 Terrific. Well, hey, thanks so much for being here this morning. It's great to be here with you. I'm Jim Howard. I'm in private practice here in the Salt Lake area. We've got offices in Provo and Layton and Logan as well as our main office at the Intermountain Medical Center in Murray. So today we're talking about lasers end off the minus and protracted me surgery. And so we'll start off by talking about posterior segment laser. So there are a number of different types of posterior segment laser. One is photo coagulation, another is transpupillary thermotherapy and then photodynamic therapy. And it's interesting just as things have evolved with kind of the takeover of anti-veg F therapy. It's interesting to see how laser treatment is gone. Do you guys feel like there's been a decrease in the amount of laser treatment used in your clinics? Have you guys noticed that or have you not been around long enough to maybe appreciate that? I don't know if they'd be here, but I've been there for two and a half months and I haven't got a single focal laser. Okay, do you still get to do some focal laser treatment? If they come in and yeah, but so often we're just doing anti-veg yet. Yeah, how about pan-rentinal photo coagulation? Are you guys still doing very much pan-rentinal photo coagulation? All right, how about transpupillary thermotherapy? Have you ever worked with any of the doctors who do that? Okay, how about photodynamic therapy? Do any of you use that? Have you seen it done? Yeah, okay Well sounds good. So just there are a few principles to kind of keep in mind here. So coagulative necrosis occurs at 149 degrees Fahrenheit 65 degrees Celsius and really it's dependent on the intensity and duration of the laser treatment much more so than the wavelength use. So there are a variety of wavelengths that we use for laser treatment but the actual volume of photo coagulation is much more correlated with the duration the time that you spend doing the laser treatment as well as the intensity of the laser. So we'll go over some of the indications for treatment. We'll talk about delivery systems, choice of wavelength or color, power and duration, anesthesia, lens selection, and then discuss some of the pitfalls and complications of laser treatment. So here are some of the indications. So there's pan-rentinal photo coagulation for neovascularization, either not neovascularization of the posterior segment or neovascular glaucoma. Now you guys are kind of fortunate to live in a world where we have anti-vegeta therapy and I don't know if you realize this but back in the olden days when I started my residency in 2001 if we had somebody who came in with the central retinal vein occlusion with neovascular glaucoma often their pupil was bound down there's a lot of hemorrhage in the eye and then we would try to get laser into the eye and so we'd block the eye and it felt like a little bit of a medieval torture type of chamber but we're in there trying to put pan-rentinal photo coagulation into the eye through a really small constricted bound-down pupil and we just tried to get as much as we could in often in the setting of a very poor view and these days we typically give them an anti-vegeta injection and then the neovascularization then regresses and within a couple of weeks or a few weeks the view starts to clear up and then you can do pan-rentinal photo coagulation later but like I say going back 15, 16 years that wasn't an option for us because we don't have anti-vegeta treatment at that time. Other things that you can use laser for are focal laser treatment from macular edema closure of microannurisms or telangiectasia associated with Coat's disease, creation of chororental adhesion in the setting of rental breaks or rental detachment, full coagulation of extrafovial curvilineovascularization. This may be something that you'll never see in your training. I haven't done one of these for years and years and years but this used to be the standard under the macular photo coagulation study. This was the gold standard up until about 2000 where that's the way extrafovial and even juxtafovial curvilineovascular membranes were treated. Other things like central cirrus choreo-retinopathy and tumors can also be treated with laser. There are a number of different delivery systems. One is traditional laser treatment, argon or diode or krypton, whatever wavelength you're using that's considered to be a traditional type of laser treatment. You can also use an array applicator like the Pascal laser. Do you have a Pascal laser here? Have any of you used the Pascal laser? That's kind of nice. You hit the button and all of a sudden you've got 200 spots of laser so that's a pretty slick deal. It's a lot easier, a lot quicker than doing single spots of laser. The other thing that's kind of come on the scene recently is this micro pulse laser treatment and do any of you have experience with micro pulse laser treatment? Have you seen that used? Do you have a micro pulse laser here at the University or the VA? You do have micro pulse laser? All right so micro pulse laser is relatively new within just the last few years and the concept behind micro pulse laser is that you're using an infrared wavelength so you're using an 810 nanometer wavelength and it's got a duty cycle so it's on part of the time and then off part of the time so it's on about 15 percent of the time and the concept behind this is that with the off period there's a chance for the heat and energy to dissipate and so as a result you get less damage to the photoreceptor cells. The energy is concentrated in the RPE where you want it and you don't get as much burn or energy uptake by the photoreceptor cells so you sort of spare the photoreceptor cells and there are a few different companies or at least a couple of different companies that have worked on this quite a bit. Erodex has worked on it a lot as has this other company Optos so this is something that you can get for your office and you know truth be told I think that if this would have come out 15 years ago people would have just absolutely loved it and would have taken off. The reality is that where laser treatment is gone we don't use laser treatment as much anymore so people are less willing to go out and spend 40 to 70 thousand dollars or more on a laser for something that they're hardly ever going to use and when you look at the business dynamics of a practice a private practice or even in the university setting sometimes it's hard to justify that sort of expenditure if you're hardly ever going to use it. The other thing that's happened too is that reimbursement for laser treatment has gone down and so like I say looking at the business aspect of this if the reimbursement is declining and you're hardly ever using it again it's a little hard to justify buying some things like this that are a little bit more expensive. There's another way to do it you can put the indirect ophthalmoscope on your head with the laser treatment and you can treat retinal tears, retinal breaks, retinal detachments. Endofotoquagulation is something that we use frequently in protracted surgery so in diabetic cases or central retinal vein inclusions, branched retinal vein inclusions, retinal detachments, endofotoquagulation has become a really important part of this. Does anybody know when and where endofotoquagulation was developed? It was developed here at the University of Utah or at least some of the original concepts going into endofotoquagulation were developed here at