 So, welcome to Grand Rounds. It's my pleasure to introduce Dr. Ronny Bola. Ronny, one word, next word, Bola. Not Ron, E-Bola, if I said that too quickly. I had the pleasure of making an acquaintance with Dr. Bola through the American Academy of Ophthalmology's leadership development program. He's one of their current nominees and participants, and it's a highly competitive program to be welcomed into. The Moran has a budding partnership with his hospital San Fernando Hospital on the island of Trinidad. And from this point forward, there will be quite an exchange between the programs as we try to build a residency program there and help host and train some of their physicians and their residents. So he has some really interesting talks this morning to deliver, and I know we'll all enjoy it. So, perfect. Good morning everybody, and it's a real pleasure to be here, and thanks for allowing me to speak this morning at the Grand Rounds. I'm from Trinidad and Tobago. We are Twin Island state, and just to let you know where we are, because some people may not have been to the Caribbean area. Most people know Jamaica. We're not too far from Jamaica. We're actually at the end or the bottom of the chain of islands in the Caribbean, and we are this little small island, and I bring you greetings from our little island. I hope in the future that residents or trainees as well as faculty would be able to visit the island and help us develop ophthalmology, and also you'll be able to enjoy some of the beautiful beaches and all the other stuff that I have in these slides, so you can come and see and enjoy. So I am Ronnie Bola, my specialty is vitro retinal surgery, and one of the reasons I'm here, and we talk a little more about this on faculty day because they allow me 10 minutes to talk about the partnership between Trinidad and Tobago and the Moran, but we are looking to develop a partnership to try and improve training in Trinidad and in ophthalmology and try to build a public eye facility to try and develop services for the people of Trinidad and Tobago. That's eye services. Today I'll talk a little bit about some new surgical techniques that I've been using, about three. If we have more time, I'll talk a little more about some of the cases, interesting cases that we see and do. So I'll give about three talks. I know it's said two, but I'll probably try and add a couple on. So the first talk is on trocarcystic sutureless sulcus scleral fixation of a PCIOL. It's really nice to start to talk a little bit clinical because I've only been talking about some academic stuff for the last week or two. So implantation of an IOL with insufficient capsular support still remains a surgical challenge, and the ACIOL is associated with corneal decompensation and angle-related glaucoma, as we know. The PCIOL related, there are problems, suture erosion, suture tract infection and ophthalmitis and IOL displacement. This is the lens that I chose to sulcus fixate, and it's a good lens. I like it. It's a soft tech 3-piece foldable, and the haptics are polyimide haptics, and they are very flexible, and they support really well. We've done eight eyes of eight patients, and all cases had primary surgery for some severe ocular trauma, and if you do get the opportunity to come out of Trinidad, we see a lot of severe trauma. It's a very violent type of society, so if you come out there, you have to be a little careful. As this case showed, we had a posterior scleral rupture here before we were able to implant the lens. So the procedure, the first thing you need to do is get an infusion, and you can either use an AC mantina or a pulse planar infusion, then do sclerostomies, 180 degrees apart, about two millimeters from the limb bus, as you see here. This, I use a 20 gauge MVR, and then just make it a little bit wider. In the lens, you could insert the lens as you do normally for cataract surgery, just make sure the trailing haptic is outside the eye when you insert the lens. So just don't put it on top of the lens as you load the lens, and it will allow the haptic to remain outside the eye. If the lens is in the back of the eye on the retina, you can just rescue it, bring it up and extubate the haptics through the sclerostomies. So externalize the haptics. So here you could use a forceps to do that, 23 gauge forceps as you see here, and a lens dial to maneuver the lens into position. The haptics are very flexible, so you don't need to grab it at the tip, you could grab it anywhere along its length and just pull it through the 19 gauge sclerostom. To externalize the haptics, I use our bi-manual technique most of the times, where you use the dial to bring the haptic into view, and then you, once you can see the haptic, you grab it with the forceps. The next step is to introduce the trocar. You introduce the trocar, half thickness, you make it half thickness, interest sclerotunnels with the MVR blade and the trocar. It's a 25 gauge MVR trocar system, and this is what it looks like when it's in place. Then you, there are two methods I use. The first method is to take the Asuchatayan forceps, hold the haptic and insert it or feed it into the trocar. As you see the second method, which I like a little more, is to use a vicaral suture. It doesn't have to be 10-0, it could be 8-0. So you tie it onto the haptic and then you pass the suture through the trocar and then feed the haptic into the trocar and pull the haptic into the entire length of the tunnel. So this second method allows you to get the haptic through the entire length of the tunnel and gives you a little more flexibility with haptic placement. So here's me pulling the suture and haptic into the trocar and into the tunnel. And then at the end you just remove the trocar and as you see here the haptic now is through the entire length of the tunnel and you can see the haptic now at the distal end