case_images: PMC10601813_01
case_images: Overview of treatment (upper part) and outcome of treatment (lower part) of the peripheral retinal hemangioblastoma (PRH) and juxtapapillary retinal hemangioblastoma (JRH) between 2016 and 2022. As the outcome of treatment, the course of best corrected visual acuity (black dashed line) and central foveal thickness (black solid line) pre- and postoperatively are presented. The red dotted line indicates the timepoint of application of the novel surgical technique in which intraocular bipolar diathermy of the feeder and draining vessel of the JRH was performed.
case_images: cop-2023-0014-0001-530687_F01.jpg
case_images: PMC10601813_01_cop-2023-0014-0001-530687_F01.jpg
case_images: F1
case_images: Figure 1 gives an overview of treatments performed for the patient's right eye in the Rotterdam Eye Hospital (Fig. 1, upper part) and the treatment outcome from May 2016 to September 2021 (Fig. 1, lower part). Visual acuity increased to 0.4 decimal 3 months after surgery and to 0.5 decimal 4 months postoperatively (Fig. 1, lower part).
case_images: Video still images illustrating the different steps of the novel surgical technique for feeder vessel (a-f) and draining vessel (g-l) coagulation of a sessile juxtapapillary retinal hemangioblastoma (JRH). Identification of the blood vessels (a, g); retinal incision above, parallel to, and as deep as the blood vessels using a bent 23-gauge stiletto tip (b, h); blood vessels pulled up just above the retinal surface with the bent stiletto tip (c, i); blood vessels visible between the open jaws of the diathermy forceps (d, j); blood vessels compressed and coagulated with closed forceps jaws above the retinal surface (e, k); closed blood vessel with limited visible retinal collateral damage after coagulation using the 23-gauge intraocular diathermy forceps (f, l).
case_images: cop-2023-0014-0001-530687_F02.jpg
case_images: PMC10601813_01_cop-2023-0014-0001-530687_F02.jpg
case_images: F2
case_images: Because of tumor growth, exudation, and bleeding, in September 2020, a new surgical technique was applied by the first author, in which intraocular bipolar diathermy forceps were used to coagulate feeder (Fig. 2a-f) and draining vessels (Fig. 2g-l) above the retinal surface (see also the online suppl. A newly formed feeder vessel and draining vessel were identified and elected for coagulation (Fig. 2a, g). During a 23-gauge pars plana vitrectomy, retinal incisions were made just above and as deep as the feeder and draining vessel using a bent stiletto tip (Fig. 2b, h). Using the same bent stiletto tip, the blood vessel was hooked up and pulled above the retinal surface (Fig. 2c, i). Then, the intraocular bipolar diathermy forceps were used to grab, compress, and coagulate the blood vessel above the retinal surface (see Fig. 2d-f, J-l).
case_images: Pre- and postoperative fundus photography (upper row), optical coherence tomography (OCT) thickness map (middle row), and OCT cross-section of the juxtapapillary hemangioblastoma (JRH). a 4 years preoperatively: decimal visual acuity (VA) 1.0, early stage juxtapapillary hemangioblastoma (JRH) with cystoid macular edema (CME) requiring regular treatment with intravitreal bevacizumab and subconjunctival triamcinolone acetonide. b 2 months preoperatively: VA was reduced to 0.15 with a larger JRH; some retinal hemorrhages, exudates, and more CME were retreated with bevacizumab and triamcinolone acetonide. c 1 month preoperatively: VA was 0.15 with less CME, more retinal hemorrhages and exudates, after which it was decided to perform the novel surgical technique. Briefly, intraocular bipolar diathermy forceps were used to grab, compress, and coagulate the feeding and draining blood vessels of the JRH during this surgery. d 3 months postoperatively: VA was 0.4 with much fewer retinal hemorrhages, exudates, and a whitish lesion, indicating reduced to no perfusion. e 6 months postoperatively: VA was 0.5 with no CME, retinal hemorrhage, and exudates 4 weeks after restarting bevacizumab and triamcinolone acetonide for CME reappearance. f 12 months postoperatively: VA was 0.4 with a new JRH temporal superior and a larger new or reperfused JRH temporal of the optic disc with increased CME and enlarged blood vessels temporal inferior of the optic disc.
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case_images: PMC10601813_01_cop-2023-0014-0001-530687_F03.jpg
case_images: F3
case_images: These blood vessels were chosen by comparing fundus examination and fluorescence angiography imaging of 4 years and 2 months before surgery (Fig. 3a, b). An increased thickness of a vein inferior to the JRH was noticed, which now seemed to function as the main draining vessel (Fig. 3f).