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Surgical Video Cases

Welcome to BEAVRS online VR surgical course.

This platform is aimed at vitreoretinal fellows but consultants may also find it refreshing to learn from other colleagues.

The course is designed to be studied in your in your own time and can be completed more than once. It will consist of sections each containing 3-4 lectures 15-20 min each. Each course will have objectives and with time We will add self-assessment quizes. We hope to add to the body of lectures yearly and aim to build up a library of wide range of topics covering most of everyday vitreoretinal practice. We are very grateful to our distinguished speakers who have generously agreed to contribute to this course & we hope you will enjoy it.

This course is evolving so please send any suggestions/ requests to shohista.saidkasimova@nnuh.nhs.uk

alider graphic 1Free papers

alider graphic 1Covid session

alider graphic 1VR fellows video competition

alider graphic 1Challenging cases session 4 please

01:10:12 David Steel: re the bilateral RD risk

01:12:51 David Steel: do you know if the fellow eyes of the pseudophakic eyes were pseudophakic themselves when RD occurred ? Phakic eyes of pseudophakic eyes also seem to have a higher risk based on Danish data.

01:13:49 David Yorston: The proportion of mac-on and mac-off RD was identical in 2009 and 2019.

01:20:08 Alistair Laidlaw: Does anyone have the inside track on the best device to image the AF ghost vessels?

01:21:02 Alistair Laidlaw: Roxanne: what device did the illustration use please?

01:26:20 Roxane Hillier: @Namita 40% of patients that received air had 360 laser, why was this?

01:28:03 Richard Haynes: Re Air v Gas: did the two groups have comparable RDs? (eg. Were gas cases more complex with inferior breaks?)

01:35:49 Richard Haynes: Re litigation: where did refractive surgery come in the table of risk by specialty?

01:36:15 Tim Jackson: is it possible to only remove the gas you need from the canister- what happens to that left behind if buried or incinerated?

01:39:47 Roxane Hillier: Re TPA AND GAS: Why not do an AC tap, to allow injection of a larger volume of a short acting gas e.g. SF6 and avoid need for Diamox?

01:41:14 Richard Haynes: Answer to Roxanne – to avoid using SF6 – eco warriors unite!

01:41:28 David Steel: were the expansile gas fails related to posturing inability or big haemorrhages etc? average age ~85 typically

01:42:47 David Steel: unless you use multi-use cannisters … many units do

01:44:48 Richard Haynes: Re macular schisms – how did you determine “ILM detachment” – (how do you know it’s just the ILM and not NFL etc.?)

01:50:40 David Steel: the fact that the success of expansile gas works in patients who probably do not posture suggests that gravity with TPA is a big factor in these smaller haemorrhages

01:54:47 Alistair Laidlaw: It’s also good not to have any high concentration cefuroxime in theatre that can accidentally get into the posterior segment despite going into the sub conj space

01:55:27 Richard Haynes:To Tom – do you use Aprokam or mix up your own conc?

01:56:33 David Steel: duration and refraction needs to be taken into account

02:04:37 David Steel: when does the ILM flap question get added to the BEAVRS database David ?

02:05:14 David Steel: It was certainly a great application Assad

02:08:46 David Steel: the problem re health economics I think was that it was a rfPB and therefore had 350 cap and difficult to fit HE in to budget

02:09:28 David Steel: BEAVRS found an approx. 500 threshold when success rate drops

02:10:00 David Yorston: This represents approx. 25% of FTMH in the BEAVRS database

02:11:32 David Yorston: Agreed. The Australian database has much smaller holes, so it is possible.

02:15:09 David Steel: agree but size is not just time – it’s also ethnicity related

02:17:40 Gerry McGowan: Australian cases tend to be operated on in private sector, NHS wait a lot longer than UK for MH surgery

02:26:18 William Luke Membrey: Main issue locally was loss of all Anaesthetists to ITU. We therefore reverted to LA with surgeon administered oral sedatives/anxiolytics for patients who would not tolerate LA only.

02:26:40 David Steel: why haven’t we seen the big increase in numbers we expected to see post lockdown? where are they!

02:28:21 Gerry McGowan: Is that your standard day 1 post op fundal pic in the background Aman?

02:28:22 Noemi Lois: Agree with David, this is the big mystery…. where are the patients?