the University of Utah so my partner Mano Swartz was a professor here for a long time at the University of Utah and was instrumental in developing endofotoquagulation because back in the day when protracted surgery was first getting off the ground that wasn't an option and so you had to use indirect laser or something like that to be able to treat the retina and endofotoquagulation didn't exist at that point in time. Trans scleral application of lasers, another possibility too, you can use this for neovascular glaucoma and in particular with cyclofotoquagulation and do you guys do this as part of your glaucoma rotation? Have you seen any of this and cyclofotoquagulation? We turn up the laser a little bit to the ciliary volume pops and then you keep going so yeah when you hear that little pop you know you've got just the right amount of laser treatment so this is actually a useful adjunct in cases of you know poor vision potential and somebody who's got raging neovascular glaucoma pain in the eye and things like that it's better than having to remove the eye or inject ritual or alcohol or something like that. So laser is absorbed by different things in different ways so melanin in the coroid absorbs green yellow red and infrared laser macular xanthophil is will absorb blue laser but doesn't usually absorb yellow or red very well and then hemoglobin will absorb blue green or yellow but has minimal absorption of red. One of the reasons that that last point is important with hemoglobin is that if you're doing laser treatment and trying to get through blood in the eye using red laser treatment is often a little bit better than using blue green or yellow because you can shoot through the blood a little bit more effectively and get to the retina and coroid where you want it to be. There are a variety of wavelengths that we use really for our intense and purposes in our clinics we usually use 532 nanometer green laser treatment there's also yellow laser treatment which a lot of people use for macular work or use it for doing hitting micro aneurysms and that sort of thing in the macula. Red laser treatment can be beneficial like we talked about in penetrating vitreous hemorrhage and sometimes dense cataracts it also is minimal minimally absorbed by xanthophil so sometimes it's thought to be a little bit better for treatment of curviline vascularization adjacent to the fovea again this is something that's just not done that much anymore so you probably won't see that and then infrared laser treatment as we discussed is used for micro pulse laser and a couple of other applications so here's some sample settings for laser treatment panrenal photocoagulation you start usually with about 250 milliwatts of power a spot size of about 400 microns a duration of 0.1 second for focal laser treatment you want to be a little bit ginger with this because you're starting right at the macula and usually I go to kind of a safer spot in the macula so to speak you don't want to treat something that's right around the fovea initially with a high laser power because if you break through brook's membrane you can cause curviline vascularization furthermore if you cause a bad laser burn in or adjacent to the fovea then that results in significant vision deficits for the patient so you usually want to go to kind of a safer spot in the macula like the inferior temporal macula or something and test out your laser power but a power of 80 milliwatts is usually a pretty reasonable power to start with you'd start with the spot size of 50 to 100 microns and then have a duration of once a 0.1 second mps style thermal laser is kind of gone out of vogue like I say this is probably something that you won't ever see in your training but I usually start with a power of 200 milliwatts spot size of 200 microns in a duration of 0.2 seconds and then for laser demarcation I usually start with about 300 milliwatts with a duration of 0.1 seconds with Pascal one of the things we did learn with the Pascal laser is that if you decrease the duration of the laser and maybe do it a little bit less than 0.1 seconds sometimes it's a little less painful for the patient so if you go with a little higher power a little lower duration of the laser sometimes it's a little less painful and it's just a little makes it a little bit easier on them there are a number of different ways you can anesthetize the eye for laser treatment there's topical topical anesthetics that you can use to anesthetize the eye there's peri-bulbar and subconjunctival I really like subconjunctival when it comes to demarcation of rental tears I usually use 2% lidocaine without epinephrine for this and if you give just a little bit of subconjunctival anesthetic right in the area where you're going to do the laser demarcation it makes it pretty comfortable for the patient also it makes it so that you don't have to necessarily do a retrobobar block and the tough thing about having a retrobobar block is that usually you feel obligated to patch the eye so that the cornea doesn't get abraded and so forth and so usually doing a little bit of subconjunctival lidocaine is a slick way to go and gives the patient quicker vision recovery and doesn't make it so that you need to patch the eye a retrobobar anesthetic can be useful if you're doing really extensive pan-rental coagulation or extensive laser demarcation having hyaluronidase is really helpful when there have been shortages and we've had to do retrobobar blocks without hyaluronidase I always notice the difference it just diffuses better and gets around better if you have hyaluronidase in your block you can use 2% lidocaine for that or bupibocaine 0.75% or you can use a combination of the two and some people kind of like the combination of lidocaine and bupibocaine in the retrobobar blocks there are a couple of different types of lenses that you can use at the slit lamp for doing pan-rental coagulation or focal laser treatment the negative power planoconcave lenses provide an upright image with high resolution but they have a very narrow field of view and so they're good for focal laser treatment of the macula where you're trying to be very precise and you're trying to hit micro aneurysms or do a grid laser treatment you can also use high plus power lenses for pan-rental coagulation laser this does provide an inverted image it's lower resolution but it does give you a nice wide field of view and of course this doesn't have to be quite as precise because you're lasering in the mid and far peripheral retina these are just different magnifications that you get with the different types of lenses so these are focal laser lenses the goldman 3 mirror the anusia lens there is in trellis and this tells you what the optical magnification is as well as the laser spot magnification pan-rental pan-rental coagulation lenses include the quadrospheric the super quad and the rodent stock and there are others as well but they usually decrease your optical magnification but increase your laser spot size so kind of a general rule of thumb to use is that they'll essentially double your laser spot size so if you want to have a 400 micron laser spot usually you start with a 200 setting on your on your laser and that will give you a 400 micron laser spot size um here's some of the complications or pitfalls problems that can occur with laser treatments so one is accidental foveal burns this can be a really bad one because you can't take it back there's no way to really fix that sometimes you can get brooks