During this live surgical demonstration, we will discuss repeatable, safe, and effective techniques working with the macular surface. This will include tissue stains, relieving vitreous traction, peeling cortical vitreous, peeling epiretinal tissue, and peeling the internal limiting membrane. Techniques with forceps, pics, and the vitrector will be used to demonstrate surgical options.
Lecturer/Surgeon: Dr. David Miller, Retina Associates of Cleveland, Ohio, USA
DR. Miller: All right. Welcome, everybody. This is Dr. David Miller coming to you live from the Cleveland Eye and Laser Surgery Center in Cleveland, Ohio. We have done several presentations with Cybersight and I have been fortunate enough to be invited back and talk to you today about the fundamentals of macular surgery. So, I want to thank you all for joining us this morning. And making this program so wildly successful. We’re gonna cover principles of macular surgery and hopefully get through two live surgeries for you. One macular pseudo hole. One a membrane related to a retinal detachment in silicon, more complex. See how the cases go and if we get both in or not. So, to start out this morning, I have a lecture of small PowerPoint presentation that I’m gonna through while they’re prepping the patient behind me here. And I’ll stop the block whenever you are ready. We’re gonna do the block first. I’ll just point the camera over this way a little bit. And we’ll get that done. Okay. Jennifer, we’re gonna get the eye numbed up for ya here. Little retral bulbar, this is 5ccs of marcaine and lidocaine, mixed one-to-one. And we saw the globe come up and the lid come down. I think we have a pretty adequate block. Jennifer, you did great there. All right. Get ya going. Now go back and pick up our PowerPoint slides. And Rachel is helping me here in the OR with all the tech components and she’s also one of the key components of — just go to the title slide. There we go. So, fundamentals of macular surgery. I work with a group here in town called Retina Associates of Cleveland. We have a 15-surgeon group that kind of centers around Northeast Ohio here in the United States. And this is our location where we’re coming live you from. That is five OR Nathalie does just eye surgery in Cleveland, Ohio. That’s year we did about 3,000 retinal surgeries here. So, considerations. What we’re trying to show you here today is techniques and surgery that can be repeatable, safe, effective. Cover tissue stains. The principles of surgery including relieving the vitreous traction, peeling the cortical vitreous, peeling the epiretinal membrane rain, whether there’s needed. Techniques, pinch and peel with forceps, pinch, and the system peeling and also things like the flex loop for those who like a more specific device to create a membrane peel. So, I want to cover a little bit about the risk was vitrectomy in general. It’s always worth covering again. Infection and endophthalmitis, retinal tear, de-attachment, cor Roy Dalana effusion or hemorrhage, cataracts, glaucoma with gas in the eye, and anesthesia block-related. For macular surgery safety, you want to have a nice pre-op evaluation. I think with macular work, optical clearance tomography, OCT, is very helpful. I wouldn’t say it’s essential. I was around before OCT was being used and we did macular work just then fine. But this gives us a better idea of our considerations where surgery is indicated and what things are healing like post-operatively. Ideally, f, if you can do this kind of work with the OCT in your clinic, it can be very advantageous. On the flip side, I don’t think you need OCT on the microscope at all. There’s technology out there, I have used it. I have not found it advantageous or needed it in well over 99% of cases. When it comes to macular surgery, OCT in the microscope, while it’s nice, isn’t something you have to have. Adequate anesthesia, keeps the eye from moving, patient comfortable. Sterile prep and technique, and Jenny is on the block with us here. She’s my PA. And turn to Page, my other PA. But Page will not be assisting on this one. A good surgical assistant like Jenny is extremely helpful in making you comfortable working with the people, proper sclerotomy is important for the vitrectomy. And check the surgical notes, make sure you have the eye marks, all those procedures, everyone agrees, which eye, et cetera. During the case, you want to have great visualization. It’s very hard to do macular work without seeing the macula clearly and sharply. You want to avoid all the retina trauma that can happen with pics forceps or scrapers. Make sure you have the proper vitreous substitute during the case. Balanced salts all we use here with no additives. At the end of the case, there’s air, fill, gases, oils, or just the BSS. Tight wound closure. I’m going to emphasize again, this is suture-less vitrectomy. There’s possibility for post-op hypotony or infection. And post op should be included with every surgery. The techniques would be a vitrectomy, creation of a vitreous separation, remove the cortical vitreous is important. Removal of the epiretinal membranes, possible removal of the internal limiting membrane, gas fluid exchange, face down positioning and in particular. I wanted to cover a little bit about stains, dyes, and chromovitrectomy. We use vital dyes or crystals to improve visualization during the surgery. I’m going to use these today. In particular, we use IC green most of the people. I’m going to demonstrate the use of crystals. You can use trypan blue, brilliant blue, infracyanine green, and other stains to help you guide your dissection in your peels. This shows a couple quick slides of the advantage of staining the internal membrane. In this sequence of pictures, you can see the membrane being peeled. Triamcinlone, they are on the surface, to show the vitreous is removed. I find it helpful in peeling the hyaloid rather than the epiretinal tissue. But it can be used for that too if that’s helpful. IC green that we’re using here has a high infinity for the internal limiting membrane. We use a pre-packaged product that’s used for ICG. It’s been gaining popularity ever since the 1990s. The internal limiting membrane in particular is a difficult membrane to peel without staining. I think even today at my experience level, it would still be difficult to peel the ILM without ICG staining. It’s 2.5 microns thick. I’ve heard the smallest structure or thinnest structure removed surgically anywhere in the body. So, to do it when it’s clear and not really visible is a whole ‘nother level of talent that I think you’re much safer and it’s more effective if you can stain it to stain it. And there’s the IC green that we use. And a couple issues about IC green in particular. There is a risk of toxicity. It’s a direct chemical toxic effect to the RPE cells. It can be — with light exposure. I want to be careful about how much time we’re in the eye with the light pipe if we’re using IC green dye. We want to keep the IC green dye off the RPE. The retinal surface is fine, but not sub-retinal or into the base of a macular hole. And I’ll demonstrate that when I’m putting it in. Blue stains can be also used and approved for epiretinal tissue peeling and ILM peeling also. But didn’t stain with different properties. Just an example of some of those there. You want to use the lower the concentration the better, less light exposure, the better. Wet versus dry methods. Be careful in dry method staining if you’re drying the eye out first, doing an air-fluid exchange and putting it directly on the macula. You’re getting a better stain, but exposing the retina to more possible toxicity. So, the benefits are improved surgical results, decreased operative time. Lower re-operate. The downside is toxicity concerns. So, be careful with chromovitrectomy. We’re going to start shortly, confirm intraocular placement of the infusion, maintain intraocular spatial orientation, control pressure and trauma. And they can and post-op instructions. At end, it’s nice to talk with the patient and go over some of those introduction. Our first case is a 61-year-old woman with blurry vision in the right eye for 6 months. Vision is only 20/30, you have pretty good visual acuity. Be careful in the cases, why doing the surgery? Macular surgery for the most part is electricity. You want to pick and choose your battles up to your confidence level. In her case, diabetic macular edema we have been struggling with for several years. Using many injections, and ended up with an ERM and lamellar hole. Not a true — but lamellar. The part that’s confusing us, whether to continue treating with the