How to achieve a calm, stress-free OR

September 11, 2017

Achieving the best visual outcomes in challenging cases is a high priority in surgical retina. However, meeting that goal involves a high level of creativity, especially in complex cases associated with other ocular comorbidities.

Reviewed by Ronald Gentile, MD

Achieving the best visual outcomes in challenging cases is a high priority in surgical retina. However, meeting that goal involves a high level of creativity, especially in complex cases associated with other ocular comorbidities.

Ronald Gentile, MD, described some of the tools he uses that ease the tension in the operating room and make the postoperative course uneventful.

“Surgery is built on a solid foundation of the previous step,” Dr. Gentile said. “The ideal operating room experience should be calm and stress-free for all. We are really searching for operating room nirvana.”

Dr. Gentile is clinical professor of ophthalmology, director of the Ocular Trauma Service (posterior segment), and coordinator of the Retina Service, The New York Eye and Ear Infirmary of Mount Sinai, affiliated with the Icahn School of Medicine, New York.

He explained that there are some simple and effective gadgets and techniques that can prevent intraoperative and postoperative surprises, making the lives of all involved in the surgery much easier during and after the surgery.

Complex diabetic vitrectomy

Dr. Gentile explained how he approaches what can be a scary scenario of a combined tractional rhegmatogenous retinal detachment in which the membranes extend past the equator. The rhegmatogenous component makes this an extremely challenging case.

He uses valved trochars, which decreases flow. “Previous to this, we had leaking sclerotomies that caused the retina to be extremely mobile, making it very difficult to remove some of the membranes,” Dr. Gentile explained.

While not a new instrument, the MPC membrane cutter/peeler enables the surgeon to get into tight membranes, especially in the retinal periphery, and remove plaque that can be adherent to the retina. Available in small gauges, this instrument can hit these tight membranes without causing additional retinal breaks.

“In the past, we actually had to remove the retina to remove the plaque, especially if there was an adjacent retinal break,” Dr. Gentile added..

The new chandeliers provide substantial illumination in the surgical space and facilitate bimanual surgery.

Techniques for cornea and retina

A corneal protector is a device that many cornea and cataract surgeons use to protect the cornea as well as the macula from phototoxicity. To prevent phototoxicity to the macula, Dr. Gentile injects a small amount of kenalog into the back of the eye while the anterior segment surgery is under way. The kenalog settles over the macula and acts as an internal shield.

Macular Phototoxicity (Image courtesy of Ronald Gentile, MD)

Another pearl involves intraocular lenses (IOLs). “When condensation forms behind the IOL, I use a 25-gauge needle beveled up to inject and place Healon (OVD) behind the IOL to remove the condensation,” Dr. Gentile explained.

For cases when silicone oil is adherent to the back of a silicone lens, Dr. Gentile described this as irreversible and requires removal of the IOL. He can sometimes remedy this situation by using an instrument he referred to as a “hydraulic squeegee.”

This was devised by one of his past fellows, Mital Mehta, MD, with Christopher Riemann, MD, in Cincinnati. This is actually a 27- or 30-gauge cannula bent with a forceps. When attached to a balanced saline solution syringe, the squeegee is used to blow the silicone oil off the IOL without removing the implant.

Another gadget that he uses is a temporary keratoprosthesis. Dr. Gentile described the case of a patient who presented with severe trauma, a ruptured globe with detached retina, and an opaque blood stained cornea.

“The temporary keratoprosthesis is very helpful by enabling us to perform the surgery and reattach the retina,” Dr. Gentile noted. 

Aids for glaucoma specialists

When measuring the intraocular pressure (IOP) during surgery, historically the Barraquer and Schiøtz tonometer was used exclusively. Dr. Gentile has devised another method in which a Tonopen is put into a size 8 glove to measure the postoperative IOP in a sterile manner.

In cases of aqueous misdirection, the important factor is to prevent a recurrence of glaucoma. Dr. Gentile pointed out that a vitreous cutter is used to make an iridectomy, but he was doing more than just removing the anterior hyaloid membrane.  

Case of aqueous misdirection: Preop (left), intraoperative (middle), postop (right). Images courtesy of Ronald Gentile, MD

“I want to remove the peripheral capsule and the zonules behind my iridectomy,” Dr. Gentile said. “If this is done, the posterior chamber of the eye has a direct communication with the anterior chamber of the eye and the glaucoma should not recur.”

Implanting glaucoma drainage tubes can be complicated by vitreous plugging those tubes. Dr. Gentile advised surgeons not to use the vitreous cutter to cut the vitreous from the end of the tube. The result will be a vitreous plug that prevents the tube from working. The plug from within the tube must be removed first with forceps and then vitrectomized to prevent an obstruction. 

Tips for cornea and glaucoma

Silicone oil is useful for retina specialists, but it is a problem for cornea and glaucoma specialists. “Once the oil enters the anterior chamber, it can cause glaucoma as well as keratopathy,” Dr. Gentile said.

Dr. Gentile outlined how he uses “silicone oil retention sutures” to prevent silicone oil from contacting the corneal endothelium and trabecular meshwork. He uses Prolene sutures placed from sulcus to sulcus to simulate iris plane.

After placing the sutures, the knot can be rotated into the eye. Different patterns of suture placement can prevent prolapse of the silicone oil into the anterior chamber. He prefers the triangular shape because it is the fastest to perform with the fewest passes.

 

Ronald Gentile, MD

E: rgentilenyee@gmail.com

This article was adapted from a presentation that Dr. Gentile delivered at the 2016 Precision Ophthalmology meeting. Dr. Gentile has no financial interest in any aspect of this report.