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Chapter

 

4 2

Management of Complicated Retinal Detachment

J M. L

G W. A

J C. W

Retinal detachments are considered “complicated” when reparation requires more than a scleral buckle. Complicated retinal detachments may be associated with vitreous hem- orrhage, proliferative vitreoretinopathy (PVR), giant tears, posterior holes or tears, choroidal detachments, ocular inflammatory diseases, trauma, and tractional retinal detach- ments. Complicated retinal detachments associated with giant retinal tears, ocular inflammatory diseases, trauma, and proliferative retinopathies such as diabetic retinopathy will be discussed elsewhere.

RETINAL DETACHMENT WITH PROLIFERATIVE VITREORETINOPATHY

Overview

PVR is the leading cause of failure in retinal detachment surgery, occurring in approximately 7% of all retinal detach- ments (1). During the past two decades, major advances have been made both in the understanding of the pathogenesis of PVR and in the surgical treatment of the disease (2–8). PVR is characterized by the formation of cellular mem- branes on the retinal surface, the retinal undersurface, and in the vitreous cavity (Fig. 42-1) (9). Cells within the mem- branes are derived from the retinal pigment epithelium (10,11) and from retinal glial tissue (12,13).These cells enter the vitreous cavity or subretinal space via breaks in the retina, undergo transformation to take on characteristics of fibroblasts or macrophages, and proliferate in a sheet-like configuration. Fibroblast-like transformed cells have con- tractile properties, with the ability to pull collagen fibers in a “hand-over-hand” manner (2). Thus the proliferative cel- lular membrane can insert into the vitreous and exert forces leading to tractional retinal detachment. Involvement is often most severe inferiorly; this finding is consistent with

the idea that dispersed retinal pigment epithelium cells that settle on the inferior retina due to gravitational effects play a prominent role in PVR formation. Primary PVR can occur in a long-standing rheg- matogenous retinal detachment. More commonly, it occurs secondarily after scleral buckling, vitreous surgery, or pneu- matic retinopexy treatment for rhegmatogenous retinal detachment, and is the leading cause of surgical failure and redetachment of the retina. Experimental study has shown that various factors associated with surgery, such as exten- sive application of cryotherapy (14), fibrin formation (15), and blood–retinal barrier breakdown may increase PVR formation.

Surgical Anatomy

The severity and extent of PVR can be described accord- ing to a classification system developed by the Retina Society in 1983 (Table 42-1) (5) and updated in 1991 (Tables 42-2 and 42-3) (6). Posterior PVR (posterior to the equator) consists of focal and diffuse retinal contractions and subretinal membranes, while anterior PVR (at or anterior to the equator) consists of focal, diffuse, or circumferential full-thickness folds, anterior retinal displacement, and sub- retinal membranes. Focal contractions are “star folds,” which are caused by contraction of a localized epiretinal mem- brane. Diffuse contractions involve four or more disk areas and are induced by larger membranes (Fig. 42-2). Folds without epiretinal membranes usually indicate the presence of subretinal membranes. Anterior PVR may result from deposition and pro- liferation of pigment epithelial cells on the inferior periph- eral retina along with contraction at the posterior edge of the vitreous base (Fig. 42-3). These membranes induce cir- cumferential contraction,shortening the circumference of the

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B A C
B
A
C

FIGURE 42-1.

903–1012.)

A. Migration of pigment epithelial and other

cells into vitreous cavity and subretinal space. B. Proliferation and contraction of cells on retinal and vitreous interfaces. C. Fixed folds

due to contraction of cellular membranes. (Adapted from Abrams GW, Aaberg TM. Posterior segment vitrectomy. In: Waltman SR (ed.). Surgery of the eye. New York: Churchill-Livingstone, 1988:

532 P ART III Retina and Vitreous Surgery B A C FIGURE 42-1. 903–1012.) A .
  • FIGURE 42-2.

Posterior PVR: Starfold (small arrow) (posterior

type 1), diffuse contraction (large arrow) (posterior type 2).

Classification is CP12. (Reprinted by permission from Abrams GW, Aaberg TM. Posterior segment vitrectomy. In Waltman SR (ed.). Surgery of the eye. New York: Churchill-Livingstone,

1988:903–1012.)

retina at the posterior vitreous base, which is pulled centrally. The retina posterior to the vitreous base develops radial folds, while retina anterior to the posterior edge of the vitreous base is smooth and pulled centrally (Fig. 42-4).With chronic- ity, there may be contraction of the vitreous base, which pulls the retina posterior to it anteriorly toward the pars plana, thus resulting in anterior retinal displacement. However, anterior retinal displacement is more commonly seen in eyes that have

532 P ART III Retina and Vitreous Surgery B A C FIGURE 42-1. 903–1012.) A .

FIGURE 42-3.

Contraction along posterior edge of vitreous

base with central displacement of retina. Peripheral retina stretched(*); posterior retina in radial folds( ) (anterior type 4). (Reprinted courtesy of Ophthalmic Publishing Company, from Machemer R, Aaberg TM, Freeman HM, et al. An updated

classification of retinal detachment with proliferative vitreoretinopathy. Am J Ophthalmol 1991;112:159–165.)

Table 42-1.

The Retina Society Classification of Retinal

Detachment with PVR

Grade

Clinical Signs

A

Minimal vitreous haze Vitreous pigment clumps

B

Moderate wrinkling of the inner retinal surface Rolled edge of retinal break Retinal stiffness Vessel tortuosity

C

Marked full-thickness fixed retinal folds

 

C1

One quadrant

C2

Two quadrants

C3

Three quadrants

D

Massive fixed retinal folds in four quadrants

 

D1

Wide funnel shape

D2

Narrow funnel shape*

D3

Closed funnel (optic nervehead not visible)

*

Narrow funnel shape exists when the anterior end of the funnel can be seen by indirect ophthalmoscope within the 45-degree field of a 20 D condensing lens

 

(Nikon or equivalent).

previously had a vitrectomy (Fig. 42-5). In these eyes, prolif- erating cells form a membrane on the surface of the remain- ing peripheral vitreous, which contracts, pulling the retina posterior to the vitreous base anteriorly toward the pars plana (Fig. 42-6A), the pars ciliaris (Fig. 42-6B), or even the pos- terior surface of the iris (Fig. 42-6C). In the most extreme instances, the membranes can pull the retina to the edge of the retracted pupil (Fig. 42-6D).

Chapter 42 Management of Complicated Retinal Detachment 533 Table 42-2. Updated Classification of PVR Described by
Chapter 42
Management of Complicated Retinal Detachment
533
Table 42-2.
Updated Classification of PVR
Described by Grade
Grade
Features
A
Vitreous haze
Vitreous pigment clumps
Pigment clusters on inferior retina
B
Wrinkling of inner retinal surface
Retinal stiffness
Vessel tortuosity
Rolled and irregular edges of retinal break
Decreased mobility of vitreous
C
CP1–12*
Posterior to equator:
CA1–12
Focal, diffuse, or circumferential full-thickness folds
Subretinal strands
Anterior to equator:
FIGURE 42-4.
Proliferative vitreoretinopathy grade C. Type 4:
Focal, diffuse, or circumferential full-thickness folds
Anterior displacement
Subretinal strands
Condensed vitreous with strands
circumferential contraction with proliferation immediately behind
insertion of the posterior hyaloid pulling retina centrally, stretching
the retina anterior to it, and creating radial folds posteriorly.
Schematic drawing of situation in nonvitrectomized eye (left) and
vitrectomized eye (right). Arrows show direction of pull. (Adapted
courtesy of Ophthalmic Publishing Company, from Machemer R,
Aaberg TM, Freeman HM, et al. An updated classification of retinal
detachment with proliferative vitreoretinopathy. Am J Ophthalmol
*
Expressed in the number of clock hours involved.
1991;112:159–165.)
Table 42-3.
Updated Classification of PVR:
Grade C PVR Described by Contraction Type
Type
Location
Features
1
Focal
Posterior
Starfold posterior to vitreous base
2
Diffuse
Posterior
Confluent starfolds posterior to
vitreous base
Optic disk may not be visible
3
Subretinal
Posterior
Proliferations under retina:
A
B
or Anterior
“Napkin-ring” around disk
“Clothesline” moth-eaten-
appearing sheets
4
Circumferential
Anterior
Contraction along posterior edge of
vitreous base with central
displacement of the retina
Peripheral retina stretched
Posterior retina in radial folds
5
Anterior displacement
Anterior
Vitreous base pulled anteriorly by
proliferative tissue
Peripheral retinal trough
Ciliary processes may be stretched or
may be covered by membrane
Iris may be retracted
C
FIGURE 42-5.
Anterior retinal displacement in PVR. A.
Surgical Technique
Proliferation of cells on vitreous base and retina following vitrectomy
and scleral buckle. B. Contraction of cellular membranes pulls retina
at posterior vitreous base anteriorly. C. Vitreous base depressed into
view. Membrane exerting anterior–posterior traction is sectioned
with vertically cutting scissors. (Adapted from Abrams GW, Aaberg
TM. Posterior segment vitrectomy. In: Waltman SR (ed.). Surgery of
the eye. New York: Churchill-Livingstone, 1988:903–1012.)
Scleral Buckle vs. Vitrectomy

Primary retinal detachment associated with low-grade PVR (grade A or B and limited grade C) can usually be managed by retinal reattachment surgery with a scleral buckle (16). In cases where retinal detachment is associated with higher grades of PVR and in recurrent retinal detachment with

significant PVR, or anytime when it is not anticipated that a scleral buckle will adequately relieve traction to reattach the retina, vitreous surgery is usually indicated to relieve tractional membranes and successfully reattach the retina.

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534 P ART III Retina and Vitreous Surgery A B C D E FIGURE 42-6. Anterior
A B
A
B
534 P ART III Retina and Vitreous Surgery A B C D E FIGURE 42-6. Anterior
C D
C
D
534 P ART III Retina and Vitreous Surgery A B C D E FIGURE 42-6. Anterior

E

534 P ART III Retina and Vitreous Surgery A B C D E FIGURE 42-6. Anterior

FIGURE 42-6.

Anterior PVR: Anterior retinal displacement. Retina at posterior aspect of vitreous base is drawn to anterior vitreous base (A),

to ciliary processes (B), to posterior iris (C), and to pupil with iris retraction (D). (E). Posterior insertion of the vitreous base drawn anteriorly creating

retinal trough. Folds that radiate posteriorly are caused by circumferential contraction. (Adapted from Lewis H, Aaberg TM. Anterior proliferative vitreoretinopathy. Am J Ophthalmol 1988;105:277.)

Management with Scleral Buckle Only

When scleral buckling alone is judged adequate to treat a retinal detachment associated with PVR, the general goals of retinal reattachment surgery must be achieved, including closure of all breaks and relief of vitreoretinal traction. The techniques required are discussed in detail in Chapter 41, but special considerations must be made in the presence of PVR. With few exceptions, it is necessary to support the vitreous base for 360 degrees by placing an encircling element. Sometimes a fairly high degree of indentation is necessary to relieve anterior traction adequately. The rec- ommended width of the buckling element may vary with the location of retinal breaks and the width of the vitreous base.A narrower element will suffice if retinal breaks are rel- atively anteriorly located and the vitreous base is not exces- sively broad; however, a broader silicone tire or sponge might be preferable if the vitreous base extends more pos- teriorly. We use silicone tires or sponges varying from 5 to 7mm in width. Scleral sutures are usually placed 2mm wider than the buckle, to increase scleral indentation and buckle height. In general, placement of the buckle with its anterior edge 2mm posterior to the muscle insertion ring provides support for the posterior vitreous base and ante- rior insertion of hyaloidal traction. Obviously, specific con- ditions require modifications of these general rules of thumb, such as long myopic eyes with altered anatomic rela- tionships. If a silicone tire and encircling band are used in an eye with PVR, it is important that the tire be extended throughout the inferior 180 degrees of the vitreous base, and a conscious effort may be made to achieve greater

buckle height inferiorly by varying the width of the scleral bites, since the inferior fundus is usually the most severely involved with tractional membranes. As in any retinal detachment repair, all retinal breaks must be carefully identified and localized. Additional radial buckling elements sutured in place beneath the encircling element may sometimes be helpful in rhegmatogenous retinal detachment with PVR that is treated by scleral buck- ling alone. Breaks associated with traction can sometimes be supported sufficiently to relieve tractional forces.

Opening for Pars Plana Vitrectomy

When a vitrectomy is done for an eye with PVR, if no scleral buckle is present, we recommend encircling the eye with a scleral buckle to support the vitreous base and the retina just posterior to the vitreous base. If the eye already has an encircling scleral buckle, we usually do not revise or replace that element. Sometimes it is necessary to supple- ment an existing scleral buckle, especially inferiorly, if there is not adequate inferior support of the vitreous base. If the eye has previously had only a radial scleral buckle, the radial element is usually removed and an encircling scleral buckle placed. If the decision is made to perform a pars plana vitrec- tomy, eyes with significant PVR still require an encircling element to support the vitreous base and relieve anterior traction. Therefore, in eyes that do not have a preexisting encircling element, a 360-degree conjunctival peritomy is made just posterior to the limbus and the rectus muscles isolated with 2-0 silk sutures.We often place the sutures for

Chapter 42

Management of Complicated Retinal Detachment

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the scleral buckle prior to vitrectomy. At this time, the eye is firmer and easier to place the sutures. We usually wait until after the vitrectomy is completed to place the buck- ling element around the eye. In most cases, we use a 4.5- mm-wide encircling band to create a moderate buckle. Some surgeons prefer to preplace scleral “belt-loop” inci- sions, which may be technically easier prior to vitrectomy when the eye is firmer. The disadvantage of preplacing sutures or belt loops is that the surgeon loses the ability to choose the type and placement of the buckle based on the intraoperative findings; however, in our experience we rarely have to change the location or type of scleral buckle following the vitrectomy. We feel that the 4.5-mm encircling band will adequately support the vitreous base in most cases of PVR following vitrectomy and that the reduced volume of the band and reduced compression of vortex veins by the narrower element reduce complications related to the scleral buckle in comparison with broader, bulkier elements. If the eye has an encircling element in place, it can be left unaltered in most cases and conjunctival incisions made in the usual fashion for a vitrectomy, exposing the tempo- ral and superonasal sclera. Occasionally, modification of the previous buckle is desirable.The buckling element is located by dissecting through its fibrous capsule.Then the band can be tightened, the buckle can be repositioned, additional sutures can be placed to increase the height or location of the buckle, or an additional scleral buckling element can be placed. If, however, only a radial or segmental circum- ferential element was placed at the time of previous surgery, it is usually best removed and replaced by an encircling element. Vitrectomy is most often performed via a 3-port pars plana approach. Sclerotomy incisions are made 3.0mm from the limbus in aphakic and pseudophakic eyes, or when pars plana lensectomy is planned. In the somewhat uncommon circumstance in which the eye is to be left phakic (see below), the incision is made 3.5mm from the limbus. These distances must be modified if significant anterior displacement of the retina exists, in which case entry into the vitreous cavity is made more anteriorly. Incisions for the infusion and instruments are generally made parallel to the limbus. When performing repeat vit- rectomy, parallel incisions intended for the instruments should be separated by at least 1mm from previous incisions so the sclerotomies do not extend into the old sclerotomy sites during vitrectomy and create large scleral defects. If the sclera is thinned and macerated at the sites of the previous sclerotomies, it may be advantageous to make radial inci- sions, as these are less likely to extend into previous inci- sions. The actual entry into the vitreous cavity must be controlled, especially if the retina is bullous, to avoid retinal perforation. In aphakic or pseudophakic eyes, the microvit- reoretinal (MVR) blade should be inserted iris-parallel, and the tip visualized in the pupil before it is withdrawn. The infusion cannula is then inserted and tied permanently in

place. A 4-mm cannula is preferred in most cases, but in cases with severe anterior proliferative membranes and poor visualization, a 6-mm cannula may facilitate entry into the vitreous cavity. Before infusion to the eye is initiated, the tip of the cannula must be visualized through the pupil to prevent subretinal infusion of fluid. This can be done through the operating microscope by grasping the base of the cannula with nontoothed forceps and rotating the eye until the tip comes into view, or by using a fiberoptic light probe externally and looking at the eye from an acute angle (17). Once it has been positively ascertained that the tip of the cannula is in the vitreous cavity and is free of any mem- branes or tissue, the infusion is turned on. If the pupil will not dilate adequately, we dilate the pupil using mechanical pupillary stretching (Fig. 42-7). Our pre- ferred pupillary stretching devices are small plastic hooks placed through the limbus in four quadrants (18) (Flexible Iris Retractors, Grieshaber, Inc., Kennesaw, GA). We lyse synechiae and remove residual capsular material as much as possible prior to placing the stretching hooks in order to minimize iris trauma. Limbal openings are made parallel with and just anterior to the iris plane with a Ziegler-type blade. The small hooks are secured externally at the limbus with a small locking device.

