New M.D.

By Allen Chiang, M.D.

Surgical Journals

A Priceless Resource

Although it’s early in my training, I’ve quickly learned that becoming a competent ophthalmic surgeon demands endless practice, perseverance and a compulsive attention to detail. To that end, each residency program makes a commitment to teach us the basic fundamentals of ophthalmic surgery. However, the highly motivated resident continually searches for ways to excel beyond this in hopes of becoming an outstanding surgeon.

With the help of Uday Devgan, M.D., I’ve discovered that one useful approach is to make a habit of keeping a “surgical journal.” Each surgical case, regardless of outcome, represents a unique opportunity to not only refine fundamental skills, but to obtain surgical pearls as well. In many instances, these come from some of the best surgeons in the field and may become invaluable tools in future practice — if they are added to your surgical armamentarium.

That’s where mentally reviewing each case and scribbling critical learning points into the journal comes in. Some pearls may focus on crucial aspects of a certain procedure while others may pertain more to the finer details, such as the one I am about to discuss.

A New Surgical Pearl

A few months ago, I was operating on one of my first glaucoma cases with Dr. Devgan, which involved implantation of an Ahmed valve. Aside from obtaining practical experience with the core components of the procedure, I gained a neat surgical pearl from him regarding the utility of intraocular triamcinolone. It involves injecting a small amount of triamcinolone into the anterior chamber once the Ahmed valve has been secured into position. This achieves the dual effect of verifying aqueous outflow through the tube shunt by direct visualization (see Figure), in which the white particles are whisked through the tube and out of the anterior chamber, and providing some reduction in conjunctival inflammation postoperatively.¹

Purifying Triamcinolone

Though triamcinolone has not been officially labeled for intraocular use, its use in various scenarios is well recognized, such as intravitreal injection for posterior segment inflammatory disease.² Purifying the triamcinolone of the preservatives in the vial will help to minimize potential adverse effects within the eye. This being said, be aware that the miniscule risk of complications such as retinal artery occlusion can never be fully eliminated.

Purification can be achieved through a straightforward process that has been described in previous articles by Dr. Devgan. First, draw 1 mL of triamcinolone (40 mg/mL) into a 5 mL syringe. Then place a 0.22 um filter onto the syringe and reattach the needle. Force the fluid through the filter and discard; this leaves the triamcinolone particles trapped in the filter. Next, draw 4 mL of sterile balanced salt solution into the syringe in order to re-suspend the particles. Repeat these last two steps once more to further “wash” the triamcinolone particles. The filter and needle can now be replaced by a blunt cannula, which can be inserted through a paracentesis into the anterior chamber. The final triamcinolone concentration comes out to 10 mg/mL and a few drops are all that is needed. Take care to shake the syringe before injecting, as the triamcinolone particles settle rather quickly. Lastly, inject some balanced salt solution to swirl the particles and increase the intraocular pressure slightly in order to overcome the preset limit of the Ahmed valve.

Overall, I have found that the small expense of time and effort spent in creating my surgical journal has offered me an invaluable resource for subsequent cases.

References