- Email: [email protected]
Pars Plana Vitrectomy, Laser Retinopexy, and Aqueous Tamponade for Pseudophakic Rhegmatogenous Retinal Detachment
Pars Plana Vitrectomy, Laser Retinopexy, and Aqueous Tamponade for Pseudophakic Rhegmatogenous Retinal Detachment Vicente Martínez-Castillo, MD,1,2 Miguel A. Zapata, MD,1,2 Anna Boixadera, MD,1,2 Alex Fonollosa, MD,1,2 José García-Arumí, MD1 Objective: To evaluate a novel pars plana vitrectomy (PPV) approach with aqueous tamponade for repair of primary pseudophakic rhegmatogenous retinal detachment (RRD). Design: Prospective, noncomparative, interventional case series. Participants: Sixty nonconsecutive patients (60 eyes) with primary pseudophakic RRD. Intervention: Patients underwent PPV alone with injection of perfluoro-n-octane followed by fluid–air exchange and transscleral diode laser retinopexy and then balanced salt solution (BSS) tamponade. All patients were observed for at least 1 year. Main Outcome Measures: Anatomic outcome, visual acuity (VA), and complications. Results: The mean follow-up period was 16.4 months (range, 12.1–21.5). Preoperatively, 32 patients (53.3%) had 1 break and 28 patients (46.7%) had 2 to 4 breaks (mean, 2.7). Intraoperatively, 108 retinal breaks were identified, 82 (75.9%) superior and 26 (24%) inferior. Eight breaks in 8 patients that were not seen preoperatively or intraoperatively were diagnosed after air–BSS exchange. Mean preoperative best-corrected VA (BCVA) was 20/700 (range, hand movements [HM]–20/20). Final BCVA was a mean of 20/59 (range, 20/200 –20/20). For the 13 eyes with macula-attached RRD, BCVA was the same preoperatively and postoperatively (mean, 20/27; range, 20/50 –20/20). For the 47 eyes with macula-detached RRD, the mean BCVA was 20/888 preoperatively (range, HM–20/50) and 20/68 postoperatively (range, 20/200 –20/20). Final VA was ⱖ20/40 in 34 of 60 eyes (56.6%). Primary retinal reattachment (attachment at 1 month postoperatively) was attained in 59 of the 60 patients (98.3%). The single failure was due to a new break postoperatively; this break was treated by pneumatic retinopexy and photocoagulation of the break. At the 12-month follow-up visit, reattachment had been attained in all 60 eyes (100%). Postoperatively, 1 patient (1.6%) had hypotony at the 1-day postoperative visit, but intraocular pressure was 14 mm at the 4-day visit, and 2 patients (3.3%) had mild vitreous hemorrhage during the first 48 hours that resolved spontaneously during the following 10 days. Conclusion: Pars plana vitrectomy with laser retinopexy followed by BSS tamponade is effective for intraoperative sealing of retinal breaks causing pseudophakic RRD. We did not identify safety concerns in this 60-patient series. Ophthalmology 2007;114:297–302 © 2007 by the American Academy of Ophthalmology.
Since the principles of pars plana vitrectomy (PPV) were first described by Machemer et al in 1971,1 the surgical technique has advanced considerably. The use of intraocular gases2,3 and the development of wide-angle field Originally received: August 1, 2005. Accepted: July 19, 2006. Manuscript no. 2005-709. 1 Vall d’Hebrón Hospital, Universidad Autónoma de Barcelona, Barcelona, Spain. 2 Instituto Oftalmológico de Barcelona, Barcelona, Spain. The authors have no personal or family ownership in, and did not receive financial support from, any company, product, drug, instrument, or piece of equipment discussed in the article, including stock or ownership of a business entity connected to a described product, paid consulting for any company or competing companies, or patent rights to any drug or piece of equipment mentioned. Correspondence to Vicente Martínez-Castillo, MD, Calle Londres n° 54 4° 1° B, Barcelona, Spain. E-mail: [email protected]. © 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
viewing systems, perfluorocarbon liquids,4 and improved instruments for vitrectomy have contributed to increasing the role for PPV in the management of pseudophakic retinal detachment. With the conventional PPV technique for repair of retinal detachment, after laser retinopexy the eye is filled with a nonaqueous tamponade agent (air, a medical gas, or silicone oil). The rationale for using this type of tamponade at the end of the procedure is to allow sufficient time for chorioretinal adhesion to develop, while avoiding seepage of fluid through the causative break.5,6 Nonetheless, there are several drawbacks to the use of these agents. Postoperative morbidity owing to elevated intraocular pressure and cataract progression is not unusual in phakic patients. In addition, patients may experience considerable discomfort from the face-down positioning required for healing, become ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2006.07.037
297
Ophthalmology Volume 114, Number 2, February 2007 discouraged with the delay in return of visual function, and be inconvenienced by postoperative restrictions on air travel when gas or oil tamponade is used.5,6 Furthermore, until the gas has been absorbed or the silicone oil removed, the surgeon cannot be sure that the retina is reattached. In this study, we evaluated the safety and efficacy of a novel PPV technique that was designed to achieve intraoperative chorioretinal adhesion in eyes with pseudophakic rhegmatogenous retinal detachment (RRD) and to allow the use of an aqueous tamponade postoperatively, increasing the intraoperative diagnosis of retinal breaks and providing considerable advantages for the patient.
Patients and Methods Candidates for this study were patients who were scheduled for PPV for pseudophakic RRD. Patients were fully informed of all aspects of the procedure, and all provided written informed consent to participate in the study. The study was approved by the institutional review board of the Vall d’Hebrón Hospital. Patients with giant tears, ⬎5 retinal breaks on preoperative examination, retinal detachment with grade B or greater proliferative vitreoretinopathy (PVR),7 retinal detachment due to a macular hole, bilateral RRD, or no vision in the other eye were excluded. Patients who had been followed up for ⬍1 year were also excluded. Preoperative assessments included fundus examination and evaluation of the peripheral retina by slit-lamp biomicroscopy with an indirect contact lens. The number, type (atrophic hole or horseshoe tear), position (anterior, equatorial, or posterior to the equator), and size of the breaks were determined preoperatively. All procedures were performed under retrobulbar anesthesia on an outpatient basis by the same surgeon (VMC). Three-port PPV was performed using a wide-angle viewing system. Lighted infusion or a 25-gauge sutureless xenon chandelier light (Synergetics USA Inc., O’Fallon, MO) were used at the surgeon’s discretion. It was also the surgeon’s decision whether to use an aqueous suspension of triamcinolone (Trigon Depot; 40 mg/mL, Bristol-Myers Squibb SL, New York, NY), prepared as described previously.8,9 Peripheral vitrectomy was performed first, around the sclerotomy sites, followed by central (core) vitrectomy. In all cases perfluoro-n-octane (C8F18; Adato-octa, Adatomed, Munich, Germany) was injected over the posterior pole through a 20-gauge Chang cannula (Synergetics Inc., St. Charles, MO) to promote drainage of subretinal fluid through retinal breaks. When the perfluoro-n-octane meniscus reached the posterior border of the retinal break, the vitreous around the break was dissected while the sclera was depressed and the remaining subretinal fluid was drained. In cases of horseshoe tears, the anterior flap was removed with the vitreous probe. Drainage of subretinal fluid was more difficult in eyes with bullous RRD or detachments caused by small retinal breaks. In these cases, perfluoro-n-octane was injected step by step after progressive drainage of subretinal fluid through the break. Retinal breaks were checked to be sure they were completely covered by perfluoro-noctane to promote adherence of the retina to the retinal pigment epithelium (RPE) (as shown in Video 1 [available at http://aaojournal. org]). Before fluid–air exchange, a diode laser (IRIS Medical Inc., Mountain View, CA) was used to mark each break at 4 points so that the borders of the break could be identified accurately under air, and each sclerotomy was examined under scleral depression. Fluid–air exchange was performed by aspirating fluid through the retinal break with a silicone-tipped cannula, and then a transscleral diode laser was used to seal each break. A light probe was inserted through one of the sclerotomy wounds to improve visu-
298
alization of the borders of the retinal break. The laser probe was held at 90 degrees to the sclera. The laser was initially set to deliver 300 mW of power continuously for 1000 msec. If this power setting had no noticeable effect on retinal tissue, the power setting was increased in increments of 50 mW until application of laser energy resulted in whitening of the border of the retinal break. Then diode laser retinopexy was performed in every case by applying laser power along each border of the break to seal the break by adherence to the choroid. Adherence was indicated by a change in the border of the retinal break from white to gray. In no case was a 360-degree prophylactic retinopexy performed. After retinopexy of all identified retinal breaks, the sclerotomy wounds were closed and air was exchanged for balanced salt solution (BSS) with a 27-gauge needle inserted through the pars plana. Once the vitreous cavity had been filled with BSS, the retinal breaks were carefully examined by depressing the sclera sequentially so that the entire retinal periphery and the sclerotomy sites could be examined. When this examination revealed a break that had been missed, the break was managed as a primary break, as described. Postoperatively, all patients were examined at 3, 24, 48, and 72 hours; at 1 week and 2 weeks; and at 1, 3, 6, and 12 months after surgery. Visual acuity and anatomic reattachment were recorded at 1, 3, 6, and 12 months postoperatively. The first patient in the series (patient 1) also underwent optical coherence tomography (OCT) at each follow-up visit. Optical coherence tomography was performed with a Stratus system (OCT Model 3000, software version 3.0; Carl Zeiss-Meditec, Dublin, CA). A series of at least 2 horizontal and 2 vertical scans, each 3 to 8 mm long, was performed each time. Scans were centered on the retinal break and performed in the system’s line scan mode (not the fast macula mode). All OCT studies were performed by 2 of the authors (VM-C, MAZ). All statistical analyses were performed with a commercially available statistical software package (SPSS for Windows, version 10.0; SPSS, Chicago, IL).