Lensectomy

The crystalline lens, if present, should be removed in most cases with significant PVR, even if clear. Visual rehabilita- tion is most critically related to the status of the retina, and therefore refractive concerns must be secondary. It is not possible to do an adequate vitreous base dissection in the phakic eye. Removal of the lens allows more complete dis- section of the vitreous base and anterior membranes, and removal of all capsular material may decrease the likelihood

FIGURE 42-7. Pupillary stretching using flexible iris retractors.
FIGURE
42-7.
Pupillary stretching using flexible iris
retractors.

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of recurrent anterior PVR. In addition, with prolonged gas tamponade, the lens will almost always develop a cataract. Management in the postoperative period, including the ability to do a fluid–gas exchange and to administer postoperative laser photocoagulation, is facilitated by remov- ing the lens. If, on the other hand, a posterior chamber intraocular lens (IOL) is already in place, it can usually be left in place, as, in most cases, it does not hinder dis- section of the vitreous base and anterior membranes. Occa- sionally, proliferative tissue adherent to the residual lens capsule must be trimmed or removed with the vitreous cutter to facilitate adequate visualization and surgical manip- ulations in the periphery. If it appears excessive membranes are adherent to the peripheral lens capsule, or if the poste- rior chamber IOL is unstable, we remove the IOL through the limbus. Anterior chamber IOLs are somewhat more problematic. The optic may come in contact with and damage the corneal endothelium if the lens is pushed forward by a gas bubble postoperatively. Gas or silicone oil can easily prolapse around the lens into the anterior chamber, degrading visu- alization of the retina intraoperatively as well as postopera- tively. For these reasons, many surgeons prefer to remove anterior chamber IOLs. This step is completed via a limbal incision after infusion has been established to the eye, but with the infusion in a closed position. Sodium hyaluronate or another viscoelastic material is used to maintain the volume of the anterior chamber as well as to protect the corneal endothelium during this procedure. The crystalline lens is removed through the pars plana, except in cases with extremely hard nuclei, in which case the nucleus is removed through the limbus. Following ultra- sonic fragmentation of the nucleus and removal of the cor- tical material, we recommend complete removal of the lens capsule (19). An opening is made in the anterior capsule with the vitrectomy instrument. One can then grasp the peripheral capsule with vitreous forceps and exert enough traction to expose the zonules in the pupil. While retract- ing the capsule, the zonules can then be cut with a verti- cally cutting scissor (we prefer the MPC scissor, Grieshaber, Inc., Kennesaw, GA) placed through the opposite sclerotomy site (Fig. 42-8).We feel complete removal of the lens capsule will reduce the likelihood of recurrent anterior PVR that can sometimes present with membranes adherent to the peripheral lens capsule. In addition, removal of the capsule will prevent synechiae of the iris to the lens capsule, which can leave a distorted, retracted, fixed pupil.

Vitrectomy

A lens ring to hold the contact lens can be placed follow- ing placement of the pupillary stretching devices.We suture a lens ring in place and utilize several lenses as necessary to visualize the posterior and peripheral retina. We peel most posterior membranes using a plano-concave lens, while prism lenses are used in the periphery. A wide-angle lens system with image inverter is also used in selected situations

Central opening in lens capsule Capsule Forceps holding MPC scissors lens capsule cutting streched zonules
Central opening
in lens capsule
Capsule
Forceps holding
MPC scissors
lens capsule
cutting streched
zonules
P ART III Retina and Vitreous Surgery of recurrent anterior PVR. In addition, with prolonged gas

FIGURE 42-8.

En bloc removal of the lens capsule following

phacofragmentation and removal of the nucleus and cortex of the lens. After opening is made in the anterior lens capsule in the pupillary area with the vitrectomy cutter, the edge of the central capsulotomy is grasped with vitreoretinal forceps, and the capsule

is retracted to expose the zonules in the pupil. The zonules are sectioned with automated, vertically cutting vitreoretinal scissors, and the capsule is removed through the sclerotomy site or with the vitreous cutter.

(20,21). The wide-angle lens is especially useful if there is a constricted view due to a posterior chamber lens with opacified peripheral capsule. We remove the central vitreous with the vitreous cutting instrument, then remove gross peripheral vitreous. In most cases a posterior vitreous detachment will already be present in cases of PVR. Rarely, in eyes with high myopia or vit- reoretinal degenerations, there is incomplete or no posterior vitreous separation. In those cases, after the core vitrectomy is completed, the posterior cortical vitreous should be separated from the disk with the vitreous cutter, suction catheter, or membrane pick, then peeled from the retinal surface. If the vitreous is tightly adherent to the pos- terior retina such as seen in Stickler syndrome, vitreous should be trimmed close to the adhesions and sectioned as much as possible with automated vertically cutting scissors. If there is significant anterior PVR, we delay extensive shaving of the vitreous base and peripheral membrane dis- section until after posterior membranes have been removed, because access to and removal of these membranes are easier once posterior membranes and midperipheral membranes with adherent vitreous have been removed. In the absence of anterior PVR, it is best to excise or “shave” the vitreous to the surface of the retina and pars plana at the vitreous base area at this stage of the case.The posterior membranes fixate the retina and reduce mobility of the anterior retina, which makes peripheral viteous removal safer with less risk of anterior retinal breaks. If at any point the retina is excessively mobile during peripheral vitrectomy and there is danger of peripheral retinal damage, peripheral vitrectomy can be delayed until posterior membranes have been removed. Then perfluorocarbon liquid (PFCL) can be used to stabilize the retina during peripheral vitreous removal.

Chapter 42

Management of Complicated Retinal Detachment

537

The vitreous base can be visualized with a standard lens system (either hand held or with a sutured lens ring) using scleral depression, or by using a wide-angle system without scleral depression. Using a standard lens system, we perform anterior vitrectomy by two methods. In the first method, the vitreous cutter and the fiberoptic endoillumination probe are both placed in the eye. An assistant depresses the peripheral retina and vitreous base into view as the vitreous is excised (Fig. 42-9). This method is especially useful for removing vitreous in the inferior 140 degrees and the supe- rior 100 degrees. Using this method, it is difficult to excise all of the peripheral vitreous in the horizontal meridians. The second method, especially useful in the horizontal meridians, utilizes external illumination (22).The vitrectomy cutter is placed through a sclerotomy site. A plug is placed

Cotton tip applicator Retina pulled forward as vitreous is cut A Cotton tip applicator retina Perfluorocarbon
Cotton tip
applicator
Retina pulled
forward as
vitreous is cut
A
Cotton tip
applicator
retina
Perfluorocarbon
liquid
B
Chapter 42 Management of Complicated Retinal Detachment 537 The vitreous base can be visualized with a

FIGURE 42-9.

Vitrectomy removal of anterior vitreous in an

eye with bullous retinal detachment. A. Retina is extremely mobile and is pulled toward the vitreous cutter as vitreous is excised, risking anterior retinal breaks. B. PFCL is injected to flatten and stabilize the

posterior retina. PFCL is injected to the posterior edge of remaining vitreous, holds retina in place, and reduces retinal mobility during peripheral vitrectomy.

in the opposite sclerotomy site, and the surgeon depresses the retina and vitreous base in the area 180 degrees from where the vitreous cutter has entered the eye. The assistant holds the fiberoptic light probe in contact with the contact lens, directing the light toward the area to be cut (Fig. 42-10). Because the light probe actually touches the contact lens, there is no light reflection, and the visualization is similar to that seen with endoillumination. We have found this method superior to that in which the microscope light is used for peripheral visualization. Scleral depression is not always required to visualize and shave the vitreous base when using the 125-degree wide-angle lens with an image inversion system. A “bullet” light probe is used to disperse the light over a broad area when using the wide-angle lens system. The vitreous structure is more easily seen when using a standard light probe held close to the vitreous, so we have found the standard lens system with scleral depression most useful for PVR.

Membrane Peeling

Posterior Membranes We begin epiretinal membrane dis-

section at the posterior pole. All membranes that can be

located are meticulously stripped from the retinal surface.

Posterior membranes are peeled from the surface of the

retina in a posterior-to-anterior fashion, so that greater force

is applied to the thicker posterior retina. The technique of

bimanual dissection, using an illuminated pick (Fig. 42-11)

Chapter 42 Management of Complicated Retinal Detachment 537 The vitreous base can be visualized with a
Chapter 42 Management of Complicated Retinal Detachment 537 The vitreous base can be visualized with a

FIGURE 42-10.

Lightpipe (L) held in contact with contact

lens (C) illuminates vitreous base pushed into view by scleral depressor (D). (Reprinted courtesy of the American Medical Association, Chicago, IL, from Murray TG, Boldt HC, Lewis H, et al. A technique for facilitated visualization of the vitreous base, pars

plana, and pars plicata. Arch Ophthalmol 1991;109:1458–1459.)

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P ART III Retina and Vitreous Surgery FIGURE 42-11. Instruments for membrane removal in PVR. Left:
P ART III Retina and Vitreous Surgery FIGURE 42-11. Instruments for membrane removal in PVR. Left:

FIGURE 42-11.

Instruments for membrane

removal in PVR. Left: Diamond-dusted vitreoretinal forceps (Grieshaber and Company, Fallsington, PA). Right: Illuminated pick (Escalon, Mukwanago, WI). Bending shaft of pick 30 degrees away from the light axis gives a broader field of illumination and reduces the shadow cast by the pick.

and vitreous forceps, is the most effective for this purpose. There are several types of forceps that can be used to grasp membranes, but we have found that diamond-dusted forceps (see Fig. 42-11) most reliably hold the membrane during bimanual dissection. Membrane peeling can be initiated by either of two methods, depending on the characteristics of the membrane:

thicker membranes with prominent edges can be directly grasped with the forceps (Fig. 42-12), and flatter, less dis- tinct membranes are best elevated with the illuminated pick prior to grasping with the forceps. Membranes can usually be easily seen, but sometimes with extensive confluent membranes, no edges can be identified. Signs of this type of membrane include obscuration of portions of retinal vessels by the membrane and a stiff, smooth, gray appear- ance of the retina. Large retinal folds can be obscured by the membranes. In this situation, the pick is placed in a fold and gently pulled toward the center of the fold in order to engage the membrane (Fig. 42-13A). Once the membrane is engaged and the edge elevated, it is grasped with the forceps for stripping (Fig. 42-13B). Some tightly adherent membranes can be more easily engaged with a sharp-barbed blade such as the MVR blade (Fig. 42-14). When an edge of the membrane has been partially elevated, it can be grasped with forceps and stripped ante- riorly, with the pick used to separate adhesions and stabilize the retina (see Fig. 42-13B). During removal of midperiph- eral membranes, the membrane is often pulled centrally with the forceps, and the blunt edge of the pick is placed between the membrane and the peripheral retina (Fig. 42-15). As the membrane is pulled centrally, the blunt edge of the pick sep- arates the membrane from the retina. When a tight adhe- sion is encountered, excessive force should not be applied, as a retinal tear is likely to occur. Rather, vertically cutting automated scissors should be introduced to segment the membrane from the retina at the adherent site. If any retinal

P ART III Retina and Vitreous Surgery FIGURE 42-11. Instruments for membrane removal in PVR. Left:

FIGURE 42-12.

Grasping epiretinal membrane with

vitreoretinal forceps. The forceps grasp the body of the membrane by

“pinching” the surface or edge of the membrane. While the diamond- dusted vitreoretinal forceps (see Fig. 42-11) will engage membranes with thickened edges, newer, finer, pointed end-grabbing forceps are superior for this maneuver. Once the membrane is grasped with the forceps, the illuminated pick is used to apply counter-traction on the retina as the membrane is peeled.

breaks do occur, they should immediately be marked with intraocular diathermy. Often, large membranes can be peeled in a single sheet from the retinal surface. This is especially true in so-called “mature PVR,” in which several weeks have passed and the membranes have become fairly thick. In the past, some experts recommended waiting for this point in the disease process before intervening, allowing the proliferation to “mature” to facilitate membrane removal. Thin “immature”

A
A

Vitreous

Retina

Chapter 42 Management of Complicated Retinal Detachment 539 Vessel tortuous under membrane Stripping in fold with
Chapter 42
Management of Complicated Retinal Detachment
539
Vessel tortuous
under membrane
Stripping in
fold with MVR
blade
Retinal
vessels
Epiretinal
Retina
membrane

B

A Vitreous Retina Chapter 42 Management of Complicated Retinal Detachment 539 Vessel tortuous under membrane Stripping

Vitreous

Retina

A Vitreous Retina Chapter 42 Management of Complicated Retinal Detachment 539 Vessel tortuous under membrane Stripping

FIGURE 42-13.

Bimanual membrane-peeling using an

illuminated pick and vitreoretinal forceps. A. The edge of the membrane is elevated with the illuminated pick. If an edge is not apparent, the tip of the pick is placed in the trough of a retinal fold and stripped toward the center of a star fold until the membrane is engaged. The membrane is usually engaged in the center of the star fold. B. After the edge of the membrane is elevated with the illuminated pick, the edge is grasped with the diamond-dusted vitreoretinal forceps and pulled anteriorly. The blunt, posterior edge of the illuminated pick is placed against the retina adjacent to the membrane to hold the retina in place as the membrane is peeled from the retina.

membranes are friable and more likely to fragment, leaving residual islands of tissue that are difficult to remove and a potential source of reproliferation. However, the dis- advantage of waiting for membranes to mature is poten- tial progression of photoreceptor degeneration, and most authorities no longer delay surgery for this reason. A helpful technique for very immature membranes is to stroke them with a silicone “brush” found on the tip of the backflush brush. Zivojnovic has found the “retinal scratcher” useful for this technique. A new instrument, a diamond-dusted silicone cannula, is now available that is useful for the removal of small patches of thin epiretinal membranes (Fig. 42-16) (23). The posterior cortical vitreous is often adherent to peripheral membranes posterior to the vitreous base. This

  • FIGURE 42-14.
    Most membranes can be elevated in this fashion.

Thinner, “tight” membranes may be difficult

to engage with the blunt illuminated pick, so these membranes are

sometimes best engaged for peeling with a sharp blade. We prefer

the microvitreoretinal (MVR) blade. We barb the tip of the blade prior

to membrane peeling. The barbed MVR blade is placed in a fold

adjacent to the membrane and stripped toward the membrane.

A Vitreous Retina Chapter 42 Management of Complicated Retinal Detachment 539 Vessel tortuous under membrane Stripping

FIGURE 42-15.