injections, when is this edema, when is this traction. And we are going to peel this macular surface off the retina, collapse this hole that’s probably stretched apart with probably an air bubble. Probably don’t need long-term gas for her. With that being said, we’ll start the case now and I’ll talk my way through it with you. Thank you. All right. So, let me get my hands prepped here. Got a thumbs up from Janine, everything going well in the hall. That’s good. The rest of the team I’ll introduce while we’re getting gloved. Kim, a surgical assistant. Been with us a long time here at Cleveland Eye and Laser. And who else is in the room? Rachel on IT. Michelle, circulator, Don, Jenny is on the block, as we mentioned. Tennessee Mike couldn’t make it today. Sleeping in somewhere. Yeah. And anesthesiology. Which I didn’t catch your — Sandy. Sandy has been with us a while. But the group changes around and Gary, or anesthesiologist out front doing all of our pre-op evaluations or running the rooms. And I always like having someone else take care of anesthesia because I don’t have to worry about the medical part, just the eye. Very helpful. It’s nice to have a very familiar team and comfortable. Here you see the eye is prepped, draped. >> Circles. DR. MILLER: You do, right. Circles on the left, she’s seeing through the eye shield. Couple things in from the prep and drape. Notice the lashes caught mind the drape. I like to use a solid speculum. I don’t like lashes on the cornea. Keep the cornea wet. Use a Q-tip or forceps to displace the con slightly. I don’t always measure. But I will today at the 3, 3.5 mark and we’ll look to put an incision right there. Like to make these wounds kind of long and straight going through the conj. And you can see — and I like to make it near the horizontal. Okay. Displace the conj again. But again, I like the wounds to be kind of long and straight. And the cannula pointed towards me. The reason we do that is for wound closure at end of the case. It’s kind of nice to have it set up that the cannulas are oriented towards me. I know the wound is long and straight. A nice, long scleral tunnel is easier to collapse at the end of the case. We are using a 25-gauge torque system. And so, I put all the cannulas in first. Because the eye is nicely pressurized. We already have the infusion on. But I already also know that it’s in the eye. I can see the tip. And we tape in the infusion cannula. How are you doing, Jennifer? Are you okay? Okay. Don’t talk now because it makes your head move a little bit. Okay? If you’re having pain or have to cough or sneeze, let us know. Otherwise, just kind of enjoy the show and me talking, okay? All righty. Thank you. So, we’re gonna — got the light pipe in the eye and vitrector. We’re using an EIBOS wide field visualizing system. Nice to work through a wide field device. Get that focused real well. Get ourselves comfortable. And we are well-focused. No, we’re not. We’re just gonna take out this written — in the back. Yeah. Just the retinal work. Here we’re starting our vitrectomy. Great. Thank you. And so, we want to do a nice, safe vitrectomy. We’re gonna core out the vitreous here. And then look to create a vitreous separation or confirm that. I will demonstrate using Kenalog, or the triamcinolone crystals so it stains — doesn’t stain — it helps you visualize the vitreous. Let’s do that now to give everyone an idea what that looks like. Jenny is helping us here. We’re fine, we’re fine. Unless this cannula is long. There we go. So, we’re just gonna come down here and put in not even a tenth of a cc. Go ahead. A little bit more. Just think of go, poof! There we go. Again. There we go. So, you can see how it’s kind of being held together there. Indicating some vitreous is likely in the neighborhood. We’re gonna take a look here. And you’ll see how to reacts. You can see how it’s kind of tugging. And the Kenalog comes out pretty easily. One of the reasons — I’m using the trade name. Triamcinolone or Triesence is something you can use. At one time, it was in shortage. What are we use something Kenalog. The triamcinolone is still difficult to get. See this? You can see how it’s pulling down here. So, the vitreous is still down here at the nerve. So, we’ll turn the cutter off. Turn up the vacuum. And engage the cortical vitreous here. What’s nice, you can see the shadow out here. Watch the shadow right here as we pull up. I often don’t use triamcinlone. Sure thing. We just stretch it different directions. You can see it popping up all very nicely. And here goes the vitreous out temporally too. And so — and so, we got the — sometimes I get questions about the settings on the machine, Jenny. What are we using today? >> I put you up to 450 for the hyaloid and then back to 350. DR. MILLER: Okay. We’re aspirating at 350 with the cut rate here on the machine. And we put it — did run it up to 450 to — on the vacuum to pop the posterior hyaloid out there. You can see that came up. And now we’re just gonna trim around here. I’ll tend to use — always start temporally with whatever hand is temporally. But if you’re really right-handed dominant. I certainly have partners and many colleagues who just always use the one hand even in doing vitrectomy. It’s a little easier for some maneuvers if you can use the left hand on occasion. We’re gonna switch hands here and take away a little more vitreous. And that alone in this particular case with her type of traction, what we already have done, could actually be pretty curative. But since we do have this lamellar hole, which is not really affecting the vision too much, the lamellar hole is probably not affecting the vision too much. But it does impact how we treat the patient with the injection. You can see the injection in the periphery. Another is to add a little laser at the end of the case. Even though she’s not prolific vitrectomy, a lot of times it’s hard to understand how patients will progress in the retinopathy. I think we want to do that Jenny, endolaser at the end of the case. Now move on to the staining piece of this. We’re going to use IC green dye. Your cataract looks pretty good. >> Lay real quiet, this is the most important part, the peeling, okay? We don’t want you to talk because it makes your head move, okay? DR. MILLER: Here we go. Before she squirts, I’m just gonna talk a little bit here. Sorry, Jenny. We’re gonna — there grow. Now, that’s enough there. Now look how I — when I put this in, I definitely avoid the center of the macula. You know, one more right there. I avoid the center of the macula just in case there was a macular hole here or — or some of the dye inadvertently goes sub retinal through a really hard push. We don’t want that dye being under the center of the macula. I put it under, under wet technique. Meaning we don’t drain the eye out. I find that to be quite adequate. Saves a step. Also, I don’t like the idea of putting the IC green dye or anything on the macula under air. I don’t like that idea of something that concentrated being in touch with the most sensitive part of the retina. You can see how the dye does stain the vitreous a little bit. So, if you don’t use triamcinlone here, and the vitreous was down, you would see the ICM dye around the vitreous. A little bit of a squirt. Didn’t quite go over. There you go. Just a short-term one, yep, she’s asking about the gas bubble, the patient is. And we’re gonna probably give her air. It will be gone in a few days it will be pretty short acting. Okay. Now our macular work, which is what we all came for. Yeah, there you go. A little bit of light, huh if had and we’re trying to keep the image pretty nice. I meant to ask Rachel. Yeah, let me show my normal technique, which is the PICC. I’m gonna show you how I do most of my cases. There’s a reason for this. Right. You got it. So, we’re gonna — so, we’re gonna start with the PICC here. And I meant to ask anyone watching the video if we’re okay, if you need more zooming or something. Let me know. I could have okay. You can see here, the green stain, ILM stains really green. What’s not staining, where it’s missing like here and here and here, these parts where it’s not stained, that’s the epiretinal membrane. So, IC green will stain ILM, but not ERM. The ERM is really broad and diffuse, you get no staining at all. I like to use this little PICC to start an edge. And you see, we got one there. I don’t put the PICC — look how I use the PICC sideways almost. I like to use it sideways, not point down. But almost brushing with the broadside of the PICC. You don’t need the PICC to be sharp. Just some type of surface to engage that little ILM. Okay. And then what