Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6023_Библиотеки_им_академика_М_И_Перельмана.pdf
342
ab
BSS
19 Vitrectomy forDicult Retinal Detachment (PVR)
PFC
Backflush
instrument
Fig. 19.16 PFCL against silicone oil exchange: In a rst step (a), silicone oil is injected and lls
the eye from anterior to posterior. Aspirate rst the BSS phase. After the removal of BSS (b), hold
the ute needle into the PFCL phase and remove it
Silicone oil
BSS
PFC PFC
Backflush
instrument
Silicone oil
Intraocular Tamponade
Gas or silicone oil: According to the silicone oil study, C3F8 is superior (higher reat-
tachment rate and better visual outcome) to SF6 in complicated detachments. The
silicone oil study does not compare C3F8 with silicone oil. The advantages and disadvantages of C3F8 are listed in Table19.2 and of silicone oil in Table19.3. For
complicated retinal detachments, we prefer silicone oil. The main reason is that the
recurrent detachment risk in complicated RD’s is higher than in easy detachments.
And a recurrent detachment under silicone oil is better than a recurrent detachment
under gas. Why? A recurrent detachment under gas develops fast into a PVR detachment. A recurrent detachment under silicone oil develops slowly. Under gas an
immediate surgery is required. Under silicone oil you can postpone and plan surgery.
Gas Tamponade Gas has two great advantages over silicone oil. The surface ten-
sion pressure of gas is much higher than for silicone oil which enables a more effective sealing of retinal holes. Secondly, the gas is a temporary tamponade. Long-term
damages of gas are therefore not existent compared to silicone oil.
Injection of gas: SF6, C2F6, and C3F8 are heavier than air because of their uorine
atoms. The gases sink therefore to the ground whereas the lighter air stays above.
Hold the Charles ute needle behind the lens to aspirate the air, and the gases can
ll the vitreous cavity from posterior to anterior (Figs.19.17 and 19.18).
Surgical Pearls No. 91
Shake the 50cc gas syringe before injection because the gas sinks to the bottom of
the syringe resulting in a wrong concentration of the gas in the eye.
Air
19.4 Every Surgical Step inDetail
343
Table 19.2
cons of C3F
Table 19.3
Advantages of silicone oil Disadvantages
“Non-temporary” longer tamponade Need for a second operation
Does not require positioning Scaffold for reproliferation (?)
Earlier visualization (option for monocular patients) Cataractogenic
Air-travel is possible Low surface tension pressure
Lower risk of hypotony
Fig. 19.17 The setup for a
gas injection. The gas is
injected through the
infusion line and the ute
needle evacuates the air
The pros and
8
The pros and cons of silicone oil
Advantages of C3F8Disadvantages of C3F
Disappears
spontaneously
High surface tension
pressure
Only temporary tamponade
8
Specic head positioning (not for
children, disabled)
Air travel must be postponed (risk
of expansion)
Vision is restricted (not for
monocular patients)
Cataractogenic
Infusion line
Gas
Backflush
instrument
Silicone Oil Tamponade
Silicone oil is an excellent temporary tamponade but a very bad permanent tamponade. It causes high IOP, emulsies, and the nal result is an optic atrophy. Silicone
oil should be avoided in fresh and primary detachments. Silicone oil is indicated in
recurrent detachments, in complicated PVR detachments, and in diabetic tractive
detachments. But even in these cases, try to remove the silicone oil after 3 months.
Silicone Oil Injection (Figs.19.19, 19.20, and 19.21)
344
Air
Fig. 19.18 The heavy gas
lls the vitreous cavity
from posterior to anterior
and the ute needle
aspirates the light air
19 Vitrectomy forDicult Retinal Detachment (PVR)
Backflush
instrument
flute needle
Fig. 19.19 Silicone oil
injection under view to the
retina. Note that a
chandelier light is required
Fig. 19.20 Setup for oil
injection with view to the
retina
Chandeller
light fiber
Air
Air
Gas
Air infusion
Backflush instrument
Silicone oil
Air
19.4 Every Surgical Step inDetail
Fig. 19.21 You work
bimanual in order to inject
the silicone oil under view
to the retina
Backflush
instrument
345
Silicone oil
Air
Table 19.4
Duration of silicone oils
1000/1300 cSts silicone oil 1.5–3months 6–8weeks
5000 cSts silicone oil 3months to ∞6–8weeks
Densiron 68 1.5–3months 6–8weeks Exchange to 5000 cSts silicone oil
The duration of a silicone oil tamponade at the University of Uppsala
Normal case Young patient
Trauma case (with low IOP)
6months to ∞
6months to ∞
1000 cSts or 5000 cSts Silicone Oil 5000 cSts induces less IOP increase and less
emulsication. If you plan a long silicone oil tamponade (longer than 6months),
then use 5000 cSts silicone oil. If you plan a short duration (shorter than 6months),
then use 1000 cSts silicone oil. The duration of the silicone oil is listed in Table19.4.