Separation of peripheral membranes and

vitreous from the retina. The membrane or vitreous is grasped with diamond-dusted vitreoretinal forceps and pulled centrally. The blunt edge of the illuminated pick is placed at the junction of the vitreous

or membrane with the retina and the tissue is pulled over the pick. The membrane will usually separate, and vitreous will usually separate anteriorly to the posterior edge of the vitreous base.

probably occurs because of incorporation of the posterior hyaloid into membranes formed at the junction of the sep- arated posterior vitreous and the vitreous base (Fig. 42-17A). With increasing and more posterior membrane formation, we suspect that the vitreous is gradually pulled in by the contracting membranes to give a relatively posterior adher- ence of the posterior hyaloid, well posterior to the vitreous base (Fig. 42-17B). It is important to strip the posterior hyaloid anteriorly to its insertion into the vitreous base.We

540

PART III

Retina and Vitreous Surgery

P ART III Retina and Vitreous Surgery Retinal break Separated RPE cells Vitreous loosely laying on

Retinal break

Separated RPE cells Vitreous loosely laying on retina A FIGURE 42-16. Diamond-dusted membrane cannula. The tapered
Separated
RPE cells
Vitreous loosely
laying on retina
A
FIGURE 42-16.
Diamond-dusted membrane cannula.
The tapered silicone tip has been dusted with diamonds to create
a surface that will engage and peel diaphanous, immature
membranes.
Vitreous fused
to retina
B
FIGURE
42-17.

have found it useful to grasp the edge of the posterior hyaloid with the vitreous forceps, place the blunt portion of the illuminated pick at the junction between the hyaloid and the peripheral retina, and pull the hyaloid centrally to allow the pick to separate the hyaloid from the retina (similar to the method described in Fig. 42-15). This tech- nique also identifies the point of permanent adherence of the hyaloid to the posterior border of the vitreous base. Once the peripheral hyaloid is separated to the vitreous base, it is excised with the vitrectomy instrument. If the retina becomes excessively mobile, PFCL can be injected over the posterior pole to stabilize the retina during vitrec- tomy (see Fig. 42-9; see also below) (24). Anterior Membranes If anterior PVR is present, peripheral membranes must be dissected. Membranes may be focal, diffuse, or subretinal (see Tables 42-1 and 42-2; Figs. 42-3–42-6). Focal and diffuse membranes are peeled in a fashion similar to posterior membrane peeling, although vit- reous is often adherent to the membranes. Subretinal mem- branes may not be apparent until after epiretinal membranes have been removed. The most difficult form of anterior PVR to manage is anterior retinal displacement, in which the retina at the posterior vitreous base or even more pos- teriorly is pulled anteriorly by contracting anterior vitreous and membranes (see Fig. 42-6) (4,25). A circumferential “trough” of variable depth and area may be present at the vitreous base formed between the anteriorly displaced retina and the anterior retina and pars plana. Initially, the type of anterior PVR must be identified. Sometimes, in advanced forms of anterior PVR, it is difficult to see a peripheral trough, and the surgeon might erroneously believe that no anterior retinal displacement is present. The only sign of anterior retinal displacement may be obscuration of the ora serrata and the finding of a fibrous circumferential membrane adherent to the pars plana or

Reattachment of peripheral separated

vitreous

vitreous to the retina posterior to the vitreous base in PVR. A. Rhegmatogenous retinal detachment with posterior vitreous separation and large retinal break. Released pigment epithelial cells in the vitreous cavity settle on the inferior retina between the detached retina and the vitreous. As membranes form, the vitreous attaches to the membranes that are attached to the retina. B. PVR with vitreous now fused with the peripheral retina posterior to the vitreous base. As membranes are peeled, the vitreous should be separated anteriorly to the posterior aspect of the vitreous base.

ciliary processes. Usually, however, a peripheral trough can be seen peripheral to a circumferential fold of anteriorly displaced retina. The membrane that bridges from the anteriorly displaced retina toward the anterior structures must be cut (Fig. 42-18). It is often easiest to initially open this membrane with the sharp tip of the MVR blade (Fig. 42-18A). Then vertically cutting vitreoretinal scissors can be inserted to section the membrane circumferentially (Fig. 42-18B). The membrane should be circumferentially sectioned throughout the extent of anterior displacement of the retina.

Chapter 42

Management of Complicated Retinal Detachment

541

When the membrane is sectioned, the anterior-posterior element of traction is relieved, and the anteriorly displaced retina will fall posteriorly. Remnants of the membrane can exert circumferential traction and sometimes can be excised with the vitrectomy instrument. If membrane remnants are tightly adherent, then a bimanual technique is used in which the membrane is fixated with an illuminated pick or illu- minated forceps as it is cut with the vertically cutting scis- sors (Fig. 42-18C). If possible, the whole extent of the membrane should be eliminated, but if this is not possible, remnants should be sectioned vertically in multiple areas along its circumference in order to eliminate circumferen- tial traction.Vitreous in the trough should be trimmed back to the surface of the pars plana and peripheral retina with the vitreous cutter. The techniques of peripheral vitreous removal utilizing scleral depression or a wide angle viewing system are described above. Retinal breaks are sometimes created during the dissection process. Breaks should be identified, and all traction relieved around the area of these breaks. In some cases, it is not possible to relieve anterior contraction adequately with dissection so a peripheral relaxing reti- notomy is necessary (see below). Because it is difficult to remove posterior and peripheral membranes after an extensive retinotomy, we wait until all of the posterior and peripheral membranes have been removed before proceeding with retinectomy. Once the posterior and peripheral membranes have been removed, the retina becomes quite mobile. The pars plana is often detached, and any remaining vitreous is easily incar- cerated in the sclerotomy sites. There is risk of peripheral retinal incarceration in the sclerotomy sites. The retina can

be stabilized and further peripheral vitreous removal and membrane dissection can be facilitated by the use of PFCL (Fig. 42-19; see also Fig. 42-9). An initially small volume of PFCL (usually about 1mL) is injected over the optic nerve. We usually wait until posterior membranes have been com- pletely removed before injecting the PFCL. While a small posterior retinal break is not a contraindication to the use of PFCL, we usually do not use PFCL in the presence of large breaks. Excessive traction on the retina in the presence of even a small retinal break may also cause PFCL to go through the break. It is important not to inject the PFCL directly over a break as the stream of PFCL will go beneath the retina. Initially, only enough PFCL is injected to stabi- lize the posterior retina and improve the ability to remove peripheral vitreous and membranes. Injection of too much PFCL may cover and compress the remaining vitreous. Additional PFCL can be injected to further flatten the retina as the dissection is carried anteriorly.

Subretinal Membranes

Subretinal membranes are less common in PVR than epiretinal membranes, and even when present, often do not interfere with successful retinal reattachment (26). In these cases they can be left in place. In some cases, subretinal membranes that appear to be elevating the retina will break or stretch during fluid–gas exchange or after injection of PFCL, leading to release of traction (see below). In cases in which subretinal membranes prevent retinal reattachment after fluid–gas exchange or injection of PFCL, of if they are felt by an experienced surgeon to be significant, the traction from these membranes must be relieved (27). If a single subretinal strand is tenting the

A

Chapter 42 Management of Complicated Retinal Detachment 541 When the membrane is sectioned, the anterior-posterior element

B

Chapter 42 Management of Complicated Retinal Detachment 541 When the membrane is sectioned, the anterior-posterior element
Chapter 42 Management of Complicated Retinal Detachment 541 When the membrane is sectioned, the anterior-posterior element

C

Chapter 42 Management of Complicated Retinal Detachment 541 When the membrane is sectioned, the anterior-posterior element

FIGURE 42-18.

Management of anterior retinal displacement in PVR. A circumferential membrane has formed on the peripheral vitreous

and, with contraction, has pulled the retina at the posterior aspect of the vitreous base anteriorly to the anterior pars plana. The membrane obscures a “trough” of redundant retina created by the anterior displacement of the retina. A. The membrane is sectioned circumferentially with an MVR blade. B. Once an opening is made in the membrane with the MVR blade, the automated, vertically cutting vitreoretinal scissors use used to section the membrane throughout its extent. Anterior retinal displacement is most commonly found in the inferior 180 degrees of the retina. C. The “trough” has opened up and the retina has relaxed posteriorly. If a circumferential membrane remains on the posterior aspect of the vitreous base, it should be removed or radially sectioned. An illuminated pick or illuminated forceps can be used to fixate the membrane fo r removal or sectioning with automated, vertically cutting vitreoretinal scissors. The arrow points at an area that has been radially sectioned, while the forceps holds the edge of the membrane and exposes it for dissection with the scissors.

542

PART III

Retina and Vitreous Surgery

542 P ART III Retina and Vitreous Surgery AB C FIGURE 42-19. Use of PFCL for
542 P ART III Retina and Vitreous Surgery AB C FIGURE 42-19. Use of PFCL for

AB

C
C
542 P ART III Retina and Vitreous Surgery AB C FIGURE 42-19. Use of PFCL for

FIGURE 42-19.

Use of PFCL for PVR. A. Following removal of posterior membranes, a small volume of PFCL is injected over the posterior

retina. The PFCL reduces retinal mobility during removal of peripheral membranes. B. After the membranes have been removed, the retina is reattached by injecting more PFCL. Subretinal fluid drains into the vitreous cavity from the anterior retinal break. C. More PFCL has been injected to

reattach the retina. Sometimes a small amount of subretinal fluid will remain anterior to the PFCL. Try to avoid immersing the infusion cannula in the PFCL, because bubbles will obstruct the view and small bubbles can go through large open breaks.

retina, it can be cut with scissors after creating an adjacent retinotomy with diathermy and will often retract back, allowing the retina to settle (Fig. 42-20). If not, or if mul- tiple subretinal strands or a large sheet is present, the retinot- omy is enlarged to allow the insertion of microforceps.The membrane should be grasped and gentle traction applied in a back and forth motion, breaking adhesions and attach- ments, while both ends are observed to ensure that the retina is not torn at a remote site (Fig. 42-20C). In rare cases of extensive subretinal fibrosis with a so-called napkin ring configuration, where the membranes completely encircle the optic nerve in the subretinal space, a large peripheral retinotomy must be made (see below), usually on the order of 90 degrees or more, and the retina folded over to allow complete removal of the membrane. A bimanual technique is required, with a lighted pick or similar instrument used to elevate and hold the inverted retina, while scissors are used to section the membrane. Then microforceps are used to grasp, tease, and regrasp the membrane until it is completely free (Fig. 42-21).

Scleral Buckle

When all membranes have been removed from the surface of the retina, it should be mobile and ready to be reattached. In eyes that do not already have an encircling band, this is an appropriate time to place a scleral buckle. Determination of the appropriate position of the scleral buckle follows many of the same considerations discussed previously. If removal of all anterior membranes and most of the anterior vitreous was accomplished, a 3.5- or 4.5-mm encircling element is usually adequate to support the vitreous base. If continued peripheral vitreoretinal traction is present, espe-

cially if this traction extends postequatorially, a broader buckle is required. A 7-mm-wide solid silicone element will provide broad support in this situation. One disadvantage of placing a buckle at this stage in the procedure is that the subretinal fluid makes it difficult to assess buckle height. However, after retinal reattachment with PFCL injection or fluid–gas exchange, buckle height can be reassessed and adjusted if need be.

Relaxing Retinotomies and Retinectomies

Some eyes with severe PVR, particularly those undergoing reoperation and those with anterior PVR, have areas of retinal shortening that make reattachment impossible, despite meticulous removal of membranes. In such instances, raising the height of the scleral buckle can sometimes ade- quately relieve persistent traction. If this maneuver is not successful, or if the surgeon decides against revising the scleral buckle, retinotomy with or without retinectomy is necessary to reattach the retina (28,29). Sometimes this determination is not made until air or PFCL is injected into the eye (see below) and is noted to go subretinally through a break associated with elevated retina. Relaxing retinotomy is usually done because of retinal contraction due to anterior PVR, with anterior retinal displacement being the most common indication. How- ever, any type of contraction, especially when chronic, can sometimes require retinotomy to relieve traction. Rarely, a focal area of posterior contraction cannot be relieved by removal of membranes, and a focal retinotomy must be performed. For anterior contraction, after all other membranes have been removed, diathermy is applied posterior to the area of

Chapter 42 A
Chapter 42
A
Management of Complicated Retinal Detachment 543 A
Management of Complicated Retinal Detachment
543
A
B Extraction of Subretinal subretinal strand strand through retinotomy C
B
Extraction of
Subretinal
subretinal strand
strand
through retinotomy
C
Chapter 42 A Management of Complicated Retinal Detachment 543 A B Extraction of Subretinal subretinal strand

FIGURE 42-20. A. Branching subretinal strand. B. Sectioning of subretinal strand through peripheral retinotomy. Scissors are placed through a small retinotomy created adjacent to the membrane with diathermy. If the membrane is not adherent to the retina or choroid, the ends of the membrane should retract after sectioning. C. Extraction of subretinal strand through retinotomy. The membrane is grasped with forceps and removed with a gentle, side-to-side motion. If the membrane is strongly adherent to retina or choroid, it should be sectioned. (A. Courtesy of Hilel Lewis, MD, Cleveland Clinic Fandation, Cleveland, OH; B, C. Adapted from Abrams GW. Retinotomies and retinectomies. In: Ryan SJ (ed.). Retina. vol. 3. St. Louis: CV Mosby, 1989:317–346.)

contraction (Fig. 42-22). For focal contraction, diathermy is used to encircle the area to be excised. It is important to treat all vessels with heavy diathermy to prevent hemor- rhage. The retinotomy should extend beyond the area of contraction into normal retina. The actual retinotomy is usually made with automated vertically cutting vitreous scis- sors (see Fig. 42-22A). Cutting the retina with the vitreous cutter is less controlled and can lead to hemorrhage and inadvertent excision of larger areas of the retina than desired. For anterior retinal contractions, circumferential

A
A
B
B
Chapter 42 A Management of Complicated Retinal Detachment 543 A B Extraction of Subretinal subretinal strand

FIGURE 42-21.

A, B. Subretinal “napkin ring” membrane

(posterior type 3). C. Membrane sectioned and removed through

peripheral retinotomy. (A. Courtesy of Hilel Lewis, MD, Cleveland Clinic Fandation, Cleveland, OH; B, C. Adapted from Abrams GW. Retinotomies and retinectomies. In Ryan SJ (ed.). Retina. vol. 3. St. Louis: CV Mosby, 1989:317–346.)

retinotomies are usually performed. Radial retinotomies are rarely indicated. Radial retinotomies tend to extend poste- riorly into the posterior pole and often inadequately relieve traction. Retinotomies in the posterior pole, which involve more functionally important retina, should also be avoided. Use of a partial fill of PFCL will stabilize the retina during performance of the retinotomy and prevent folding and inversion of the flap of the now giant tear after the retina is cut. If the retinotomy extends into attached retina, the retina should be carefully separated from the underlying retinal pigment epithelium with the tip of the scissors or a membrane pick before cutting, to avoid damage to the choroid.The ends of the retinotomy may be angled toward the ora serrata to relieve residual traction present in these regions (Fig. 42-22B). In most cases, we prefer to remove the anterior flap of devascularized retina to decrease the

544

PART III

Retina and Vitreous Surgery

A
A
B RPE
B
RPE
P ART III Retina and Vitreous Surgery A B RPE FIGURE 42-22. A . Inferior relaxing

FIGURE 42-22.

A. Inferior relaxing retinotomy to relieve

traction in contracted retina. The retina to be cut is diathermized, primarily by diathermizing blood vessels, extending into normal retina on each end of contracted retina. Cut is made with vertically cutting scissors along the posterior edge of contracted retina. B. Retina reattached following relaxing retinotomy. Retinotomy is extended anteriorly to ora serrata or ciliary body (if pars plana is involved). The anterior retina is excised. (Adapted from Abrams GW. Retinotomies and retinectomies. In: Ryan SJ (ed.). Retina. vol. 3. St. Louis: CV Mosby, 1989:317–346.)

likelihood of reproliferation and possibly lower the risk of rubeosis. This procedure is accomplished with the vitreous cutter, again with care taken to avoid damage to the choroid. A retinotomy greater than 90 degrees in circumference creates the problem of management of a giant retinal tear. The best method for reattaching the retina in the presence of a giant tear is the use of a PFCL (discussed below) (30). PFCLs have the advantage of ease of use and do not require manipulation of the flap under gas or silicone oil. If a large relaxing retinotomy ( 90 degrees) is performed to treat an eye with PVR, careful consideration should be made of the type of retinal tamponade to use. Eyes under- going retinotomy and retinectomy are more likely to have postoperative hypotony, which suggests that silicone oil may be preferred in such eyes (31).

Reattachment of the Retina with PFCL

If PFCL was used to stabilize the retina during membrane removal or retinotomy, additional PFCL is injected to reat- tach the retina (24). If PFCL was not used, the retina can be reattached pneumatically with air or with PFCL, accord- ing to the characteristics of the retina. If a large retinotomy has created a giant tear, PFCL should be used to reattach the retina (30). If there is no giant break and a posterior break exists, pneumatic reattachment can be performed, using the posterior break to simultaneously drain subretinal fluid. More often, however, breaks will be fairly anterior, and

reattachment of the retina is performed with PFCL prior to fluid–air exchange. When PFCL is to be used, the surgeon should make quite sure that all traction has been removed from around

retinal breaks. If breaks with elevated edges are present, the

PFCL can pass through the break and move subretinally,

requiring further manipulations to remove it, even includ-

ing a retinotomy.

