ENDOSCOPY ASSISTED ARTERIO-VENOUS SHEATHOTOMY FOR BRANCH RETINAL VEIN OCCLUSION

Stephen H. Sinclair (Upland)

Introduction: Arterio-venous sheathotomy combined with pars plana vitrectomy has been previously reported as a method to remove venous outflow obstruction for branch retinal vein occlusions. However, bleeding of nerve-fiber-layer capillaries surrounding the embedded vessels may reduce visualization of the dissection and make opening of the sheath hazardous especially for small tertiary veins occlusions involving the macula.

Materials and Methods: The author has had experience with utilization of the GRIN lens 20G endoscope (Insight Instruments) to assist in the visualization during sheathotomy in 9 eyes with non-ischemic vein occlusions in which loss of vision was associated with a progression of edema or the progressive development of cystoid degeneration with edema. The endoscope was utilized intermittently to obtain a highly magnified view of the sheath and vessels and surrounding tissue with dissection carried out under binocular stereo microscopy with elevated IOP to prevent bleeding. This technique prevented ripping of the vessel and allowed careful dissection even of small tertiary branch occlusions affecting the macula.

Results: Mean age 70.8. Five of the eyes had quadrantic branch occlusions while 3 had small tertiary vein occlusions involving the macula, and one a mild central vein occlusion with a superimposed more severe quadrantic vein occlusion. Pre-operative ETDRS vision ranged from 20/60 to 20/270 with macular edema in all cases and recognizable cystoid changes in 7. Follow-up has been for more than 1 year in 4 eyes, > 6 months in 3 eyes and > 3 months in 2 eyes. Vision improved by more than 3 lines (doubling of visual angle) in 5, remained the same in 2 eyes, and decreased by 3 lines in 2 (at early follow-up). Complications included a secondary rhegmatogenous detachment and a subretinal choroidal neovascular membrane (each in one eye, successfully treated) and an aggravation of intra-retinal hemorrhage in 2 eyes, currently in the early post-operative course.

Conclusion: Intra-ocular endoscopy appears to facilitate visualization during sheathotomy for retinal vein occlusions. Videos of the surgery will be presented along with a discussion of the evolving decision making regarding the optimum choice of candidates for this procedure versus other methodologies.


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