Heads-up Digitally Assisted Surgical Viewing with Intraoperative Optical Coherence Tomography for Myopic Schisis Repair.

PURPOSE: To describe the surgical approach with a screen-based heads-up, three-dimensional (3-D) digital viewing with intraoperative optical coherence tomography (I-OCT) for the successful repair of a myopic macular schisis (MMS) case. CASE REPORT: A 62-year-old woman with vision loss in the left eye was scheduled for pars plana vitrectomy (PPV) and MMS repair. Surgery was performed using the NGENUITYⓇ system for surgical viewing, and foveal-sparing internal limiting membrane (fs-ILM) peeling was performed without gas tamponade, after confirming the absence of iatrogenic macular hole with I-OCT. There were no intraoperative or postoperative complications. Visual acuity improved to 20/40 and the subfoveal macular thickness improved from 706 µm (preoperative) to 221 µm after seven months of follow-up. CONCLUSION: Heads-up digitally assisted viewing technology with I-OCT may be useful or preferred for patients requiring vitreoretinal surgery in the setting of MMS.

Clinical Study on the Initial Experiences of French Vitreoretinal Surgeons with Heads-up Surgery.

Purpose: To evaluate the initial experience of four experienced vitreoretinal surgeons, in France, with a three-dimensional (3-D) system, and to explore the potential advantages and disadvantages of this technology. We also report anatomical surgical outcomes of full-thickness idiopathic macular holes (MH) and primary rhegmatogenous retinal detachment (RRD), by using traditional microscopy and heads-up method. Methods: Four French retinal surgeons performed several types of ophthalmic surgeries with this new technology. To compare the 3-D system with ocular viewing, ergonomics, educational value, image sharpness, depth perception, field of view, technical feasibility, advantages and disadvantages, and expectations for the future, were assessed using a questionnaire. We also compared the same questionnaire with the answers of six Brazilian experienced vitreoretinal surgeons. For treating MHs, the surgeons performed 88 surgeries (44 with microscopy and 44 with 3-D). They performed 100 PPV for treating primary RRD (50 with ocular viewing and 50 with 3-D). The visualization method for each patient, as well as the assignment of each surgeon for a specific patient, were all randomly selected. Results: On the questionnaire, 3-D was preferred to traditional microscopy, except for technical feasibility; the type of surgery benefitting most from the 3-D was macula surgery and the least was anterior segment surgery; the most used by all is the black and white filter in patients with atrophic RPE during ILM peeling. Eighty-one (92.1%) MHs was successfully closed with one surgery and out of the 100 eyes with a primary RRD, the anatomical success after 3 months of follow-up was 91%, with no statistical significance between 3-D and ocular viewing. Conclusions: The surgeons in this study preferred 3-D to ocular viewing. Vitrectomy surgery to treat MHs and RRDs can be performed using the 3-D with the same efficiency as microscopy. Digital integration of 3-D and iOCT can be useful in some cases. With continuous refinement to improve the ability to visualize inside of the eye, this promising technology may enhance what we do as surgeons.

An experimental and clinical study on the initial experiences of Brazilian vitreoretinal surgeons with heads-up surgery.

