Timothy W. Olsen, M.D., an ophthalmologist and vitreoretinal surgeon at Mayo Clinic in Rochester, Minnesota, performs a 25-gauge pars plana vitrectomy to address a complex, diabetes-related tractional retinal detachment in an eye with active proliferative disease. He uses bimanual techniques in a modified en bloc dissection for a macula-off detachment and a preexisting atrophic nasal stretch hole. Yeah, Today we have a traction retinal detachment involving the Macula with 360° Macula off. Uh and a small a trophic nasal break from a stretch whole. Let's look at how we would approach this using a modified unblock dissection technique. We started the optic nerve, work our way out. Okay, so right now we're just doing a core of attracting me. I want to maintain peripheral vitreous traction. The reason is I want that anterior posterior attraction to remain in place because that will help us when we do our on blocked by section. So I'm going to have them go through the posterior hi Lloyd here in the indie sector of the sclerotic me. So at this point we have a nice core of a trek to me, we've modified our anterior posterior attraction slightly by opening up spaces through the posterior cortical victories or post here. Hi Lloyd. We're looking at a circumferential traction detachment Immaculata. Our goal at this point is to get all the traction off the macula. So here is separating the traction at the temporal border of the desk. We'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 poster attraction, you can see right there because that part of the complex is held up interior lee off the surface of the retina. Alright, so now we've got again, ap traction. You can see real well on this little sector. And so were 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 attraction. There we go. Now we've separated this little sector off. We're behind the high Lloyd 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. Now you've got floppy vitreous behind a localized attraction or attachment of vitreous here, you know, we've got more envy tissue here. You can see it's kind of this diaphanous vascular stuff. Okay, our nerves up there, we've got an inferior area of traction. We've got a big area of traction here. That's along the super temporal arcade. So I use a pinch technique with bi manual, so pinches cutting the pegs when I clamp one side with the pick the other side. I used the vitreous cutter. Okay, so the beauty of the Lovenox is what you see right now. Much easier to ask. Great blood that just is loose like sand than it is to peel clots from off the surface of the retina. Okay, here's our ap traction, which I just cut through. See this is vascular rised. High Lloyd. So I'm coming into the eye and extending the probe but along the vitreous base. So to do it systematically out of go 180 degrees in the temporal first and then 180 degrees nasal. Always starting at six o'clock. And as you get closer to your report, you have to come out of the I'm or the hardest spot to do this. The trek to me is super. Oh nasal. Alright. So we've got posterior sub retinal fluid probably from this nasal break, but the immaculate free attraction at this point. Yeah. So we've got nice tissue response around the break so that should seal it up Nice mm. Hmm mm. Hmm hmm. Hmm. Hmm. Hmm hmm hmm hmm hmm. Yeah. Yeah. Yeah.