We prefer a PFCL with an index of refraction allowing good visibility such as perfluoro-n-octane (32). The PFCL

can be injected manually with a syringe or with a surgeon-

controlled automated fluid injector. We inject the PFCL

through a silicone-tipped cannula and start injection over

the optic disk. Once a large enough bubble of PFCL is

present over the optic nerve, the tip of the silicone cannula can be inserted into the PFCL during subsequent injection to ensure that a single bubble is produced (see Fig. 42-19A). During injection, fluid is allowed to escape from the sclerotomy site. As the bubble of PFCL slowly increases in size, the posterior pole should be noted to flatten, and the choroidal pattern should become apparent. The PFCL is injected slowly and the peripheral retina assessed during injection. This procedure is particularly important if a giant retinotomy has been created, because the edge can become folded beneath the perfluorocarbon. In addition, it is important to observe if the peripheral retina flattens during PFCL injection. If the retina remains elevated, injection should be stopped. PFCL should be removed to at least the posterior aspect of the remaining traction and the traction relieved. A wide-angle viewing system is ideal for observation of the entire fundus during this process. Injection is continued until the PFCL extends well onto the scleral buckle anteriorly (see Fig. 42-19C).Try to avoid immersing the tip of the infusion port in the PFCL, because multiple bubbles of PFCL are created by the fluid flow. These bubbles may obstruct the view and go beneath the edge of a large break. In most cases, fluid will drain from known or unrecognized anterior retinal breaks, and the contour of the buckle will be apparent. Occasionally, fluid will accumulate anteriorly, obscuring the outline of the buckle (Fig. 42-23A). In such cases, tipping the eye so that the PFCL forces the fluid toward a known retinal break will sometimes flatten the retina (Fig. 42-23B). Occasionally, however, intraocular diathermy must be used to create an anterior drainage retinotomy over the buckle in an area of nonvascular retina.This retinotomy should be made as ante- riorly as possible to avoid trapping subretinal fluid anterior to the retinotomy (Fig. 42-23C). At this point, the entire posterior retina should be re- attached. Areas of persistent retinal elevation beneath the PFCL indicate persistent traction, which must be relieved if surgery is to be successful. Most remaining epiretinal mem- branes can be removed beneath the PFCL. If it is necessary to remove the PFCL, it should be carefully aspirated into a syringe for reuse later in the case. Further membrane peeling can then be performed, or retinotomy and retinectomy can

Chapter 42 Management of Complicated Retinal Detachment 545 Sharp diathermy Hole in Retinal probe retina break
Chapter 42
Management of Complicated Retinal Detachment
545
Sharp
diathermy
Hole in
Retinal
probe
retina
break
PFCL
PFCL
PFCL
AB
C
FIGURE 42-23.
A. Fluid trapped anterior to retinal break following retinal reattachment with PFCL. B. Eye tilted so PFCL will force subretinal
fluid out of retinal break. C. If unable to force subretinal fluid out by tilting the eye, an anterior drainage retinotomy is made with endodiathermy to
allow drainage of subretinal fluid (arrow). Injection of more PFCL will now attach the anterior retina.

be carried out as discussed above if separation of membranes is not possible. Occasionally, retinal reattachment under PFCL is pre- vented by subretinal strands or membranes. In many cases, the retina will reattach despite such tissues. Sometimes the weight of the PFCL acting over time will relax the traction applied by subretinal membranes, and the surgeon may wish to wait for several minutes to reassess the retinal status. If there appears to be less retinal elevation, more PFCL can be injected and further observation for retinal flattening carried out. If the PFCL does not overcome the traction from the subretinal membranes, the PFCL should be removed by aspirating it back into the same syringe, for reuse later in the case, and the subretinal membranes dealt with as discussed above.

Laser Endophotocoagulation

The PFCL affords an excellent view for application of laser endophotocoagulation to the now reattached retina, although the field of view is less than with a gas-filled eye. All retinal breaks, previously marked with diathermy, are surrounded with confluent laser spots (Fig. 42-24). Laser can then be applied over the scleral buckle for 360 degrees, using the prism fundus contact lens or a wide-angle viewing system (Fig. 42-25). Peripheral laser is facilitated by raising the level of the PFCL well onto the buckle, to ensure that no subretinal fluid is present. An angled laser probe is also helpful for treating superior retina. Laser burns should be of moderate intensity and placed for two to three rows, with a separation between spots of approximately one burn width (Fig. 42-26). Confluent and overly intense peripheral pho- tocoagulation (Fig. 42-27) can occasionally lead to stasis of venous return from the ciliary body to the vortex system.

Chapter 42 Management of Complicated Retinal Detachment 545 Sharp diathermy Hole in Retinal probe retina break

Retinal

break

Laser

Chapter 42 Management of Complicated Retinal Detachment 545 Sharp diathermy Hole in Retinal probe retina break

FIGURE 42-24.

Laser endophotocoagulation. Treated retinal

breaks with one or two rows of confluent laser. (Adapted from

Abrams GW. Retinotomies and retinectomies. In: Ryan SJ (ed.). Retina. vol. 3. St. Louis: CV Mosby, 1989:317–346.)

Occasionally, visualization of the periphery is difficult, and photocoagulation of this region is delayed until the eye is filled with air. We treat any posterior retinal breaks with laser, but do not perform scatter treatment posterior to the scleral buckle.

Removal of PFCL

On completion of laser endophotocoagulation, an inferior peripheral iridectomy is made if silicone oil is to be used in an aphakic eye (see below) (33). Then, fluid/PFCL–air exchange is carried out. We prefer active suction with an

546

PART III

Retina and Vitreous Surgery

546 P ART III Retina and Vitreous Surgery FIGURE 42-25. Laser endophotocoagulation using a wide- angle
546 P ART III Retina and Vitreous Surgery FIGURE 42-25. Laser endophotocoagulation using a wide- angle

FIGURE 42-25.

Laser endophotocoagulation using a wide-

angle system. The wide-angle view allows visualization of the peripheral retina during endophotocoagulation. Treatment is applied using a scatter technique on the retina supported by the scleral buckle. The bullet light probe is used with the wide-angle viewing system to give wide field illumination. (Adapted from Abrams GW, Glazer LC. Proliferative vitreoretinopathy. In: Freeman WR (ed.). Practical atlas of retinal disease and therapy. 2nd ed. Philadelphia: Lippincott-Raven, 1997:303–323.)

aspiration silicone-tipped cannula for this purpose. Alterna- tive instruments preferred by some surgeons are backflush brushes or extrusion needles, providing passive egress of PFCL and intraocular fluid from the eye. In the phakic or pseudophakic eye, a biconcave contact lens is placed on the cornea to overcome the higher refractive power of the air-filled eye. With the aspiration cannula and fiberoptic light probe in the eye, the infusion line is switched from fluid to air, with the pressure of the air pump typically set at approximately 40mmHg. Preliminary aspiration is per- formed just behind the iris plane, until air fills the anterior vitreous cavity. Then the silicone cannula tip is placed near the peripheral retina at the level of the PFCL–fluid inter- face, so that an air–PFCL interface is achieved and there is minimal risk of reaccumulation of subretinal fluid. Next the cannula is positioned over the optic nerve, and the remain- der of the PFCL is aspirated. As the eye fills with air, the fluid level can be safely determined by the “dipping” maneuver.The silicone cannula is inserted toward the optic nerve head until the bright reflex disappears, indicating that the tip of the cannula has reached the fluid (Fig. 42-28). Aspiration is initiated and continued until the reflex

546 P ART III Retina and Vitreous Surgery FIGURE 42-25. Laser endophotocoagulation using a wide- angle

FIGURE 42-26.

One burn width between laser applications

during scatter treatment. (Adapted from Abrams GW, Glazer LC. Proliferative vitreoretinopathy. In: Freeman WR (ed.). Practical atlas of retinal disease and therapy . 2nd ed. Philadelphia: Lippincott- Raven, 1997:303–323.)

546 P ART III Retina and Vitreous Surgery FIGURE 42-25. Laser endophotocoagulation using a wide- angle

Excessive laser treatment to peripheral retina

FIGURE 42-27.

on scleral buckle.

reappears. This process is continued until all the fluid is removed from the eye. In the presence of a giant retinotomy (usually 180 degrees or more), there is a risk of retinal slippage during the exchange of PFCL for air.This can be prevented by ade- quate “drying” of the edge of the retinotomy during the air exchange (24), accomplished by filling the vitreous cavity anterior to the flap of the giant retinotomy with air, then aspirating fluid from beneath the anterior edge of the retinotomy before removing the PFCL (Fig. 42-29). The anterior edge of the retina can be visualized during fluid–air exchange with a wide-angle viewing system or, alternatively, with an indirect ophthalmoscope. If fluid is left behind the edge of the retinotomy, as PFCL–air exchange proceeds,

Chapter 42

Management of Complicated Retinal Detachment

547

fluid forced posteriorly during the exchange will allow pos- terior slippage of the edge of the tear. If PFCL goes beneath the retina, it must be removed, which may require refilling the eye with fluid. Once fluid is removed from behind the anterior edge of the retina, PFCL–air exchange is completed and all PFCL is removed from the eye. Perfluoro-n-octane is easily seen and removed, and because of the high vapor pressure, remaining small bub- bles will evaporate in air at body temperature. How- ever, perfluorodecalin and perfluorophenanthrene, two other commonly used liquid PFCLs, are less easily seen, have a lower vapor pressure, and will not evaporate in air (32), so we recommend dripping approximately 0.1 to 0.3mL of balanced saline onto the posterior retina to identify any remaining PFCL (which will coalesce into more easily seen bubbles in the balanced saline) to facilitate removal.

A
A
B
B
Chapter 42 Management of Complicated Retinal Detachment 547 fluid forced posteriorly during the exchange will allow

FIGURE 42-28.

A. Fluid–air exchange. The tip of the suction

needle is held just anterior to the break. Note the fluid meniscus (arrow) on shaft of drainage needle. B. Removing final bit of fluid over optic nerve. The needle tip is repeatedly “dipped” into fluid at the retinal break and over the optic disk. A light reflex is seen to disappear as the needle tip contacts the fluid meniscus. (Adapted from Abrams GW, Aaberg TM. Posterior segment vitrectomy. In:

Waltman SR (ed.). Surgery of the eye. New York: Churchill- Livingstone, 1988:903–1012.)

The optical properties of a gas-filled eye allow a wider field of view than those of liquid, and usually a more com- plete view of the periphery is obtained after fluid–air exchange. If inadequate laser treatment of the periphery was accomplished under PFCL, particularly laser treatment of retina overlying the scleral buckle, more complete endopho- tocoagulation can now be performed in many cases. In pseudophakic eyes, condensation of fluid on the IOL can impede visualization, as discussed below.

Reattachment of the Retina Without PFCL

If PFCL is not used, we reattach the retina with a fluid–air exchange. All retinal breaks should be marked with endo- diathermy prior to fluid–air exchange so they can be seen

Chapter 42 Management of Complicated Retinal Detachment 547 fluid forced posteriorly during the exchange will allow
Chapter 42 Management of Complicated Retinal Detachment 547 fluid forced posteriorly during the exchange will allow

FIGURE 42-29.

Unfolding flap of giant tear or large

retinotomy with PFCL. A. PFCL is injected over the posterior pole to unfold flap of giant tear. With retina stabilized with PFCL, removal of anterior vitreous and anterior dissection are made easier. PFCL can be injected to the level of the anterior edge of the giant tear after all membranes are removed. B. PFCL–air exchange. The space anterior to the PFCL is filled with air. The edge of the tear is “dried” to prevent slippage. Fluid behind the edge is aspirated with the soft-tip needle until the edge is completely flat. C. PFCL–air exchange is completed. All PFCL is removed with the soft-tip needle. (Adapted from Abrams GW, Glazer LC. Proliferative vitreoretinopathy. In: Freeman WR (ed.). Practical atlas of retinal disease and therapy. 2nd ed. Philadelphia:

Lippincott-Raven, 1997:303–323.)

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and treated through the air bubble. Before switching from fluid to air, the decision of whether to use gas or silicone oil tamponade must be made, because if silicone oil is to be used, it is preferable to create an inferior peripheral iridec- tomy in a fluid-filled eye (see below). Air is supplied by the air pump and fluid is usually removed with an aspiration soft silicone–tipped needle, just as described above for removal of PFCL.There is usually a posterior or peripheral retinal break available for removal of subretinal fluid. If a posterior break is present, then it is used for subretinal fluid drainage (Fig. 42-30). If no posterior break is present, we do not usually make a posterior drainage retinotomy. Drainage through a peripheral break is facilitated by the use of the extendable cannulated extrusion needle in which the soft-silicone tube can be extended through the peripheral break into the subretinal space posteriorly (Fig. 42-31) (34). In most cases, a simple nonextendable, soft-tipped cannula will suffice for the same purpose. If there is no accessible break for drainage, we usually make a drainage retinotomy with the endodiathermy probe in the peripheral retina in an area to be supported by the scleral buckle. Once the retina is reattached under air, confluent laser endophotocoagulation is applied to surround all breaks, identification of which is facilitated by previous labeling with diathermy as discussed above. If a retinal burn is not noted despite adequate power and laser application interval, residual subretinal fluid is likely present at the margin of the break, and further aspiration should be performed.Treatment of all breaks is followed by peripheral laser treatment over the scleral buckle as described above in conjunction with PFCL.

Soft tip needle Air insufflation Air Subretinal fluid aspiration
Soft tip
needle
Air insufflation
Air
Subretinal fluid
aspiration
P ART III Retina and Vitreous Surgery and treated through the air bubble. Before switching from

FIGURE 42-30.

Fluid–air exchange. Subretinal fluid

is aspirated through the posterior retinal break as the eye is

simultaneously filled by the air pump. (Adapted from Abrams GW. Retinotomies and retinectomies. In: Ryan SJ (ed.). Retina. vol. 3. St. Louis: CV Mosby, 1989:317–346.)

Not uncommonly, visibility will deteriorate after fluid– air exchange due to the appearance of corneal striae, or due to condensation of fluid on the IOL in pseudophakic eyes, occasionally to the point where completion of endolaser treatment becomes difficult or impossible. Use of a wide-angle viewing system can often improve fundus visualization.The posterior surface of the IOL can be more evenly wetted by application of a soft-tipped cannula in a sweeping fashion. Another maneuver that is often helpful is the application of sodium hyaluronate to the corneal endothelium. A small amount of viscoelastic injected onto the endothelial surface often dramatically improves visibility. Silicone IOLs may create significant problems during fluid–air exchange (35). Because of the hydrophobic nature of the silicone, condensation will reoccur during fluid–air exchange, even if it is wiped away with a silicone-tipped cannula, obscuring the view of the retina in the air-filled eye. It may be possible to dry the posterior surface with a steady stream of air from the air pump via a needle held against the posterior surface of the IOL during fluid–air exchange (36).

P ART III Retina and Vitreous Surgery and treated through the air bubble. Before switching from

FIGURE 42-31.

Fluid–air exchange using a peripheral retinal

break. Drainage retinotomy is created anteriorly over the scleral buckle. Extendable soft silicone tubing of the cannulated extrusion needle is passed through the retinotomy into the posterior subretinal space for fluid–air exchange. (Adapted from Abrams GW, Glazer LC. Proliferative vitreoretinopathy. In: Freeman WR (ed.). Practical atlas of retinal disease and therapy . 2nd ed. Philadelphia: Lippincott- Raven, 1997:303–323.)

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549

Air–Gas Exchange

Following laser treatment, two sclerotomy sites are closed, usually with 7-0 polyglycolic acid sutures. At least 25mL of a nonexpansile mixture of C 3 F 8 gas (12% to 14%) are flushed through the eye (37). We have shown experimentally that a predictable gas concentration can be obtained using this method.The gas mixture is insufflated through the infusion port and allowed to egress through a 27-gauge, 1 /2-inch- length needle inserted through the pars plana and vented to atmosphere. A tuberculin syringe with the plunger removed can be used as a handle for the needle. Following the gas flush, the needle is removed, then the infusion port is removed and that site closed. We then reform the eye to a normal pressure with the gas mixture via a 30-gauge needle through the pars plana. We try to leave the intraocular pressure at approximately 10mmHg at the completion of surgery. The conjunctiva can be closed with absorbable suture such as 6-0 plain gut, bringing the flap of conjunctiva to the limbus and assuring that all sclerotomies are well covered. In eyes that have undergone multiple prior surgi- cal procedures, this can be quite difficult and time consum- ing, but must be done in careful fashion. If the conjunctiva is retracted, it can sometimes be released by making multi- ple small circumferential cuts in the undersurface of Tenon’s capsule with a sharp, rounded blade, and drawn closer to the limbus. Subconjunctival injection of an antibiotic, while of unproven value, is standard practice, as is subconjunctival corticosteroid injection, usually with dexamethasone. Place- ment of ointment in the palpebral fissure and an eye patch completes the procedure.

