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Chandelier-assisted Vitrectomy for RRD: Tips and Achievements

Wael Ewais, Egypt Chandelier illumination during vitrectomy for RRD allows the surgeon to perform the procedure with a great deal of versatility through the following: – Bimanual manipulations when needed – Better stability of the working hand by using the second hand as a stabilizer to the working hand. During Retinal detachment surgery, chandelier illuminations enables: – Targeted triamcinolone acetonide injection for...

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Buckle Vitrectomy Versus Vitrectomy Alone for PVR

Wael Ewais, Egypt Introduction: Presence of epiretinal proliferations prevent proper retinal reattachment during vitrectomy for RRD with PVR C. Despite meticulous dissection of PVR tissue, the retina may not completely become reattached. Thus, there are one of two options; – whether to perform a Retinotomy (retinectomy) to relax the contracted retina, OR – to counteract residual traction and support the vitreous base by an...

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Endolaser Application During Diabetic Vitrectomy: An Attempt to Achieve Maximum Benefit

Wael Ewais, Egypt Introduction: Endolaser application is one of the main targets of during diabetic vitrectomy, to induce regression of neovascularization and to prevent vitreous hemorrhage. However, it may not prevent early postoperative recurrent hemorrhage during the first 4 weeks, especially in absence of silicone oil tamponade. Methods: I perform the Endolaser PRP in two stages: 1st: Direct PRP: these are targeted laser burns that are...

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Redundant Retina During Vitrectomy for Rhegmatogenous Retinal Detachment

ABSTRACT Redundant Retina during vitrectomy for Rhegmatogenous Retinal Detachment Redundant Retina refers to a persistently detached peripheral retina despite an almost complete fill of the vitreous cavity with perfluorocarbon liquid (PFC). Perfluorocarbon liquid (PFC) fill is sometimes associated with a peripheral cuff of subretinal fluid (SRF) in presence of peripheral retinal breaks (RBs) and in absence of PVR C. Fluid- air exchange...

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Double-staining for Epimacular Membranes. Is It Mandatory?

ABSTRACT Identification of Epimacular membranes (EMM): BBG stains ILM not EMM. Identification and complete peeling of the EMM is essential. Moreover; complete peeling of the underlying (surrounding) ILM is no less essential, to reduce possibility of recurrence of EMM. Technique: BBG is injected. The surgeon identifies the EMM as the unstained area that is surrounded by a stained area. In case of a visible EMM edge; the surgeon grasps and...

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Retinal Push During Vitrectomy for Primary Retinal Detachment in Children

Retinal Push During Vitrectomy for Primary Retinal Detachment in Children ABSTRACT Background: Posterior Hyaloid poses a serious challenge to surgeons during vitrectomy for primary pediatric Retinal Detachment. It’s toughly adherent to the underlying Retina. PVR and Recurrent RD are inevitable, if posterior Hyaloid isn’t properly removed. Purpose: To report anatomical and functional outcome of Retinal push technique in...

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Self-indentation During Chandelier-assisted Peripheral Vitrectomy Under Air for Primary Retinal Detachment

Self-indentation During Chandelier-assisted Peripheral Vitrectomy Under Air for Primary Retinal Detachment ABSTRACT Purpose: To report the incidence of iatrogenic retinal breaks in eyes for whom self-indentation during chandelier-assisted peripheral vitrectomy under air, for primary retinal detachment, had been performed, compared to eyes for whom a non-indentation chandelier-assisted peripheral vitrectomy under air had been...

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Approach to Diabetic Epimacular Membranes in DME Surgery

Approach to Diabetic Epimacular membranes in Diabetic macular Edema surgery Risk of Diabetic Epimacular membranes (ERM) Peeling: These membranes are rather toughly adherent to an underlying fragile ischemic macula. Vascular connections may be present, in or around, the area of the membranes. This may elicit: iatrogenic retinal breaks, uncontrolled retinal bleeding. My Technique: I use Chandelier as the illumination tool, and an aspheric...

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Role of Endo-diathermy Probe in PDR Surgery

I use the endodiathermy probe as one of two instruments for bimanual dissection of diabetic fibrovascular proliferations. It replaces either the forceps or the vitreous cutting probe and scissors. Forceps Replacement: I identify the surgical planes, by inserting the endodiathermy probe tip underneath the membranes; this allows me to dissect with the vitreous cutting probe under good visulaization. Probe/scissors Replacement: In the...