of the tunnel. You just use a forceps and push it back so that it doesn't protrude through the distal end and as you can see these IOLs are extremely well centered at the end. So this is this sclerostomy superior, inferior sclerostomies. They don't have to be at 6 on 12 o'clock. In these very difficult cases, sorry, trauma cases, you may not be able to get 6 on 12 o'clock. So here is the IOL inserted and now here is the inferior haptic being externalized at 6 o'clock and then I do the same thing with the superior haptic, bring it in the sclerous sulcus area behind the iris with the dial and then you go in now with the 23 gauge forceps. You just pull the optic and that brings the haptic into view. Once you get the haptic, sorry the haptic, you just pull it through the superior sclerostomy and once you have the both haptics externalized, the next step is to create the intra sclerotunnels with the 25 gauge troca and then feed the haptic into the troca and that will put the haptic in the sclerotunnel and you just remove the troca and that puts the haptic into the tunnel itself. So you feed the haptic into the troca as you see here, right in and then you just remove the troca and that leaves it and these lenses are very very well centered. Then we suture, well I suture these sclerostomies with hetovicryl and it looks really nice and they remain pretty good well centered. Yeah, I'll show you the next video. That one has the tie in. So this is the second method. This is the method I really like. I just showed you the first method because that's what I started to do. Sorry. So in this method first of all you make, you just create the tunnels the same way I did before and once you have your tunnels, in this one you'll see I just extubate this haptic just a little differently. I could see it. This was a much more dilated pupil so it's a bit easy. So I tie the suture on the haptic and then I pass the suture through the tunnel. I feed the haptic into the troca and the tunnel and now I'm pulling the suture and haptic into the tunnel. Remove the troca and here you could see the haptic at the distal end of the tunnel all the way through and that's the suture there. So the suture is connected to the haptic and I just feed the haptic back into the scleral tunnel and remove the suture and these lenses look really well centered. So I would say suture aided its placement of the haptic into the troca. It allows for good control of the haptic in the tunnel. You could push it back you could pull it back out and that's not a nice technique. It takes a little bit longer but it's better and this is how these lenses look post-op. This is one of the cases. A follow-up we've had about two to six months follow-up with most cases. We've seen no serious problem. It takes a little bit long when you now start. I did them under general anaesthetic because it was a new technique and now we do them under local anaesthetic. It takes about half an hour to 40 minutes. I just to recap place incisions about two millimeters from the limbers. Use a 20 gauge MVR, score it to 19 gauge and use 25 gauge trocas to keep the scleral tunnels open. 10-0 or 8-0 vicaral. The important thing about the vicaral suture is really the needle. It has to be long enough to go through the entire length of the troca, which is about four to five millimeters. So you're really looking at your needle, not so much the suture, suture size. 8 or smaller is okay. Haptic position in the tunnel can be adjusted by pulling on the suture or pushing the haptic back into the tunnel. I just want to let you all know we do have red rocks in Trinidad but it's under the water and we do have arches but they are made of coconut branches. Thank you. Any questions about this one? They almost all had vitrectomies because they were complex cases but I would have no concern doing it as an anterior segment procedure once you've cleared all the vitreous or if it was a vitrectomized eye then you don't have a problem but you would have to make sure you don't have vitreous as with any anterior segment procedure because if you did then I would be getting involved with the posterior segment problem. That's why you need either 8-0 or smaller suture because if you use a bigger vicaral suture like a 6-0 or smaller it would affect the ability to pull the knot would be too big. It wouldn't come through the troika. You could just explain that again. It's under tension. We haven't seen it and the reports using the MA-60 lens which is the lens that has been used a lot hasn't shown that that's happened but that is a concern that it could come back into the eye and there may be a problem with it but they haven't seen any reports or not. Yes, yes I have. He uses, he actually extubates it through a point tunnel and then he creates a flap, a scleral flap and he puts the haptic under the flap and glues it on. That looks like a really nice technique but it involves a lot more surgery. You have to cut the sclera and you also have to use glue or something else to close the flaps. So I think it's a good technique but I really like this technique because when you create those thin tunnels it's almost like you lock the haptics in and I really like that. These lenses look really nice and well-centered post-op. So probably feel a little more comfortable talking about a retina. I know a lot of people here may not enjoy this as much as me but you'll have to bear it a little bit. So I'm just going to talk about viscode delamination and diabetic vitrectomies. We have a huge diabetic population in Trinidad and if ever you get the opportunity to come down I could promise you you'll see a lot of diabetic advanced diabetic disease and you'll see a lot of advanced diabetic surgical maneuvers and I think that will be a benefit for fellows as well as residents who may attend or be able to come and you'll also be able to enjoy some of