BUSINESS OF RETINA FELLOWS FOCUS SECTION EDITORS: DARRELL E.

BASKIN, MD;

JEREMY D. WOLFE, MD; AND CHIRAG P. SHAH, MD, MPH

Clinical Pearls for Office-Based Procedures

BY NETAN CHOUDHRY, MD; AND KRISTINE PIERCE, MD; WITH CONTRIBUTIONS BY JOHN LOEWENSTEIN, MD
We all want to do well for our patients, medically and surgically. You will acquire many skills and tips as you progressand hopefully do not stumblethrough your fellowship. This month, two first-year fellows from opposite coasts offer pearls to help you shine in the office. Darrell E. Baskin, MD; Jeremy D. Wolfe, MD; and Chirag P. Shah, MD, MPH

1. AS A FIRST-YEAR FELLOW, WHAT ARE SOME OF THE MOST IMPORTANT THINGS YOU HAVE LEARNED FROM YOUR ATTENDINGS ABOUT INTRAVITREAL INJECTION PROTOCOL? Postinjection corneal abrasions are a pain for both you and the patient. We have all met a patient who had posttraumatic stress disorder induced by an abrasion sustained during a prior injection. The key here is patience and cooperation. It is always a good idea to let the patient know that you are about to place the speculum (or anything for that matter) onto their eye. This may mitigate blinking or moving against the speculum during insertion. Try to minimize the time the speculum is in place. Most abrasions seem to occur while retracting or removing the speculum from the upper lid. Therefore once the lower lid is stabilized, have the patient look down, manually retract the upper lid, and then disinsert the speculum. Some clinicians advocate rotating the speculum 90 to disengage the lids upon removal. Although as retina surgeons we sometimes perform corneal epitheliectomies to improve our view intraoperatively, this is one instance where we must respect the cornea. There is little consensus and no evidence regarding postinjection antibiotics. The majority of us prescribe some sort of antibiotic drop, while others argue against any. While we know that povidone-iodine lowers endophthalmitis risk, it dries the cornea and can lead to significant patient discomfort as soon as the topical
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Consider postinjection antibiotic ointment to lubricate the ocular surface while providing some antibiotic effect.
anesthesia wears off. Do not let that sway you from using the proper amount of povidone-iodine. Consider postinjection antibiotic ointment to lubricate the ocular surface while providing some antibiotic effect. 2. FLASHES AND FLOATERS: YOU LOOK IN AND SEE A PHAKIC SUPERIOR RETINAL DETACHMENT WITH A SINGLE, 1-CLOCK-HOUR BREAKTHE PERFECT CANDIDATE FOR PNEUMATIC RETINOPEXY. WHAT HURDLES HAVE YOU ENCOUNTERED IN PERFORMING THIS PROCEDURE? A common hurdle for first-year fellows learning pneumatic retinopexy is deciding which gas to inject. There are many considerations in choosing the appropriate gas. Assess the anterior chamber depth to determine how much fluid can be aspirated during the paracentesis. Also, it is important to remember that myopic eyes can be large with correspondingly large posterior cavities; the ultimate gas bubble should be big enough to cover the break with coverage to spare. Further, patients

BUSINESS OF RETINA FELLOWS FOCUS

who may be able to position adequately but not perfectly may benefit from a larger C3F8 bubble. Remember that C3F8 requires a smaller injectable volume than SF6 and quadruples in size, helping to reduce postprocedure spikes in intraocular pressure. The longer duration of C3F8 (6 weeks vs 2 weeks), however, may be overkill for some patients.

Most patients who have experienced PRP from the conventional laser will tell you that the PASCAL is far more comfortable.
Consider this scenario: You have chosen and injected a gas, and seconds later you see the retina covered with caviar. Fish eggs are a common problem for fellows still on the learning curve, but they can be readily avoided by keeping the needle vertical while trying to inject steadily within the gas bubble. A 30-gauge needle is approximately 12 mm in length. Find a location to inject that is away from the detached retina (if possible). When you first enter bevel up, aim toward the center of the globe and make sure that two-thirds of the needle is in the eye. At this point, the globe can be slightly rotated with the needle so that the needle is positioned at the uppermost portion of the eye (now it should be vertical in space and normal to the globe). Withdraw slightly to expose two-thirds of the needle, leaving one-third buried in the eye; inject at a moderately brisk speed. This maneuver minimizes the travel of the gas after leaving the tip of the needle. Having too much of the needle buried in the eye facilitates the development of fish eggs around the shaft of the needle. If, however, you see fish eggs, consider the following: 1) Position the patient to keep the fish eggs away from retinal breaks, thereby preventing migration of gas into the subretinal space. 2) Fish eggs usually coalesce spontaneously within 24 hours. If 1 or 2 bubbles are present, they can usually be left alone, and the patient can adopt a position with the retinal break(s) uppermost the next day. 3) Fish eggs can usually be coalesced by flicking the eye with a cotton-tipped applicator or gloved finger. Rotate the patients head so that sclera without underlying retinal breaks is uppermost, and this site can be firmly flicked. 3. YOU THOUGHT YOU KNEW HOW TO DO LASER UNTIL YOU ARRIVE AT YOUR NEW FELLOWSHIP LOCATION AND THEY HAVE THE NEW PASCAL

(PATTERN SCAN LASER; OPTIMEDICA, SANTA CLARA, CA). NOW WHAT? The PASCAL laser utilizes a 532-nm wavelength laser and was designed to deliver energy rapidly, thus providing better patient comfort. The laser settings are different from those we learned for conventional lasers. Panretinal photocoagulation (PRP): Typical settings include a 200-m spot size and 20-ms duration. Start the power low, at 200 mW (some retinal specialists recommend starting at 400 mW), and titrate up to achieve an appropriate burn. You can increase the duration, but that may result in patient discomfort. Be mindful that your burn will be more intense as you treat more anterior retina; be prepared to titrate down as you move anteriorly. As a new retina fellow, consider demarcating the most posterior aspect of the retina you wish to treat and then fill in anteriorly; this will keep you away from the macula if the beautifully unfolding grid hypnotizes you. Focal: Typical settings include 100-mW power, 100m spot size, and 20-ms duration (some retinal specialists recommend 100-ms duration). Titrate outside of the arcade before treating the macula. While some may use the PASCALs grid function for focal, consider single shots for more control. When faced with the decision of whether to block the patient, consider that most patients who have experienced PRP from the conventional laser will tell you that the PASCAL is far more comfortable. The use of a retrobulbar block depends on the individual patients level of comfort throughout the procedure. If you cannot proceed with PRP because of patient pain, however, go ahead and block the patienthe or she will thank you later. The authors would like to acknowledge John Loewenstein, MD, at Massachusetts Eye and Ear Infirmary for his contribution. Netan Choudhry, MD, is a first-year vitreoretinal surgery fellow at Massachusetts Eye and Ear Infirmary in Boston, MA. He can be reached at netan.choudhry@gmail.com. Kristine Pierce, MD, is a first-year vitreoretinal surgery fellow at Casey Eye Institute in Portland, OR. She can be reached at piercekristine@hotmail.com. Darrell E. Baskin, MD; Jeremy D. Wolfe, MD; and Chirag P. Shah, MD, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA, and members of the Retina Today Editorial Board. Dr. Baskin may be reached at darrellbaskin@gmail.com; Dr. Wolfe may be reached at jeremydwolfe@gmail.com; and Dr. Shah may be reached at cshah@post.harvard.edu.
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