membrane rupture which is where you pop through brooks membrane and you can either get sub-rental hemorrhage or you can get vitreous hemorrhage as a result of this you can also get crudal neovascularization so on the macula this is a really big thing it's a big deal if you pop through brooks membrane whereas if you do it in the rental periphery it's not as big of a deal and sometimes this just happens as you're lasering along sometimes you'll hit a spot of vitreous hemorrhage you'll crank up the laser a little bit to be able to get through the hemorrhage and then you'll get to a spot where the hemorrhage is a little less dense and boom you'll pop through brooks membrane like I say as long as this is in the rental periphery it's not that big of a deal and usually doesn't cause any problems I usually kind of take extra care to surround that area with some laser spots just in the event that there's a hole in the retina or in the event that there's some sub-rental hemorrhage or the potential for crudal neovascularization it's nice to isolate that area and wall it off but like I say to me that's not that big of a deal as long as it happens in the rental periphery you don't want to break through brooks membrane in the macula you can also use one of the the concerns is retinal lesions like retinal holes or fibrosis or hemorrhage can result from laser treatment crudal lesions like atrophy of the rpe and this is one of the things we used to see when we did a lot of focal laser treatment for diabetic retinopathy is we do focal laser treatment there'd be kind of this phenomenon known as scar creep and the laser scar would gradually get bigger and bigger to where it would start to approach on the fovea or sometimes the laser spots would become confluent so you'd see somebody come in and they'd have just a little spot of their fovea remaining and then they'd have you know a lot of kind of fluid laser treatment right around the fovea which is a bad thing it's almost like having retinitis pigmentosa with just having a few little foveal cells preserved exudative retinal detachment and crudal detachment are problems that can arise if you do a lot of heavy laser treatment so if you lot it do a lot of laser demarcation of the periphery or if you do heavy pan-rental photacoagulation you can also get serious crudal serious retinal detachment or sometimes crudal detachment as well so these are things that you've got to be kind of cognizant of is that there can be problems or complications that kind of rise with this sort of treatment now typically corticosteroids are helpful and inflammation usually peaks after just a couple of days and then spontaneously resolves so this is a problem that will usually go away on its own the one other thing that I didn't put down on here but that is worth mentioning is have you ever heard of crunch syndrome is that ring a bell for anybody so crunch syndrome is where you do massive pan-rental photacoagulation or anti-vegeta therapy and a patient who's diabetic and if they've got a lot of membranes in the posterior pole or in the mid peripheral retinas sometimes those membranes will contract very abruptly very suddenly and it will kind of bring the retina in on itself almost in a napkin ring-like configuration causing a fractional retinal detachment of the posterior pole in mid periphery this can be a big deal and a real challenge to deal with I've only seen it once in the setting of pan-rental photacoagulation but if somebody has extensive membranes in the posterior pole and you're just trying to get started with pan-rental photacoagulation sometimes it's better to split it up into sessions rather than hitting them with like 1400 laser spots all at once trans-pupillary thermotherapy so I don't own one of these lasers I don't think they're very useful but it's in your textbook and probably something just worth mentioning so it's not very useful for crudal neovascularization some people like it for crudal melanoma some people used it as standalone treatment for relatively flat minimally elevated tumors and so one of the techniques that can be used is the sandwich technique we use trans-pupillary thermotherapy and so you hit it from the retinal side and then you do a plaque on the other side so you're kind of killing the tumor from both sides one of the concerns about standalone treatment is that sometimes if you use trans-pupillary thermotherapy as a standalone treatment you can develop kind of this fibrotic dead plaque on top of the tumor but you can continue to have growth underneath that fibrotic fibrotic dead plaque and sometimes you'll actually get extra scleral extension of the tumor as a result of that so you think the tumor is dead and from your view looking inside of the eye the tumor looks dead and regressed but they can develop tumor growth in the opposite direction that goes through the sclera and gets out of the eye that way so I think there's caution that is appropriate you should ought to treat this appropriately cautiously in treating tumors with trans-pupillary thermotherapy um these are just the specifics it's an infrared wavelength and the beam size and so forth but like I say I I don't have this sort of laser I only know of one group in the Salt Lake area that has this sort of laser so I don't think many people are using it at this point in time photodynamic therapy does anybody know how this works or has anybody seen how this works so you inject some dye you inject vis you dye and then you have to do this complex or the somewhat complex calculation of how much the patient weighs and their skin surface area and so forth and then you inject the visutine dye and then after 15 minutes you hit that area with red laser treatment for 82 seconds and what that does is it creates reactive oxygen species and those reactive oxygen species essentially create little blood clots or thrombosis within the capillary buds of crudel neovascularization and in theory that way kills the crudel neovascularization this is was kind of the standard for treatment of exudative macular degeneration between 2000 and 2005 and then once anti-veget therapy came along in 2005 photodynamic therapy kind of fell by the wayside a little bit we still use it sometimes so there's some patients who you know for whatever reason they don't like the injections or they want to have fewer injections so as a result we'll try to do photodynamic therapy to decrease the overall number of injections that they require to keep their crudel neovascularization under control the other thing is sometimes in patients with sort of poor vision potential but with the desire to control the crudel neovascularization you could do photodynamic therapy some of the complications or potential complications or side effects of photodynamic therapy is that creates photosensitivity so people who have photodynamic therapy will want to cover up really well as they're leaving the building so you want to make sure that they bring a hat and gloves and you know long sleeve shirt to the visit so that they don't get sunburned i've had patients where they've gone home stuck their finger hands outside the window and gotten a bad second degree burn as a result of sticking their hand outside the window on their way home from photodynamic therapy they usually last for about 48 hours so it's something to just kind of keep in mind as you're doing this another thing that can occur is patients can get backside or chest pain this happens in about two and a half percent and then there's also a