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15 Combined Phaco/Vitrectomy
Removal of subretinal fluid
Air
Scleral
depressor
PFCL
Scleral
depressor
Fig. 15.22 A total retinal detachment with one retinal break. The anterior subretinal uid is
located subretinal uid is removed with a scleral depressor
removed with air. The posterior-located subretinal uid is removed with PFCL.The horizontal-
Encircling Band, Vitrectomy, Retinotomy,
andC3F8 (Stockholm Technique)
This technique is the standard surgical technique for retinal detachments at the
University hospital in Stockholm, Sweden. The typical patient has its natural lens
and is myopic with lattice. All types of detachments including an inferior detachment can be operated with this technique (Figs.16.1 and 16.2). The surgery is performed with encircling band, vitrectomy and C3F8 tamponade. The encircling band
is 3.5mm wide (Labtician, Canada).
A second feature of this technique is that in most cases a phacoemulsication is
not performed. Only in the case of a dense nucleus a phacoemulsication is
performed.
Another feature is that the subretinal uid is removed with a posterior retinotomy. (Remark: The subretinal uid can either be removed with PFCL from a peripheral rupture or with air from a central rupture. The central retinal rupture is iatrogenic
and called posterior retinotomy.) However, this depends on the surgeon’s preference, and removal of subretinal uid with PFCL is also possible.
16
Anesthesia We always use general anesthesia because the placement of the encir-
cling band causes pain.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_16
309
310
Fig. 16.1 All types of
retinal detachments can be
operated with this method
Fig. 16.2 Even an inferior
detachment with a break at
6 o’clock can be operated
with this technique. But
the break must be located
on the impression of the
encircling band because
the gas cannot tamponade
this break
16 Encircling Band, Vitrectomy, Retinotomy, andC3F8 (Stockholm Technique)
16.3 Every Step inDetail
Fig. 16.3 3.5-mm
encircling band from
Labtician (S2970), Canada
16.1 Surgery
Instruments
1. 25G or 27G four-port vitrectomy with chandelier light
2. Retinal detachment tray
3. 3.5-mm encircling band (Labtician, Canada) (Fig.16.3)
16.2 Main Surgical Steps
311
1. Four holding sutures
2. Encircling band
3. Insertion of trocars and chandelier light
4. Maybe: phaco + IOL
5. Core and peripheral vitrectomy
6. Marking of breaks with endodiathermy
7. Posterior retinotomy
8. BSS against air exchange
9. Laser treatment
10. C3F8 tamponade
11. Close the conjunctiva
16.3 Every Step inDetail
1. Four holding sutures
2. Encircling band
Open the conjunctiva along the limbus 360° with Westcott scissors, dissect the
Tenon capsule from the sclera with a strabismus scissors, and place four holding silk
3-0 sutures on all straight muscles. Place the encircling band under all four straight
muscles, and then xate the band with a Mersilene 5-0 suture in each quadrant. The
312
16 Encircling Band, Vitrectomy, Retinotomy, andC3F8 (Stockholm Technique)
band should be located on the equator. You can measure this location; it is the axial
length divided by two (AXL/2).
3. Insertion of trocars and chandelier light
4. Maybe: phaco + IOL
5. Core and peripheral vitrectomy
Then insert the trocars and a chandelier light. Start with a core vitrectomy. Be
cautious with the natural lens. Then continue with a peripheral vitrectomy. Also
perform limited vitreous base shaving with scleral indentation; thorough vitreous
base shaving is not required.
6. Marking of breaks with endodiathermy
7. Posterior retinotomy
Mark the retinal breaks with endodiathermy. Decide whether you want to continue with or without PFCL.If you choose to continue without PFCL, you need to
remove the subretinal uid with a central retinotomy. The retinotomy is located
outside the temporal arcade at the site of the maximal amount of subretinal uid
(Fig.16.4).
8. BSS against air exchange
9. Laser treatment
10. C3F8 tamponade
11. Close the conjunctiva
Retinotomy
Retinotomy
Fig. 16.4 Depending on the shape of the detachment you need to create a retinotomy. The retinotomy is located outside the temporal arcade at the site of the maximal amount of subretinal uid
16.4 FAQ
313
The next step is a BSS against air exchange. Remove the peripheral subretinal
uid rst from the peripheral break, and then the central subretinal break from the
(posterior) retinotomy. Continue with laser photocoagulation. Laser three rows of
laser around the retinal ruptures. Then continue with the PFCL against air
exchange. This is the most difcult step because visualization is poor. Remark:
The best visualization system for an air-lled eye is the Resight system from
Zeiss. We use a 14% C3F8 tamponade. Finalize surgery and close the conjunctiva
with Vicryl 8-0.
16.4 FAQ
Q: How is the risk for macular folds?
A: The risk for slippage is small with this technique.
Q: Choice of gas tamponade
A: We recommend a long-lasting gas such as C2F6 or C3F8 for this technique because
both gases cover the peripheral breaks as well the retinotomy well. SF6 may not be
sufcient to cover the retinotomy.
Q: What are the pros and cons of no phacoemulsification?
A: Pros are reduced postoperative inammation. Cons are that the anterior vitreous
is not removed and that the visualization of the fundus is much reduced in the postoperative follow-up. This is especially true for the rst postoperative week and
improves at the second postoperative week.