I’ll typically do is use — sure, show them the loop forcep too. Might as well do that. This is a device I do not use really ever. But I’m gonna try and show it you. I will not claim to be the expert with this device. It’s called a loop scraper. And you can see how it retracts. And — >> A little bit. DR. MILLER: Yeah, I will. So, this loop scraper retracts in and out like this. And we can push it out. So, it’s very flexible. And we can brush against the retinal surface. To create an edge. And it’s just starting there. And you can see how you can create an edge that way too. So, now we got two edges that we started. Right? One is right here. And one’s over here. Okay? So, and you can use this loop scraper if you wanted to going all the way around and just scrape, scrape, scrape your way around. Trying to avoid any direct trauma to the central macula, of course. We’re not going to demonstrate that. I will go with my forcep here, a 25-gauge reusable forcep. A lot of forceps are disposable. And that can be a bit of a cost issue. So, depending where you’re working at, or your cost sensitivity, reusable can be a nice option if you can preserve the tips and not have a lot of damages. So, we just grasp these started edges, right? And we peel out. And you can kind of see that ERM coming up first. So, the ERM will kind of come off first. The rolling that have is a good sign you got some of the ILM too. Let me focus back down. And, of course, you can also go to your other pinch point, or start point, which was down here. And do something similar. I don’t worry about trying to keep it as one piece. And I tend to knock the pieces off in the eye with the light pipe and then come back later and get all those out. So, now we got a peeled spot here. Doesn’t stain quite as well because the ERM was blocking some of our stain. This is more of a jigsaw piece, a jigsaw puzzle piece missing here which is kind of nice. It’s easier to see the edge. We can go down and pinch that edge and grab it. And notice how I’m peeling away from the central macula. I tried to stay around the outside. The center piece will come up. Now you can see an even larger piece missing, right? It goes all the way from here to here. Kind of a kidney-shaped piece. I’m just trying to get a little better focus for ya. And for myself. And we’re gonna do the same thing again. And try and grab that edge. Well, let me show you another technique. I just thought of something else. Oh, sure. Jenny just handed me the disposable forceps to the show difference. These forceps are disposable. And the nice thing about disposable forceps is you can just do pinch and peel. More adequately. So, you can just go down and start a new spot. The edges are sharp on these forceps because they’re not reused. You can just go down and grab the retina usually. And start your own new spot. You can see that right there. See how that works? You just go around with these. So, instead of having to use the PICC. The downside is these are disposable and you throw them away. the PICC that I showed first is reusable, been used hundreds of times. This forcep, very nice forcep. Is this from Vortex? Yes, this is a Vortex instrument. You can see how nice that will just go around without having to use that — that PICC at all. I’m gonna show you another way to peel, which is with the vitrector. Now, this is a little bit probably less common. But these vitrectors are such fine instruments nowadays that you can peel the intralaminar membrane with a vitrector. Sometimes it’s handy because the vitrector has a wide biting spot, if the membrane is shredding a lot. This one is flying around. What we can do is stain again first so everyone can see what’s happening here. A lot of times I try to re-stain. I try not to stain more than two times. Ideally, you get one stain and you’re done. Just because it avoids toxicity issues. Putting more stuff in the eye. So, we’ll just do a little puff here and here and here. And here. And gentle. That’s gentle. >> That’s very gentle. DR. MILLER: Got it. Very gentle. And as we’re pulling out the die, right? You can see where it’s at and where it’s not at. Because we re-stained that internal membrane, that is. I find that if I go close to the membrane and hit the aspirator, I can quite often times engage the internal limiting membrane just like this. And so, that peels the central macula pretty well. You see how the green is gone now. The membrane around the center. And I’m gonna show you a little bit more of this technique. I’m gonna peel that nasal piece of the ERM. You just come down and hit the floor of the vitrector. Rub up on these edges. You can see how that is — does such a nice job of peeling up almost under tension of the suction. The trick is engaging the edge. And I would definitely caution that if you’re starting that technique, you know, to be away from the central macula. If you engage the retina, you want to know where your reflux is, you know? So, I’m not gonna engage the retina here purposely. But I will show now the reflux piece. I find that very helpful. So, I stop — if I engage the retina right there, kick it over. You hear the machine go “Click” and it spits it out. If you don’t engage the retina, pull it away. Triple the trauma. But if you hit the reflex button like this, it just shoots it out. Then you can pull away. And so, we’ll show you this again. Just because we’re having so much fun, Jenny. And that’s about it. So, let’s take look at our macula here. We have a big peel of this ERM that was causing vitriol macular traction in the case, getting lots of Ilea injections. When I peeled over the pseudo hole, you saw the hole jump up and look like a volcano a little bit. Close to being a full macular hole, but not quite. And this is gonna put her a long way towards probably getting better treatment for the diabetic macular edema off the ilea injections. I’m gonna put the PRP in and then look around with the depressor. Put light PRP in, a moderate diabetic patient. On the angiogram done pre-op. Which I didn’t bring photos for. You could skip this and keep her on injections. I think that’s a tremendous burden for the patient to be injected for diabetic retinopathy. And, of course, I need the laser pedal by my left foot. So, I’ll wait for the circulator, someone to get that for me. Thank you. And I’ve learned through experience not to reach out with my foot and fall off my chair. Yeah. Make Jenny catch me. It’s happened before. And so, now I ask for help to get the pedal in the right place. So, we don’t need to put heavy burns in here. These can be fairly light, gray burns. You know, that’s my preference anyhow on PRP. I know in the old days, you would see eyes that look like a bomb went off inside. PRP was so heavy and intense. And, you know, we’re just gonna put — scatter some light PRP around here. Doesn’t have to be real symmetrical. You just have to get some peripheral laser in. What this does in the eye, obviously, it treats areas of retinal ischemia, which lowers the amount of veg-F in the eye, growth factor, levels drop. Then I need less of the ilea injections which are anti-vascular injectors. I’m trying to get away from pharmaceuticals to control the problem and using treatment like this where the patient won’t have to — no patient wants to, you know, get injections indefinitely. Certainly those injections are extremely helpful. Been really landmark and paradigm shift in treatment with better outcomes than we have ever achieved. Doesn’t mean we abandon the old techniques. Plenty of room for those. I don’t worry about if I hit the bleeding spots or not, getting the ischemia, in the peripheral and temporal periphery. Don’t ignore the temporal periphery. Switch hands to get that. There’s macular bleeding from some of the spots where I started the peels or brushing with the pick or the loop or pinching with the forcep. Switch hands here. We use an extendible laser, by the way. You can see how that’s a nice curve on there. And I’m going to — we can focus that a little bit. Then I do care a little bit more about the laser and the temporal macula. And the temporal periphery. It seems that’s a hot spot for an — ischemia. I think this is a major contributor to her diabetic retinopathy and her DME. Also remember her retinopathy is somewhat blunted bit years of Ilea injections. If we withdraw the injections, she may drop into a more rapid proliferative space. Be careful about withdrawing the injections without laser in the eye. Be watching out for vascularization. We can go far out. These wide feel viewing, getting wide into the periphery here and we’re almost done. Again, not too heavy. Doesn’t have to