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Long-term Results of Vitrectomy and Perfluorocarbon Gas for the Treatment of Severe Proliferative Vitreoretinopathy
Long-term Results of Vitrectomy and Perfluorocarbon Gas for the Treatment of Severe Proliferative Vitreoretinopathy Robert Lopez, M.D., and Stanley Chang, M.D.
The results of 87 patients who underwent vitrectomy, scleral buckling, and injection of perfluorocarbon gas in one eye each for prolif erative vitreoretinopathy of grade C3 (marked, involving three quadrants) or worse were studied. The retinas of 60 of the 87 patients (69%) were attached posterior to the scleral buckle one month after disappearance of the gas, with the initial reattachment rate being inversely proportional to the severity of proliferative vitreoretinopathy. Follow-up data ranging from six to 106 months were available on 54 eyes with attached retinas. Final visual acuity in those patients ranged from light perception to 20/40 and was not related to severity of proliferative vitreoreti nopathy or duration of reattachment. Thirtyeight of the 54 patients (70%) had a visual acuity of 20/400 or better. Twenty-nine of the 37 patients (78%) with retinas attached 24 months or longer had the same or better visu al acuity than at six months postoperatively. Macular pucker was observed in 16 of the 54 eyes (30%) and was the most frequently seen long-term retinal complication affecting visu al acuity. 1 ROLIFERATIVE VITREORETINOPATHY i s t h e m o s t
common cause for failure in retinal detachment surgical procedures. The treatment approach for this condition involves the use of vitrectomy in combination with a broad encircling scleral buckle, membrane peeling, and long-term in-
Accepted for publication Jan. 30, 1992. From the New York Hospital-Cornell Medical Center, New York, New York. This study was supported in part by the Vitreous Research Fund, Cornell University Med ical College, New York, New York (Dr. Chang); and t h e Dyson Foundation, New York, New York (Dr. Lopez). Reprint requests to Robert Lopez, M.D., Edward S. Harkness Eye Institute, 635 W. 165th St., New York, NY 10032.
424
traocular tamponade with either silicone oil or perfluorocarbon gas.1"7 Silicone oil has been in use for many years and the long-term visual results and associated complications are well known. 8 Perfluorocar bon gases, conversely, have been in use for a shorter period of time, and less is known of their long-term results and complications. In formation on the long-term effects of perfluoro carbon gases is especially important because the use of silicone oil may be increasing and a choice must be made between the use of sili cone oil or perfluorocarbon gas. We studied 87 patients who underwent vit rectomy scleral buckling, and intraocular injec tion of perfluorocarbon gas in one eye each for severe proliferative vitreoretinopathy, and the follow-up (ranging up to 106 months postoper atively) on those patients with attached retinas. Special attention was given to quality and sta bility of visual acuity, retinal status, and recur rence of the proliferative process.
Material and Methods The records of 87 consecutive patients who underwent vitrectomy and injection of perfluo rocarbon gas in one eye each for proliferative vitreoretinopathy of grade C3 (marked, involv ing three quadrants) or worse dating from Sep tember 1981 to March 1987 were examined. There were 61 males and 26 females, ranging in age from 7 to 87 years (mean, 52 years). Sixteen patients had sustained blunt or penetrating trauma, ten had giant tears, and two had expul sive hemorrhages. Twenty-nine patients were aphakic and 13 were pseudophakic. Eight of the 13 pseudophakic patients had anterior chamber intraocular lenses and five had posterior cham ber lenses. Sixty-one patients (70%) had under gone at least one previous scleral buckling procedure, and 24 (27%) had undergone at least one previous vitrectomy. Twenty-two pa-
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Vitrectomy and Proliferative Vitreoretinopathy
