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Professor Chen Song talks about the clinical skills of complex vitreoretinal surgery

Posting time:2023-01-31 07:37:29

Professor Chen Song talks about the clinical skills of complex vitreoretinal surgery

Editor's note: Minimally invasive vitreoretinal surgery (VRS) has brought light to countless patients with fundus diseases, but ophthalmologists still feel powerless when facing some patients with complicated fundus diseases. For this reason, "International Ophthalmology News" specially invited Professor Chen Song from Tianjin Eye Hospital to share his experience and clinical skills in complex vitreoretinal surgery, hoping to bring some inspiration to the majority of ophthalmologists. The key steps of VRS Professor Chen summarized the key steps of VRS for severe proliferative diabetic retinopathy (PDR), and doing well in every link of the operation will help to improve the final quality of the operation: 23G/25G/27G minimally invasive surgery; Painless anesthesia: Professor Chen originally applied Tenon capsule anesthesia in 1996. Patients are satisfied with the anesthesia effect, which is beneficial to the cooperation of pain-sensitive patients, which can avoid patient tension and reduce vitreous rebleeding (PVH). Wide-angle surgical system: ROLs wide-angle endoscopy The field is clear and convenient, which is beneficial to the prevention and treatment of PVH. The serrated edge (130°) around the fundus can be clearly seen under the self-service ROLs microscope. Avoid the assistant's top pressure, which will damage the optic nerve. Use a wide-angle lens (25-30mmgh) to control the intraocular pressure, and avoid assistants when operating with both hands. Top pressure cut around the periphery; peel the membrane, with the help of light guide one-handed or double-handed membrane peeling technique, to avoid severe PVH caused by tearing blood vessels forcibly; TA combined with complete vitrectomy, clearing the vitreous and membrane + hemostasis, preventing postoperative proliferation, can improve the macular area Retinal thickness, reducing PVH; internal limiting membrane peeling; electrocoagulation: The blood clot generated by the broken end of the electrocoagulation tube during surgery can also lead to PVH, and the residual vitreous cortex during surgery is an important cause of PVH. Electrocoagulation removes peripheral vitreous tissue, stops bleeding, inhibits PVR, and reduces PVH; gas-liquid exchange: gas-liquid exchange under self-service wide-angle lens reduces PVH, retinal electrocoagulation incision at the posterior pole of retinal detachment (RD), suction of subretinal fluid, gas can stop bleeding Effect; intraocular laser; episcleral freezing: episcleral freezing under wide-angle lens gas-liquid exchange to reduce postoperative recurrent bleeding. Peripheral neovascularization sometimes cannot be resolved by PRP, and anti-VEGF drugs can only temporarily prevent it. Silicone oil or gas filling: Severe PDR filling with silicone oil is of great significance to prevent PVH. Severe PDR silicone oil has advantages over gas filling, which can prevent PHV and relieve growth factors in the vitreous cavity. Aggregation, cutting off the communication between the anterior and posterior segments, is conducive to the subsidence of iris redness; it can also prevent complications such as RD, make patients feel clear, restore vision faster, and is conducive to postoperative laser supplementation; the application of anti-VEGF drugs. The Magical Use of ROLs Wide-Angle Mirror Professor Chen has been using the self-service Rols wide-angle lens since 2000, which is an international and domestic initiative. This innovative use helps the assistant to relax, so as to better cooperate with the chief surgeon. The key to using it is the cooperation skills of both hands. The advantages of using the ROLs wide-angle lens are as follows: the peripheral serrated edge of the fundus can be clearly seen, and the surrounding vitreous tissue can be completely removed. If the operation is skilled, there is no need for assistant pressure; VRS can be used in the case of small pupils 3-5 mm and the refractive interstitium is not clear. Complete excision of all vitreous body and membranous tissue, membrane peeling and internal limiting membrane peeling; complete lens preservation VRS; clear gas-liquid exchange, up to 160 degrees, assisting in the removal of residual peripheral vitreous tissue; Prof. Chen The ROLs wide-angle lens is innovatively used to replace the emulsified oil droplets by gas-liquid exchange under direct vision under indirect ophthalmoscope after removal of silicone oil, which does not need to enter the fundus and is highly safe. This technology is an international innovation with high technical difficulty and requires more training to master it; it is convenient for complete PRP; it is convenient for moderate episcleral freezing. Rational application of anti-VEGF drugs can reduce VRS bleeding. Anti-vascular endothelial growth factor (VEGF) drugs have been widely used in the treatment of eye diseases, and they also have a role in the treatment of fundus diseases. However, anti-VEGF drugs are a double-edged sword. Reasonable application can achieve the best effect. Studies have shown that surgery should be performed in time after the application of anti-VEGF drugs (5-7 days is the best). For PDR with proliferative membranes, anti-VEGF therapy alone without VRS may easily cause membrane contraction and lead to traction retinal detachment. Impaired visual function. In addition, intraoperative use of anti-VEGF drugs can also avoid peeling PVH. Familial exudative vitreoretinopathy (FEVR) is a rare hereditary abnormal retinal vascular development, which not only damages vision, but also causes retinal detachment and blindness. Professor Chen shared his experience in the use of vitrectomy (PPV) in the treatment of FEVR with rhegmatogenous retinal detachment (RRD): complete removal of the vitreous, especially the peripheral vitreous, release of retinal traction factors, and release of the retina are successful key to reset. The use of wide-angle lens can appropriately reduce the negative pressure and cutting speed, and TA staining should be repeated when the color of the vitreous is not clear; peeling the membrane: using electrocoagulation to cut the membrane can reduce bleeding, retinal incision to remove or cut off the subretinal membrane; Laser and moderate episcleral condensation, reduce laser energy as much as possible to avoid laser retinal holes; silicone oil filling should be preferred; use of anti-VEGF. Basic qualities that surgeons should possess. Complex fundus surgery tests the ability of the chief surgeon in an all-round way. In order to better help patients with fundus diseases through surgery, doctors need to work hard to improve their own abilities. Professor Chen shared his points on this. Recommendation: Keeping pace with the times: minimally invasive 23G/25G/27G + auxiliary anti-VEGF drugs + hormone use both internal and external: Proficient in wide-angle lens + binocular indirect ophthalmoscope fundus disease medicine + surgical vitreous surgery + scleral buckling surgery before and after penetration: VRS + phacoemulsification + treatment of glaucoma with high intraocular pressure + ocular surface lesions Strong heart: good psychological quality + sharp resilience + full of confidence Precision surgery: excellence during surgery, proper treatment of complications after surgery Unity and cooperation: doctors at all levels do their best to explain Take good care of the disease and manage medical records. Surgical innovation: good at clinical research, summarizing and improving

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