- - MICHAEL A. KLUFAS, MD MD MICHAEL A. KLUFAS, and Hybrid Vitrectomy Continuing with the theme of diabetic sur diabetic of theme the with Continuing 27-gaugethe introduce to way good a gery, withpatient a in procedure a into cutter 25-gaugeor 23- startwith to is diabetes vitrectomy; 25-gauge is used in this video by The authors share their top 10 surgical retina videos top 10 surgical retina videos authors share their The one is worthy of a look. and explain why each BY DAVID XU, MD; 2 Although 27-gauge vitrectomy may not be the rightthe be not may vitrectomy 27-gauge Although 27-gaugethe of size the how highlights video Berrocal’s Dr. Murtaza Adam, MD. Once you have performed the initial vit initial the performed have you Once MD. Adam, Murtaza cutter27-gauge standalone a separation, hyaloid and rectomy option for every patient with diabetes, and preoperativeand diabetes, with patient every for option intraoperativeof risk the minimized has therapy anti-VEGF becan selection gauge vitrectomy, diabetic during bleeding isbreaks iatrogenic reduces that technique surgical A critical. repair. RD diabetic efficient of pillar important an andmembranes adherent tightly to access enables cutter tocutter the allow systems today’s of fluidics the how thedecreasing potentially while retina the to close remain orpick lighted a use always you If breaks. retinal new of risk cutter27-gauge a try and down them put scissors, curved surprised. pleasantly be you’ll think We time. next THE BEST OF OF BEST THE 2018 EYETUBE 27- Gauge Dissection of Tractional Retinal 27- Gauge Dissection of Tractional Retinal Detachment Membranes detachmentsretinal tractional Diabetic difficultmost the of some be can (RDs) trainingin surgeons vitreoretinal for cases alike.surgeons attending experienced and

bit.ly/Berrocal1118 bit.ly/Berrocal1118 1 | NOVEMBER/DECEMBER 2018| NOVEMBER/DECEMBER For retina specialists, time is a valuable and limited commodity, and we don’t always have enough of it to keep currentkeep to it of enough have always don’t we and commodity, limited and valuable a is time specialists, retina For havewe on, up catch to thing more one of you relieve To resources. other and publications, trade journals, the all with

yetube.net is the place to go for high-quality, narrated ophthalmic surgical videos, and there’s a channel especially forespecially channel a there’s and videos, surgical ophthalmic narrated high-quality, for go to place the is yetube.net othersstill and complications, document others successes, surgical show videos Some subspecialty. retina the in those video. each from learned be to something there’s content, the what matter No techniques. new at looks close offer 1 Before we get into our video selections, we take a moment to acknowledge all of the surgeons who have submitted videos tovideos submitted have who surgeons the of all acknowledge to moment a take we selections, video our into get we Before Maria H. Berrocal, MD, is one of the best diabetic vitrectomydiabetic best the of one is MD, Berrocal, H. Maria easy. look procedure the makes always she and surgeons, these videos. We simply picked those we felt would be of the most value or the greatest interest to the largest number of ourof number largest the to interest greatest the or value most the of be would felt we those picked simply We videos. these youif same, the do can You demonstrated. techniques the of some on comments own our included also We colleagues. retina video. each under Eyetube on sections comments the in wish, specialists. retina other for resources valuable as serve they and appreciated, much are contributions Your year. this Eyetube chosen our 10 favorite surgical retina Eyetube videos from 2018. Note that we did not use an official system to rate or chooseor rate to system official an use not did we that Note 2018. from videos Eyetube retina surgical favorite 10 our chosen E RETINA TODAY

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are used to create sclerotomies for externalization of a scleral-fixated IOL. In this case, Dr. Thanos uses the CT Lucia 602 IOL (Zeiss), pointing out that its haptics, made of poly- vinylidene fluoride, are stronger and tolerate externalization better than some more widely used three-piece lenses.