Easy Diabetic Retinopathy
17
17.1 Introduction
The difculty of a diabetic retinopathy depends on the status of a PVD.If a PVD is
present then the vitrectomy is easy. If a PVD is not present and if tractional membranes are present, then vitrectomy is difcult.
The grade of surgical difculty depends on the severity of the diabetic retinopathy. We differentiate between easy and difcult proliferative diabetic retinopathy:
Easy PDR A complete PVD with vitreous hemorrhage is present. The retina is
treated with scatter laser (Fig.17.1).
The surgical planning of the diabetic eye is very important; this is especially the
case in active proliferative diabetic retinopathies. What is the right timing for a vit-
-rectomy? Do not operate too early; if the eye is not pretreated with PRP or antiVEGF injections and the diabetes is poorly controlled, then the vitrectomy becomes
VERY difcult (see Fig.17.2).
We therefore favor a stepwise procedure, i.e., we operate the eye in several sessions: First, phacoemulsication combined with an anti-VEGF injection and 4
weeks later a vitrectomy. The vitrectomy is much easier, if the eye is pretreated with
phacoemulsication and Avastin. The posterior hyaloid is easier to open, less intraoperative bleeding will occur, the membranes are easier to remove, and so forth.
And the postoperative healing is of course faster.
A cautionary note regarding the timing of phaco and Avastin treatment: The
effect of Avastin lasts 6 weeks. After 4–6 weeks, a laser treatment with/without
vitrectomy should be scheduled. Alternatively, repeat an Avastin injection.
Otherwise, the proliferative vessels will reopen and the PDR will reoccur after
2–3 months.
The more active the retinopathy, the more stepwise we operate:
In an easy PDR, we operate in two sessions: (1) Phacoemulsication and intravitreal anti-VEGF and 4 weeks later (2) vitrectomy (Fig.17.2).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_17
315
316
Fig. 17.1 A mild
(surgically easy) PDR with
vitreous hemorrhage. Note
that a complete PVD is
present. Fibrovascular
membranes are usually not
present because the
posterior hyaloid is
detached
17 Easy Diabetic Retinopathy
Fig. 17.2 Our treatment
algorithm for surgical
planning of a PDR for an
easy diabetic vitrectomy
Old patient with type 2 diabetes
Vitreous hemorrhage with PVD
Phaco and anti-VEGF
1 month later
Vitrectomy
17.2 Combined Phacoemulsification
andAnti-VEGF Treatment
A diabetic vitrectomy is easier if the eye is pretreated with anti-VEGF 1–4 weeks
prior to the vitrectomy. If you have an opacied lens and the patient is older than 50
years, then alsoperform cataract surgery before the vitrectomy. It only takes 10
minutes of extra surgical time. Especially in advanced diabetic retinopathy cases,
avoid anterior segment inammation with iris rubeosis. A diabetic eye, which is
pretreated with anti-VEGF and cataract surgery, is much easier to vitrectomize.
17.2 Combined Phacoemulsication andAnti-VEGF Treatment
Fig. 17.3 A diabetic eye
with vitreous hemorrhage.
We apply a stepwise
technique: First, a
combined
phacoemulsication with
intravitreal Avastin and 1
month later, if still
necessary, a vitrectomy
Fig. 17.4 After
implantation of the IOL
and before removal of the
viscoelastics, an
intravitreal injection of
Avastin (0.1ml) is
performed
317
Perform a phacoemulsication as usual. Inject the IOL and place it into the capsular bag. Before removing the viscoelastics, perform an intravitreal injection with
an anti-VEGF medication. Inject 0.1 to 0.2ml. Then remove the viscoelastics and
hydrate the incisions (Figs.17.3 and 17.4).
Surgical Pearls No. 95
If a patient has a bilateral PDR and you decide to vitrectomize one eye, then do
not forget the other eye. Treat the other eye in the same session (or shortly after)
with phaco + IOL + Avastin or at least only Avastin. It easily happens that the
clinical focus lies on the vitrectomized eye and the other eye (often the better eye)
gets worse.
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17 Easy Diabetic Retinopathy
17.3 Vitrectomy
A vitreous hemorrhage with attached retina and no associated major vitreoretinal
pathology is suitable for the beginner. In most cases, a PVD is present and the hemorrhage lls out the vitreous gel behind the lens (Fig.17.5). In the presence of vitreous hemorrhage, a previous history of panretinal photocoagulation usually facilitates
the surgery, because it is associated with a higher rate of posterior vitreous detachment and promotes retinal adhesion to the RPE and choroid. He/she learns to work
with the vitreous cutter and apply a PRP, but does not need to perform any signicant manipulations of the retina.
The main problem with this procedure is that there is no view of the fundus. The
procedure is even harder when the natural lens is still present, due to the risk of
injuring the posterior capsule. In the learning phase, perform only PPV’s in pseudophakic eyes.
Practice the application of panretinal laser photocoagulation (PRP) very well
using a chandelier light. On the one hand, hold the scleral depressor and indent the
sclera and retina, and on the other hand, hold the laser probe and apply a PRP up to
the ora serrata. This surgery can be performed under local anesthesia. We use mostly
27G for these cases.
Surgical Pearls No. 96
B-scan: In cases with vitreous hemorrhage, always perform a detailed preoperative
ultrasound examination. Try to determine the state of the posterior vitreous face
(attached, partially attached or detached) and the retina.
Fig. 17.5 A dense
vitreous hemorrhage with
attached retina behind the
vitreous