be contiguous, certainly. What I would consider to be light or moderate amount of PRP in the periphery is more than fine. So, here we are. So, now we’re looking at the back of the eye. You can see the staining peel area. Laser in the standby. And we retract the probe, withdraw the laser. Take a look now with our depressor. She dropped the pressure in the eye, the infusion a little bit so I can depress a little easier. Again, never a bad idea to check the peripheral retina under spell at the conclusion of the case. Like looking at the post-retinal tearing or detachment. In this particular case, certainly when you peel the vitreous, those are the cases where you’re going to tear the retina. Always a good idea to get a good look when you’re pulling up the posterior hyaloid. Very good. We had a nice case there. Now let’s go to, again, another very important part of the case. And that’s pulling out the cannulas and making sure we don’t have wound leaks. Can I have the other forcep too. I’ll start with that. >> Lights on. DR. MILLER: I’m gonna pull this nasal cannula first p out the way I put it in. This way. We have a tunnel here that’s like this, you can see that hole. Take my forcep, the more pointed ones, and press it right over the roof of that tunnel. Why do I do that? It helps collapse the wound. Okay. Jenny will check. Jenny will check with a Q-tip over there for me. And we’ll see that it’s not leaking. This one, same thing. Look for where the wound is at. We see it right there. Learned that from Dr. Galdoni, spread the forceps, find the hole. This is one of my partner’s technique, one of my partners. I’m learning from partners who help me make this make sense. I love collapsing this, and Jenny shows us there’s no leak. Now we’re good-bye pull this last one. And again, we’ll take a look at where the wound is at. It’s right there. Look how the conj is displaced so the wounds don’t line up. That’s good. Press pretty hard, don’t be afraid to press hard over the tunnels to where it almost makes a black mark. Check again with my trusty finger. And it says about 15. And we are set. Very good. So, Jennifer, we’re all done here. We’re gonna get you out in a moment. We did not put air or gas in because I did not feel we had a true macular hole. So, sometimes we leave you with air or gas. We did not in your case the way it peeled up, I feel quite confident we can watch that post-op and you’ll be just fine. With all the traction off. So, let me just — what we’re gonna do here is I’m gonna take a question and answers. And we’re gonna flip the room over and bring in the next patient. And do a case for — of a little different case coming up. We’re gonna — let me just see if we can’t back up just a touch. So, what we’re gonna do is — here, I’ll get this down too. A little warm. So, anyhow, thank you. So, the next case is a little more involved. We have an eye with multiple surgeries from an outside surgeon. It was referred in from the outside. They had three retinal detachment surgeries, oil is in the eye, the oil needs to come out and there’s a big membrane across the macula. We’re gonna try to peel that. Try to answer the questions here. And try to get the second case in if that’s okay with Cybersight. Those of you who have to go, of course, just watch later, or not. So, I’ll go through a few of the question and answers here. What is the fate of the vitreous substitutes? I think what we’re asking is, what happens to the ones we put in the eye? So, in this case, it’s salt solution at the end of the case. The eye will recirculate that on its own and that fluid will probably be replaced by aqueous within three or four days. Whether it’s gas, gas can be absorbed relatively quickly. If it’s air, oil stays in there until removed. Gas bubbles, SF6, different lengths of different solutions last different lengths of time. The next question. Any types for separating the posterior high reside from the retinal surface in cases of breakthrough hemorrhage without using iatrogenic breaks in areas with dotted pre-retinal hemorrhage. You want to get those off. Whether there’s hemorrhages or not. I wouldn’t worry too much about it. Thing a diabetic case, it’s a more difficult case. I think a vast and pre-operatively, will help with bleeding. Raise the bottle. I tend to use bottle pressure a lot for controlling intraocular bleeding. I don’t hesitate at all to run the pressure up to 60, 70, even 100 millimeters of mercury. I know the optic nerve will flash, the blood pressure of the patient is pretty high too. But I use intraocular tamponade with BSS. Not indefinitely, but a few minutes can go a long, long way. Next. During intra surgery, how do you control vitreous hemorrhage? Again, I think the bottle pressure is your best friend there. And even your better friend is preoperatively treating for that in diabetics or neovascular cases with intraocular, inter– injections. Your favorite veg, whatever you have access to. We should peel the membrane from which direction? In general, epiretinal tissue, severe macular pucker. Always better peeling from the optic nerve towards the periphery. The reason is the retina is thickest near the optic nerve and the retina is much less likely to tear when peeling away from the optic nerve. It’s well-anchored. If you start peeling in the periphery and towards the macula or towards the optic nerve, you get more iatrogenic breaks. It can help to use both hands to maintain my strong preference of going from the nerve out. Why do you prefer green dye instead of blue? I don’t know they prefer it. It’s what I kind of grew up with. Now that I’m old, we had green way before blue. And I’ve just always stayed with it. Now, I’ve used blue a little bit here recently in just the last year. And I do like the green because it stains the internal lam myal membrane. The blue stains epiretinal, but not the ILM quite as well. There’s a transition over time. I’m probably going to be using more blue. I know IC green is tough to get, there’s been a supply interruption. And brilliant blue — not brilliant blue. But whatever the blue trade name is made by DORQ actually as a matter of fact is improved in this country and is available and we’ll be looking at using more of that. What is the ideal starting point of the internal laminal peeling membrane. Like I did, that’s my standard case. I start a PICC peel above or below, at the fovea arcade. I like to start at a spot that’s stained green to have the right plane. If there’s an ERM and there’s no green, I don’t like to start the peel. I don’t know how deep to go. Look for a green area, that I have the internal membrane. And then I go above or below for that type of peeling away from the fovea. I typically will start two points with the little PICC above and below just in case one doesn’t peel well with the forcep. I can go back to the other stop without having another PICC point. Start two points with the PICC, above and below. If it’s going well, go along the edge. If I need to re-stain, I finish with the vitrectomy. I’m out of the eye and can finish the peel with that nice wide mouth of the vitrectomy. What parameters do you use while peeling the ILM with the cutter. It’s the same I have set for the vitrectomy. In this case, it’s aspirating at 350. It’s not any higher than a standard vitrectomy for me. And I do have the pedal floored so I’m getting all 350. Then it’s just a matter of how deep you go into the retina with that tipped. You have to make a little indentation and hit the retinal surface. That can be nerve wracking. You’re not above the retina to grab that. But you can dent the retina a little bit. It’s almost like retinal depression instead of scleral depression. You can have the smooth, back corner of the vitrector and go up into the cutter mouth and keep going. You saw me make during the case multiple passes to engage and I finally got it and then we went out. How far air do you peel in a case of a macular hole? You know, I just did a macular hole as my — a true macular hole as the second case today. And the way the peel went, we ended up with about one disk diameter around the hole. I was like, it was done. It was a small macular hole. Probably 250 microns across. And I thought to myself, god, I could go back and grab a whole lot more ILM and peel it out from the arcade. And I’m like, but what’s the point in the hole is gonna close. If the traction is off the edges of the hole, there’s no benefit to going way out in a standard macular hole case. I could think of some in high — and posterior staphylomas, trying to get more retinal stretch. But in a standard macular hole eye, really get the traction off from the center. That can be as little as 1 millimeter radius around the hole. I typically probably do more like 2 millimeter radius, just because that’s what I end up with when I start the peels fourth. But in this last case, it stayed tight and didn’t go further on. And that was fine. Oh, yes, ready for the block. We’re going to block the next patients. And get started. Congratulations again to our team at the Cleveland Eye and Laser Surgery Center. With the quick turn around. Pretty much our standard here. Which is very nice. We’re about 9 or 10 minutes. This is Eric. Hey, Eric, look up for me. We’re doing a little videoconferencing while we’re working on your eye today. And we’re injecting the same medication. A little burn here, Eric. And some pressure. Yep. Same solution, lidocaine and marcaine. 