small risk of severe vision loss within seven days of treatment this doesn't happen very often but it's somewhere in the range of point seven to two point two percent so it's something to caution patients about just make sure that they understand the risk before you go ahead with this sort of treatment the next topic that we're going to cover is vitriol retinal surgery any questions or comments about lasers to this point you know it's interesting i think that probably the way you're seeing ophthalmology in your training and the way things are evolving you're probably not seeing a lot of laser treatment it's one last comment about this is that i was at the the investigators meeting for dr cr protocol t when they announced the results at the academy a couple of years ago and and lee jam paul who's at northwestern university in chicago who's one of the more preeminent retina specialists in the united states said as part of this meeting as the adults and the results were being announced he said well it might be time for everybody to just throw away their lasers and i don't know that we're quite to that point yet but the i think that he was onto something there and that we might not need laser treatment as much in the future and certainly i think that the number of laser treatments that you're seeing in your clinics and your training that i'm seeing in my clinics has gone down fairly dramatically so the next thing is vitro rental surgery and so this is a i love this topic this is great i love doing surgery so helmholtz developed the first ophthalmoscope in 1850 and then jules gonan came up with this surgical technique called igno puncture in 1919 where they would use diothermia externally on the globe to create a little bit of irritation that diothermia would go into the core rate and retina and then you'd have patients lay on their side so that the retinal detachment was dependent and then the retinal detachment would settle down over this irritated area of coroid and eventually read here and it would often fix retinal detachments but that's before we had scleral buckles and vitrectomy so there wasn't really another good way of repairing retinal detachments at that time in 1949 custodists to develop scleral buckling and then in 1955 open sky vitrectomy was developed but as you can imagine with open sky vitrectomy there could potentially be a number of problems one of which would be supercruital hemorrhage which is absolutely disastrous and can end the surgery very quickly in a bad way in 1959 dr haruda began publishing unclosed system vitrectomy but it wasn't really perfected at that point in time and then dr machemer bob machemer came along and dr machemer was born in germany in 1933 and he helped pay for his way through medical school by working in a machine shop so he developed all of this expertise with machining precision tools and so 1966 he received a two-year nato fellowship and went to the university of miami to the bascom plumber eye institute and there began developing or experimenting with closed vitrectomy systems and and as i understand it he did a lot of the work in his garage he'd go out to the his garage at night and experiment in machining tools and vitrectomy systems that could be used inside of the eye so another great thing that was developed in somebody's garage but this is bob machemer he used to say that progress comes from doing the unconventional one of my attendings karen gears at the university of Iowa was trained by bob machemer so i kind of view myself as a grandchild of bob machemer but he's one of my heroes just for the sort of guts and gumption and daring that he showed in developing vitrectomy surgery so in 1971 he had perfected or not perfected but he had got to the point where he had this machine called the visc vitrectomy unit which stood for vitreous infusion suction cutter and this thing was pretty big it was a 19 gauge single port vitrectomy system and so it was it was really big but to this point in time there's no way to safely remove the vitreous inside of the eye in a reliable reproducible way and so as a result of somebody had vitreous hemorrhage or complex retinal detachment scar tissue in the eye or something like that there's just nothing that could be done those patients lost their vision and so here's a picture of one of the early surgeries and this is the visc cutter that they would insert into the eye you look how big that incision is and here's an early video of the visc cutter being used so this is 1972 and this is inserting this 19 gauge cutter into the eye and the thing that's interesting about this is that initially the cut rate was really low you know it was like a handful of cuts per minute and they improved that it got a lot better but in today's world you know 5,700 cuts per minute is a really common number of cuts per minute but here you can see the vitrectomy cutter inside of the eye just gradually cutting and chomping away at the vitreous but can you can imagine how much traction that would put on the peripheral retina by having suction like that as well as a slow cut rate so in 1975 O'Malley and Heinz introduced three port 20 gauge parse plate of vitrectomy which was the gold standard for about three decades and then about 15 years ago Dr. Fuji introduced 25 gauge parse plate of vitrectomy but the instruments were a little bit flimsy and flexible and so as a result you put the instruments into the eye and you try to manipulate the globe or turn the globe and the instruments were bent would bend and so Klaus Eckert in 2003 introduced 23 23 gauge vitrectomy which was thought to be kind of a nice compromise between 20 gauge vitrectomy and 25 gauge vitrectomy and then in 2010 27 gauge vitrectomy was introduced and so these are the different types of vitrectomy cutters you can see 20 gauge all the way up to 27 gauge and these are the incision sizes that are required to put these instruments into the eye so with 20 20 gauge it was it's a well it was a 1 millimeter incision that we had to make to get into the eye with a 27 gauge it's only a 0.4 millimeter incision the thing that's interesting so I did my fellowship from 2005 to 2007 so I finished my fellowship 10 years ago from 2005 to 2007 at the University of Iowa we were still using almost all 20 gauge by the time I'd finished my fellowship I'd really only done a handful of 23 and 25 gauge vitrectomy and then I got into private practice and that transition became much more complete where we went almost all 23 and 25 gauge vitrectomy in today's world hardly anybody uses 20 gauge vitrectomy so as you guys rotate through your retina rotations or do retina fellowships you'll probably hardly ever see 20 gauge vitrectomy done but 20 gauge vitrectomy was a little tough on people we had to suture the ports with vicaral suture and then we'd usually close the conjunctiva with either plain gut suture or vicaral suture but by the end of the surgery I mean the patient would have anywhere from six to nine or ten sutures in the eye and so the eye was really red and inflamed and uncomfortable and in fact I remember when I was an intern here in 2001 in the fall of 2001 over the weekend I saw one of Paul Bernstein's post-ops that came in she was having some trouble so as the dutiful intern I came in to see this post-op to see what she looked like and I think it was a dropped nucleus and Paul Bernstein had done this surgery to go in and remove this dropped nucleus and anyway I looked at the eye and I just couldn't believe how bloody and beat up