SURGICAL TREATMENT O F GIANT RETINAL TEARS W I T H INVERTED POSTERIOR RETINAL FLAPS

JESUS V I D A U R R I - L E A L , M.D. , SERGE DE BUSTROS, M.D. , AND R O N A L D G. M I C H E L S , M.D.

Baltimore, Maryland

We treated 23 consecutive cases of giant retinal tears with inverted retinal flaps. We used pars plana vitrectomy together with an intravitre-al bubble to unfold the posterior retinal flap, combined with cryothera­py to cause a chorioretinal adhesion and a broad scierai buckle. The vitrectomy was done after applying cryotherapy so viable retinal pigment epithelial cells in the vitreous cavity could also be removed. Thirteen eyes had giant tears measuring 90 to 180 degrees (Group 1), eight eyes had giant tears measuring 180 to 270 degrees (Group 2), and two eyes had giant tears larger than 270 degrees (Group 3). The retina was successfully reattached in 11 of the 13 eyes in Group 1, each of the eight eyes in Group 2, and one of the two eyes in Group 3. We believe that vitrectomy and lavage of the vitreous cavity after applying cryo­therapy was important in reducing the incidence of proliferative vitreoretinopathy and improving our success rate.

Giant retinal tears are a difficult and challenging surgical problem. Recent ad­vances in vitreoretinal surgical tech­niques have improved the overall success rate,1"8 but treatment still fails in a high percentage of cases with giant retinal tears, primarily because of the develop­ment of proliferative vitreoretinopa­thy. 1 3 '5 '6 ·9 We treated 23 consecutive cases of giant retinal tears with inverted retinal flaps by pars plana vitrectomy, an intraoc­ular bubble to unfold the retinal flap, and a scierai buckle. The vitrectomy was per­formed after applying cryotherapy to re­move any viable pigment epithelial cells released into the vitreous cavity. This was

Accepted for publication Aug. 13, 1984. From the Vitreoretinal Service, Department of

Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Reprint requests to Ronald G. Michels, M.D., Maumenee 127, Johns Hopkins Hospital, Baltimore, MD 21205.

done in an effort to reduce postoperative proliferative vitreoretinopathy.

SUBJECTS AND ME T H O D S

We reviewed the records of 23 consec­utive patients with giant retinal tears and inverted retinal flaps treated by one of us (R.G.M.) since July 1, 1980. We excluded patients who underwent surgery else­where.

This series included 17 males and six females, aged 12 to 55 years (mean age, 34 years). None had bilateral giant tears. Nine patients had moderate or severe myopia ranging from —4.00 to —20.00 diopters (mean, —10.00 diopters). Five patients had surgical aphakia. Two pa­tients had significant trauma. Five pa­tients had a combination of these factors (trauma and aphakia in three patients, trauma and severe myopia in one patient, and severe myopia and aphakia in one patient). Two patients had uveitis. The right eye was involved in 13 cases and the

©AMERICAN JOURNAL OF OPHTHALMOLOGY 98:463^166, 1984 463

464 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTORER, 1984

left eye in ten cases. Four patients were blind in the fellow eye as the result of trauma (two cases) or retinal detachment (two cases).

The patients were divided into three groups depending on the extent of the retinal tear. Group 1 comprised 13 pa­tients with giant retinal tears larger than 90 degrees but smaller than 180 degrees (range, 120 to 165 degrees; mean, 145 degrees). Group 2 comprised eight patients with giant retinal tears measur­ing 180 degrees to 270 degrees (range, 180 to 240 degrees; mean, 204 degrees). Group 3 comprised two patients with giant tears larger than 270 degrees. Three patients also had massive prolifera-tive vitreoretinopathy before the initial operation.

In each case there was partial or com­plete inversion of the retinal tear flap, and we used vitrectomy with an intravit-real bubble to unfold the flap. In 22 of 23 cases cryotherapy was used to produce a broad zone of peripheral chorioretinal adhesion for 360 degrees. A broad encir­cling scierai buckle was created extend­ing from the equator to the ora serrata. In the remaining case the cryotherapy and scierai buckle extended for 180 degrees. During this time we operated on one additional case involving a giant retinal tear but without an inverted retinal flap. This case was successfully treated by cry­otherapy and a segmentai scierai buckle.

