Author: Roslyn Manrique (United Kingdom)
Co-authors: Sidath Liyanage, Johannes Keller, Richard Haynes, Nick Muthiah
To describe the management of subretinal air migration occurring during fluid air exchange.
Vitreoretinal Service. Bristol Eye Hospital. University hospitals of Bristol NHS, Bristol, United Kingdom.
A 63 years-old man presented to our Eye Emergency Department with a history of three weeks of loss of vision in his right eye. An unremarkable past ocular history and mild vascular dementia as a medical general condition were referred. Under examination, the visual acuity was hand movements with a mild cataract and a positive Shafer sign. Fundus view presented a total retinal detachment with open funnel configuration associated with a large post equatorial break (2 hours) with rolled edges and PVR CPA4 compromising the inferior quadrant.
25-gauge core vitrectomy (PVD present), and peripheral vitrectomy with carefully trimmed of the vitreous base was performed. Then, Brilliant peel dual dye was injected for removal of anterior star folds affecting the inferior quadrant (9 to 7 clock hours) as well as on the posterior pole. After that, the rolled edges of the large tear were trimmed. After careful peripheral examination under scleral indentation no more breaks found. Next, a fluid air exchange was performed with the migration of a large bubble of air under the retina through the large break, immediate fluid is returned attempting unsuccessfully to aspirate the air bubble with an extrusion cannula. Hence, the infusion port is removed and placed in the inferonasal quadrant. A gentle rolled motion scleral massage with an indenter is performed starting superiorly to the location of the subretinal air bubble and tilting the eye inferior-nasally, achieving the evacuation of the air bubble through the large tear. Fluid air exchange is repeated with drainage of subretinal fluid obtaining a flat retina, then laser was applied around the large tear, followed by 1000 Cs silicone oil injection. Finally, ports were removed and sclerotomies were sutured with 8/0 Vicryl.
Subretinal air is a complication that could occur in presence of a large tear located in the proximity of the infusion cannula and after the formation of multiple small bubbles during fluid air exchange. Some simple manoeuvrers may be useful to deal in this situation, first relocate the infusion cannula away from the retinal tear, back to fluid by aspirating the subretinal air bubble, if it is unsuccessful, then tilting the eye and a gentle scleral indentation at the same time will permit the evacuation of the subretinal air.
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