this eye looked I thought how can anybody ever do this sort of thing to an eye it just looked atrocious but after you know having gone through residency and fellowship I just realized that that's what vitrectomized eyes look like and and now in today's world you know especially if you do a 25 or 27 gauge vitrectomy sometimes it doesn't look any worse than a cataract surgery eye so it's gotten a lot better with time here the ads or the advantages and disadvantages of small gauge pars plaintive trectomy so it decreases your operative time as you can imagine if you're not making big sclerotomies and not having to suture them at the end of the case then it's a lot quicker it's a lot faster it doesn't require as much time patients are a lot more comfortable because you're not putting 10 sutures in the eye by the end of the surgery there's faster vision recovery because one of the things is when you're really tightly suturing down sclerotomy incisions 20 gauges sclerotomy incisions sometimes you would induce astigmatism especially if you're cranking in the sutures and putting in really tight sutures it would induce since astigmatism so as a result it would sometimes take sometimes take weeks or months for those sutures to dissolve and for the eye to rebound to its normal shape and so vision recoveries are much quicker much faster some of the disadvantages and this is probably the main disadvantage is dealing with post operative hypotomy and this really has to do with appropriate wound construction so if you do a beveled incision to the eye usually works better than putting a straight incision into the eye except with 27 gauge with 27 gauge most people just put it right in but with 25 and 23 gauge usually if you use a beveled incision it decreases the risk of post operative hypotomy and part of the reason for that is you create a little flap and then the pressure that's within the eye pushes on that flap and closes the incision some of the risks or disadvantages of small gauge vitrectomy surgery initially Ingrid Scott at Baskin Palmer published a series of patients who had had small gauge vitrectomy in 2008 and they she showed a pretty significantly increased risk of endothemitis well it's interesting because those patients were I think it was from 2005 to 2007 that those patients had had surgery and then she went back and did another series that was from like 2008 to 2011 and in that second series they found absolutely no difference in the risk of endothemitis so it's probably learning curve and improvement in techniques in using small gauge vitrectomy surgery but she published that in 2011 where it was shown that there's really no difference in the risk of endothemitis between 20 gauge and 23-25 gauge and so we don't really feel like that's a real disadvantage or concern at this point in time and then Govetto in 2013 published a meta-analysis of 148,000 cases of small gauge vitrectomy surgery compared to 20 gauge surgery and in those 148,000 cases there wasn't any statistically significant difference between 20 gauge and then 23 slash 25 gauge also there was initially a concern about an increased risk of retinal tears or retinal detachment and that's actually turned out to not be the case either so Nuhon published an ophthalmologica in 2013 there were there were actually fewer tears in cases of 23 and 25 gauge vitrectomy so what do we use vitrectomy for well one of the things is retinal detachments and that's outside of the scope of this talk today but other things that we use it for are macular epiretinal membranes vitro macular traction macular holes submacular hemorrhage and sub foveal crudal neovascularization we hardly ever use it for sub foveal crudal neovascularization at this point in time and this is once again something that's gone by the wayside but this is an epiretinal membrane most patients the majority will gain at least two lines of vision improvement in vision can continue for six to twelve months after the surgery so this is one of those things where I really try to give the patients appropriate expectations before we go into the surgery so I'll tell them for instance I'll say this isn't going to be like cataract surgery or lasik this is a much more protracted recovery time and your vision will likely get better over the course of months and months and months and you know nine months down the road a year down the road will really know what your maximum vision potential is after having this sort of surgery the other rule of thumb to kind of keep in mind is that patients in general will will get about halfway back to 2020 from their surgery so for instance if you start with somebody who's got 2100 vision to start out with and you remove the epiretinal membrane you would expect them to get maybe back to 2050 or 2060 but it's unlikely that they'll get back to 2020 so again it's about setting appropriate expectations when you're signing patients up for surgery so that they don't expect it to be like cataract surgery or lasik and come in the next day and boom have perfect vision. Some of the risks associated with this is that nuclear sclerosis is often accelerated so about 50% of patients who've had a protracted surgery will need cataract surgery within two years and then tears and retinal detachment or other risks in addition to end off the mitus and hemorrhage inside of the eye. Vitromacular traction this is what this looks like symptoms include decreased vision and memomorphopsia it can cause a shallow serous or exudative retinal detachment in the macula and often causes vision loss that's more significant than an epiretinal membrane alone. Jatria came out a few years ago and how many of you have used or seen Jatria used have you used Jatria? You've seen it? Did it work? Kind of so-so? Yeah. Did it release the vitromacular traction? Yeah yeah so we use Jatria when it first came out I don't think anybody in our clinic has done Jatria within the last couple of years. The initial success rate reported in the literature was 26% so pretty low success rate it's expensive it costs $4,000 per vial of Jatria. They came up with some rules of thumb to keep in mind in using Jatria. One was if there's an area of epiretinal membrane or the area of traction is more than 400 microns in breadth then Jatria probably won't work or doesn't have as good a chance of working. So typically with Jatria you want somebody with kind of a full small focal point vitromacular traction you don't want there to be any significant epiretinal membrane and if you satisfy those requirements then maybe Jatria will work it would be a good option for your patient. But like I say at $4,000 a pop you can go to some surgical centers and do have a tractomy surgery for $4,000 so it's a little bit pricey. macular holes so stage one macular holes, stage two, stage three and stage four. Stage four of course has posterior vitreous separation or posterior vitreous detachment. Stage three has the posterior hyloid still attached or intact. Here's an example of OCT findings in each of these different types of macular hole. If a patient has a stage one macular hole you can often observe it. You can watch it for a little while and see if it will close on its own. I've had a number of patients over the years who've had stage one macular holes that have just spontaneously resolved so I think it's reasonable to give something like this time to see if there's spontaneous resolution. If it's a stage two macular hole then it's a lot less likely that it's going to go away on its own and