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TIMOTHY W. OLSEN: Today we have a traction retinal detachment involving the macula with 360 degrees macula-off and a small atrophic nasal break from a stretch hole. Let's look at how we would approach this using a modified en-bloc dissection technique. We start at the optic nerve, work our way out.

So right now, we're just doing a core vitrectomy. I want to maintain peripheral vitreous traction. The reason is I want that anterior-posterior traction to remain in place, because that will help us when we do our en-bloc dissection. So I'm going to have them go through the posterior hyaloid here, in the sector of the sclerotomy. So at this point, we have a nice core vitrectomy.

We've modified our anterior-posterior traction slightly by opening up spaces through the posterior cortical vitreous, or posterior hyaloid. We're looking at a circumferential traction detachment of the macula. And our goal at this point is to get all the traction off the macula. So here, it's separating the traction at the temporal border of the disk. They've got a nice little contracted vitreous up here.

And if you have a nice visible trough, it's easy to segment. Now you've got the advantage of the anterior-posterior traction. You can see right there, because that part of the complex is held up anteriorly off the surface of the retina. So now we've got, again, AP traction-- you can see real well on this little sector. And so we're basically done with this quadrant.

You can see it quite nicely. The beauty of the PRP is it's holding the retina back. But there's the traction--

There we go. Now we've separated this little sector off. We're behind the hyaloid there, and we've got nice laser peripheral to that. Now all you have to do is free this up from the vitreous attachment. And the pick helps a lot here, again, because it helps separate that.

And there you've got floppy vitreous behind, a localized tractional attachment of the vitreous here, and we've got more in-V tissue here. You can see it's this diaphanous vascular stuff. OK, our nerve's up there. We've got an inferior area of traction.

We've got a big area of traction here that's along the supra-temporal arcade. So I use a pinch technique with bimanual. So [INAUDIBLE] is cutting the pegs when I clamp one side with the pick. The other side, I use the vitreous cutter. OK. So the beauty of the Lovenox is what you see right now. Much easier to aspirate blood that is loose like sand than it is to peel clots from off the surface of the retina.

OK, here's our AP traction, which I just cut through. See, this is all vascularized hyaloid. So I'm coming into the eye and extending the probe, but along the vitreous base. So to do it systematically, I would go 180 degrees in the temporal first, and then 180 degrees nasal, always starting at 6 o'clock. And as you get closer to your port, you have to come out of the eye more.

The hardest spot to do this vitrectomy is supranasal. All right, so we've got posterior subretinal fluid, probably from this nasal break. But the macula's free of traction at this point. So we've got nice tissue response around the break. So that should seal it up nicely.

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