Introduction to Retinal Surgery PDF

-flashes and floaters are more of a concern when they are unilateral bc that indicates a retinal tear or detachment -acute is more concerning than chronic à will be explained later -ocular surgery such as cataract extraction increases risk of retinal tear and detachment -superior findings are...

-flashes and floaters are more of a concern when they are unilateral bc that indicates a retinal tear or detachment -acute is more concerning than chronic à will be explained later -ocular surgery such as cataract extraction increases risk of retinal tear and detachment -superior findings are more concerning than inferior findings bc of gravity so if you have a superior traction from the vitreous pulling you also have gravity that’s pulling it down -if a pt has had prior retinal surgery, they may have pigment in the vitreous -if a pt complains of flashes/floaters and have (+) Schafer’s sign but no retinal tears, there is two things to do: refer the pt and also see them back very soon to make sure they don’t have a hole or tear bc you need to know where the pigment is coming from - -on the left we have a vitreous gel is coming out towards you and you have a flat horseshoe tear and forming an anterior flap meaning its going towards the ora -on the right we have what was a previous traction there’s no more traction so the little piece of retina was pulled off and now we have a operculated hole which is a lot less concerning than holes that are not operculated Do you think this is a hole or a tear? -this is a superior retinal tear with associated hemorrhaging -these are retinal holes that are circular, well defined, no areas of fluid or pulling traction on the retina -holes are significantly less concerning than a tear -horseshoe tear and the flap is pointing anteriorly or towards the ora -this is a large tear and is concerning bc its not that far from posterior pole -these are other examples of retinal holes -the one on the left looks more chronic because there are areas of chorioretinal atrophy (dark pigmentation around it) but it is a atrophic hole -pigment is a sign of chronicity so if you see a hole and pigment around it chances are that hole has been there for a long time à less concerning -the image on the right appears to be a newer hole, because you see a small fluid cuff, no pigment deposition and whitened area around it -you can also see the operculum floating above the hole and another small hole inferior to it -if there is a cuff of fluid around the hole, we have a higher level of concern -even if it is operculated, we may still refer to get it treated, particularly if there are other factors like the patient is symptomatic, it is superior, high myopia, among other things - This the pathophysiology of a retinal detachment - if you have a highly myopic pt who has had a PVD their retinas are much safer than those who haven’t had a PVD bc there is no more traction on the retina from the vitreous - Some of this is review from what Dr. Yang was mentioning last week -this is a tobacco paper appearance of the retina -many retinal detachments start usually start as a tear You may remember seeing a similar image of this in Dr. Yang’s slides We are looking at an OCT of the right or left eye? The left eye bc typically we see detachments coming temporally - You see a large area of retinal detachment approaching temporally and approaching the macula - Is this usual? Would we generally expect a tear to be temporal and approach the macula from this side or to come from the side of the optic nerve? - There are not many eye emergencies, but this is one of them You may remember seeing a similar image of this in Dr. Yang’s slides We are looking at an OCT of the right or left eye? The left eye and the macula is on - You see an area of retinal detachment approaching temporally and approaching the macula - Is this usual? Would we generally expect a tear to be temporal and approach the macula from this side or to come from the side of the optic nerve? - There are not many eye emergencies, but this is one of them You may remember seeing a similar image of this in Dr. Yang’s slides We are looking at an OCT of the right or left eye? The left eye and macula off - Retina itself looks hazy and you see an area of retinal detachment approaching temporally and approaching the macula - You don’t want your patient to have to re-invent the wheel - There are times when you’ll have to send a patient to an emergency room and other times where you will have the ability to send them privately - You want to make sure the patient has what they need to take the next step to - The patient should get a paper with the surgeon’s address and telephone number and if there is retinal pathology, particularly a retinal tear, I’ll draw where it is - This makes it easy for the retinal specialist to know where you are talking about - Given that we are all electronic, you may not be writing it on an rx pad at this point, but any method you can find to communicate clearly the information is goo - Also note the questions mark – if you don’t know what you are looking at, it is perfectly fine to say that; “lesion of concern” “areas of concern” - You can describe it “red lesion with white spots” but just be as clear as you can – don’t guess - There are some retinal specialists that I have and can communicate via messaging or text. In those cases I will send them a picture so they know where the tear is and can locate it quickly - This the pathophysiology of a retinal detachment - Non-surgical meaning these can be performed in the office -cropexy: basically freezing the retina back on by taking the probe and applying outside of the globe to the area where the tear is then you apply cold energy to freeze the area and create swelling which leads to scarring and that will seal off the retinal tear for Cryoretinopex you need some kind of subconjunctival or regional anaesthesia -for lesions behind the equator, a small conjunctival incision may be necessary for access. A lid speculum is used. The cryotherapy probe tip must be exposed beyond its rubber sleeve. The instrument should initially be purged (e.g. 10 seconds at −25 °C, repeating after a minute). The treatment temperature is set (typically −85 °C); it is useful to check the effectiveness of the instrument by activating it in sterile water for 10 seconds, when a 5 mm ice ball should form. Under BIO visualization, the lesion is indented and the foot pedal depressed until visible whitening of the retina is seen. It is critical not to remove the tip from the treated area until thawing is allowed (2–3 seconds). Care should be taken to maintain orientation of the probe whilst the tip is not visible, and not to mistake indentation by the shaft of the probe for that of the tip. The lesion is surrounded by a single row of applications, in most cases achieved by one or two applications to a tear. The eye is usually padded -pic of the left eye where there is a fresh cryo though there is an area of whitening or swelling around the break, eventually you see a very prominent scarring -looks similar to cobblestone degeneration but the diff is that cobblestone is more out in the far periphery -more common used by retinal specialist  You will learn more about this in your advanced procedures lab and class; about retinal lasers and how they are applied - When you have your laser lab, you will be trying some of these laser machines - But there are a few things you can change; how long each puslse of laser is applied, how much power you are using, and the size of the spot - There are some standards for various procedures, but you can change within a range  You will learn more about this in your advanced procedures lab and class; about retinal lasers and how they are applied - When you have your laser lab, you will be trying some of these laser machines - But there are a few things you can change; how long each puslse of laser is applied, how much power you are using, and the size of the spot - There are some standards for various procedures, but you can change within a range  You will learn more about this in your advanced procedures lab and class; about retinal lasers and how they are applied - When you have your laser lab, you will be trying some of these laser machines - But there are a few things you can change; how long each puslse of laser is applied, how much power you are using, and the size of the spot - There are some standards for various procedures, but you can change within a range