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Vitreoretinal Surgery
Sandeep Saxena, Carsten H Meyer, Masahito Ohji, Levent Akduman
SECTION 1: PRINCIPLES, TECHNIQUES AND INSTRUMENTATION IN VITRECTOMY
1:
Wide-Angle Viewing Systems for Vitreoretinal Surgery
Introduction
Overview of Available Systems
Comparison of Contact Lens Systems
Comparison of Noncontact Wide-angle Systems
Adjuncts to Viewing
2:
Illumination Considerations for Vitreous Surgery
Introduction
Illumination Strategies
Endoillumination
Light Pipes
Chandelier Illumination
Illuminated Instruments
Microscope Mounted Slit Lamp
The Light Source
Types of Light
Light-induced Retinal and Retinal Pigment Epithelial Damage
Types of Light Toxicity
Risk of Light Toxicity
Light Toxicity Risk Reduction
Light Toxicity Predisposing Factors
3:
Vitreoretinal Instrumentation
Surgical Fluidics
Infusion System Concepts
Infusion Line Resistance
Regurgitation Issues
Aspiration Fluidics
The Alcon Constellation Vision System
Management of Epiretinal Membranes
Membrane Peeling
Internal Limiting Membrane Peeling
Staining and Particulate Marking
Scissors Segmentation and Delamination
Inside-out Versus Outside-in Technique
Cutter Delamination
En Bloc Dissection
Bimanual Surgery
Exchanges and Subretinal Fluid Drainage
Surface Tension Management and Exchanges
Interfacial Tension Agents
Nomenclature
Drainage of Subretinal Fluid
Drainage Retinotomy
Intraocular Lens Fogging During Fluid-Air Exchange
Air-Gas Exchange
Liquid Perfluorocarbon
Medium Term Perfluorooctane
Giant Retinal Breaks
Air-Silicone Exchange
Silicone Removal
Silicone Reoperations
Interface Vitrectomy
Vitrectomy Under Air
Postoperative Positioning
4:
20-Gauge Pars Plana Vitrectomy
Introduction and Brief History
Indications for 20-Gauge Vitrectomy
Indications for Posterior Segment Vitrectomy
Advantages of 20-Gauge Vitrectomy
Disadvantages of 20-Gauge Vitrectomy
Basic Concepts
Vitrectomy Machines
Types of Cutters
Fluid Dynamics and Cutter Parameters
Surgical Technique
Preparation of the Patient
Incision of Conjunctiva
Sclerotomies and Infusion Cannula
Machine Settings
Infusion Height/Pressure
Vacuum
Cutting Rate
Use of the Light Pipe
Vitrectomy
Use of Plugs
Closing of Sclerotomies and Conjunctiva
Tamponading Agents
Complications
Intraoperative Complications
Iatrogenic Breaks and Retinal Incarceration
Bleeding
Choroidal Hemorrhage
Lens Touch
Postoperative Complications
Future or Emerging Trends
Small Gauge, Sutureless
Sutureless 20-Gauge Vitrectomy
Simple Vitrectomy or Combination with Buckling Procedure
Acknowledgment
5:
23-Gauge Pars Plana Vitrectomy
Introduction
Operative Techniques
Anesthesia
Two-step Sclerotomy Technique
Single-step Sclerotomy Technique
Vitrectomy
Removal of Microcannulas
Indications of 23-Gauge Vitrectomy
Contraindications of 23-Gauge Vitrectomy
Advantages of 23-Gauge Vitrectomy
Disadvantages of 23-Gauge Vitrectomy
Complications of 23-Gauge Vitrectomy
Subconjunctival Hemorrhage
Wound Leak and Hypotony
Endophthalmitis
Conclusion
6:
The Use of Silicone Oil in Vitreoretinal Surgery
Introduction
7:
Long-term Intraocular Tamponade with Silicone Oil
Introduction
The Silicone Study20–27