Silicone Oil

The Silicone Study found that visual and anatomic results in eyes with PVR were similar in most analyses regardless of whether silicone oil or C 3 F 8 gas was used as the intra- ocular tamponade and both modalities were superior to SF 6 gas (38–40). While the surgeon and patient will jointly decide on the tamponade to use in most cases, some factors will contribute to the decision. Gas may be preferred over silicone oil if it is likely that silicone oil will herniate into the anterior chamber and contact the cornea, such as when the iris diaphragm is not intact or when an IOL is present without an intact iris-capsular-IOL diaphragm. Oil may be preferred for patients unable to maintain prone positioning such as children or mentally or physically impaired patients. Silicone oil is associated with a lower incidence of postop- erative hypotony and is preferred in certain cases, including eyes with preoperative hypotony and eyes with rubeosis or requiring extensive anterior dissection of membranes, as these eyes are at greater risk of postoperative hypotony. Silicone oil may be preferred in the face of a giant tear or retinotomy, which will also more likely have postoperative hypotony. Silicone oil is preferred if the patient must travel by air or if the patient must travel to a higher elevation. Silicone oil is preferred over gas in the presence of residual

vitreous or choroidal or large subretinal hemorrhage. An obvious disadvantage of silicone oil as a means of intraoc- ular tamponae is the need for a second operation if silicone oil is eventually removed. When silicone oil is to be used, an inferior iridectomy should be created in the aphakic eye (Fig. 42-32) (33). The vitreous cutter is inserted behind the inferior peripheral iris at its base, with the vitrectomy instrument facing the iris, then the iris is engaged. Excision of iris tissue must be controlled, and care must be taken to confine the iri- dectomy to near the iris base and not to extend it to the pupillary margin. As partial thickness iris is removed,

Silicone oil A Silicone oil B
Silicone
oil
A
Silicone
oil
B
C
C
Chapter 42 Management of Complicated Retinal Detachment 549 Air–Gas Exchange Following laser treatment, two sclerotomy sites

FIGURE 42-32.

Inferior iridectomy. A. Without inferior

iridectomy, silicone oil herniates into the anterior chamber due to pupillary block mechanism. B. Inferior iridectomy allows access of aqueous into the anterior chamber, relieving pupillary block so that aqueous no longer forces silicone oil into the anterior chamber. C. Inferior iridectomy. (Adapted from Abrams GW, Glazer LC. Proliferative vitreoretinopathy. In: Freeman WR (ed.). Practical atlas of retinal disease and therapy . 2nd ed. Philadelphia: Lippincott- Raven, 1997:303–323.)

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the surgeon begins to see the tip of the vitreous cutter through the thin residual anterior iris stroma and can in this manner guide placement of the instrument to complete the process. If the retina has been reattached with air, then silicone oil can be infused into the air-filled eye at the end of the case. Alternatively, a fluid–silicone exchange or PFCL– silicone oil exchange can be performed. When infusing silicone oil into the air-filled eye, the 5000-centistoke oil that is most commonly used has high viscosity and requires high pressure tubing if injected through the infusion port. We usually inject silicone oil into the air-filled eye in the following manner. With the infusion port in place and the air pump engaged to the infusion port tubing, we close one sclerotomy site and preplace a suture in the other site. We inject the silicone oil through an 18- or 20-gauge angio- cath that has been trimmed to approximately 10mm in length. As the silicone oil is injected, the pressure is adjusted and maintained at the present pressure by the air pump, which remains attached to the infusion tubing. In phakic or pseudophakic eyes, injection of silicone oil is continued until the oil just reaches the posterior lens. The syringe is removed and the preplaced sclerotomy suture closed. The infusion cannula can then be removed and the final sclerotomy closed. A small amount of oil will escape during suturing of the final sclerotomy, helping to ensure that the eye is not overfilled with silicone oil. In aphakic eyes, injection is continued until the oil level is at the level of the infusion cannula.The silicone syringe is removed from the eye, and the preplaced superotemporal sclerotomy suture is closed.Then, after clamping the air line, the infusion cannula can be removed from the eye and the tip of the silicone oil syringe inserted into the infusion scle- rotomy.To maintain the appropriate intraocular pressure and allow the escape of air from the eye, a 30-gauge needle can be attached to the air pump (still set at 15mmHg) and inserted into the anterior chamber through the limbus. Injec- tion is continued until the silicone oil just reaches the iris plane.Then the silicone oil syringe and needle are removed from the eye, and the final sclerotomy is closed.Again, a small amount of oil will escape, helping to prevent an overfill of silicone oil. Regardless of the phakia status of the eye, it may be prudent to place a plug in the sclerotomy before closing it and measure the intraocular pressure.A pressure reading of above 20mmHg may indicate an overfill, and a small amount of silicone oil should be removed through the open sclerot- omy and the pressure remeasured.We try to leave the closing pressure at approximately 10mmHg. The anterior chamber is left at normal depth. If the anterior chamber shallows, a small amount of oil is removed and the anterior chamber is reformed with air injected through the limbus. It is impor- tant that the intraocular pressure be left at a low-normal level so as not to inadvertently overfill or underfill the eye with silicone oil. If a posterior chamber IOL is present with an intact iris- capsular-IOL diaphragm, we do not make an inferior iri-

dectomy. If the diaphragm is not intact and/or silicone oil herniates around the IOL into the anterior chamber, an inferior iridectomy will sometimes keep the silicone oil out of the anterior chamber; however, sometimes the oil will go into the anterior chamber in spite of the iridectomy. Residual capsular material can obstruct an iridectomy, so patency should be confirmed at surgery. If the iridectomy is open and oil has gone into the anterior chamber, the oil can be pushed posteriorly with viscoelastic material injected into the anterior chamber. If the eye is making adequate aqueous, it may be necessary to remove the IOL and capsule and reopen the iridectomy in order to keep the silicone oil out of the anterior chamber. A stable anterior chamber lens can be left in place if an adequate inferior iridectomy is made. Unstable anterior chamber lenses should be removed. After all sclerotomies are closed, the eye is irrigated copi- ously with saline solution to remove residual silicone oil, and the conjunctiva is closed as described above. If the pressure is within a normal range and the retina is stable, the silicone oil can be removed 2 months or more following surgery. It is often possible to remove recurrent epiretinal membranes at the time of silicone oil removal. The Silicone Study found that approximately 20% of retinas detach following silicone oil removal (41). In the presence of hypotony, it is probably best to leave the silicone oil in the eye. Hypotonous eyes usually end up with corneal decompensation in the presence of silicone oil, because the silicone oil herniates forward and touches the corneal endothelium. Unfortunately, with silicone oil removal, these eyes often become phthisical. Whereas the visual prognosis is poor in either situation, the eye will probably remain more stable with silicone oil remaining in the eye than otherwise.

Early Postoperative Management

Eyes with PVR require significant postoperative manage- ment. Early postoperative management is directed toward 1) careful control of the intraocular pressure (IOP), 2) adequate retinal tamponade, 3) control of inflammation, 4) elimination of hemorrhage and fibrin, and 5) detection and management of recurrent retinal detachment. Han et al (42) found that 36% of patients developed an intraocular pressure of 30mmHg or more following vitrec- tomy. Patients undergoing surgery for PVR have many of the risk factors for elevation of IOP: scleral buckle, lensec- tomy, scatter endophotocoagulation, and sometimes a fibrin pupillary membrane postoperatively. We monitor IOP care- fully in the postoperative period. We normalize IOP at the end of the case, and if the patient has preexisting glaucoma or other factors indicating high risk for elevation of the IOP (e.g., scleral buckle and scatter photocoagulation), we give topical ocular antihypertensive medications. We check the IOP approximately 2 to 4 hours following surgery, then re- check as needed. We treat elevated IOP medically in most

Chapter 42

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551

cases, but extreme elevation of pressure sometimes requires paracentesis of fluid or gas. We ensure that the gas bubble is adequate to tamponade all retinal breaks and laser treatment postoperatively. We prefer to have the eye at least 80% filled with gas in the postoperative period. If the gas bubble is inadequate post- operatively, as sometimes occurs, we do a fluid–gas exchange to “top up” the gas bubble. For fluid–gas exchange in the aphakic eye, we prepare the eye with 5% povidine-iodine solution to the lids and the conjunctival cul-de-sac.We make a limbal incision with a disposable Ziegler-type blade.Then, with the patient prone, we inject gas into the eye through a 30-gauge needle inserted through the limbal incision (Fig. 42-33). As gas is injected, fluid will run out around the shaft of the needle through the limbal opening. The limbal incision is self-sealing and usually leaves a relatively normal IOP. We usually use a 15% mixture of C 3 F 8 for the postoperative fluid–gas exchange. In a phakic eye or in an eye with a posterior chamber implant, we perform the fluid–gas exchange through the pars plana.We use a two-needle technique.With the patient placed on his or her side, we insert a 30-gauge needle attached to a 10-cc syringe filled with the selected gas mixture (usually 14% C 3 F 8 gas) through the pars plana in the most superior position and into the vitreous cavity. We then insert a 27-gauge needle attached to a 10-cc syringe through the pars plana at the most dependent position. We usually place the needle for air insufflation (which is now superior) nasally, and the needle for fluid

Gas bubbles Fluid flows out of eye
Gas bubbles
Fluid flows
out of eye
Chapter 42 Management of Complicated Retinal Detachment 551 cases, but extreme elevation of pressure sometimes requires

FIGURE

42-33.

Postoperative fluid–gas exchange in the

aphakic eye. A selected gas mixture (5 to 10 mL) is insufflated into

the eye through a 30-gauge needle placed through a limbal incision made with a Ziegler-type blade. Because the self-sealing limbal incision is larger than the diameter of the needle, fluid will drain out of the incision as the gas is injected. Small bubbles will coalesce in the first hours after the exchange.

aspiration (which is now dependent, inferiorly) temporally (Fig. 42-34). We aspirate fluid from the dependent syringe as we simultaneously fill the eye with air from the superior syringe. We sequentially equalize the volume of fluid aspi- rated through the dependent syringe with the amount of gas injected through the superior syringe. Usually, we sequentially aspirate 0.5mL of fluid then inject 0.5mL of gas, until the fluid is replaced with gas. As we fill the eye with air, we turn the head toward a more prone position so we can aspirate more fluid. We aspirate as the needle is slowly withdrawn to remove as much fluid as possible. To control inflammation, we give subconjunctival Decadron (5–10mg) at the conclusion of surgery. We also treat with frequent topical corticosteroids postoperatively. We usually give the topical corticosteroids every hour while awake for the first few days of the postoperative period.We usually do not give systemic corticosteroids because of the potential systemic risks involved and because the benefit has not been clearly demonstrated. If significant postoperative fibrin formation causes pupil- lary block, interferes with postoperative fluid–gas exchange, or interferes with the view to the extent that it complicates postoperative evaluation and management, we lyse the fibrin

Chapter 42 Management of Complicated Retinal Detachment 551 cases, but extreme elevation of pressure sometimes requires
Chapter 42 Management of Complicated Retinal Detachment 551 cases, but extreme elevation of pressure sometimes requires

FIGURE

42-34.

Postoperative fluid–gas exchange in the

phakic or pseudophakic eye. The superior (nasal) syringe contains air or gas mixture. The inferior (temporal) syringe is for aspiration of fluid in the vitreous cavity. Exchange is done by sequentially injecting 0.5 mL of air or gas and aspirating the same volume of fluid until the fluid in the vitreous cavity is exchanged for the air or gas. We use a 30-gauge needle for injection and 27-gauge needle for aspiration.

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with tissue plasminogen activator (tPA) (43–45). We usually wait 48 to 72 hours following surgery to administer tPA in order to minimize the possibility of intraocular hemorrhage. We recommend injecting 3 µg of tPA in 0.1mL of balanced saline with a 30-gauge needle through the limbus. In the presence of severe fibrin formation and/or hemorrhage, we usually do a fluid–gas exchange to clear the fibrin products and/or hemorrhage after lysis with the tPA. We closely monitor patients for the development of recurrent retinal detachment. Retinal detachment is most easily seen by looking around (not through) a gas bubble. We usually examine the patients every 1 to 2 weeks until the gas bubble has resolved. If retinal detachment is detected, we look for the cause. Usually retinal detachment indicates the presence of an untreated retinal break and/or excessive retinal traction. The most common cause of recurrent retinal detachment is residual anterior traction that opens an anterior break. Eyes with anterior contraction can sometimes be reattached successfully with a repeat fluid–gas exchange. After the retina is flattened, laser treatment is applied in several rows to the retina over the scleral buckle and some- times 360-degrees posterior to the scleral buckle. We have found that postoperative laser photocoagulation in the air- filled eye is most easily administered using a laser with a long wavelength, such as krypton red or diode laser, and a panfunduscopic contact lens. Although some degree of retinal detachment anterior to the scleal buckle may remain, often fluid can be demarcated, and the posterior retina will remain attached. This is com- patible with long-term stability and recovery of functional visual acuity in some cases; however, some cases with ante- rior retinal detachment will become hypotonus. If there is significant retinal contraction posterior to the scleral buckle, we do not recommend doing a fluid–air exchange because of the risk of further contraction and posterior tear formation. With posterior contraction, we recommend reoperation. Eyes with silicone oil can have unique postoperative con- siderations, including herniation of the silicone oil into the anterior chamber and pupillary block glaucoma due to the silicone oil. Both problems usually result from closure of the peripheral iridectomy. Sometimes, however, the oil will be in the anterior chamber in the first few days following surgery in spite of an open iridectomy. If the eye is pro- ducing adequate aqueous, the silicone oil will recede behind the pupil as flow of aqueous is established through the peripheral iridectomy. Keeping the patient in an upright position with the face tilted forward will help establish the proper aqueous flow. If the eye is not making adequate aqueous, the oil will continue to herniate forward. Usually, if the silicone oil has pushed the iris forward with shallow- ing of the anterior chamber following surgery, simply posi- tioning the patient upright with the face tilted forward or having the patient lie prone will cause it to recede to its normal position.

Fibrin can close a peripheral iridectomy and cause pupil- lary block with shallowing of the anterior chamber and glaucoma or herniation of the silicone oil into the anterior chamber. Sometimes the fibrin will resolve with topical cor- ticosteroids, but if it persists more than 48 to 72 hours, we inject tPA (3 µg) to lyse the fibrin. If postoperative fibrin formation has caused adherence of the peripheral iris to the cornea, surgically reforming the anterior chamber may be necessary. In the surgical suite, we inject viscoelastic to reform the anterior chamber. Removing a small amount of silicone oil may occasionally be necessary.

