Catheter-guided suprachoroidal buckling of rhegmatogenous retinal detachments secondary to peripheral retinal breaks

The applications of viscoelastic agents in vitreoretinal surgery

The introduction of viscoelastics in human ocular surgery dates back to 1972.Subsequntly, several substances were proposed as adjuvants, particularly for cataract surgery; however, the rheologic properties of ophthalmic viscosurgical devices (OVDs), such as viscosity, pseudoplasticity, and coatability led to their employment also in vitreoretinal surgery. OVDs can be used to separate tissues and create space, to break adhesions, to allow space for surgical manipulation, and to contain hemorrhage by dampening capillary oozing. We focus on the principles and clinical results of several viscosurgery techniques, such as viscodissection and viscodelamination for the management of proliferative vitreoretinopathy and diabetic retinopathy and suprachoroidal buckling for primary retinal detachment. Furthermore, we analyze the techniques in which OVDs served as adjuvants in macular hole surgery, particularly in the handling of the internal limiting membrane, and as volumetric substances against hypotony. Finally, we analyze recent perspectives on vitreous humor biochemical features. Preclinical research led to the belief that hyaluronic acid-based hydrogels could become ideal vitreous substitutes, thanks to their viscoelasticity, porosity, optical properties, and biocompatibility; however, although promising, long-term toxicity issues have limited studies on human subjects.

Modification of the Suprachoroidal Buckling Technique for the Treatment of Rhegmatogenous Retinal Detachment

PURPOSE

To describe modification of the suprachoroidal buckling technique for the treatment of rhegmatogenous retinal detachment (RRD), which may improve the safety profile.

METHODS

A single-surgeon foot-pedal-controlled automated suprachoroidal injection (SCI) of sodium hyaluronate 1%, namely ProVisc (Alcon Laboratories, Fort Worth, TX) was used for the treatment of RRD. MicroDose Injection Kit (MedOne Surgical, Sarasota, FL) including a connector and a 1-mL syringe, designed for subretinal injection, was used to adapt Constellation Vision System (Alcon Laboratories) console for SCI of ProVisc from the 1-mL syringe.

RESULTS

This approach enables better surgeon control during SCI. Three highly myopic eyes of three patients with primary macula-on RRD and single superior peripheral retinal break were treated. Complete retinal reattachment was achieved in all eyes without complications.

CONCLUSION

Injecting ProVisc under foot-pedal control provides a more precise and potentially safer suprachoroidal buckling technique compared with the manual technique with more variable injection speed and pressure.

Vortex Vein Imaging: What Can It Tell Us?

This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.

Hemorrhagic complications associated with suprachoroidal buckling

Background

Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve.

Methods

A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts.

Results

Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement.

Conclusion

SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.