Pars plana vitrectomy was done in each of the 23 eyes with inverted retinal flaps. While the patient was in a prone position, an intravitreal bubble of 20% sulfur hexa-fluoride and 80% air was injected during surgery and used to unfold and reposition the retinal flap.4 In aphakic eyes the vitreous cavity was completely filled with the gas bubble. A smaller bubble filling 30% to 50% of the vitreous cavity was used in eyes in which the lens was clear and the giant retinal tears was less than 180 degrees. In these cases postoperative

rotation was used so the bubble would unfold the retinal flap and position it against the treated pigment epithelium.

Transvitreal retinal suturing was done in one case and temporary retinal incar­ceration was performed in five cases.10

We used these techniques to unfold the inverted retinal flap before the fluid-gas exchange. Vitrectomy was performed after application of cryotherapy in all but one case. This was done so any viable retinal pigment epithelial cells released into the vitreous cavity during the cryo­therapy could be removed at the time of vitrectomy. Supplemental postoperative fluid-gas exchange was done in four cases and supplemental postoperative laser co­agulation was used in 13 cases.

In the 20 successful cases, the follow-up interval ranged from six to 60 months (mean, 22 months). The three failures were followed up for less than six months, because these patients preferred not to return once the eye was healed and com­fortable.

RESULTS

The retina was reattached in 20 of the 23 eyes. Successful results were obtained in 11 of 13 eyes in Group 1, in each of the eight eyes in Group 2, and one of two eyes in Group 3. The visual results were generally good (Table). Six patients achieved final visual acuities of 20/40 or better and 17 achieved final visual acui­ties of 20/400 or better. One patient in

TABLE FINAL VISUAL ACUITY IN 20 SUCCESSFUL CASES

Visual Acuity

20/20 20/25 to 20/40 20/50 to 20/100 20/200 to 20/400 5/200 1/200

Group 1

1 2 3 3 1 1

Group 2

1 2 2 2 1

—

Group 3

— — 1

— —

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Group 1 developed a recurrent retinal detachment followed by proliferative vit-reoretinopathy that necessitated a total of five operations. The retina was finally reattached, but the patient's visual acuity was only 5/200. Another patient in Group 1 had had a giant tear and severe prolifer­ative vitreoretinopathy for three months before referral. The retina was reattached after one operation, but the patient's vis­ual acuity was limited to 1/200. One pa­tient in Group 2 had had poor vision from glaucoma before developing the retinal detachment and had a final visual acuity of 5/200.

Intraoperative complications—Cho-roidal hemorrhage occurred in one eye during drainage of subretinal fluid. This occurred in a location opposite the site of drainage. The eye eventually developed phthisis bulbi.

The inverted retinal flap was rigid and could not be unfolded in one patient who had had a giant tear and retinal detachment with massive proliferative vitreoretinopathy for more than four months. This case was considered a sur­gical failure.

Postoperative complications—Intra­ocular hemorrhage occurred postopera-tively in four cases. One of these pro­gressed to phthisis bulbi. Another eye required a vitreous lavage to remove the blood. The hemorrhage resolved without sequelae in the other two eyes.

Glaucoma developed postoperatively in one patient but responded to medical therapy. One patient developed a sepa­rate peripheral inferior retinal detach­ment ten weeks after surgery, necessitat­ing revision of the scierai buckle. Interestingly, this patient was operated on early in the series and had a superior 120-degree tear initially treated with cry-otherapy and a scierai buckle only in the superior 180 degrees. In one patient, an asymptomatic abscess adjacent to the buckle was diagnosed four months after

surgery, necessitating surgical interven­tion and drainage.

Localized nonprogressive epiretinal membranes developed postoperatively in four cases. One of these patients under­went additional surgery with successful removal of the epiretinal membrane.

Proliferative vitreoretinopathy devel­oped in three cases and required further surgery. Interestingly, in one of these cases cryotherapy had been performed after vitrectomy. In all three cases there was a successful anatomic result. These three cases were treated before we recog­nized the value of careful lavage of the vitreous cavity after cryotherapy.

DISCUSSION

Our findings agreed with previous ob­servations that giant retinal tears occur primarily in young males with myopia, trauma, aphakia, or a combination of these factors.1"3'6·7

The anatomic results of this series were favorable compared to those of earlier reports,1"3,6,7 probably because of the re­finement of surgical techniques combin­ing vitreous surgery and scierai buckling methods with an intraocular bubble to assist in unfolding the inverted retinal flap.410 Using a broad encircling scierai buckle and a broad zone of chorioretinal adhesion seems to prevent recurrent reti­nal detachment if the retinal flap can be unfolded and properly positioned at the time of the initial operation.

Proliferative vitreoretinopathy, a major cause of failure in previous series, has been reported in 22% to 58% of cases.1"3·6

In our series, however, postoperative proliferative vitreoretinopathy with re­current detachment occurred in only three of the 23 cases. Each of these three eyes was successfully treated by further surgery.