5ccs. And if that doesn’t work, we can always supplement during the case. The reason I said that, I felt the needle be a little bit low in Eric’s block. But the eye is coming up nicely. So, I expect we’ll be fine. It may not be a bad idea to have a little extra local on the field if we’re gonna do a cut down. So, we’ll go through and answer a few more questions while we’re waiting for them to prep the patient, get him sterilely prepped and draped. They’re doing the prep behind us, you can watch that too if you would like. Where are we at? My preferred method of anesthesia, local or general. I prefer local. the patients are very cooperative, they’re short cases. And it’s easier for them to go home without the effects of general anesthesia. I do pediatric, they’re under general. From babies up to 16 perhaps. I prefer general. Sometimes you get really claustrophobic patients, psychological issues, they are under general. I don’t have a need for general anesthesia for pain. A buckle or a VIT or a buckle VIT, they do very well, during the case and post-operatively. What are the different vitreous substitutes we use? So, besides salt solution, which I believe comes from Elcon, pretty sure. The other choices are for the gas is air, SF6 gas, 20 or 25%. C3FA gas, typically 15% for me. I’ll get about a good tamponade, four weeks at that concentration. SF6, get a good 10 days at SF6. Silicon oil, I prefer 1,000 stroke, it’s thinner, more easy going in and out. I suspect Eric here may have 5,000 cena stroke. We’ll find out. It wasn’t my case. depending how thick it is, we might have to alter our technique to get it out. Occasionally on a rare case, I’ll leave Perfluoron in the eye. It’s heavier than oil and tamponades really well. It can be nice. It’s not on label to be used for long-term tamponade or vitreous substitute. But it’s tolerated for weeks without any type of inflammation or difficulties and we go back and take it out. Pardon? Oh, yeah. Let’s do the case presentation. I’ll come back to these questions if there’s time at the end so you know more about Eric’s case here. It’s like the patient too. Yeah. There you go. Patient 2 here, 56-year-old, blurry vision for 6 months. No change over 6 months. His visual acuity is hand motions. Had a retinal detachment repair times three using vitrectomy techniques. It was done at an outside facility and surgeon. Referred over for removal of oil and macular surgery work. So, not exactly a simple macular pucker. But things that are very common out there why the real world. So, we’ll start the case here about now, I think. Right, Jenny? Yeah, we’re gonna start the case. Okay. So, we’re gonna go back to the microscope. Jenny is assisting again. We have the patient prepped and draped. And… okay. Saw that we’ll have to get that, of course. 15 degree blade. Jenny just mentioned, she sees an oil bubble in the anterior chamber. Commonly, oil will migrate to the anterior chamber. We are gonna take that out for you too and show you how we do that. So, like I said, this case, a little more going on than the last one. And there’s our guy. He is a phasic also. There’s been quite a bit of contraction there on the anterior capsule. Does have a capsule opening in the middle. That’s left like that purposely by the prior surgeon I think to facilitate an eye sulcus PCI at a later date, which we are not doing today. One thing with doing a re-op case, trying to avoid all old incisions. We don’t want to hit the old sclerotomy wounds. I like the — yeah, I don’t like two forceps. Because an eye this red is gonna bleed easily. And you can see how the conj doesn’t to want move too much. Pull it over a little bit. Drop — and I know I didn’t measure here, that’s about 3 millimeters. Okay? Did that hurt? We’re gonna — we’re gonna make you a little more numb. And so, how we’re gonna do that, Eric, is we’re gonna pull up some more block and some scissors here. I prefer to do a sub-tenons injection if possible. Is that pinchy there, Eric? Okay. Just hang on one second. We’re gonna make a little incision here and get you more anesthesia. So, I think this is a nice way to show a little spread action there. And then we got a blunt cannula here, 19 gauge. Same solution. And we like to put that right back there. We’ll do one more cut down spot. I like to do two. Scissors. And is any block left in that syringe? That was pretty miserly. >> You have a half — left. DR. MILLER: Same technique. We like to cut down — spread a little bit there. How you feeling now, Eric? Does that pinch there? Nope. How about over there? A little something. Okay. How about over here. So, I’m gonna put the next cannula in. We’re not gonna get the conj to move too much in this area. That’s kind of a shame. But I don’t want to use the old wounds. >> Probably high. DR. MILLER: Yeah, they’re high. I agree. We’re gonna stay down near the horizontal even though the conj isn’t dislocating for me too much. I don’t like to go near old wounds. They spread and leak. This is one of the problems of using sutures in previous cases. You see how the conj goes down and gives fits to move through it. I’m almost at the horizontals. There’s no trouble or fear about hitting arteries, veins, nerves there. I’ve never had that be a problem. I know that’s where some anatomy people are concerned about and if I ever get a case reported actually see one where someone injured that with sclerotomies, I would be very interested. So, we’re going to take the oil out first. We have a 25-gauge setup. And we’re gonna see how this oil is coming out. Whether it’s gonna come out fast enough. Oil extraction. Okay. So, we’re gonna see how quick that oil is coming. Oh, it’s not bad. >> I think it’s 1,000, just because of the time frame. DR. MILLER: Yeah, the time frame, right. no, his last surgery was a few months ago. But 1,000 was back in stock by then. So, we have the oil coming out here. It’s a little — I wonder if we can speed that up with a — Jenny — by — >> Popping the cap off maybe? DR. MILLER: Popping the cap off and putting the it up over the top. >> Yep. DR. MILLER: You need this back. We’re gonna take another way to do this. We’re gonna — there’s another device. Instead of putting the cannula in the eye to pull out the oil. We’re gonna do it by putting the cannula over the top. We pull off this little cap. Things are progressing there. Quite often we can get a little — I’ll try to get an idea how quick that’s working for us. And I do think that’s working quite a bit better. The advantage being, you don’t put that metal cannula inside, which is a lumen inside of a lumen. Now we’re using the full page of the 25-gauge cannula for the oil to come out. Anything that’s thinner is going to slow down your egress of oil quite a bit. So, the bigger the hole, the quicker the oil moves out. And that’s what we’re going for here. Now, we lost our valve. We’ll try and — try and put it back on the case. It is nice to have valves. Helps maintain fluid, et cetera. Jenny, we lost the suction. Hit air there. Probably the little air bubble. But we have to push this back down so the cannula, the oil extraction device just filled with air. So, we had a little leak or something. So, we’re just gonna reset it. Push the plunger back down. Start over. No problem. This is just a little bit of patience. You know, I — and this is oil in here yet. Can you get that higher so it pushes — yeah. The oil on this line so it got backed up into the infusion. And to push that oil out, we had to raise the bottle pressure, it went up to 60. Because we want to push that oil in so we can get the eye firmed back up. And so, we’ll keep the eye firm. Encourage the oil evacuation. We can probably almost — you can see the corneal situation here. I don’t think we need that anymore, Jenny. You might as well take that out while we’re doing this. And you got like a .12 there or