Treatment of Giant Retinal Tears Combined with Proliferative Vitreoretinopathy BERT M. GLASER, MD

Abstract: Giant retinal tears with foreshortened and stiffened retina secondary to advanced proliferative vitreoretinopathy (PVR) pose a complex problem for the retinal surgeon. In the past, tractional forces on the retina in these eyes have been counteracted temporarilYby retinal sutures, retinal incarceration, or retinal tacks, often combined with fluid-gas exchange in the prone position. These techniques are complex and add multiple additional maneuvers to the surgical procedure. The current report describes the use of a simple, stepwise fluid-gas exchange technique with the patient in the supine position in which the expanding gas bubble traps the edge of the stiffened and foreshortened retina against the pigment epithelium. Long-term counteraction of tractional forces was achieved by the use of intraocular silicone oil. Using this technique, 18 of 19 eyes with giant retinal tears and PVR Grade 01 to 03 could be suc­cessfully reattached. Four of these successfully reattached eyes had 360 0 giant retinal tears. The most common and significant complication in our series was the recurrence of periretinal membranes. All 18 eyes that were initially reattached suffered the recurrence of significant periretinal membranes. Four of those 18 eyes developed recurrent inferior traction detachments one to four months postoperatively. [Key words: fluid-gas exchange, giant retinal tears, proliferative vitreoretinopathy, retinal detachment, silicone oiL] Ophthalmology 93: 1193-1197,1986

Giant retinal tears with foreshortened and stiffened ret­ina secondary to advanced proliferative vitreoretinopathy (PVR) pose a complex problem for the retinal surgeon. I A necessary step towards successful retinal reattachment is the unfolding and reapposition of the retina to the retinal pigment epithelium. I This is accomplished by the elimi­nation or counteraction of tractional forces tending to detach the retina. Tractional forces can be partially elim­inated by peeling, delaminating, and/or segmenting peri­retinal membranes. 1,2 In the past, the remaining tractional forces have then been counteracted temporarily by retinal sutures, retinal incarceration, or retinal tacks, often com­bined with fluid-gas exchange in the prone position. 1,3-10

These techniques are complex and add multiple additional maneuvers to the surgical procedure. The current report

describes the use of a simple, stepwise fluid-gas exchange technique with the patient in the supine position in which the expanding gas bubble traps the edge of the stiffened and foreshortened retina against the pigment epithelium. Long-term counteraction of tractional forces was achieved by the use of intraocular silicone oil. Using this technique, 18 of 19 eyes with giant retinal tears and PVR grade D 1 to D3 could be successfully reattached. I I

From the Wilmer Ophthalmological Institute Center for Vitreoretinal Re­search, Baltimore.

Presented at an Annual Meeting of the American Academy of Ophthal­mology.

Reprint requests to Bert M. Glaser, MD, Wilmer Institute, 601 N. Broadway, Baltimore, MD 21205.

MATERIALS AND METHODS

Nineteen consecutive patients with giant retinal tears combined with Grades DI-D3 PVR were entered into the study. All patients were referred to the author after having at least one previous surgical procedure. The pa­tients ranged in age from 9 to 59 years. The follow-up ranged from 6 to 15 months with a mean of 8 months.

SURGICAL PROCEDURE

At the beginning of surgery a 19-9auge infusion cannula was placed through a sclerotomy in the inferior temporal

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quadrant. The 19-9auge cannula and infusion tubing pro­duce less resistance to the infusion of silicone oil than does a 20-gauge cannula. Black silk 4-0 sutures were used to secure the tubing at both ends. This prevents the tubing from coming loose when the increased pressure for silicone oil infusion is applied. In all but one of the cases, all ex­ternal buckling material was removed from the eye for reasons that will be explained later. Two additional scle­rotomies were made in the two superior quadrants to allow the introduction of 20-gauge instruments. If the eye was phakic, a pars plana lensectomy was then performed. An inferior iridectomy was performed to prevent pupillary blockade in the presence of silicone oil. A vitrectomy was then performed. Intraocular scissors were then introduced and all preretinal membranes were either peeled, seg­mented, or delaminated. An attempt was made to relieve as much traction as possible.