02:28:33 Roxane Hillier: I must admit, had a bit of a surge back in August… mainly macula off detachments that have been sitting about

02:29:11 Cordelia McKechnie: Yes so did we and also lots of severe TRDs/RRDs in diabetics. Anyone had problems with their eye theatres becoming ‘green zones’ so that emergency surgery is unable to take place there and how have they resolved that?

02:29:21 Edward Herbert: Is watching boxsets protective for RD? Moving is dangerous

02:29:28 Noemi Lois: But to the levels expected for all the surgery not done during lockdown, Roxanne?

02:30:15 Imran Khan: Had a large amount of bad diabetic eye disease and were doing more of these than RDs a few months back.

02:30:40 Roxane Hillier: Agree, although I did have my first 15 detachment week in August

02:31:24 Noemi Lois: We will see worse diabetic TRDs as people with diabetes are not been monitored, unfortunately, as normal… diabetologists are very worried about this already…

02:33:11 Rahila Zakir: We delivered emergency surgery throughout lockdown at Western Eye Hospital. When we went to a ‘covid-green’ pathway we put covid managed (no test result) urgents at the end of the list. Has been working well, but there was a lot of work done assessing risk prior to getting approval for this. We had anaesthetic cover and were able to do GAs throughout where indicated

02:36:29 Edward Herbert: We had swabs fast tracked within 2 hours – never significantly delayed surgery

02:36:42 Rumana Hussein: Swabs are the bane of our life. Our Mac ons now wait 24hours with an urgent swab, we only use a red theatre if they are urgent and swab positive

02:37:14 Cordelia McKechnie: Also need the kit in these general theatres

02:37:53 Roxane Hillier: If Aman leans back any further, he’ll be in the sub-retinal space

02:37:54 Mark Costen: Main issue in Hull was the redeployment of theatre staff, this is looking quite possible again

02:37:57 Sami Habal: I believe that if swabs results could take only 20 mins in Heathrow airport then it we should be able to do it at NHS Hospitals!

02:38:45 Mandeep Bindra: has anyone actually had to cancel surgery because of a positive swab? we’ve done over 2000 swabs on cataract and VR patients (who pass our screening questionnaire) and have had zero positive results

02:39:03 Aman Chandra: swab results shouldn’t delay anything. Negative result doesn’t necessarily mean no sars-cov-2. So, we don’t wait for results for emergency; just get on with it.

02:39:15 Gerry McGowan: likewise

02:39:22 Kirti M Jasani: Yes, we have had a few cancellations on our elective cases due to +ve swabs

02:39:30 Alexander Brent: We do mac ons as ‘red’ cases if no swab. Interestingly I have done 2 cases with no Covid symptoms who turned out to be positive. No one involved came down with anything

02:39:33 Aman Chandra: Treat all as if positive.

02:39:59 Mustafa Kadhim: Universal Precautions type approach

02:40:06 Tim Jackson: are people taking patients’ masks off for surgery, given concern from injection clinics that the mask may vent patient’s breath onto eye and increase risk of endophthalmitis

02:40:24 Mandeep Bindra: yes – mask off

02:40:51 William Luke Membrey: Agreed, masks off as drape is applied

02:45:57 William Luke Membrey: Kirti, we have done something similar but using local opticians to do VA and OCT which are sent in and uploaded to EPR prior to telephone clinic.

02:46:22 Cordelia McKechnie: yes masks off – can’t clean the eye properly if it is there!

02:46:29 Kirti M Jasani: Hi William .. thats great … is that for FU or new patients?

02:46:44 David Yorston: Q for Kirti – should the virtual clinic be in hospital or optometrist in the community?

2:47:05 Rahila Zakir: Does the Topcon OCT also take a macular photo? If so, do you feel this is an important factor in the success of virtual VR clinics? The Optos gives widefield but low mag…

02:47:42 Kirti M Jasani: The eye hospital has an offsite centre in a DGH where regular clinics (virtual and F2F) are run

02:48:22 William Luke Membrey: Kirti, that is for both. New patients who are then listed get seen in VR clinic at same time as preassessment so saving a visit to hospital.