tients (25%) had grade D3 proliferative vitreo retinopathy (massive, with fixed retinal folds in four quadrants, and closed funnel shape [optic nerve head not visible]), 32 (37%) had grade D2 (massive, with fixed retinal folds in four quad rants, and funnel shape), 26 (30%) had grade Dl (massive, with fixed retinal folds in four quadrants, and wide funnel shape), and seven (8%) had grade C3. 9 The presence or extent of preoperative anterior proliferative vitreoreti nopathy was not documented in many of the earlier cases. Patients who developed prolifera tive vitreoretinopathy after vitrectomy for pro liferative diabetic retinopathy were excluded from this study. Vitreous surgical procedures were performed by one of us (S.C.). If the patient did not have a scleral buckle, a broad silicone sponge was placed to support the vitreous base from the ora serrata to the equator. In 24 patients, the preex isting scleral buckle was revised. If necessary, a pars plana lensectomy was performed followed by vitrectomy with removal of epiretinal mem branes by using a bent 22-gauge needle, mem brane pick, and membrane forceps. Scleral de pression was used to allow maximal removal of the anterior vitreous base. An air-fluid ex change was performed with internal drainage of subretinal fluid accomplished through an existing break or, infrequently, through a pos terior retinotomy. This was followed by the application of argon laser photocoagulation around the retinal holes and along the circum ference of the buckle. In some patients, cryopexy was used to seal the retinal breaks. Perfluoroethane (C2F6) or perfluoropropane (C3F8) was injected into the vitreous cavity, either as an undiluted volume ranging from 0.7 to 1.2 ml, or flushed through as a 15% to 20% mixture. Seventy-nine patients received C3F8 and eight received C2F6. Perfluoroethane was used in phakic eyes to minimize cataract formation. An undiluted vol ume of gas was injected into an eye if there was residual subretinal fluid at the end of the proce dure, whereas a mixture of air and gas was flushed through the eye if the retina was com pletely flat. A bubble that filled approximately 80% of the vitreous cavity was usually present on the first postoperative day. If the intraocular pressure was increased, it was controlled with timolol 0.5% drops or acetazolamide pills, or both. Infrequently, a small volume of gas had to be removed from an eye if the intraocular pres sure was increased because the bubble was too large. If the bubble was too small postopera-
425
tively, fluid-gas exchange was performed in an outpatient setting to supplement the bubble.
Results Twenty-six of the 87 patients (30%) under went at least one additional procedure consist ing of a revision of the scleral buckle, revision of vitrectomy, or both. Forty-two patients (48%) received postoperative laser treatments and 38 (44%) required postoperative gas sup plementation. If the gas bubble was not supple mented postoperatively, it would usually be completely absorbed by six to ten weeks. In those patients who required additional gas, the bubble remained in the eye for periods up to 20 weeks. The duration of reattachment was mea sured from the time of complete disappearance of the gas postoperatively. The retinas of 60 of the 87 eyes (69%) were attached posterior to the scleral buckle one month after disappearance of the gas. Four eyes required silicone oil to achieve reattachment of the retina and were considered failures of perfluorocarbon gas treatment and were not in cluded in the 60 eyes. Six retinas redetached at four, five, six, eight, 24, and 30 months, respec tively; but three of these have since been reattached, one spontaneously. The reasons for redetachment were new retinal breaks in two eyes and recurrent proliferation that opened existing breaks in four eyes. Six-month followup was not available on three eyes, leaving follow-up data on 54 eyes with retinas attached from six to 106 months. Initial reattachment success rate was inverse ly related to severity of proliferative vitreoreti nopathy, with seven of seven patients with grade C3 proliferative vitreoretinopathy at tached at one month after disappearance of the gas, 19 of 26 patients (73%) with grade D l , 21 of 32 patients (66%) with grade D2, and 13 of 22 patients (59%) with grade D3 (Table 1). As more experience was gained, the success rate improved; the retinas of 24 of the first 40 eyes (60%) were reattached, whereas in the last 47 eyes, 36 retinas (76%) were successfully reat tached. The retinas were reattached in 12 of the 16 eyes (75%) that had sustained trauma, eight of the ten eyes with giant tears, and both eyes with expulsive hemorrhages. All eight eyes in which C2F6 was used had attached retinas at the time of their last examination. The most com mon reasons for failure were large posterior
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TABLE 1 RELATIONSHIP OF INITIAL REATTACHMENT SUCCESS RATE TO SEVERITY OF PROLIFERATIVE VITREORETINOPATHY PROLIFERATIVE VITREORETINOPATHY
NO. OF
GRADE
EYES
C-3 (marked, involving three quadrants) D-1 (massive, fixed retinal folds in four quadrants and wide funnel shape) D-2 (massive, fixed retinal folds in four quadrants and narrow funnel shape) D-3 (massive, fixed retinal folds in four quadrants and closed funnel shape [optic nerve head not visible]) Total