something. Well, these are gonna be too big anyhow. Never get them around it. Give me a .12 first. And we’re just gonna — take out the little suture here. Gonna dry that again. Well, let’s see what you got now. Okay. We’ll get a little scissors and then we’ll cut that out. So, I will pull the oil out. We’re gonna… cut this. Now we’ll want something to pull that. And not the one twos. Give me a vincula or something. Ah, got gonna work. Give me the one twos, or something fine. I know a suture tier would be perfect. >> Is that a .5? Better? DR. MILLER: Nope. I’m not going to get that with that. Give met .12. >> Yeah, higher? DR. MILLER: I’ll get it now. You got the –? Like to pull it the other way, really. That won’t work. It’s going through the deep. Yeah, we’ll just get the tires. I’ll get the instrument and we’ll pull that suture out. The oil is about up to 2 or 3ccs, the eye is kind of large. So, I know we got a ways to go yet. I don’t want to take out this bubble to the end because once I start pulling that out, it may just pull more oil to the front. Don’t really need that either. Here you go. There we go. Success getting out our suture. It was quite the struggle. Hopefully that will be the hardest part of our case. And the oil continues to come out. You’re just not seeing it in here. But it’s doing just fine. And our plan on this is a couple things here. Be sure the retina is attached from the oil comes out. There’s always a risk of retinal re-detachment. Numbers can be as high as 20% when taking out silicon oil. I don’t think his risk is that high. I think you can kind of judge that or modify that number when you’re looking in the eye before surgery. You know, what kind of scar tissue are you seeing? Where are you seeing it? How are the edges of the retinectomy look? I think he had a large inferior retinectomy already. We’ll look at that when doing the membrane peel. The one thing about peeling the macula, it gives a lot of circulation in the eye. If something is open or not, secured in terms of retinal breaks, we should see the retina re-detaching, you know, while we’re still on the eye. Not having to wait to find it tomorrow or a week later. Which is always very disappointing. If we find it today, we will still peel the membrane and the macula. Probably end up cutting the retina again if it’s that severe. And reattaching the retina and lasering things and perhaps even using more oil. But I’m hoping the case won’t go that way. I’m more optimistic we can just take the oil out, peel the membrane, leave the eye with salt solution, after we check the peripheral retina and make sure there are no peripheral retinal tears or breaks. And we’re probably around 4ccs now for oil out. And again, the eye may be a little large. So, it’s gonna take us a little time. It’s also nice that if we can take oil out this way, instead of cutting down, you can make larger incisions. The next choice would have been to cut the conj down, make a larger opening. 20-gauge instance, for instance, and use an 18-gauge AngioCath, you know, to put through that sclerotomy. And pull the oil out more quickly. But then so the 18-age hole shut. Again, I try to avoid that in multiple re-op eyes and you don’t know if you’re coming back. Any sutures and wounds you make for a large wound is gonna be a weak point in the sclera for the next case. So, if we made a big wound like to and sewed it shut, it may save us a little time today. But then if something happened and we had to come back in a half clock hour of a sclerotomy incision, I can see the blue areas in the sclera a little bit. Which make me very hesitant to put any wounds there and have wound leaks post operatively. So, going very well here. Just takes time. And so, I know it’s a live video stream. But we’ll get there. And you can kind of see what we deal with in these cases too. >> [ Away from microphone ] DR. MILLER: Well, we don’t know. So, Eric just asked, how much dang is done? The thing, in this type of eye, it’s very hard to predict what our final vision will be. I think you’re looking at this surgery, Eric. And then letting the eye heal and then ultimately a lens implant will be needed yet. But I like the idea of putting in the sulcus, the way they left the interior capsule there. We will open it a little bit so it’s not so little for the surgery. But should be able to leave it intact to put a sulcus-based piece in there at a later date. You know, I would be hopeful with how things — depending how it does and how much macular damage is, with the lens implant we get you to the middle of the eye chart. Now the oil across the eye in the back, you can see the meniscus. So, we’re almost done with this. And you always want to be a little careful towards the end because the — this device will pull fluid a lot faster than the infusion can put it in. You don’t want to have the eye collapse and cause a hemorrhage. He’s a myope. That risk is higher in Eric than others and down into the final few drops of the oil. You hear me go off the pedal a little bit. Bending the cannula towards the iris. Trying to get the rest of the oil without hitting the fluid pockets and really creating a problem. You can see the water come in now a little bit. Along with oil, both. You can see the water hitting into the syringe. And there, it just got real soft real quick. So, I stop immediately. Kind of recenter ourselves a little bit. Nope. That’s about all we’re gonna get. So, I’m gonna pull this off. And you can see the oil — the water freely flowing out. You can see our syringe. There. I don’t letting this run a little bit. Yeah, great. Okay. Great. So, we got our little valve there. And we’re gonna just push it back on. Very nice. Well, that was clever. So, we got the valve back on. Now take the oil out of the anterior chamber, if you can wet the cornea for me. Get this oil bubble pout look the way the eye wants to rotate most easily. It kind of wants to go this way. I’m happy to let it do that. I’m gonna make my incision here. And got a forcep there, move the eye. Thank you. Not that, pinguecula. Just gonna grab the conj here and rotate the eye and then gate this wound open a little bit. And maybe the oil is gonna want to move a different direction. Go ahead and squirt that again for me. And there we go. We just stab into it and let the oil egress out by gaping the wound a little bit. It tends to want follow itself pretty well. You can see the oil still coming out there in the last of the bubble. And that’s that. Okay. So, the oil is out of the anterior chamber. Now we’re gonna cut open the anterior capsule a little bit. This eye is certainly more, you know, the tissue is more friable. The tissue is more inflamed. Let’s put the cutter on. There grow. And so, this is our anterior capsule. We’re gonna try and cut into that. And it’s very thick. We’ll get it one way or another. >> You want me to take the cut rate down? DR. MILLER: I don’t think so. I think we’ll be fine. All right. Now we’ve got an edge. Which is a very — you have the capsule phimosis, the capsule contracts. We’re just cutting that edge through. The cutter is not the best at this. You can see it snap open there, right? We just cut both sides. Take the traction off. I’m not even necessarily worried about having to cut the fibrosis off all the way around. You could — we could take more that have out. But I don’t know that we have to. We’re gonna try and do that — this case without taking all that out. As long as we opened up the aperture, I think we’ll get a pretty good view. Hang on a second, something is just — I think it’s just an oil droplet and it is again. She’s putting some disco lactic on the eye for us. Okay. Get a look with the wide field first, look at the retina. Make sure we’re staying attached. And then address the macula. So, here is our case. This is actually the best view I’ve had of this eye too. Of course, the view in the clinic wasn’t certainly any better. You can see the patient has had a large retinectomy, inferior with extensive laser. He’s had a 360retinectomy, up here too, and nasally. The retina is attached. I’m not seeing any detachment. This could be a tractional detachment. We’re gonna go ahead and stain that. I’ll try and zoom in a little bit. So, you can see what I’m looking at. Together. Very good. So, we’re looking at this tissue in particular. This big ridge here. Distortion of the macula. How is our video doing? A little — let’s take the IC green dye. Okay. And we’re gonna put our green in. You know the vitreouses are already off. You got a little bit of — let the green fly around. As we aspirate it out of the eye. So, the green here is going to help us see