- •Acknowledgment
- •Abbreviations and Glossary
- •Contents
- •Introduction
- •1: Should You Become a VR Surgeon?
- •2.2 A Word of Caution
- •Introduction
- •3: Fundamental Rules for the VR Surgeon
- •3.4 The “What, When, How – and Why” Questions
- •3.5 Don’t Start What You Cannot Finish
- •3.6 Common Sense vs Dogma
- •3.7 Maximal Concentration During the Entire Operation
- •3.8 Make Life as Easy for Yourself as Possible
- •3.9 Under Peer Pressure: To Yield or Not to Yield
- •3.10 Referral of the Patient
- •3.11 The Rest of the Eyeball…
- •4.1 What If the Surgeon Has Tremor?
- •4.2 How Important Is Good Dexterity?
- •4.5 Combined Surgery or Cataract Surgery Separately?
- •4.7 How Much Confidence in Himself Should the VR Surgeon Have?
- •4.8 How Long Do Vitrectomies Take?
- •4.9 Was Surgery Successful?
- •5.1 The “Target” of Counseling
- •5.2 The Patient Does Not Know Most of What Is so Obvious to the Surgeon
- •5.3 Communicating with the Patient
- •5.4 Coaching vs Trying to Be Objective
- •5.5 The Ultimate Treatment Decision: “Whose Eye Is It?”
- •5.6 Which of the Two Eyes to Operate on First?
- •5.7 What if the Eye Has Two Diseases?
- •5.8 What if the Eye Has Severe Visual Loss and the Chance of Improvement with Another Surgery Is Low?
- •5.9 Empathy: The Single Most Important Component of Counseling
- •5.10 The Prognosis with the Chosen Surgical Option
- •5.11 If the Patient Chooses to Undergo Surgery
- •5.12 The Benefits of Proper Counseling
- •5.14 The Dogmas
- •6: The VR Surgeon’s Relation to His Nurse
- •7: Examination
- •8: The Indication Whether to Operate
- •8.1 The Argument in Favor of Surgery
- •8.3 The Age of the Patient
- •8.4 The Condition of the Fellow Eye
- •11: The Surgeon’s Relation to Himself
- •11.3 Self-Examination
- •Introduction
- •12.1.1 The Pump
- •12.1.1.1 Peristaltic Pump: Flow Control
- •12.1.2 The Probe
- •12.1.2.2 Port Location
- •12.1.2.3 Port Configuration and Size
- •12.1.2.4 Cut Rate
- •12.1.2.6 Probe Length
- •12.1.3 The Light Source/Pipe
- •12.1.4 The Infusion Supply
- •12.1.5 The Trocar
- •12.1.6 The Cannula
- •12.1.7 System to Inject/Extract Viscous Fluid
- •12.1.8 The Pedal
- •12.1.10 Endodiathermy Probe
- •12.1.11 The User Interface of the Vitrectomy Console
- •12.1.12 Troubleshooting
- •12.2 The Microscope
- •13: Instruments, Tools, and Their Use
- •13.2.1.1 General Concepts of Working with Squeezable Instruments
- •13.2.1.2 The Handle
- •13.2.1.3 Forceps
- •13.2.1.4 Scissors
- •13.2.2 Hybrid Instruments
- •13.2.2.2 Retractable Instruments
- •13.2.3 Non-squeezable Hand Instruments
- •13.2.3.1 Bent (Hooked, Barbed) Needle
- •13.2.3.2 Membrane Scraper
- •13.2.3.3 Spatula/Pic
- •13.2.3.4 Intraocular Magnet
- •13.3.1 Membrane Dissection (“Viscosurgery”): Viscoelastics as a Spatula
- •13.3.2 Opening a Closed Funnel
- •14: Materials and Their Use
- •14.2 Intravitreal Gas
- •14.3 Silicone Oil
- •14.3.1 Types of Silicone Oil
- •14.3.3 Complications Related to Silicone Oil Use
- •14.3.4 Complications Related to Silicone Oil Use Removal
- •14.4 PFCL
- •14.6 Sutures
- •15: Anesthesia
- •15.1 How to Decide the Type of Anesthesia
- •15.2 If Local Anesthesia Is Chosen
- •15.3 Medications If Local Anesthesia Is Used
