Perfluorocarbon Liquid Air Exchange

In this part of the presentation, I’ll be speaking about perfluorocarbon liquid, or PFCL injection technique, PFCL air exchange, and also, possible complications in relation to PFCL use.

This is a case of a giant retinal break and suprachoroidal hemorrhage after a complicated cataract surgery. In this case, the use of perfluorocarbon liquid can be useful to unroll the flap, and also to displace the hemorrhage.

Using a dual bore cannula, PFCL is injected over the optic nerve. And here, I’m trying to get the bubbles to coalesce to be a single bubble, and keep injecting in this bubble. It’s very important not to inject forcibly, as the PFCL jet can penetrate into the retina.

Further injection of PFCL in the bubbles continue till the PFCL level reaches to the edge of the giant tear. With the retina being flat, laser is performed.

Another indication where I would use perfluorocarbon liquid is when there is a retinal detachment, a rhegamtogenous detachment, and I cannot find the break. Putting PFCL till the equator pushes the fluid peripherally, and puts the retina under pressure, this can facilitate detection of the break, where you can see the schliern through the break. And sometimes the break pouts from being put under pressure.

In bullous retinal detachment, a PFCL can stabilize the posterior retina, making vitreous removal in the periphery easier.

Perfluorocarbon liquid can also be used routinely in uncomplicated retinal detachment to displace the fluids through the main break, and avoid the need for a drainage retinotomy. Personally, I try to avoid the use of perfluorocarbon liquid unless I really need it for complex retinal detachment.

When I use this retinal attachment, I inject the PFCL to the posterior edge of the break. Air is then being introduced, and I spend a time aspirating the BSS layer between the coming air and the perfluorocarbon liquid. The endpoint is when the edges of the retinal tear are flat on the choroid.

In this case, I would then move over the optic nerve to aspirate the perfluorocarbon liquid and increase the airfield. For this surgery, I am using a 25-gauge vitrectomy system. The aspiration is active, connecting the backflush to the extrusion system.

There are potential complications in relation to perfluorocarbon liquid use, which include subretinal perfluorocarbon liquid, retinal slippage and giant retinal tear, and also retained perfluorocarbon liquid.

This is a case of subfoveal perfluorocarbon liquid, which is a possible complication of its use. Here, as you can see, one of the risk factors that can cause subfoveal or subretinal PFCL is sloshing of the PFCL, which can happen during indentation and release of indentation. One needs to be very wary to try to avoid the sloshing that can lead to PFCL bubbles going under the retina through a retinal break.

Another reason for a possible perfluorocarbon liquid injection is what we call double dipping. Here, there is a perfluorocarbon liquid silicone oil exchange. The perfluorocarbon liquid is removed, with further drainage over the nerve. Now, moving again to the peripheral break with a flute cannula can lead to some bubbles of PFCL from the flute cannula to go under the retina through this break.

Another case of giant retinal tear to further illustrate the technique of PFCL air exchange, and some of the tips and the pitfalls related. Here, I’m injecting the perfluorocarbon liquid over the nerve, trying to get the bubbles to coalesce in one bubble. And further injecting into the bubble to unroll the retina.

And as the bubble enlarges, the retina is put back into its normal position under the perfluorocarbon liquid. The retina is now flattened under the perfluorocarbon liquid, and retinopexy can be performed.

This is the start of the exchange with air coming in the vitreous cavity. The backflush is placed in the BSS layer just behind the air. In general, and especially when dealing with giant retinal tear, careful attention is needed to aspirate the BSS at the edge of the tear completely, so that the edges are stuck down on the choroid before moving over the optic nerve to aspirate the perfluorocarbon liquid.

Having drained the fluid anteriorly, now I’m moving towards the optic nerve head with the backflush to remove the perfluorocarbon liquid from the vitreous cavity. Trying to do this in one motion decreases the risk of retained perfluorocarbon liquid.

This is a photograph of retinal slippage in a case of giant retinal tear during PFCL air exchange.