02:48:22 Steve Winder: I thought the virus is only present in eyes with conjunctivitis. It has not been isolated from the conjunctiva of asymptomatic patients

02:48:32 Steve Charles: Topcon OCT does take ok mac photo, Optos gives wide field so most of retina covered

02:48:46 Kirti M Jasani: We need to have specialist ophthalmic imaging technicians so i suppose if the community centre can have them than it will be fine

02:48:49 Harry Bennett: yes, masks off patient just before draping. Surgeons and scrub staff in Edinburgh haven’t used FFP3 masks for VR or phaco surgery since May 23rd when Scottish Guidelines came out

02:49:30 Rahila Zakir: @Steve, if we don’t have an OCT that takes a good macular photo, would this compromise the info available for virtual? We have Heidelberg so no macular photo

02:49:53 William Luke Membrey: Agree with Steve Winder, aerosol does not mean increased risk of COVID transmission

02:49:57 Tim Jackson: Not sure if we can find a cut-off for safety eg how many cigarettes are dangerous?

02:49:57 Steve Charles: Is there a problem with access to rapid swabs to deal with urgent cases on the panel?

02:50:15 Kirti M Jasani: Hi Edward…this patient would have normally had an OCT, IOP, VA at the least even if they came to the hospital

02:50:18 Edward Herbert: Is greatest risk from breathing rather than surgery

02:50:34 Tim Jackson: not a single positive

02:51:48 Steve Charles: In Manchester….Quite a few positives, most recently routine ERM last week

02:52:02 Roxane Hillier: We cannot easily access rapid swabs, and some of our older/more cautious anaesthetists insist on a negative swab before proceeding – it can be a headache!

02:52:05 Alistair Laidlaw: What was the device on the Manchester presentation for anterior segment imaging

02:52:24 Mark Costen: Part of the problem with community imaging is the IT infrastructure for optoms

02:52:57 Kam Balaggan: Who pays for the community OCT/optos scans if virtual VR clinic imaging capture done in the community?

02:52:59 Andrew Davies: Our virtual clinics have been in hospital and although not ideal does give the patient a very quick turnaround as all predictable and regimented schedule, unlike any VR clinic

02:53:32 Steve Winder: Our offsite is a local arena which is used by us and phlebotomy

02:53:36 George Morphis: What sort of PPE surgeons wear when operating pts with unknown COVID status? simple surgical mask or FFP2/3?

02:53:46 Roxane Hillier: We have had a few positives. On one occasion AFTER a patient went home. The whole bay of patients then had to self-isolate for 14 days (!)

02:54:22 Harry Bennett: offsite=optom OCT in Scotland, then secure SCI gateway referral, listing for surgery after telephone consult, one visit to hospital for surgery

02:55:48 Cordelia McKechnie: Totally agree with David. Patient’s expectations need to be addressed before the ‘virtual clinic’

02:57:55 Ibrahim Masri: At Sunderland, I am not aware of any patients who tested positive coming to the VR Service. For urgent cases, we swab the patient but proceed with surgery with full PPE and they are treated as presumed positive. The patient is placed at the end of the operating list.

02:58:25 Ibrahim Masri: Saying that, patients are rarely operated on the same day. So, Most cases get done the following day with many of them have their results back

02:58:45 Rahila Zakir: For our unit and confirmed COVID positive cases were referred to Royal Free if surgery was urgent

02:59:51 Noemi Lois: we have focus group work showing that patients like real clinics much more than virtual clinics (this was work on diabetic retinopathy – we have just published it in Ophthalmology and we will be publishing an article specifically on this soon showing all the focus group work). But, as Louisa mentioned, we cannot cope with the demand so this results in delays which can be much more dangerous for patients. We learnt from our focus group work that there are ways to make virtual clinics more acceptable to patients and I think this is what we should all pursue.

03:00:03 Mustafa Kadhim: In Newcastle, all GAs swabbed, everyone else 2 weeks of self isolation (!) then date given. After VR and cataract surgery was deemed ‘non-AGP’, PPE has varied between full FFP3 masks and not.

03:00:11 Edward Herbert: Is this the ‘Oxford’ vaccine? Will we have safety/efficacy data by 1st Dec?