Results The 60 patients (60 eyes) with pseudophakic RRD in this study included 42 men (70%) and 18 women (30%). The mean patient age was 64⫾10 years (range, 39 – 85 years). Six patients (10%) had a history of RRD in the contralateral eye, but the retina in that eye was attached when they were enrolled in this study. At the time of study enrollment, 13 patients (21.6%) had refractive myopia, 3 (5%) were aphakic, and 57 (95%) were pseudophakic in the study eye; of these 57 patients, 1 (1.7%) had an anterior chamber intraocular lens and 56 (98.2%) had a posterior chamber intraocular lens in the study eye. Fifty-two patients (92.8%) had undergone phacoemulsification in the study eye. The posterior capsule was broken in 18 eyes (32.1%) and intact in the other 38 eyes (67.8%). The mean interval between the cataract operation and the diagnosis of retinal detachment was 32.4 months (range, 1–180 months). Before PPV for RRD, the macula was attached in 13 study eyes (21.6%) and detached in 47 eyes (78.3%). On preoperative examinations, a single break was identified in 32 eyes (53.3%) and in the other 28 eyes (46.7%) 2 to 4 breaks were identified (mean for the 60 eyes, 2.7). The mean number of quadrants affected by RRD was 2.8 (range, 1– 4). The results of OCT scanning of the study eye of patient 1 at various times during postoperative follow-up are shown in Figures 1 through 4.
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment Intraoperative Findings Intraoperatively, 108 retinal breaks were identified in the 60 eyes, 82 (75.9%) superior, and 26 (24%) inferior. In 15 eyes (25%), at least 1 break was detected intraoperatively that had not been seen preoperatively. Ninety-four breaks (87%) were horseshoe tears and 14 (12.9%) were atrophic holes. Ninety-five breaks (87.9%) were anterior to the equator, 12 (11.1%) were equatorial, and 1 (0.9%) was posterior to the equator. Patient demographic data and RRD characteristics are shown in Table 1 (available at http://aaojournal. org). When the retina was examined after the vitreous cavity had been filled with BSS at the end of the surgical procedure, subretinal fluid leakage from missed breaks was detected in 8 eyes (13.3%). The break in each of these 8 eyes was anterior to the equator and less than one-quarter disc diameter in size. Six breaks were horseshoe tears and 2 were atrophic holes. Two breaks were located at the sclerotomy site. Patients were followed for a mean of 16.4 months (range, 12.1–21.5) after PPV.
Visual Acuity For all 60 study eyes, the mean preoperative best-corrected visual acuity (BCVA) was 20/700 (range, hand movements–20/20) and the mean final BCVA was 20/59 (range, 20/200 –20/20). Visual acuity was ⱖ20/40 in 34 (56.6%) of the 60 study eyes. The mean final BCVA was statistically significantly better relative to mean preoperative BCVA (P⬍0.05, Wilcoxon test). For the 13 eyes with macula-attached RRD, BCVA was the same preoperatively and postoperatively (mean, 20/27; range, 20/ 50 –20/20). For the 47 eyes with macula-detached RRD, the mean preoperative BCVA was 20/888 (range, hand movements to 20/50) and the mean postoperative BCVA was 20/68 (range, 20/200 –20/20).
Retinal Reattachment Primary retinal reattachment, defined as complete reabsorption of subretinal fluid at 1 month, was attained in 59 of the 60 study eyes (98.3%). The single reattachment failure was the result of a new break. This patient underwent pneumatic retinopexy and photocoagulation of the retinal break under scleral depression. This treatment was successful in achieving final reattachment in all 60 of the patients (100%) by the 12-month follow-up visit.
Complications One patient developed intraoperative bleeding into the anterior chamber. One patient had hypotony at the 1-day postoperative visit but intraocular pressure of 14 mm at the 4-day visit. Two patients had mild vitreous hemorrhage during the first 48 hours that resolved spontaneously during the following 10 days.
Discussion Starting with the earliest reports of PPV for the management of RRD, a tamponade agent has always been used to fill the vitreous cavity at the end of the procedure.10 –20 The rationale for this measure is that laser retinopexy is not sufficient to maintain tight approximation of the retina to the choroid, so the pressure exerted by a tamponade agent is needed to keep the retina pressed against the choroid for the first 2 weeks after retinopexy, until a chorioretinal scar has devel-
oped.5,6 With conventional PPV, the tamponade material must be air, gas, or oil, because an aqueous fluid would seep under the edge of the retinal break, leading to redetachment of the retina. With our novel PPV technique, however, we ensure chorioretinal adhesion and seal the edges of all retinal breaks intraoperatively. Because the retinal breaks are sealed intraoperatively, BSS can be instilled at the end of the procedure to restore vitreous volume and provide tamponade.
