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20 Dicult Proliferative Diabetic Retinopathy
• Severe Bleeding
If the bleeding is so severe that there is no view of the fundus, and despite aspiration with the ute needle it does not clear up, then you should perform a uid x air
exchange. The bleeding will stop. Now try to cauterize the bleeding source with
endodiathermy or compress it mechanically with the knob spatula. The vitrectomy
can also be continued in an air-lled vitreous cavity. Another alternative is silicone
oil. One can either work under silicone oil or end surgery with a silicone oil tamponade with Avastin.
Surgical Pearls No. 104
Intraoperative hemorrhage and adrenaline: If there is constant bleeding from several vessels under surgery, then add adrenaline to the BSS bottle. Adrenaline will
constrict the vessels and reduce the bleeding.
20.3.6 Removal ofAttached Posterior Hyaloid inthePeriphery
(Figs.20.22, 20.23, and20.24)
Trim the peripheral vitreous and the vitreous base with a bimanual technique. Indent
the sclera with the sclera depressor and cut the vitreous with the vitreous cutter.
After the removal of the posterior hyaloid from the posterior pole, remove the
residual attached posterior hyaloid in the periphery. Remember: The posterior hyaloid in the periphery is in the most cases only partially detached. The detached part
with a posterior hyaloid rhexis was opened in the beginning. Now the attached part
must be removed. This part is rmly attached to the retina (Fig.20.22). Simply
inducing a PVD with the vitreous cutter does not work because this creates retinal
tears. The surgeon must delaminate the posterior hyaloid with a bimanual technique
(Fig. 20.23). The posterior hyaloid has to be removed up to the vitreous base
(Fig.20.24).
20.3 The Surgery Step-by-Step
Fig. 20.22 In the initial
steps a vitreous rhexis was
performed, and the
vitreous was removed to
the arcades. Then the
brovascular membranes
together with the central
posterior were removed.
The nal step is the
removal of the attached
posterior hyaloid in the
periphery—often on the
nasal side
Fig. 20.23 Using
bimanual technique—with
an endgripping forceps and
a knob spatula—the
residual posterior hyaloid
is removed from the disc to
the ora serrata
363
Attached posterior hyaloid
364
Fig. 20.24 Now a
complete PVD has been
performed. The most
difcult part of the surgery
has been completed
20 Dicult Proliferative Diabetic Retinopathy
20.3.7 Panretinal Photocoagulation (PRP) Under BSS (Figs.20.25
and20.26)
The next step is a PRP.Perform a dense PRP from the arcades up to the ora serrata.
By using the scleral depressor, the surgeon can laser treat up to the ora serrate.
After endolaser photocoagulation check if a new hemorrhage has occurred at the
central pole, and treat it before moving on to the tamponade.
Surgical Pearls No. 105
Postoperative vitreous hemorrhages are the number one problem following vitrectomy for proliferative diabetic retinopathy. In order to lower the rate of this complication, be meticulous with hemostasis. Watch out for small oozing bleeding sites
after PRP has been performed. Even small collections of blood point at continuous
bleeding sites that should be treated before closing up.
20.3.8 Fluid Against Air Exchange (Figs.20.27 and20.28)
Perform a uid against air exchange. In the case of 25G or 27G, use active aspiration with abackush instrument or use the vitreous cutter.
Air bubbles behind IOL: During a uid-air exchange, the water condenses at the
posterior surface of the IOL in the area of the capsulotomy, thereby greatly impairing the view of the fundus. It can either be removed with a ute instrument or injection of viscoelastics onto the posterior surface of the IOL.
20.3 The Surgery Step-by-Step
Fig. 20.25 Perform a
dense PRP from the
arcades to the ora serrata
Fig. 20.26 Use preferably
a curved laser probe in
order to perform a laser
treatment up to the ora
serrata
365
20.3.9 Intravitreal Avastin
We always inject 0.2ml of Avastin intravitreally at the end of a diabetic case. We use
0.2ml and not 0.1ml because the vitreous is removed.
