From the División de Oftalmología, Universidad Miguel Hernández, Instituto Oftalmológico Alicante, Alicante, Spain.
Vitreoretinal surgery increasingly implies elimination of the posterior hyaloid. Many different surgical techniques have been described. The aspiration of the posterior hyaloid with a flexible silicone cannula and posterior separation with an illuminated spatula is the most frequently used. We herein describe a slight variation of this technique that makes the dissection of the posterior hyaloid easier in cases in which it has a strong attachment to the retina. We have used this technique on 12 patients (7 with choroidal neovascularization and 5 with idiopathic macular hole [1 patient with stage 2 and 4 patients with stage 3]) with strong attachment of the posterior hyaloid to the retina, immediately obtaining in all cases the separation of both structures without complications.
Dissection of the posterior hyaloid (PH) is an important and necessary step in the performance of vitrectomy to completely eliminate traction in conditions such as macular hole,1 submacular surgery for choroidal neovascularization,2 proliferative vitreoretinopathy,3 and in all vitrectomies in which it is suspected that the PH may either cause a retinal detachment by means of traction or serve as a support on which a proliferation will develop.
Many techniques have been described for the elimination of the PH, such as endodiathermy4 or incision and aspiration with different types of cannulas.1 This last technique, based on aspiration with a flexible silicone cannula alone or combined with an illuminated spatula5 is probably the most frequently used. However, in some cases in which the attachment between the PH and the retina is very strong, it is not possible to create a space big enough between them to introduce the illuminated spatula under the PH and separate it from the retina.
In this article we describe a slight variation of this technique that easily enables the separation of the PH in these cases and minimizes the time needed. This technique avoids the repetition of maneuvers with the tip on the retina.
After performing the vitrectomy, we introduce the flexible silicone cannula to test the attachment of the PH to the retina. If a deviation of the cannula is produced and is joined perpendicular to the retina when suction is applied, the existence of posterior cortical vitreous is confirmed.5
If it is not possible to obtain enough space to introduce the illuminated spatula while aspirating with the cannula and simultaneously pulling, we then maintain the suction and make the illuminated spatula go through just at the tip of the silicone cannula (Figure 1). Then we take away the tip of the spatula and sustain the suction and pulling, thus letting the irrigation fluid go through the 2 orifices made in the PH and facilitating the complete separation of the PH (Figure 2).
Posterior segment illustration showing the flexible cannula with posterior hyaloid impaled in the tip. The illuminated spatula goes through just at the tip of the silicone cannula.
Posterior segment illustration showing elevation of the posterior hyaloid with the cannula, letting the irrigation fluid go through the 2 orifices made in the posterior hyaloid, facilitating the complete separation.
We have used this variation of the technique described by Mein and Flynn5 on 12 patients with strong attachment of the PH to the retina, immediately obtaining in all cases the separation of both structures and shortening the time of surgery, without complications caused by this maneuver. The indications for surgery in these patients were submacular surgery for choroidal neovascularization in 7 cases and idiopathic macular hole in 5 cases (1 patient with stage 2 and 4 patients with stage 3).
Accepted for publication July 14, 1998.
Corresponding author: José M. Ruiz-Moreno, MD, División de Oftalmología, School of Medicine (Campus de San Juan), Universidad Miguel Hernández, 03550 Alicante, Spain (e-mail: firstname.lastname@example.org).
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