SUBRETINAL ENDOSCOPIC SURGERY TO TREAT LARGE SUBRETINAL HEMORRHAGES SECONDARY TO AGE-RELATED MACULAR DEGENERATION

Heads-up 3-Dimensional Visualization to Enhance Video Endoscopy During Vitreoretinal Surgery

Purpose: To describe 2 cases in which video endoscopy was combined with heads-up 3-dimensional (3D) visualization. Methods: The imaging modalities of the heads-up 3D visualization system and video endoscopy were combined by converting the endoscope's S-Video output into a high-definition multimedia interface. The technique was used in 2 cases that included lens dislocation and endophthalmitis. Results: In the 2 cases, the heads-up split-screen view simplified the surgical setup. Simultaneously viewing the endoscopic image and widefield 3D image anecdotally appeared to improve ergonomics, help keep the probe oriented, and assist in guiding surgical movements endoscopically. Conclusions: These cases show the advantages of a heads-up 3D system to simultaneously view endoscopic and widefield images during ophthalmic endoscopy in vitreoretinal surgery.

SUBRETINAL ENDOSCOPIC SURGERY FOR METASTATIC CHOROIDAL TUMOR

PURPOSE

To report a case of a metastatic choroidal tumor treated with subretinal endoscopic surgery.

METHODS

A single case report.

RESULTS

A 68-year-old woman presented with a metastatic choroidal tumor in the right eye and an intraocular pressure of 54 mmHg. Chemotherapy and radiotherapy were ineffective in eliminating her eye pain. Subretinal endoscopic surgery was performed to remove the metastatic choroidal tumor with the complex retinal detachment attached to the posterior surface of the lens. The day after subretinal endoscopic surgery, the patient's intraocular pressure decreased to 7 mmHg and her pain subsided. The chemotherapeutic strategy was modified according to the pathological findings. Survival prognosis improved from 3 to 18 months. Twenty-one months after the surgery, the retinal detachment was reattached under silicone oil with a best-corrected visual acuity of 20/1,000 and an intraocular pressure of 15 mmHg.

CONCLUSION

In this case, subretinal endoscopic surgery preserved visual function, eliminating the need for enucleation.

High-Resolution Ex-Vivo Imaging of Retina with a Laptop-Based Portable Endoscope

Purpose. Ophthalmic endoscopy is useful in vitreoretinal surgery with opaque anterior segments or anatomically challenging structures. However, standard ophthalmic endoscopy devices are usually large and costly. Thus, the development of a portable endoscope is necessary. Methods. The portable endoscope consisted of a probe, an illumination system, a high-resolution camera module, and a universal serial bus (USB). It was connected to a laptop and applied for intraocular imaging of porcine eyes in vitro. Basic parameters and pictures of the same tissue target were compared with those of the standard Endo Optiks E4 system. Results. The retinal images were displayed on the laptop screen, which clearly showed the overall appearance of the central and peripheral retina, and the details of the retinal vasculature and ciliary body. Compared with a standard endoscope, our portable endoscope is smaller and more affordable. It can be taken anywhere for intraocular imaging and vitreoretinal surgery. Conclusion. A laptop-based portable endoscope is a promising device in vitreoretinal surgery. It provides high-resolution images of intraocular tissues that should make a noticeable difference in intraocular surgery with disordered anterior segments. With its portability and high-resolution imaging, it may promote the application of endoscopes in ophthalmology.

Treatment of old submacular hemorrhage by subretinal endoscopic surgery and intraoperative subretinal endoscopic findings

Purpose

We report a case of old submacular hemorrhage (SMH) due to polypoidal choroidal vasculopathy (PCV). Subretinal endoscopic surgery (SES) was performed, which improved visual function. In addition, we show the intraoperative findings of subretinal aberrant PCV vessels as seen under endoscopic observation, which cannot be observed by microscopic surgery.

Observations

A 71-year-old Japanese man presented with an old dehemoglobinized SMH due to PCV in his left eye. At the time of presentation, three weeks had already passed after the onset of the patient's symptoms, and the best-corrected visual acuity (BCVA) was 20/200. SES was performed to remove the SMH and treat the subretinal PCV lesions. After creating retinal detachment using a 38-gauge cannula, three subretinal 25-gauge trocars were inserted from the sclera to the subretinal space. Then, SES was performed under ophthalmic endoscopic observation with continued subretinal irrigation for maintaining the retinal detachment. After removal of the SMH, subretinal polyp-shaped nodular vascular lesions (polyps) and a branching vascular network, which is located inside the retinal pigmented epithelium, were identified. The sites that presumably originated from the aberrant vessels of the PCV and the associated polyps were coagulated using endodiathermy. After the subretinal procedure, the retina was flattened with fluid/air exchange, and silicone oil (SO) was injected into the vitreous cavity. The SMH completely disappeared after surgery. Although at one-month follow-up BCVA (20/250) was slightly worse than that before surgery, there was an improvement in postoperative retinal sensitivity in the macula compared to that before surgery. At the three-month follow-up, the SO was removed. The BCVA was 20/200 one month after SO removal. No postoperative complications occurred. Additional treatment was not required, including anti-vascular endothelial growth factor therapy, for PCV progression or SMH recurrence in the left eye till the final visit two years after surgery.