TABLE 2 RELATIONSHIP OF VISUAL ACUITY TO SEVERITY OF PROLIFERATIVE VITREORETINOPATHY IN 54 EYES WITH RETINAS ATTACHED FROM SIX TO 106 MONTHS
NO. OF RETINAL REATTACHMENTS
7
7
26
19
32
22
87
21
13
60
breaks that could not be closed and extensive recurrent proliferation. The retinas were attached for periods ranging from six to 11 months in nine patients, 12 to 23 months in eight patients, 24 to 35 months in ten patients, 36 to 47 months in 11 patients, and 48 to 106 months in 16 patients. A wide range of visual acuities were seen in every group. When visual acuity was correlated to severity of proliferative vitreoretinopathy, no direct relation ship was evident (Table 2). Long-term visual acuity appeared to be sta ble; when visual acuity on last examination was compared to visual acuity at six months in those 37 patients with retinas attached 24 months or longer, 13 patients (35%) had better visual acuity, 16 (43%) had the same visual acuity, and eight (22%) had worse visual acuity (Figure). Of those patients who had better visu al acuity, one had undergone a cataract extrac tion and another had undergone a penetrating keratoplasty, while one patient with the same visual acuity had also undergone a penetrating keratoplasty. Of those patients with worse vis ual acuity, three had macular pucker, one had a dense cataract, and one had corneal decompen sation. Twenty-five of the 54 patients (46%) with retinas attached six months or longer had a final visual acuity of 20/200 or better and 38 of the 54 patients (70%) had a final acuity of 20/400 or better. Complications seen within 30 days postoper-
NO. OF EYES WITH GRADE C-3 PROLIFERATIVE VISUAL ACUITY
20/40 20/50 20/70 20/80 20/200 20/300 20/400 20/800 Counting fingers Hand motion Light perception Total
VITREORETINOPATHY OR WORSE C-3
D-1
— 1
D-2
D-3
2
2
—
1
—
1 1
1 2 6
4 1 4 1 1 1 1 16
1 1 8
4 1 1 1 19
1
— 3 1 2 1 4 1 13
atively included a transient intraocular pres sure increase in ten patients, choroidal effu sions in five patients, marked iris neovascularization in four patients, and hyphema, expul sive hemorrhage, and hypotony in one patient each. Late complications in the 54 patients with retinas attached six months or longer included macular pucker in 16 (30%), corneal decompen sation in five (9%), hypotony in four (7%), prolonged increased intraocular pressure in four (7%), and marked iris neovascularization in one (2%). Of the 45 phakic patients, 37 (82%) under went lensectomy at the time of the retinal detachment repair. This was usually done to permit visualization in cases of lens opacities or to facilitate removal of the anterior vitreous. Of the eight remaining patients, two developed detached retinas that could not be repaired and five developed clinically significant cataracts. Two of these five patients have undergone cata ract extraction and have visual acuities of 2 0 / 40 and 20/80, whereas the other three have visual acuities of counting fingers (one patient) and hand motions (two patients). The one pa tient with a noncataractous lens has a visual acuity of 20/400.
Discussion In this study, vitreoretinal surgical proce dures and extended tamponade with perfluoro-
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Vitrectomy and Proliferative Vitreoretinopathy
20/100 ■ 20/200 ■ 20/400 -
"S 3
S
COUNT FINGERS" HAND . MOTION
T—I—i—i—r ~ i — i — i — r
HAND COUNT 20/400 20/200 20/100 MOTION FINGERS Visual Acuity at 6 months
20/50
Figure (Lopez and Chang). Visual acuity at six months compared to visual acuity on last examina tion in those patients with retinas attached from 24 to 106 months. Numbers in parentheses indicate multiple points at that location. carbon gases resulted in successful retinal reattachment in approximately two thirds of the cases of severe proliferative vitreoretinopathy. Initial reattachment rate was inversely related to severity of proliferative vitreoretinopathy, but final visual acuity was not. A notable per centage of patients with attached retinas achieved good visual acuity, which remained stable for periods up to several years. Surpris ingly, 13 of the 37 patients (35%) with retinas attached 24 months or longer continued to have improvement in vision after six months, the point at which it is generally assumed that visual rehabilitation ceases after retinal detach ment surgical procedures. Recent advances in surgical technique, as well as an improved understanding of the path ologic mechanisms involved, have resulted in higher rates of reattachment in cases of severe proliferative vitreoretinopathy. 1011 Important components of the vitrectomy include removal of all epiretinal membranes and trimming of the vitreous base with scleral depression to release anterior proliferative vitreoretinopa thy.12 Photocoagulation or cryopexy, or both, is used judiciously to seal all tears and secure the retina on the buckle. The properties that make perfluorocarbon gases useful in the treatment of proliferative vitreoretinopathy are their expansivity and in traocular persistence. 1314 Both of these useful properties are attributable to the low solubility of perfluorocarbon gases in blood, with the expansion phase resulting from the entry of serum nitrogen and oxygen into the gas bubble