PURPOSE: To evaluate the initial experiences of several vitreoretinal surgeons in Brazil, both experienced and beginners, with a three-dimensional (3D) system, and to report the advantages and disadvantages of this technology. We also report surgical manipulations performed using the heads-up method in porcine eyes. For full-thickness idiopathic macular holes (MHs), we analyzed the times required for pars plana vitrectomy (PPV) and internal limiting membrane (ILM) rhexis by using traditional microscopy and 3D system, and to evaluate anatomical surgical results. METHODS: During experimental vitreoretinal surgery on porcine eyes, two retinal surgeons applied the heads-up method. In clinical surgery, 14 retinal surgeons performed almost all types of vitreoretinal surgeries in association with facectomy, Ahmed glaucoma valve implant, or minimally invasive glaucoma surgery using an iStent®. The Ngenuity® 3D Visualization System was digitally integrated with intraoperative optical coherence tomography, the Verion™ Image-Guided System, and an endoscope (with a modified GoPro® camera). To compare the 3D system with traditional microscopy, ergonomics, educational value, image sharpness, depth perception, field of view, advantages and disadvantages, and technical feasibility were assessed using a questionnaire. One year later, the 14 surgeons answered the same questionnaire again, in order to assess whether they became more comfortable or not with 3D. For treating MHs, four surgeons (surgeon 1, fellows 1, 2, 3) performed the total of 40 surgeries. Each one performed 10 surgeries (5 with traditional microscopy and 5 with 3D visualization). The completion time for PPV and ILM rhexis were determined by using both methods. RESULTS: In porcine eyes, disabling the color channels allowed better visualization of the ILM, either with Brilliant Blue G (BBG), indocyanine green chorioangiography (ICG), or açai dye; transillumination through the sclera was also better without a color channel, but visualization of the peripheral vitreous was better with a blue channel. Regarding clinical experience, the questionnaire responses showed that the respondents generally favored the heads-up method compared with traditional microscopy (p < 0.05); however, despite a slightly higher average score, the 3D system was not statistically significantly preferred in terms of technical feasibility (p = 0.1814). Answering again the same questionnaire 1 year later, the 14 surgeons felt more comfortable with 3D (p < 0.05). The type of surgery benefitting most from the 3D system was peeling of the ILM or epiretinal membrane (p < 0.001), and that receiving the least benefit was anterior segment surgery (p < 0.001). In addition, surgeons did not report benefits of color channels, preferring to disable it (p < 0.001). Comparisons between the average time for full PPV and ILM rhexis by using the two methods were non-significant, neither in each individual case of 3D surgery for each surgeon. Surgeon 1 had always been faster than his fellows. Thirty-six (90%) full-thickness MHs were successfully closed with one surgery. CONCLUSIONS: The 3D system was preferred to traditional microscopy. The 3D system was especially helpful for certain specific types of surgeries and served as an educational tool, having reduced illumination and allowing precise focusing. Concerning MH surgery, heads-up method was similar to traditional microscopy regarding length of time and anatomical surgical results. As a digital platform, it will be amenable to constant upgrades and may ultimately become the new standard for ophthalmic surgery.

Learning curve of three-dimensional heads-up vitreoretinal surgery for treating macular holes: a prospective study.

PURPOSES: To compare surgeons' opinions regarding idiopathic full-thickness macular hole (MH) surgery by using traditional microscopy and three-dimensional (3-D) visualization system. To analyze the required time for pars plana vitrectomy (PPV) and for internal limiting membrane (ILM) rhexis by using both visualization methods. To evaluate anatomical surgical results. METHODS: Four surgeons (surgeon 1, fellows 1, 2, 3) performed the total of 40 surgeries for treating MHs. Each one performed 10 surgeries (5 with traditional microscopy and 5 with 3-D visualization). The completion time for PPV and ILM rhexis was determined by using both methods. Ergonomics, educational value, image sharpness, depth perception, field of view and technical skills were analyzed through answering a questionnaire. RESULTS: Forty patients were included in the study. The MH size for surgeon 1, fellows 1, 2 and 3 groups, individually, ranged from 237 to 602 µm; 228 to 590 µm, 271 to 611 µm and 289 to 600 µm, respectively. In the 3-D and in the traditional microscopy subgroups (which includes all 4 physicians on the use of one or the other method), the MH size ranged from 228 to 602 µm and 237 to 611 µm, respectively. Comparisons between the average time for full PPV and ILM rhexis by using the two methods were non-significant, neither in each individual case of 3-D surgery for each surgeon. Surgeon 1 had always been faster than his fellows. Depth perception was rated as similar for both methods. Field of view and educational values were rated as superior when using the 3-D system. Image resolution and ergonomics were rated as superior when using traditional microscopy. Technical skills strongly tended toward 'superiority' when using traditional microscopy. Thirty-six (90%) full-thickness MHs were successfully closed with one surgery. CONCLUSION: The 3-D system for MH surgery had a short learning curve and was a refined educational tool, when used with reduced illumination and precise focus. Concerning MH surgery, heads-up method was similar to traditional microscopy regarding length of time and anatomical surgical results. Heads-up surgery may become a new pattern for ophthalmic surgery as ongoing improvements are applied.

Choroidal thickness using EDI-OCT in adult-onset vitelliform macular dystrophy.

