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3 Intraocular TamponadeAgents
3.5.4 Injection andDrainage ofHeavy Liquid
(1) Injection
-In some countries, a dual bore cannula is often used to inject heavy liquid. The tip
is placed within the heavy liquid droplet, while the side opening is kept above the
heavy liquid level. The obvious advantage of this method is that, during heavy liquid injection, the side opening drains uid from the vitreous cavity, thereby preventing an excessive rise in intraocular pressure.
In China, a blunt cannula (0.4mm diameter) is commonly used. During injec-
tion, the cannula is rst placed close to the posterior pole and should be positioned
-within the heavy liquid droplet to prevent the formation of sh -egg like heavy liquid droplets (Fig.3.24). The principle of “slow injection, multiple layers” should be
followed to avoid compromising retinal blood perfusion due to excessive IOP.After
injecting a certain amount of heavy liquid, the cannula should be withdrawn from
-the vitreous cavity to release pressure, then re inserted for further injection. At the
-same time, observe the mobility of the mid peripheral retina. If it appears relatively
stiff, heavy liquid should not be injected forcibly, as this may cause heavy liquid to
enter the subretinal space or induce retinal rupture.
Fig. 3.24 During heavy
liquid injection, sh-egglike droplets may form.
These droplets can easily
enter the subretinal space
and should be avoided or
aspirated promptly
3.5 Heavy Liquid
59
(2) Removal
Depending on the situation, heavy liquid can be removed by the following methods:
1. Drainage with a syringe. After heavy liquid injection, if retinal wrinkles have not
been completely attened, the heavy liquid in the vitreous cavity can be aspirated with a syringe for potential reuse.
2. Fluid/air exchange. This is the most commonly used method. Perfusion pressure
-in the gas lled vitreous cavity can be increased to 50 mmHg, and heavy liquid
is extracted using a vitrectomy cutter or ute needle.
3. Oil/uid exchange. While under heavy liquid tamponade, rst inject some sili-
cone oil to stabilize intraocular pressure, then use a ute needle to aspirate the
heavy liquid. During this process, closely monitor intraocular pressure changes.
4. Fluid/uid exchange. If a large amount of heavy liquid remains or heavy liquid
-is being removed during a second stage surgery, uid/air exchange may not be
necessary. Under BSS perfusion, a ute needle can be used to rapidly drain
offthe heavy liquid.
(3) Complications of Heavy Liquid
Complications of heavy liquid are the key reason hindering its wider application.
These mainly include the following aspects:
1. -Dislocation into the anterior chamber.When the patient is in the face down posi-
-tion postoperatively, heavy liquid may cross the lens iris septum (in phakic or
pseudophakic eyes) or directly (in aphakic eyes) enter the anterior chamber
under gravity (Fig.3.25a). If the amount of heavy liquid is large, it can damage
the corneal endothelium. Most residual heavy liquid can be removed at the slit
lamp through an inferior corneal incision. If the anterior chamber becomes signicantly shallow during removal, the procedure may be performed in multiple
sessions.
2. Preretinal residue. When lying at, patients often experience subjective discomfort of small droplets shaking in the center of the visual eld, especially when
vision is good (Fig.3.25b, c). The main cause is that during gas/liquid exchange,
a small amount of heavy liquid remains layered on the posterior pole and
-mid peripheral retina. This is more likely if the retinal surface is irregular.
Prevention can be achieved by the following two methods: (1) - “Eye shake” technique: The surgeon uses both hands—an endoillumination probe and a ute needle—to gently shake the eyeball. The centripetal force overcomes friction between
the heavy liquid droplet and the retina, allowing the droplet to fall to the posterior
pole under gravity, where it is then aspirated with the ute needle. (2) BSS ush:
Inject a small amount of BSS to ush heavy liquid from the retinal surface toward
the posterior pole, then aspirate all liquid with a ute needle.
3. Subretinal residue. If a heavy liquid droplet lies outside the vascular arcades, it
generally does not affect vision. However, if it is located beneath the macula, it
causes signicant visual disturbance (Fig.3.25d, e). Various methods have been
used to remove subretinal heavy liquid, primarily by creating a retinotomy with
60
3 Intraocular TamponadeAgents
a
d
Fig. 3.25 Common postoperative complications of heavy liquid. (a) Heavy liquid enters the ante-
rior chamber (white arrow). (b) During silicone oil removal, small heavy liquid droplets remain
anterior to the retina (white arrow). (c) Patient complaint: when lying at, small droplets rotate in
front of the eyes; the patient drew the perceived image with a pen. (d) Heavy liquid retained in the
neuroepithelial layer, involving the fovea (white arrow). (e) OCT image conrming heavy liquid
retention in the fovea (white arrow)
e
b
c
a thin needle and then draining the droplet. However, secondary damage is
almost inevitable, and symptoms may not improve substantially. (A simple tech-
-nique is to use a 27 gauge diathermy to create a retinotomy, followed by passive
-drainage with a 27 gauge ute needle.)