Results

There has been slow, steady improvement in the surgical results of PVR management in the past 25 years. Grizzard and Hilton (16) used a high encircling scleral buckle tech- nique and reported a 35% retinal reattachment rate in eyes with the equivalent of C1 to D2 PVR (Retina Society classification). Machemer and Norton (46) found vitrectomy alone was not successful for PVR, but Machemer and Laqua (3) combined membrane peeling techniques with vit- rectomy and their retinal reattachment rate at 6 months increased to 36%. Early surgical techniques of vitrectomy and membrane peeling were effective in managing posterior membranes in PVR.The major cause of failure was anterior retinal prolif- eration and contraction. Charles (47) first described anterior displacement of the retina in PVR. Lewis and Aaberg (4) described the pathoanatomy, and Elner and colleagues (25) showed the histopathology of anterior PVR. Aaberg (48) correlated the chronology of surgical advances and under- standing of the pathoanatomy of PVR with improvement in results and management of PVR. There has been continued improvement in both anatomic and visual results in management of PVR. Lewis, Aaberg, and Abrams (7) reported complete retinal reattach- ment in 73 (90%) of 81 eyes that had not undergone a previous vitrectomy. Of the eyes that were completely reattached, 85% (62/73) obtained a visual acuity of 5/200 or better. Lewis and Aaberg (8) reported complete anatomic reattachment in 27 (73%) of 37 eyes that had undergone a previous vitrectomy for PVR, with visual acuity of 5/200 or better in 67% (18/27) of eyes with complete attachment. The IOP was less than 5mmHg in 4 of their 5 cases with recurrent anterior retinal detachment. The cause of surgical failure was cellular reproliferation and traction with anterior PVR present in 9 of 12 cases that developed a recurrent retinal detachment. The Silicone Study was a multicenter, randomized, con- trolled clinical trial funded by the National Eye Institute comparing silicone oil and gases in the management of PVR. The surgical method included vitrectomy, removal of posterior membranes, dissection for anterior PVR if present, and reattachment of the retina with air, followed by ran- domization to 1000-centistoke silicone oil or gas. An infe-

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553

rior iridectomy was created in silicone oil eyes. There were two groups of eyes: group 1 eyes had not undergone a pre- vious vitrectomy; group 2 eyes had undergone a previous unsuccessful vitrectomy with gas for retinal detachment.The study involved a 36-month follow-up on most eyes ran- domized to silicone oil or C 3 F 8 gas, and long-term follow- up, up to 72 months, on many of the eyes with attached maculas at 36 months. Eyes were randomized to silicone oil or 20% SF 6 gas in the initial portion of the study and silicone oil or 14% C 3 F 8 gas in the major portion of the study. While results with silicone oil were superior to SF 6 (38), there was little difference between silicone oil and C 3 F 8 gas (2). Thus, both silicone oil and C 3 F 8 gas produced better results than SF 6 gas. At 36 months, C 3 F 8 eyes had a higher rate of complete retinal attachment posterior to the scleral buckle than sili- cone oil eyes (approximately 80% versus 60%, p 0.05) in group 1 (no previous vitrectomy) (40). No such difference was found in group 2 (previous vitrectomy) eyes. Between 55% and 65% of oil and gas eyes with complete posterior attachment in both group 1 and group 2 had visual acuity of 5/200 or better (no significant difference). Although hypotony was more common in gas eyes than oil eyes, the difference was not significant among eyes with complete posterior attachment in either group 1 or group 2. There was no difference in keratopathy in eyes with com- plete posterior attachment. On long-term follow-up (up to 72 months) of all eyes with attached maculas at 36 months, regardless of gas used or previous vitrectomy status, there was no significant dif- ference between gas and oil in anatomic or visual outcome or in the incidence of keratopathy. In contrast, significantly more gas eyes had hypotony than did oil eyes (approximately 18% versus 5%, p 0.001). Further analyses compared gas-treated, oil-retained, and oil-removed eyes.

1. Oil-retained versus oil-removed eyes: Oil-removed eyes had a higher rate of complete posterior retinal attachment, a higher percentage of eyes with visual acuity of 5/200 or better, and a lower rate of keratopathy. There was no difference in hypotony.

  • 2. Gas-treated versus oil-removed eyes: There was no difference in complete posterior retinal attachment, but oil-removed eyes had a higher percentage of eyes with visual acuity of 5/200 or better at 60 months, less keratopathy at 48 months, and a lower rate of hypotony.

  • 3. Gas-treated versus oil-retained eyes: Gas-treated eyes had a higher rate of complete posterior attachment and visual acuity of 5/200 or better. There was no difference in hypotony, but oil-retained eyes showed a trend toward more keratopathy (not significant).

Oil-removed eyes had a better outcome than oil-retained and gas-treated eyes in this study. However, silicone oil

removal was at the surgeon’s discretion, and oil was more likely to be removed in eyes with attached retinas, better visual acuities, and fewer complications. Oil-removed eyes also had fewer reoperations than oil-retained eyes, so surgeon bias makes it difficult to determine if it is better to remove or retain oil. An earlier Silicone Study report attempted to remove surgeon bias from the analysis (41). Silicone oil was removed from 100 (45%) of 222 eyes that received silicone oil in the study. In a matched-pairs analy- sis, eyes with silicone oil removed were more likely to expe- rience improvement in visual acuity and suffer retinal detachment than eyes with silicone oil retained. A number of subgroup analyses were reported in the Silicone Study. There was no difference in retinal reattach- ment or visual acuity between group 1 and group 2 eyes (49). Though uncommon, elevated IOP ( 25mmHg) was more prevalent in silicone oil eyes (8%) than in C 3 F 8 eyes (2%) ( p 0.05) (50). Chronic hypotony (IOP 5mmHg) was 1) more prevalent in eyes randomized to C 3 F 8 gas than in those randomized to silicone oil (31% versus 18%; p 0.05), 2) more prevalent in eyes with anatomic failure (48% versus 16%; p 0.01), and 3) correlated with poor post- operative vision ( p 0.001) and retinal detachment ( p 0.001). Diffuse contraction of the retina anterior to the equator was an independent factor prognostic of chronic hypotony. Relaxing retinotomies were more commonly done in group 2 eyes (42%) than in group 1 eyes (20%) ( p 0.0001) (31). The incidence of hypotony (IOP 5mmHg) was greater in gas eyes than silicone oil eyes undergoing relax- ing retinotomies. Relaxing retinotomies were done more commonly in eyes with anterior PVR than in eyes without anterior PVR.Visual acuity and the retinal reattachment rate were better in eyes without relaxing retinotomies than in eyes with relaxing retinotomies. Eyes with posterior PVR had a better outcome at 6 months than eyes with anterior PVR (51). For eyes with anterior PVR, significant predictors of poor ( 5/200) visual acuity were a preoperative PVR grade of D1 or worse (Retina Society Classification) and the use of

  • C 3 F 8 gas as the intraocular tamponade. Eyes with anterior

PVR and clinically significant posterior PVR changes had a better visual prognosis if silicone oil was used instead of gas. In eyes with attached maculae, the incidence of corneal abnormalities at 24 months was 27% and did not differ significantly between silicone oil and gas groups (52). Corneal abnormalities were correlated with poor visual acuity and hypotony. Factors predictive of corneal abnormalities were iris neovascularization, aphakia or pseudophakia, postoperative aqueous flare, and reoperations. The overall prevalence of macular pucker among eyes with attached maculae was 15% (53). There was no differ- ence in the prevalence of postoperative macular pucker in

eyes randomized to gas versus silicone oil or between group 1 and group 2 eyes. Postoperative macular pucker

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was three times as likely to develop in eyes that were preoperatively aphakic or pseudophakic than in eyes preoperatively phakic. Recent improvements such as PFCL and wide-angle viewing were not available for the Silicone Study. The impact of these advances on the results of the study are unknown. We expect further technical advances to improve our ability to manage PVR. In spite of the excellent surgi- cal results in PVR management, many problems with recur- rent proliferation remain. Whereas an increased percentage of cases can be reattached with surgery, inhibition of repro- liferation with pharmacologic agents to prevent subsequent retinal detachment has been sought by many investigators for over 20 years and counting. There are five major areas of investigation into reducing cellular proliferation in PVR:

anti-inflammatory therapy (54), direct inhibition of cellular proliferation (55–60), prevention of attachment of prolifer- ating cells to collagen (61), immunotoxin therapy (62), and gene therapy (involving the “suicide gene”) (63). Addition- ally, there are new modalities under development, such as sustained release devices, to better deliver drug therapy to the eye.These avenues of research offer hope that PVR can be prevented from occurring in most cases, and cured if it does occur.

RETINAL DETACHMENT ASSOCIATED WITH VITREOUS HEMORRHAGE

Overview

Vitreous hemorrhage most commonly occurs due to retinal tears associated with posterior vitreous separation. The patient frequently has photopsia and floaters followed by visual loss. Retinal detachment may also be associated with postsurgical hemorrhage, or hemorrhage may be present fol- lowing a failed retinal reattachment procedure. Vitreous hemorrhage can obscure the retina. However, peripheral tears and retinal detachment can sometimes be visualized with the indirect ophthalmoscope in spite of a dense vitreous hemorrhage because the area of the vitreous base may not be obscured. Visualization is sometimes obtained following bed rest and head elevation. Ultrasound may reveal a retinal detachment. Areas of vit- reoretinal adhesion may be identified, and larger flaps of horseshoe tears may be seen with ultrasound. Mapping the extent and degree of elevation of the retinal detachment is usually possible with ultrasound. If vitreous hemorrhage prevents adequate visualization for a scleral buckling procedure, vitrectomy is indicated. Sometimes peripheral visualization is adequate to permit a scleral buckling procedure, and visualization may be improved by bed rest, bilateral patching, and head elevation. We proceed to vitrectomy if a retinal detachment is present; the risk of PVR may be increased by delaying surgery in the presence of vitreous hemorrhage.

If a definite acute retinal tear without retinal detachment is detected by ultrasound, and visualization is not adequate for treatment, vitrectomy is indicated. However, a trial of bed rest with head elevation and bilateral patching is indi- cated for 48 to 72 hours to see whether the hemorrhage will settle enough to permit visualization and treatment without vitrectomy.

Surgical Anatomy

Posterior vitreous separation is present in most cases. Retinal tears are usually located at the posterior edge of the vitre- ous base that is the anterior extent of the posterior vitre- ous separation.The retinal detachment may be quite bullous; sometimes there is little separation between the posterior hyaloid and the retina.

Surgical Technique

The eye is prepared for vitrectomy in the usual manner. If a scleral buckle is planned, a 360-degree conjunctival inci- sion is made, and the muscles are isolated with sutures. If a preexisting buckle is not to be revised, transconjunctival sutures are placed through the rectus muscles and a limited conjunctival approach is used. Entrance into the eye is in the usual manner. If the pars plana is detached, openings should be made more anteriorly than usual.We use a 4-mm infusion port. Care must be taken if a longer infusion port is used, so that it does not impact the equator of the lens or the retina over the scleral buckle. For this reason, we rarely use the long infusion ports in phakic eyes or in eyes with anteriorly located scleral buckles. The central vitreous is removed, then the posterior hyaloid is incised over attached retina if possible. If the retina is completely detached, then a less bullous area is selected. Preoperative ultrasound is helpful, but the configuration of the retinal detachment may change at surgery. The hyaloid is incised posteriorly over the optic nerve if the retina is totally detached, because the retina is flat at the edge of the optic disk. If the posterior hyaloid is separated from the retina and the vitreous is collapsed anteriorly, the cutting port is directed anteriorly and the vitreous and posterior hyaloid face may curl around the instrument tip into the port during vitrectomy. It is usually necessary to face the cutting port parallel with a collapsed hyaloid, or directly toward a thickened or taut hyaloid, in order to incise the hyaloid. Once the hyaloid is incised, the instrument tip is placed through the opening and the cutting port is directed away from the detached retina toward the edge of the hyaloid. Low suction is applied, and the retina is kept in view during vit- rectomy. Vitreous is cut in a centrifugal fashion, eventually excising the vitreous to the surface of the vitreous base. In the periphery,there is danger of suctioning bullous retina into the cutting tip. The vitreous should be cut over detached

Chapter 42

Management of Complicated Retinal Detachment

555

retina with lower levels of suction and with the vitreous cutter facing away from the detached retina. PFCL (see above) injected over the posterior retina will stabilize the retina during excision of peripheral vitreous and reduce the likelihood of retinal damage. The PFCL should be injected so the meniscus remains posterior to the vitreous in the periphery, thus avoiding compression of the vitreous and allowing it to be engaged with the vitreous cutter.Vitreous is cut back to the periphery as far as can be safely done. The posterior retina should be examined closely for the presence of epiretinal membranes. Membranes should be removed in the same manner done for PVR. If the retina is mobile, without any folds or membranes, then the retina can be reattached. Prior to reattaching the retina, plugs should be placed in the sclerotomy sites and the peripheral retina thoroughly examined with the indirect ophthalmo- scope. All retinal breaks should be identified and localized. Peripheral retinal breaks can be treated with either laser or cryotherapy. Cryotherapy can be performed at this time or after reattachment of the retina with air or PFCL, but breaks should be marked with diathermy if possible so they can be identified when the retina is reattached. Laser is performed after the retina is reattached. If peripheral retinal breaks are present, an appropriate encircling scleral buckle is usually placed to support the breaks and vitreous base area.The sutures and scleral buckle are usually placed at this time, although some surgeons place the buckle after reattachment of the retina. If scatter treat- ment on the buckle is anticipated, it is best to have the buckle in place prior to insufflating air, because sometimes the pupil will become miotic in the aphakic eye or with fluctuation of IOP in the air-filled eye. If a posterior retinal break is present, fluid–air exchange is performed as described above for PVR. If a posterior break is not acces- sible for endodrainage, we usually reattach the retina with PFCL as described above. When the retina is reattached, laser endophotocoagula- tion is applied to all accessible retinal breaks. Laser is most easily applied through PFCL, but can also be done through air. Breaks should be surrounded with confluent laser. In aphakic and pseudophakic eyes, laser endophotocoagulation can be used to treat both posterior and anterior breaks, but in phakic eyes, there is a risk of damage to the lens with the endoprobe when treating peripheral breaks. Delivery of the laser by the indirect ophthalmoscope (indirect laser pho- tocoagulation) is often preferred for peripheral breaks. In the absence of PVR, if vitreous traction has been satisfactorily relieved, only the retinal breaks are treated with laser or cry- oretinopexy. However, if there is significant traction, laser scatter treatment should be placed on the peripheral retina supported by the scleral buckle in two to three rows, with at least one burn width between laser spots. If PFCL is in the eye, it should be exchanged for air as described above. An air–gas exchange is done if a long-acting gas is to be used.

Results

Ratner et al (64) reported retinal reattachment in 21 (50%) of 42 eyes with retinal detachment and vitreous hemor- rhage. Of the 42 eyes, 18 (43%) obtained visual acuity of 5/200 or better. A more recent study using more modern techniques reported retinal reattachment in 55 (89%) of 62 eyes with preoperative vitreous hemorrhage (65). The authors found no difference in the incidence of posto- perative PVR between eyes with and without preoperative vitreous hemorrhage. Surgical failure in these eyes may result from complica- tions of the vitrectomy. Eyes with preexisting rhegmatoge- nous retinal detachment have a higher incidence of entrance site problems, including dialysis, subretinal infusion, and retinal incarceration. Iatrogenic tears are easily created in detached retina. Other causes of failure to reattach the retina include failure to identify tears and PVR. Tears may be hidden in the hemorrhagic vitreous base. A broad buckle covering the area from the ora serrata to near the equator will close most peripheral tears. PVR probably occurs more rapidly in eyes with vitreous hemorrhage. For that reason, we recommend surgery soon after the onset of hemorrhage if retinal detachment occurs. Eyes with vitreous hemorrhage should be followed closely with ultrasound to detect retinal detachment at an early stage. Poor visual function following retinal reattachment may be due to macular dysfunction from longstanding retinal detachment, PVR, or epiretinal membrane formation.

POSTERIOR RETINAL BREAKS

Overview

Posterior breaks may lead to retinal detachment in a variety of conditions. Macular holes may be idiopathic or associ- ated with high myopia, or may follow trauma (66–70). Most do not lead to retinal detachment beyond the immediate margin of the macular hole, and management of macular holes without extensive retinal detachment is described in Chapter 52. Posterior breaks may be associated with pro- liferative retinopathies (diabetic retinopathy or branch vein occlusion), posterior lattice degeneration, or uveal colobomas. Retinal detachments due to posterior breaks usually do not extend to the ora serrata, and peripheral breaks are usually not present. A scleral buckle may reattach the retina in some eyes with breaks well posterior to the equator.Various procedures using slings, straps, scleral pockets, or permanent or tempo- rary radial scleral buckling elements have been reported (71–74). However, there is risk of damage to the optic nerve, macula, vortex veins, and posterior ciliary vessels in the treatment of far posterior tears, and a scleral buckling pro- cedure carries the risk of scleral perforation or rupture or choroidal hemorrhage in highly myopic eyes.Those eyes not

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easily and safely managed by a scleral buckling procedure are candidates for vitrectomy.