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and persistence resulting from the slow reabsorption of the gas. While the gas bubble is in the eye, its buoyant force holds the retina against the retinal pigment epithelium until the chorioretinal adhesion can become maximal. The buoyant force is directly proportional to the bubble volume and to the difference in specific gravities between the gas and saline solution. Thus, gases provide a markedly high er buoyant force than the force obtainable with silicone oil.1616 The higher surface tension and higher buoyant force of gases result in better internal tamponade properties. The expansile properties of perfluorocarbon gases can be useful in several respects. Intraoperatively, residual subretinal fluid may be left and a mildly expansile gas concentration (that is, 20% perfluoropropane) can be used to fill the vitreous volume as the subretinal fluid reabsorbs. Thus, if epiretinal traction is completely removed, a posterior retinotomy is not re quired. Postoperatively, a small gas bubble can be easily supplemented using outpatient fluidgas exchange techniques. The most notable long-term complication seen in this study was macular pucker, which was present in 16 of 54 patients (30%) with retinas attached six months or longer. This probably represents continued proliferation of the cellular elements responsible for prolifera tive vitreoretinopathy, even after successful retinal reattachment. 1011
References 1. Chang, S., Coleman, D. J., Lincoff, H., Wilcox, L. M., Braunstein, R. A., and Maisel, J. M.: Perfluoro propane gas in the management of proliferative vit reoretinopathy. Am. J. Ophthalmol. 98:180, 1984. 2. Stern, W., Johnson, R., Irvine, A., Barricks, M., Boyden, B., Hilton, G., Lonn, L., and Schwartz, A.: Extended retinal tamponade in the treatment of reti nal detachment with proliferative vitreoretinopathy. Br. J. Ophthalmol. 70:911, 1986. 3. Hanneken, A. M., and Michels, R. G.: Vitrec tomy and scleral buckling methods for proliferative vitreoretinopathy. Ophthalmology 95:865, 1988. 4. Fisher, Y. L., Shakin, J. L., Slakter, J., Sorenson, J. A., and Shafer, D. M.: Perfluorocarbon gas, modi fied panretinal photocoagulation, and vitrectomy in the management of severe proliferative vitreoreti nopathy. Arch. Ophthalmol. 106:1255, 1988. 5. Aaberg, T. M.: Management of anterior and posterior proliferative vitreoretinopathy. XLV Edward Jackson Memorial Lecture. Am. J. Ophthal mol. 106:519, 1988.
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6. Lewis, H., Aaberg, T. M., and Abrams, G. W.: Causes of failure after initial vitreoretinal surgery for severe proliferative vitreoretinopathy. Am. J. Ophthalmol. 111:8, 1991. 7. Lewis, H., and Aaberg, T. M.: Causes of failure after repeat vitreoretinal surgery for recurrent prolif erative vitreoretinopathy. Am. J. Ophthalmol. 111:15, 1991. 8. Federman, J. L., and Schubert, H. D.: Complica tions associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology 95:870, 1988. 9. Retina Society Terminology Committee: The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 90:121, 1983. 10. Machemer, R., and Laqua, H.: Pigment epithe lium proliferation in retinal detachment (massive periretinal proliferation). Am. J. Ophthalmol. 80:1, 1975.
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11. Ryan, S.: The pathophysiology of proliferative vitreoretinopathy in its management. Am. J. Oph thalmol. 100:188, 1985. 12. Lewis, H., and Aaberg, T. M.: Anterior prolif erative vitreoretinopathy. Am. J. Ophthalmol. 105:277, 1988. 13. Lincoff, A., Haft, D., Liggett, P., and Reifer, C : Intravitreal expansion of perfluorocarbon bubbles. Arch. Ophthalmol. 98:1646, 1980. 14. Lincoff, H., Maisel, J., and Lincoff, A.: Intravit real disappearance rates of four perfluorocarbon gas es. Arch. Ophthalmol. 102:928, 1984. 15. de Juan, E., McCuen, B., and Tiedman, J.: Intraocular tamponade and surface tension. Surv. Ophthalmol. 30:47, 1985. 16. Haut, J., Larricart, J., Van Effenterre, G., and Pinon-Pignero, F.: Some of the most important prop erties of silicone oil to explain its action. Ophthalmologica 191:150, 1985.
