Hello everyone! I am Dr. Zheng Bin, Deputy Chief Physician of Hangzhou Hospital of Zhejiang Province Eye Hospital. In the last article of “Macular Premacular”, I focused on what is macular premacular, this time I will focus on the issues related to macular premacular surgery, hope it will be helpful to you!
The first question is, “How do I get anesthesia?” Most eye surgeries are performed with local anesthesia, that is, anesthesia that is only localized to the eye, in order to stop the eye from turning and eliminate pain. Therefore, the patient is very conscious during the surgery, and I sometimes chat with the patient while operating to relax the patient’s tension. Ophthalmic anesthesia generally has less impact on the general condition, compared to the overstimulation of the patient which is much more threatening. Because macular surgery is a special category in ophthalmology surgery, it requires not only profound fundus surgical skills and good psychological quality, but also the patient’s complete cooperation in the process, especially not to move around, including not to talk, not to cough, not to turn the head and other movements that cause the eye to move slightly (because the whole operation is done under the microscope), it seems difficult to say so much, but in fact it is very simple. I have done so many surgeries almost all can cooperate.
Summary.
1, mature specialist can do a good job of anesthesia, can ensure that the surgery is painless, but certain fixed pressure links will have mild discomfort.
2.Patients who have been drinking alcohol for a long time, have a history of anesthesia or are overly sensitive will have some influence on the anesthetic effect, and there will be auxiliary anesthetic measures when necessary.
3, pre-operative tension is inevitable, and will slowly relax during the operation because it is not painful.
4, the patient can not fall asleep during surgery, to have some awareness (even if they fall asleep, I will wake up, otherwise a dream to move may be a problem, huh).
5, any intraoperative patient movement, are required to report consent before activity.
6, post-anesthesia drugs last 24 hours, such as afternoon surgery, the next morning the patient may still not be able to open their eyes or eye movement is limited.
7, special anxiety or psychiatric history and other special patients need general anesthesia.
As the saying goes, “If you want to be good at what you do, you have to be good at what you do”, and even a good surgeon cannot do without advanced surgical equipment. Since ophthalmology requires very high equipment for examination and surgery, and each piece of equipment is exceptionally expensive, the difference between ophthalmic diagnosis and surgical techniques is very great. If you observe, if a place has a very good ophthalmology, other surrounding places ophthalmology is difficult to develop and gradually shrink, and often there is a situation where one is the only one. Our hospital is the only tertiary ophthalmology hospital in Zhejiang Province, with a national specialty ranking of the top 5 glory, naturally our equipment not to mention Zhejiang, that is, in the national hospital comparison is also known for good, sorry to show off, because I really benefit a lot as a posterior segment surgeon.
This slide gives you the scene of an eye operating room in our hospital.
1, vitreous cutting machine, is the core of vitreous surgery, this machine is currently the most advanced in the country, there are up to 5000 times the cutting speed, unusually fast and stable.
2, ophthalmic surgical microscope, the entire surgical process is completed through it, through it to see things are magnified, so the surgery can not move yo!
3, fully automatic surgical bed, sometimes the patient will automatically get up before and after the operation, I often joke, “up and stay still, otherwise such an expensive bed wasted,” Oh, this bed can automatically control the position.
4, video system, some difficult surgical steps will be recorded to facilitate teaching and teaching, we are also a teaching hospital to train a number of masters and doctors it.
5.Surgical instrument table, there is a full-time nurse responsible for surgical instrument management during surgery, this is our characteristic, many other hospital departments do not have nurses on the table, our surgical process will be very orderly!
6, control the above machine foot pedal, eye surgeons driving skills are better, may benefit from this, hand and foot, huh.
This one down also tens of millions of bar, so eye surgery can be called high!
This photo shows you the position of each person during surgery. There are 4 people in the picture, 1, the main surgeon, 2, the assistant, 3, the instrument nurse and 4, the patient (lying on the bed it, can not see). The main surgeon is actually sitting in the direction of the top of the patient’s head when the patient is lying flat and observing the patient from above. The patient is lying on the bed at this time, the face is all covered by the surgical towel wrap, only the surgical eye is exposed, so some patients often have difficulty breathing, in fact, each patient has a catheter to supply oxygen, this situation is still due to nervousness and fear, so it is necessary to explain the preoperative.
