1. Video conference
Surgical treatment
of PDR with TRD
R3 정현진/ Pf.이원기

2. Case (49/M) C/C Decreased VA (OU) for several months P/I P/Hx.
PDR c TRD, vit Hm (OU)로 원주기독병원에서 전신마취하 수술
권유받았으나 본원에서 치료 원해 내원.
P/Hx.
DM for 15yrs po medication
Intravit . Avastin inj.(OS) , PRP Hx(-)
Axl OS 22.67

3. Fd-photo(OU) VA OD F/C 30cm(N-C) / OS 0.04 (N-C) IOP 10/10 mmHg
Ant. Segments NVI(-/-)
OD nl. Optic disc c tractional memb c TRD at 12~9 o/c c vit Hm
OS nl. Optic disc c tractional membrane c TRD 4~2 o/c vit Hm.
Fds OD TRD c tractional memb. NVE (+) invisible disc & macula OS blurry disc margin c TRD c Tractionl memb. dot. & blot HM. at 4Q, NVE(+) vit. HM. at inf.

4. Impression Plan PDR c TRD(OU) 수술전일 Intravit. Avastin injection (OS)
Why ? 좌안 수술 먼저
수술전일 Intravit. Avastin injection (OS)
ppV(OS) under local Anesthesia

5. OP procedure ( )
ppV+ppL+TM peeling+Endodiathermy+FAE+int. SRFD+PFCL inj.+Endolaser+PFCL removal+SO inj.(OS) by Pf.이원기

6. POD#1 VA OS HM (N-C) IOP AP OS 24mmHg
Fds OS glistering appearance due to silicone oil,
flat posterior pole
endolaser scar (+)
Plan : prone position
O-GAFx 4, O-LON x 4, O-1AT x 2(OS)
Discharged at POD #2

7. POD #1wk
VA OS 0.04
IOP OS 7 mmHg
Before ppV POD # 1week
1주일 후 f/u예정

8. Review :
Surgical techniques for
proliferative diabetic retinopathy

9. Pathophysiology and Pathoanatomy
Retinal ischemia
→ Production of angiogenic factors (IGF, VEGF)
→ ocular neovascularization.
Neovascular tissue proliferates in the potential space between the
retina and the posterior hyaloid face.
Vessels continue to proliferate,
with the fibrous component,
causing the vitreous to exert traction
on the friable neovascular tissue and retina
fibrovascular proliferative epicenters

10. ppV for Diabetic tractional detachment
Objectives
(1) Relieve vitreoretinal traction by removal of the vitreous gel and excision of the post. hyaloid and epiretinal fibrovascular membrane
(2) Retinal reattachment using intraocular tamponade
(3) Prevention of reproliferative NV’s by laser photocoagulation
Numerous studies have documented benefit of surgical treatment
; 59%~71% : VA of 5/200 or better
; 66%~88% : macular reattachement

11. Surgical techniques for PDR
Delamination.
Aim : To cut rather than avulse the neovascular pegs.
Avulsion of vessels would lead to perioperative hemorrhage
from the sidewall of a retinal vessel, which may be difficult to control.
Finding the correct plane between
the posterior hyaloid and the retina near,
to avoid iatrogenic tears.
Epiretinal dissection is begun posteriorly using bimanual techniques and multifunctional instruments. Illustrated here is a membrane being grasped by microforceps and stripped by a fiberoptic pick (arrow). B. Once the edge of a membrane is identified, it is lifted and the illuminated pick is swept (arrows) along the retinal surface to strip the membrane.

12. Surgical techniques Segmentation.
Vertical cutting of epiretinal membranes into small segments
Accomplished with vertical scissors or a cutter.
Segmentation is used to release circumferential traction
Useful when delamination is difficult by mobile retina in the
presence of a retinal break.
Disadvantage : residual islands of fibrovascular tissue may
encourage reproliferation and recurrent bleeding.
Epiretinal dissection is begun posteriorly using bimanual techniques and multifunctional instruments. Illustrated here is a membrane being grasped by microforceps and stripped by a fiberoptic pick (arrow). B. Once the edge of a membrane is identified, it is lifted and the illuminated pick is swept (arrows) along the retinal surface to strip the membrane.

13. Surgical techniques for PDR
En-bloc delamination
Preferable to segmentation, because it can completely remove all
the fibrovascular tissue
A small window in the partially detached posterior hyaloid is made
→ horizontal scissors is introduced into the retrohyaloid space.
When the membranes have been
separated from the retina
the remaining posterior hyaloid
complex can be removed with cutter.
Epiretinal dissection is begun posteriorly using bimanual techniques and multifunctional instruments. Illustrated here is a membrane being grasped by microforceps and stripped by a fiberoptic pick (arrow). B. Once the edge of a membrane is identified, it is lifted and the illuminated pick is swept (arrows) along the retinal surface to strip the membrane.

14. Surgical techniques for PDR
Laser treatment.
To decrease the neovascular drive and minimize recurrent or delayed hemorrhage.
A 360-degree search of the entire retina is made before the end of the surgery, in order to identify any pre-existing or iatrogenic breaks (e.g. posterior tears or entry site breaks).
If found they must be treated with either laser photocoagulation or cryotherapy in conjunction with a tamponading agent (e.g. air, expanding gas or silicone oil).
Epiretinal dissection is begun posteriorly using bimanual techniques and multifunctional instruments. Illustrated here is a membrane being grasped by microforceps and stripped by a fiberoptic pick (arrow). B. Once the edge of a membrane is identified, it is lifted and the illuminated pick is swept (arrows) along the retinal surface to strip the membrane.

15. 감사합니다
References
Aylward GW, Sullivan P, Vote B. The Video Atlas of Eye Surgery. Vitreoretinal-Basic Techniques. Eye Movies Ltd., 2005.
Kanski JJ, Gregor ZJ. Retinal Detachment: A Colour Manual of Diagnosis and Treatment. Butterworth-Heinemann, 1994, p. 161.