OPHTHALMIC MINIATURE
To be sure, neither did his fellow passengers ever look at one another; at the slightest eye contact, James declared, " a n instant film would surge u p . . . just as a N e w p o r t fog suddenly surges u p from the cold remorseless sea, and wrap the organ in the dullest, fishiest, most disheartening of stares." For a lover of omnibuses, it was very discouraging, and James concluded that the English were simply the worst-mannered people in Christendom. R. W. B. Lewis, The Jameses: A Family Narrative New York, Farrar, Straus and Giroux, 1991, p . 115
The results of 87 patients who underwent vitrectomy, scleral buckling, and injection of perfluorocarbon gas in one eye each for prolif erative vitreoretinopathy of grade C3 (marked, involving three quadrants) or worse were studied. The retinas of 60 of the 87 patients (69%) were attached posterior to the scleral buckle one month after disappearance of the gas, with the initial reattachment rate being inversely proportional to the severity of proliferative vitreoretinopathy. Follow-up data ranging from six to 106 months were available on 54 eyes with attached retinas. Final visual acuity in those patients ranged from light perception to 20/40 and was not related to severity of proliferative vitreoreti nopathy or duration of reattachment. Thirtyeight of the 54 patients (70%) had a visual acuity of 20/400 or better. Twenty-nine of the 37 patients (78%) with retinas attached 24 months or longer had the same or better visu al acuity than at six months postoperatively. Macular pucker was observed in 16 of the 54 eyes (30%) and was the most frequently seen long-term retinal complication affecting visu al acuity. 1 ROLIFERATIVE VITREORETINOPATHY i s t h e m o s t
common cause for failure in retinal detachment surgical procedures. The treatment approach for this condition involves the use of vitrectomy in combination with a broad encircling scleral buckle, membrane peeling, and long-term in-
Accepted for publication Jan. 30, 1992. From the New York Hospital-Cornell Medical Center, New York, New York. This study was supported in part by the Vitreous Research Fund, Cornell University Med ical College, New York, New York (Dr. Chang); and t h e Dyson Foundation, New York, New York (Dr. Lopez). Reprint requests to Robert Lopez, M.D., Edward S. Harkness Eye Institute, 635 W. 165th St., New York, NY 10032.
424
traocular tamponade with either silicone oil or perfluorocarbon gas.1"7 Silicone oil has been in use for many years and the long-term visual results and associated complications are well known. 8 Perfluorocar bon gases, conversely, have been in use for a shorter period of time, and less is known of their long-term results and complications. In formation on the long-term effects of perfluoro carbon gases is especially important because the use of silicone oil may be increasing and a choice must be made between the use of sili cone oil or perfluorocarbon gas. We studied 87 patients who underwent vit rectomy scleral buckling, and intraocular injec tion of perfluorocarbon gas in one eye each for severe proliferative vitreoretinopathy, and the follow-up (ranging up to 106 months postoper atively) on those patients with attached retinas. Special attention was given to quality and sta bility of visual acuity, retinal status, and recur rence of the proliferative process.
Material and Methods The records of 87 consecutive patients who underwent vitrectomy and injection of perfluo rocarbon gas in one eye each for proliferative vitreoretinopathy of grade C3 (marked, involv ing three quadrants) or worse dating from Sep tember 1981 to March 1987 were examined. There were 61 males and 26 females, ranging in age from 7 to 87 years (mean, 52 years). Sixteen patients had sustained blunt or penetrating trauma, ten had giant tears, and two had expul sive hemorrhages. Twenty-nine patients were aphakic and 13 were pseudophakic. Eight of the 13 pseudophakic patients had anterior chamber intraocular lenses and five had posterior cham ber lenses. Sixty-one patients (70%) had under gone at least one previous scleral buckling procedure, and 24 (27%) had undergone at least one previous vitrectomy. Twenty-two pa-
©AMERICAN JOURNAL OF OPHTHALMOLOGY 113:424-428, APRIL, 1992
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Vitrectomy and Proliferative Vitreoretinopathy
tients (25%) had grade D3 proliferative vitreo retinopathy (massive, with fixed retinal folds in four quadrants, and closed funnel shape [optic nerve head not visible]), 32 (37%) had grade D2 (massive, with fixed retinal folds in four quad rants, and funnel shape), 26 (30%) had grade Dl (massive, with fixed retinal folds in four quadrants, and wide funnel shape), and seven (8%) had grade C3. 9 The presence or extent of preoperative anterior proliferative vitreoreti nopathy was not documented in many of the earlier cases. Patients who developed prolifera tive vitreoretinopathy after vitrectomy for pro liferative diabetic retinopathy were excluded from this study. Vitreous surgical procedures were performed by one of us (S.C.). If the patient did not have a scleral buckle, a broad silicone sponge was placed to support the vitreous base from the ora serrata to the equator. In 24 patients, the preex isting scleral buckle was revised. If necessary, a pars plana lensectomy was performed followed by vitrectomy with removal of epiretinal mem branes by using a bent 22-gauge needle, mem brane pick, and membrane forceps. Scleral de pression was used to allow maximal removal of the anterior vitreous base. An air-fluid ex change was performed with internal drainage of subretinal fluid accomplished through an existing break or, infrequently, through a pos terior retinotomy. This was followed by the application of argon laser photocoagulation around the retinal holes and along the circum ference of the buckle. In some patients, cryopexy was used to seal the retinal breaks. Perfluoroethane (C2F6) or perfluoropropane (C3F8) was injected into the vitreous cavity, either as an undiluted volume ranging from 0.7 to 1.2 ml, or flushed through as a 15% to 20% mixture. Seventy-nine patients received C3F8 and eight received C2F6. Perfluoroethane was used in phakic eyes to minimize cataract formation. An undiluted vol ume of gas was injected into an eye if there was residual subretinal fluid at the end of the proce dure, whereas a mixture of air and gas was flushed through the eye if the retina was com pletely flat. A bubble that filled approximately 80% of the vitreous cavity was usually present on the first postoperative day. If the intraocular pressure was increased, it was controlled with timolol 0.5% drops or acetazolamide pills, or both. Infrequently, a small volume of gas had to be removed from an eye if the intraocular pres sure was increased because the bubble was too large. If the bubble was too small postopera-
425
tively, fluid-gas exchange was performed in an outpatient setting to supplement the bubble.
