0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Surgical Technique | Surgeon's Corner

Modified External Needle Drainage of Subretinal Fluid in the Management of Rhegmatogenous Retinal Detachment Using a “Guarded Needle” Approach FREE

John W. Kitchens, MD
[+] Author Affiliations

Author Affiliation: Retina Associates of Kentucky, Lexington.


Arch Ophthalmol. 2011;129(7):949-951. doi:10.1001/archophthalmol.2011.165.
Text Size: A A A
Published online

External needle drainage of subretinal fluid is a useful technique to assist with retinal detachment surgery. This technique provides the ability to directly visualize the removal of subretinal fluid in a controlled manner. The major difficulty in learning this technique is the potential for overpenetration with the needle. Using a “guarded needle” approach can reduce this risk and increase the adoption of this useful method.

Figures in this Article

Drainage of subretinal fluid is a useful adjuvant to aid in the repair of retinal detachment during scleral buckling surgery.15 Since its initial description by Steve Charles in 1985,6 external needle drainage of subretinal fluid has served as a successful technique to assist with retinal detachment surgery. Other studies7,8 have demonstrated the advantages and low complication rate of this procedure. The benefits of this technique include the ability to directly visualize the removal of subretinal fluid in a controlled manner. Theoretically, these advantages may reduce the risk of drainage complications such as subretinal hemorrhage and retinal incarceration. Typically, external needle drainage takes place after cryotherapy has been applied and the scleral buckle has been placed around the eye with sutures or scleral tunnels. Drainage of subretinal fluid by either scleral cutdown or external needle drainage can be performed before or after9 tightening the anchoring sutures of the buckle.

One disadvantage of the external needle drainage technique is the steep learning curve. The most difficult portion of initial attempts at drainage involves identifying the location of the needle in the subretinal space. Intraoperatively, corneal edema9 as well as retinal clarity can make localizing the needle in the subretinal space difficult with indirect ophthalmoscopy. Iatrogenic damage from inadvertent needle placement can result in subretinal or choroidal hemorrhage, damage to the retinal pigment epithelium, and retinal tears or incarceration. In an attempt to better control the placement of the needle, the “guarded needle” approach was developed.

The guarded needle technique serves to address overpenetration of the needle during attempted drainage of subretinal fluid (Figure 1A and B). In addition to increased safety, this technique can be performed with standard scleral buckling elements and needles of various sizes (25-27 gauge) and lengths (3/8 to 5/8 in).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. A, Overpenetration with unguarded needle. B, “Guarded needle” prevents overpenetration.

After successful placement and tightening of the encircling element, the 26-gauge, 3/8-in needle is placed on a syringe (1 or 3 cm3). Before the needle is advanced into the subretinal space, the plunger is removed from the syringe to allow for passive egress of the subretinal fluid. An additional technique, which can aid in the drainage of subretinal fluid, involves the placement of a traction suture around the scleral buckle 180° away from the proposed drainage site. The surgical assistant can retract this suture, increasing the intraocular pressure, to aid in the egress of fluid.

The guarded needle is prepared by sliding the buckle sleeve (element 270 or 70; Mira, Inc, Uxbridge, Massachusetts) over the shaft of the needle. Owing to the length of the sleeve, it will overlap the tip of the needle. Surgical scissors are used to trim the sleeve, revealing approximately 4 mm of needle tip when the sleeve rests at the base (hub) of the needle (Figure 2). Care should be taken when maneuvering the guarded needle into position for drainage because the sleeve can slide off the needle.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. “Guarded needle” (26-gauge needle with buckle sleeve [element 270; Mira, Inc, Uxbridge, Massachusetts]).

The needle is then positioned at the anterior edge of the scleral buckle in the most bullous area of retinal detachment. General principles in the drainage of subretinal fluid by the external needle technique include the avoidance of draining within the 1-o’clock position of the retinal break as well as in the area of any vortex veins. The bevel of the needle should be directed away from the retina (ie, bevel toward the sclera). This needle position theoretically reduces the risk of retinal incarceration into the needle tip. Gentle depression of the sclera with the needle can help to identify the potential area of entry. The needle should enter the subretinal space in a controlled fashion. The entry angle should be steep, almost parallel to the scleral buckle, to help prevent inadvertent perforation of the retina. Upon entry, the needle tip should be seen beneath the retina with either the indirect ophthalmoscope or the surgical microscope with the assistance of a chandelier light or other lighting source. The surgical assistant can retract the traction suture to aid in drainage of the fluid or to increase the intraocular pressure in the case of hemorrhage. As the retina begins to settle, it will begin to “flutter.” Once it draws close to the needle, the needle should be removed from the eye to avoid inadvertent perforation of the retina. Tension should remain on the globe (via the traction suture) to assist in draining the residual amount of subretinal fluid through the needle track (Figure 3). A brief video tutorial of the modified external drainage procedure is available online.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Modified external needle drainage of subretinal fluid in the management of rhegmatogenous retinal detachment: placement of guard (sleeve [element 270; Mira, Inc, Uxbridge, Massachusetts]) over 26-gauge needle (A); trimmed needle guard (B); needle with guard in place positioned at anterior aspect of scleral buckle (C); and view of needle tip in the subretinal space during drainage (D).