- •16: The Surgeon at the Operating Table
- •16.1 The OR Personnel
- •16.2 The Operating Table and the Surgeon’s Chair
- •16.2.1 The Operating Table
- •16.2.2 The Surgeon’s Chair
- •16.4 The Microscope
- •16.5 The BIOM
- •16.5.1 BIOM: The Advantages
- •16.5.2 BIOM Use: Practical Information
- •16.5.3 BIOM: Setting Up for Daily Use
- •16.5.4 BIOM: Checklist
- •16.5.5 BIOM: Troubleshooting
- •16.6 The Patient
- •16.7 The Surgeon
- •16.7.2 At the Start of Vitrectomy
- •16.7.3 Staring into the Microscope
- •16.8 Music in the OR
- •16.9 The Brightness in the OR
- •16.10 The Quality of the Air in the OR
- •16.12 The Blueprint of the OR
- •16.13 The Captain in the OR
- •16.14 The Fundamental Technical Rules of Performing Intravitreal Surgery
- •Introduction
- •17.3 The Endoscope Approach (EAV)
- •17.4 Portable Systems
- •17.5 3D Viewing
- •18.1 Disinfection and Draping
- •18.2 The Monocular Patient
- •18.3 At the Conclusion of the Operation
- •19: The Speculum and Its Placement
- •19.1 General Considerations
- •19.2 Speculum Placement
- •20.3 Injecting into the Vitreous Cavity During Surgery
- •21: Sclerotomies and the Cannulas
- •21.2 Location of the Sclerotomies
- •21.2.1 Distance from the Limbus
- •21.2.2 Location in Clock Hours
- •21.2.3 In Case of a Reoperation
- •21.2.4 In Case of Scleral Thinning
- •21.3 Inserting the Cannula
- •21.4 The Order of Cannula Placement
- •21.5 If the Palpebral Opening Is Small
- •21.6 Checking the (Infusion) Cannula
- •21.6.1 Cannula Under the Choroid/Retina: Prevention
- •21.6.2 Cannula Under the Choroid/Retina: Management
- •21.6.3 Infusion Going Under the Choroid/Retina: Management
- •21.7 The Cannulas in Use
- •21.8 The Removal of the Cannulas
- •21.8.1 Hypotony: The Causes
- •21.8.2 Hypotony: The Consequences
- •21.8.3 Hypotony: Prevention
- •21.8.4 Hypotony: Postoperative Management
- •22: Illumination
- •22.1 The Light Pipe
- •22.3 Light Built into the Handheld Instruments
- •24: Using the Vitrectomy Probe
- •24.1 Removal of the Vitreous
- •24.2 Removal of Proliferative Membranes
- •24.3 Removal of the Retina
- •24.4 Removal of the Lens
- •25: Maintaining Good Visualization
- •25.1.1 The Microscope
- •25.1.2 The Contact Lens
- •25.1.3 The Corneal Surface
- •25.1.4 The Corneal Stroma
- •25.2 Internal Factors
- •25.2.2 Pupil
- •25.2.2.1 Mechanical Forces Preventing Pupil Dilation
- •25.2.2.2 Intracameral Adrenalin or Visco
- •25.2.2.4 Iris Ring
- •25.2.2.5 Iridotomy
- •25.2.3 Lens
- •25.2.3.1 Cataract
- •25.2.3.2 “Feathering”
- •25.2.3.3 “Gas Cataract”
- •25.2.3.4 “Lens Touch”
- •25.2.4.1 Phimosis of the Anterior Capsule
- •25.2.4.2 Deposit on the Anterior IOL Surface
- •25.2.4.3 Problems with the IOL Itself
- •25.2.4.4 Fluid Condensation
- •25.2.5 The Posterior Capsule
- •25.2.6 The Vitreous Cavity
- •25.2.7 Epiretinal (Subhyaloidal) Materials
- •25.2.7.1 Blood
- •25.2.8 The Surgeon’s Actions
- •25.2.9 “Chromovitrectomy”
- •26.1.1 Vitreous Macroanatomy
- •26.1.2 Vitreous Biochemistry and Its Anatomical and Functional Implications
- •26.1.3 Retinal Histology and Macroanatomy
- •26.1.4 Anterior Segment Dimensions
- •26.2 External Anatomy for the VR Surgeon
- •26.3 Physiology: What Keeps the Retina Attached?
