Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

A Two Forceps Technique For Approaching Tractional Diabetic Membranes

Talia R. Kaden, MD; Michael Engelbert, MD, PhD

Abstract

BACKGROUND AND OBJECTIVE:

To describe a two-forceps bimanual approach for complex diabetic detachments.

PATIENTS AND METHODS:

Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface.

RESULTS:

Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient.

CONCLUSION:

The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176–e178.]

Abstract

BACKGROUND AND OBJECTIVE:

To describe a two-forceps bimanual approach for complex diabetic detachments.

PATIENTS AND METHODS:

Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface.

RESULTS:

Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient.

CONCLUSION:

The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176–e178.]

Introduction

Since Hutton et al. described four cases of “table-top” diabetic tractional retinal detachments in 1980, great improvements have been made in both surgical techniques and visual outcomes for patients with these detachments.1–5 In particular, high-speed, small-gauge vitrectomy has revolutionized the surgical approach to complex diabetic detachments.2,5 The vitreous cutter can be used to sever the bridges between proliferative foci in the setting of a peripherally detached posterior hyaloid (Figure 1; closed arrow). However, even with the use of 25- and 27-gauge vitreous cutters, there are situations that require bimanual maneuvers, especially when there is peripheral proliferation or where a thin retina and difficult angle can make use of the cutter alone difficult or ineffective.2,4,6

A schematic representing a tractional retinal detachment with detached hyaloid anterior to the inferior arcade (solid arrow). This is often amenable to anterior-posterior segmentation with the vitreous cutter. The open arrow illustrates an area with broadly attached hyaloid anterior to the superior arcade. Cutter segmentation of the hyaloid is therefore not possible. Our reported technique may be helpful in this situation.

Figure 1.

A schematic representing a tractional retinal detachment with detached hyaloid anterior to the inferior arcade (solid arrow). This is often amenable to anterior-posterior segmentation with the vitreous cutter. The open arrow illustrates an area with broadly attached hyaloid anterior to the superior arcade. Cutter segmentation of the hyaloid is therefore not possible. Our reported technique may be helpful in this situation.

Technique

In this case of a previously vitrectomized patient with massive residual fibrovascular proliferation and progressive tractional detachment of the macula, a bimanual approach involving tangential peeling of the previously cut fibrovascular falx with two forceps (Grieshaber ILM and Maxgrip forceps; Alcon, Fort Worth, TX) was employed to both relieve traction between the foci and to separate the posterior hyaloid from the retinal surface outside of the vascular arcades (Supplemental video available below). It may be helpful to use curved scissors (Alcon, Fort Worth, TX) to first cut the thick portion of the membrane (Figure 2A), thus creating a zone of decreased resistance within the fibrovascular membrane. Next, using two forceps to grasp the resultant leaves, the linear defect can be propagated into the periphery in a direction tangential to the retina (Figures 2B and 2C). The tissue is repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface. Illumination is provided with a 25-gauge chandelier light (Alcon, Fort Worth, TX) placed inferiorly.

A still image from our surgical video demonstrating where (A) curved scissors are used to create a line of lesser resistance in the thick edge of the fibrovascular membrane. (B) This linear defect is propagated with two forceps in a direction tangential to the retina, simultaneously separating the attached vitreous cortex from the retina. Illumination is provided with a chandelier light. (C) is a model demonstrating how regrasping the edge of the tear in the fibrovascular membrane leading into the attached hyaloid can allow for progressive separation of the hyaloid from the retinal surface.

Figure 2.

A still image from our surgical video demonstrating where (A) curved scissors are used to create a line of lesser resistance in the thick edge of the fibrovascular membrane. (B) This linear defect is propagated with two forceps in a direction tangential to the retina, simultaneously separating the attached vitreous cortex from the retina. Illumination is provided with a chandelier light. (C) is a model demonstrating how regrasping the edge of the tear in the fibrovascular membrane leading into the attached hyaloid can allow for progressive separation of the hyaloid from the retinal surface.

Discussion

Reports of bimanual techniques often suggest the use of microscissors and forceps or a lighted pick and forceps to remove the fibrovascular membranes.2–6 We find that these can place undue stress on the retina, leading to an increased risk of iatrogenic tears. Even where the use of two forceps is suggested for complex detachments, the second forceps is recommended for blunt dissection or as a fulcrum.6 Here, we report a two-forceps bimanual technique for removing fibrovascular membranes in diabetic tractional detachments that is particularly helpful in situations where the vitreous is firmly adherent to the retina anterior to the fibrovascular ring proliferation (Figure 1; open arrow). Like others, we have found that one cannot use the vitreous cutter alone in these situations, as anterior vitreous separation can usually not be safely achieved with the cutter, even if used as a blunt instrument sweeping under the partially separated hyaloid, or with a bimanual scissor-forceps combination. Dense proliferation over the arcades in the setting of an anteriorly attached posterior hyaloid may also exceed the capability of cutter segmentation, as it may be too thick to fit in the operating system of the cutter.

We report this two-forceps technique for dense fibrovascular proliferation and suggest it as an additional bimanual technique that may be employed in particularly severe cases of diabetic retinopathy with traction and fibrovascular membranes in the setting of an attached hyaloid anterior to the proliferation.

References

  1. Hutton WL, Bernstein I, Fuller D. Diabetic traction retinal detachment. Ophthalmology. 1980;87(11):1071–1077. doi:10.1016/S0161-6420(80)35116-6 [CrossRef]
  2. Berrocal MH, Acaba LA, Acaba A. Surgery for diabetic eye complications. Curr Diab Rep. 2016;16(10):99. doi:10.1007/s11892-016-0787-6 [CrossRef]
  3. Wang ZY, Zhao KK, Li JK, Rossmiller B, Zhao PQ. Four-port bimanual 23-gauge vitrectomy for diabetic tractional retinal detachment. Acta Ophthalmologica. 2016;94(4):365–372. doi:10.1111/aos.12951 [CrossRef]
  4. Park KH, Woo SJ, Hwang JM, Kim JH, Yu YS, Chung H. Short-term outcome of bimanual 23-gauge transconjunctival sutureless vitrectomy for patients with complicated vitreoretinopathies. Ophthalmic Surg Lasers Imaging. 2010;41(2):207–214. doi:10.3928/15428877-20100303-09 [CrossRef]
  5. Berrocal MH, Acaba LA. Surgical management of fibrovascular membranes. Retinal Physician. 2018;15(May 2018):20–23.
  6. Thomas A, Vajzovic L. Bimanual tissue manipulation in vitrectomy. Retinal Physician. 2018;15(May 2018):30–33.
Authors

From Vitreous-Retina-Macula Consultants of New York, New York (TRK, ME); the Department of Ophthalmology, Manhattan Eye, Ear and Throat Hospital, New York (TRK); the Department of Ophthalmology, New York University School of Medicine, New York (TRK, ME); and The LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear and Throat Hospital, New York (TRK, ME).

Supported by the Macula Foundation, New York, New York.

The authors report no relevant financial disclosures.

Address correspondence to Michael Engelbert, MD, PhD, Vitreous-Retina-Macula Consultants of New York, New York, 460 Park Avenue, New York, NY 10022; email: Michael.Engelbert@gmail.com.

Received: July 16, 2018
Accepted: November 06, 2018

10.3928/23258160-20190605-12

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