03:00:45 William Luke Membrey: Not the Oxford Vaccine

03:00:59 Kam Balaggan: We have a 1 hour (almost) accelerated swab test for emergency patients at Wolverhampton

03:04:47 Harry Bennett: to answer an earlier question we only swab GAs ( as this is the only part of the procedure that is AGP producing ) . So all other patients ( ie >95%) are unknown Covid status ( beyond the usual Hx taking , temp check, contact questions) and for these we use normal fluid resistant masks in theatre. Only the anaesthetist and ODP use FFP3 mask and gown for the induction of GA in anaesthetic room. Everyone in the theatre itself use normal mask etc

03:06:05 Aman Chandra: Does this glycoprotein generate all types of immunity?

03:06:42 Ibrahim Masri: The decision at Sunderland was to swab everyone coming to our main theatre suit regardless of the nature of their procedure (even minor lid surgery) because they share the same pathway as ward patients. But our cataract treatment centre patients don’t get swabbed now because they don’t hit the ward (if the cataract surgeon has done their job properly that is) 🙂

03:10:21 Noemi Lois: Now, if people can get COVID19 twice, and there is clear evidence now that this happens, could this be happening even if people get vaccinated? Or will immunity induced by a vaccine be more robust that the natural immunity induced by the virus itself?

03:11:51 Cordelia McKechnie: Which vaccine would you have? That is a question for David!

03:12:58 Edward Herbert: The mutations that have already been seen – do they change the spike protein? Coronavirus mutations, Will we get enough data by Dec 1st if frontline staff due

03:16:15 Roxane Hillier: Dr Baxter: Do you suggest we await later iterations of the vaccine?

03:20:15 Aman Chandra: the one coming for NHS staff; should we have it?

03:22:05 Mustafa Kadhim: VRVC in Newcastle: VA/IOP (tonopen)/pheny/Mac OCT) Heidelberg/OPTOS 5 views (for pilot), 2 questions: vision better? & eye comfortable? Nurses add comments. Consultant phone call afterwards + letter. Patients happy overall. Some say it’s strange not having to wait for x hours to see doctors. EPR: Medisoft

03:31:16 Andrew Davies: Hi Mustafa, similar setup for me in Preston. Phone call afterwards and all patients seem very happy with this. No waiting!

03:33:50 Kirti M Jasani: Thanks Andy and Mustafa for your comments. Glad to see it run in Preston and Newcastle and that patients seem to like it!

03:34:09 Rahila Zakir: @Optos – we have an Optos, wpiud really valuse some more guiance on image manipulation to get the best out of it – @Western Eye, London; also tips to improve superior and inferior views, and better macular images with a view to supporting VR virtual

03:38:28 Mustafa Kadhim: Hello Rahila – I rely mainly on the OCT for macula assessment. OPTOS when dilated is great for all views. The senior photographers are in charge of the imaging – so always spot on.

03:39:59 Rahila Zakir: @Mustafa – thanks, in addition to OCT macula I think quality macular photo is also helpful, although we may just rely on OCT; Thanks for the tip of Optos after dilation

03:40:24 Kirti M Jasani: Hi Rahila … would recommend pupillary dilatation to aid inferior and superior views. Also use of a cotton bud to keep eyelids open have been shown to increase depth of capture.

03:45:20 Noemi Lois: where was your break? Could you not have drained through it rather than doing a new retinotomy?

03:45:58 Mustafa Kadhim: ?reason for inferior retinotomy

03:48:19 Assad Jalil: Foscarnet is now first line treatment for ARN anyways. Oral antivirals are adjunctive. So, in theory it treats ARN better and presumably would reduce RD

03:51:35 Roxane Hillier: I am surprised you tries AFX a second time, without relieving some traction…sub-retinal air passage means the retina is too short

03:52:35 Rumana Hussein: Do you think the oil went sub retinal intraoperatively the first time?

03:52:59 David Yorston: Agree with Roxanne. That is the lesson of this video.

03:53:30 Rahila Zakir: Agree with Roxanne – when things go under the retina it is because there is traction/shortening

03:54:36 Edward Herbert: We don’t know what would have happened with a primary retinectomy- could have been a shrivelled heap. Perhaps this approach gave a better final outcome.