20.3.10 Internal Postoperative Tamponade
In young type 1 diabetics, we prefer 15% C2F6 as postoperative tamponade because
it causes less postoperative secondary glaucoma compared to silicone oil. Silicone
oil may result in secondary glaucoma after silicone oil removal. We use silicone oil
366
Fig. 20.27 We perform in
almost all cases a uid
against air exchange. If the
vitreous cavity is lled
with PFCL, we perform a
PFCL against air exchange
and then the tamponade. In
this case with a detached
retina, we would use 1000
cSts silicone oil
Fig. 20.28 For 23G we
use a Charles ute needle
with passive aspiration. For
25G and 27G, we use
Charles ute needle with
active aspiration
20 Dicult Proliferative Diabetic Retinopathy
in difcult cases, extensive retinal bleeding, and in functionally only the eyes. In old
type 2 diabetics, we use in the most cases only an air tamponade.
• Silicone Oil Tamponade (Figs.20.29 and 20.30)
In the case of a silicone oil, we use in most cases 1000/1300 cSts silicone oil.
Inject the silicone oil under BIOM view. In the case of overll, cut the infusion line
and excessive silicone oil will escape. Inject a 0.1–0.2ml of Avastin bubble into the
silicone oil bubble.
20.3 The Surgery Step-by-Step
Fig. 20.29 Injection of
1000 cSts silicone oil into
an air-lled vitreous cavity.
If possible, try to perform
an air against silicone oil
exchange. It is technically
much easier than a PFCL
against silicone oil
exchange
Fig. 20.30 The excessive
silicone oil can escape and
overll is avoided. Then
0.2ml of Avastin is
injected into the silicone
oil bubble
367
Surgical Pearls No. 106
Lens-sparing vitrectomy: In young diabetic patients, we experienced good results
with a lens-sparing vitrectomy and then a C2F6 gas or 1000 cSts silicone oil tamponade. Even after 10–20years, the lens hardly opacies.
20.3.11 Removal ofTrocars (Fig.20.31)
If silicone oil is used, one should suture the sclerotomies, otherwise oil might ow
under the conjunctiva. Suture 25G sclerotomies with Vicryl 8-0. 27G sclerotomies
require usually no suture.
368
Fig. 20.31 The
sclerotomies are sutured
with Vicryl 8-0
20 Dicult Proliferative Diabetic Retinopathy
20.4 Complications
1. Injury of a retinal artery during peeling. Fibrovascular membranes may hide the
temporal arcade. Be careful with delamination here. Begin with blunt instruments such as a knob spatula or a vacuum cleaner. Prefer a curved scissors (27G
curved scissors, DORC).
2. Extensive bleeding: (1) Try to cauterize the bleeding vessel. (2) Place the tip of
the vitreous cutter or the knob spatula onto the bleeding vessel for 1minute. (3)
Perform a BSS against air exchange and try to cauterize the vessel. (4) Inject silicone oil and anti-VEGF, and close the case; reoperate when the bleeding has
subsided.
20.5 FAQ
Which type of silicone oil you use?
We use routinely 1000/1300 cSts silicone oil. We remove the oil after 3months. We
see no advantage of using 5000 cSts oil in diabetic cases, even with tractional
detachment.
What procedure do you recommend in the case of an eye with iris rubeosis,
cataract, and vitreous hemorrhage?
Do not operate this eye before the iris rubeosis is treated and has disappeared. We
would inject immediately 0.1ml of Avastin. After 1month, we would perform a
combined phacoemulsication + IOL implantation + intravitreal 0.1ml of Avastin.
Again 1month later we would perform a vitrectomy.
20.5 FAQ
369
What procedure do you recommend in case of a young type 1 diabetic with
PDR and poor compliance?
I would perform an immediate Avastin injection in both eyes. One month later I
would schedule a laser coagulation (LIO) in general anesthesia (Figs.20.32 and
20.33). And again 1month later, I would perform a lens-sparing vitrectomy if
necessary.
What procedure do you recommend in case of an old type 2 diabetic with
vitreous hemorrhage secondary to diabetes?
I would schedule a phaco + Avastin. One month later I would perform a vitrectomy
with laser, Avastin, and air tamponade.
Fig. 20.32 The retina was
treated from the temporal
arcades to the ora serrata
with 1879 laser effects
Fig. 20.33 This eye was
treated with 1500 laser
effects
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