Foveal translocation surgery with 360° retinotomy involves several surgical procedures, including creation of a total retinal detachment, rotation of the retina, and complete reattachment of the retina. Some of these procedures, which are time-consuming and difficult to perform, may damage the retina when conventional surgical instruments are used. To make these procedures safer and easier, we have developed 3 soft instruments: an atraumatic forceps, a modified Chang double-barrel cannula with a silicone tip, and a light pipe with a silicone tip. The atraumatic forceps allows the surgeon to grasp and peel off the retina with less damage during the creation of retinal detachment. A bimanual technique using the other 2 instruments allows surgeons to rotate and reattach the detached retina easily and safely. We believe that these soft-tipped instruments make foveal translocation a less complicated surgery.To date, no treatment has been reported that improves or stabilizes vision in most patients with subfoveal choroidal neovascular membranes. However, various treatments, including photocoagulation, radiation, interferon, or surgical removal, have been attempted.Foveal translocation is an innovative procedure that displaces the fovea of the sensory retina onto healthy pigment epithelium.Three different techniques of foveal translocation have been reported: translocation with 360° retinotomy,partial retinotomy,and scleral shortening without retinotomy.Foveal translocation with scleral shortening, developed by de Juan and coworkers,is of the 3 procedures the one that has the least associated complications. It may be the most suitable procedure for patients with small choroidal neovascular membrane, because it seems to cause the least damage to the retina.The indication for foveal translocation with 360° retinotomy is wider than that of translocation with scleral shortening, because it can displace the fovea more. Eckardt et alrecently reported promising results using a 360° retinotomy for the treatment of subfoveal choroidal neovascular membranes. Foveal translocation surgery with 360° retinotomy involves several surgical procedures: creation of a total retinal detachment, 360° peripheral retinotomy, removal of the choroidal neovascular membrane, return of the flipped retina, rotation of the retina, complete reattachment of the retina, and tamponade with silicone oil or long-acting gas. Because surgeons need to manipulate the retina during the surgery, the very fragile retina can be easily torn or damaged when manipulated with conventional vitrectomy instruments that are mostly made of steel. Although surgical instruments with soft tips, including brush back-flush needle or diamond-dusted membrane scraper, have been developed,it is difficult to manipulate the retina properly with only these instruments.To make these procedures safer and easier, we have developed 3 soft-tipped instruments, an atraumatic forceps, a double-barrel cannula with a soft tip, and a light pipe with a silicone tip, to manipulate the retina safely and effectively during translocation surgery with 360° retinotomy.The specific feature of the atraumatic forceps is the soft tip, and the handle is a conventional vitreoretinal microforceps or microscissors. The soft tip is made of a set of C-shaped flexible silicone rods (Figure 1). Surgeons can grasp the retina with the flexible silicone tip with less risk of retinal damages or breaks. Although the retinal detachment is created by injecting balanced saline solution into the subretinal space using a 36-gauge needle,the retina is completely detached only by peeling with the retinal forceps, because the retina is attached firmly at several points. The surgeon can grasp the retina very gently and peel off the retina that adheres firmly to the retinal pigment epithelium. The retina can be peeled off from the retinal pigment epithelium with less damage to the retina, because the tip of the forceps can grasp the peripheral edge of the retinotomy very gently (Figure 2).Figure 1.Atraumatic forceps. The tip is composed of a set of C-shaped silicone rods (arrows).Figure 2.A light pipe with diamond-dusted silicone tip on the left and the atraumatic forceps on the right. The surgeon can grasp and peel off the retina with less damage by using the atraumatic forceps (from videotape).The second instrument is a modified Chang double-barrel cannula with a soft tip; one barrel is a 23-gauge needle used for the injection of fluid, and the other is a 25-gauge needle for passive outflow of fluid from the vitreous cavity (Figure 3). We modified the Chang doubled-barrel cannula by attaching a beveled silicone tube to the tip. After creation of total retinal detachment and removal of the choroidal neovascular membrane, perfluorocarbon liquid is injected onto the retina between the optic disc and the macula to reattach the posterior retina using the double-barrel cannula with a soft tip. By injecting a small bolus of perfluorocarbon liquid, surgeons can still rotate the retina safely and easily. After rotating the retina to the appropriate position, the surgeon must hold the retina at that position to prevent it from rotating back to the