Results Twenty-six of the 87 patients (30%) under went at least one additional procedure consist ing of a revision of the scleral buckle, revision of vitrectomy, or both. Forty-two patients (48%) received postoperative laser treatments and 38 (44%) required postoperative gas sup plementation. If the gas bubble was not supple mented postoperatively, it would usually be completely absorbed by six to ten weeks. In those patients who required additional gas, the bubble remained in the eye for periods up to 20 weeks. The duration of reattachment was mea sured from the time of complete disappearance of the gas postoperatively. The retinas of 60 of the 87 eyes (69%) were attached posterior to the scleral buckle one month after disappearance of the gas. Four eyes required silicone oil to achieve reattachment of the retina and were considered failures of perfluorocarbon gas treatment and were not in cluded in the 60 eyes. Six retinas redetached at four, five, six, eight, 24, and 30 months, respec tively; but three of these have since been reattached, one spontaneously. The reasons for redetachment were new retinal breaks in two eyes and recurrent proliferation that opened existing breaks in four eyes. Six-month followup was not available on three eyes, leaving follow-up data on 54 eyes with retinas attached from six to 106 months. Initial reattachment success rate was inverse ly related to severity of proliferative vitreoreti nopathy, with seven of seven patients with grade C3 proliferative vitreoretinopathy at tached at one month after disappearance of the gas, 19 of 26 patients (73%) with grade D l , 21 of 32 patients (66%) with grade D2, and 13 of 22 patients (59%) with grade D3 (Table 1). As more experience was gained, the success rate improved; the retinas of 24 of the first 40 eyes (60%) were reattached, whereas in the last 47 eyes, 36 retinas (76%) were successfully reat tached. The retinas were reattached in 12 of the 16 eyes (75%) that had sustained trauma, eight of the ten eyes with giant tears, and both eyes with expulsive hemorrhages. All eight eyes in which C2F6 was used had attached retinas at the time of their last examination. The most com mon reasons for failure were large posterior
426
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AMERICAN JOURNAL OF OPHTHALMOLOGY
TABLE 1 RELATIONSHIP OF INITIAL REATTACHMENT SUCCESS RATE TO SEVERITY OF PROLIFERATIVE VITREORETINOPATHY PROLIFERATIVE VITREORETINOPATHY
NO. OF
GRADE
EYES
C-3 (marked, involving three quadrants) D-1 (massive, fixed retinal folds in four quadrants and wide funnel shape) D-2 (massive, fixed retinal folds in four quadrants and narrow funnel shape) D-3 (massive, fixed retinal folds in four quadrants and closed funnel shape [optic nerve head not visible]) Total
TABLE 2 RELATIONSHIP OF VISUAL ACUITY TO SEVERITY OF PROLIFERATIVE VITREORETINOPATHY IN 54 EYES WITH RETINAS ATTACHED FROM SIX TO 106 MONTHS
NO. OF RETINAL REATTACHMENTS
7
7
26
19
32
22
87
21
13
60
breaks that could not be closed and extensive recurrent proliferation. The retinas were attached for periods ranging from six to 11 months in nine patients, 12 to 23 months in eight patients, 24 to 35 months in ten patients, 36 to 47 months in 11 patients, and 48 to 106 months in 16 patients. A wide range of visual acuities were seen in every group. When visual acuity was correlated to severity of proliferative vitreoretinopathy, no direct relation ship was evident (Table 2). Long-term visual acuity appeared to be sta ble; when visual acuity on last examination was compared to visual acuity at six months in those 37 patients with retinas attached 24 months or longer, 13 patients (35%) had better visual acuity, 16 (43%) had the same visual acuity, and eight (22%) had worse visual acuity (Figure). Of those patients who had better visu al acuity, one had undergone a cataract extrac tion and another had undergone a penetrating keratoplasty, while one patient with the same visual acuity had also undergone a penetrating keratoplasty. Of those patients with worse vis ual acuity, three had macular pucker, one had a dense cataract, and one had corneal decompen sation. Twenty-five of the 54 patients (46%) with retinas attached six months or longer had a final visual acuity of 20/200 or better and 38 of the 54 patients (70%) had a final acuity of 20/400 or better. Complications seen within 30 days postoper-