Factors for Success with This Procedure The following factors govern the success of our novel procedure to establish chorioretinal adhesion and seal retinal breaks intraoperatively. First, perfluorocarbon liquid must be used to promote drainage of subretinal fluid beneath the break. Maximal drainage of subretinal fluid is essential for 3 reasons: to develop an initial adhesive force between the RPE and the outer retinal layer; to avoid fluid seepage between the 2 layers during fluid–air exchange; and to avoid collection of subretinal fluid at breaks located on the equator or posteriorly. To achieve these goals, the bubble of perfluorocarbon liquid must be manipulated to cover the break completely. The most important physical property of perfluorocarbon liquids is their high specific gravity.4 We found that as subretinal fluid is drained through retinal break(s) and the bubble is manipulated to cover the entire lesion, the heavier-than-water specific gravity of the perfluorocarbon bubble firmly presses the borders of the break against the underlying RPE. Second, the entire border of the retinal break must be attached to the RPE. Thus, in cases of horseshoe tears, it is important to dissect the anterior flap so there is no vitreous traction on loose retinal tissue. It is not possible to remove all peripheral vitreous, and with aspiration of subretinal fluid through the break, remaining subretinal fluid is displaced posteriorly. When the borders of the break are effectively held against the RPE by perfluorocarbon liquid, the adhesive force between the RPE and outer retinal layer will prevent seepage of residual fluid between the layers. Third, retinopexy should be performed with a diode laser using a transscleral approach. The principal site of laser energy absorption is melanin in the RPE and choroid. Absorption of laser energy by melanin converts the laser energy to heat that in turn coagulates tissue. It is this tissue coagulation, followed by secondary gliosis, that results in tissue adhesion.21–25 Although coagulative necrosis can be achieved with either an endolaser or a transscleral diode laser, in our experience the amount of energy absorbed by the RPE and choroidal pigment seems to be greater with the second option. Furthermore, when a transscleral diode laser is applied the sclera is depressed, which displaces away from the break any subretinal fluid that may still be present between the RPE and the outer retinal layer. The success of our technique requires that laser energy be applied precisely along the entire border of the retinal break. That is why diode laser marking is performed before fluid–air exchange. It is important to note that achieving chorioretinal adhesion intraoperatively does not depend on the amount of laser energy applied. We always use an initial power setting of
299
300
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment 300 mW, a level that is safe because it is not sufficient to cause a retinal burn or excessive photocoagulation. Last, it is important that air–BSS exchange be performed through a 27-gauge needle after the sclerotomy wounds have been closed. This surgical maneuver is important to avoid incarceration of vitreous in the sclerotomy wounds during air–fluid exchange.
Comparison of Conventional and Novel Techniques The purpose of the study reported here was to evaluate the safety and effectiveness of our novel technique for repairing pseudophakic retinal detachment by sealing the break intraoperatively, without air, gas, or oil tamponade. In comparing our study to studies in which conventional techniques with air, gas, or oil tamponade were used, we found that our patient population was similar in age (mean age at which RRD occurred in our patients was 64⫾10 years).11,12 In our study, primary reattachment of the retina (within the first month after surgery) occurred in 98.3% of eyes and 100% had reattachment at the 12-month follow-up visit. Improvement in visual acuity from a mean preoperative BCVA of 20/700 to a mean final BCVA of 20/59 after PPV with our novel technique was also comparable to results reported in the literature for conventional techniques.10 –20 In our study, as in other studies, final BCVA was better for eyes in which RRD did not involve the macula (20/27 vs. 20/68). To the best of our knowledge, this is the first study in which OCT was used to monitor the development of a chorioretinal scar around a retinal break after PPV starting from the first postoperative day. As the OCT results from patient 1 show, the borders of the breaks were completely sealed 24 hours after completion of our novel PPV technique (Fig 1) and there was no evidence of subretinal fluid at that time or at subsequent times over the course of follow-up. Retinal edema decreased during the second week (Figs 2, 3), and by 2 months after surgery, a chorioretinal scar could be seen (Fig 4). In cases of pseudophakic retinal detachment it can be difficult to detect all retinal breaks. Ho and Tolentino26 reported that preoperative evaluation missed breaks in 20% of cases. There are no reports of case series or studies in which 100% of breaks were detected intraoperatively in all patients, although Rosen et al27 reported having identified
all retinal breaks in 95% of cases and Speicher et al13 reported being able, in a retrospective study of preoperative and intraoperative attempts, to detect all breaks in 94% of cases. In the largest reported series of patients undergoing repair of pseudophakic retinal detachment by PPV alone, extensive scleral depression was not performed preoperatively and no information was provided on the intraoperative identification of retinal breaks.11 In our series, retinal breaks that had been missed preoperatively were detected intraoperatively in 15 cases (25%). Furthermore, unique to this study is the finding that 8 breaks in 8 patients were not seen preoperatively or intraoperatively and were only diagnosed after air–BSS exchange. There have been reports in the literature that 360-degree laser photocoagulation is beneficial in promoting retinal reattachment.11,12 With the novel technique we describe, however, neither 360-degree photocoagulation nor laser sealing of sclerotomy sites was needed in any patient. The fact that the vitreous cavity is filled with aqueous fluid at the end of our procedure allows the surgeon to perform an exhaustive examination of the entire retinal periphery, at which time any missed breaks can be detected. None of the patients in this pilot study developed PVR postoperatively, although this is to be expected because we excluded patients who had preoperative risk factors such as grade B or C PVR,28,29 giant tears, or retinal detachments with ⱖ5 breaks. In the largest series of patients with pseudophakic retinal detachment we could find in the literature, the incidence of postoperative PVR was 6%.11 The results of the study we report here support results in our earlier studies and may have important implications for clinical practice. We previously reported19,20 on a new approach for managing inferior breaks in eyes with pseudophakic retinal detachment, namely air tamponade for only a few hours after surgery and no face-down positioning in the postoperative period. In the present study, we demonstrated that the key factor to obviate the need for air, gas, or oil tamponade at the end of the procedure is complete apposition of the borders of the retinal break to the RPE before performing transscleral diode laser photocoagulation. In summary, this pilot study of a novel PPV technique for managing pseudophakic RRD showed that this new technique can be effective for sealing retinal breaks intraoperatively and avoid the numerous disadvantages of gas or
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ Figure 1. Patient 1, eye with pseudophakic rhegmatogenous retinal detachment (RRD), 24 hours after vitrectomy with continuous diode laser photocoagulation. A, Color fundus photograph. The retinal break that caused RRD and remnants of triamcinolone acetonide suspension are visible. Arrows, site of optical coherence tomography scanning. B, Optical coherence tomography horizontal 6-mm scan. The borders of the retinal break (arrowhead) are evident. The coagulated area involves the deep retinal layers (arrow). There is marked edema and retinal thickening. C, Optical coherence tomography vertical 3-mm scan. The borders of the break are completely attached (arrowheads). Figure 2. Same eye as in Figure 1, 8 days after surgery. A, Color fundus photograph. Arrows, site of optical coherence tomography scanning. B, C, Optical coherence tomography horizontal 4- and 5-mm scans. The borders of the retinal break (arrowhead) and persistent retinal thickening (arrow) can be seen. Figure 3. Same eye as in Figures 1 and 2, 12 days after surgery. A, Color fundus photograph. Partial pigmentation is visible around the borders. Arrows indicate the site of optical coherence tomography scanning. B, C, Optical coherence tomography horizontal 4- and 7-mm scans show a decrease in retinal thickness (arrow) compared to Figures 1B, 1C, 2B, and 2C. Figure 4. Same eye as in Figures 1 to 3, 2 months after surgery. A, Color fundus photograph. A chorioretinal scar has developed around the borders of the break. Arrows indicate site of optical coherence tomography scanning. B, C, Optical coherence tomography scans. The chorioretinal scar borders are evident (arrowheads).
301
Ophthalmology Volume 114, Number 2, February 2007 oil tamponade. As a pilot study, this case series had some limitations, namely, that the patients treated were nonconsecutive, selected cases, and the experience of only 1 surgeon is presented. Nevertheless, we believe that the results warrant further studies to determine what role this novel technique could play in the management of pseudophakic RRD.