the beaches that we have and we have sun all year round and our lowest temperature is probably 25 degrees Celsius. I don't know how much Fahrenheit that is but it's hot and that's Tobago. That's our twin small island but Trinidad is not to be outdone. We also have letterback turtles. They come up on the beaches 3,400 come up for the season and so you'll get to see these large turtles and you'll also get to see the birds. We have a wider real birds. This is our national bird. It's called the scarlet ibis and you'll visit the colony swamp and see them light up the sky all red. Okay I'll just talk a little bit about clinical stuff now. So the aim in delamination really is to really remove the membranes as completely as you can and this is our case here showing the membranes. For the residents, tractional retinal detachment release caused by small vitro retinal adhesions as you see here. This is one with a TRD involved in the macula. Sometimes you get these broad base vitro retinal adhesions as you see here and this is when it becomes a little more difficult because to try and remove these demands a little more surgical maneuvers and techniques gets more difficult if you have a hole in the retina and you have a combined tractional rigmatogenous detachment. It gets a little more difficult if it's left for months and months because then you get localized PVR and the retina and the membrane sticks together and that's when you need more advanced techniques. The principles of diabetic vitrectomy, the first step is to achieve adequate visualization of the retina by clearing the medial opacity that is cataract, vitreous hemorrhage, release all the traction on the retina and we like to apply a lot of endophoto coagulation because these eyes are very ischemic, there's a high chance of them, these eyes go in a robotic poster and we use a retinal tamponade and sclerobocline when necessary. There's two methods of dissection I use from time to time, one is segmentation and the other one's end block dissection. Segmentation is where we remove the membranes in between the pegs or fibrovascular proliferative attachments and then you are left with these little pegs at the end. End block dissection, we cut the pegs themselves and you remove the whole membrane as one block. On average I do about 500 vitrectomies a year and about 200 of these are really diabetic related vitrectomies. Out of those 200 about a third have rigmatogenous combined retraction, about a monster about one to two every week. The reason we could use this technique now, this visco delamination technique so well is because of the advances in vitrectomy. Small gauge vitrectomy, high speed cut-in, pressure infusion systems, chandelier illumination. My standard technique is using a four-port vitrectomy technique and I use two self-sealing trocar at the top to allow the instruments to go in. One is an infusion and the other one is a chandelier. I usually start with indentation vitrectomy. It's important to remove the vitreous rally, not at the vitreous base rally, that's not so important but at the ports because you're going to go in and out with instruments and you don't want to be pulling on the vitreous. To do the delamination it's best to use a high magnification lens where possible so you get really good visualization of the space. I usually start with a spatula, 23 gauge spatula and the tractor in the other hand. You get the spatula under the membrane, make sure it's safe then put the cutter in place. Then I usually move on to the forceps and pull on the membranes. Usually pull along the retina surface to lift the membrane up but you have to be really careful with these atrophic very thin retinas because they could tear. This is the instrument I use for viscodes section. It's a 30 gauge tip but a 20 gauge instrument so you'll have to cut the the 23 gauge port if you're going to go to viscodes section. You place the viscodes sector underneath the membrane as you see here and then in the other hand you come in with the cutter under the membrane to cut the membrane. This is the video. So the first thing I do is do a bimanual vitreous base shave and removed vitreous and then here I use another bimanual technique. You really switch in hands a lot with the spatula. So this is the spatula here. This is the vitrector in the other hand and you just lift the membranes and remove them. So here again the spatula lifting the membrane up and again spatula now switch left to right spatula in right cutter in left. So a lot of bimanual maneuvers is done to limit the amount of in and out movements of instruments. Again cutter in left spatula in the right. After a while the spatula you can't do much more so then I pull with the forceps. You have to be careful. Don't pull up. You pull along the retina surface and you're really watching where the traction areas are and it could be away from the forceps so you have to watch very carefully. So pull in is a bit dangerous. You have to be careful. Again bimanually. Cutter in the right forceps in the left and there comes a point when you realize if you pull any further you're going to tear the retina and then you have to stop and use another maneuver. So here you can see this very atrophic thin retina and I'm pulling and you'll see it's going to tear here. So you have to you can't use this technique any longer. I then move on to the I don't actually here I moved to this side but this I don't think this worked out. So I moved on to viscodesection. So here is the viscodesector placed under the membrane and I'm injecting viscoelastic and once I create a space between the membrane and the retina I leave viscoelastic between the two tissues come in with a cutter with the other hand and just now cut safely between the membrane and the retina. So now I've segmented out this this area here and you can see not going in and out with instruments. You