Subretinal endoscopic surgery for large subretinal haemhorrage secondary to the age-related macular degeneration

Session Details

Session Title: Free Paper Session 13: Vitreoretinal Surgery IV

Session Date/Time: Friday 08/09/2017 | 14:30-16:00

Paper Time: 14:48

Venue: Room 117

First Author: : T.Kaga JAPAN

Co Author(s): :                                 

Abstract Details

Purpose:

We newly developed subretinal endoscopic surgery to eliminate the subretinal haemhorrage and fibrovascular pigmented epithelial detachment (PED) including the choroidal neovascularization (CNV). We will present the usefulness and future possibility of this surgery in the age-related macular degeneration (AMD)

Setting:

Subjects were five consecutive cases with thick SRH decondary to AMD that extended from macular area to outside of arcade vessels. All patients were examined at the Chukyo Hospital since June 2015 to January 2017.

Methods:

After the vitrectomy, huge retinal detachment (RD) was create by injecting BSS® and air into subretinal space using 38G needle. Then, a 25G trocar with infusion cannula was inserted into the subretinal space under the RD through the conjunctiva. The RD was enlarged up after infusion was changed from vitreous to subretinal space. Then other two trocars were also inserted, and endoscope and a vitreous cutter were inserted from the two trocars. The SRH were aspirated by the 25G cutter or a cannula with soft tip under the observation of endoscope. In 4 cases, fibrovascular PED including CNV was completely removed by a forceps or the vitreous cutter.  In 3 cases of the 4 case, bleeding occurred from fissure of choroid, and the bleeding vessels were coagulated by diathermy. As a final step, air under the retina was aspirated as much as possible. The 3 subretinal trocars were removed after infusion was changed from subretinal to vitreous space. Silicon oil in 4 cases and SF6 in 1 case were injected. Silicon oil was removed from 3 to 6 months after initial surgery in all cases. Distance corrected visual acuity were examined before and 3, 6, 12 months after the surgery.

Results:

The SRH was eliminated almost completely on the day after the surgery in all cases. In case 1 which Fibrovascular PED wasn’t removed, SRH was recurrent 1 month after the surgery and intravitreal aflibercept (IVA) was repeated until haemhorrage was gone. After 6 times of IVA, haemhorrage disappeared and silicon oil was removed. IVA has not been injected for 8 months after the final IVA . In 4 cases which Fibrovascular PED was removed, SRH was not observed at the final observation (6 to 15 months after surgery) even though IVA was not injected after subretinal endoscopic surgery. In case 1 and 5, RPE was maintained at central fovea, and visual acuity improved after surgery. However in case 2, 3 and 4, it did not improve due to the lack of RPE at central fovea. Iatrogenic retinal breaks occurred during the surgery in case 1 and case 5. In all cases, there was no intraoperative or postoperative choroidal haemhorrage from trocar insertion area. In the final observation, there was no case showing retinal detachment or proliferate vitreous retinopathy after the surgery.

Conclusions:

By subretinal endoscopic surgery, complete removal of SRH & fibrovascular PED included with CNV is possible. By fibrovascular PED excision, postoperative intravitreal anti-VEGF may be unnecessary. In order to improve visual function, improvement of a surgical procedure in RPE preservation such as using tPA injection to subretinal space before subretinal endoscopic surgery or RPE transplant for defected area may be necessary. Safety evaluations by long term follow-ups for many cases are desired.

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