(4) Foreign Body Inflammatory Reaction
-Heavy liquid is a uorine containing synthetic substance with a certain amount of
polar impurities. If too much heavy liquid remains in the eye for too long, it can
stimulate a foreign body inammatory reaction involving macrophages and multinucleated giant cells. In severe cases, it may cause dense macular epiretinal membranes (Fig.3.26). Pathological examination can reveal transparent heavy liquid
vesicles within macrophages in the vitreous cavity, beneath the posterior capsule,
-and within the retina. In silicone oil lled eyes, heavy liquid droplets may interact
with silicone oil, accelerating its emulsication. The resulting inammatory reaction can further promote epiretinal membrane formation.
3.6 Summary
Fig. 3.26 Epiretinal
membrane caused by
heavy liquid residue.
Heavy liquid droplets are
visible anterior to the
retina (blue arrow), and
heavy liquid droplets
wrapped by the epiretinal
membrane (green arrow)
3.6 Summary
61
“A tool is only as good as the hand that wields it.” In summary, intraocular tamponade agents—whether gas, silicone oil, or heavy liquids—remain indispensable pillars of vitreoretinal surgery, yet their success depends entirely on the surgeon’s
mastery of their behavior. For the beginner, these agents should not be viewed as
simple “llers,” but as dynamic pharmacological and physical tools. Mastery begins
with a rigorous understanding of their unique physical and chemical properties,
such as surface tension, buoyancy, and viscosity. Only with this foundational knowledge can a surgeon identify the optimal scenarios and precise timing for their use,
leveraging their specic advantages to solve complex clinical challenges like giant
retinal tears or proliferative vitreoretinopathy.
Equally critical is the ability to look beyond the successful injection and understand
the pathological and anatomical basis of potential complications. A skilled surgeon
is dened not just by their ability to use a tool, but by their foresight to anticipate
intraoperative shifts and postoperative risks, such as secondary glaucoma or emulsication. By learning to recognize the early warning signs of these complications,
you can intervene before serious, irreversible consequences develop.
This chapter has laid the groundwork for that transition. By integrating the physical
principles of these agents with a deep respect for ocular anatomy, the novice surgeon can move beyond mechanical repetition. Only through this disciplined
approach can you gradually grow from a trainee into a master, wielding intraocular
tamponade agents with the precision and skill necessary to achieve superior, lifechanging surgical outcomes for your patients.
Part II
Vitrectomy in China
Preoperative Preparation
andAnesthesia
Preoperative evaluation is an essential step in all surgeries, and vitreoretinal surgery
is no exception. An accurate and objective preoperative evaluation helps surgeons
better understand the patient’s condition and expectations, develop an individualized treatment plan, and establish realistic expectations for surgical outcomes,
thereby laying a solid foundation for a long-term, positive doctor-patient
relationship.
Anesthesia for vitreoretinal surgery also has certain unique aspects, particularly
local anesthesia, which is often administered by the surgeon. How to ensure the
anesthetic effect while avoiding related complications is a topic that beginners in
vitreoretinal surgery need to study in depth. This chapter will briey describe preoperative evaluation and anesthesia precautions, aiming to create more favorable
conditions for the smooth performance of vitreoretinal surgery.
4
4.1 Doctor-Patient Interaction
Before starting vitreoretinal surgery, the following points must be carefully
conrmed.
1. The patient’s general ocular condition. Do not rely solely on fundus examination
ndings or on reports from assistants. The surgeon must personally check the
patient’s vitreoretinal condition and conrm whether there are other ocular
abnormalities, such as blepharitis, conjunctivitis, or dacryocystitis, which are
high-risk factors that can easily cause postoperative intraocular infection.