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Vitrectomy Under Air in Rhegmatogenous RD Surgery

After perfoming central vitrectomy, I inject perfluro-carbon liquid (PFCL) into the vitreous cavity, to re-attach retina, up to the level of the retinal breaks. If there are no detectable breaks, I inject the PFCL as peripheral as possible up to the level of the posterior border of the vitreous base. Subsequently, air is infused, to fill the anterior part of the vitreous cavity. At the air level: I perform meticulous shaving of the...

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Underestimation of Subretinal Bands in PVR Surgery

My mistake: I ignored the subretinal band because the surgery went on smoothly with proper retinal reattachment under heavy liquid. after performing a heavy liquid/ air exchange I observed a pocket of posterior subretinal fluid in the nasal part of the retina at the subretinal band area. I ignored this observation and injected silicone oil with the rationale that this is an isolated pocket of fluid that will be spontaneously absorbed by...

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Bleeding During Retinectomy in PVR

Bleeding during Retinectomy in PVR bleeding during Retinectomy maybe due to: insufficient diathermy for the retinectomy area especially if it is done posteriorly OR rarely a direct choroidal injury at areas of retinochoroidal adhesion e.g scar bleeding is avoided by proper meticulous diathermy of the intended area, especially at terminal branches of retinal vessels. To do the retinectomy as peripheral as possible. Cautious management of...

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Posterior Insertion of the Vitreous Base. What to Do? What Not to Do?

Contact Details: Email: waelewais74@gmail.com Cell Phone: /+201223638643

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Limited Field with Aspheric Macular Contact Lens

The Aspheric Macular Contact Lens provides superb visualization of the macula. However, the field of view is 30 degrees. Sometimes, I need to tilt the lens slightly to one side of the cornea to see a wider area of the macula. In certain situations the contact lens alone is not sufficient for complete macular maneuver. These include: wide extensive epimacular membranes, and small pupil. My Strategy is so simple: I try to use the contact...

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Silicone Oil in the Anterior Chamber: Obstacles and Options

I present a case of emulsified silicone oil in the anterior chamber, which hides an underlying total cataract, and a very thick calcified anterior capsule and mild subluxation. I evacuated the emulsified silicone oil from the anterior chamber. and then i managed the calcified anterior capsule by fashioning an opening using a cannas scissors. I used a cautious divide and conquer Phacoemulsification for the cataract. After implanting the...

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Phimosis in Recurrent PVR Cases: Challenges and Timing of Management

Phimosis in Recurrent PVR cases: challenges and timing of management I present 2 cases with capsular Phimosis. Phimosis elicit a contracted field of vision during vitreoretinal procedures. The ideal management is to perform a pre operative YAG enlargement of the phimosis. However, i had Phimosis in a 5 year old child, who isn’t cooperative enough for a YAG…. so i had to manage intra operatively. in the second case, i had an...

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Dislocated IOL: Obstacles and Priorities

This is a case of posterior Dislocation of Intra ocular lens, with inadequate posterior capsular support . The retina was attached but there was fibrous tissue proliferation and picture of old Branch Retinal Vein occlusion. Priorities: either to retrieve the IOL to the anterior chamber level and keep till end of surgery then exchange. OR Explantation of the IOL at the beginning of the procedure then complete the vitrectomy, then implant....

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Tilted IOL with Retinal Detachment

Strategic Difficulty: Explantation of the IOL at the beginning of the procedure via a large wound will disturb intra ocular fluid dynamics during the rest of the surgery. keeping the IOL tilted will obscure visualization of the posterior segment and the IOL may be dislocated posteriorly at any time during the procedure. My Option: I could readjust and relocate the 3 piece IOL into the anterior chamber level, and kept it centered so that i...

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Dislocated Nucleus: The Vitreous Cutter Is not Superman

Management of posteriorly dislocated nucleus depends on the density of the cataract. relatively soft nuclei can be managed in situ, however dense nuclei need floatation into the anterior chamber, then either an anterior chamber phaco fragmentation is performed or the nucleus is delivered via a cornel/ corneoscleral wound. I present 2 cases: Case 1: Average density nuclear fragment. i performed a Bimanual mechanical manipulation and...

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Advanced PDR: Surgical Approach

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Methods: Preoperative Avastin 24 hours Always Bimanual approach For dissection I use: a 23G vitreous cutter, Scissors, Fashioned 23G Pick. I use the lower temporal trocar sometimes- in cases with dense fibrovascular proliferations in the upper retina. the working trocars in these cases are the lower temporal and upper nasal The membrane...

