Advantages:

Peeling of severe fibrovascular proliferation of the posterior pole using a 25-gauge Atkinson retrobulbar needle with a bent tip and ILM forceps. This technique allows the surgeon to find a cleavage plane with an inexpensive and ‘easy to build’ tool in the absence of more sophisticated tools.

Methods:

The authors report the case of a 13-year-old boy with a chronic intermediate uveitis in his left eye, which underwent a 23-gauge pars plana vitrectomy. On preoperative observation, his BCVA was 10/10 in the right eye and 2/10 in the left eye. Biomicroscopy and fundoscopy were unremarkable in the right eye whereas the left fundus showed an area of fibroglial proliferation extending from the optic nerve head along the upper temporal vascular arcade, with progression over the previous 6 months, as well as an epiretinal membrane. An area of retinal ischemia was also identified on the upper nasal periphery on fluorescein angiography. The surgery began with the placement of 23-gauge valved cannulas at 3, 5 and 9 o’clock positions, 4mm from the limbus. The core vitreous was removed and triamcinolone was injected in order to stain and identify the posterior hyaloid and proceed to the posterior vitreous detachment, which was induced using the vacuum of the cutter. Then, using a 25-gauge Atkinson retrobulbar needle with a bent tip, a cleavage plane between the optic nerve and fibroglial proliferation was created, in order to proceed whit the dissection. Afterwards, ILM forceps were used to peel the proliferation, avoiding tearing the retina. Since the remaining fibrotic tissue was extremely adherent to the optic nerve head, it was cut using a high-rate cut and gentle aspiration. Membrane Blue Dual was injected in order to stain the macular epiretinal membrane, which was then peeled using asymmetric ILM forceps. Endolaser was applied to the upper nasal retinal periphery, in the area of ischemia previously identified on fluorescein angiography and fluid-air exchange was performed. Sclerotomies were sutured with 8-0 polyglactin. Postoperatively special attention was given to positioning, in order to prevent cataract formation. After one month of follow-up, BCVA is 5/10, without complications.

Effectiveness / Safety:

Using a 25-gauge Atkinson retrobulbar needle with a bent tip and ILM forceps is a valid, effective and cheaper option for treating the fibroglial proliferation of the posterior pole and a safe alternative to the use of scissors, viscodissection or even bimanual surgery. However, it should be used in selected cases or in the absence of primary instruments.