Surgical Anatomy

Macular holes usually do not lead to extensive retinal detachment. The incidence is extremely low in nonmyopic eyes with macular holes but is not uncommon if myopia of 6.00 diopters (D) or greater is present (Fig. 42-35A, B) (75–76). Retinal detachment is usually associated with vit- reoretinal adhesion and traction. Gass believes that macular holes are the result of tangential retinal traction, and that the vitreous remains attached to the retina surrounding the hole in most cases. It is the combination of the macular hole and the associated vitreous traction that leads to both the common localized and the less common extensive retinal detachment. In cases of proliferative retinopathy, posterior lattice degeneration, and uveal coloboma, traction is nearly always present. These breaks are usually the result of partial posterior vitreous separation, with vitreous traction on the flap of the tear and often on the adjacent retina. In most retinal detachments associated with posterior holes, vitreous traction is necessary for the retinal detachment to occur. Exceptions are highly myopic eyes with posterior staphylo- mas in which the retina may detach even though a com- plete posterior vitreous separation occurs. In these eyes, the retina is probably relatively shortened in comparison to the configuration of the deep staphyloma, and the retinal pigment epithelium may function inadequately to pump out subretinal fluid.

Surgical Technique

A scleral buckle is usually not performed. Preparation and vitrectomy are the same as described above. Frequently,

vitreous adhesions not identified preoperatively are recognized at surgery. Adhesions are initially recognized when the retina moves and is pulled toward the vitreous as the adherent vitreous is cut. Sometimes it is necessary to strip vitreous and/or associated epiretinal membranes from the retinal surface. We use an illuminated pick or barbed needle or a blade to strip the vitreous. Sometimes the vitreous is best grasped near the retina with vitreous forceps, then in a bimanual technique, the retina is held back with the blunt side of the illuminated pick and the vitre- ous is stripped free. Alternatively, the pick can be used to bluntly separate adhesions as the vitreous is held under trac- tion. If vitreous is tightly adherent and will not strip free, it is cut near the retinal surface, then adhesions are cut with automated vertically cutting scissors. All adhesions are cut, and remaining vitreous is trimmed back toward the vitreous base.

Macular Hole Without Staphyloma

After all vitreous adhesions have been released and vitrec- tomy is completed, we inspect the peripheral retina for retinal breaks. If no breaks are seen, the retina is reattached with a fluid–air exchange. Fluid can be drained through the macular hole to reattach the retina. The subretinal fluid is aspirated with gentle suction with a soft-tipped needle. Alternatively, a backflush brush can be used if care is taken that the air pressure is somewhat lower than for a routine fluid–gas exchange, so the extrusion pressure is not too high. It is important not to suction the retina into the orifice of the aspirating needle. Usually, the subretinal fluid will stream out of the hole when low suction is applied while the soft-tipped needle is held just anterior to the hole. Too much suction will sometimes enlarge the hole by stretching the edges as the fluid traverses the hole. If chronic subretinal fluid has become proteinaceous, the fluid is easily

A
A
B
B
556 P ART III Retina and Vitreous Surgery easily and safely managed by a scleral buckling

FIGURE 42-35.

The right eye of a patient with high myopia who had a localized rhegmatogenous retinal detachment due to a macular

hole. A. Preoperative fundus photograph. B. Appearance of the macula 10 days after pars plana vitrectomy and fluid–gas exchange, with no direct

treatment applied to the macular hole. There is still a partial gas fill in the vitreous cavity. The retina is reattached.

Chapter 42

Management of Complicated Retinal Detachment

557

visualized as it streams out of the hole into the aspirating needle. At the end of the fluid–air exchange, we do not aggres- sively aspirate fluid at the hole when the retina is flat. We remove as much intraocular fluid as possible by waiting approximately 15 minutes to let more fluid accumulate in the posterior pole, then aspirate the accumulated fluid. We do not treat the macular hole with laser or other adhesive modality. The air is exchanged for a nonexpansile gas (12% to 14% C 3 F 8 ). We ask the patient to stay in the prone position for the first two weeks following surgery. If retinal detachment recurs postoperatively, a repeat fluid–gas exchange is performed (77). Then, when the macula is flat, the hole is treated with external laser.

Macular Hole with Posterior Staphyloma

Initial management is the same as for macular hole without posterior staphyloma. Most macular holes associated with staphylomas will require treatment; nevertheless, we gener- ally do not treat these tears initially. If retinal detachment recurs postoperatively, we flatten these tears with repeat fluid–gas exchange and treat with laser.

Posterior (Nonmacular) Break

After vitrectomy and release of all traction from the break, the margins of the break are marked by whitening with endodiathermy. Fluid–air exchange is performed with drainage through the posterior break by an aspirating soft-tipped needle. The break is treated with two rows of surrounding laser endophotocoagulation. The patient is in a prone position postoperatively for approximately 1 week to keep the tear closed while air or gas remains in the eye.

Results

Binder and Riss (78) compared 27 eyes with macular holes and retinal detachments treated with nonvitrectomy tech- niques from 1972 until 1977 with 18 eyes treated with vit- rectomy and gas insufflation from 1978 until 1981 at the same eye clinic.The anatomic reattachment rate was higher in the vitrectomy group (17 of 18) than in the nonvitrec- tomy group (16 of 27). No eyes in the nonvitrectomy group had better than 6/60 vision, while one-third of eyes that underwent vitrectomy had visual acuity of 6/12 to 6/48. Poorer vision in the nonvitrectomy group was due to buck- ling of the macula or sometimes repeated treatment of the macula. In 3 cases treated with vitrectomy, no treatment was applied to the macular hole. Gonvers and Machemer (79) treated 6 cases of retinal detachment due to macular holes with vitrectomy and fluid–gas exchange and positioning. No treatment was applied to the breaks. Of the 6 eyes, 5 remained attached, but one required a repeat fluid–air exchange. Also, 5 of 6 eyes were highly myopic. Final vision ranged from 3/200 to

20/100.

Several authors have also attempted treatment of retinal detachment due to macular hole by performing gas injec- tion without pars plana vitrectomy. Blankenship and Ibanez- Langlois exchanged liquid vitreous with an intravitreal gas bubble and achieved successful reattachment in 15 of 19 eyes (80). One patient required repeated exchange and 3 required vitrectomy. Visual acuity of 20/400 was obtained in 9 patients. Miyake reported successful reattachment after gas injection in 15 of 18 eyes, with follow-up from 4 to 32 months (81). Another study compared vitrectomy and gas injection with gas injection alone in 43 eyes, and found similar final attachment rates (82). Complications are the same as for vitrectomy surgery in general. Because the intraocular maneuvers are limited and the procedures short, a low incidence of complications is found in this group of eyes. However, redetachment rates are high, and the need for reoperation is not uncommon. Residual epiretinal tissue over the posterior retina causing tangential traction is thought to be the cause of recurrent detachment in some cases (83,84). Complications may be less with vitrectomy than with scleral buckling for some highly myopic eyes.

NONDIABETIC TRACTION RETINAL DETACHMENT

Most retinal detachments result from vitreous traction. However, we differentiate traction retinal detachments from other retinal detachments by the presence of either direct vitreous traction that prevents the retina from contacting the retinal pigment epithelium, or direct vitreous traction that prevents a retinal break from settling on an adequately posi- tioned scleral buckle. Traction retinal detachment requires pars plana vitrectomy to adequately relieve vitreoretinal trac- tion and reattach the retina. Common etiologies of traction retinal detachment such as proliferative diabetic retinopathy, advanced proliferative vitreoretinopathy, retinopathy of pre- maturity, and penetrating trauma are discussed elsewhere in the text. Other etiologies include vitreous incarceration in a surgical wound, lower grades of PVR, vitreomacular trac- tion syndrome, and complicated branch retinal vein occlu- sion and associated diseases. While other conditions can also cause traction retinal detachments, the principles of treatment of the above conditions can be used for most other etiologies.

Vitreous Incarceration in a Surgical Wound

Overview

Vitreous incarcerated in a cataract wound can cause direct vitreous traction on the retina. Incarceration may result from vitreous loss from a broken posterior capsule during phacoemulsification or from a limited choroidal hemorrhage in which vitreous is extruded from the wound (Fig. 42-36A). This may result in traction retinal detachment with vitreous

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strands bridging between the wound and the retina (Fig. 42- 36B). These detachments may occur soon after surgery if a great deal of vitreous was lost at surgery or if a retinal break occurred at the time of cataract surgery. Alternatively, the retinal detachment may occur weeks to months after surgery if fibrous proliferation at the wound caused additional trac- tion. A similar picture can sometimes be seen following vit- rectomy if inadequate vitreous was removed and vitreous traction from the sclerotomy wound is transmitted to the retina (Fig. 42-37A). In addition, vitreous incarceration in a scleral drain site during a scleral buckling procedure can lead to significant vitreous traction.We have seen traction retinal detachment following resolution of a postoperative, nonex- pulsive choroidal hemorrhage following glaucoma filtration surgery. In this case, vitreous was extruded through the filter site into the subconjunctival space.

Surgical Anatomy

Characteristically, these retinal detachments are rhegmatoge- nous and have horseshoe retinal breaks with highly elevated retinal flaps, though occasionally the retinal detachments are purely tractional. Vitreous can usually be seen bridging between the wound and the retina.

Surgical Technique

We initiate pars plana vitrectomy as described above.Vitre- ous traction is usually directed toward the vitreous base, and the posterior vitreous is often separated. If posterior vitre- ous separation has not occurred, then vitreous is separated from the optic disk and retina with suction, picks, and/or vitreous forceps as necessary. Vitreous strands from the wound to the retina are severed with the vitrectomy cutter (Fig. 42-37B). If the vitreous is organized, it may be neces-

sary to cut the membranes with scissors, though this is rare. We remove vitreous attached to flaps of retinal breaks and strip any epiretinal membranes present. The vitreous is shaved to the surface of the peripheral retina at the vitre- ous base using scleral depression or a wide-angle viewing system. If the retina becomes bullous as traction is released, then PFCL can be used to stabilize the retina as peripheral vitreous or membranes are removed. If a posterior break is present, a fluid–air exchange will reattach the retina. If breaks are only peripheral, the retina can be reattached with PFCL. We usually treat retinal breaks with laser endopho- tocoagulation, although indirect laser photocoagulation or cryotherapy can be used alternatively. No gas tamponade or scleral buckle is required if there are no retinal breaks and traction has been released. We usually place an encircling scleral buckle to support peripheral retinal breaks.

Results

Kreiger (85) reported on 4 patients who developed retinal detachments secondary to tears caused by traction from incarcerated vitreous at a sclerotomy site, and who under- went reoperation. All detachments were successfully re- paired, although visual outcome was poor in 1 eye in which silicone oil was required because of severe PVR.

Vitreous Traction on Retinal Breaks Following Scleral Buckle

Overview

Most retinal detachments with lower grades of PVR are managed with a scleral buckle. With grades A and B (see Table 42-1), there can be vitreous contraction induced by

Open cataract wound Taut vitreous Vitreous Retinal detachment to wound wound Iris incarcerated inwound Retinal detachment
Open cataract wound
Taut vitreous
Vitreous
Retinal detachment
to wound
wound
Iris incarcerated
inwound
Retinal
detachment
Haemorrhage in
supra choroidal
A
space
B
558 P ART III Retina and Vitreous Surgery strands bridging between the wound and the retina

FIGURE 42-36.

An intraoperative choroidal hemorrhage leading to a tractional retinal detachment. A. An eye with an intraoperative

choroidal hemorrhage during cataract surgery. The mass effect of the choroidal hemorrhage displaces vitreous into the open cataract wound. B. With resolution of the choroidal hemorrhage, the band of incarcerated vitreous applies tractional force to the retina, leading to tractional retinal detachment.

Chapter 42 A
Chapter 42
A

Management of Complicated Retinal Detachment

559

Old sclerotomy with vitreous incarceration Vitrectomy insrument Subretinal fluid Border of retinal detachment Optic nerve head
Old sclerotomy
with vitreous
incarceration
Vitrectomy
insrument
Subretinal
fluid
Border of
retinal
detachment
Optic nerve
head
B
Chapter 42 A Management of Complicated Retinal Detachment 559 Old sclerotomy with vitreous incarceration Vitrectomy insrument

FIGURE 42-37.

Vitreous incarceration in a sclerotomy wound after pars plana vitrectomy leads to a retinal detachment. A. Vitreous

streams from the sclerotomy site in the pars plana to the vitreous base, producing peripheral traction on the retina, with a resultant retinal break

formation and a traction/rhegmatogenous retinal detachment. B. Release of vitreous traction with vitrectomy.

proliferative cells. Vitreous traction on a retinal break can sometimes prevent the retinal break from making contact with the retinal pigment epithelium on a scleral buckle and prevent reattachment of the retina (Fig. 42-38A). In addi- tion, some large posterior retinal breaks, even in the absence of PVR, can “fish-mouth” and not close on a scleral buckle. If the retinal break is in the superior 180 degrees, injection of an air or gas bubble will usually tamponade the break, except for extreme levels of traction. Inferior retinal breaks are problematic because of the difficulty of tamponading with air or gas. Sometimes elevating the height of a scleral buckle or adding a radial element will close the retinal break, but it is less traumatic to the eye to directly relieve traction with a vitrectomy in some cases.

Surgical Anatomy

In PVR, findings include pigmented vitreous cells and reduced mobility of the vitreous on eye movement. Breaks are often large, and vitreous can be seen tenting the flap of the tear.

Surgical Technique

The central vitreous is removed with the vitreous cutter. Vitreous attachments to the flap of the retinal tear should be cut (Fig. 42-38B). Scleral depression or a wide-angle viewing system may be necessary to visualize the retinal break. We recommend shaving the peripheral vitreous to the surface of the anterior retina. If there is significant mobility of the anterior retina, PFCL can be used to

stabilize the retina. We usually reattach the retina with PFCL, then apply laser photocoagulation to the retinal breaks. We use laser endophotocoagulation in aphakic and pseudophakic eyes and indirect laser photocoagulation in phakic eyes. In reoperation of eyes with early PVR, we rec- ommend scatter laser photocoagulation 360 degrees to the retina supported by the scleral buckle, because of the risk of anterior retinal traction in the postoperative period. We leave air or gas in the eye for postoperative tamponade of the retinal breaks.

Results

Friedman and D’Amico treated 9 patients who had recur- rent retinal detachents due to persistent vitreous traction on retinal breaks after scleral buckle surgery (86). All patients were treated with vitrectomy, relief of traction on the retinal break, and gas tamponade. Long-term reattachment was achieved with 7 of the 9 patients with a single operation, and in 1 additional patient after two vitrectomies.

Vitreomacular Traction Syndrome

Overview

Vitreomacular traction syndrome classically has vitreoretinal traction on the posterior pole causing visual loss.While most cases do not have retinal detachment, sometimes traction retinal detachment of the macula and even a larger area of the posterior pole evolves when vitreous separates from the retina, except at the macula and optic disk area.

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A
A
B
B
560 P ART III Retina and Vitreous Surgery A B FIGURE 42-38. Recurrent rhegmatogenous retinal detachment

FIGURE 42-38.

Recurrent rhegmatogenous retinal detachment after scleral buckle surgery due to vitreous traction on a preexisting retinal

break. A. A band of vitreous elevates the inferior retinal break, leading to subretinal fluid overlying the buckle and extending posteriorly to involve

the macula. B. Release of vitreous traction with vitrectomy allows the retina to be reattached.

Surgical Anatomy

On examination, the vitreous is seen to bridge in a taut fashion from the posterior pole adherence to the vitreous base, separated from the midperipheral retina. There is epiretinal membrane that fuses the posterior cortical vitre- ous to the retina in the posterior pole, and there is often fibrous tissue at the optic disk where the vitreous remains attached (Fig. 42-39). The contractile elements in the epiretinal and epipapillary fibrous tissue may be the cause of the taut antero-posterior traction between the vitreous base and the posterior pole that results in traction retinal detachment.

Surgical Technique

At vitrectomy, the vitreous attachments to the posterior pole are cut, relieving antero-posterior traction.Then the epireti- nal membranes are stripped with a membrane pick and forceps. If no retinal breaks are discovered after the vitreous is removed to the vitreous base area, air or gas tamponade is not necessary.