03:54:41 Kaykhosrov Manuchehri: Interesting case Fatemeh, Thank you. I think that an inferior retinectomy of greater than 200 degrees would have helped during the first surgery

03:57:02 Roxane Hillier: If the edge of the break was enough to break the surface tension of the gas, oil was bound to follow. But this is the drama we all expect from the Fellows’ video competition, so well done 🙂

04:00:18 Richard Haynes: Great music editing! How did you get the oil out from under the retina, this can be tricky..?

04:01:46 David Steel: Did you try steroids ? – interesting series form US on benefits of steroids in UES

04:02:06 Assad Jalil: not in a nanophthalmic eye

04:02:13 Imran Khan: Are our glaucoma colleagues better placed to do these procedures?

04:04:04 Assad Jalil: It was done inferiorly because the fluid was mostly inferior. When it scarred up we went superior

04:10:32 Edward Lee: great to see those structures but in vivo with a bit of red about I wonder how easy to go through the space without damaging nerves and vortex veins

04:13:00 Teresa Sandinha: great Jared and Shohista. What do you think the role of endoscopy might be in suprachoroidal buckles? should we be thinking of using endoscopy more often?

04:13:09 Kam Balaggan: Several recent reports of choroidal haem with suprachoroidal buckling

04:17:31 Imran Akram: What was the oil type used in primary surgery?

04:17:56 Roxane Hillier: Has anyone tried low viscosity SiO (5mPas) for this? It worked a treat, but seemingly unavailable now

04:18:21 Kam Balaggan: Conor. I don’t see this anymore ever since doing 3-4 FAX with ALL ROSOs (even phaco/Roso, aphakics etc. Have used the washout substance on several cases referred from elsewhere where the oil was left in too long and emulsification occurred. Variable oil clearance and its very expensive (approx £240) per vial. Whilst simple ROSO (without PPV) is easy and quick, this should be discouraged as patients do experience silicone oil bubble floaters and possibly and increased rate of chronic glaucoma

04:18:24 Andrew Davies: How many times were FAX performed during the first two cases?

04:18:56 Harry Bennett: agree with above, multiple FAX is the way to go

04:19:34 David Steel: Revealing patient comment – I think we really underestimate the effect of droplets – re air fluid recent papers showing this doesn’t work as well as believed!

04:19:59 Teresa Sandinha: D Wong showed in the past that multiple FAXs end up in more residual droplets of oil

04:20:04 Assad Jalil: FAX doesn’t remove it completely if marked emulsification

04:20:10 Rahila Zakir: Davis Wong presented some data about the effects of FAx on residual oil (can’t remember details but advised against). I still use FAX routinely

04:20:26 Assad Jalil: FAX does reduce the droplets though. Not convinced by the data from David Wong

04:21:20 Teresa Sandinha: different FAxs compress the bubbles of oil rather than helping the removal

04:21:39 Tom Williamson: used to use F6H8 in the same way. now do FAX and not noticed a difference

04:21:48 Kam Balaggan: I just can’t see how that is the case. When doing FAxs you can directly see the aspiration of the “oil slick” on the fluid/air interface. Mirrors what I see post op compared with numerous cases from before we started doing FAxs and full PPV for ROSO

04:22:04 Assad Jalil: Exactly. FAX does help and we see it clinically

04:22:52 Roxane Hillier: David Wong felt that the most harmful micro-droplets would get plastered to the retina with recurrent AFX, and thereby increase the risk of retinal toxicity…. But, agree that recurrent AFX certainly reduces the gross retention of visible droplets.

04:23:19 Harry Bennett: I agree Kam and Tom. Have to be patient to get it all out. It’s not a quick registrar procedure 🙂

04:24:54 Mustafa Kadhim: On the Bond theme: Shaken, not stirred.

04:24:54 Kam Balaggan: Important to shake the eye quite a lot whilst doing the FAXs to encourage dislodging of trapped oil in the VR and zonules.

04:25:02 Roxane Hillier: …but now unavailable

04:25:20 Kam Balaggan: It IS available via Daybreak medical

04:25:28 Mustafa Kadhim: Shake, Fax, Shake and repeat.