Retinal pigment epithelial cells con­tribute to the development of prolifera­tive vitreoretinopathy.11"13 Vidaurri-Leal,

466 A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y O C T O B E R , 1984

Hohman, and Glaser14 demonstrated in vitro that human retinal pigment epithe­lial cells migrate along collagen fibrils and transform into cells resembling fibro-blasts with contractile properties. They hypothesized that this phenomenon may account for the high incidence of prolifer-ative vitreoretinopathy in giant tears where a large area of retinal pigment epithelium is exposed to the vitreous collagen. Migration of retinal pigment epithelial cells is also enhanced by human serum components15 which might be re­leased into the vitreous cavity after alter­ations in the blood retinal barrier caused by cryotherapy.

The lower incidence of postoperative proliferative vitreoretinopathy in our se­ries may have resulted from our practice of performing vitrectomy and vitreous lavage after application of retinal cryo­therapy. In this way, most retinal pig­ment epithelial cells released into the vitreous cavity by cryotherapy are re­moved before the intravitreal bubble is introduced and the operation is com­pleted.10

The major complication in our series was intraocular hemorrhage either intra-operatively or postoperatively. Intraocu­lar hemorrhage was responsible for two of our three failures. We are currently in­vestigating methods to control intraocu­lar bleeding better.16

REFERENCES 1. Holland, P. M., and Smith, T. R. : Broad scierai

buckle in the management of retinal detachment with giant tears. Am. J. Ophthalmol. 83:518, 1977.

2. Norton, E. W. D., Aaberg, T., Fung, W., and Curtin, V. T. : Giant retinal tears. I. Clinical manage­

ment with intravitreal air. Trans. Am. Ophthalmol. Soc. 67:374, 1969.

3. Machemer, R., and Allen, A. W. : Retinal tears 180 degrees and greater. Management with vitrec­tomy and intravitreal gas. Arch. Ophthalmol. 94:1340, 1976.

4. Michels, R. G.: Vitreous Surgery. St. Louis, C. V. Mosby, 1981, pp. 250-255.

5. Charles, S.: Vitreous Microsurgery. Baltimore, Williams and Wilkins, 1981, pp. 135-141.

6. Freeman, H. M., and Castillejos, M. E.: Cur­rent management of giant retinal tears: Results with vitrectomy and total air-fluid exchange in 95 cases. Trans. Am. Ophthalmol. Soc. 179:89, 1981.

7. Federman, J. L., Shakin, J. L., and Lanning, R. G.: The microsurgical management of giant reti­nal tears with trans-scleral retinal sutures. Ophthal­mology 89:832, 1982.

8. Schepens, C. L. : Retinal Detachment and Al­lied Diseases. Philadelphia, W. B. Saunders, 1983, vol. 2, pp. 520-542.

9. Hilton, G., Machemer, R., Michels, R. G., Okun, E., Schepens, C. L., and Schwartz, A.: The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 90:121, 1983.

10. Michels, R. G., Rice, T. A., and Blankenship, G. : Surgical techniques for selected giant retinal tears. Retina 3:139, 1983.

11. Machemer, R., and Laqua, H.: Pigment epi­thelial proliferation and retinal detachment (massive periretinal proliferation). Am. ] . Ophthalmol. 80:1, 1975.

12. Laqua, H., and Machemer, R.: Clinical-pathological correlation in massive periretinal prolif­eration. Am. J. Ophthalmol. 80:913, 1975.

13. Machemer, R., van Horn, D., and Aaberg, T. M.: Pigment epithelial proliferation in human retinal detachment with massive periretinal prolifer­ation. Am. ] . Ophthalmol. 85:181, 1978.

14. Vidaurri-Leal, J., Hohman, R., and Glaser, B. M.: Effect of vitrectomy on retinal pigment epi­thelial cell morphology. A new approach to the study of proliferative vitreoretinopathy. Arch. Ophthalmol. In press.

15. Campochiaro, P. A., Jordan, ] . A., and Gla­ser, B. M.: Human serum contains chemoattractants for human retinal pigment epithelial cells. Arch. Ophthalmol. In press.

16. de Bustros, S., Glaser, B. M., Johnson, M., and de Juan, E.: Thrombin infusion for the control of intraocular bleeding during vitreous surgery. ARVO Abstracts. Supplement to Invest. Ophthalmol. Vis. Sei. Philadelphia, J. B. Lippincott, 1984, p. 309.