BACKGROUND: To compare choroidal thickness in patients with adult-onset foveomacular vitelliform dystrophy (AOFVD) with healthy subjects and to correlate choroidal thickness with age, gender and spherical equivalent. METHODS: A prospective, observational study of 37 eyes (15 eyes in AOFVD group and 22 eyes in control group) was conducted. Images were acquired by enhanced depth imaging optical coherence tomography (EDI-OCT). Choroidal thickness measurements were performed in the subfoveal region and at 500, 1000 and 1500 µm intervals from the foveal center to nasal and to temporal regions for subsequent averaging of values. RESULTS: The AOFVD group consisted of four male eyes (28.6 %) and 10 female eyes (71.4 %); age was 33-62 years; spherical equivalent (SE) ranged from -1.50 to 1.50 spherical diopters (SD); mean subfoveal thickness was 325.6 µm, ranging from 186 to 420 µm; and the average of thicknesses was 309.4 µm, ranging from 188 to 413 µm. The control group consisted of 12 male eyes (54.5 %) and 10 female eyes (45.5 %); age was 27-62 years; SE ranged from -2.50 to 0.50 SD; subfoveal thickness was 294.8 µm, ranging from 213 to 481 µm; and the average of thicknesses was 279.4 µm, ranging from 201 to 458 µm. CONCLUSIONS: The AOFVD group and the control group showed similar choroidal thickness by correcting for age, SE and gender. Not yet known, completely, which biochemical and vascular flow alterations of the choroid, and which functional RPE changes may play a role in the pathogenesis of this disease. EDI-OCT, incorporated in some SD-OCT devices, allows higher quality assessment of the choroid. In this article, choroidal thickness of patients with AOFVD, a rare disease with a not fully understood pathogenesis, was assessed.

Tratamento endovascular de angiomiolipoma renal por embolização arterial seletiva / Endovascular treatment of renal angiomiolipoma by selective arterial embolization

Relata-se um caso de um paciente com queixa principal de dor lombar à esquerda, portador de angiomiolipomas renais (AMLRs) bilaterais, com a lesão mais volumosa de 6,2 cm em seu maior diâmetro, submetido a tratamento endovascular por embolização arterial superseletiva com microesferas. Os AMLRs são tumores benignos raros. A maioria é esporádica, enquanto uma minoria está associada à Esclerose Tuberosa Complexa (ETC). Os AMLRs maiores do que 4 cm devem ser tratados devido ao maior risco de complicações, principalmente hemorrágicas. A embolização arterial seletiva (EAS) é um tratamento efetivo e seguro para os AMLRs.

We report a case of a patient with a major complaint of left lumbar pain, diagnosed with bilateral renal angiomyolipomas (AMLRs), with the most voluminous lesion of 6.2 cm in its largest diameter, underwent endovascular superselective arterial embolization with microspheres. The AMLRs are rare benign tumors. Most are sporadic, while a minority is associated with Tuberous Sclerosis Complex (ETC). The AMLRs larger than 4 cm must be treated due to higher risk of complications, especially hemorrhagic. A selective arterial embolization (EAS) is an effective and safe treatment for AMLRs.

Endovascular treatment of giant splenic artery aneurysm.

Introduction. Visceral artery aneurysms are uncommon. Among them, splenic artery is the most common (46-60%). Most splenic artery aneurysms are asymptomatic and diagnosed incidentally, but its rupture, potentially fatal, occurs in up to 8% of cases. Presentation of Case. A female patient, 64 years old, diagnosed with a giant aneurysm of the splenic artery (approximately 6.5 cm in diameter) was successfully submitted to endovascular treatment by stent graft implantation. Discussion. Symptomatic aneurysms and those larger than 2 cm represent some of the main indications for intervention. The treatment may be by laparotomy, laparoscopy, or endovascular techniques. Among the various endovascular methods discussed in this paper, there is stent graft implantation, a method still few reported in the literature. Conclusion. Although some authors still consider the endovascular approach as an exception to the treatment of SAA, in major specialized centers these techniques have been consolidated as the preferred choice, reserving the surgical approach in cases where this cannot be used. For being a less aggressive approach, it offers an opportunity of treatment to patients considered "high risk" for surgical treatment by laparotomy/laparoscopy.