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Файл:Ординатура / Офтальмология / Учебные материалы / Vitreoretinal Surgery Farenc Kuhn Springer.pdf
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- •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
192 |
21 Sclerotomies and the Cannulas |
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|
Pearl
A narrow palpebral opening often causes an intraoperative problem too. As the eye is rotated, the lower lid can crimp the infusion line. You do not see this in the dark; only note that during vitreous removal, the eye collapses (you suspect the infusion bottle is empty). This may not be preventable since the eye must be rotated; simply stop and wait until the IOP normalizes.
21.6Checking the (Infusion) Cannula
The consequences of suprachoroidal (occasionally even subretinal) infusion can range from the inconvenient to the extremely serious.
Q&A
Q Can the VR surgeon actually kill his patient during surgery?
AYes. If F-A-X is performed and the infusion cannula is in the suprachoroidal space, the air can enter the bloodstream by tearing the choroid from the vortex vein ampullae. The air embolus will stop the heart.
21.6.1 Cannula Under the Choroid/Retina: Prevention
Even if it is “only” BSS that infuses the suprachoroidal space, it can rapidly lead to a choroidal detachment. To prevent this complication, the surgeon should do the following:
•Before the infusion is opened, the tip of the cannula must be checked.
–A brief peek does not suffice. The choroid and ciliary epithelium may be depigmented19; the quick peek will not allow the surgeon to detect that something is covering the tip of the cannula.
•Even an initially properly placed infusion cannula may be but pulled out intraoperatively. It is easy to detect if the line is completely out but more difficult if only partially so.
–Periodically check the position of the infusion cannula’s external position (i.e., is it pushed into the cannula all the way?) during surgery, but especially during scleral indentation and before switching to air.
19 Or appear to be so, due to tissue stretching.
21.6 Checking the (Infusion) Cannula |
193 |
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•The position of the working-sclerotomy cannulas should also be checked. These do not represent the same danger, but iatrogenic damage can still be caused if they are partially out.
21.6.2 Cannula Under the Choroid/Retina: Management
If during the initial cannula insertion the tip of the cannula cannot be advanced all the way through the tissue, there are several options.
•Push a needle through the cannula itself; this will create a small opening in the choroid, which may slide back.
•If this does not work,20 introduce another cannula, insert a needle21 through that one, indent the sclera by pushing the first cannula in, and slice open the tissue around it so that you have a clear view of the tip. Once you created an opening, push the infusion cannula through it and then open the infusion and only then let the cannula, slowly, back into its normal position.
21.6.3 Infusion Going Under the Choroid/Retina: Management
If fluid did get under the choroid, the following usually restores the normal anatomy:
•Close the infusion immediately.
•Pull out the infusion line.
•Put the infusion line through another cannula – and check its position before opening it.
•Drain the suprachoroidal fluid through the infusion cannula.
–If no fluid is coming or not all fluid has drained, pull out the cannula and enlarge the sclerotomy. Once the fluid has been drained, suture this sclerotomy and reinsert the infusion cannula at a different location.
Q&A
Q Is it possible to drain suprachoroidal fluid internally?
AIn principle, yes; in reality, it is very difficult. The choroid shrinks when diathermized (see Sect. 59.2). If the pressure in the suprachoroidal space is high and the fluid not viscous (BSS, not blood), a simple needle/blade puncture may work.
20It may not since the choroid is elastic, and the opening may immediately close.
21Bleeding is extremely rare from this. Do not use diathermy because it may shrink the tissue.
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