just keep in these two instruments in the eye. It's much much safer when done using our bimanual technique. Also you can remove membranes way out in the periphery which is very difficult to do with other techniques. So now we remove in membranes all the way out in the mid periphery. So it's a really handy technique for membranes that are difficult to remove in the in the periphery and you continue doing that until you remove all the membrane. So segmentation really is what's the technique that's been used here. Bisco dissection and so we're trying to get from here to here. Now as you see in the in the video this is when I just started to do it. I used to leave a lot of little islands. I didn't get much problems leaving the islands but now you can even remove these little islands as we get better and better. I always use some anti-veg F before we have a vast in so that's what I like. I use it about a week or two before surgery. I used I like a four-port technique with the chandelier and using bimanual techniques. I like that. It's very important to clear the ports before doing the maneuvers, the retracting maneuvers. You can use a single-handed or bimanual disco dissection technique and use high magnification as much as possible. Start with the cutter then move to the spatula and forceps and always remember to do endophoto coagulation and either cryo or laser to the port area. Just to let you know that if you do come to Trinidad these are domestic injuries so be very careful with the woman in Trinidad that you may find and probably don't go to the kitchen with them because this is a kitchen utensil being used. I didn't want to scare you but be careful. In vitrectomies I see probably about I would say 50 to 60 trauma related vitrectomies so we get a lot of corneal sclerolacerations. We get a lot of intraocular foreign bodies. There isn't a lot of health and safety regulations. So the weed worker was introduced a few years ago and we see a lot of IOFTs as a result of that. So if you do come you'll get a lot of trauma experience. Thank you. Any questions? Yeah. Thanks very much. Do we have time for one more? I'll show one more presentation. So I do do some general ophthalmology as well and this is a presentation by one of our residents and hopefully Dr. Maraj would be able to visit the Moran at some time. She is one of our I would say one of the best residents we have and she did this work and I'm going to present some of her work. This really is to report our first five cases of successful graft fixation using the otologous blood fixation of these grafts. Tyrigeum is very common in the tropics. Prevalence range from 0.03 to 29% in the literature and I would say probably 1 in 10 in Trinidad. The main aims of Tyrigeum excision is to achieve a cosmetically acceptable outcome to restore the ocular surface integrity and to try and prevent the recurrence of the growth. Do you all see a lot of Tyrigeums here? No? Okay. Currently there's a number of surgical techniques that exist for removing these Tyrigeums. The base sclerotectic, the use of anti metabolites such as mitomycin C, amniotic membrane grafting and conjunctival autografting. The base sclerotectic is associated really with unacceptably high recurrence rates and it's really not used anymore. Sorry, the use of anti metabolites carry a significant risk of site retina complications and really we left with conjunctival autografting because it has the lowest recurrence rate as well as less site retina problems and this is some of the recurrence rates from the literature and as you can see conjunctival autografting is the lowest. So when we do the grafts you could use suture or you could use fibrin glue which is pretty good and we're really moving away from sutures to fixate grafts because sutures are thought to have a higher recurrence rate and this meta-analysis just highlights that and sutures really have other complications as you see here, granuloma formation, foreign body sensation and others. But glue also has drawbacks. It is manufactured from pooled human plasma and therefore carries a theoretical risk of transmission of prion diseases and viral diseases and there's a potential risk of anaphylactic shock. So other than that why use autologous blood? Well autologous blood is readily affordable because it's the patient's own blood you don't have to pay for it. It's accessible and there are no suture related problems. So we conducted it's our first five cases so you know we we looked at those first five in a small prospective non comparative interventional series looking at five eyes or five patients. All had primary nasal tourgia. All were patients of the ophthalmology unit at the hospital, general hospital. All patients received suture free glue free autologous blood fixation of the graft. Patients who wore aspirin or anticoagulant medication were excluded. The patients were followed for three months to determine recurrence, cosmetic outcome and comfort. It was seen at day one, day four, week three, six and three months. Postoperative pain was recorded using a non-linear pain scale which consisted of four choices. Non-mild moderate or severe. Patients were asked to grade their overall cosmetic result with the procedure using the following choices. Poor, fair, acceptable good or excellent. The technique, the section of the teridium off the sclerar cornea and conjunctiva. Then you allow a tin film of blood to clot over the base sclerar area while we dissect the graft. We inject local anesthetic at the harvest site to separate the t-nones from or help separate the t-nones from the conjunctiva and allow dissection of the conjunctiva with a t-none free graft. Metaculous dissection, removing the conjunctiva and dissecting off as much t-nones as possible. And then we align the graft on the tin film of blood in this area. I usually use tie-in forceps to