04:25:32 Roxane Hillier: Ahhh… it works a charm

04:25:33 David Steel: It’s the lipophilicity of the retina that’s the problem – air fluid doesn’t overcome that – so the non-vitreous cavity oil stays in place

04:26:18 Harry Bennett: yes agree, I do shaking too .. displaces the anteriorly trapped oil in VB …gently though lol

04:26:36 Kam Balaggan: David that may be the case but the overall amount of oil in the eye is most certainly significantly less with the additional FAxs. Agree no perfect method to extract all the oil that would otherwise never be fully removed

04:29:26 Mandeep Bindra: I thought Aflibercept and Tpa can’t be used together?

04:33:29 Tim Jackson: not an issue as the tpa is subretinal and works very quickly, whereas the aflibercept goes in at end and even if it did get slightly reduced efficacy that is only one dose (as patient get aflibercept regular thereafter)

04:34:08 Aman Chandra: How is Tim talking and answering? Or is this recorded? Very skilled!

04:34:24 Alistair Laidlaw: Tim, how long does it take the TPA to lyse a clot of this sort of size?

04:34:50 Timothy Cochrane: are you including predominantly sub-RPE haemorrhage at macula?

04:34:56 Aman Chandra: remind us the level of myopia? Refractive or axial length?

04:35:00 Tim Jackson: tpa works seconds (mr bond), mainly subretinal haem as that is accessible with TPA

04:37:11 Tim Jackson: 6D

04:37:47 Rahila Zakir: @Mahi how quickly is the early vity?

04:43:30 David Yorston: We have used the CryoTreq in Glasgow and it works very well. It seems to get colder than the standard cryo and will freeze in a fluid filled eye (could be good for small bubble technique). Downside is that it takes a long time to defrost, so best for single breaks.

04:46:08 Rahila Zakir: @David, could your assistant squirt some room temperature BSS on the cryo tip to thaw it more quickly? Or is it slow to defrost despite that?

04:47:22 Gerry McGowan: I’ve used it a lot. Never needed a squirt to defrost. Works well. First time, every time (so far)

04:47:55 Rahila Zakir: I like the idea of cryo quick in fluid filled eyes

04:49:40 Roxane Hillier: A disincentive to using CryoTreq is that is single use and disposable

04:49:56 Harry Bennett: agree with David, it takes longer to defrost/”let go” of the eye. Would be useful for out of hours work too if you can’t get access to theatre for a quick cryo

05:15:54 David Steel: does anyone else find the cryotech button hard to push – or am I just weak ?

05:16:10 David Yorston: Yes, it is quite stiff

05:33:13 Rahila Zakir: @David Yorsten, thank you and your board for working so hard on our behalf.

05:33:57 David Yorston: Thank you

05:34:26 Cordelia McKechnie: Any update on credentialing and VR training?

05:36:00 Harry Bennett: is there going to be a trainee member of the board?

05:43:05 Edward Herbert: How do you get your PDT laser to the ora?

05:43:28 Rumana Hussein: they are usually visible with a 3 mirror…they are not usually so peripheral that you can’t get there. PDT is less invasive than cryo, and cryo can kick start more exudative problems if its thick

05:48:00 Edward Herbert: Would Doppler Ultrasound help determine tumour presence?

05:50:07 Aman Chandra: Half fluence PDT? Similar treatment to CSR?

05:50:47 Roxane Hillier: I have only encountered a large and necrotic melanoma twice, and both times the pressure was grossly raised. Is this a diagnostic clue?

05:51:13 Edward Herbert: I had one present with brown hypopyon- thought about exotic endog endopth, elderly and couldn’t travel. Did enucleation for blind painful eye

05:52:06 Rumana Hussein: Full dose single shot PDT. Full hyphaema in a relatively young patient is always suspicious…

05:53:07 Grace Chew Wei Min: how do you decide where to treat with pdt- ffa guided or clinical exam?

05:53:33 Rumana Hussein: you know these eyes have poor visual potential so sometimes we advise a diagnostic enuc…PDT on the visible lump…

05:55:34 Gerry McGowan: Now use 10k bevelled

05:56:18 Rumana Hussein: Roxy, I am not sure the high IOP is Diagnostic but if the ciliary body is involved and there’s AC shallowing it makes sense…

05:57:59 Steve Charles: Why not bimanual dissection to begin with? ran out of chandeliers?

05:58:47 Roxane Hillier: Yes, definitely, makes sense. Interestingly my two had ‘normal’ anterior segments with tonnes of pigment in the angle – I presumed melanocyte dispersion. Rare and scary.