- •26.3.1 The RPE Pump
- •26.3.3 Presence of the Vitreous Gel
- •27: The Basics of Vitreous Removal
- •27.1 The Rationale for PPV
- •27.2 How Much Vitreous to Remove?
- •27.3 Recognizing the Presence of the Vitreous Gel
- •27.3.1 Mechanical Aids
- •27.3.2 Air (Pneumovitrectomy)
- •27.3.3 Stains and Markers
- •27.4 The Sequence of Vitreous Removal
- •27.5.2 Vitrectomy Anterior to the Equator
- •27.5.3 Vitrectomy Behind the Lens
- •28: Scleral Indentation
- •28.1 The Advantages of Scleral Indentation
- •28.2 The Mechanics of Vitrectomy with Scleral Indentation
- •28.3 Internal vs External Illumination
- •28.5 External Illumination and Nurse Indentation
- •28.6 Instrumentation and Technique
- •29: Cryopexy
- •29.1 Indication in RD
- •29.2 Surgical Technique
- •29.3 Cryopexy as a Destructive Force
- •30: Endolaser
- •30.1 The Consequences of Laser Treatment
- •30.2 The Setup
- •30.3 The Technique of Endolaser Treatment
- •30.3.1 General Considerations
- •30.3.2 Panretinal Treatment
- •30.3.3 Endolaser Cerclage and Its Complications
- •30.3.4 Endolaser as a Walling-Off (Barricading) Tool
- •30.3.5 Endolaser as a Welding Tool
- •30.4 Peripheral Laser and the Beginner VR Surgeon
- •30.5 Endocyclophotocoagulation
- •30.6 Laser Cerclage at the Slit Lamp
- •31: Working With and Under Air
- •31.1.1 Attached Retina
- •31.3 The Utilization of an Air Bubble
- •32: Working with Membranes
- •32.1.1 Instrumentation and Infrastructure
- •32.1.2 Opening the ILM
- •32.1.2.1 Sharp Opening: Incision First
- •32.1.2.2 Blunt Opening: No Incision
- •The Scraper
- •32.1.3 Peeling the Membrane
- •32.1.4 The Extent of ILM Peeling
- •32.1.5 What If the ILM Cannot Be Peeled?
- •32.1.6 ILM Removal in Eyes with Detached Macula
- •32.1.6.1 Reattaching the Macula First
- •32.1.6.2 Peeling When the Macula Is Still Detached
- •32.2.2 Removal Technique
- •32.2.2.1 Staining or Not?
- •32.2.2.2 Instrumentation
- •32.2.2.3 Location of the Point of Attack
- •32.2.2.4 The Major Risks When First Grabbing an EMP
- •32.2.2.5 The Direction of Peeling: Centripetal vs Centrifugal
- •32.2.2.6 The Speed of Peeling
- •32.2.2.7 The Extent of Peeling
- •32.2.2.8 ILM Peeling
- •32.2.2.9 Completion of Surgery
- •32.3.1.1 Recognition
- •32.3.1.2 The Goals of Surgery
- •32.3.1.3 Instrumentation
- •32.3.1.4 Surgical Steps
- •32.3.1.5 Closed Funnel/Retinal Incarceration
- •32.3.1.6 ILM Removal
- •32.4 Subretinal Membranes/Strands
- •33.1 Retinectomy
- •34: Chromovitrectomy
- •34.1 Posterior Vitreous Cortex
- •34.3.1 False-Positive Staining with ICG
- •34.3.2 Injection Technique for Staining the ILM
- •34.4 Newly Formed (PVR) Membranes
- •35: Tamponades
- •35.2 Gases
- •35.2.1 General Considerations
- •35.2.3 Gas Injection into the Nonvitrectomized Eye