fixate the graft or to place the graft into the area. And this is the graft in position here over the tin film of blood. So first you do the standard dissection or removal of the teridium as you see here. Then I do a hydro type of hydro dissection and that gives you a plane to separate the conjunctiva from the t-nones. So you get less t-nones to dissect out. And then I meticulously dissect as much t-nones off as possible. So you get a really thin graft as you see here. And I just move the graft over to the other side. Used to tie-in forceps to position the graft and just put the graft in position as you see there. I usually wait about three minutes minimum to allow the graft to settle and fixate and then just remove the specular. Post-op we just use antibiotic steroid combination for about three weeks. A total of five eyes of five patients underwent the procedure. All patients were female and had primary nasal teridium. Average follow-up time was three months. There were no intraoperative or postoperative complications requiring intervention. However one patient had a cross graft recurrence. Visual acuity was unaffected in all five. And this is some of the cases. Case one the one post-op graft well positioned excellent cosmesis according to the patient. The four looks really nice. Case two preop. Case two graft well fixated. Case two however is the case that developed the recurrence about three months post-op. But as you can see it really and we've seen this patient up to six months now and it really hasn't changed and patients is pretty happy with it. Case three the one post-op pretty good. Case four graft well positioned. Case four months later looks looks really nice. And another case had a bit of a slippage of the graft but really not cosmetically a problem. Seen months later and looks pretty good. So there was one case of recurrence which occurred between six weeks and three months follow-up and one patient experienced a slippage of the graft in this series. Cosmetically either good or excellent results according to the patients and pain or almost no pain really in the group. So we recommend a few things. One is I like to hydro dissect here and not sure if this is the right word to use but we inject the somewhat unesthetic to get less tenons to dissect off on the graft and also we you must try to get the graft as tenons free as possible. Pay to stick better. There is a little concern sometimes at the end when when you remove the speculum make sure that the graft doesn't move especially the superior part of the graft. So after removal of the speculum just check and make sure your graft is in position. This rally was just a small five case report of our first experience with the procedure and we would like to do more work on it and have a larger study population to look at and do a comparative series. However we found that the procedure looks looks like there is it's wood pursuing and it's wood looking at in more detail. There's no real pain post-op good cosmesis it's quick and easy to perform and it's easy to reproduce. From the literature there are reports using this procedure and they also have low recurrence no recurrence and really good outcomes. Our experience is that it's affordable it's easily accessible and there are no no complications with it so far and we are trying to look at a larger series at this point in time. We really want to look at the recurrence rate a little more accurately because we've only looked at five cases so we want to do about a hundred and see what is the true recurrence rate using this procedure. This is our national instrument it's the only instrument that has been invented in the last 100 years it's a steel pan. So when you come to Trinidad this is our national flag you hear the steel pan quite a lot especially if you come around carnival time where we have this big carnival it's bigger than real we think. Okay thank you very much. Any questions about the terrarium fixation? Anybody using what what techniques you all use here to do the graphs? Glue. We have glue but it's not available in the public service so if we did have glue maybe we could compare glue to blood that would be something to look at. Yes yes you know we I'm very surgically minded but you must pre-op these patients well before surgery. We don't operate on patients who have ocular surface problems that that could be treated and not treated so if they have blepharitis or they have other ocular surface conditions we usually ensure that we treat that way before doing doing the procedure it would help we think with reducing the likelihood of recurrence. Yes yes yeah and it's a perfect technique I think is what he uses you know PR FECT and I think is what as Jeff said there when we when you dissect in the the the terrarium to lift the conjunctiva and get underneath the conjunctiva and remove tenons because that that is where the problem seems to start and if you could remove tenons as much tenons as you can I think you're going to reduce recurrence so we probably don't need to remove as as wide conjunctiva as as you see in some in the video but that one was actually a recurrent terrarium so we did do a wide dissection. I think I didn't mention but we do use subtenons anesthetic so a peri-balba would probably be a good idea what it does it it reduces the which allows you to well what we do after we give that block is we pad the eye and we usually leave them padded for a day so that you don't get much movement of the eyeball underneath the pad to displace the graft so there are there is a few little things we do other than just put the graft on that I didn't mention so if you want to use a technique I think you could email me that may be the best thing and before and I could tell you all the little bits that we do before and after to try to get the graft to not displace and for this to work. Thanks very much.