Surgical Pearls No. 92
Silicone oil overll (Fig.19.22): Cut the infusion line with a scissors so that the
excessive silicone oil can escape. An IOP of approximately 10mmHg is ne, or
wait so long until no more oil escapes from the infusion line.
346
Fig. 19.22 Cut the
infusion line after silicone
oil injection so that
excessive oil can ow out
19 Vitrectomy forDicult Retinal Detachment (PVR)
Difficult Proliferative Diabetic Retinopathy
20.1 Introduction
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 vitrectomy? Do not operate too early; if the eye is not beenpretreated with PRP or
anti-VEGF injections and the diabetes is poorly controlled, then the vitrectomy
becomes VERY difcult (see Fig.20.1). Surgical trauma triggers the diabetic retinopathy and consequently the postoperative healing. It alsoincreases the risk of
recurrence of brovascular membranes. If you only operate on the cataract of an eye
with active proliferative diabetic retinopathy, then the retinopathy will progress in
most cases, and an iris rubeosis may occur. Therefore, combine a phacoemulsication always with an intravitreal anti-VEGF treatment in order to prevent a progression of the retinopathy and to quiet the retinopathy for the following vitrectomy.
We therefore favor a stepwise procedure, i.e., we operate the eye in several sessions: rst, phacoemulsication combined with an anti-VEGF injection and 4weeks
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.
Why a stepwise procedure? The difculty of the vitrectomy depends on the
severity of the PDR.A severe diabetic retinopathy requires a long traumatic surgery.
The surgical trauma however aggravates the diabetic retinopathy, resulting in a
vicious cycle. It is therefore vital to dry out the brovascular membranes BEFORE
vitrectomy; i.e., remove the vascular component with laser and anti-VEGF.
The main rule is not to perform a vitrectomy in an untreated eye. Pretreat the eye
rst with PRP and anti-VEGF, keep a tight follow-up until the retinopathy is inactive, and then schedule surgery. Secondly, avoid a combined phaco/vitrectomy.
Operate instead rst a phaco with Avastin and 1–4weeks later a vitrectomy.
20
© 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_20
347
348
20 Dicult Proliferative Diabetic Retinopathy
Fig. 20.1 Our treatment
algorithm for surgical
planning of a difcult
diabetic vitrectomy
Young patient with type 1 diabetes
Tractional PDR, no PVD
immediate
anti-VEGF
1 month later
Panretinal laserphotocoagulation
1 month later
Lenssparing vitrectomy
A cautionary note regarding the timing of phaco and Avastin treatment: The effect
of Avastin lasts 6weeks. After 4–6weeks, 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 2–3months.
In conclusion The grade of surgical difculty depends on the severity of the diabetic retinopathy. We differentiate an easy and a difcult proliferative diabetic
retinopathy:
Difcult PDR
Only a partial PVD is present. Fibrovascular membranes are located
at the posterior pole. A tractional retinal detachment is present. No or insufcient
laser treatment has been performed (Fig.20.2).
The more active the retinopathy, the more stepwise we operate:
# In a difcult PDR, we operate in several sessions: In young type 1 diabetics,we
inject anti-VEGF into both eyes within 1 week. One month later, if the vitreous is
clear, we perform a laser photocoagulation. The laser photocoagulation is performed
in general anesthesia with a laser helmet: the so-called laser indirect ophthalmoscopy (LIO). If the vitreous is not clear, we repeat anti-VEGF.A vitreous hemorrhage clears up after amaximum of four anti-VEGF injections. Then we perform a
lens-sparing vitrectomy. In old patients, we start with phacoemulsication and
intravitreal anti-VEGF and 3–4weeks later 2) vitrectomy (Fig.20.1).
Caution Do not forget the second eye while treating the rst eye. We use to inject
anti-VEGF in the second eye every time when operating the rst eye. We have seen
many times a second eye progress to a tractional PDR under treatment of the
rst eye.