Chemical Properties of Silicone Oil
Physical Properties of Silicone Oil
Specific Gravity
Physical Properties of Tamponade
Buoyancy
Interfacial Tension or Surface Tension
Viscosity
Refractive Indices
Clinical Indications
General
Retinal Detachment with Severe Proliferative Vitreoretinopathy
Giant Retinal Tear
Severe Proliferative Diabetic Retinopathy
Macular Hole
Pathologic Myopia
Cytomegalovirus Retinitis
Complicated Pediatric Retinal Detachment
Trauma
Surgical Techniques in the Use of Silicone Oil
Infusion of Silicone Oil
Air-Silicone Oil Exchange
Perfluorocarbon Liquid-Silicone Oil Exchange
Fluid-Silicone Oil Exchange
Removal of Silicone Oil
Implications of Silicone Oil Removal
Complications of Silicone Oil
General
Specific
Silicone Oil Emulsification
Refractive Changes
Others
8:
Intraocular Gases in Vitreoretinal Surgery
Introduction
Intraocular Gases and Kinetics
Techniques of Fluid-Air Exchange and Intraocular Gas Injection
Uses of Intraocular Gases
Pneumatic Retinopexy
Macular Hole Surgery
Pneumatic Displacement of Submacular Hemorrhage
Unrolling the Edges of a Giant Retinal Tear
Postoperative Positioning and Duration of Positioning
Contraindications for Intraocular Gas
Complications of Intraocular Gases
Elevated Intraocular Pressure
Cataract
Migration of the Intraocular Gas Bubble
Inadequate Gas Bubble Size
Other Complications
9:
Perfluorocarbon Liquids and Vitreoretinal Surgery
Introduction
Chemical and Physical Properties
Chemical Properties
Physical Properties
Indications for Use
Giant Retinal Tears
Proliferative Vitreoretinopathy
Rhegmatogenous Retinal Detachment without Proliferative Vitreoretinopathy
Tractional Retinal Detachments in Proliferative Diabetic Retinopathy
Ocular Trauma and Foreign Bodies
Submacular and Suprachoroidal Hemorrhages
PFCL-Assisted Vitreous Biopsy
Drawbacks of PFCL Use
10:
Chromovitrectomy
Introduction
Use of Vital Dyes for Internal Limiting Membrane
Indocyanine Green
Infracyanine Green
Brilliant Blue
Triamcinolone Acetonide
Trypan Blue
Vital Dyes for Epiretinal Membranes
Trypan Blue
Patent Blue
Bromophenol Blue
Indocyanine Green
Subretinal Vital Dye for Facilitation of Retinal Breaks Visualization
Clinical Application of Vital Dyes for Subretinal Breaks Identification
Vital Dyes for Vitreous
Triamcinolone Acetonide
Sodium Fluorescein
Fluorometholone Acetate
Trypan Blue
Surgical Techniques for Dye Application during Vitreoretinal Surgery
Double Staining Technique
Reconstitution, Dilution and Concentration
Dye Injection
Macular Hole Protection
Illumination
11:
Endophotocoagulation and Safe Intravitreal Injection Technique
Introduction
Principle
Parts of Endolaser
LASER Console
Active Medium
Endoprobes
Cone Angle
Types of Endoprobes
Indications
Endophotocoagulation with Indirect Ophthalmoscopy
Microendoscope Endophotocoagulation
Safe Intravitreal Injection Technique
Intravitreal Drug Delivery
Anticoagulation and Intravitreal Injections
Surface Preparation with Betadine
Local Topical Anesthesia
The Injection Procedure and Recommended Technique
Ocular Complications
SECTION 2: RETINAL DETACHMENT
12:
Scleral Buckling
Introduction
Who is a Potential Candidate for Scleral Buckles?