External needle drainage of subretinal fluid can result in successful reattachment of the retina.6,8 With this technique, the surgeon can monitor the drainage of the subretinal fluid to ensure a more complete drainage and identify the presence of hemorrhage during the drain. In addition, the elevated intraocular pressure of the tightened scleral buckle9 may reduce the risk of significant hemorrhage.

The difficulty that many surgeons have with adopting this technique is associated with identifying the needle in the subretinal space. This can lead to iatrogenic damage to the retina, the retinal pigment epithelium, or the choroid. Using the guarded needle technique ensures that the needle cannot penetrate the eye farther than the length of exposed needle. This can allow for an easier and safer transition to external needle drainage for retinal reattachment surgery.

Correspondence: John W. Kitchens, MD, Retina Associates of Kentucky, 120 N Eagle Creek Dr, Ste 500, Lexington, KY 40509 (jkitchens@gmail.com).

Submitted for Publication: May 12, 2010; final revision received October 1, 2010; accepted October 5, 2010.

Financial Disclosure: None reported.

Eifrig DE. Techniques for drainage of subretinal fluid.  Surv Ophthalmol. 1973;17(5):348-356
PubMed
Freeman HM, Schepens CL. Innovations in the technique for drainage of subretinal fluid, transillumination and choroidal diathermy.  Mod Probl Ophthalmol. 1975;15:119-126
PubMed
Gärtner J. Release of subretinal fluid with the aid of the microscope: report on 100 cases.  Mod Probl Ophthalmol. 1975;15:127-133
PubMed
Meyer-Schwickerath G, Klein M. Drainage of subretinal fluid with a cathode needle.  Mod Probl Ophthalmol. 1975;15:154-157
PubMed
Wilkinson CP, Bradford RH Jr. The drainage of subretinal fluid.  Trans Am Ophthalmol Soc. 1983;81:162-171
PubMed
Charles ST. Controlled drainage of subretinal and choroidal fluid.  Retina. 1985;5(4):233-234
PubMed   |  Link to Article
Ibanez HE, Bloom SM, Olk RJ,  et al.  External argon laser choroidotomy versus needle drainage technique in primary scleral buckle procedures: a prospective randomized study.  Retina. 1994;14(4):348-350
PubMed   |  Link to Article
Kim JH, Bertram KM, Quirk MT, Arroyo JG. Modified external needle drainage of subretinal fluid in primary rhegmatogenous retinal detachment: a prospective, consecutive, interventional, single-surgeon study.  Retina. 2007;27(9):1231-1237
PubMed   |  Link to Article
Jaffe GJ, Brownlow R, Hines J. Modified external needle drainage procedure for rhegmatogenous retinal detachment.  Retina. 2003;23(1):80-85
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. A, Overpenetration with unguarded needle. B, “Guarded needle” prevents overpenetration.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. “Guarded needle” (26-gauge needle with buckle sleeve [element 270; Mira, Inc, Uxbridge, Massachusetts]).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Modified external needle drainage of subretinal fluid in the management of rhegmatogenous retinal detachment: placement of guard (sleeve [element 270; Mira, Inc, Uxbridge, Massachusetts]) over 26-gauge needle (A); trimmed needle guard (B); needle with guard in place positioned at anterior aspect of scleral buckle (C); and view of needle tip in the subretinal space during drainage (D).

Tables

References

Eifrig DE. Techniques for drainage of subretinal fluid.  Surv Ophthalmol. 1973;17(5):348-356
PubMed
Freeman HM, Schepens CL. Innovations in the technique for drainage of subretinal fluid, transillumination and choroidal diathermy.  Mod Probl Ophthalmol. 1975;15:119-126
PubMed
Gärtner J. Release of subretinal fluid with the aid of the microscope: report on 100 cases.  Mod Probl Ophthalmol. 1975;15:127-133
PubMed
Meyer-Schwickerath G, Klein M. Drainage of subretinal fluid with a cathode needle.  Mod Probl Ophthalmol. 1975;15:154-157
PubMed
Wilkinson CP, Bradford RH Jr. The drainage of subretinal fluid.  Trans Am Ophthalmol Soc. 1983;81:162-171
PubMed
Charles ST. Controlled drainage of subretinal and choroidal fluid.  Retina. 1985;5(4):233-234
PubMed   |  Link to Article
Ibanez HE, Bloom SM, Olk RJ,  et al.  External argon laser choroidotomy versus needle drainage technique in primary scleral buckle procedures: a prospective randomized study.  Retina. 1994;14(4):348-350
PubMed   |  Link to Article
Kim JH, Bertram KM, Quirk MT, Arroyo JG. Modified external needle drainage of subretinal fluid in primary rhegmatogenous retinal detachment: a prospective, consecutive, interventional, single-surgeon study.  Retina. 2007;27(9):1231-1237
PubMed   |  Link to Article
Jaffe GJ, Brownlow R, Hines J. Modified external needle drainage procedure for rhegmatogenous retinal detachment.  Retina. 2003;23(1):80-85
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,531 Views
4 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.