Retina specialists are increasingly seeing patients in the operating room who require complex procedures. Retinal Physician convened a roundtable of surgeons experienced in complex surgical cases to present and discuss approaches to a series of difficult cases.

Dr. Khanani: This was a difficult case to see in private practice. The patient was a 45-year-old female with a history of Behcet disease. She’d had cataract surgery, tubes in both eyes, and multiple Retisert implants (Bausch + Lomb). She was treated at a university hospital in the past and had a vitrectomy for a posteriorly dislocated Retisert. I had been giving injections because she’d had so many surgeries in the past. We were holding off on doing a Retisert, and her disease was controlled. Yutiq (Eyepoint Pharmaceuticals) in the other eye was not successful, so she’d been receiving Ozurdex (Allergan). She presented with a dislocated lens, and I was worried about the Ozurdex implant migrating to the anterior chamber, so we stopped using Ozurdex. I decided to place a Retisert implant inferiortemporally and not to remove the old Retisert.

I made my incision inferiotemporally, in the same manner as is done for a Port Delivery System (Genentech), and placed the Retisert there. I closed that wound successfully. Then, because the conjunctiva was very scarred, I considered an anterior-chamber intraocular lens (ACIOL) instead of a sutured IOL. I went to the back of the eye and noted only a small amount of bleeding from the choroidal incision for Retisert, and prior laser in the periphery.

After removing the dislocated lens and placing the ACIOL and suturing the cornea, I visualized the retina to make sure there were no tears. We noticed a dislocated old Retisert implant. My colleagues had recommended removing the old Retisert and placing a new one, but I hesitated because that area of the eye didn’t seem healthy enough. So now the challenge is a dislocated Retisert. We have an ACIOL, the anterior chamber is closed nicely, but I had no option but to make a sclerotomy and take the Retisert out, and it was not easy.

We made a large sclerotomy and, due to fluid effluxing from the wound, it was difficult to grab the Retisert, but we were able to remove it (Figure 1). After the procedure, the patient had corneal edema and the eye took several weeks to heal (Figure 2).

Dr. Murray: Our European colleagues have iris clip and circlage lenses that are amazing and would be ideal for these complex cases. We still don’t have FDA approval. I think placing an ACIOL was not unreasonable. Sometimes in these very complex cases I’ve actually pushed the IOL up and captured the IOL optic in the AC, left the haptics behind, and then never dilated the patient again.

As for the indwelling implant, there have been some discussions about displacement, so in retrospect, you might have explanted it when it was still in place and then closed. If it had dislocated earlier, before you put the ACIOL in, you could have removed it through the AC wound. But the timing here was really complex, and all things considered, you did an amazing job. In private practice you have to really be comfortable doing complex cases.

Dr. Kaiser: In general, we place Retisert at least 2 or 3 times in the same spot before moving to a new position, unless the patient has some sort of melt. You can use a free flap to cover it because you absolutely need to cover it with the conjunctiva. I dealt with dislocations when I participated in the Retisert studies. What I did was first try to turn off the infusion, get very close, away from the macula, and grab it. If that doesn’t work, there’s no harm in closing the wound and going through it with your instrument. Now you have better fluidics, and you can grab it much easier. If you still have one, a 20-gauge instrument works best for this.

Dr. Weng: Has anyone tried to lift a dislocated Retisert using the vitrector probe on vacuum-only? I like the nontraumatic technique of aspirating with the cutter, and then passing the object hand-to-hand to forceps rather than directly grasping the object with forceps, which aren’t designed to pick up things like the Retisert implant. I would have done what Dr. Murray suggested: take advantage of the ACIOL scleral tunnel by inserting the forceps through that wound, but I would first use the vitrector probe to elevate the implant to the level of the iris plane. That way, you’re not switching instruments as much.

Dr. Vajzovic: It also can be helpful to put in a chandelier to free up one hand, then use a soft-tip cannula to aspirate the foreign body up, then trade off foreign body to forceps (anterior segment forceps thru paracentesis wound or posterior segment forceps thru pars plana sclerotomy) to bring it to the anterior segment. I find that the soft tip works better, because the suction is right at a tip as opposed to on the side with the cutter, but both can work.

Dr. Murray: I agree. I’ve been places in Europe where they don’t do a case without a chandelier in the eye. I think we tend to be a lot more frugal or concerned about the use of a chandelier, but a chandelier is an excellent suggestion for complex surgery. That chandelier may be the difference between a great outcome and a questionable one. Don’t feel like you have to use one, but know that that option is uniquely available. RP