Abstract
Finishing vitrectomy by leaving behind material other than BSS provides tamponade for the retina. Some of these materials may also serve as an intraoperative tool in accomplishing certain tasks, acting as a “third hand.” The tamponade itself may be short term or permanent, with a great variety in-between. The VR surgeon must learn the criteria for selecting one tamponade over another and the various techniques of implanting, exchanging, and removing the tamponades.
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Notes
- 1.
Chapter 14 provides additional information about these materials.
- 2.
Unless the patient is at high altitude; see below.
- 3.
Some surgeons tried it in macular hole surgery, but the initial enthusiasm for air use has subsided.
- 4.
Pure SF6 will expand by ~250% as N2O penetrates it.
- 5.
See Fig. 35.1.
- 6.
My default choice is 30% SF6. This provides tamponade for a sufficiently long period (~10 days) for the laser spots to take effect.
- 7.
This means that you never look up from the microscope during the entire process.
- 8.
This is determined by the patient’s facial anatomy.
- 9.
More if the IOP was high and less if the IOP was low at the beginning of air withdrawal; more in a myopic and less in a hyperopic eye.
- 10.
Hence the high (up to 30%) rate of secondary retinal tears: the traction is weakened at where the gas bubble is but may occur elsewhere.
- 11.
In other words, it is the change in altitude that matters, not the absolute height above sea level.
- 12.
This is why it is only a waste of PFCL if the nurse tries the usual deaeration before she hands the PFCL-filled syringe over to the surgeon.
- 13.
Fish eggs.
- 14.
The same principle applies if BSS is reimplanted into an air-filled eye that had an RD and a posterior retinal break earlier during the operation.
- 15.
In other words, PFCL can be injected if the posterior break is not under traction. The only exception to this rule is a closed-funnel RD (see Sect. 32.3.1.6).
- 16.
BSS in-between silicone oil and PFCL.
- 17.
Which needs to be levitated; see above.
- 18.
See below for additional details about exchanges.
- 19.
This includes PFCL that is under the retina (see below, Sect. 35.3.1.2).
- 20.
“Double fill,” with 1,000 cst silicone oil as the counterpart. The potential problem with such a mixture is that the two materials will not completely fill the vitreous cavity, leaving space between them and thus allowing the proliferation to develop in-between – i.e., centrally.
- 21.
The bubble height is indicated by the interface seen on the shaft of the flute needle.
- 22.
Emulsification, see below.
- 23.
Emulsification is also dependent on other factors such as silicone oil purity, the completeness of the fill (100% fill representing the smallest possible risk), the patient’s lifestyle etc.
- 24.
If the eye is aphakic and silicone oil prolapsed into the AC intraoperatively, the pupil must not be constricted as long as there is oil in front of it.
- 25.
Unless there is significant cataract, the axial length can be measured under oil with the LenStar (Haag-Streit AG, Koeniz, Switzerland).
- 26.
For patients who cannot position and for failed holes (see Sect. 50.2.5). Some surgeons use silicone oil as their primary tamponade.
- 27.
Typically less than 4 mmHg.
- 28.
That is, reoperation is not necessarily indicated.
- 29.
Visco may be needed in the AC to prevent silicone oil prolapse; see below.
- 30.
This obviates the need for the rather expensive disposables.
- 31.
Since the intraocular task had been completed before the air was injected, there is no need to observe the oil implantation inside the vitreous cavity through the BIOM.
- 32.
In other words, it is not proportional to the amount of oil being implanted.
- 33.
Rotate the eye so that the superotemporal area is the uppermost part of the globe.
- 34.
The risk of lens damage is rather high.
- 35.
The “colibri” forceps is the ideal tool for this: it has teeth that are sharp and large enough to grab sclera through the conjunctiva, but small enough to minimize the risk of tissue damage.
- 36.
This suture looks like an X underneath the sclera; the 2 threads are parallel on the surface.
- 37.
To avoid coating the AC structures; this reduces the severity and duration of IOP rise.
- 38.
The iridectomy is much more difficult to perform if air in the vitreous cavity is pushing the iris forward. Create the iridectomy before the F-A-X.
- 39.
It develops if the aqueous is misdirected posteriorly, behind the oil and thus pushing forward.
- 40.
Which is the periphery of the iris, away from the sphincter.
- 41.
The AC is already full of oil in the aphakic eye or the oil cannot find a passage to the AC in the (pseudo)phakic eye.
- 42.
The clinical experience is that the retina is more fragile if it has been in contact with the oil for extended periods.
- 43.
Since the oil removal is never complete (see below), the glaucoma may persist for many months.
- 44.
Such as macular hole or VH.
- 45.
And on the individual surgeon’s philosophy. I err on the side of keeping the oil longer.
- 46.
Passive removal is also an option. With a gaped 20 g sclerotomy (the conjunctiva must obviously be opened first), the oil will readily exit the eye, but the surgical field will be messy. Copious irrigation of the ocular surface is needed to avoid trapping silicone oil subconjunctivally.
- 47.
This reduces the diameter of the channel through which the oil must flow.
- 48.
Again, make sure that vitreous is not left on the retinal surface.
- 49.
Which will often need to be flushed.
- 50.
It speeds up the process and prevents blockage.
- 51.
Active aspiration in the subretinal space with the probe may be necessary, which increases the risk of catching the retina or injuring the choroid.
- 52.
This must be explained to the patient in great detail. The maneuver is detailed under Sect. 54.6.3.1.
- 53.
Also, remember to do an inferior iridectomy (see above, Sect. 35.4.4).
- 54.
That is, the diameter of the air bubble is much smaller than the diameter of the cornea.
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Kuhn, F. (2016). Tamponades. In: Vitreoretinal Surgery: Strategies and Tactics. Springer, Cham. https://doi.org/10.1007/978-3-319-19479-0_35
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