Gore-Tex Suturing Another popular approach to fixation of a posterior chamber IOL involves the use of 4 nonabsorbable PTFE monofilament sutures (Gore-Tex, W.L. Gore). Although use of this technique with the Akreos AO60 IOL 2 (Bausch + Lomb) is popular, that lens can become opacified bit.ly/Adam1118 due to use of intraocular air/gas or inflammation. This opacifi- cation can be mitigated with the use instead of the hydropho- can be used to segment and delaminate membranes. This is bic MX60 IOL (Bausch + Lomb), as implanted in this video by known as hybrid vitrectomy. Dr. Adam’s use of the 27-gauge Ferhina Ali, MD, and Dr. Klufas. cutter enabled near complete dissection of an extensive dia- betic tractional detachment over a mobile retina in some areas, without the creation of iatrogenic retinal breaks. It looks like Dr. Adam took some hints from Dr. Berrocal that led to his success in this case. Additionally, his use of triamcinolone helps to confirm that the hyaloid has been removed and that his dissection proceeded in the correct plane.

Secondary Three-Piece IOL Fixation At retina conferences it’s not uncommon to 4 3 hear great debate among surgeons regarding bit.ly/Ali1118 the best approach to secondary IOL place- ment. Increasingly there has been a focus At first Dr. Klufas was skeptical about the stability of the on scleral fixation of IOLs. Although there MX60, given its different design, but he reports that he has is nothing wrong with placement of an anterior chamber lens, had great results with it. In fact, this is now his go-to technique retina and anterior segment surgeons often need techniques to for posterior fixation of an IOL. If a patient develops a macular help them fixate an IOL posteriorly when clinically indicated. hole or RD after MX60 placement, gas tamponade can be This video by Aris Thanos, MD, highlights a modified placed without worry regarding opacification of the IOL. Yamane technique in which 25-gauge vitrectomy cannulas

Surgical Management of Endophthalmitis In this video, David Almeida, MD, MBA, 5 PhD, presents a case of vitrectomy for infectious endophthalmitis. Typically, the goal of vitrectomy in endophthalmitis is to debride the inflammatory material, perform a limited vitrectomy, and administer intravitreal antiinfective agents. The elegant technique he shows here includes placing a cannula through clear cornea for infusion into the anterior chamber. There is almost always an inflammatory hypopyon and fibrin membrane over the IOL in these cases. Typically, we remove the anterior membrane with MaxGrip forceps (Alcon), 3 bit.ly/Thanos1118 but Dr. Almeida shows that this can be accomplished just as well using the vitreous cutter, which is a more cost-effective

NOVEMBER/DECEMBER 2018 | RETINA TODAY 57 - - Heads-Up Suprachoroidal Buckle Acute Retinal Necrosis RD Acute Retinal A primary scleral buckle should be in everyin be should scleralbuckle primary A thoseeven armamentarium, surgeon’s retina systemsvitrectomy excellent to access with Christophersystems. viewing wide-angle and thatvideo this in admits MD, Riemann, D. What’s worse than a schisis-related RD? schisis-related a than worse What’s to secondary RD an suggest we Might retinal Extensive necrosis? retinal acute orinvolvement posterior with necrosis with end will nerve the of infiltration bit.ly/Grandinetti1118 bit.ly/Grandinetti1118 7 8 7 In this video, Alexandre Grandinetti, MD, PhD, performs PhD, MD, Grandinetti, Alexandre video, this In scleral buckling has its limitations, as shown in this case ofcase this in shown as limitations, its has buckling scleral aperforms Riemann Dr. sclera. the of staphyloma significant sodiumwith buckle, scleral suprachoroidal chandelier-assisted Johnson GV, &(Healon hyaluronate Johnson)an via delivered barricade laser to the areas of necrosis around nearly 360˚ nearly around necrosis of areas the to laser barricade the of resection advocate We tamponade. oil silicone with this prevent to vitrectomy of time the at retina necrotic prolifera anterior in resulting and contracting from tissue is buckle scleral a of Placement vitreoretinopathy. tive necrosis retinal the If cases. of types these in controversial there if however, uncertain; be may benefit the 360˚, spans buckle scleral a then necrosis, of hours clock 3 to 2 only is eyes, inflamed these in base vitreous the support help may vitreoretinopathy. proliferative to prone are which a poor visual outcome, even with surgery. These detach These surgery. with even outcome, visual poor a been has infection acute the after late, occur also can ments andhealthy of junction the at occur breaks retinal if treated, samplevitreous a send to useful be can It retina. unhealthy polymerasevirus zoster virus/varicella simplex herpes for beenhas infection the whether determine to reaction chain vitrectomy. plana pars of time the at treated adequately - - Vitrectomy Repair of Schisis-Related RD With Vitrectomy Repair of Schisis-Related RD With PVR and Bimanual Forceps dif Retinoschisis-related RDs are notoriously traditionalinto exactly fit not do and ficult thisIn techniques. buckling or vitrectomy aperforms PhD, MD, Blaha, Gregory video, bit.ly/Blaha1118 bit.ly/Blaha1118 bit.ly/Almeida1118 bit.ly/Almeida1118 6 | NOVEMBER/DECEMBER 2018| NOVEMBER/DECEMBER