original position. By using the double-barrel cannula with the soft tip, the surgeon can hold the retina at the appropriate position and inject more perfluorocarbon liquid until the retina completely reattaches. If the mobile retina is drawn into the outflow cannula, the height of the irrigating bottle can be lowered. Thus, the double-barrel cannula with the soft tip can make the rotating procedure safer and easier.Figure 3.A double-barrel cannula with a silicone tip; one tip of the silicone cannula is a 23-gauge needle used for the injection of perfluorocarbon liquid (white arrow), and the other is a 25-gauge needle for passive outflow of fluid from the vitreous cavity (black arrow).The third instrument is a light pipe with a diamond-dusted silicone tip (Figure 4). After creating the total retinal detachment, the retina tends to roll onto the disc. The surgeon then needs to unroll or flip the retina to inject perfluorocarbon liquid onto the surface of the retina. Bimanual technique using the soft-tipped instruments is useful and effective in unrolling the flipped retina, finding the disc, and injecting perfluorocarbon liquid (Figure 5). In addition to the usefulness of bimanual technique, friction by diamond-dusted tips allows the surgeon to hold the displaced retina more effectively than the soft-tipped instrument without diamond dust. The surgeon can complete this procedure more effectively and more safely by using the diamond-dusted light pipe and the double-barrel cannula with the silicone tip simultaneously. The illumination provided by the light pipe with a diamond-dusted silicone tip is approximately equal to that provided by regular light pipes. The surgeon can also obtain better illumination by moving the light pipe closer to the retina as surgeons do with a regular light pipe. This is an advantage compared with an illuminated cannula. Surgeons can use the light pipe with a diamond-dusted silicone tip bimanually in combination with regular microscissors or regular microforceps during vitrectomy in patients with proliferative diabetic retinopathy or proliferative vitreoretinopathy.Figure 4.A light pipe with diamond-dusted silicone tip.Figure 5.The light pipe with diamond-dusted silicone tip on the left and the double-barrel cannula with silicone tip on the right. The surgeon can inject perfluorocarbon liquid and rotate and hold the retina by the simultaneous use of a double-barrel cannula with silicone tip and a light pipe with diamond-dusted silicone tip (from videotape).We have used these 3 instruments on 25 consecutive patients who underwent translocation surgery with 360° retinotomy. We believe that these soft instruments make the complicated foveal translocation surgery with 360° retinotomy less complicated. We also believe these instruments will be useful in vitreous surgery other than translocation.Macular Photocoagulation Study GroupLaser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration: results of a randomized clinical trial.Arch Ophthalmol.1991;109:1220-1231.GJBerginkCBHoyngRWvan der MaazenJRVingerlingWAvan DaalAFDeutmanA randomized controlled clinical trial on the efficacy of radiation therapy in the control of subfoveal choroidal neovascularization in age-related macular degeneration: radiation versus observation.Graefes Arch Clin Exp Ophthalmol.1998;236:321-325.Pharmacological Therapy for Macular Degeneration Study GroupInterferon alfa-2a is ineffective for patients with choroidal neovascularization secondary to age-related macular degeneration: results of a prospective randomized placebo-controlled clinical trial.Arch Ophthalmol.1997;115:865-872.MAThomasJDDickinsonNSMelbergHEIbanezRSDhaliwalVisual results after surgical removal of subfoveal choroidal neovascular membranes.Ophthalmology.1994;101:1384-1396.RMachemerUHSteinhorstRetinal separation, retinotomy, and macular relocation, II: a surgical approach for age-related macular degeneration?Graefes Arch Clin Exp Ophthalmol.1993;231:635-641.YNinomiyaJMLewisTHasegawaYTanoRetinotomy and foveal translocation for surgical management of subfoveal choroidal neovascular membranes.Am J Ophthalmol.1996;122:613-621.Ede Juan JrALoewensteinNMBresslerJAlexanderTranslocation of the retina for management of subfoveal choroidal neovascularization II: a preliminary report in humans.Am J Ophthalmol.1998;125:635-646.CEckardtUEckardtHGConradMacular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration.Graefes Arch Clin Exp Ophthalmol.1999;237:313-325.RZivojnovicGVijfvinkelA brush back-flush needle.Arch Ophthalmol.1988;106:695.JMLewisIParkMOhjiYSaitoYTanoDiamond-dusted silicone cannula for epiretinal membrane separation during vitreous surgery.Am J Ophthalmol.1997;124:552-554.ALoewensteinRSRaderTHShelleyEde Juan JrA flexible infusion micro-cannula for subretinal surgery.Ophthalmic Surg Lasers.1997;28:774-775.Accepted for publication March 17, 2000.Reprints: Masahito Ohji, MD, Department of Ophthalmology, Osaka University Medical School, E7 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan (e-mail: firstname.lastname@example.org).
JAMA Ophthalmology – American Medical Association
Published: Oct 1, 2000
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