1. Illumination and light toxicity vitreoretinal surgery
Retina Sessions I.M.O 2009
Leyla Asgarova, MD
Illumination and light toxicity in
vitreoretinal surgery

2. Light toxicity
Verhoeff, 1916
Noell, 1966
Light source intensity
Spectral content of the light
Exposure time

3. Focal
Diffuse
Specular
Retroillumination
Slitlamp attachment for the OM

4. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery
Bullet light probes
Shielded bullet probes (provide up to 180Þ of illumination while controlling glare)
Chandelier lighting systems

5. ILLUMINATED INSTRUMENTS, CHANDELIER LIGHTING
Dual-mode cannula
Tornambe Torpedo (Insight Instruments, Stuart, Fla)
Synergetics Awh Chandelier
Tissue manipulator
Viscodelamination light probes

6. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery
Tungsten halogen system
Alcon Accurus: Fort Worth, Texas
Short-arc Xenon illumination system:
Alcon Accurus
Synergetics’ Photon box (O’Fallon, Mo)
Metal halide system
Millennium, Bausch & Lomb, (Rochester, N.Y.)
Mercury vapor

7. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery

8. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery

9. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery

10. Evolutionary and Revolutionary Trends in Vitreoretinal Surgery

11. Spectral content of the light

12. Spectral content of the light

13. Broadband blue light (400-520 nm)
Function and morphology of the retinal pigment epithelium after light-induced damage
Purpose: To determine the threshold energy for light-induced functional damage of the retinal pigment epithelium at various wavelengths
Broadband blue light ( nm)
Yellow light ( nm)
Narrowband blue light (408, 417, 439, 455, 485, 501)
58 pigmented rabbit eyes, 21 albino rabbits.
Blue light 30 times more efficient than yellow light in causing dysfunction of the blood-retinal barrier.
Melanin seemed to play no role. No influence on the threshold energy.

14. Endoillumination during vitrectomy and phototoxicity thresholds
Br J Ophthalmol 2000;84:1372–1375
Not safe with respect to photochemical retinal damage
International Commission on Non-Ionizing Radiation Protection (ICNIRP)
1 min - 10 mm working distance

15. CONCLUSIONS: 10 human eyes 6 pig eyes
Histology of the Vitreoretinal Interface after Indocyanine Green Staining of the ILM, with Illumination Using a Halogen and Xenon Light Source
10 human eyes
6 pig eyes
3 min light exposure: xenon and halogen
CONCLUSIONS:
Care should be taken when comparing results obtained in human eyes and porcine eyes.
Investigative Ophthalmology and Visual Science. 2005;46:

16. Three general mechanisms: Thermal (thermal confinement)
Light toxicity
Three general mechanisms:
Thermal (thermal confinement)
Mechanical (stress confinement)
Photochemical effects

17. Retinal vessel abnormalities of phototoxic retinopathy in rats
Progressive loss of outer retina
Approximation deep capillary bed
Vaso – obliterative changes
Extensive pyknosis and reduction of nuclei in the outer nuclear layer, damage to ganglion cells, and edema formation.

18. Newer Endoilluminators Ease 25-Gauge Surgery (Retina today, Allen C)
Normal and 1.5-hour light exposed retina with a fixed position endoilluminator. Images show a normal rabbit retina (A), a Tungsten-halogen exposed retina (B), a xenon-bipass exposed retina (C) and a metal-halide exposed retina (D).

19. Light toxicity and BIO
Exposure to the indirect ophthalmoscope for more than 15 minutes is necessary to cause retinal lesions.
Robertson DM, Erickson GJ. The effect of prolonged indirect ophthalmoscopy on the human eye. Am J Ophthalmol 1979;87:
Ts'o MOM, Fine BS, Zimmerman LE. Photic maculopathy produced by the indirect ophthalmoscope. 1. Clinical and histopathologic study. Am J Ophthalmol 1972

20. Long-term follow-up of iatrogenic phototoxicity.
Arch Ophthalmol 1998;116:753-7.
Iatrogenic phototoxicity following either cataract or vitrectomy surgery
average duration of surgery minutes %
longer %
(Khwarg et all)

21. 3% - 7% of cataract cases (0-28%) Light duration (?) – 11 min
6 patients
3% - 7% of cataract cases (0-28%)
Light duration (?) – 11 min
McDonald HR, Irvine AR. Light-induced maculopathy from theoperating microscope in the extracapsular cataract extraction and intraocular lens implantation. Ophthalmology. 1983;90:

22. Symptomatic vs asymptomatic Visible vs invisible
The early finding: deep retinal whitening +/- serous retinal detachment
Oval shaped vs round homogenous
Resolution 48 hours after surgery
Mottling RPE in late postop
IVFA: window defect
Autoflurescence (!)
OCT
Kleinmann G, Hoffman P, Schechtman E, Pollack A. Microscope-induced retinal phototoxicity in cataract surgery of short duration. Ophthalmology. 2002;109:

23. OCT Y FOTOTOXICIDAD MACULAR
ARCH SOC ESP OFTALMOL 2008; 83:

24. Light toxicity after cataract surgery

25. Light toxicity after cataract surgery

26. Light toxicity and ECCE

27. Light toxicity in MH surgery
In a controlled clinical trial for macular hole repair surgery 7% of patients had presumptive photo- chemical retinal toxicity with a significantly worse visual outcome.
Banker AS, Freeman WR, Kim JW, et al. Vision-threating complications of surgery for full-thickness macular holes. Ophthalmology 1997;104:1442–53.