usually surgery is indicated. So typically by the time it gets to this point you just want to go to the operating room because the chance of them getting spontaneous resolution is very low. Here's a stage three macular hole and a stage four. Actually the posterior hyloid doesn't look quite as detached as I might think in a stage four macular hole but you can see it's a little bit broader probably 500 microns or so with some edema surrounding the hole and perhaps even a little atrophy at the fovea. But macular hole surgery was first described in 1991 and this was reported by Kelly and Wendell and they found a success rate of 58% by going in removing the vitreous peeling up your other membranes and putting a gas bubble in the eye. Subsequent series have shown a success rate as high as 95%. In my experience closure of macular holes is closer to 95% if you do the right things and so it's thought that ILM peeling is important in the closure of macular holes or increases the success rate with macular hole surgery. So whenever I do macular hole surgery I try to be very careful about removing the internal limiting membrane and so I use ICG with that to make sure that I've gotten the internal limiting membrane. One thing that's kind of interesting about this is just within the last couple of years there was a study that came out looking at size of the peeling area for the internal limiting membrane and what they actually found out was that a larger area of ILM peel pretended a poorer prognosis than just a smaller area of focal ILM peel right around the hole. Interoperative dyes and stains are often used so ICG is a very common one as well as tripan blue or brilliant blue and then triumcinolone can be used. There were concerns for a while about triumcinolone or steroids potentially decreasing the inflammatory response inside of the eye and potentially decreasing the chance that the hole would close after the surgery. That doesn't really seem to be founded and hasn't been borne out in the studies. One of the concerns with ICG is toxicity and the concern here is that when we put ICG on the macula it can potentially be toxic to the retinal cells in the RPE cells and in vitro there's certainly toxicity seen with ICG and so this is a big concern. I've actually seen a couple of patients in my career who I thought had ICG toxicity so what can you do to lower the risk of ICG toxicity in macular hole repair at the retinal membrane peeling? Well one of the things you can do is you can just put it on for kind of a small amount of time, a minimal amount of time so I usually leave the ICG in the eye for about 30 seconds. There are a couple of different ways that you can use ICG. You can mix it with dextrose so that it's heavy and it just falls back on the macula and then you can suck it out and remove it. Another way to do it is to do an air fluid exchange and then put the regular concentration of ICG in the eye and let it sit over the macula. They're pros and cons both ways and I've kind of gone back and forth. But recently there was an article out of Baskin Palmer that talked about the different ways of using ICG and one of the arguments that they made was that if you use the heavy ICG mixed with dextrose in a macular hole then potentially the ICG can get into the macular hole and get under the macular hole. I've usually done the air fluid exchange approach and that's what they advocated for doing macular hole surgery so that the ICG doesn't get underneath the macula through the macular hole and potentially cause toxicity for the RPE cells. So anyway it's changed my thinking a little bit in the way I approach membrane peeling and ICG usage but I usually use I usually leave the ICG on the macula whichever way I do it for 30 seconds and then take it out of the eye as completely as I can and the other thing I do is I try not to shine light inside of the eye so I take my light pipe out of the eye while the ICG is on the retina and one of the concerns there's some theoretical concerns about the effect that endo illumination that light from your light pipe has on the macula in combination with the ICG thinking that it may augment or increase toxicity. Another recently developed technique was this technique of ILM flap closure so what you can do in that is you peel the ILM but you leave a little tiny flap of ILM and then you flop it over the macular hole so it creates almost like a little wound closure of its own and then you put the gas in the eye and that holds that little flap in place and that's thought to potentially produce better closure rates but also may decrease positioning requirements for the patient. Face down positioning is you know really a topic of debate at this point in time so it ranges from no face down positioning to up to four weeks of face down positioning. I usually tell my patients about five to seven days if you put C3F8 gas in the eye or silicone oil in the eye think that positioning requirements need to be less stringent because you're going to have a decent tamponade against the macula with C3F8 or silicone oil. Nevertheless I still have them do some positioning just because it's worked well for for a number of years and I've had good success rates and I the last thing I ever want to do is take a patient back to the operating room to address the same problem a second time and so I really want them to have a successful outcome on the first surgery. How do you do it here just in your experience working with the retina doctors here into the VA? Do you do face down positioning? Do you recommend face down positioning for the patients? How long do you usually have them do it? Seven to ten days but almost everybody here still does face down positioning. You know my my thought on this is if you have if you say okay well you don't need to do face down positioning and you have you know an 85 success rate with that whereas if you have them do face down positioning for a week and you have like a 98 or 99 success rate with that why would you not have them just do the face down positioning and take care of it once and for all? Like I say the thing that I dislike the most is having to tell somebody look your surgery didn't work we've got to go back to the operating room and do the surgery again. To me that's that's my one of the least enjoyable things I have to do so I'd rather just do it right the first time. Sub-macular surgery can be used for sub-macular hemorrhage so if somebody has sub-macular hemorrhage you can go into the eye remove the jelly remove the vitreous gel and take a little microcannula and create a little bleb inject tpa in there and then put gas in the eye and that will help to displace the blood. I've had kind of mixed results with this and seen mixed results I'm not convinced that it's all that effective I usually think that anti-vegF monotherapy is adequate but some people are big proponents of displacement of the sub-renal hemorrhage and then parts point of attractive me sir for sub-renal extraction of prolineovascularization this was looked at as part of the sub-macular surgery trials or sub-macular surgery trial that was done 16 17 years ago and what they do is they make a little tiny retinotomy in the macula and then put a force up underneath the macula and grab the prolineovascular membrane and pull it out you have to remember that that was in the days before anti-vegF therapy was developed so as a result there weren't a lot of options for patients they'd either get MPS style macular photo coagulation or they could have