5 6 provide countertraction. The need for the chandelier couldchandelier the for need The countertraction. provide instrument. lighted functional a of use with avoided be also membranes, versus vitreoschisis, which he removes using ausing removes he which vitreoschisis, versus membranes, Removingillumination. chandelier with technique bimanual giventricky, be can retina detached over membranes these aof use by aided is removal countertraction; no is there that per place to be would option Another technique. bimanual andretina posterior the tamponade to liquid fluorocarbon vitrectomy in such a case using the Ngenuity 3D Visualization3D Ngenuity the using case a such in vitrectomy ishyaloid the although that, out points He (Alcon). System cutter.vitreous the with elevated easily relatively is it down, epiretinalinferior remaining are there that observes Blaha Dr. to the back is improved after the anterior segment is cleared. is segment anterior the after improved is back the to approach. Removing the anterior segment hypopyon and fibrinand hypopyon segment anterior the Removing approach. viewthe as vitrectomy, posterior safer allows also membrane RETINA TODAY

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Hydraulic Centripetal Macular Displacement Technique Patients and vitreoretinal surgeons typi- 10 cally feel better when a macular hole is sur- gically closed. The rate of successful hole closures approaches or exceeds 90% in standard cases involving microincisional vitrectomy surgery, internal limiting membrane removal, and gas tamponade. Andrii Ruban, MD, PhD, presents a series of traumatic macular holes with posterior pole chorioretinal scarring 8 bit.ly/Riemann1118 treated with subretinal injection of balanced salt solution to create a macular detachment and encourage closure of the macular hole. This technique can also be useful in nontrau- El Rayes Olive Tip Suprachoroidal Cannula (MedOne Surgical) matic cases in which closure was not achieved on the initial under the area of the retinal break. Although some will say the surgery with traditional techniques. Ngenuity Visualization System is not ideal for anterior segment procedures, the technique here is performed with excellent visualization. If you encounter significant scleromalacia during your next case scheduled for primary scleral buckle, will you try suprachoroidal buckling instead?

IOFB Removal in 3D In this video, John Miller, MD, and Patrick Oellers, MD, show that the Ngenuity 3D 9 Visualization System allows not only ante- rior segment work, but also lensectomy and complex RD repair. The surgeons remove an intraocular foreign body (IOFB) via a pars plana sclerotomy. Another option in this case would be to remove the IOFB through a corneal incision, given the initial laceration, but 10 this could compromise the view needed to complete the RD bit.ly/Ruban1118 repair; therefore, a pars plana incision was preferred. The shape and size of the IOFB can influence the type of instrument That concludes our roundup of the top 10 Eyetube (eg, intraocular magnet, large forceps, retractable kidney stone videos of 2018. Submit your own video today—on Eyetube basket) used to remove it from the posterior segment. or Eyetube3D—and share your tips, tricks, and interesting cases with colleagues around the world. It’s easy! Find out how at eyetube.net/other/submit.asp. n

MICHAEL A. KLUFAS, MD n Vitreoretinal Surgeon, Mid Atlantic Retina; Assistant Professor of Ophthalmology, Thomas Jefferson University, both in Philadelphia, Pennsylvania n Retina Chief, Eyetube.net n [email protected] n Financial disclosure: Consultant (Allergan, Novartis, Genentech)

DAVID XU, MD n First-Year Vitreoretinal Surgery Fellow, Wills Eye Hospital, Philadelphia, Pennsylvania 9 n bit.ly/Miller1118 [email protected] n Financial disclosure: None

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