Nowadays, many medical units are emphasizing minimally invasive and how fine their instruments are, etc. In fact, this is very one-sided. I often tell graduate trainees and junior doctors that the concept of minimally invasive should be implemented throughout the surgery, especially in the surgeon’s technique, even conventional instruments can make minimally invasive results, and even minimally invasive instruments can cause more than conventional damage. Here I will specifically show an important instrument of our surgery – knife! Oh, you must have noticed by looking at the picture that this is actually our scalpel – the vitreous cutting head, which is the message you often look up on the Internet.
Minimally invasive to say simply that the incision is small, you see 2 Figure shows three different fine knife, the bending degree under the same weight, the thickest 20G bending small, the thinnest 25G, the middle is 23G is also currently the most most commonly used. Figure 3 shows the partial magnification, you can see the right fine. Conventional surgery requires six incisions in the eye, while minimally invasive surgery involves inserting three cannulas directly into the eye via the sclera (Figure 1)) to quickly establish surgical access and facilitate the movement of instruments in and out of the eye, minimizing the occurrence of surgical complications. When the cannula is removed after surgery, the wound is able to close on its own due to its thin diameter. To minimize complications due to wound leakage after surgery, I often perform suturing.
In this slide I am going to focus on the core of the anterior macular membrane surgery – the stripping of the membrane. I am very sorry that I cannot show the video of my surgery, but only by means of screenshots, but the reasoning is very simple. I hope that through the explanation, you can understand the details of the surgical design and have a visual judgment on whether the surgery is safe or not.
1. In this set of pictures of staining I did not show the steps of staining, but only the results. Do you observe a green color in the pictures? This is the part that is stained, which is normally completely transparent. For the safety of surgical operation staining should be done. In Figure 1, we can see that the area of the anterior membrane surrounded by the dotted line is not stained and there is significant staining outside of it. Accordingly, the surgeon can determine the location and extent of the anterior membrane.
I am used to start the flap at the edge of the anterior membrane, at this point we can see that the starting position is far from the center of the macula, and the risk of surgery is reduced a lot, but this step is also the most dangerous, the slightest inadvertent instrumentation will damage the retina. But for a mature fundus surgeon is not a problem!
In general, the membrane is not very tightly attached to the macula, but it is not so easy to peel it off, but the longer the disease is, the tighter it is sometimes, it is not easy to peel it off or it cannot be peeled off completely. This is one of the reasons why surgery should be performed as early as possible.
4. In Figure 4, we can see that the membrane is completely free. However, you notice the bleeding spots shown by the red arrows, are you a bit worried? In fact, this is a common phenomenon during the procedure, caused by the rupture of individual capillaries when peeling the membrane, some of them will be more obvious, and generally will not have any effect on vision.
Summary.
1, the surgery requires the peeling of two layers of membrane – the anterior membrane and the inner boundary membrane, the latter peeling can reduce the incidence of recurrence.
2, The surgery is not deliberately operated in the center of macula, so the safety is guaranteed.
3.The difficulty of removing the anterior membrane is very much related to the course of the disease, the longer it is, the more difficult it is to remove, and the damage will be large.
4.Any macular surgery has more or less damage to the macula, but the damage of the disease itself is greater.
5.So far, there is no medicine to treat the macular anterior membrane, the only way is surgery.
These two elderly people are both women around 80 years old, with good financial base and access to medical care, both suffering from macular pre-macular, both experienced at least 2 years of so-called conservative treatment, both raised victory gestures after the surgery, the only difference is different cities. This also reflects 2 points, 1. Many doctors in many places still have misconceptions about pre-macular surgery, or even do not understand the situation at all. (The old man on the right had been hospitalized in a large local hospital for cataract 2 years before the surgery, and the examination found the macula previa, the doctor thought the cataract surgery was not effective, and the macular area was not operable, and suggested to discharge; the old man on the left was diagnosed in a local hospital, the doctor thought the macular surgery was risky and ineffective, and did not suggest surgery and medication); 2, the surgery process itself is comfortable.
Many macular disease patients experienced the long process of seeking medical treatment, saw many hospitals and many experts, often heard two completely different opinions, at a loss! I hope my explanation can make you see the clouds and choose correctly. If you still have questions, please feel free to contact me and I wish you a speedy recovery!