This is a patient with Diabetic Retinopathy who presented with subhyaloid hemorrhage on the macula. The vitreous was removed and the blood was cleared from the hemorrhage. A 360º laser was done as PRP to regress the retinopathy.
Surgery location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Surgeon: Dr. Manish Nagpal, Retina Foundation & Eye Research Centre, Ahmedabad, India
Dr. Manish Nagpal: Yeah, he’s a patient for diabetic retinopathy who, in the other eye had a fraction of some sort with a membrane, but was stable. And this eye had a subhyaloid hemorrhage on the macular with diabetic retinopathy changes. So, what we’re going to do is go and remove the vitreous and approach the subhyaloid hemorrhage and clear the blood. And once we clear the blood, we will do a laser 360s as a PRP to regress retinopathy. So, that is the plan, and then we will see if anything else is required. If we are doing the surgery or not.
So, we will start the case by putting the cannula in side. The three cannulas.
How do you gauge where to put your ports from the limbus based on this lens status of the patient?
The previous case was a phakic eye. And we took a measurement of 4 to enter. This one is sort of phakic. So we do about 3.5. And the placement of the ports is just above the horizontal meridian. The inferior one is about two to three clock hours below there. The horizontal meridian.
One of the things we had talked about in the clinic was using anti-VEGF agents before surgery.
How do you make that decision? What do you look for? When do you inject? When must you operate after injecting an anti-VEGF agent?
So, anti-VEGF preoperative we use — when we see florid proliferations which are there and it’s an untreated patient in the eye of a patient that has — which we anticipate that when he operate they will bleed a lot during the surge. So, we to want reduce the chances of that bleeding. So, that’s when we inject. And when you ask me the timing, what we like is a difference of three days. We inject it. And wait three days. On the fourth day, if you operate, it’s a good window. You can operate anywhere between the fourth and tenth day.
And you need to make sure that you do operate that patient. Because if you don’t, sometimes the anti-VEGF will lead to a sudden, you know, kind of fibrotic changes. Pulling the retina and causing more damage.
You know, with the anti-VEGF agents, they’re wonderful. But certain cases with TRDs it can cause a contraction or a crunch which will create a tabletop detachment of the macula, so —
Yes. It can lead to a crunch formation if you don’t operate. But if you’re operating within the fourth to tenth day, it’s totally all right.
Okay. So, now I’m approaching the hemorrhage, what I can see.
I go gradually. This is a subhyaloid hemorrhage. It’s typically a boat-shaped hemorrhage.
That’s what you’re seeing if the patient lying down. But if he’s sitting up, you will see the boat of had shaped hemorrhage much more. And on the — it’s lying by this de-hemoglobinized blood around the side. So, what I’ll do is I’ll now go into the vacuum mode and start to see if the hyaloid is still attached here or not. So, the hyaloid is still attached. And that’s holding that — the blood. Now, I’m pulling. Can you see?
I’m gently trying to pull and create a space there.
So, this is similar to a P — inducing a PVD.
Yes. But here you have to be a bit careful.
Unlike a megalocornea, once you have a grasp on the hyaloid, you can just pull it up. Here, because there are chances of bleeding, you can’t do that. Because here there are proliferations which are attached to the underlying surface of the retina. You will see this hyaloid wave created.
By the gross appearance of the subhyaloid hemorrhage, how long has this been there? How long do you think this blood has been settled under the hyaloid?
Must be a month or so. Not too — yeah, not too far back.
Have you ever seen GSL glaucoma after a subhyaloid hemorrhage? Have you ever seen — when have you seen GSL glaucoma in retina patients?
Yeah. If it’s a long standing hemorrhage, sometimes you can see. So, now you can see that the blood is more mobile because the hyaloid is gone from there. It’s slowly getting absorbed as I take the vacuum closer to that area. Because previously it was trapped under the hyaloid. This is the part that we have to do carefully because you’re spreading very close to the retinal surface and there’s a proliferation there.
So, you see this bleeder here?
From the proliferation. So, now you can see where it’s oozing from.
I think one of the nice things you’ve demonstrated during this case is the importance of visualization and being patient while we get the best visualization.
Okay. So, now you see this blood clot. Now, I can see a bit better so I’m removing it effectively. And there are a few oozers. So, we will just cauterize them. I’m raising the pressure to 60 now so that the constant bleed stops.
So, just to repeat what you’ve said, you’ve raised the intraocular pleasure to tamponade, the oozing blood vessels, while you finish the case.
Yes. So, now the blood has totally cleared up from the macular area. Okay. So this is this — this is the maculate —
It’s totally free from blood now.
And there is a small oozer here.
And some here. So, we will just cauterize it. After that, we will do the good laser all around. So, now I’m taking it close to this one oozer here. You see a slight whitening.
Yes, sir. And you just want slight blanching as you attach the —
Absolutely. Yeah, yeah.
So, one question would be, why can’t you use the endolaser to cauterize these vessels?
The vacuum is way for effective at stopping the bleed.
I mean, you have to use the laser at a much higher power to cauterize these. Okay. So, now I will reduce the pressure and see if the ooze comes back or not. Because here the bleeder was constantly oozing. So, now I reduce the pressure.
And wait for a bit to see if there are re-bleeds. Of course, slightly, once I take the cutter inside and the vacuum starts coming in. But otherwise it looks secure. I’ll just clear up some of the residual blood which was there in the periphery. Because I was watching with a, you know, a magnified view. So the field was less. So, the spillover blood in the periphery, I’m just trying to aspirate it now.
So, the cornea is totally clear now.
With endolaser, do you try to do a full treatment of PRP and what are the advantages? How can you get a full treatment of endolaser PRP?
Yeah, we do a 360 laser treatment which will help regress. Just like what we do externally with laser PRP.
We will try to achieve that with our surgery.
I think one of the nice things — I mean, you have demonstrated a lot in this case, being gentle with the tissue, making sure you have good visualization. Can you just tell us why you’re doing an air-fluid exchange on this patient?
Yes. So, air-of fluid exchange I basically do at the end of all of my refractometers mainly to have an air bubble. It’s a partial exchange that I would do. It’s mainly to have the wounds secure. Because a suture-less retraction is the liquid — once you have saline inside, the wounds can be a bit leaky.