28. Light toxicity by fiber light probe

29. Iatrogenic phototoxicity during vitrectomy.
3 cases
one week after surgery
size DD
2 eyes fovea spared
Macular phototoxicity caused by fiberoptic endoillumination during pars plana vitrectomy. Am J Ophthalmol Sep 15;114(3):287-96
A2e mediated phototoxic effects of endoilluminators, Br. J. Ophthal, 2006
Michels M, Lewis H, Abrams GW, et al. Macular phototoxicity caused by fiberoptic endoillumination during pars plana vitrectomy. Am J Ophthalmol 1992; 114: ,

30. Xenon light induced phototoxicity lesions
Arch Soc Espanola de Oftalmologia, Febr 2000

31. Xenon light induced phototoxicity lesions

32. Long-term Follow-up of Iatrogenic Phototoxicity
24 eyes (20 ant. segment surgeries, 4 – vitrectomy)
min, aver. surgical time min.
Follow-up - 34 months
Lesions spared to fovea – ant. segment surgeries
involved fovea – after vitrectomy
Inferior the fovea – 9
superior – /20 – 20/25
temporal – 3
subfoveal /400
Arch Ophthal, Vol. 116 No. 6, June 1998

33. Long-term Follow-up of Iatrogenic Phototoxicity

34. Long-term Follow-up of Iatrogenic Phototoxicity
Decreasing in size – 21%
No correlation age - visual outcome. (VO)
change in lesion size - VO
Symptomatic – 33%

35. Long-term Follow-up of Iatrogenic Phototoxicity

36. Predisposing conditions and light toxicity
39 years old F
Systemic lupus erythematosus (SLE) + hydroxychloroquine treatment
Phototoxic maculopathy following uneventful cataract surgery in a predisposed patient. Br J Ophthalmol June; 86(6): 705–706

37. Phototoxicity to the retina: mechanisms of damage.
Int J Toxicol Nov-Dec;21(6):
Antibiotics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Psychotherapeutic agents (Amitrityline, Chlorpromazine, Imipramine, Iprindol, Prozac Thioridazine)
Herbal medicine

38. D/D
Applying aspiration to macular holes for drying purposes when using adjuvants
ICG and other dyes used to visualize the ILM
Aminoglycoside antibiotic toxicity
Unrecognized mechanical trauma to RPE

39. Light toxicity and ICG assisted ILM peeling
72 years old man
MH stage III
Xenotron II, Geuder, Germany
2 times 0.05 % ICG
10-15 attempts – 10 min + 2 min
Post op: MH closed
Vis postop – HM + centra (12 weeks)
Severe retinal damage after macular hole surgery with extensive indocyanine green-assisted internal limiting membrane peeling (Eye (2004) 18, 538–539

41. Banker AS, Freeman WR, Kim JW, Munguia D, Azen SP
Banker AS, Freeman WR, Kim JW, Munguia D, Azen SP. Vision-threatening complications of surgery for full-thickness macular holes. Vitrectomy for Macular Hole Study Group. Ophthalmology 1997; 104: 1442–1452

42. SURGICAL CONSIDERATIONS
Any illumination system can be phototoxic, therefore usually precautoins apply.
Surgical time shortened (?)
Various filters are introduced during surgery.
Try to vary the directionality and intensity of light throughout the case; combining diffuse and tangential "spot" lighting
No use illuminated forceps or scissors in macular surgery (small gauge surgery)

43. To reduce the risk of retinal phototoxicity:

44. Xenon BrightStar - 1266-XIII, DORC
420nm cut-off: standard
435nm cut-off: for core vitrectomy and general membrane removal
475nm cut-off: for removal of membranes adherent to the retina
515nm cut-off: for macular repair

45. SURGICAL CONSIDERATIONS
Illuminating just the area between the vascular arcades, which has a diameter of about 10 mm, would correspond with a fibre- optic distance of only 5 mm
Minimize the time that the fiber optic tip is less than 8-10 mm from the retinal surface
Not to use the light probe as an instrument to manipulate the detached retina (photochemical damage)
Exposure to the operating microscope light should be minimized as much as possible by either turning off the illumination source or placing a small shield or cover on the cornea when not using the microscope

46. To reduce the risk of retinal phototoxicity:

47. SURGICAL CONSIDERATIONS
Use of intraoperative dyes, such as indocyanine green, or systemic medications, such as tetracycline, may alter the threshold for damage.
Be aware of the output power from the fiber optic; ideally aim for mW.
Power output range from 24 lumens for stiff 25- gauge light probes to over 80 lumens on some chandeliers.
Remember that a fresh bulb will increase the power output.
Surgical video!

48. GRACIAS
Festival Grec
Ennogata, Sylvie Guillem
July 2009

49. Application of a Newly Developed, Highly Sensitive Camera and a 3-Dimensional High-Definition Television System in Experimental Ophthalmic Surgeries (Arch Ophthal. 1999, 117, 1623 – 1629)

50. A, Removal of the vitreous gel (4500 lux)
A, Removal of the vitreous gel (4500 lux). B, Procedures during "back flash" technique for creating posterior vitreous detachment (14,700 lux). C, Membrane peeling. Note the fine fibrous tissue (8900 lux). D, Membrane peeling (6300 lux).