photodynamic therapy photodynamic therapy was introduced while this trial was going on so even that wasn't in wide usage at the time the trial was initiated and so as a result of that you know there just weren't a lot of good options this is really fallen by the wayside I don't think anybody has done one of these surgeries for many years and then macular translocations so macular translocations where they cut part of the retina in the retinal periphery they'd elevated up with a bleb through microcannula and then cut the peripheral retina and they could either do part of the peripheral retina or the entire peripheral retina and then they would translocate it so they would move the retina move the macula over healthy rpe and then put silicone oil in the eye laser around the edge of the retina and essentially try to give the patient a new macula again with the anti-vegeta therapy this is fallen by the wayside I don't think anybody has done macular translocation for a very long time some of the complications of diabetic retinopathy that can be addressed with course point of attractomy or vitreous hemorrhage tractional diabetic retinal detachment and diabetic macular edema so when you're going into the eye there are a couple of different approaches you can shave down the membranes you can try to peel the membranes and the idea is they want to eliminate give all of the traction off of the macula so that the macula can lay down flat if you've got a tractional detachment that's outside of the macula outside of the arcades and isn't particularly macula threatening you can often watch those and just see how they progress see how it evolves because you may not need to do a vitreous surgery but as the traction starts to creep inside the macula and especially as it starts to threaten the the phobia you need to go to surgery and remove the traction one of the problems that can occur is sometimes patients will develop a break in the retina either why well peeling membranes or sometimes they'll have a break already so they'll have a combined tractional regmatogenous detachment which is an even more challenging situation because peeling membranes off of a mobile retina like that can be kind of tough and can result in more problems and complications so anyway the the concept the principle is you want to remove the membranes in so far as safely possible so that the macula will lay down flat one of the things that one of the attendings told me when I was in my training is that he said that some some doctors if they're not very careful in peeling membranes diabetic membranes off the retina and off the macula will cause golf course retinopathy and he said that was 18 holes in the in the retina and so you don't want to do that you want to try to prevent the formation of retinal holes as you're peeling membranes off the retina sometimes vitrectomy surgery is useful for diabetic macular edema as well especially if there's an epiretinal membrane that's creating a little bit of traction or if there's a very top posterior hyaloid sometimes anti-vegeta therapy or steroid treatment just isn't enough to get the macula to settle down and be flat so as a result the best way to go is vitrectomy surgery now this is a vitrectomy surgery that I did for a few years ago for a diabetic patient so I thought I just show you this video as an example of what can be done so this is a 23 gauge system you can tell by the orange cannula here and so we're just putting in the infusion line and typically with this I like to displace the contractive a little bit like I say I typically go in at an angle initially and then straighten out there's some controversy about that a little bit some people say that you should just go in with an angled incision because they say if you straighten out straighten out you can actually tear the little beveled edges and make wound closure less likely or less elegant less probable so as a result of that I still like to go in beveled and then straighten out and I feel like I usually have good closure so just putting in the supero nasal cannula there so we've got our three ports in we've got our light pipe and our cutter this is a patient who had he had some vitreous hemorrhage he had proliferative diabetic retinopathy also a diabetic macular edema so this is the lens system that we use this is a volclarivate lens it's a little older style lens there are newer lenses that can be used they don't make this particular lens anymore but then there's the hrx and the avi lens and a number of different lens options but you can see this is the hemorrhage inside of the eye that's being removed with a vitrectomy cutter and this guy had moderately dense vitreous hemorrhage but was fairly impaired by it it really interfered with his life and what he was able to do and to me these cases are very gratifying because you take somebody who's in many cases functionally blind in that eye you remove the blood peel the membrane clean things up do laser treatment and you essentially give that patient their vision back which to me like I say is very gratifying this patient had some blood accumulation over the posterior pull that has just sort of pooled or accumulated over the macula so I'm essentially puffing and sucking that blood off of the macula you can now see the optic nerve and this is the macula you can see some heart exudates in the macula this is the icg I've done an air flute exchange so we're putting icg in the eye I've left it in place for 30 seconds and now we're using a silicone tip extrusion canula to remove the icg from the eye and then the next step of this is that we'll use a high magnification macula lens so something like the charles lens or the mochimer lens and well this patient still had a little bit of blood on the macula so I'm using the soft tip to just reflux a little bit onto the macula causing the blood to dissipate so that I can remove the the hemorrhage from inside of the eye and off the surface of the macula but you can see the patient's got a number of heart exudates resulting from his diabetic macular edema and you'll see here in just a second I've got the ILM forceps so you can see the shadow of the ILM forceps one of the ways you can tell how deep you are in the eyes by looking at the shadow I mean it's just kind of a quick and dirty way to figure out how close you are to the macula so you put that in you see the shadow from your light pipe and you can tell in this case that we're pretty close to the macula this is a we're trying to grab the ILM and often it's interesting but in these patients with diabetic macular edema you can see the little strands of ILM coming off often in patients with diabetic macular edema for whatever reason the ILM is really sticky and so sometimes you have to do multiple grasps to get all of the ILM off of the macula so anyway you can see the membrane coming off there and I think we're about done with that I sometimes will put a little bit of air inside of the eye you can see the little air bubbles coming into the eye through the infusion cannula one of the reasons to do that is it often helps with closure of the sclerotomy incisions if you put a little air in the eye at the end of the surgery it seems to tamponade those little flaps the beveled incisions that you make it seems to push that incision up against the wall of the eye and just help it to close a little bit better so here we are taking the cannulas out of the eye and no sutures and so this is a whole lot better than what we used to do 10 or 15 years