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Core vitrectomy, posterior vitreous separation if not yet present, vitreous base shaving, usually those eye are pseudophakic otherwise the natural lens can be shifted anteriorly by anterior chamber drainage, so that the vitreous base is accessible without damage to the lens. BSS injection is used to detach the retina, first transretinally to create a retinal bleb of sufficient size to allow further BSS injection transretinally via a 30 or 27 gauge cannula. As long as the peripheral retina is without break and no leak exists from the subretinal to the vitreous space, the retina will continue to detach until complete retinal detachment. Then the vitreous cavity will be reestablished by intravitreal PFCL injection in conjunction with a small peripheral retinectomy. Once two third of the vitreous cavity is filled with PFCL the peripheral retina is being cut and removed together with the vitreous base using a cutter. After aspiration of the PFCL the submacular space is accessible and the CNV can be removed. Eventual bleeding stops either by itself or requires cautery. The central retina is reattached by semifluorinated fluorocarbon which has a specific gravity of 1.3 and facilitates to slide and rotate the retina around the optic disc as much as needed. In this film the surgeon is positioned over the head, thus the superior fundus is represented in the lower part of the picture. Eventually the macula is sufficiently distant from the choroidal defect, which itself is located in the inferior temporal arcade (superior part of the picture). Finally PFCL is added to the already existing semiflurorinated fluororcarbon to completely reattach the retina, laser the edge of the retina 360 and exchange the PFCL against silicone oil.
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  • Video
The surgeon who performed the vitrectomy and silicone oil fill and silicone oil removal in optic pit was uncertain whether the central silicone oil bubbles were under the retina. Subretinal oil has been described in conjunction with silicone oil surgery of optic pits. In this case however the bubbles were entangled between retina (macula) and ILM. The ILM could be stained and removed over the attached macula. The oil bubbles were aspirated and PFCL was injected transiently to allow adhesion of eventually undetected remnants of silicone oil from the surface of the macula.
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  • Video
The goal of treatment of such advances stages of FEVR is to get to the abnormal peripheral retinal vessels and coagulate them. On the way lensectomy and vitrectomy are necessary. The vitreous consists for typical multiple onion-like layers of veils, that are rather stiff, but not very tractional and grow out of the retina. They cannot be completely detached but only trimmed back.
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  • Video
This short film shows that the macula area is spared from ICG staining one year after the ILM was removed from the same spot. Apparently ILM, once it is peeled, cannot rebuild. Sine ILM is a precondition to epiretinal membrane formation, ILM peeling should protect from pucker recurrence.
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  • Video
The advantage of triamcinolone in the context of the creation of posterior vitreous separation is to better visualize the hyaloid. Being able to directly see the hyaloid may help to improve the effectiveness of detaching the hyaloid via the cutter and helps to realize a beginning separation. But triamcinolone does not directly interfere with vitreo-retinal adhesion. A jet of fluid, BSS, applied through a small glass capillary pipette however can sever and weaken vitreo-retinal adhesions and facilitate the hyaloid detachment by the subsequent cutter aspiration as shown here. Too strong a jet of fluid however can perforate the retina an create a accidental retinal bleb.
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  • Video
Rarely heavy silicone oil is so adherent to the retina that it does not coalesce during aspiration. It is of course nerve racking to aspirate with high suction very close to the retina and still not be able to completely remove the oil. The remedy is to add liquid perfluorocarbon to the layer of adherent silicone oil. The adhesion to PFCL is much stronger than to the adhesion to the retina. One must add as much PFCL into the eye that all parts of the retina in contact with oil are in contact with PFCL as well. The oil will immediately detach from the retina and float on the surface of the PFCL bubble where it can be easily aspirated via a flute needle.
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Technique for atraumatic viscoexpression of intaocular foreign body affecting the lens is demonstrated in a short video.
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  • Video
The combination of retinal detachment and adherent hyaloid is a situation a risk of iatrogenic retinal holes. The retina is mobile and aspiration of cortex cannot be separated from aspiration of retina. The cutter is apparently not a suitable instrument here. Two iatrogenic retinal holes occurred until the procedure was completed in a primary vitrectomy approach. Posterior vitreous separation is left for an eventual secondary procedure possibly in conjunction then with PVR surgery.
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  • Video
Triamcinolone does clearly demonstrate the hyaloid, but does not help to loosen the vitreo-retinal adhesion. A jet of water directed obliquely onto the surface of the retina finds its way through the hyaloid and is then deflected by the retinal surface into the vitreo-retinal interface unless the jet is too strong. Then it can perforate the retina. Such a jet of fluid is often just enough to lift off the hyaloid locally, allowing the cutter to aspirate effectively and start the detachment of the hyaloid from there.
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  • Video
The typical situation for subchoroidal infusion is ocular hypotony. In the first instance hypotony exists because an infusion in place is removed and another infusion is introduced through the same sclerotomy. The line contains air which instantly escapes through the adjacent sclerotomy for the light pipe. An angulated spatula is used from the opposite site of the infusion to free the tip of the subchoroidal infusion cannula from ciliary body tissue. Eventual remaining subchoroidal air can be left for spontaneous absorption, also in the next scene subchoroidal water can be left. In the third instance subchoroidal silicone oil entering through an excision site of choroid and RPE was also left untreated.
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  • Video
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