Attention was then turned to the subretinal surface. In several cases, significant subretinal membranes had formed in a napkin-ring configuration. These membranes were segmented and completely separated from the outer surface of the retina. In order to achieve this goal, it was occasionally necessary to extend the retinal tear using the vitreous cutter. Any bleeding from the cut edge of retina was treated with bipolar bimanual diathermy. After all preretinal and subretinal membranes were removed, the mobility of the retina was assessed. Occasionally, it was necessary to do an additional retinotomy to allow suffi­cient retinal mobility for retinal reattachment. In 16 of the 19 eyes treated, the retinal tear extended for more than 200 0 at this stage of the procedure. Four eyes had 3600 retinal tears. A fluid-gas exchange was begun and the anterior chamber filled with air so that the contact lens could be removed. The area of torn retina that ex­tended most anteriorly was then identified (Fig 1, top left). Using the light pipe, this area of retina was positioned gently against the retinal pigment epithelium. With the other hand, a 20-gauge blunt needle on a flute handle was introduced into the vitreous cavity. The end of the 20-gauge needle was positioned just anterior to the torn retina which was being held against the retinal pigment epithe­lium with the light pipe (Fig 1, top right). The fluid-gas exchange was then continued using a continuous flow air pump. Once the bubble extended to the edge of the retina, the blunt tip needle was used to carefully dry the area where the retina touched the pigment epithelium. It was essential that all fluid be removed from this region. Once this was accomplished, the retina in this region was trapped against the retinal pigment epithelium by the air bubble.

Attention was then turned to the next most anterior region of torn retina. The procedure was repeated in order to trap this adjacent region of torn retina against the retinal pigment epithelium. This was repeated sequentially until the entire retinal tear was trapped by the air bubble (Fig 1, top right). Once this was accomplished, the fluid-gas exchange was continued so that the entire eye was filled with air. Occasionally, a small amount of sub retinal fluid was trapped posteriorly. This was removed by creating a small retinotomy just nasal to the disc and aspirating this

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residual fluid (Fig 1, bottom). There was occasionally a small amount of retinal slippage during the initial phase of this procedure, but never more than 1 to 2 mm. Once the fluid-gas exchange had been completed and the edges of the torn retina were adequately dried, it was very easy to gently push the retina anteriorly with the blunt tip nee­dle to correct any slippage. Once the slippage was corrected and the retinal edge dry, no further slippage occurred in any of the patients treated.

At this point, all edges of the retinal tear and any pos­terior retinotomies were treated with transvitreal argon laser photocoagulation. Next, the two superior scleroto­mies were sutured closed. The infusion cannula was then connected to a syringe containing silicone oil (1000 cen­tistokes). At the same time, a 30-gauge needle on a flute handle was introduced via the pars plana. Silicone oil was injected as air was allowed to exit the eye via the 30-gauge needle. Nine eyes were filled with silicone oil to the level of the iris. The ten remaining eyes had significant loss of iris tissue either from trauma or from previous surgery. It was believed that there was no possibility of keeping the silicone oil behind the iris in these eyes, therefore, these eyes were completely filled with silicone oil. The infusion cannula was then removed from the eye and the sclerotomy sutured closed. In no eye did retinal slippage occur at the time of the silicone oil infusion. No special positioning was performed postoperatively.