the ERM, the ILM. We know the ILM is the last layer before the retina. That’s a good dissection plane. We’re removing all the pathological tissue. And then we’re gonna use our PICC and reusable forcep for this case. We go to a contact lens here. They get a better view. And let’s see what we got here. Oh, the capsule may interfere a little bit too much. I think it does. Let’s take out more of the capsule. Yeah, the capsule is obstructing us a little bit here. So, we’re gonna have to do a little work on that capsule piece to get a better view. Just take us a couple minutes, I think. Won’t be that bad. Again, in a case like this, whether the capsule is left at all or not is debatable. And you could even just remove it entirely. And what I’m gonna do is just cut around the capsule. The fibrotic part, that is. And there we go. It count take much capsule support. As long as it’s in the periphery, you have the sulcus IL. I’m not too worried about this opening. And there we go. The capsule is still there. You see it. And all the quadrants. We’ll worry about that later. Like I said, it’s not the most critical piece. There’s always ACIOLs, or suture IOLs if that was truly not gonna hold us. So, this here, I notice when we put this in the eye, this is a special forcep. We call this the Jenny broken forcep. R-PICC. It has a lack of a tip. So, I named it after — So, I named this after my PA here. Because she doesn’t really seem to mind what she hands me during the case. >> I can’t see the — DR. MILLER: Yeah. I’m gonna show you. >> I have a scraper. DR. MILLER: No, no, no. It’s fine. Actually, just need nothing is make an edge. We have several in the sets that are broken. And I don’t think the surgeons mind. Because, again, you’re just trying to get an edge going. And you kind of got one already there. See that? So, again, I look for the green. I went to the — in this case, that’s the inferior macula, right? Now we’re gonna switch gears and go to the superior macula. Look for an area of green because I know that’s the ILM. You can see that roll coming up there. So, I think the — like the loop stripper in a case like this will actually be more difficult to use in some ways. How are we there? Are we on the screen? >> Yes. DR. MILLER: Because it’s a little flimsy. >> Better? More? DR. MILLER: you can see what we’re trying to do there. Trying to keep this centered for you guys. And we grab that flap we made by the ILM. Sometimes you can get the ILM to come with the ERM. Sometimes you have to peel two layers in a more severe ERM like this. But it wants to come all at one time. Fine by me. I’m peeling towards the nerve there. I will almost stop and go in the other direction. But it’s nice to go around too if we can. And we’re getting a little out of focus. See if I can’t focus that better for you. I’m gonna take the vitrector. This is awkward with this hand. I’m going to show you something with the vitrector we can use. I’m going to use the left hand, and peeling with the vitrector one advantage in the left hand, you don’t have to actuate a forcep. You just use your foot. So, I took off that big piece. And here is the ILM behind it. I’m not as comfortable with that. I’m gonna come back to the forcep. And peel a little bit more with this. You’re doing well. The scar tissue is coming off real nice. A little better focus. I don’t think so. We’re gonna use the pressure a little bit there for that hemorrhage in the macula. This membrane is gonna cause a little bit more bleeding. And you can see PVR membrane. >> We’re off the screen. DR. MILLER: Oh, we’re off the screen. There we go. Funny how it just kind of popped on its own there. And so, there’s your optic nerve. Membrane’s peeled off through here. What we’re probably gonna do at this point, Jenny, take the IC green stain at this point and see what’s left to peel. And see, I’m thrilled with the image. I hope it’s better than that. Okay. So, just like in the other cases, she’s gonna put a little green in there. Hang on, Jenny, you got a oil bubble or a air bubble. There grow. >> Gently. DR. MILLER: Gently. Gentle Jenny. That’s what we call her. And we’re gonna take out the green and fragments that we’ve already peeled. And see what we got left that we can do. But we’ve taken off a significant amount of traction and scar tissue already off this macula. As you can see that piece there. And we still got a little bit to go here that I’m gonna grab. And there that came to, that vitrector is very nice at grabbing loose membranes too. The other thing is, when you peel the macula, what you oftentimes see is the retina turns a little bit white from the trauma of the peel. A little bit of edema all through here. All up here. Right? Here you can see the edge of the IC green now real clearly. As well as down here. But that’s not our biggest problem. So, we’re just playing with the pleasure a little bit. We went from 35 to 60. Back to 35, back up to 60. But all that’s going very well. So what about we’re gonna look at doing now is peeling down here. Making sure we’re not leaving any tissue, epiretinal tissue. I don’t think we are, actually. And we’ll peel this piece down. And then we’ll take a look just a little bit outside the arcades, being an RD case, make sure we got everything. The patient did have a prior macular hole. During one of his retinal detachments. That was closed under the oil. But closed and scarred are — different things too. So, there we go. We’re gonna — I know we’re probably off the screen at times. I apologize. More complex case. Go ahead and grab this edge. Knock this piece off. And you can see this go across. To the only place where there’s any tissue left, which is the bottom. So, the traction is all off the center. Nice curved linear pattern of peeling all the way around. We can take the ILM out a little further. ILM in a case like this is a little bit more difficult peel. Tends to be more sticky. Doesn’t like to separate quite as well. It comes off more piecemeal typically. So, we’re in pretty good shape. Homogenous staining like this, nice residual stain, shows no ERM. There’s a little bit down here, but pretty far from the macula and there’s no traction. I’m not worried down here. Not worried out here because there’s no non-staining area. And we’ll take a look maybe a little closer at that hemorrhage site. You can see how the retina was folding here from the ERM. Let that unfold naturally. Look at the hemorrhage. If we have a break there, certainly want to be leaving gas. And help smooth things out. Do you have a soft tip? Let’s try to pop that macular hemorrhage. Lift that up and see what’s under there. And… now, this is very gentle aspiration. Thank you. Yep, keep — yeah, let me know every time. So, there’s no hole down here, it’s just a hemorrhage spot where the ERM was very thick. It was its epicenter more or less, right? It was very adherent. I still don’t like this case in terms of not tamponading. There’s a prior macular hole in this case. We are gonna leave SF6. Okay. Which is immediate-acting, medium-term gas. Now we’re gonna take a look also at the periphery a little bit. I’m going put the SF6, smooth out the macula. I know he’s a prior hole, and the macula is very thin. I’m very hesitant to let that heal up without a tamponade. So, let’s take a look here in the peripheral retina. Make sure we’re nicely attached before we put the gas in. Don’t touch. Don’t touch. We’ll try — oh. Pretty good focus. So, you can see the peel. Almost the entire macula was peeled in this case. Look a lot of scar tissue away from the epicenter height here, which we’re gonna leave away. All this white. The peripheral retina is still attached. The prior surgeon did a nice job keeping this retina on for us to get to this point. And that’s where we’re at. A little impression, you saw me run it over there, over here too. I’m really not seeing anything up in the periphery, we see some opacity vitria here, where it’s not trimmed out. Not seeing any cylitic membranes, it was good preoperatively. I’m optimistic there. Put the air in and then we’re set. Air, then gas. Okay. And we’ll grab the rest of these little fragments. 