A Brief History of Scleral Buckling
Orbital Issues
Topographic Considerations
Preoperative Examination
Contact Lens and Scleral Depression at the Slit Lamp
Drawing
Double Patching
Practical Considerations: Nuts and Bolts
Radial Buckles
Circumferential Segmental Buckles
Encircling Buckles
Attention to Detail
Expected Outcomes
Obstacles to Teaching the Lost Art of Scleral Buckling
13:
Pneumatic Retinopexy
Introduction
The Philosophy of Pneumatic Retinopexy
Results: Data Analysis
Anatomic Success
Visual Recovery
Complications
Operative Complications
Postoperative Complications
New Breaks
Proliferative Vitreoretinopathy
Epimacular Membrane Formation
Choroidal Detachment, CME, Macular Hole, Cataract
Reoperations
Discussion
Anatomic Success
Visual Recovery
Prognostic Indicators
Pseudophakia
Retinal Detachment Size
The Type and Number of Retinal Defects
Gas
Optimal Case Selection Combined with the Most Effective Surgical Technique
Follow-up Recommendations
Quality and Cost-effective Measurements
The Learning Curve
Comparison with Other Surgical Techniques
14:
Primary Vitrectomy for Retinal Detachment
Introduction
Evolution of Primary Vitrectomy
Techniques and Variations of Primary Vitrectomy
Clinical Studies and Results of Primary Vitrectomy
Comparison to Other Methods
Advantages of Primary Vitrectomy
Disadvantages of Primary Vitrectomy
Indications and Contraindications
15:
Proliferative Vitreoretinopathy
Introduction
Clinical Aspects and Classification
Risk Factors
Pathogenesis
Surgical Management
Postoperative Care or Complications
Surgical Outcomes
Future Directions
16:
Giant Retinal Tears
Introduction
Background
Classification, Risk Factors and Etiology
Pathogenesis
Preoperative Evaluation
Surgical Techniques for Repair
Historical Techniques
Perfluorocarbon Liquids
Surgical Technique
Giant Retinal Tears with Proliferative Vitreoretinopathy
Prophylaxis of the Fellow Eye
Complications
Slippage of GRT
Proliferative Vitreoretinopathy and Recurrent Redetachment
Complications of PFCL
Prognosis
SECTION 3: DIABETIC RETINOPATHY
17:
Proliferative Diabetic Retinopathy: Surgical Considerations
Introduction
Pathophysiology
Degree of Posterior Vitreous Separation
Type of Vitreoretinal Adhesions
Surgical Indications
Severe Non-clearing Vitreous Hemorrhage
Traction Retinal Detachment Involving or Threatening the Macula
Combined Traction or Rhegmatogenous Retinal Detachment
Dense Premacular Hemorrhage
Severe Fibrovascular Proliferation
Diabetic Macular Edema Associated with Posterior Hyaloidal Traction
Hemolytic or Ghost Cell Glaucoma
Anterior Segment Neovascularization with Media Opacity
Surgical Objectives and Techniques
Removal of Media Opacities
Relieving Vitreoretinal Traction
Control of Bleeding
Intraoperative Issues
Corneal Edema
Pupillary Constriction
Lens Opacities
Intraocular Hemorrhage
Retinal Breaks
Postoperative Care
Elevated Intraocular Pressure
Management
Corneal Epithelial Defects
Management
Lens Opacification
Management
Rubeosis and Neovascular Glaucoma
Management
Anterior Hyaloidal Fibrovascular Proliferation
Management
Fibrinoid Syndrome and Intraocular Fibrin Formation
Management
Vitreous Hemorrhage
Management
18:
Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema
Introduction
Pegaptanib
Bevacizumab
Retrospective Studies
