Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

Scleral Transillumination With Digital Heads-Up Display: A Novel Technique for Visualization During Vitrectomy Surgery

Bozho Todorich, MD, PhD; Maxwell S. Stem, MD; Tarek S. Hassan, MD; George A. Williams, MD; Lisa J. Faia, MD

Abstract

BACKGROUND AND OBJECTIVE:

To describe a novel technique of scleral indentation and transillumination for single-surgeon, unassisted vitrectomy and vitreous base shaving enhanced with a digital heads-up display system (NGENUITY 3D Visualization System; Alcon, Fort Worth, TX).

PATIENTS AND METHODS:

This technique was utilized in six eyes of six patients during vitrectomy surgery for common vitreoretinal surgical diagnoses. In each case, the transillumination was performed with the traditional intraocular light pipe set at 100% power, placed obliquely just posterior to the vitreous base insertion, with or without a transillumination adapter. The visualization of the vitreous cavity was digitally enhanced using a heads-up display system (NGENUITY 3D) with light amplification settings increased to near-maximal gain. In each case, the adequacy of the surgical view was judged intraoperatively by two independent surgeons who shared the same surgical view as the primary surgeon.

RESULTS:

In this series, the surgical view provided by the scleral transillumination was deemed adequate to safely perform surgery in five of six cases. In the one patient in whom this was not the case, vitrectomy was completed using traditional endo-illumination and scleral depression performed by a skilled assistant. Lighter fundus pigmentation, myopia, thin sclera, and absence of dense peripheral media opacities were associated with improved view with scleral transillumination. There were no intraoperative complications.

CONCLUSION:

Digitally enhanced scleral transillumination affords surgeons another option for safe and effective simultaneous scleral depression and illumination for unassisted peripheral vitrectomy.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:436–439.]

Abstract

BACKGROUND AND OBJECTIVE:

To describe a novel technique of scleral indentation and transillumination for single-surgeon, unassisted vitrectomy and vitreous base shaving enhanced with a digital heads-up display system (NGENUITY 3D Visualization System; Alcon, Fort Worth, TX).

PATIENTS AND METHODS:

This technique was utilized in six eyes of six patients during vitrectomy surgery for common vitreoretinal surgical diagnoses. In each case, the transillumination was performed with the traditional intraocular light pipe set at 100% power, placed obliquely just posterior to the vitreous base insertion, with or without a transillumination adapter. The visualization of the vitreous cavity was digitally enhanced using a heads-up display system (NGENUITY 3D) with light amplification settings increased to near-maximal gain. In each case, the adequacy of the surgical view was judged intraoperatively by two independent surgeons who shared the same surgical view as the primary surgeon.

RESULTS:

In this series, the surgical view provided by the scleral transillumination was deemed adequate to safely perform surgery in five of six cases. In the one patient in whom this was not the case, vitrectomy was completed using traditional endo-illumination and scleral depression performed by a skilled assistant. Lighter fundus pigmentation, myopia, thin sclera, and absence of dense peripheral media opacities were associated with improved view with scleral transillumination. There were no intraoperative complications.

CONCLUSION:

Digitally enhanced scleral transillumination affords surgeons another option for safe and effective simultaneous scleral depression and illumination for unassisted peripheral vitrectomy.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:436–439.]