2. The patient’s demands and expectations. The complexity of vitreoretinal surgery
makes the postoperative outcome highly uncertain. We should listen carefully to
the patient’s subjective complaints before surgery and accurately grasp their
expectations when they are referred to us, and then make a decision on whether
to perform surgery. For example, some patients come to the clinic only because
of dry eyes and a foreign body sensation, but are found to have an epiretinal
© 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_4
65
66
4 Preoperative Preparation andAnesthesia
membrane or a macular hole as an incidental nding. In this situation, we should
inform the patient and decide whether to perform vitreoretinal surgery based on
the severity of the disease.
3. Risk communication.Patients must be fully informed of the surgical objectives
and potential risks through an objective, comprehensive preoperative consultation. This dialogue should encompass four critical pillars: (1) expected anatomical success rates; (2) the inherent uncertainty regarding functional visual
recovery; (3) potential intraoperative and postoperative complications; and (4)
the specic postoperative compliance required from the patient to optimize
outcomes.
For example, for non-complex rhegmatogenous retinal detachment, we not
only need to explain why surgical intervention is the only option (because it is a
sight-threatening disease) but also need to inform the patient which surgical
approach will be taken and why (e.g., why pars plana vitrectomy is chosen
instead of scleral buckling). We should then inform them about the anatomical
success rate of the rst surgery (approximately 90%), the uncertainty of postoperative visual recovery (individual outcomes vary considerably), possible complications during and after surgery (this should not be done with a “reading from
a book” mentality; the surgeon should emphasize and fully inform according to
the specic condition), and nally the tasks that patients need to cooperate with
after surgery (such as maintaining a face-down position and attending scheduled
follow-ups). Full and frank communication before surgery can lay a solid foundation for a good doctor-patient relationship.
4. Guarantee of objective conditions. Conrm whether the patient’s pupil can be
fully dilated and whether the refractive media are clear enough. Design the surgical procedures and their sequence in advance, and conrm with the operating
room staff whether all required instruments and medications are available.
5. Ensuring the safety of patients. For patients with poor systemic conditions, ECG
monitoring and rescue measures must be prepared in advance. It is best to schedule the operation during the time when medical staff at all levels in the hospital
are most fully present.
4.2 Preparation oftheSurgeon
The surgeon is denitely the key factor for surgical success. The surgeon is not only
the planner of the surgery and the dispatcher of human and material resources but
also the operator of the key steps of the procedure. In addition to non-replicable factors such as surgical experience, the surgeon’s physical and mental states are also
crucial in determining the nal success or failure of the surgery.
1. Anticipate difculties and propose solutions. The surgeon should carefully consider the patient’s ocular condition, make a comprehensive estimate of the key
points and possible complications during the surgery, and mentally rehearse the
surgical steps.
4.2 Preparation oftheSurgeon
67
For example, patients with retinal detachment concomitant with severe PVR
or choroidal detachment are likely to experience inadvertent infusion at the early
stage of surgery; they may also require retinectomy due to severe retinal shortening, resulting in signicant bleeding from the retina; heavy liquid may accidentally enter the subretinal space, and slippage of the retinal ap may occur during
silicone oil injection.
We should have an adequate knowledge base to manage this series of emergencies. The long-term accumulation of experience and extensive observation of
surgeries can provide a solid foundation for the growth of novices.
Although we often emphasize that prevention is key, timely and appropriate
interventions are also essential qualities and skills for surgeons.
2. Objectively evaluate your own surgical ability. Never start a procedure that you
are not capable of completing without the guidance of a senior surgeon. Note
that this refers to your “ability” rather than “condence.”
Under normal circumstances, the rst vitreoretinal surgery for an individual
patient often has the best outcome. If the rst surgery fails due to lack of experience or shortage of instruments, the subsequent intervention will become more
complicated, and the outcome will often be poor.
For example, when a young patient with fresh rhegmatogenous retinal detachment presents and the surgeon decides to perform PPV.Novicesurgeons sometimes overlook the key step of creating posterior vitreous detachment. Because
the patient’s vitreous body is relatively transparent, the surgeon may mistakenly
believe that the vitrectomy can be completed in a very short time, when in fact a
large amount of transparent vitreous remains. If the retina is directly reattached
at this point, proliferative changes and recurrent detachment may occur postoperatively. As a result, the difculty of the second operation will increase signicantly, and the prognosis will be greatly worsened.
Another example is severe proliferative diabetic retinopathy with condense
brovascularmembranes. Without rich experience and delicate skills, the surgeon is very likely to be unable to nish the surgery well, ultimately causing
excessive iatrogenic breaks and severe hemorrhage.