NO. OF EYES WITH GRADE C-3 PROLIFERATIVE VISUAL ACUITY
20/40 20/50 20/70 20/80 20/200 20/300 20/400 20/800 Counting fingers Hand motion Light perception Total
VITREORETINOPATHY OR WORSE C-3
D-1
— 1
D-2
D-3
2
2
—
1
—
1 1
1 2 6
4 1 4 1 1 1 1 16
1 1 8
4 1 1 1 19
1
— 3 1 2 1 4 1 13
atively included a transient intraocular pres sure increase in ten patients, choroidal effu sions in five patients, marked iris neovascularization in four patients, and hyphema, expul sive hemorrhage, and hypotony in one patient each. Late complications in the 54 patients with retinas attached six months or longer included macular pucker in 16 (30%), corneal decompen sation in five (9%), hypotony in four (7%), prolonged increased intraocular pressure in four (7%), and marked iris neovascularization in one (2%). Of the 45 phakic patients, 37 (82%) under went lensectomy at the time of the retinal detachment repair. This was usually done to permit visualization in cases of lens opacities or to facilitate removal of the anterior vitreous. Of the eight remaining patients, two developed detached retinas that could not be repaired and five developed clinically significant cataracts. Two of these five patients have undergone cata ract extraction and have visual acuities of 2 0 / 40 and 20/80, whereas the other three have visual acuities of counting fingers (one patient) and hand motions (two patients). The one pa tient with a noncataractous lens has a visual acuity of 20/400.
Discussion In this study, vitreoretinal surgical proce dures and extended tamponade with perfluoro-
Vol. 113, No. 4
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Vitrectomy and Proliferative Vitreoretinopathy
20/100 ■ 20/200 ■ 20/400 -
"S 3
S
COUNT FINGERS" HAND . MOTION
T—I—i—i—r ~ i — i — i — r
HAND COUNT 20/400 20/200 20/100 MOTION FINGERS Visual Acuity at 6 months
20/50
Figure (Lopez and Chang). Visual acuity at six months compared to visual acuity on last examina tion in those patients with retinas attached from 24 to 106 months. Numbers in parentheses indicate multiple points at that location. carbon gases resulted in successful retinal reattachment in approximately two thirds of the cases of severe proliferative vitreoretinopathy. Initial reattachment rate was inversely related to severity of proliferative vitreoretinopathy, but final visual acuity was not. A notable per centage of patients with attached retinas achieved good visual acuity, which remained stable for periods up to several years. Surpris ingly, 13 of the 37 patients (35%) with retinas attached 24 months or longer continued to have improvement in vision after six months, the point at which it is generally assumed that visual rehabilitation ceases after retinal detach ment surgical procedures. Recent advances in surgical technique, as well as an improved understanding of the path ologic mechanisms involved, have resulted in higher rates of reattachment in cases of severe proliferative vitreoretinopathy. 1011 Important components of the vitrectomy include removal of all epiretinal membranes and trimming of the vitreous base with scleral depression to release anterior proliferative vitreoretinopa thy.12 Photocoagulation or cryopexy, or both, is used judiciously to seal all tears and secure the retina on the buckle. The properties that make perfluorocarbon gases useful in the treatment of proliferative vitreoretinopathy are their expansivity and in traocular persistence. 1314 Both of these useful properties are attributable to the low solubility of perfluorocarbon gases in blood, with the expansion phase resulting from the entry of serum nitrogen and oxygen into the gas bubble