25. You’re doing well, Eric. The scar tissue came out real nicely. The retina is remaining attached. I like how the scar tissue came off the macula. Peeled out very well. And relieved all the traction. Now it’s a matter of seeing what we can recover for vision. I know that hand motion is where we started. She’s gonna focus this a little bit better. As we go to air, there’s often a change in focus. And some glare. Sorry for that, everyone. We’ll try and get you the best views we can. That’s about it. So, now we’re gonna go through the wounds again. You can see the air bubble in the anterior chamber, doesn’t bother me at all. Aphasic eye, will be okay with any pressure issue. Close this one. You had .12 there. So, we’re gonna press down on this guy. This eye just tissue everywhere, very inflamed. Multiple surgeries. Let’s go ahead and put the gas bubble through the SF6. Venting in the spot, putting the .12 forceps in and letting them passively open. Okay. And we’ll pull that one out. And I’ll need some resistance from you. Keep going. Keep going. She’s pushing fluid — air in, or gas in while I’m pressing down on this hole. There you go. You can come off. Jenny, ease up. There we go. So, I made my little black mark ORF the roof of the tunnel. Not sure this one is going hold. Very thin sclera, high — this was in a tough spot. We manipulated this wound quite a bit too. The more manipulations you do — go ahead and pump that up again for me. Okay. Stop right there. That’s holding. Let’s see what we get here now. Okay. A little bit more. Q-tip there. We do have a leak at this site. Go ahead. A little Q-tip can plug it while we check this one and see how many holes we’re gonna have here that are a problem. So, it’s only this one. So, I’m gonna hold a Q-tip here for a minute. A lot of times if you just wait, these wounds will swell up and close. But if that’s not the case here, like the other two are closed and not leaking at all. If this one continues to leak, no hesitation to throw a suture through this to close it. And it’s doing great. Eye is a little firm, actually. Probably a little too firm. Yeah. >> Since I was gonna grab — DR. MILLER: Well, we’re gonna have to — yeah. Probably gonna have a pull a little gas up. We’re a little firm. So, we did get it to close. We’re just gonna take a little bit of gas out. So, we’re just gonna soften the eye a little bit. And we won’t have to be in here long. We just come down here. And that’s it. That’s all it took. Eric, we’re getting you out. We got a gas bubble in the eye. I’m gonna ask you to hold your head down for two days like the macular hole case. You’re not gonna see until the gas goes away. Which is gonna take about 2 weeks in your larger eye. And that’s when the vision will return. Hold your head down for two days and after that, you can just sleep face down. So, that’s how we’re gonna leave this case. I can answer a few more questions if people want to stay with me or if everybody’s gone, we can — we can skip that. I’m not sure where we’re at. Rachel’s gonna queue us up and we’ll take a look. So, yeah. I’m happy to answer a few questions here. 5, 10 minutes. So, the role of ILM peeling in this patient with ERM and no macular hole, I think it helps us get the right plane, not to leave any epiretinal tissue behind. Again, if it’s stained completely green, there’s no benefit. But if you have patchy green, you know you have some E RM in there and just take the ILM to make it clean all the way around. And what advice would you give to new vitriol retinal fellows who want to learn macular hole surgery? Apply to our fellowship here at Cleveland Eye and Laser. We run a great fellowship. We have our first this July. We have a team of ten surgeons. You know, I would let any of these guys operate on my own eye. They’re fantastic. Combined 300 years experience. You want to get to a mentor, anyone you can to work side-by-side for a few dozen cases. And not just watch, but actually get the chance to put the instruments in your hand and have them suggest things to you. I think that’s the best way to go about it. Otherwise, if you don’t have that opportunity to train with someone, just go ahead and — I would say take yourself to a spot where you’re working on the simplest cases with the highest return for the risks. So, like a macular hole that’s 2200. Start with those types of cases. I would not do the 2030 case like my first case. I would try and go for people starting out with worse vision, with lots of upside. And be very gentle and cautious in your approach. You know, in terms of if you can peel the posterior lidocaine and everything is green, let that case go, pull the hyaloid, and maybe it’s not staining because of a membrane, work your way up. To clarify the second question, I wanted to know if there was any separate techniques for the posterior hyaloid, poly– you know, vascularization or polypoidal disease, for those types of cases. Kids are the most adherent ones I deal with. You know, the cutter under aspiration. The cutter down in the optic cup. And using the edge of the cutter to grasp the edge of the Weiss ring. Trying to get that up, that fibrous tissue around the optic nerve. If I can’t get it on the cutter, try on the PICC. I’m making retinal hemorrhages, I think I can make them in the layer. The Flex Loop is nice. You can extend it just partially out and use just that as a wider surface area of that little loop to get under that Weiss ring and elevate up. If you can’t get it there, it can be problematic. Certainly challenging for any of us. And any consequences from iatrogenic hemorrhages from the macula? Really none. If you get a hemorrhage on the macular surface, almost always gone the next day. An RPDR effector atrophy, be away from the fovea. This last case had a hemorrhage near the fovea. It could not be helped. The tissue was extremely adherent, very dense over the macula there. You saw the fold in the macula. If you don’t get the fold out, we’re kind of stuck anyhow. Just have to be more aggressive sometimes. Any antibiotics? I did not use any antibiotics in either case. Cataract surgery uses some intra-cameral antibiotics, retinal surgery, still not. How many milliliters of silicone oil did I aspirate? That was a high myope. Had about 7 to 8ccs of oil in the eye. Which is a lot. Comes about 10 per vial. They almost used all of it. How can the silicone oil be completely removed? The best way is the way I did it. And when you’re doing — after the oil is out, this person is aphasic, that’s not trapped near the lens. I would use fluid to air exchanges, and go up and down with the water level in the eye, and the water collect the on the surface. You can keep aspirating the surface as you go down. Then fill the eye back up with fluid, and the oil is there, and always sucking right from the surface, grabbing the oil slick on the top of the water. Using the advantage that oil floats on water but sinks on air and it’s right at the interface. Will oil evacuation affect pew fill open something do you use intraocular adrenaline to maintain dilation? I do not, I go right to a mechanical if I have issues. Any particular reason why silicon oil took this long. Yeah, there’s a lot of oil and there’s a 25-gauge aspiration. But that allowed us to avoid sutures post operatively. I would be disappointed to do all that and then have to suture it close. That would have been not what I wanted. But it worked out. Any difference between removing oils that are different — yeah, there is a big difference. If you’re using 1,000 weight oil, it goes in and out pretty easily. The 5,000 weight oil has a problem, it’s so thick, it won’t come out through 25 or 23 gauge easily. You have to cut the eye over and use an 18 gauge AngioCath in my opinion and pull it out that we or you’ll be there for a terribly long time. Why not remove the capsule and perform silicon foil suture fixated OL later, you can. No doubt if I was doing the RD repairs in this gentleman, I would have taken the capsule, hypotony, if you are going to leave a capsule in, be confident that you have the PVR piece covered. If that was my initial surgery, correct, I would have taken it all out. At this point, I think it’s inferior to salt displacement of an IOL. It’s faster, no external fixation, nothing for later possible infections. Is it the laze marks or retinectomy scar? The white was from PVR and laser scarring. Any particular tips for the choice of the type of gas? You know, not really. You got to pick and choose here. He didn’t have a macular hole, had one in the past. Not in this case. The macula was folded up. I’m concerned the hole could reopen I used a short-acting gas. Another is BSS. Are all surgically peelable? I think they are. There’s a rare, rare patient with the epiretinal tissue from the desist may be integrated into the retina by a bad diabetic with full — this is one case where you may not be able to remove the tissue from the fovea. You’re going to make a macular hole or a macular defect. I appreciate the time being with you. Enjoy my time at Cybersight. Get this great hat. If you see me at the conferences, happy to say hi. Happy to talk to anyone. Thank you.