3. Reasonable arrangement of surgeries. Surgeries should be scheduled in an order
that reects their difculty. When beginning to perform vitreoretinal surgery
independently, the surgeon must estimate the difculty and duration of each case
and strive to balance challenging and routine cases within each surgical session.
For example, we can place noncomplex rhegmatogenous retinal detachment at
the beginning of the surgical day, which can improve our condence and exibility in subsequent operations in a very short time. Macular holes and epiretinal
membranes can be arranged subsequently, which require very precise operations.
consuming surgeries. This arrangement not only allows us to concentrate on completing simple cases but also allows us to focus on solving complex problems
without distraction.
4. Always maintain optimal psychological and physiological readiness. Ophthalmic
surgery has a near-zero tolerance for error; even a minor lapse in judgment or
And nally, to deal with proliferative diabetic retinopathy and other time-
68
4 Preoperative Preparation andAnesthesia
focus can result in severe, irreversible ocular damage. This demanding environment requires the surgeon to possess unwavering concentration and exceptional
manual stability.
Prior to surgery, adequate rest and restorative sleep are mandatory. Surgeons
should limit the intake of stimulants, such as caffeine and strong tea, and avoid
strenuous physical activities like heavy lifting to minimize physiological tremors. These precautions are essential to ensuring the uid and precise execution of
delicate intraocular procedures.
When managing high-stakes cases or complex pathologies, maintaining a
composed and objective mindset is vital. A disciplined mental state ensures that
the surgeon’s cognitive agility and manual dexterity remain uncompromised by
psychological pressure, even in the most challenging surgical scenarios (Fig.4.1).
5. Always maintain a good mental and physiological state. Ophthalmic surgery has
a very low tolerance for error. Any carelessness may lead to serious, irreversible
damage, which requires the surgeon to have good concentration and hand
stability.
We must ensure adequate rest and sleep before surgery, avoid excessive coffee and strong tea intake, avoid lifting heavy objects, and minimize hand tremor
during surgery to ensure high-quality completion of delicate procedures. For
patients with special conditions, the surgeon must maintain a normal mindset to
ensure optimal performance. When encountering difcult situations, one should
not allow mental factors to reduce the agility of thinking or the dexterity of the
hands (Fig.4.1). The distance between the operating table, operating chair, and
microscope jointly determines whether the surgeon can achieve good sitting posture. The surgeon must ask the nurse to adjust the height of the operating table
and then adjust the height of the operating chair accordingly, keeping the head
and back naturally straight and the shoulders naturally relaxed (Fig.4.2a).
The most common mistake that surgeons make is to bend over unconsciously
to accommodate the height of the microscope and the operating table. This
causes the muscles of the waist and back to become overstretched. Long-term
strain can lead to chronic pain, which may ultimately affect the successful completion of surgeries. When using microscopes, the surgeon’s head and neck must
inevitably maintain a xed posture. To relieve fatigue, joints can be moved and
Fig. 4.1 Relationship
between mental stress and
surgical performance
4.3 Choice ofAnesthesia
69
ab
Fig. 4.2 Correct sitting posture under different microsurgery systems. (a) Correct sitting posture
when using a microscope for vitreoretinal surgery. (b) When using a head-up three-dimensional
imaging system, the surgeon’s sitting posture is relatively comfortable, but the assistant sometimes
has to turn his head to face the screen, which increases his fatigue
relaxed during intervals between surgeries. Studies in recent years have shown
that the application of head-up three-dimensional imaging systems can signicantly improve surgeon comfort and effectively reduce muscle and joint fatigue
(Fig.4.2b).
In scleral buckling, using an indirect ophthalmoscope to locate retinal breaks
is a step that is particularly likely to cause surgeon fatigue. Almost all beginners
will unconsciously move their heads closer to the indirect ophthalmoscope and
the patient in an attempt to observe the vitreous and retina more clearly. Excessive
bowing and bending will aggravate fatigue. The surgeon should gradually nd
the most comfortable working distance through daily practice.
4.3 Choice ofAnesthesia
Anesthesia is a key component of all surgeries, and vitreoretinal surgery is no
exception. Good anesthesia not only relieves the patient’s pain but also ensures the
normal performance of the surgeon. If the patient cannot cooperate well due to pain,
it will greatly affect the surgeon’s attention and skill level, resulting in an inability
to optimally manage various possible complex conditions.
Anesthesia methods are divided into local anesthesia and general anesthesia,
each with different advantages and disadvantages. The choice is primarily determined by multiple factors, including the patient’s systemic condition, the complexity of the surgery, and the surgeon’s preference.