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and persistence resulting from the slow reabsorption of the gas. While the gas bubble is in the eye, its buoyant force holds the retina against the retinal pigment epithelium until the chorioretinal adhesion can become maximal. The buoyant force is directly proportional to the bubble volume and to the difference in specific gravities between the gas and saline solution. Thus, gases provide a markedly high er buoyant force than the force obtainable with silicone oil.1616 The higher surface tension and higher buoyant force of gases result in better internal tamponade properties. The expansile properties of perfluorocarbon gases can be useful in several respects. Intraoperatively, residual subretinal fluid may be left and a mildly expansile gas concentration (that is, 20% perfluoropropane) can be used to fill the vitreous volume as the subretinal fluid reabsorbs. Thus, if epiretinal traction is completely removed, a posterior retinotomy is not re quired. Postoperatively, a small gas bubble can be easily supplemented using outpatient fluidgas exchange techniques. The most notable long-term complication seen in this study was macular pucker, which was present in 16 of 54 patients (30%) with retinas attached six months or longer. This probably represents continued proliferation of the cellular elements responsible for prolifera tive vitreoretinopathy, even after successful retinal reattachment. 1011
References 1. Chang, S., Coleman, D. J., Lincoff, H., Wilcox, L. M., Braunstein, R. A., and Maisel, J. M.: Perfluoro propane gas in the management of proliferative vit reoretinopathy. Am. J. Ophthalmol. 98:180, 1984. 2. Stern, W., Johnson, R., Irvine, A., Barricks, M., Boyden, B., Hilton, G., Lonn, L., and Schwartz, A.: Extended retinal tamponade in the treatment of reti nal detachment with proliferative vitreoretinopathy. Br. J. Ophthalmol. 70:911, 1986. 3. Hanneken, A. M., and Michels, R. G.: Vitrec tomy and scleral buckling methods for proliferative vitreoretinopathy. Ophthalmology 95:865, 1988. 4. Fisher, Y. L., Shakin, J. L., Slakter, J., Sorenson, J. A., and Shafer, D. M.: Perfluorocarbon gas, modi fied panretinal photocoagulation, and vitrectomy in the management of severe proliferative vitreoreti nopathy. Arch. Ophthalmol. 106:1255, 1988. 5. Aaberg, T. M.: Management of anterior and posterior proliferative vitreoretinopathy. XLV Edward Jackson Memorial Lecture. Am. J. Ophthal mol. 106:519, 1988.
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6. Lewis, H., Aaberg, T. M., and Abrams, G. W.: Causes of failure after initial vitreoretinal surgery for severe proliferative vitreoretinopathy. Am. J. Ophthalmol. 111:8, 1991. 7. Lewis, H., and Aaberg, T. M.: Causes of failure after repeat vitreoretinal surgery for recurrent prolif erative vitreoretinopathy. Am. J. Ophthalmol. 111:15, 1991. 8. Federman, J. L., and Schubert, H. D.: Complica tions associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology 95:870, 1988. 9. Retina Society Terminology Committee: The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 90:121, 1983. 10. Machemer, R., and Laqua, H.: Pigment epithe lium proliferation in retinal detachment (massive periretinal proliferation). Am. J. Ophthalmol. 80:1, 1975.
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11. Ryan, S.: The pathophysiology of proliferative vitreoretinopathy in its management. Am. J. Oph thalmol. 100:188, 1985. 12. Lewis, H., and Aaberg, T. M.: Anterior prolif erative vitreoretinopathy. Am. J. Ophthalmol. 105:277, 1988. 13. Lincoff, A., Haft, D., Liggett, P., and Reifer, C : Intravitreal expansion of perfluorocarbon bubbles. Arch. Ophthalmol. 98:1646, 1980. 14. Lincoff, H., Maisel, J., and Lincoff, A.: Intravit real disappearance rates of four perfluorocarbon gas es. Arch. Ophthalmol. 102:928, 1984. 15. de Juan, E., McCuen, B., and Tiedman, J.: Intraocular tamponade and surface tension. Surv. Ophthalmol. 30:47, 1985. 16. Haut, J., Larricart, J., Van Effenterre, G., and Pinon-Pignero, F.: Some of the most important prop erties of silicone oil to explain its action. Ophthalmologica 191:150, 1985.
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To be sure, neither did his fellow passengers ever look at one another; at the slightest eye contact, James declared, " a n instant film would surge u p . . . just as a N e w p o r t fog suddenly surges u p from the cold remorseless sea, and wrap the organ in the dullest, fishiest, most disheartening of stares." For a lover of omnibuses, it was very discouraging, and James concluded that the English were simply the worst-mannered people in Christendom. R. W. B. Lewis, The Jameses: A Family Narrative New York, Farrar, Straus and Giroux, 1991, p . 115