Prospective Studies
Ranibizumab
Vascular Endothelial Growth Factor Trap
19:
Surgery for Diabetic Macular Edema
Introduction
Pathogenesis
Indications and Outcome
Surgical Methods
Prognostic Factors
Future Aspects
20:
Laser in Diabetic Retinopathy
Introduction
Principles of Laser
Light-tissue Interaction
Thermal Effect
Photocoagulation
Hyperthermia
Photovaporization
Ionizing Effect
Photodisruption
Photochemical
Equipment
Laser Source
Laser Delivery Systems
Modes of Laser Application
Laser Contact Lens
Factors Influencing Laser Output
Ocular Pigment
Laser Wavelength
Modifiable Laser Parameters
Complications of Laser Photocoagulation
Pattern Scan Laser Photocoagulation (Pascal Laser)
Clinical Applications in Diabetic Retinopathy
Diabetic Macular Edema (DME)
Types of DME
Treatment Protocol
SECTION 4: OTHER RETINAL VASCULAR DISORDERS AND INFLAMMATION
21:
Surgical Management of Retinal Vein Occlusion
Central Retinal Vein Occlusion
Introduction
Pharmacologic Treatment
Recombinant Tissue Plasminogen Activator
Intraocular Corticosteroids
Anti-Vascular Endothelial Growth Factor Drugs
Vitrectomy
Radial Optic Neurotomy
Branch Retinal Vein Occlusion
Introduction
Vitrectomy
Sheathotomy
Pharmacologic Treatment
Recombinant Tissue Plasminogen Activator
Intraocular Corticosteroids
Anti-VEGF Drugs
22:
Vitreoretinal Surgery in Eales' Disease
Introduction
Clinical Features
Fluorescein Angiography
Management
Medical Therapy
Corticosteroids
Methotrexate
Photocoagulation
Vitreoretinal Surgery
Indications
Prognosis
Critical Surgical Evaluation and Results
Role of Preoperative Intravitreal Bevacizumab
23:
Vitrectomy in Uveitis
Introduction
Vitrectomy in Patients with Uveitis for Diagnostic Purposes
Diagnostic or Therapeutic Challenge
Technique
Testing the Specimen
Cases Where Definite Diagnosis Requires Biopsy
Vitrectomy for Therapeutic Purposes in Patients with Uveitis
Media Opacity
Better Control of Intraocular Inflammation
Chronic Uveitic Hypotony
Sequelae of Uveitis and Cases that Require Lensectomy
Intraocular Implants
Non-biodegradable
Biodegradable
Retinal Detachment
Choroidal Neovascularization
Intraocular Parasites
SECTION 5: MACULAR SURGERY
24:
Macular Epiretinal Membrane Removal
Introduction
Epidemiology
Etiology
Pathogenesis
Classification
Symptoms
Diagnosis
Differential Diagnosis
Treatment
Clinical Criteria for Surgery
Pars Plana Vitrectomy
Epiretinal Membrane Removal
Internal Limiting Membrane Peeling
Indocyanine Green Staining
Infracyanine Green Staining
Trypan Blue Staining
Patent Blue Staining
Brilliant Blue G Staining
Triamcinolone Acetonide
Double Staining
Management of Coexisting Cataract
Outcome
Complications
25:
Vitrectomy for Macular Hole
Introduction
Optical Coherence Tomography of Macular Hole
Impending Macular Hole
Stage 1A: Impending Macular Hole
Stage 1B: Impending Macular Hole or Outer Macular Hole
Full-Thickness Macular Hole
Stage 2 Macular Hole
Stage 3 Macular Hole
Stage 4 Macular Hole
Differential Diagnosis
Macular Pseudohole
Lamellar Macular Hole
Lamellar Macular Hole: Evolution of an Impending Hole
Lamellar Macular Hole of Various Origins
Secondary Macular Holes
Traumatic
High Myopia
Vitreomacular Traction Syndrome
Other Causes of Secondary Macular Holes
Adult-Onset Pseudovitelliform Dystrophy
Group 2 Macular Telangiectasis