05:59:14 Mustafa Kadhim: Can we do a poll on pre-op anti VEGF for delam?

05:59:35 Louisa Wickham: Agree – prefer 27g where I can for delam

05:59:51 Edward Herbert: I worry about rubeosis and risk of serous detachment if no prior PRP (hence needing more laser on day)

05:59:58 Mandeep Bindra: as Louisa – 27g has meant i hardly do bimanual anymore

06:01:09 Louisa Wickham: I agree – when the view is poor the PRP treatment is suboptimal and wastes time before getting more definitive treatment

06:01:13 Ravi Gandhewar: We have currently suspended prop Anti-VEGF in case of potential disruptions from Covid. oWner anyone else has.

06:01:21 Timothy Cochrane: would most have preferred to operate at first presentation?

06:02:52 Cordelia McKechnie: Would be too risky with COVID doing pre-op anti-VEGF. Too many cancellations on the day and COVID swab results not back

06:02:57 Mandeep Bindra: we have found that having the VR surgeons running/involved in the MR service in our dept, we operate much earlier

06:03:04 Alistair Laidlaw: The visual result was good despite the crunch, doing surgery before angio fibrotic crunch preserves better vision

06:04:18 Gerry McGowan: Is that optos or Clarus Aman?

06:09:42 Rahila Zakir: I’ve heard a few people mention using 2000Cs oil today – I’ve not used anything other than 1300. What are the advantages over 1300?

06:09:47 Roxane Hillier: @Aman – looking back, do you wish you had drained trans-sclerally first time round? I have always preached ‘non-drainage’, but recently I have had problems with breaks not settling onto the indent following a band or extensive circumferential buckle. @panel – better to drain when siting a band or extensive circumferential buckle??

06:10:28 Roxane Hillier: …as opposed to a focal buckle, which is (I think) more forgiving

06:11:21 Jonathan Smith: Hi Aman. Did you measure her inner retinal thickness.?

06:12:23 Noemi Lois: what is the visual acuity and visual field now?

06:12:31 Alan Fitt: Does she still have no RAPD?

06:12:43 Kam Balaggan: Electrodiagnostics??

06:12:49 Noemi Lois: Have you done electrophysiology (ERG, PERG and VEPs)?

06:13:07 Edward Herbert: could this be an ipsilateral sympathetic type process?

06:13:36 Alistair Laidlaw: OCT?

06:13:44 Rahila Zakir: Any FFA imaging? Choroidal perfusion?

06:14:04 Harry Bennett: 360 band related

06:14:09 Rumana Hussein: post labour induced eclampsia complication???

06:14:13 Ravi Gandhewar: Any OCTA, Autofluoresence?

06:14:17 Richard Haynes: BP / IOP mismatch?

06:14:35 Palpandian Viswanathan: any relation to pressure related to child delivery, increased BP / compromised choroidal perfusion during delivery

06:15:33 Louisa Wickham: Could increased blood flow at 3rd trimester masked decrease in perfusion to retina

06:16:04 Harry Bennett: any ocular pain during labour? Increased choroidal swelling due to valsalva against a non-compliant band ( I’m sure she was thinking about her eye during labour ..)

06:16:08 Alistair Laidlaw: If her OCT/OCTA are normal? this has to be a neuropathy doesn’t it?

06:16:28 Aman Chandra: Thanks all!

06:16:40 Steve Charles: Thanks Aman, We felt your pain…..

06:18:48 David Yorston: Flap over optic disc pit and leave to drain naturally

06:19:07 Edward Bloch: Fluid seems to take many months to reabsorb

06:20:55 Rahila Zakir: scary that there is a suction mechanism in the pit – was any heavy liquid also being suctioned in??

06:21:19 Rumana Hussein: heavy liquid into the CSF??

06:21:31 Aman Chandra: Sounds toxic!

06:22:51 Rumana Hussein: Are there any cases published of heavy into the CSF causing problems? Because now I’m freaked out!!

06:23:21 Alistair Laidlaw: Oil has been reported into the ventricular system

06:24:31 Sami Habal: Do you think that using PFCL was not a good idea in this case?