ago but that's the end of the case on that one so like I said those are really gratifying surgeries because you see you see almost immediate results in the next day or within a few days they're usually very happy uh parts plan of a tract to me or excuse me parts plan of a tract to me for complications of anterior segment surgery so this is one of those things where you're in the operating room you're an anterior segment surgeon and you're like oh my gosh I can't believe that just happened call the retina surgeon and and so these are the types of things that the retina surgeon does to go and manage complications of anterior segment surgery so the first and most important one is retain lens fragments after fake omulsification don't beat yourselves up about this this happens to everybody here's some tips for dealing with this uh don't go digging for fragments you don't need to be macho you don't have to be the hero if you've got some dropped fragments that are in the posterior vitreous and not easily accessible don't try to be the hero I've seen doctors get into trouble I've seen lawsuits over this just if you can't get the fragments just close up put a lens in the eye if you can and get out of there and send it to the retina surgeon and let the retina surgeon deal with it these patients are going to do fine the only time they're not going to do fine is if you're in there mucking around with the fake oprobe or the anterior vitrectomy and you cause you cause a big supercurtle hemorrhage or a big giant retinal tear because you've spent too much time in the eye doing things you probably shouldn't be doing so like I say don't feel bad about it don't take it personally all of you guys will have this happen to you at some point your career and everybody has it happen and what will happen is you'll go out into practice and you'll talk to your partner and they'll say oh I haven't you know had a retained lens fragment for 15 years or whatever and just forget about that blow that off don't even think about that because everybody has this happened sooner or later and as you get more experience it will happen less frequently but there are people who have been out for 10 15 20 years and then all of a sudden boom they'll have two cases of retained lens fragments so just don't sweat it I've got to just tell you that because I know as a resident I used to just agonize over stuff like this and was so afraid that the patient was going to go blind and then I'd done permanent harm and then I'd really done a bad thing and it's not that big of a deal and the retina surgeon will actually love you for it they'll get the business and it's a great thing for them other ways that you can use paris plaintive attract me for managing anterior segment complications of anterior segment surgery so they're dislocated intraocular lenses sometimes there are a bunch of different ways to deal with this eight million ways in counting I think but I've tried a bunch of different ones you can glue the lens you can suture the lens you can put an ACI a well you can I just a couple days ago I squirrel fixated a lens with suture the challenge with suture is it seems like there are a lot of gymnastics I mean just getting the lens in the right position getting it to center it can be kind of a tough thing sister macular edema you try topical meds first and then subtenons or intravitral steroids and if all else fails you can go to attract me with ILM peeling supercruital hemorrhage and needle penetration of the globe or bad complications but you know once again just get them to the retina surgeon to let the retina surgeon deal with that postoperative endothelitis we'll have to go through this kind of quickly but it's usually if it's less than six weeks in duration it's considered to be acute onset the most common type of postoperative endothelitis is coag negative staff and usually this is causes kind of a mild to moderate endothelitis streptococcus species in my experience causes horrible endothelitis this is eye melting endothelitis most of the cases I've seen of streptococcal endothelitis the patient loses their vision to go blind and often end up with a tisical eye I've seen a couple salvaged but these are really hard cases gram negative is kind of a mixed bag bacillus can be really bad sometimes it's fairly mild if it's beyond six weeks and it's chronic usually this is due to p-acnees coag negative staff fungi can cause this as well as neoplasia so just kind of be on the lookout for lymphoma and then blood associated off the mullage or end off the mitis is often streptococcus caused and so once again terrible eye melting endothelitis you've got to jump on those fast and often doing a prompt the track to me is appropriate one of the things to keep in mind is toxic anterior segment syndrome and so that was described by dr. manless here at the university of utah and usually this has a rapid onset within 12 to 24 hours limbis to limbis corneal edema increased pressure vitreous inflammation is usually absent these patients usually don't have a hypopian to me the hypopian or a hypopian is kind of the hallmark sign of endothelitis if you see a hypopian you think endothelitis if you're not sure treat them with steroids and watch them closely i did have a track to me on my neighbor a few months ago and i have not had a case of post-operative endothelitis in my career since being out of fellowship but this neighbor of mine a few months ago got post-operative endothelitis he lives across the street from me it was terrible but he came in he said my eyes red it hurts and i can't see and so he came in at noon and he didn't really have much of a hypopian i wasn't sure and i said well i i think you might but i'm not sure so let's bomb you with steroids it could just be post-operative inflammation i hit him with steroids every hour had him come back that night at 6 or 7 p.m and he had a little hypopian for me and was worse he definitely was not better so i said you've got endothelitis we're doing a tampon inject but like i say if you need to just watch them closely hit them with steroids and see how it goes but you've got to be meticulous you can't hit them with steroids and say come back next week because if they come back next week there may not be anything to salvage um the endothelitis vitrectomy study was published in 1995 it looked at doing vitrectomy versus tap and inject if a patient is light perception or worse than you do have a tractomy if their hand motions are better than you do to tamp and inject they also looked at intravenous antibiotics in this study they used uh let's see they used ciphtasidium and amacasin they found that intravenous antibiotics were beneficial but with fourth generation fluoroquinolones they actually penetrate really well into the vitreous this was shown by Dr. Hari Prasad at the University of Chicago and actually get very good levels of moxifloxacin in the vitreous and anterior chamber and so in some cases of more severe endothelitis it's probably worth using oral moxifloxacin and you get just as good a levels with oral moxifloxacin as you would with intravenous treatment um this is just kind of the technique for tap and inject and then for chronic you usually want to do a vitrectomy. Bleb associated is bad um like I say get them right in do a tamp and inject possibly a vitrectomy but you have to be very aggressive with blood associated endothelitis and that's the end. Thanks so much for being here I appreciate you coming out any questions okay awesome thank you