Principles and Technique of Macular Hole Surgery
Vitrectomy
Sclerotomy Size
Core Vitrectomy
Vitreous Cortex Separation and Vitrectomy Completion
Epiretinal Membrane Removal
Internal Limiting Membrane Peeling
Gas Filling
Postoperative Positioning
Process of Macular Hole Closure and Prognostic Factors
Histology
Optical Coherence Tomography Findings
Prognostic Factors
Functional Results
Complications of Macular Hole Surgery
Conclusion
26:
Vitreoretinal Surgery for Myopic Foveoschisis
Introduction
Clinical Manifestations of Myopic Foveoschisis
Incidence
Clinical Features
Optical Coherence Tomography Findings
Pathogenesis
Management of Myopic Foveoschisis
Natural Course
Treatment
Scleral Buckling
Vitrectomy
Surgical Procedures
Complications
27:
Submacular Hemorrhage Removal and Pneumatic Displacement of Submacular Hemorrhage
Introduction
Surgical Steps
28:
Anti-VEGF Therapy for Neovascular Age-related Macular Degeneration
Introduction
Angiogenesis and Vascular Endothelial Growth Factor
Pathogenesis of Choroidal Neovascularization
Pegaptanib
Efficacy
Anatomic Outcomes
Safety
Ranibizumab
Efficacy
Anatomic Outcomes
Safety
Bevacizumab
Efficacy
Use of Anti-VEGF Therapies in Clinical Practice
Initiation
Maintenance
Termination
CNV Activity “Refractory” to Treatment
Anti-VEGF Tachyphylaxis
Future Directions and Conclusions
Role of Combination Therapy
Other Anti-VEGF Therapies – VEGF Trap
Other Therapies
Conclusion
SECTION 6: TRAUMA
29:
Vitrectomy in the Management of the Injured Eye
Introduction
Instrumentation
Vitrectomy for Ocular Trauma: Conditions and Techniques
Vitreous Prolapse Through the Wound
Basic Concepts
Technique
Timing
Hyphema
Basic Concepts
Technique
Timing
Lens Trauma
Basic Concepts
Technique
Timing
Endophthalmitis
Basic Concepts
Technique
Timing
Glaucoma
Basic Concepts
Technique
Timing
Vitreous Hemorrhage
Basic Concepts
Technique
Timing
Intraocular Foreign Body
Basic Concepts
Technique
Timing
Retinal Break/Macular Hole
Basic Concepts
Technique
Timing
Retinal Detachment
Basic Concepts
Technique
Timing
Proliferative Vitreoretinopathy
Basic Concepts
Technique
Timing
SECTION 7: ENDOPHTHALMITIS
30:
Vitreoretinal Surgery in Endophthalmitis
Introduction
Clinical Presentation
Infectious Endophthalmitis
Exogenous Endophthalmitis
Post-traumatic
Causes of Endogenous Endophthalmitis
Sterile Endophthalmitis
Organisms
Bacteria
Gram-positive cocci
Gram-positive bacilli
Gram-negative cocci
Gram-negative bacilli
Actinobacteria
Fungi
Helminths and Protozoa
Management of Infectious Endophthalmitis
Pars Plana Vitrectomy
Antibiotics
Corticosteroids
Other Causes
Endogenous Endophthalmitis
Outcomes
SECTION 8: PEDIATRIC VITREORETINAL SURGERY
31:
Vitreoretinal Surgery for Retinopathy of Prematurity
Introduction
Surgical Technique
Discussion
SECTION 9: SURGICAL TECHNIQUES IN VIRAL RETINITIS
32:
Surgical Management of Cytomegalovirus Related Retinal Detachment in Patients with AIDS
Introduction
Incidence of Retinal Detachment in Cytomegalovirus Retinitis
Risk Factors for Retinal Detachment in Cmv Retinitis
Clinical Features of Retinal Detachment in CMV Retinitis
Pathophysiology of CMV Related Retinal Detachments
Management of Retinal Detachments in CMV Retinitis
Pneumatic Retinopexy and Laser Photocoagulation
Scleral Buckle
Pars Plana Vitrectomy with Silicone Oil Injection