RESULTS

At the end of each procedure the retinas in 18 of 19 eyes were reattached (Figs 2-4). The one eye in which retinal reattachment could not be achieved had suffered extensive penetrating trauma with incarceration of large areas of temporal retina, including the macula, in the scleral wound. Four of the eyes had 3600 giant tears and all of these were reattached at the end of surgery. A key factor in the ability to reapproximate the retina using the stepwise fluid-gas exchange was prior removal of all scleral buckling material. The convex curvature of the eye wall created by scleral buckling caused significant retinal slip­page during the fluid-gas exchange. However, when the retinal edge was trapped against the normal concave sur­face of the eye during the fluid-gas exchange, slippage was negligible. Therefore, removal of external scleral buckles is a key element to the success of this simple tech­nique. In one eye the edge of the retinal tear was posterior to a circumferential scleral buckle and therefore the buckle was not removed. After the retina is flattened and the eye is filled with air it is possible to place scleral buckles with­out retinal slippage.

Four of the 18 eyes with initially reattached retinas later developed corneal complications. Three of those four de­veloped band keratopathy, which was treated with corneal scrapping and topical EDT A with subsequent clearing of the cornea. One eye in our series developed total corneal decompensation with striate keratopathy. This eye later underwent successful corneal transplantation without re-

GLASER • GIANT RETINAL TEARS WITH PVR

moval of the silicone oil. All four eyes that developed corneal complications had silicone touching the endothe­lial surface of the cornea. In none of the eyes in which silicone oil was behind the iris did corneal complications occur. None of the eyes developed chronic glaucoma. The mean postoperative pressure was 8 mmHg.

The most common and significant complication in our series was the recurrence of periretinal membranes. All 18 eyes that were initially reattached suffered the recur­rence of significant periretinal membranes (Fig 5). Four of those 18 eyes developed recurrent inferior traction de­tachments one to four months postoperatively. In all four ofthese eyes the membranes contracted under the inferior meniscus of the silicone bubble and caused an inferior traction retinal detachment (Fig 6). All four eyes under-

Fig 1. Top left. a fluid-gas exchange was begun and the anterior chamber filled with air. The contact lens was removed at this point. The fundus could then be well visualized without need of the contact lens. The area of tom retina that extended most anteriorly was then identified. Top right. using the light pipe, the area of tom retina that extended most anteriorly was positioned gently against the retinal pigment epithelium. With the other hand, a 20-gauge needle on a flute handle was introduced into the vitreous cavity. The end of the 20-gauge needle was positioned just anterior to the tom retina, which was being held against the retinal pigment epithelium with the light pipe. The fluid-gas exchange was then continued using a continuous flow air pump. Once the bubble extended to the edge of the retina, the blunt tip needle was used to carefully dry the area where retina touched the pigment epithelium. It was essential that all fluid be removed from this region. Once this was accomplished, the retina in this region was trapped against the retinal pigment epithelium by the air bubble. Attention was then turned to the next most anterior region of tom retina. The procedure was repeated in order to trap this adjacent region of tom retina against the retinal pigment epithelium. This was repeated sequentially until the entire retinal tear was trapped by the air bubble. Bottom left. once the maneuvers in Figure I, top right were accomplished, the fluid-gas exchange was continued so that the entire eye was filled with air. Occasionally, a small amount of sub retinal fluid was trapped posteriorly. This was removed by creating a small retinotomy just nasal to the disc and aspirating this residual fluid.

went reoperation which consisted of peeling the epiretinal membranes under the existing silicone oil bubble. The procedure was simple to perform and in three out of four of the cases resulted in reattachment of the retina.

Eight of the 18 patients achieved a visual acuity of 5/ 200 or better. In two of these patients the visual acuity at last follow-up was 20/200. Visual acuity of less than 5/ 200 in ten patients was attributed to severe retinal damage from trauma and/or longstanding detachment.

