Vit-Buckle Society’s tips for challenging retina cases

Bios Dr. Zheng is a vitreoretinal surgery fellow at Duke Eye Center. Dr. Woodward is a vitreoretinal surgery fellow at Mass Eye and Ear. Dr. Bommakanti is a vitreoretinal surgery fellow at Wills Eye Hospital/Mid Atlantic Retina. Dr. Zhang is a resident at Vanderbilt University Medical Center DISCLOSURES:  The authors have no relevant financial disclosures.

The 13th Annual Vit-Buckle Society conference brought together retina specialists from across the country for an engaging meeting in Austin, Texas. The conference showcased innovative surgical techniques and spirited debates on the most pressing issues in retina. With the hallmark VBS energy, this year’s event was truly the “Wild Wild VBS.”

The conference started with outstanding tips about some common challenging retina cases.

Lasso that lens

Archana Seethala, MD, from Atrius Health opened the session with an engaging and insightful presentation on secondary intraocular lens techniques, focusing on the Gore-Tex sutured Akreos and scleral-fixated Yamane techniques—tools that are essential in the retina surgeon’s armamentarium.

• Akreos lens with Gore-Tex fixation. Dr. Seethala emphasized the stability of the Akreos lens, citing its four points of fixation and foldable design, which facilitates small-incision insertion. She walked the audience through meticulous marking techniques and emphasized the directionality of the Gore-Tex suture when threading the lens. She also emphasized centering the lens before locking the sutures, and rotating the suture knot into the sclerotomy. She provided high-yield pearls including using iris hooks for small pupils, and demonstrating a technique to salvage tangled and caught sutures. Despite the lens’s material and potential for opacification, its predictable refractive outcome and teachability make it an attractive option.

• Yamane technique. Transitioning to the sutureless technique, Dr. Seethala covered the Yamane technique using three-piece IOLs (MA60AC, CT Lucia, AR40). For MA60AC lenses, she noted that while this lens can result in quick postoperative recovery due to smaller wound size, the haptics can be flimsy and the lens can tilt. The CT Lucia may be unstable at the optic-haptic junction and she suggests using endolaser to stabilize the optic-haptic junction more. The AR40 haptic provides rigidity but risks exposure and breakage. Real-world surgical videos highlighted both seamless cases and common pitfalls. These served as reminders of the unpredictable nature of these cases.

Key takeaways of this talk included: No perfect lens exists, but selecting the right lens for the right patient is critical; setting realistic expectations is essential; and mastery of multiple techniques builds surgical resilience.

Operating one mile high: Altitude considerations for gas-filled eyes

Scott Oliver, MD, from the University of Colorado drew on his experiences treating patients in the Denver area to share practical strategies for managing patients who live at or travel to elevated regions. He pointed out that at higher elevations, reduced atmospheric pressure can affect surgical instruments, in particular Venturi-based systems which experience decreased vacuum efficiency. Dr. Oliver next reinforced the dangers of air travel with intraocular gas, citing multiple case reports of severe eye pain, vision loss and elevated IOP in patients who flew against medical advice. Cabins are pressurized, but typically only to 8,000 feet, and patients are advised to avoid flying until the gas bubble dissipates.

Dr. Oliver also emphasized the importance of incorporating the patient’s home elevation and anticipated travel into surgical plans. If patients must fly or travel to higher elevations, options include avoiding gas by considering scleral buckling or silicone oil tamponade. If gas is used, he advises his patients to stay in the Denver metro area for a month. And before driving home, his patients are equipped with a map and directions to avoid dangerous elevations. When driving home with a partial gas fill, acetazolamide or other ocular hypotensives are prescribed.

Altitude and gas-filled eyes can be a risky combination. To ensure patient safety, verify the patient’s home elevation and discuss travel expectations; use oil when appropriate; and equip patients with education, maps and medications to prevent complications.

Approach to biopsies (vitreous, choroidal, retinal biopsies)

Phoebe Lin, MD, PhD, from the Cole Eye Institute presented a clinical vignette to highlight planning strategies and useful techniques for diagnostic vitrectomy. Success begins with a thorough systemic evaluation and communication with cytopathology and hematopathology teams before the day of surgery. Dr. Lin also pointed out the importance of a meticulous specimen collection strategy, including preparing necessary media and requisitions, sequentially obtaining non-dilute and dilute samples, and using Luer-lock syringes and red caps to prevent loss of small-volume specimens. Her intraoperative tips included tailoring port placement to avoid active snowbanks or retinal detachment sites. False negatives can result from low cellularity or degraded samples, making it crucial to freeze and preserve unused vitreous for future testing.