Introduction

Efficient and safe vitrectomy surgery is predicated on adequate illumination and visualization of the retina and vitreous. The advent of a small-gauge transconjunctival vitrectomy has been closely followed by improvements in endo-illumination technology.1,2 Smaller gauges initially provided poor illumination with standard halogen and metal halide light sources, but this problem was overcome with the advent of high-output xenon light sources powered either as a stand-alone console or integrated within a full-function vitrectomy system. Since then, retina specialists have acquired numerous endo-illumination choices for unimanual and bimanual work, including widefield light pipes, lighted instruments (such as pics and forceps), illuminated laser probes, and lighted infusion and chandelier systems.3–6 Many of these endo-illumination choices can be combined and then tailored to the particular needs of a surgical case or an individual surgeon's preference. Despite these advances, peripheral vitreous removal with scleral depression in most cases is still performed with the aid of a skilled assistant providing scleral indentation for vitreous base shaving by the primary surgeon using a widefield viewing system. Herein, we report a technique of peripheral vitreous visualization using scleral depression with a transilluminating light pipe, enhanced by three-dimensional (3-D) digital heads-up display technology that allows an individual surgeon to simultaneously perform peripheral vitrectomy and scleral depression with good illuminated visualization, without the need of a skilled assistant.

Surgical Technique

In this report, we describe our experience performing vitrectomy surgery using the direct application of a transscleral illuminated light pipe to provide adequate peripheral vitreous visualization. The 23-gauge light pipe, set on 100% power on the vitrectomy machine (Constellation system; Alcon, Fort Worth, TX) was placed externally on the sclera, just posterior to the vitreous base insertion and used to gently indent the sclera as needed to perform peripheral vitrectomy. The visualization of the vitreous cavity was enhanced using a digital camera and its accompanying heads-up display system (NGENUITY 3D Visualization System; Alcon, Fort Worth, TX), with its light amplification settings increased to near-maximal gain. Doing so allowed us to improve visualization of areas of the vitreous cavity with low luminance. The Figure demonstrates the surgical view using conventional illumination with an intraocular light pipe compared to the view obtained with the scleral transillumination approach. In this white pseudophakic myope with vitreous hemorrhage secondary to a retinal arterial macroaneurysm (RAM), the blood was safely removed from the central vitreous cavity, and vitreous base trimming was performed with transscleral illumination (Supplementary Video). In this case, a single surgeon safely performed vitrectomy with vitreous base shaving without the aid of a surgical assistant, by simultaneously doing vitrectomy with one hand and transilluminated scleral depression with the other.

Surgical view of vitrectomy performed with conventional endo-illumination (A) and with scleral transillumination (B). The technique of scleral transillumination affords for core and peripheral vitrectomy by placing the light pipe probe on the conjunctiva and sclera and angling the light beam posteriorly and toward the center of the vitreous cavity (C). The safety and effectiveness of scleral transillumination can be enhanced by using a blunt clear adaptor sleeve with a reflective coating that would direct all luminance into the eye (D)

Figure.

Surgical view of vitrectomy performed with conventional endo-illumination (A) and with scleral transillumination (B). The technique of scleral transillumination affords for core and peripheral vitrectomy by placing the light pipe probe on the conjunctiva and sclera and angling the light beam posteriorly and toward the center of the vitreous cavity (C). The safety and effectiveness of scleral transillumination can be enhanced by using a blunt clear adaptor sleeve with a reflective coating that would direct all luminance into the eye (D)

We evaluated the effectiveness of this technique in six cases, which are summarized in the Table. Surgical indications included vitreous hemorrhage secondary to RAM, proliferative diabetic retinopathy and hemorrhagic posterior vitreous detachment, retained lens fragments following complex cataract extraction, macula-on retinal detachment, and full-thickness macular hole. The patient's lens status, race, fundus pigmentation, and refraction are summarized in the Table. For all patients at the beginning of the case, the adequacy of the surgical view provided by scleral transillumination was assessed by the surgeon (attending) and assistant (retina fellow) independently, both of whom had the identical view of the surgical field with the heads-up display system. In five cases, scleral transilluminated depression provided an adequate and safe surgical view for core and/or peripheral vitrectomy. In one patient, in whom the fundus pigmentation and density of vitreous hemorrhage precluded the use of this technique, the case was completed using a conventional endo-illumination approach. There were no complications in any of the cases.