DISCUSSION

The technique described provides the retinal surgeon with a simple, rapid, and safe alternative to retinal sutures,

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Fig 2. Top left. preoperative fundus photograph of the left eye of a 24-year-old white woman with a giant retinal tear extending from 10 o'clock clockwise to 9 o'clock (330 0 giant tear) with Grade 02 proliferative vitreoreti­nopathy. Top right. fundus photograph of the same eye on the second postoperative day. Note peripheral laser le­sions along the inferior edge of the retinal tear. Fig 3. Sec­ond row left. a 17-year-old white woman with high my­opia and a giant retinal tear in the right eye extending from 6 o'clock to II o'clock with Grade 02 proliferative vitreoretinopathy. Second row right. the same eye on the second postoperative day. Note the retinotomy nasal to the disc with surrounding laser spots. Fig 4. Third row lldi. the right eye of a 45-year­old white man with a giant retinal tear extending from 2 o'clock to 7 o'clock and Grade 01 proliferative vit­reoretinopathy. The fundus appearance is shown two months postoperatively. The vision at this point was 20/ 300. Third row right. the same eye showing the inferior area of bare retinal pigment epithelium adjacent to the inferior edge of the giant ret­inal tear. Some additional laser treatment was added at this point because the edge of the tear in this region did not seem to be completely sealed. Fig S. Bottom lldi. the left eye of a 13-year-old black male six months after surgery for a 3600 giant retinal tear and Grade 03 proliferative vit­reoretinopathy. At the time of surgery, extremely dense subretinal fibrosis was present in a napkin-ring configura­tion. Note the reproliferation

of membranes along the inner retinal surface. The vision at the time of this photograph was 20/200. Fig 6. Bottom right. the left eye of a 47-year­old white man with a giant retinal tear extending from 2 o'clock to 8 o'clock. This photograph was taken three months postoperatively. This was the only case in which a scleral buckle was left in place. The decision to leave it in place was made because the edge of torn retina did not reach the buckle and therefore did not result in slippage of the retina when reattachment was attempted under air. Note the elevated membrane forming inferiorly, extending from the edge of torn retina anteriorly over the buckle. This fibrous tissue is growing along the inferior meniscus of the silicone bubble. Over the course of the following month, further contraction of the fibrous tissue occurred and detached the retina. The fibrous tissue was cut and the retina was reattached successfully.

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GLASER • GIANT RETINAL TEARS WITH PVR

Fig 7. As best as can be determined, silicone oil does not seem to have any inhibitory effect on the regrowth of periretinal membranes. Silicone oil seems to work primarily by redirecting the force vectors induced by the membranes. Left. without silicone oil the vectors generated by regrowth of membranes would have a large perpendicular component tending to detach the retina. Right. in the presence of silicone oil. the forces would be directed more tangentially. minimizing the perpendicular forces tending to detach the retina. This is probably the main role of silicone in eyes with proliferative vitreoretinopathy.

retinal incarceration, and retinal tacks to reposition a stiffened retinal flap in an eye with a giant retinal tear and PVR. The maneuver worked in 18 of 19 eyes with giant retinal tears and PVR Grades D1 to D3. Retinal slippage was not a problem as long as existing scleral buckles were removed. In several more recent cases, not included in the current study, we have found that a scleral buckle can be replaced without problem after the fluid-gas exchange and photocoagulation are performed.

The most common complication occurred between one and four months postoperatively and involved the repro­literation of periretinal membranes. As best can be de­termined, silicone oil does not seem to have any inhibitory effect on the regrowth of these membranes. Silicone oil works primarily by redirecting the force vectors induced by the membranes. Without silicone oil (Fig 7, left), the vectors generated by regrowth of membranes would have a large perpendicular component tending to detach the retina. In the presence of silicone oil (Fig 7, right), the forces would be directed more tangentially, minimizing the perpendicular forces tending to detach the retina. I believe this is the main role of silicone in eyes with PVR. Since periretinal membranes continue to proliferate in the presence of silicone oil one would expect that upon the removal of the silicone oil the force vectors would be redirected from a tangential action to a more perpendic­ular action and the retina would redetach. Consequently, I have thus far left the silicone oil in all of the eyes. Since the long-term effect of silicone oil is still unknown, silicone

oil should probably be removed from the eye whenever continued traction is not present.

REFERENCES

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