20.2 General Introduction
Fig. 20.2 Illustration of a
difcult PDR.The retina is
laser treated. Many retinal
proliferations and
vitreoretinal adhesions are
present. The posterior
hyaloid is attached in the
posterior pole and partially
detached in the periphery;
the nasal posterior hyaloid
is often attached
20.2 General Introduction
The main surgical steps in a severe PDR are as follows:
1. Posterior hyaloid rhexis
2. Bimanual removal of membranes
349
In most cases of severe PDR, you can use the periphery to disc (outside-in) technique. Start therefore with a posterior hyaloid rhexis.
The surgical time is approximately 90–150minutes.
The eye should be pseudophakic, an exception is the young type I diabetic
patient. In the latter case, we perform a lens-sparing vitrectomy. We usually work
with a 27G trocar system. If extensive membranes are present, we use a hybrid
25G/27G system because the whole range of 25G peeling instruments is required.
In the case of a long eye, we use 27G.
Surgical Pearls No. 101
BSS damages the phakic lens: In pseudophakic eyes BSS is used as irrigation uid
and in phakic eyes BSS Plus® (Alcon). BSS Plus® also contains glutathione, glucose, and sodium bicarbonate.
Instruments
1. 27G three-port trocar system with chandelier illumination
2. 120D lens, for peeling: 60D lens
3. Vitreous cutter
4. Backush instrument
350
20 Dicult Proliferative Diabetic Retinopathy
5. 27G endgripping forceps (DORC)
6. 27G curved scissors (DORC)
7. Silicone tip Charles ute needle/vacuum cleaner
8. Endodiathermy (DORC, Alcon)
9. Laser probe
10. Scleral depressor
Maybe:
25G straight scissors
25G knob spatula
Dye
• Triamcinolone or Trypan blue
Tamponade
• 20% SF6, 1000 cSts silicone oil
Individual Steps
1. Three-port trocar system with chandelier illumination
2. Posterior hyaloid rhexis
3. Removal of tractional membranes
4. Instruments for removal of membranes
• Delamination of membranes with membrane pic, knob spatula, and vacuum cleaner
• Dissection of membranes with curved scissors
• Removal of dissected membranes with vitreous cutter
5. Hemostasis
• Slight bleeding
• Moderate bleeding
• Strong bleeding
6. Removal of attached posterior hyaloid in the periphery
7. PRP under BSS
8. Fluid against air exchange
9. Intravitreal Avastin
10. Internal tamponade
• Gas tamponade
• Silicone oil tamponade
11. Removal of trocars
20.3 The Surgery Step-by-Step
351
20.3 The Surgery Step-by-Step: Figs.20.3, 20.4, 20.5, 20.6,
20.7, 20.8, 20.9, 20.10, 20.11, 20.12, 20.13, 20.14, 20.15,
20.16, 20.17, 20.18, 20.19, 20.20, 20.21, 20.22, 20.23,
20.24, 20.25, 20.26, 20.27, 20.28, 20.29, 20.30,
and20.31
20.3.1 Three-Port Trocar System withChandelier Illumination
Insert rst three trocars and then inferonasally the chandelier light. Continue with a
core vitrectomy. We recommend 27G trocars (Fig. 20.3); an alternative is a
hybrid system.
Surgical Pearls No. 102
Corneal lubrication: A major problem during vitrectomy, especially in combined
surgeries with a duration of over 1hour, is corneal epithelial edema. With the application of methylcellulose (Celoftal®, Alcon or Ocucoat®, Bausch&Lomb) on the
cornea, the cornea can remain clear for many hours. A debridement of the epithelium is rarely necessary, but if needed use a broad blade (crescent knife).
20.3.2 Posterior Hyaloid Rhexis (Figs.20.4 and20.5)
The posterior vitreous is usually attached in eyes with brovascular membranes. An
important aim of surgery is the induction of PVD.The induction of PVD is extremely
challenging in eyes with ischemic retina because the posterior hyaloid is rmly
attached to the retina. When inducing a PVD, the surgeon can easily make tears in
the retina.
To avoid this damage, the surgeon should begin with a peripheral vitreous detach-
ment. In most cases of proliferative diabetic retinopathy, a partial vitreous
Fig. 20.3 A three-port
vitrectomy with chandelier
light is the best surgical
setup for a difcult PDR; a
chandelier light allows
bimanual surgery and
bimanual removal of
membranes