Summary of Six Cases in Which Vitrectomy Was Performed With Transscleral Illumination

Table:

Summary of Six Cases in Which Vitrectomy Was Performed With Transscleral Illumination

Discussion

We present a novel approach for visualization during vitrectomy surgery that utilizes scleral transillumination combined with a digitally enhanced camera image and heads-up display. This technique may supplement an already rich armamentarium of vitrectomy endo-illumination options. It may be particularly useful to a retina surgeon who operates without a skilled assistant since it allows the solo surgeon to perform unassisted simultaneous scleral depression and illumination of the vitreous base. The other advantages of this technique are that it is easy to master, inexpensive, and requires no additional sclerotomies or use of ancillary equipment such as chandeliers.

The success of this technique is dependent on the ability of the scleral transilluminator to provide adequate penetration of the necessary amount of light through the sclera. Thus, as expected, this technique worked best in lightly pigmented myopic eyes without dense peripheral vitreous opacities. In fact, in these eyes, scleral transillumination improved vitreous base visualization as the Tyndall effect of transillumination light scatter improved the view of the vitreous base. The view was further enhanced using the digital camera and heads up display system where endogenous luminance can be significantly amplified. The system's high-definition camera, with high dynamic range, optimized the display quality by averaging multiple images with different exposures, which improved the view compared to that obtained with the traditional microscope. Additional manipulation of color channels may offer the potential of enhancing contrast in areas with lower luminance, further improving the surgical view. Although, in the current iteration, this technique works best with digital viewing system, it can also be used with conventional microscope in select cases.

One concern is that scleral indentation using a light pipe alone in myopic eyes with thin sclera may increase the risk of inadvertent scleral perforation during surgery. Conversely, thicker sclera and moderate or heavily pigmented RPE may block adequate transillumination, limiting the quality of the surgical view. One way that both problems can be addressed is by utilizing a blunt rigid adapter sleeve to cover the tip of the light pipe. The adapter can be made from plastic, polycarbonate, or other biocompatible, and molded into the shape of a conventional scleral depressor, thereby reducing the risk of scleral perforation (Figures C and D). One such adapter is commercially available (Katalyst Surgical, Chesterfield, MO), and in its present form, is moderately useful for this technique (Supplemental Video). The goal of using the adapter with this technique is not to replace, but to supplement the conventional endo-illumination by using the same light pipe for unassisted single-surgeon depression illumination for vitreous base shaving.

In summary, we believe that this approach of transscleral illuminated scleral depression, combined with digitally enhanced signal amplification using the 3-D high-definition camera system, allows for an adequate surgical view for peripheral vitrectomy in most eyes and afford surgeons another option to safely and effectively perform unassisted peripheral vitrectomy for a number of surgical conditions.

References

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Summary of Six Cases in Which Vitrectomy Was Performed With Transscleral Illumination

Patient No. Surgical Indication Etiology Phakic Status Race Fundus Pigmentation Refraction View Adequate for Safe VB Shaving Complications
1 Vitreous hemorrhage RAM PCIOL White Light Moderate myopia Yes None
2 Vitreous hemorrhage PDR PCIOL Black Dark Emmetrope No None
3 RLF Complex CE Sulcus IOL White Light Myopia Yes None
4 Vitreous hemorrhage Hemorrhagic PVD 2+ NSC White Light Myopia Yes None
5 Macula on retinal detachment RD PCIOL White Light Moderate Myopia Yes None
6 Macular hole FTMH PCIOL White Light Emmetrope Yes None
Authors

From Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, MI (BT, MSS, TSH, GAW, LJF); Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, MI (TSH, GAW, LJF); and Pennsylvania Retina Specialists, Camp Hill, PA (BT).

The authors report no relevant financial disclosures.

Address correspondence to Lisa J. Faia, MD, Associated Retinal Consultants, P.C., William Beaumont Hospital, 3535 West Thirteen Mile Road, Suite 344, Royal Oak, MI 48073; email: faia.lisa@gmail.com.

Received: August 06, 2017
Accepted: December 04, 2017

10.3928/23258160-20180601-08

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