Levison: Hi, we're here today with Akshay Thomas.
He's a vitreoretinal surgeon and uveitis specialist
at Tennessee Retina.
We were recently at the Vit-Buckle Society
in Miami Beach, Florida,
where he gave an excellent talk
on the surgical management of infectious uveitis.
Since these cases are less common
than our bread-and-butter vitreoretinal surgery cases,
he gave excellent recommendations
on how to approach these cases.
Akshay, thank you so much for joining us today.
Thomas: Thank you for having me.
Levison: So as a vitreoretinal surgeon,
what special considerations do you take
when you approach these surgical cases?
Thomas: Well, I think there's a number of things to consider,
especially in infectious uveitis.
Number one, just like noninfectious uveitis,
would be pre-operative inflammatory control,
and if we have the option of having the eye
under appropriate inflammatory control prior to surgery,
that's great, often not the case.
Second would be location of your trocars.
You know, so for the average vitrectomy, for example,
where we don't really care where we place our trocars,
pretty standard positioning.
But if you have a patient with Toxocara, for example,
or some sort of pars planitis
or some peripheral granuloma,
you kind of want to avoid placing trocars through those areas.
One additional special consideration in eyes
with infectious uveitis is just your surgical view.
I mean, we all know from operating on
endophthalmitis patients, you know,
the view can be very challenging.
But if you have a case where you have to repair
a retinal detachment, for example,
you need to kind of decide in the beginning
whether you're going to be going translimbal
with your cannula placement,
if you're going to be taking the lens during the case,
whether you're going to be placing iris hooks,
so a lot of pre-operative considerations prior
to actually getting to the operative room.
Levison: These are awesome recommendations
and will definitely help all the vitreoretinal surgeons
who do have to approach these cases.
What uveitis cases do you find
to be most challenging surgically?
Thomas: Yeah, I mean, I think probably the most challenging
infectious uveitis cases are in children.
One thing I've noticed,
and I'm sure others have noticed, is that if you have,
you know, an infectious macular lesion
or a posterior lesion in a child, you know,
the vitreous tends to contract very rapidly.
And so those patients can very rapidly get
a rhegmatogenous detachment
or a giant retinal tear just from that contracting vitreous.
So there are situations in which I have entered an eye
earlier than I would've anticipated, just
because you can kind
of see the contraction where things are going.
I mean, those eyes, the vitreous behaves very much like
an eye with a tractional retinal attachment
where the vitreous actually lifted in the mid-vitreous,
in the mid-peripheral retina
and then kind of contracted over the infectious lesion.
So those can be especially challenging
because you're, we're hesitant to operate on children,
but in those cases, you need
to actually get in sooner than you might for an adult.
Levison: Yeah, the young vitreous can be challenging at baseline,
so add an infection
and it can make it even more challenging.
Are there any other pearls that you have
for the ONE Network listeners today?
Thomas: The one thing I'd consider is
that if you're taking a patient with any form of uveitis,
certainly infectious uveitis to the operating room,
it's probably the time you're going to have the largest,
the opportunity to get the largest surgical sample.
So if there's any question as to the etiology
of their uveitis, definitely don't throw away that vitreous.
Send it for each and every test possible, and
before you do so, make sure you know how
to order those tests and the appropriate handling
of the specimen so that you can kind
of get the greatest diagnostic yield.
Levison: Well Akshay, these were awesome recommendations
and suggestions for us all,
and we really appreciate you taking the time to talk to us.
Thomas: Thanks again, Ashleigh.