- •35.2.4 The Eye with Gaseous Tamponade
- •35.3.1 Indications to Use Heavier-Than-Water Liquids
- •35.3.2 Surgical Technique
- •35.3.2.1 Implantation
- •35.4 Silicone Oil
- •35.4.1 Selecting the Type of Silicone Oil to Implant
- •35.4.2 General Considerations
- •35.4.3 Indications
- •35.4.3.1 Semipermanent Tamponade
- •35.4.3.2 Permanent Tamponade
- •35.4.4 Implantation
- •35.4.5 With Silicone Oil in the Eye
- •35.4.5.1 General Considerations
- •35.4.5.2 Emulsification
- •35.4.6 Removal
- •35.4.6.1 Timing
- •35.4.6.2 Surgical Technique
- •35.5 Exchanges
- •35.6 If the Eye Is Aphakic
- •36: Submacular Hemorrhage
- •36.1 The Nonsurgical Approach: Intravitreal Gas and tPA
- •36.2 Removal of the Clot In Toto
- •36.4 The Minimalistic Surgical Approach
- •37: Subretinal Biopsy
- •38: Combined Surgery
- •38.1 Phacoemulsification
- •38.2 Lensectomy
- •38.2.1 Lens In Situ
- •38.3.1 Lens In Situ
- •38.3.2 Lens in Vitreous
- •38.4.2 No IOL Implantation
- •38.5 Capsule Removal
- •38.5.1 Indications
- •38.5.2 Surgical Technique
- •38.6.1 Advantages
- •38.6.2 Surgical Technique
- •38.6.3 Subsequent Sub/luxation of an Iris-Claw IOL
- •38.6.3.1 Subluxated Lens
- •38.6.3.2 Luxated Lens
- •39: AC Basics
- •39.1 Paracentesis
- •39.2 Iris Prolapse
- •39.3 Anterior Synechia
- •39.5 Material in the AC
- •40.2 Retinal Tear
- •40.3 Reopening of a Posterior Scleral Wound
- •40.4 Lens/IOL Trauma
- •41: Pediatric Patients
- •42: The Highly Myopic Eye
- •42.1 The Risk of RD If Cataract Surgery Is Needed
- •42.2 Vitrectomy in the Highly Myopic Eye
- •42.3 Posterior RD over a Staphyloma
- •43: Intravitreal Injections
- •Introduction
- •44: Dropped Nucleus and Dislocated IOL
- •44.1 General Considerations
- •44.1.2 Dislocated IOL
- •44.2 Surgical Technique
- •44.2.1 Dropped Nucleus
- •45: Endophthalmitis
- •45.1 General Considerations
- •45.1.1 Etiology
- •45.1.2 Clinical Diagnosis
- •45.1.3 Timing
- •45.1.4 Treatment Options and Management Philosophy
- •45.2 Surgical Technique
- •45.3 Posttraumatic Endophthalmitis
- •46: Floaters
- •46.1 General Considerations
- •46.1.1 Indication for Surgery
- •46.1.2 Timing of Surgery
- •46.2 Surgical Technique
- •47: Hyphema
- •47.1 General Considerations
- •47.1.1 The Rationale for Surgical Removal
- •47.1.2 Medical Treatment
- •47.2 Surgical Technique
- •47.2.1 Liquid Blood
- •47.2.1.1 Monomanual Technique
- •47.2.1.2 Bimanual Technique
- •47.2.2 Clotted Blood
- •48: Iris Abnormalities
- •48.1 General Considerations
- •48.1.2 Timing of Iris Reconstruction
- •48.2 Surgical Technique
- •48.2.2 Iridodialysis
- •48.2.3 Permanent Mydriasis
- •49: Macular Disorders: Edema
- •49.1 General Considerations
- •49.1.1 Etiology
- •49.1.2 Indications for Treatment: Surgical or Nonsurgical?