Conclusion and importance

SES could effectively remove the old SMH, and the activity of PCV was suppressed by intraoperative subretinal coagulation. The retinal sensitivity of the macula improved after the SES. In addition, we observed subretinal polyps and a branching vascular network located internal to the retinal pigmented epithelium under intraoperative subretinal endoscopic observation. SES is a good surgical option for the removal of old SMH or treatment of subretinal lesions.

Endoscopic vitreoretinal surgery: Review of current applications and future trends

Endoscopy provides unique optical properties to circumvent anterior segment opacities and visualize difficult-to-access anatomical regions, including retroirideal, retrolental, ciliary body, and anterior retinal structures. We summarize the basic principles and utilization of endoscopic vitreoretinal surgery, along with recent technological advances in the field base on a structured literature search in Pubmed, Embase, and Google Scholar database up to February, 2020. Endoscopy has been used in the management of retinal detachment, ischemic retinopathies with neovascular glaucoma, severe ocular trauma, endophthalmitis, lens-related disorders in the posterior segment, pediatric vitreoretinal diseases, and implantation of retinal prostheses. Ongoing development of endoscopic technology aims to provide higher resolution images with endoscopes of smaller diameter. New surgical techniques supported by the adoption of endoscopy are available to manage challenging surgical scenarios. Endoscopy can be a useful adjunct to microscope wide-angle viewing systems in the management of complex vitreoretinal diseases.

Translational Retinal Imaging

The diagnosis and treatment of medical retinal disease is now inseparable from retinal imaging in all its multimodal incarnations. The purpose of this article is to present a selection of very different retinal imaging techniques that are truly translational, in the sense that they are not only new, but can guide us to new understandings of disease processes or interventions that are not accessible by present methods. Quantitative autofluorescence imaging, now available for clinical investigation, has already fundamentally changed our understanding of the role of lipofuscin in age-related macular degeneration. Hyperspectral autofluorescence imaging is bench science poised not only to unravel the molecular basis of retinal pigment epithelium fluorescence, but also to be translated into a clinical camera for earliest detection of age-related macular degeneration. The ophthalmic endoscope for vitreous surgery is a radically new retinal imaging system that enables surgical approaches heretofore impossible while it captures subretinal images of living tissue. Remote retinal imaging coupled with deep learning artificial intelligence will transform the very fabric of future medical care.

Endoscopic vitreoretinal surgery: principles, applications and new directions

Purpose

To analyze endoscopic vitreoretinal surgery principles, applications, challenges and potential technological advances.

Background

Microendoscopic imaging permits vitreoretinal surgery for tissues that are not visible using operating microscopy ophthalmoscopy. Evolving instrumentation may overcome some limitations of current endoscopic technology.

Analysis

Transfer of the fine detail in endoscopic vitreoretinal images to extraocular video cameras is constrained currently by the caliber limitations of intraocular probes in ophthalmic surgery. Gradient index and Hopkins rod lenses provide high resolution ophthalmoscopy but restrict surgical manipulation. Fiberoptic coherent image guides offer surgical maneuverability but reduce imaging resolution. Coaxial endoscopic illumination can highlight delicate vitreoretinal structures difficult to image in chandelier or endoilluminator diffuse, side-scattered lighting. Microendoscopy’s ultra-high magnification video monitor images can reveal microscopic tissue details blurred partly by ocular media aberrations in contemporary surgical microscope ophthalmoscopy, thereby providing a lower resolution, invasive alternative to confocal fundus imaging. Endoscopic surgery is particularly useful when ocular media opacities or small pupils restrict or prevent transpupillary ophthalmoscopy. It has a growing spectrum of surgical uses that include the management of proliferative vitreoretinopathy and epiretinal membranes as well as the implantation of posterior chamber intraocular lenses and electrode arrays for intraretinal stimulation in retinitis pigmentosa. Microendoscopy’s range of applications will continue to grow with technological developments that include video microchip sensors, stereoscopic visualization, chromovitrectomy, digital image enhancement and operating room heads-up displays.

Conclusion

Microendoscopy is a robust platform for vitreoretinal surgery. Continuing clinical and technological innovation will help integrate it into the modern ophthalmic operating room of interconnected surgical microscopy, microendoscopy, vitrectomy machine and heads-up display instrumentation.