06:25:40 Assad Jalil: CK the laser had been done twice in previous surgeries

06:26:30 Assad Jalil: I agree PFCL should be avoided but I had RD with inferior PVR and open pit, so I was planning a retinectomy.

06:26:36 Sami Habal: I know it is difficult to perform retinectomy without using PFCL but the idea of it possibly escaping into the CSF is very scary…

06:27:09 Assad Jalil: And MRI done 7 years ago had shown no communication to CSF

06:28:05 Assad Jalil: So was not sure what to do since vity, peel, flap, laser, gas twice had failed

06:28:35 Assad Jalil: I agree Sonali. It does get smaller after harvesting it from my limited experience

06:30:42 Rajeev Tanawade: Great case Assad!

06:32:19 Assad Jalil: thanks. Early days so lets see how the pt does long term

06:33:01 William Luke Membrey: Is that a Sofport Steve

06:35:55 Alexander Brent: what forceps do you use to hold the haptics?

06:36:12 Rahila Zakir: Do you use Malyugin ring for all of them routinely?

06:37:17 Rumana Hussein: it’s the flattening of the haptic that’s the key I think…thanks Steve

06:37:40 Imran Akram: Steve what IOL was it, MA60?

06:38:54 Roxane Hillier: MA60 no good?

06:39:16 David Steel: MA50s good

06:39:22 Rumana Hussein: I’m thinking the ma60 is less forgiving with manipulation?

06:40:12 Kirti Madhukar Jasani: Having used both… Zeiss is a lot more sturdier especially the haptics

06:42:24 Kam Balaggan: The secret is PDVA haptics and not PMMA. Zeiss CT lucia 202 perfect for this. Yamane uses a similar iol from Santen but chic has a 7mm optic! I don’t think its available in the UK

06:43:59 Alistair Laidlaw: Louisa: 3 on the goretex first throw?

06:45:40 Kam Balaggan: Louisa I also recommend making a partial thickness scleral groove which allows the external portion of the goretex suture to remain buried intrasclerally and reduce the risk of very late erosion. Has worked well in many cases so far

06:46:15 Kam Balaggan: *Linear grove

06:46:40 Ravi Gandhewar: Any chafing and decentration especially with flaps?

06:46:48 Alistair Laidlaw: Anyone closed these up with fibrin glue? It strikes me that they wouldn’t have the early hypotony which is common

06:48:11 Cordelia McKechnie: Carlevale is an amazing IOL do try it!!

06:48:50 Louisa Wickham: Hi – I haven’t done a scleral grove so far but haven’t seen any erosion to date – but time will tell!

06:48:53 Rumana Hussein: are they more expensive than a normal IOL?

06:50:02 Kam Balaggan: The toric carlevale is about £450

06:50:27 Richard Haynes: About £200

06:50:34 Richard Haynes: For non toric

06:51:11 Imran Akram: Do you have a bank of these or order individually?

06:51:28 Kam Balaggan: Individual order

06:51:36 Cordelia McKechnie: order two at a time

06:51:41 Cordelia McKechnie: You can build up a bank

06:51:59 Louisa Wickham: Do you use these now for everyone or are there cases you wouldn’t use them on?

06:52:10 Rumana Hussein: So you cannot really use them spontaneously in a trauma for example. It has to be planned…

06:52:31 Cordelia McKechnie: Use for all aphakics except if going to use an ACIOL

06:52:32 Richard Haynes: Just for special planned cases

06:52:43 Alistair Laidlaw: Richard, One reason I like the goretex is control of tilt. Do these lenses lie in the correct plane?

06:52:55 Cordelia McKechnie: With no scleral support

New to BEAVRS – Education Portal

New to BEAVRS – BEAVRS online VR surgical course. It’s aimed at vitreoretinal fellows but consultants may also find it refreshing to learn from other colleagues.

The course is designed to be studied in your in your own time and can be completed more than once. It will consist of sections each containing 3-4 lectures 15-20 min each. Each course will have objectives and with time We will add self-assessment quizes. We hope to add to the body of lectures yearly and aim to build up a library of wide range of topics covering most of everyday vitreoretinal practice. We are very grateful to our distinguished speakers who have generously agreed to contribute to this course and we hope you will enjoy it.

This course is evolving so please send any suggestions/ requests to “link to“ shohista.saidkasimova@nnuh.nhs.uk.