Dr. Lin then turned to chorioretinal biopsy, typically reserved for suspected neoplasm or metastases after non-diagnostic vitrectomy, or for atypical infection. She presented another clinical vignette and pointed out some key surgical techniques, including removal of any residual vitreous skirt for visualization and control, and double-pass diathermy to outline the biopsy site and preempt bleeding. Tissue dissection with multi-cut pneumatic scissors can help achieve clean specimen margins.

Diagnostic vitrectomy and chorioretinal biopsy are powerful tools in diagnosing atypical intraocular inflammation or neoplasia; preparation, multidisciplinary communication, and refined surgical techniques while tailoring the surgical plan to the patient’s systemic condition and goals of care are keys to success.

A buckle ain’t just for cowboys! How to start if you’re a tenderfoot

Chirag D. Jhaveri, MD, from Retina Consultants of Austin/Dell School of Medicine discussed the importance of scleral buckling and shared tips to become more comfortable with this procedure. He explained that buckling is the only surgical method that truly alters force vectors, and argued that primary SB and PPV/SB showed better outcomes in the PRO study reports.

To get started, he advised beginners to perform a PPV/SB, but to treat the buckle portion like a true primary buckle—marking the break and ensuring the buckle supports it directly rather than just “supporting the vitreous base.” He noted that a chandelier could be used before transitioning fully to indirect ophthalmoscopy.

Dr. Jhaveri recommended avoiding the microscope to maintain consistent movements while suturing, and to begin with simpler cases such as single-quadrant detachments. Buckling elements should be familiar and simple—he prefers the 510 sponge for segmental buckles and typically uses 41 or 42 bands.

He presented several case examples, including a multifocal IOL patient with superior and inferotemporal tears managed with a 510 sponge (with no change in refractive error), and a young phakic patient with a chronic inferior detachment who underwent segmental buckling instead of vitrectomy. Dr. Jhaveri explained that cryopexy only causes PVR when done poorly, and he noted that treatment of the RPE is sufficient with bullous detachments where the probe may not reach the neurosensory retina. He also described suture techniques such as horizontal mattress and figure-eight patterns for effective imbrication.

For drainage, he suggested a cut-down approach followed by laser to the choroidal bed to achieve hemostasis before entering with a needle (similar to when placing a port delivery implant). He closed by encouraging early adopters to “phone a friend” and ask experienced surgeons for guidance.

During the discussion, Edward Wood, MD, shared his experience with having fellows examine and perform cryopexy before prepping, as the maneuvers are more familiar, although he said he’s still looking for a good way to mark the break. Dr. Jhaveri noted that this is a good technique, although it can be more traumatic if the break is under a muscle. Shilpa Desai, MD, noted that it can take some time to develop confidence that the fluid will resolve when buckling without external drainage, because we’re used to PPV where we can drain the fluid intraoperatively.

Tips for uveitic retinal detachments

Noy Ashkenazy, MD, from UT Southwestern Medical Center shared several cases of retinal detachments associated with retinitis, which have a variety of presentations both with and without proliferative vitreoretinopathy or atrophy.

In a case of toxoplasmosis-associated giant retinal tear with extensive PVR, she illustrated the utility of MVR picks for tight membranes. PFO can be used for anterior breaks, with a low threshold for silicone oil use in uveitic retinal detachments. Sub-Tenon’s steroid injections should be avoided in these infectious cases.

In retinal detachments with retinitis that’s healing or progressing to atrophy, PVR can still occur. If no breaks are identified, the borders of the retinitis should be lasered. Once again, scleral buckling is a strong consideration.

Teaching and learning advanced diabetic vitrectomy

James Rice, MBBCh, MRCOphth, FCOphth(SA), MPH, of the University of Cape Town in South Africa, discussed the education process involved in learning advanced diabetic vitrectomy. A strong understanding of the pathophysiology and interface between vitreous and retina is needed. These are retinas with broad areas of fibrosis and firm attachment of membranes to the optic disc; the absence of any PVD creates a challenge, as it’s difficult to induce a PVD using usual techniques.

In his practice, anti-VEGF injections are used in all diabetic dissections to decrease bleeding. Obtaining access and finding the correct surgical plane sets up the surgeon for success. He then demonstrated the “c-pull” technique for extending the hyaloidal elevation, working close and tangential to the retinal surface.

He shared his strategy for learning surgical steps. By tracking surgical progress with individual steps on a spreadsheet, elements that require more practice can be identified. He shared examples of simulation with low-cost plastic models allowing for practice with real instruments and bimanual techniques. By incorporating feedback with intraoperative mentorship, this allows the trainee to understand when to change tactics, when to stop a procedure and how to manage complications. RS