess m acu lar h ole can be an ou ter lam ellar h ole or an in n er lam ellar h ole, depen d - ing on th e et iology beh in d it . It can be classified as follow s:

Fu ll-th ickn ess m acular h ole

Outer lam ellar h ole

In n er lam ellar h ole

Gass Classifica tion for Stages of Idiopa thic Macula r Hole

Stage 1A: Im pen ding h ole, foveal det ach m en t w ith yellow spot

Stage 1B: Im pen ding h ole, foveal det ach m en t w ith yellow h alo

Stage 2: Full-th ickn ess h ole (cen t ral or eccen t ric) form at ion w ith ou t vit reofoveal detach m en t or a PVD

Stage 3: Full-thickness hole w ith focal vitreofoveal detachm ent but absence of a PVD

Stage 4: Fu ll-th ickn ess h ole w ith a PVD

Differential Diagnosis

Various t ypes of m acu lar h oles su ch as lam ellar m acular h ole, pseudoh ole, m yopic m acu lar h ole, m icroh ole an d m acular h ole associated w ith epiret in al m em bran e an d ret in al det ach m en t s, an d pseu dom acular h ole

Management

Observation

Th ere are few st udies describing stage 0 m acular hole, w h ich is a n orm al an d h ealthy retinal m orphology w ith altered vitreoretinal in terface. Stage 0 m acular h ole is a clinically silen t finding detected on optical coheren ce tom ography w here a parafoveal posterior hyaloid separat ion is presen t an d a m in im ally reflective preretin al band is obliquely inserted at one end of th e fovea. A sim ilar fin ding w h en foun d in both th e eyes is associated w ith a sixfold rise in th e incidence of m acular h ole. Th us such cases m ust be follow ed closely an d such patients m ust be coun seled .

Surgica l Management

Vit rectom y is th e m ain stay in th e m an agem en t of m acular h oles. Surger y for th e t reat m en t of m acu lar h ole revolves aroun d t w o prin ciples: (1) to relieve all vit reoret in al t ract ion by m et iculous rem oval of p osterior cor t ical vit reou s an d (2) to use a tam pon ade to close th e h ole (Fig. 10.30).

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Fig . 10.30 “Apple peeling” technique for removal of the internal limiting mem brane (ILM). (1A) The ILM is stained with indocyanine green (ICG) stain. The ILM is grasped with the ILM forceps 500–700 µm above or below the fovea, and a thin strip is peeled radially (arrow) almost to the fovea and released. (1B) This shows the extent of the initial peeled flap of ILM. (1C) The exposed edge is then grasped at its midpoint and a parafoveal strip of ILM is started with a circumferential movement (arrow) around the fovea. (2A) This parafoveal circumferential rhexis is continued (arrow), releasing and regrasping as necessary. (2B) The rhexis halfway around the fovea. (3A) The rhexis approaching a full circle around the fovea as an out ward force vector (arrow) is then intentionally applied so that the ILM strip expands out wardly in a continuous fashion. (3B) Regrasping as necessary, this m aneuver is continued (arrow) until the macular ILM has been removed in a single strip. (3C) The single -piece ILM strip ready for rem oval from the eye, avoiding the need for multiple forceps removals and reinsertions. (4) A conceptual view of the microforceps holding the single -piece removed ILM strip as removed from the retina. Note the unstained area of the retina from which this ILM strip was removed. Light is provided by an endofiberoptic and infusion via a separate infusion port. (Courtesy of Highlights of Oph-

thalmology, “Retinal and Vitreoretinal Surgery: Mastering the Latest Techniques” English Edition, 2002. Editor-in-Chief: Benjam in F. Boyd, MD, FACS; Co-Editor: Sam uel Boyd, MD.)

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Idiopathic Epiretinal Membrane

Iw an off w as th e first to describe idiopath ic epiret in in 1865. It is com m on ly fou n d in older age an d h as been called by variou s n am es:

Macu lar p ucker

Preret in al m acu lar fibrosis

Epiret in al fibrosis

Ep iret in al gliosis

Celloph an e m acu lopathy

Surface w rin kling ret in opathy

Most of th ese epiret in al m em bran es (ERMs) are idiopath ic an d are called pri- m ar y epiret in al m em bran es. W h en associated w ith som e oth er ocu lar disorders, th ey are called secon dar y ERM (Fig. 10.31).

Presentation

Pat ien ts com plain of slow progressive loss of vision , m ild to severe m et am orph o- psia, an d m on ocu lar diplopia. Com plain ts u su ally progress over years. Th ey m ay give som e associated past or t reat m en t h istor y revealing th e cause for th e ERM.

Clin ical ch aracterist ics var y w ith th e grade of th e ERM. An early ERM presen ts as an altered n orm al m acular text u re w ith a glistering sh in e on th e surface. It is difficult to detect on oph th alm oscopic exam in at ion . A lit tle m ore con t ract ile m em bran e presen ts as fin e ret in al st riae radiat ing from th e cen ter of th e ERM.

A