Planned Removal of Silicone Oil
Pars Plana Vitrectomy with Intraocular Gas Tamponade
Retinal Detachment After Ganciclovir Implant
Visual Outcome After Retinal Detachment in CMV Retinitis
SECTION 10: MISCELLANEOUS
33:
Management of Dislocated Lens, Lens Fragments and Intraocular Lens
Introduction
Dislocated Crystalline Lens
Dislocated Nucleus, Lens Fragments and Cortex
Management of Dislocated Crystalline Lens, Dropped Nucleus and Lens Fragments
Observation
Surgery
Surgical Technique
Dislocated Intraocular Lens
Management of Dislocated Intraocular Lens
Observation
Retrieval of IOL
Explantation of IOL
Repositioning of IOL
Repositioning of the IOL in the Sulcus
Sclera Fixation of the Dislocated Intraocular Lens
Implanting a New Intraocular Lens
Associated Retinal Detachment
Role of Perfluorocarbon Liquid in the Management of Dislocated Crystalline Lens, Nucleus and IOL
Results
34:
Surgery for Optic Disc Pit with Retinal Detachment
Introduction
Etiology
Clinical Features
Clinical Investigations
Optical Coherence Tomography
Visual Field
Fluorescein and Indocyanine Green Angiography
Pathogenesis
Source of Intraretinal Fluid
Natural History
Management
Laser Photocoagulation
Pneumatic Retinopexy
Macular Buckle
Pars Plana Vitrectomy (PPV)
35:
Vitreoretinal Surgery for Parasitic Diseases
Introduction
Pathogenesis
Indications for Vitreous Surgery
Persistent Ocular Inflammation
Residual Vitreous Exudates or Vitreous Membranes
Removal of Intravitreal, Intraretinal or Subretinal Parasites
Secondary Complications
Surgical Procedure
Intravitreal or Subretinal Cysticercosis
Vitreous Surgery for Live Nematodes
Vitreous Traction Membranes and Epiretinal Membranes
Vitreous Exudates and Endophthalmitis- Like Presentation
Traction or Rhegmatogenous Retinal Detachment
Results
Complications
36:
Surgery for Choroidal Coloboma and Retinal Detachment
Introduction
Anatomical Considerations
Clinical Presentation of the Retinal Detachment
Retinal Breaks, Intercalary Membrane Breaks and Breaks at Locus Minoris Resistentiae
Characteristics of the Retinal Detachment
Management
Steps of Surgical Procedure
Causes of Failure of Surgery
Results
SECTION 11: ONCOLOGY
37:
Eye-conserving Surgical Treatment Methods in Intraocular Tumors
Introduction
Laser Photocoagulation
Choroidal Melanoma
Retinoblastoma
Circumscribed Choroidal Hemangioma
Retinal Capillary Hemangioma-Retinal Hemangioblastoma
Transpupillary Thermotherapy
Choroidal Melanoma
Retinoblastoma
Circumscribed Choroidal Hemangioma
Photodynamic Therapy
Circumscribed Choroidal Hemangioma
Diffuse Choroidal Hemangioma
Choroidal Nevus
Vascular Retinal Tumors
Choroidal Osteoma
Acquired Retinal Astrocytoma and Astrocytic Hamartomas
Cryotherapy
Retinoblastoma
Vascular Retinal Tumors
Episcleral Plaque Radiotherapy (Brachytherapy)
Choroidal and Ciliary Body Melanoma
Retinoblastoma
Circumscribed Choroidal Hemangioma
Vascular Retinal Tumors
Surgical Resection
Iridectomy
Partial Lamellar Sclerouvectomy or Exoresection
Endoresection
Other Vitreoretinal Procedures
Primary Vitreoretinal Lymphoma
Retinal Capillary Hemangioma
Choroidal Melanoma
Intravitreal Injections
Primary Vitreoretinal Lymphoma
Intravitreal Injections of Vascular Targeting Agents
INDEX
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