References 1. Machemer R, Buettner H, Norton EW, Parel JM. Vitrectomy: a pars plana approach. Trans Am Acad Ophthalmol Otolaryngol 1971;75:813–20. 2. Norton EW. Intraocular gas in the management of selected retinal detachments. Trans Am Acad Ophthalmol Otolaryngol 1973;77:OP85–98. 3. Lincoff H, Coleman J, Kressig I, et al. The perfluorocarbon gases in the treatment of retinal detachment. Ophthalmology 1983;90:546 –51. 4. Chang S. Low viscosity liquid fluorochemicals in vitreous surgery. Am J Ophthalmol 1987;103:38 – 43. 5. de Juan E Jr, McCuen B, Tiedeman J. Intraocular tamponade and surface tension. Surv Ophthalmol 1985;30:47–51. 6. Thompson JT. Kinetics of intraocular gases: disappearance of air, sulfur hexafluoride, and perfluoropropane after pars plana vitrectomy. Arch Ophthalmol 1989;107:687–91. 7. Machemer R, Aaberg TM, Freeman HM, et al. An updated classification of retinal detachment with proliferative vitreoretinopathy. Am J Ophthalmol 1991;112:159 – 65. 8. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinoloneassisted pars plana vitrectomy improves the surgical procedures and decreases the postoperative blood-ocular barrier breakdown. Graefes Arch Clin Exp Ophthalmol 2002;240: 423–9. 9. Peyman GA, Cheema R, Conway MD, Fang T. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000; 20:554 –5. 10. Escoffery RF, Olk RJ, Grand MG, Boniuk I. Vitrectomy without scleral buckling for primary rhegmatogenous retinal detachment. Am J Ophthalmol 1985;99:275– 81. 11. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5. 12. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9. 13. Speicher M, Fu AD, Martin JP, Von Fricken MA. Primary vitrectomy alone for repair of retinal detachments following cataract surgery. Retina 2000;20:459 – 64.
302
14. Stangos AN, Petropoulos IK, Brozou CG, et al. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol 2004;138:952– 8. 15. Tanner V, Minihan M, Williamson TH. Management of inferior retinal breaks during pars plana vitrectomy for retinal detachment [letter]. Br J Ophthalmol 2001;85:480 –2. 16. Wickham L, Connor M, Aylward GW. Vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas, and scleral buckle? Br J Ophthalmol 2004; 88:1376 –9. 17. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004;88:1372–5. 18. Hotta K, Sugitani A, Uchino Y. Pars plana vitrectomy without long-acting gas tamponade for primary rhegmatogenous retinal detachment. Ophthalmologica 2004;218:270 –3. 19. Martínez-Castillo V, Verdugo A, Boixadera A, et al. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol 2005;123:1078 –1081. 20. Martínez-Castillo V, Boixadera A, Verdugo A, García-Arumí J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 21. Smiddy WE, Hernández E. Histopathologic characteristics of diode laser-induced chorioretinal adhesions for experimental retinal detachment in rabbit eyes. Arch Ophthalmol 1992;110: 1630 –3. 22. Smiddy WE, Hernández E. Histopathologic results of retinal diode laser photocoagulation in rabbit eyes. Arch Ophthalmol 1992;110:693– 8. 23. Yoon YH, Marmor MF. Rapid enhancement of retinal adhesion by laser photocoagulation. Ophthalmology 1988; 95:1385– 8. 24. Folk JC, Sneed SR, Folberg R, et al. Early retinal adhesion from laser photocoagulation. Ophthalmology 1989;96:1523–5. 25. Kita M, Negi A, Kawano S, Honda Y. Photothermal, cryogenic, and diathermic effects on retinal adhesive force in vivo. Retina 1991;11:441– 4. 26. Ho PC, Tolentino FI. Pseudophakic retinal detachment: surgical success rate with various types of IOLs. Ophthalmology 1984;91:847–52. 27. Rosen PH, Wong HC, McLeod D. Indentation microsurgery: internal searching for retinal breaks. Eye 1989;3:277– 81. 28. Kon CE, Asaria RH, Occleston NL, et al. Risk factors for proliferative vitreoretinopathy: a prospective study. Br J Ophthalmol 2000;84:506 –11. 29. Girard P, Mimoun G, Karpouzas I, Montefiore G. Clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. Retina 1994;14:417–24.
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment Table 1. Patient Demographic Data and Characteristics of Rhegmatogenous Retinal Detachment Case/Age/ Gender
Qt
No. of Breaks
1/69/M 2/55/M 3/64/M 4/71/M 5/75/M 6/51/M 7/54/M 8/78/M 9/73/F 10/77/F 11/64/M 12/64/F 13/84/M 14/53/M 15/65/M 16/69/M 17/60/M 18/72/M 19/46/M 20/59/M 21/85/M 22/62/M 23/60/M 24/58/M 25/75/M 26/69/M 27/39/F 28/77/F 29/61/F 30/56/M 31/56/F 32/60/M 33/65/M 34/48/M 35/51/M 36/75/M 37/59/F 38/61/M 39/53/F 40/76/F 41/79/F 42/42/M 43/69/M 44/61/F 45/69/F 46/73/F 47/59/F 48/61/M 49/75/M
4 2 3 4 3 2 2 4 2 2 3 2 4 2 3 1 3 3 4 3 2 3 2 4 2 4 2 2 2 2 4 2 3 2 3 4 2 1 3 4 3 3 3 3 4 4 1 3 3
1 1 2 2 1 3 1 3 3 3 1 2 3 2 1 1 3 1 3 1 1 1 1 1 1 1 3 1 3 1 2 3 1 1 2 1 1 1 1 3 2 1 1 1 3 4 3 1 4
50/61/M 51/75/M 52/69/F 53/53/F 54/73/M 55/64/M
3 4 3 3 4 3
2 3 1 1 1 4
56/62/M 57/64/M 58/69/F 59/68/M 60/50/M
2 2 3 2 3
1 1 2 2 2
Type of Breaks HST HST HST, HST HST, HST HST HST, HST, HST HST HST, HST, HST AH, HST, HST HST, HST, AH HST HST, HST HST, HST, HST HST, HST HST HST HST, AH, HST HST HST, HST, HST HST HST HST HST HST HST HST HST, HST, AH HST HST, AH, AH HST HST, HST AH, AH, HST HST HST HST, HST AH AH HST HST, HST HST, HST, HST HST, HST HST HST HST HST, HST, HST AH, AH, AH HST, HST, HST HST HST, HST, HST, HST HST, HST HST, HST, HST HST HST HST HST, HST, HST, HST HST HST HST, AH HST, HST HST, HST
Size of Breaks (hours)
Position of Breaks (o’clock)
1 1.5 1/4, 1/4 1/4, 1/4 1/4 1/2, 1/2, 1 1/2 1/4, 1/4, 1/4 1/4, 1, 1/4 1/2, 1/2, 1/4 1/2 3/4, 1/4 1/2, 1/4, 1/4 1/4, 1/4 1 1/2 1, 1/4, 3/4 1/4 1/4, 1/2, 1/4 2 1/2 1/2 1 1/2 1 1 3/4, 1/4, 1/4 1 1/2, 1/4, 1/4 1 3/4, 1/2 1/4, 1/4, 1/2 1/4 2 1/4, 1.5 1/2 1/4 1.5 1, 1/4 1/4, 1/2, 1/2 1/2, 1/2 1/4 1/4 1/2 1/2, 1/4, 1/4 1/2, 1/4, 1/4 1, 1/4, 3/4 1/4 1/2, 1/2, 1/4, 1/4 1/4, 1/4 3/4, 1/2, 1/4 1/4 3/4 1 3/4, 1, 1/2, 1/2
9:30 10:00 2:00, 6:00 11.30, 12:00 1:30 11:00, 4:30, 6:30 7:00 1:00, 2:00, 9:00 1:00, 1:30, 4:30 11:00, 12:00, 2:00 2:30 12:30, 5:30 1:00, 2:30, 3:00 1:00, 1:30 7:00 11:0 11:00, 12:00, 1:30 4:30 1:00, 2:00, 2:30 9:00 2:30 6:00 8:30 12:00 12:00 10:00 2:00, 2:30, 3:00 5:00 12:00, 12:00, 12:30 11:30 12:00, 6:00 6:30, 7:30, 10:00 12:00 4:30 3:00, 4:00 1:00 4:30 1:00 10:00, 12:00 6:30, 7:00, 8:00 2:00, 2:30 11:00 12:30 11:00 11:00, 12:00, 12:30 8:00, 9:00, 9:30 11:30, 2:00, 7:00 10:30 6:30, 7:30, 9:00, 11:30 9:00, 11:00 12:00, 12:30, 1:30 1:00 1:30 12:00 9:00, 12:30, 2:00, 2:30 4:00 1:00 6:00, 7:00 12:00, 1:00 1:30, 6:30
1/4 1 1/2, 1/4 1/2, 1/4 1, 1/2
Equ
Macula
PreBCVA
Post-BCVA
Follow-up (mos)
P A A, A A, A A A, A, A E A, A, A A, A, E A, A, A A A, A E, A, A A, A A A A, A, E A A, A, A A A A A A A E A, A, A A A, A, A A A, A A, A, A A A A, A A A A A, A A, A, A A, A A A E A, A, A E, E, E A, A, A A A, A, A, A
Off On Off Off On On Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off On Off Off Off Off Off On On Off Off Off On Off Off Off On On Off Off Off Off Off Off Off On Off Off
HM 20/20 20/100 HM 20/20 20/20 20/200 20/400 CF HM CF CF HM 20/200 CF 20/200 20/400 HM HM HM 20/100 20/400 20/25 HM CF HM 20/50 CF 20/50 20/20 20/200 20/400 CF 20/32 20/100 20/400 20/400 20/25 20/40 CF CF 20/400 HM HM 20/400 HM 20/20 20/200 20/400
20/32 20/20 20/40 20/30 20/20 20/20 20/25 20/100 20/100 20/50 20/40 20/70 20/100 20/30 20/32 20/50 20/25 20/100 20/400 20/50 20/30 20/100 20/25 20/100 20/100 20/70 20/40 20/200 20/50 20/20 20/100 20/40 20/32 20/25 20/30 20/100 20/30 20/25 20/40 20/40 20/32 20/100 20/100 20/200 20/100 20/100 20/20 20/25 20/100
21.5 21.3 21.1 20.8 20.6 20.5 20.3 20 19.7 19.5 19.4 19.1 19 18.9 18.8 18.6 18.5 18.3 18.2 18.1 17.7 17.5 17.2 17.2 17.1 17 16.9 16.8 16.6 16.4 16.2 16 16 15.9 15.8 15.6 15.5 15.4 15.3 15.1 14.8 14.7 14.5 14.4 14.3 14.1 13.9 13.8 13.5
A, A A, A, A A A E A, E, A, A
Off Off On Off Off On
CF 20/400 20/40 CF HM 20/25
20/40 20/50 20/40 20/32 20/50 20/25
13.4 13.2 13.1 13 12.8 12.7
A A A, A E, A A, A
Off On Off Off Off
20/400 20/20 20/400 20/400 20/400
20/40 20/20 20/100 20/32 20/25
12.5 12.4 12.2 12.1 12.1
A ⫽ anterior; AH ⫽ atrophic hole; BCVA ⫽ best-corrected visual acuity; CF ⫽ counting fingers; E ⫽ equatorial; Equ ⫽ position of breaks in relation to the equator; F ⫽ female; HM ⫽ hand movements; HST ⫽ horeshoe tear; M ⫽ male; P ⫽ posterior; Qt ⫽ quadrants.