- •50.1 General Considerations
- •50.1.1 VMTS
- •50.1.2 Cellophane Maculopathy
- •50.1.3 Macular Pucker
- •50.1.4 Macular Hole
- •50.2.1 VMTS
- •50.2.2 Cellophane Maculopathy
- •50.2.3 Macular Pucker
- •50.2.4 Macular Hole
- •50.2.5 If Surgery Failed for a Macular Hole
- •51: Optic Pit
- •51.1 General Considerations
- •51.2 Surgical Technique
- •52.1 General Considerations
- •52.1.1 Indications
- •52.1.2 Preoperative Considerations
- •52.2 Surgical Technique
- •53.1 General Considerations
- •53.2 Surgical Technique
- •54: Retinal Detachment
- •54.1.1 RD Due to a Horseshoe or Giant Tear
- •54.1.2 RD Due to a Dialysis
- •54.1.3 RD Due to a Round Hole
- •54.1.4 RD Due to a Staphyloma
- •54.2 Additional Information About RD
- •54.2.1 History
- •54.2.3 Clinical Course
- •54.2.4 Using Laser to Prevent RD Development
- •54.2.4.1 Prophylaxis in the Affected Eye (RD, Current or Past)
- •54.2.4.2 Prophylaxis in the Fellow Eye
- •54.2.4.3 The Patient with a History of a Retinal Tear (No RD)
- •54.3 Treatment Principles
- •54.3.2 The Goals of Surgery
- •54.3.3 Prognosis
- •54.4.1 Preoperatively
- •54.4.2.1 Initial Steps
- •54.4.2.2 Creating a Chorioretinal Adhesion
- •54.4.2.3 Drainage of the Subretinal Fluid
- •54.4.2.5 Suturing
- •54.4.2.7 Adjusting the Buckle
- •54.4.2.8 Closing the Conjunctiva
- •54.4.2.9 Gas Tamponade
- •54.4.3 Major Intraoperative Complications of SB
- •54.5 Vitrectomy
- •54.5.2.3 Intraoperative Retinal Reattachment
- •54.5.2.4 Laser Retinopexy
- •54.5.2.5 Intraocular Tamponade
- •54.5.2.6 Postoperative Positioning
- •54.5.3 Follow-Up Visits
- •54.5.4 Prognosis
- •54.5.5 RD After Silicone Oil Removal
- •54.6 Pneumatic Retinopexy
- •54.6.1 General Considerations
- •54.6.2 Patient Selection
- •54.6.3 Surgical Options
- •54.6.3.1 Cryopexy, Followed by Gas Injection
- •54.6.3.2 Gas Injection, Followed by Laser
- •54.7 Reoperation
- •55: RD, Tractional and Combined
- •55.1.1 Characteristics of the RD
- •55.1.2 Management Principles
- •56: RD, Central
- •56.1 General Considerations
- •56.2 Surgical Technique
- •57: Retinoschisis
- •57.1.1 Anatomy and Pathophysiology
- •57.1.2 Prophylactic Laser Treatment
- •57.2 Surgical Technique
- •58.1 General Considerations
- •58.1.1 Treatment Options
- •58.1.2 The Vitrectomy Option
- •58.2 Surgical Technique
- •59: Scleroplasty
- •59.1 General Considerations
- •59.2 Surgical Technique
- •60: Suprachoroidal Hemorrhage
- •60.1.1 Indications for Surgery
- •60.1.2 Timing of Surgery
- •60.2 Surgical Technique
- •61: Uveitis, Posterior
- •62: Vitreous Hemorrhage
- •62.1 General Considerations
- •62.2 Surgical Technique
- •62.3 Severe Bleeding in a Young Patient
- •62.4 Rebleeding in a Vitrectomized Eye
- •63: Trauma
- •63.1 The Timing of Surgery
- •63.2 Contusion
- •63.3 Wound Toilette
- •63.5 Suturing the Sclera
- •63.6 Subluxated Lens
- •63.7 IOFB
- •63.7.2 Posterior Segment
- •63.8 Perforating Trauma and Ruptures
- •63.9 NLP and Sympathetic Ophthalmia
- •63.11 Hemorrhagic RD
- •63.12 Additional Considerations
- •64: Postoperative Care
- •Further Reading
- •Appendix
- •Part 2. Important Personal Experiences
53.2 Surgical Technique |
447 |
|
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Pearl
The best chance the surgeon has to treat an eye with PVR is the initial surgery. The task gets increasingly more difficult and the prognosis increasingly poorer with each operation (“more surgery for less vision”).