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Silicone Oil Injection Under Air

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Methods: I don’t perform a direct heavy liquid silicone oil exchange I do: active peripheral suction over the heavy liquid bubble, then start air infusion while staying in the interface. Then I go with the Vitrectomy probe to the heavy liquid bubble, and keep shifting between the bubble and the interface till I have a complete...

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Management of Adherent Posterior Hyaloid in PVR

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Posterior Hyaloid is the scaffold for epiretinal proliferations in PVR. Removal of posterior hyaloid is difficult because it is toughly adherent to the retina The traditional way is suction and pull by the vitreous cutter. However, this isn’t always successful. I used a Tano scraper and end gripping forceps to try to grasp and...

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Swinging Removal of Subretinal Bands in PVR Surgery

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Idea: No need for huge retinectomy for removal of Subretinal proliferations except if extensive. Swinging Removal: I do it via a small retinotomy overlying the midpoint of the course of the Subretinal band, or the most accessible point for my instruments. I grasp the band via the retinotomy and pull it up to form a loop, then pull one...

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Giant Retinal Tear: My Way

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Methods: Routine lens removal in phakic eyes Meticulous revision of the posterior hyaloid with triamcinolone Acetonide Routine ILM Peeling using chandelier, aspheric macular contact lens, and membrane blue dual stain, under heavy liquid and attached retina. 360 laser First heavy liquid air exchange then silicone oil injection under air...

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Routine ILM Peeling During Vitrectomy for Rhegmatogenous RD

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Methods: I use membrane blue dual stain, chandelier illumination, and aspheric macular contact lens. I inject the stain on detached retina, then inject heavy liquid (PFCL) for reattachment. The initial ILM incision is done either: Needle Strokes: Unbent 23G needle with bevel down unidirectional strokes OR Forceps strokes: The closed...

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Intravitreal Gas Injection: My Way

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   I use sulfur hexafluoride SF6 20%. We need to have a non expansile gas without hypotony. My way: I do a complete fluid air exchange to have an air filled globe. Then I remove all trocars from air filled globe except the infusion cannula. I fill a 5cc syringe with 2cc SF6 and 3cc air (SF6 40%). I fit a 28 G needle to the gas syring. I...

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Chandelier Manipulations

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   The chandelier position is preferably inferior at 6 ‘clock OR slightly lower nasal at 5/7 ‘clock. Insertion: vertical (less commonly oblique). Redirecting chandelier by the assistant during the procedure is possible. Mobilization of chandelier probe between trocars even if 23G trocars is possible, provided it is stabilized by the...

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The Lower Temporal Trocar: Alternative Use

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Normally the lower temporal trocar is for the infusion cannula. I use it for: • Laser probe: to do laser for peripheral upper retina 10 and 2‘clock position • Cutter for shaving of the vitreous base in the upper retina between 10 and 2‘clock • Cutter, Forceps, scissors and pick for membranes dissection for membranes in the...

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ILM Peeling During Vitrectomy for Tractional DME. My Way

I do ERM-ILM peeling by using: Chandelier illumination, aspheric macular contact lens, 23 G needle OR closed tip ILM Forceps for creating the ILM flap, clamping the infusion cannula during the BBG stain injection. Chandelier allows for satisfactory illumination with a free second hand that stabilizes the working hand and thus provides stability, precision, control and dexterity. However, positioning and redirecting by the assistant may...

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Phacovitrectomy: My Way

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   I carry out all the steps of phacoemulsification first then proceed to pars plana vitrectomy (PPV). Surgical steps of my combined phacoemulsification PPV technique involve: 1. Clear corneal temporal incisions, 2. Capsulorrhexis, 3. Phacoemulsification, 4. Irrigation/ aspiration, 5. In bag IOL implantation, 6. A single 10/0 nylon...

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Creative Package for Macular Surgery

I perform macular maneuvers now using the following package: 1. Chandelier illumination. 2. Aspheric macular contact lens 3. 23 gauge needle for creating the ILM flap 4. Clamping the infusion cannula during the BBG stain injection. The chandelier allows for satisfactory illumination with a free second hand that stabilizes the working hand and thus provides stability, precision, control and dexterity. But positioning and redirecting by the...

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Fashioned Instruments for 23 Gauge Vitrectomy

We have to perform our surgical techniques with utmost efficacy, widest safety margin, and least cost. Some instruments can be fashioned oneself in a way that achieves all targets of 23 gauge vitrectomy: 1. Intravitreal triamcinolone acetonide cannula 2. Heavy liquid (PFC) cannula 3. 23 gauge needle pick 4. Silicone oil cannula 5. Non-bent 23 gauge needle for ILM flap creation. By being able to fashion some simple instruments one can t...

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