302.e1
Since the principles of pars plana vitrectomy (PPV) were first described by Machemer et al in 1971,1 the surgical technique has advanced considerably. The use of intraocular gases2,3 and the development of wide-angle field Originally received: August 1, 2005. Accepted: July 19, 2006. Manuscript no. 2005-709. 1 Vall d’Hebrón Hospital, Universidad Autónoma de Barcelona, Barcelona, Spain. 2 Instituto Oftalmológico de Barcelona, Barcelona, Spain. The authors have no personal or family ownership in, and did not receive financial support from, any company, product, drug, instrument, or piece of equipment discussed in the article, including stock or ownership of a business entity connected to a described product, paid consulting for any company or competing companies, or patent rights to any drug or piece of equipment mentioned. Correspondence to Vicente Martínez-Castillo, MD, Calle Londres n° 54 4° 1° B, Barcelona, Spain. E-mail: [email protected]. © 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
viewing systems, perfluorocarbon liquids,4 and improved instruments for vitrectomy have contributed to increasing the role for PPV in the management of pseudophakic retinal detachment. With the conventional PPV technique for repair of retinal detachment, after laser retinopexy the eye is filled with a nonaqueous tamponade agent (air, a medical gas, or silicone oil). The rationale for using this type of tamponade at the end of the procedure is to allow sufficient time for chorioretinal adhesion to develop, while avoiding seepage of fluid through the causative break.5,6 Nonetheless, there are several drawbacks to the use of these agents. Postoperative morbidity owing to elevated intraocular pressure and cataract progression is not unusual in phakic patients. In addition, patients may experience considerable discomfort from the face-down positioning required for healing, become ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2006.07.037
297
Ophthalmology Volume 114, Number 2, February 2007 discouraged with the delay in return of visual function, and be inconvenienced by postoperative restrictions on air travel when gas or oil tamponade is used.5,6 Furthermore, until the gas has been absorbed or the silicone oil removed, the surgeon cannot be sure that the retina is reattached. In this study, we evaluated the safety and efficacy of a novel PPV technique that was designed to achieve intraoperative chorioretinal adhesion in eyes with pseudophakic rhegmatogenous retinal detachment (RRD) and to allow the use of an aqueous tamponade postoperatively, increasing the intraoperative diagnosis of retinal breaks and providing considerable advantages for the patient.
Patients and Methods Candidates for this study were patients who were scheduled for PPV for pseudophakic RRD. Patients were fully informed of all aspects of the procedure, and all provided written informed consent to participate in the study. The study was approved by the institutional review board of the Vall d’Hebrón Hospital. Patients with giant tears, ⬎5 retinal breaks on preoperative examination, retinal detachment with grade B or greater proliferative vitreoretinopathy (PVR),7 retinal detachment due to a macular hole, bilateral RRD, or no vision in the other eye were excluded. Patients who had been followed up for ⬍1 year were also excluded. Preoperative assessments included fundus examination and evaluation of the peripheral retina by slit-lamp biomicroscopy with an indirect contact lens. The number, type (atrophic hole or horseshoe tear), position (anterior, equatorial, or posterior to the equator), and size of the breaks were determined preoperatively. All procedures were performed under retrobulbar anesthesia on an outpatient basis by the same surgeon (VMC). Three-port PPV was performed using a wide-angle viewing system. Lighted infusion or a 25-gauge sutureless xenon chandelier light (Synergetics USA Inc., O’Fallon, MO) were used at the surgeon’s discretion. It was also the surgeon’s decision whether to use an aqueous suspension of triamcinolone (Trigon Depot; 40 mg/mL, Bristol-Myers Squibb SL, New York, NY), prepared as described previously.8,9 Peripheral vitrectomy was performed first, around the sclerotomy sites, followed by central (core) vitrectomy. In all cases perfluoro-n-octane (C8F18; Adato-octa, Adatomed, Munich, Germany) was injected over the posterior pole through a 20-gauge Chang cannula (Synergetics Inc., St. Charles, MO) to promote drainage of subretinal fluid through retinal breaks. When the perfluoro-n-octane meniscus reached the posterior border of the retinal break, the vitreous around the break was dissected while the sclera was depressed and the remaining subretinal fluid was drained. In cases of horseshoe tears, the anterior flap was removed with the vitreous probe. Drainage of subretinal fluid was more difficult in eyes with bullous RRD or detachments caused by small retinal breaks. In these cases, perfluoro-n-octane was injected step by step after progressive drainage of subretinal fluid through the break. Retinal breaks were checked to be sure they were completely covered by perfluoro-noctane to promote adherence of the retina to the retinal pigment epithelium (RPE) (as shown in Video 1 [available at http://aaojournal. org]). Before fluid–air exchange, a diode laser (IRIS Medical Inc., Mountain View, CA) was used to mark each break at 4 points so that the borders of the break could be identified accurately under air, and each sclerotomy was examined under scleral depression. Fluid–air exchange was performed by aspirating fluid through the retinal break with a silicone-tipped cannula, and then a transscleral diode laser was used to seal each break. A light probe was inserted through one of the sclerotomy wounds to improve visu-
298
alization of the borders of the retinal break. The laser probe was held at 90 degrees to the sclera. The laser was initially set to deliver 300 mW of power continuously for 1000 msec. If this power setting had no noticeable effect on retinal tissue, the power setting was increased in increments of 50 mW until application of laser energy resulted in whitening of the border of the retinal break. Then diode laser retinopexy was performed in every case by applying laser power along each border of the break to seal the break by adherence to the choroid. Adherence was indicated by a change in the border of the retinal break from white to gray. In no case was a 360-degree prophylactic retinopexy performed. After retinopexy of all identified retinal breaks, the sclerotomy wounds were closed and air was exchanged for balanced salt solution (BSS) with a 27-gauge needle inserted through the pars plana. Once the vitreous cavity had been filled with BSS, the retinal breaks were carefully examined by depressing the sclera sequentially so that the entire retinal periphery and the sclerotomy sites could be examined. When this examination revealed a break that had been missed, the break was managed as a primary break, as described. Postoperatively, all patients were examined at 3, 24, 48, and 72 hours; at 1 week and 2 weeks; and at 1, 3, 6, and 12 months after surgery. Visual acuity and anatomic reattachment were recorded at 1, 3, 6, and 12 months postoperatively. The first patient in the series (patient 1) also underwent optical coherence tomography (OCT) at each follow-up visit. Optical coherence tomography was performed with a Stratus system (OCT Model 3000, software version 3.0; Carl Zeiss-Meditec, Dublin, CA). A series of at least 2 horizontal and 2 vertical scans, each 3 to 8 mm long, was performed each time. Scans were centered on the retinal break and performed in the system’s line scan mode (not the fast macula mode). All OCT studies were performed by 2 of the authors (VM-C, MAZ). All statistical analyses were performed with a commercially available statistical software package (SPSS for Windows, version 10.0; SPSS, Chicago, IL).