53.2Surgical Technique
A few principles are presented here; for the actual details, see Sect. 32.3.1 and
Chap. 35.
•A complete PVD must always be performed.
•All preretinal membranes must be removed; subretinal membranes may be left behind if they do not interfere with intraoperative retinal reattachment as determined using the air test (see Sect. 31.1.2).
–The bent needle is an excellent tool to pick up membranes from the surface (see Fig. 13.8e, f), especially in areas with star folds (see Fig. 32.14), but caution is in order.1
–Fine, immature membranes are identified by staining (see Chap. 34) or by noticing the shiny reflex from the surface; this often requires changes in the angle of illumination. The immature membranes are best lifted with the scraper.
–What appears as a subretinal strand (i.e., a white line is seen) may simply be a retinal fold (see Sect. 32.4.1).
•The air test (see Sect. 31.1.2) should be done with close visual control. A shortened retina will not stretch properly and can get torn by the air. If the retina seems to resist the effect of the air, stop the exchange and deal with the retinal shortening (see below).
•Anterior PVR is more difficult to deal with than a posterior one.
•Anterior PVR threatens not only loss of vision but also loss of the eyeball, due to phthisis.2
1When working on mobile retina, the risk of causing a full-thickness iatrogenic tear is higher with a sharp tool than with the scraper. The retina moves away and the surgeon must “follow” it, combining two vectors: one perpendicular to and the other parallel with the surface; the first is to stay with the mobile retina and the second to pick up the membrane, all the while trying to avoid tearing the retina itself. Paradoxically, the more membranes are removed, the harder the task gets, precisely because the retina is increasingly more mobile.
2This is why it is so crucial to clean the vitreous base and the ciliary body in eyes with RD (see
Sect. 32.5).
448 |
53 PVR |
|
|
•Silicone oil tamponade and chorioretinectomy are currently the only effective tools in our armamentarium to reduce the PVR risk; using oil and not long-acting gas has therefore many benefits (see Table 35.1).
–If silicone oil is used, it is especially important not to leave blood on the retinal surface; this is one of the risk factors the surgeon can actually do something about.
–It may be easier to remove blood from the retinal surface under oil than under BSS or air.
•In the periphery, it may be impossible to separate the vitreous from the retina or the retina may be shortened.3
–If the vitreous is inseparable from the retina, the surgeon may elect to trim as much of the vitreous as possible, do a retinectomy, or use an encircling band to counter the effect of existing or developing traction.
–Retinectomy must never be done if vitreous and/or membranes are left on the posterior (remaining) retina (see Sect. 33.1).
•Laser must always be applied around all anterior breaks. Conversely, a posterior break may not need any “pexy” since no VR traction is present (see Sect. 30.3.5).
–Always consider a 360° laser cerclage for additional security (see Sect. 30.3.3).
–The force of PVR, however, will still detach the retina that has been lasered.
–It has benefits to laser along the edge of a retinectomy since it seals the retina so that subsequent fluid currents will not cause an RD (see Sect. 30.3.5). However, it also increases the loss of the visual field and, as just mentioned, will not prevent a redetachment if it is caused by PVR.
•ILM peeling prevents, in the event of a recurrence, the newly formed membranes from growing over the macula.
•With the use of regular oil, the RD recurrence is inferior.
•In eyes with PVR or at high risk of PVR development, the silicone oil should not be removed earlier than 4 months. Keeping it even longer is much less risky than removing it early (see Sect. 35.4.6.1).
•If reoperation is needed and there is still silicone oil in the eye, consider removing it as the initial step of the reoperation (see Sect. 35.4.5.1).
Pearl
Patients with PVR are “married to their VR surgeon”: they routinely come back for a follow-up, at least during the first year.
3 In the latter case retinectomy is the best option (see Sect. 33.1).
- #28.03.202639.38 Mб0The Wills eye manual office and emergency room diagnosis and treatment of eye disease Adam T. Gerstenblith, Michael P. Rabinowitz.chm
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- #28.03.202614.01 Кб0[Офтальмология] Jack J. Kanski Джек Дж. Кански - Клиническая офтальмология систематизированный подход [2006, PDF DjVu, RUS] [rutracker-5395873].torrent
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