Results

Melberg and colleagues (87) reported on the results of vit- rectomy in 9 patients who had vitreomacular traction syn- drome with macular detachment (87). Macula reattachment was achieved in 7 eyes (78%), and visual acuity was improved in 4 eyes and stable in 4 eyes. Visual acuity was thought to be limited in some cases by chronic macular detachment, premacular fibrosis, cystoid macular edema, and

macular schisis.These results are not as favorable as for eyes undergoing vitrectomy for vitreomacular traction without macular detachment, a condition for which one series found vision improvement of two or more lines in 12 (80%) of 15 eyes (88).

Retinal Branch Vein Occlusion and Associated Diseases

Overview

Traction retinal detachments arising from other causes are fairly rare. However, retinal branch vein occlusion can be complicated by retinal neovascularization occasionally leading to traction retinal detachment (Fig. 42-40) (89,90). Other rare causes of traction or combined tractional- rhegmatogenous retinal detachments include sickle cell disease (91), Coat’s disease (92), and angiomatosis retinae (92), which are managed in a fashion similar to that for venous occlusive disease.

Surgical Anatomy

As in proliferative diabetic retinopathy, traction retinal detachment is associated with both anterior-posterior trac- tion due to vitreous adherence to epiretinal fibrovascular membranes, and tangential traction caused by contraction of these membranes. If retinal breaks are present, the detachment is termed a combined traction-rhegmatogenous detachment.

Chapter 42 Management of Complicated Retinal Detachment 561 Vitreous base Vitreous Macula Vitreous seperated Subretinal from
Chapter 42
Management of Complicated Retinal Detachment
561
Vitreous
base
Vitreous
Macula
Vitreous
seperated
Subretinal
from
fluid
midperipheral
retina
FIGURE 42-40.
Fundus photograph of a tractional
FIGURE 42-39.
The vitreomacular traction syndrome
associated with detachment of the macula. The vitreous is separated
from the midperipheral retina, and partially separated from the
posterior pole, but remains attached at the disk and the macula.
The vitreous has become taut and exerts anterior–posterior traction
between the posterior pole and the vitreous base, leading to
elevation of the macula and subretinal fluid. A fibrous ring and
intraretinal edema are often present in the macula.
retinal detachment secondary to a branch retinal vein occlusion.
Fibrovascular membranes run from the optic disk along the superior
temporal vascular arcades, arising from NVE and NVD. As these
membranes proliferate and contract, traction is exerted on the
retina, leading to a detachment involving the macula.
Surgical Technique
The usual indication for vitrectomy in traction retinal
detachment due to venous occlusive disease is detachment
involving or threatening the macula, or a progressive extra-
macular traction-rhegmatogenous retinal detachment. The
technique is similar to that used in vitrectomy for diabetic-
related retinal detachments, detailed above.
To summarize briefly, a three-port pars plana vitrectomy
is performed, starting with a core vitrectomy and removal of
vitreous opacities, which are often significant. Starting at the
optic nerve head, fibrovascular membranes are segmented or
delaminated with intraocular scissors and forceps.Vitreous is
separated from the retinal surface as far anteriorly as possible,
with particular care taken to make sure all vitreous traction
is relieved from around any retinal breaks. Then, pneumatic
reattachment is performed, with simultaneous aspiration of
subretinal fluid via a silicone-tipped cannula through a pre-
existing or iatrogenic posterior retinal break. If no posterior
break is present, PFCL can be used to reattach the retina in
a manner similar to that described for PVR.Then, all retinal
breaks are treated with endophotocoagulation. Scatter laser
endophotocoagulation is also applied to the peripheral retinal
areas drained by obstructed vessels. An encircling band is
placed in selected cases to decrease traction from the ante-
rior vitreous, and pars plana lensectomy is performed when
cataract obscures visualization of the fundus.
final anatomic success rate of approximately 86%, with 59%
of eyes achieving visual acuity of 20/200 or better (93).
Complications in this study included iatrogenic retinal
breaks in 23% of eyes, and recurrent retinal detachment
requiring additional surgery occurred in 36%.
Less frequent complications include recurrent vitreous
hemorrhage, cataract progression, epimacular membrane
formation, corneal opacification, and neovascular glaucoma.
COMBINED RHEGMATOGENOUS
RETINAL DETACHMENT AND
CHOROIDAL DETACHMENT
Overview
Results
A recent study of pars plana vitrectomy for traction retinal
detachment after retinal branch vein occlusion revealed a
Rhegmatogenous retinal detachment presenting with simul-
taneous choroidal detachment in the absence of trauma and
recent eye surgery is considered rare (94). In one series
of 1000 consecutive retinal detachments, simultaneous
choroidal detachment was present preoperatively in only 4
cases (95). The condition is seen most commonly in highly
myopic individuals with chronic rhegmatogenous detach-
ments. There appears to be an increased incidence among
Asians, which may be related to the preponderance of
high myopia among these individuals. The presence of a
choroidal detachment has been associated with an increased
incidence of postoperative PVR formation and redetach-
ment (96) [although there is conflicting evidence in the
literature regarding this assertion (97)], leading to a
poorer prognosis than for simple rhegmatogenous retinal
detachment.
The pathogenesis of combined retinal and choroidal
detachment is theorized to be related to hypotony. A

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rhegmatogenous retinal detachment occurs first, and it may be initially unnoticed or ignored by the patient. Eyes harboring retinal detachments are known to be subject to hypotony, which may be due to decreased aqueous pro- duction and/or increased activity of the retinal pigment epithelium pump. Highly myopic, hypotonous eyes may be predisposed to development of a choroidal effusion, because of anatomic and physiologic features such as the poor support of the anterior uveal veins. With time, a significant choroidal detachment develops, which may be associated with significant anterior chamber reaction. Laser flare-cell meter measurements have shown the aqueous protein level to be 70 times higher in eyes with combined retinal and choroidal detachment than in eyes with simple retinal detachment (98).

Surgical Anatomy

Fundus examination often reveals a fair degree of vitreous haze and debris. Because of its chronic nature, the detach- ment is usually quite bullous, and multiple breaks are common. PVR may be present.

Surgical Technique

Traditionally, combined retinal and choroidal detachment has been treated with scleral buckling and external drainage of subretinal fluid, sometimes combined with drainage of suprachoroidal fluid. If there is significant ocular inflammation, some authorities recommend treatment with topical and/or systemic anti-inflammatory medi- cations, delaying surgery until anterior chamber reaction is reduced in the hope of decreasing the risk of postoperative PVR. More recently, initial repair of combined retinal and choroidal detachment using pars plana vitrectomy combined with scleral buckling has been reported (99). One potential advantage with this technique is drainage of suprachoroidal fluid via the instrument and infusion sclerotomies, eliminat- ing the need for a separate scleral cut-down. A possible dis- advantage of vitrectomy would be the potentially increased risk of postoperative PVR formation. Prior to performing surgery, the severity of the choroidal detachment should be evaluated with indirect ophthal- moscopy and possibly echography. From this information, an area with a lower choroidal elevation can be chosen for the infusion cannula site.There is risk of retinal damage and hemorrhage during creation of the sclerotomy sites, so the tip of the blade should not contact the elevated retina and choroid.There is also risk of suprachoroidal infusion, so it is important to visualize the tip of the infusion port within the eye prior to opening the infusion. As noted, suprachoroidal fluid will usually drain when sclerotomies are made for the instrument ports. Surgery then proceeds in a fashion similar to that for retinal detachment with PVR, with removal of the vitreous, membrane peeling, encircling

scleral buckle placement, endolaser treatment, and gas or silicone oil tamponade.

Results

Results in the literature are limited, but in a recent small series of patients with rhegmatogenous retinal detachment and choroidal detachment treated with pars plana vitrec- tomy, 90% achieved retinal reattachment without reopera- tion after 6 months of follow-up (99).

RETINAL DETACHMENT IN OCULAR INFLAMMATORY DISEASE

Overview

Patients with uveitis may develop retinal detachments due to several mechanisms. Retinal detachments can be exuda- tive, tractional, or rhegmatogenous.There are often tractional elements to the rhegmatogenous retinal detachments. Exudative retinal detachments are treated medically, while tractional and rhegmatogenous retinal detachments usually require surgery. Fibrous proliferation secondary to intraocular inflamma- tion may cause abnormally strong vitreoretinal adhesions posterior to the vitreous base, resulting in retinal breaks when a posterior vitreous separation occurs. Surgical repair often requires vitrectomy as well as a scleral buckle. There is a significant risk of recurrent retinal detachment with PVR following repair of retinal detachments in uveitis. Factors linked to a high propensity to develop PVR, such as breakdown of the blood-ocular barrier, influx of inflammatory cells and macrophages, and stim- ulation of growth factors, are present in active ocular inflammatory disease. Cataracts and hypotony are often found in patients with uveitis and further complicate surgical management. Certain forms of uveitis are more prone to retinal detach- ment than others. In an older series of 44 eyes with rheg- matogenous retinal detachments (1.7% of a large series of consecutive retinal detachments), the causes of the inflammatory disease were classified as follows: toxoplasmo- sis, 36%; pars planitis, 25%; and ocular toxocariasis, 7%. In 32% of the eyes, no cause could be established (100). Retinal detachments are common following viral retinitis, and these retinal detachments are covered elsewhere.

Surgical Anatomy

Foci of retinal inflammation and inflammation-induced neovascularization may cause scarring and vitreoretinal adhesions. In nonrhegmatogenous traction retinal detach- ment, there is vitreous traction on areas of viteoretinal adhesion, which causes the retinal detachment. When a retinal break occurs in an area of adhesion, a traction- rhegmatogenous retinal detachment may occur. Retinal

Chapter 42

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563

breaks at the vitreous base due to posterior vitreous separa- tion may cause retinal detachments in patients with uveitis. These may be complicated and difficult to repair because of vitreous haze and cataract. Epiretinal membranes seen before surgery can lead to fixed folds and recurrent retinal detach- ment with PVR. Even without preexisting epiretinal mem- branes, retinal detachments in uveitis are more likely to develop recurrent retinal detachment and PVR. In pars planitis, retinal breaks associated with peripheral fibrovascu- lar proliferation at the vitreous base may cause complicated retinal detachments.The peripheral retinal traction creates a picture similar to anterior PVR. In toxocariasis, there may be extensive vitreous, retinal, and subretinal proliferation that leads to retinal breaks and detachment. Additional anatomic problems these patients develop include cyclitic membranes with anterior retinal dis- placement and ciliary body traction. Hypotony may lead to phthisis bulbi even in the face of successful retinal reattachment.

Surgical Techniques

Eyes with uveitis and retinal detachment are prone to develop severe inflammation postoperatively. Preoperative treatment with periocular or systemic corticosteroids may reduce inflammation. Machemer has shown that administra- tion of corticosteroids prior to surgery is more effective than postoperative administration (54). Pretreatment with corti- costeroids may induce synthesis of intracellular effector proteins that inhibit the inflammatory cascade. While treat- ment with corticosteroids for 5 to 7 days prior to surgery will best inhibit inflammation, it is not always best to wait that long to repair a recent rhegmatogenous retinal detach- ment. In that case, pretreatment the day prior to surgery may still help to reduce the postoperative inflammatory reaction. Patients with toxoplasmosis should be treated with the full regimen for toxoplasmosis in addition to corticosteroids. In eyes with peripheral retinal breaks without PVR, and in which the media are clear enough to permit adequate peripheral retinal examination, the retinal detachment can usually be repaired using a scleral buckle without vit- rectomy. Cryotherapy should be minimized, because it may incite further inflammation. Eyes with cataract or media hazy enough to prevent ade- quate peripheral retinal examination will require a vitrec- tomy, as will eyes with significant retinal traction or PVR. The entrance sites for vitrectomy should be well planned preoperatively. Sclerotomy sites should be moved more anteriorly in eyes with the anterior retinal displacement sometimes found in pars planitis and PVR. Sclerotomy sites should be moved away from peripheral granulomas and areas of fibrosis. Preoperative ultrasound is sometimes useful in planning sclerotomy placement. Eyes with cataracts will require lensectomy. Extensive posterior synechiae are often present and complicate lensec-

tomy. After placing the infusion port, sclerotomies are created nasally and temporally. If the cataract prevents inspection of the infusion port to see if it has penetrated the pars plana epithelium, the port should not be opened to fluid infusion until penetration is visually confirmed. During lensectomy and the initial posterior vitrectomy pro- cedure, infusion can be with a handheld 20-gauge infusion needle as described above. We usually break posterior synechiae prior to lensectomy by sweeping the synechiae with a small blunt cannula on a syringe of viscoelastic. The viscoelastic will maintain anterior chamber depth, clear the anterior surface of the lens, and partially dilate the pupil after sweeping the synechiae. Iris retractors may be necessary to dilate the pupil, but should be avoided if possible because they can potentially incite more inflam- mation. The lens should be removed with ultrasound phacofragmentation, and the lens capsule removed, as described above, to reduce the likelihood of anterior fibrosis and traction. Vitrectomy techniques are similar to those described above for traction retinal detachment, vitreous hemorrhage, and PVR. Membranes can be extremely thick and tena- cious, and it is sometimes best to section membranes if they do not readily peel from the retina. Extensive fibrosis associated with toxocariasis may require sectioning as well as membrane peeling. Retinal traction should be released and the vitreous shaved to the surface of the peripheral retina at the vitreous base, using scleral depression. We apply only enough laser to treat retinal breaks, except for PVR cases, where we recommend peripheral scatter treat- ment on the retina, supported by a scleral buckle.We utilize gas for most retinal detachments; however, when the eye is hypotonous, silicone oil may be preferred. Postoperative periocular and/or systemic corticosteroids should be admin- istered in most cases. We give subconjunctival Decadron (5–10mg) at the end of all cases, and posterior subtenons (posterior to the equator) triamcinolone acetonide in some cases.

Results

Hagler and colleagues reported the results of surgery for 44 retinal detachments associated with uveitis (100). In this 1978 study, 38 eyes were treated with scleral buckle and cryotherapy and only 2 eyes were treated with vitrectomy. The retina was reattached in 91% of eyes, and vision improved in 57%. Compared to a large series of retinal detachments in eyes without uveitis, retinal detachments fol- lowing ocular inflammatory disease had a longer duration of the retinal detachment, fewer observable retinal breaks, a higher incidence of visible vitreous membranes and preop- erative macular puckers, a younger age distribution, and a higher incidence of phakic patients. No significant differ- ence in the presence or types of retinal folds, the rate of operative complications, or the rate of reattachment at six months was shown.

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Thumann and colleagues reported the results of vitrec- tomy in 50 eyes with uveitis (101). The indications for surgery were opaque media, retinal detachment, and cyclitic or preretinal membranes. Eyes with preoperative retinal detachment had a worse visual outcome (mean visual acuity of 0.2) than those without preoperative retinal detachment (mean visual acuity of 0.5). Persistent hypotony following surgery was found in 7 eyes. Retinal detachment follows pars planitis in 22% (102) to 51% (103) of eyes. In mild to moderate forms of the disease, retinal breaks may form on the posterior edge of the orga- nized peripheral fibrosis. Most of these detachments can be managed with a scleral buckle. However, severe forms of pars planitis have extensive neovascularization and fibrous proliferation with vitreoretinal traction and fixed folds, and a picture similar to anterior PVR.These eyes usually require vitrectomy (104). Small et al (105) reported the results of vitrectomy for 12 eyes with tractional macular detachment due to Toxocara canis. Traction retinal detachments were found in 10 eyes, and 2 eyes had combined traction-rhegmatogenous retinal detachments. Granulomas were located peripherally in 9 eyes and in the posterior pole in 3 eyes. One eye had a central macular granuloma.The authors found that membranes were difficult to peel from the retina and were best sectioned or delaminated from their retinal and optic nerve attachments. With a minimum of 6 months’ follow-up, the retina was completely attached in 10 eyes (83%).Visual acuity improved in 7 eyes. Poor postoperative visual acuity correlated with large folds through the macula identified preoperatively. Morse and McCuen (106) used vitrectomy and silicone oil injection to treat 5 eyes with profound hypotony asso- ciated with loss of vision complicating bilateral chronic uveitis. Uveitis was due to toxoplasmosis in 2 eyes, psoriatic arthritis in 1 eye,Vogt-Koyanagi-Harada disease in 1 eye, and an undetermined cause in 1 eye. Visual acuity and IOP improved in 3 of the 5 eyes at 6 months, but vision declined later in 2 of the 3 with initial improvement.

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