Results The 60 patients (60 eyes) with pseudophakic RRD in this study included 42 men (70%) and 18 women (30%). The mean patient age was 64⫾10 years (range, 39 – 85 years). Six patients (10%) had a history of RRD in the contralateral eye, but the retina in that eye was attached when they were enrolled in this study. At the time of study enrollment, 13 patients (21.6%) had refractive myopia, 3 (5%) were aphakic, and 57 (95%) were pseudophakic in the study eye; of these 57 patients, 1 (1.7%) had an anterior chamber intraocular lens and 56 (98.2%) had a posterior chamber intraocular lens in the study eye. Fifty-two patients (92.8%) had undergone phacoemulsification in the study eye. The posterior capsule was broken in 18 eyes (32.1%) and intact in the other 38 eyes (67.8%). The mean interval between the cataract operation and the diagnosis of retinal detachment was 32.4 months (range, 1–180 months). Before PPV for RRD, the macula was attached in 13 study eyes (21.6%) and detached in 47 eyes (78.3%). On preoperative examinations, a single break was identified in 32 eyes (53.3%) and in the other 28 eyes (46.7%) 2 to 4 breaks were identified (mean for the 60 eyes, 2.7). The mean number of quadrants affected by RRD was 2.8 (range, 1– 4). The results of OCT scanning of the study eye of patient 1 at various times during postoperative follow-up are shown in Figures 1 through 4.
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment Intraoperative Findings Intraoperatively, 108 retinal breaks were identified in the 60 eyes, 82 (75.9%) superior, and 26 (24%) inferior. In 15 eyes (25%), at least 1 break was detected intraoperatively that had not been seen preoperatively. Ninety-four breaks (87%) were horseshoe tears and 14 (12.9%) were atrophic holes. Ninety-five breaks (87.9%) were anterior to the equator, 12 (11.1%) were equatorial, and 1 (0.9%) was posterior to the equator. Patient demographic data and RRD characteristics are shown in Table 1 (available at http://aaojournal. org). When the retina was examined after the vitreous cavity had been filled with BSS at the end of the surgical procedure, subretinal fluid leakage from missed breaks was detected in 8 eyes (13.3%). The break in each of these 8 eyes was anterior to the equator and less than one-quarter disc diameter in size. Six breaks were horseshoe tears and 2 were atrophic holes. Two breaks were located at the sclerotomy site. Patients were followed for a mean of 16.4 months (range, 12.1–21.5) after PPV.
Visual Acuity For all 60 study eyes, the mean preoperative best-corrected visual acuity (BCVA) was 20/700 (range, hand movements–20/20) and the mean final BCVA was 20/59 (range, 20/200 –20/20). Visual acuity was ⱖ20/40 in 34 (56.6%) of the 60 study eyes. The mean final BCVA was statistically significantly better relative to mean preoperative BCVA (P⬍0.05, Wilcoxon test). For the 13 eyes with macula-attached RRD, BCVA was the same preoperatively and postoperatively (mean, 20/27; range, 20/ 50 –20/20). For the 47 eyes with macula-detached RRD, the mean preoperative BCVA was 20/888 (range, hand movements to 20/50) and the mean postoperative BCVA was 20/68 (range, 20/200 –20/20).
Retinal Reattachment Primary retinal reattachment, defined as complete reabsorption of subretinal fluid at 1 month, was attained in 59 of the 60 study eyes (98.3%). The single reattachment failure was the result of a new break. This patient underwent pneumatic retinopexy and photocoagulation of the retinal break under scleral depression. This treatment was successful in achieving final reattachment in all 60 of the patients (100%) by the 12-month follow-up visit.
Complications One patient developed intraoperative bleeding into the anterior chamber. One patient had hypotony at the 1-day postoperative visit but intraocular pressure of 14 mm at the 4-day visit. Two patients had mild vitreous hemorrhage during the first 48 hours that resolved spontaneously during the following 10 days.
Discussion Starting with the earliest reports of PPV for the management of RRD, a tamponade agent has always been used to fill the vitreous cavity at the end of the procedure.10 –20 The rationale for this measure is that laser retinopexy is not sufficient to maintain tight approximation of the retina to the choroid, so the pressure exerted by a tamponade agent is needed to keep the retina pressed against the choroid for the first 2 weeks after retinopexy, until a chorioretinal scar has devel-
oped.5,6 With conventional PPV, the tamponade material must be air, gas, or oil, because an aqueous fluid would seep under the edge of the retinal break, leading to redetachment of the retina. With our novel PPV technique, however, we ensure chorioretinal adhesion and seal the edges of all retinal breaks intraoperatively. Because the retinal breaks are sealed intraoperatively, BSS can be instilled at the end of the procedure to restore vitreous volume and provide tamponade.
Factors for Success with This Procedure The following factors govern the success of our novel procedure to establish chorioretinal adhesion and seal retinal breaks intraoperatively. First, perfluorocarbon liquid must be used to promote drainage of subretinal fluid beneath the break. Maximal drainage of subretinal fluid is essential for 3 reasons: to develop an initial adhesive force between the RPE and the outer retinal layer; to avoid fluid seepage between the 2 layers during fluid–air exchange; and to avoid collection of subretinal fluid at breaks located on the equator or posteriorly. To achieve these goals, the bubble of perfluorocarbon liquid must be manipulated to cover the break completely. The most important physical property of perfluorocarbon liquids is their high specific gravity.4 We found that as subretinal fluid is drained through retinal break(s) and the bubble is manipulated to cover the entire lesion, the heavier-than-water specific gravity of the perfluorocarbon bubble firmly presses the borders of the break against the underlying RPE. Second, the entire border of the retinal break must be attached to the RPE. Thus, in cases of horseshoe tears, it is important to dissect the anterior flap so there is no vitreous traction on loose retinal tissue. It is not possible to remove all peripheral vitreous, and with aspiration of subretinal fluid through the break, remaining subretinal fluid is displaced posteriorly. When the borders of the break are effectively held against the RPE by perfluorocarbon liquid, the adhesive force between the RPE and outer retinal layer will prevent seepage of residual fluid between the layers. Third, retinopexy should be performed with a diode laser using a transscleral approach. The principal site of laser energy absorption is melanin in the RPE and choroid. Absorption of laser energy by melanin converts the laser energy to heat that in turn coagulates tissue. It is this tissue coagulation, followed by secondary gliosis, that results in tissue adhesion.21–25 Although coagulative necrosis can be achieved with either an endolaser or a transscleral diode laser, in our experience the amount of energy absorbed by the RPE and choroidal pigment seems to be greater with the second option. Furthermore, when a transscleral diode laser is applied the sclera is depressed, which displaces away from the break any subretinal fluid that may still be present between the RPE and the outer retinal layer. The success of our technique requires that laser energy be applied precisely along the entire border of the retinal break. That is why diode laser marking is performed before fluid–air exchange. It is important to note that achieving chorioretinal adhesion intraoperatively does not depend on the amount of laser energy applied. We always use an initial power setting of
299
300
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment 300 mW, a level that is safe because it is not sufficient to cause a retinal burn or excessive photocoagulation. Last, it is important that air–BSS exchange be performed through a 27-gauge needle after the sclerotomy wounds have been closed. This surgical maneuver is important to avoid incarceration of vitreous in the sclerotomy wounds during air–fluid exchange.
