Tips and Tricks to Boost Success With PDR Surgery

During Friday’s Retina Subspecialty Day, Maria H. Berrocal, MD, presented five key pearls for improving surgical success rates with proliferative diabetic retinopathy (PDR). The key, she noted, is limiting complications, which can be achieved with the following steps.

1. Optimize visibility. Wide-angle viewing systems are often useful, as they offer a view of the periphery, while 3D imaging can provide increased magnification, enhanced depth of focus, and an optimal view under air. In addition, chandelier lighting is useful for viewing peripheral pathology, particularly for bimanual techniques. 

2. Control intraoperative hemorrhages. Preoperatively, surgeons should consider administering VEGF inhibitors one to five days before surgery, or performing panretinal photocoagulation. Intraoperatively, controlling the patient’s blood pressure and using the smallest possible gauge instruments are important for better control of bleeding.

3. Prevent iatrogenic breaks. Berrocal recommended a “lift and shave” technique, which involves using the highest cutting rate possible with the smallest gauge instrument that the surgeon is comfortable with. Lift with aspiration to separate the tissue, and shave it away. She recommends peeling tissue with the probe, as it eliminates excessive traction compared with forceps.

4. Prevent and manage postoperative bleeding. Good wound construction and closure are key here, Dr. Berrocal noted. She recommended closing with low pressure, combing the wound, or needling the incision. Air-fluid exchange in the office also works well, as does anti-VEGF injection at the end of the case.

5. Early recognition and management of redetachment. Unfortunately, redetachment often occurs, especially when the posterior hyaloid is not completely eliminated. It is important to first determine the cause. Residual traction should be removed, particularly if there is a rhegmatogenous component. Dr. Berrocal recommended considering use of silicone oil in monocular patients.

Finally, Dr. Berrocal urged surgeons to embrace new technology. “Don’t be afraid of it, don’t stick to doing the same things you learned in fellowship.” Have a plan and be meticulous, but be adaptable and think outside the box if complications occur, she advised. “Stay calm and think rationally; your cases will go much better.” –Keng Jin Lee, PhD

Financial disclosures: Dr. Berrocal: Alcon Laboratories: C,L; Allergan: L,C; Hemera: O.

Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

Read more news from AAO 2019 and the Subspecialty Day meetings.