Comparison of Conventional and Novel Techniques The purpose of the study reported here was to evaluate the safety and effectiveness of our novel technique for repairing pseudophakic retinal detachment by sealing the break intraoperatively, without air, gas, or oil tamponade. In comparing our study to studies in which conventional techniques with air, gas, or oil tamponade were used, we found that our patient population was similar in age (mean age at which RRD occurred in our patients was 64⫾10 years).11,12 In our study, primary reattachment of the retina (within the first month after surgery) occurred in 98.3% of eyes and 100% had reattachment at the 12-month follow-up visit. Improvement in visual acuity from a mean preoperative BCVA of 20/700 to a mean final BCVA of 20/59 after PPV with our novel technique was also comparable to results reported in the literature for conventional techniques.10 –20 In our study, as in other studies, final BCVA was better for eyes in which RRD did not involve the macula (20/27 vs. 20/68). To the best of our knowledge, this is the first study in which OCT was used to monitor the development of a chorioretinal scar around a retinal break after PPV starting from the first postoperative day. As the OCT results from patient 1 show, the borders of the breaks were completely sealed 24 hours after completion of our novel PPV technique (Fig 1) and there was no evidence of subretinal fluid at that time or at subsequent times over the course of follow-up. Retinal edema decreased during the second week (Figs 2, 3), and by 2 months after surgery, a chorioretinal scar could be seen (Fig 4). In cases of pseudophakic retinal detachment it can be difficult to detect all retinal breaks. Ho and Tolentino26 reported that preoperative evaluation missed breaks in 20% of cases. There are no reports of case series or studies in which 100% of breaks were detected intraoperatively in all patients, although Rosen et al27 reported having identified
all retinal breaks in 95% of cases and Speicher et al13 reported being able, in a retrospective study of preoperative and intraoperative attempts, to detect all breaks in 94% of cases. In the largest reported series of patients undergoing repair of pseudophakic retinal detachment by PPV alone, extensive scleral depression was not performed preoperatively and no information was provided on the intraoperative identification of retinal breaks.11 In our series, retinal breaks that had been missed preoperatively were detected intraoperatively in 15 cases (25%). Furthermore, unique to this study is the finding that 8 breaks in 8 patients were not seen preoperatively or intraoperatively and were only diagnosed after air–BSS exchange. There have been reports in the literature that 360-degree laser photocoagulation is beneficial in promoting retinal reattachment.11,12 With the novel technique we describe, however, neither 360-degree photocoagulation nor laser sealing of sclerotomy sites was needed in any patient. The fact that the vitreous cavity is filled with aqueous fluid at the end of our procedure allows the surgeon to perform an exhaustive examination of the entire retinal periphery, at which time any missed breaks can be detected. None of the patients in this pilot study developed PVR postoperatively, although this is to be expected because we excluded patients who had preoperative risk factors such as grade B or C PVR,28,29 giant tears, or retinal detachments with ⱖ5 breaks. In the largest series of patients with pseudophakic retinal detachment we could find in the literature, the incidence of postoperative PVR was 6%.11 The results of the study we report here support results in our earlier studies and may have important implications for clinical practice. We previously reported19,20 on a new approach for managing inferior breaks in eyes with pseudophakic retinal detachment, namely air tamponade for only a few hours after surgery and no face-down positioning in the postoperative period. In the present study, we demonstrated that the key factor to obviate the need for air, gas, or oil tamponade at the end of the procedure is complete apposition of the borders of the retinal break to the RPE before performing transscleral diode laser photocoagulation. In summary, this pilot study of a novel PPV technique for managing pseudophakic RRD showed that this new technique can be effective for sealing retinal breaks intraoperatively and avoid the numerous disadvantages of gas or
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ Figure 1. Patient 1, eye with pseudophakic rhegmatogenous retinal detachment (RRD), 24 hours after vitrectomy with continuous diode laser photocoagulation. A, Color fundus photograph. The retinal break that caused RRD and remnants of triamcinolone acetonide suspension are visible. Arrows, site of optical coherence tomography scanning. B, Optical coherence tomography horizontal 6-mm scan. The borders of the retinal break (arrowhead) are evident. The coagulated area involves the deep retinal layers (arrow). There is marked edema and retinal thickening. C, Optical coherence tomography vertical 3-mm scan. The borders of the break are completely attached (arrowheads). Figure 2. Same eye as in Figure 1, 8 days after surgery. A, Color fundus photograph. Arrows, site of optical coherence tomography scanning. B, C, Optical coherence tomography horizontal 4- and 5-mm scans. The borders of the retinal break (arrowhead) and persistent retinal thickening (arrow) can be seen. Figure 3. Same eye as in Figures 1 and 2, 12 days after surgery. A, Color fundus photograph. Partial pigmentation is visible around the borders. Arrows indicate the site of optical coherence tomography scanning. B, C, Optical coherence tomography horizontal 4- and 7-mm scans show a decrease in retinal thickness (arrow) compared to Figures 1B, 1C, 2B, and 2C. Figure 4. Same eye as in Figures 1 to 3, 2 months after surgery. A, Color fundus photograph. A chorioretinal scar has developed around the borders of the break. Arrows indicate site of optical coherence tomography scanning. B, C, Optical coherence tomography scans. The chorioretinal scar borders are evident (arrowheads).
301
Ophthalmology Volume 114, Number 2, February 2007 oil tamponade. As a pilot study, this case series had some limitations, namely, that the patients treated were nonconsecutive, selected cases, and the experience of only 1 surgeon is presented. Nevertheless, we believe that the results warrant further studies to determine what role this novel technique could play in the management of pseudophakic RRD.
References 1. Machemer R, Buettner H, Norton EW, Parel JM. Vitrectomy: a pars plana approach. Trans Am Acad Ophthalmol Otolaryngol 1971;75:813–20. 2. Norton EW. Intraocular gas in the management of selected retinal detachments. Trans Am Acad Ophthalmol Otolaryngol 1973;77:OP85–98. 3. Lincoff H, Coleman J, Kressig I, et al. The perfluorocarbon gases in the treatment of retinal detachment. Ophthalmology 1983;90:546 –51. 4. Chang S. Low viscosity liquid fluorochemicals in vitreous surgery. Am J Ophthalmol 1987;103:38 – 43. 5. de Juan E Jr, McCuen B, Tiedeman J. Intraocular tamponade and surface tension. Surv Ophthalmol 1985;30:47–51. 6. Thompson JT. Kinetics of intraocular gases: disappearance of air, sulfur hexafluoride, and perfluoropropane after pars plana vitrectomy. Arch Ophthalmol 1989;107:687–91. 7. Machemer R, Aaberg TM, Freeman HM, et al. An updated classification of retinal detachment with proliferative vitreoretinopathy. Am J Ophthalmol 1991;112:159 – 65. 8. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinoloneassisted pars plana vitrectomy improves the surgical procedures and decreases the postoperative blood-ocular barrier breakdown. Graefes Arch Clin Exp Ophthalmol 2002;240: 423–9. 9. Peyman GA, Cheema R, Conway MD, Fang T. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000; 20:554 –5. 10. Escoffery RF, Olk RJ, Grand MG, Boniuk I. Vitrectomy without scleral buckling for primary rhegmatogenous retinal detachment. Am J Ophthalmol 1985;99:275– 81. 11. Campo RV, Sipperley JO, Sneed SR, et al. Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 1999;106:1811–5. 12. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment. Six-month follow-up results of a single operation—report no. 1. Ophthalmology 2005;112:1421–9. 13. Speicher M, Fu AD, Martin JP, Von Fricken MA. Primary vitrectomy alone for repair of retinal detachments following cataract surgery. Retina 2000;20:459 – 64.
302
14. Stangos AN, Petropoulos IK, Brozou CG, et al. Pars-plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol 2004;138:952– 8. 15. Tanner V, Minihan M, Williamson TH. Management of inferior retinal breaks during pars plana vitrectomy for retinal detachment [letter]. Br J Ophthalmol 2001;85:480 –2. 16. Wickham L, Connor M, Aylward GW. Vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas, and scleral buckle? Br J Ophthalmol 2004; 88:1376 –9. 17. Sharma A, Grigoropoulos V, Williamson TH. Management of primary rhegmatogenous retinal detachment with inferior breaks. Br J Ophthalmol 2004;88:1372–5. 18. Hotta K, Sugitani A, Uchino Y. Pars plana vitrectomy without long-acting gas tamponade for primary rhegmatogenous retinal detachment. Ophthalmologica 2004;218:270 –3. 19. Martínez-Castillo V, Verdugo A, Boixadera A, et al. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol 2005;123:1078 –1081. 20. Martínez-Castillo V, Boixadera A, Verdugo A, García-Arumí J. Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position. Ophthalmology 2005;112:1222– 6. 21. Smiddy WE, Hernández E. Histopathologic characteristics of diode laser-induced chorioretinal adhesions for experimental retinal detachment in rabbit eyes. Arch Ophthalmol 1992;110: 1630 –3. 22. Smiddy WE, Hernández E. Histopathologic results of retinal diode laser photocoagulation in rabbit eyes. Arch Ophthalmol 1992;110:693– 8. 23. Yoon YH, Marmor MF. Rapid enhancement of retinal adhesion by laser photocoagulation. Ophthalmology 1988; 95:1385– 8. 24. Folk JC, Sneed SR, Folberg R, et al. Early retinal adhesion from laser photocoagulation. Ophthalmology 1989;96:1523–5. 25. Kita M, Negi A, Kawano S, Honda Y. Photothermal, cryogenic, and diathermic effects on retinal adhesive force in vivo. Retina 1991;11:441– 4. 26. Ho PC, Tolentino FI. Pseudophakic retinal detachment: surgical success rate with various types of IOLs. Ophthalmology 1984;91:847–52. 27. Rosen PH, Wong HC, McLeod D. Indentation microsurgery: internal searching for retinal breaks. Eye 1989;3:277– 81. 28. Kon CE, Asaria RH, Occleston NL, et al. Risk factors for proliferative vitreoretinopathy: a prospective study. Br J Ophthalmol 2000;84:506 –11. 29. Girard P, Mimoun G, Karpouzas I, Montefiore G. Clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. Retina 1994;14:417–24.
Martínez-Castillo et al 䡠 Novel Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment Table 1. Patient Demographic Data and Characteristics of Rhegmatogenous Retinal Detachment Case/Age/ Gender
Qt
No. of Breaks
1/69/M 2/55/M 3/64/M 4/71/M 5/75/M 6/51/M 7/54/M 8/78/M 9/73/F 10/77/F 11/64/M 12/64/F 13/84/M 14/53/M 15/65/M 16/69/M 17/60/M 18/72/M 19/46/M 20/59/M 21/85/M 22/62/M 23/60/M 24/58/M 25/75/M 26/69/M 27/39/F 28/77/F 29/61/F 30/56/M 31/56/F 32/60/M 33/65/M 34/48/M 35/51/M 36/75/M 37/59/F 38/61/M 39/53/F 40/76/F 41/79/F 42/42/M 43/69/M 44/61/F 45/69/F 46/73/F 47/59/F 48/61/M 49/75/M
4 2 3 4 3 2 2 4 2 2 3 2 4 2 3 1 3 3 4 3 2 3 2 4 2 4 2 2 2 2 4 2 3 2 3 4 2 1 3 4 3 3 3 3 4 4 1 3 3
1 1 2 2 1 3 1 3 3 3 1 2 3 2 1 1 3 1 3 1 1 1 1 1 1 1 3 1 3 1 2 3 1 1 2 1 1 1 1 3 2 1 1 1 3 4 3 1 4
50/61/M 51/75/M 52/69/F 53/53/F 54/73/M 55/64/M
3 4 3 3 4 3
2 3 1 1 1 4
56/62/M 57/64/M 58/69/F 59/68/M 60/50/M
2 2 3 2 3
1 1 2 2 2
Type of Breaks HST HST HST, HST HST, HST HST HST, HST, HST HST HST, HST, HST AH, HST, HST HST, HST, AH HST HST, HST HST, HST, HST HST, HST HST HST HST, AH, HST HST HST, HST, HST HST HST HST HST HST HST HST HST, HST, AH HST HST, AH, AH HST HST, HST AH, AH, HST HST HST HST, HST AH AH HST HST, HST HST, HST, HST HST, HST HST HST HST HST, HST, HST AH, AH, AH HST, HST, HST HST HST, HST, HST, HST HST, HST HST, HST, HST HST HST HST HST, HST, HST, HST HST HST HST, AH HST, HST HST, HST
Size of Breaks (hours)
Position of Breaks (o’clock)
1 1.5 1/4, 1/4 1/4, 1/4 1/4 1/2, 1/2, 1 1/2 1/4, 1/4, 1/4 1/4, 1, 1/4 1/2, 1/2, 1/4 1/2 3/4, 1/4 1/2, 1/4, 1/4 1/4, 1/4 1 1/2 1, 1/4, 3/4 1/4 1/4, 1/2, 1/4 2 1/2 1/2 1 1/2 1 1 3/4, 1/4, 1/4 1 1/2, 1/4, 1/4 1 3/4, 1/2 1/4, 1/4, 1/2 1/4 2 1/4, 1.5 1/2 1/4 1.5 1, 1/4 1/4, 1/2, 1/2 1/2, 1/2 1/4 1/4 1/2 1/2, 1/4, 1/4 1/2, 1/4, 1/4 1, 1/4, 3/4 1/4 1/2, 1/2, 1/4, 1/4 1/4, 1/4 3/4, 1/2, 1/4 1/4 3/4 1 3/4, 1, 1/2, 1/2
9:30 10:00 2:00, 6:00 11.30, 12:00 1:30 11:00, 4:30, 6:30 7:00 1:00, 2:00, 9:00 1:00, 1:30, 4:30 11:00, 12:00, 2:00 2:30 12:30, 5:30 1:00, 2:30, 3:00 1:00, 1:30 7:00 11:0 11:00, 12:00, 1:30 4:30 1:00, 2:00, 2:30 9:00 2:30 6:00 8:30 12:00 12:00 10:00 2:00, 2:30, 3:00 5:00 12:00, 12:00, 12:30 11:30 12:00, 6:00 6:30, 7:30, 10:00 12:00 4:30 3:00, 4:00 1:00 4:30 1:00 10:00, 12:00 6:30, 7:00, 8:00 2:00, 2:30 11:00 12:30 11:00 11:00, 12:00, 12:30 8:00, 9:00, 9:30 11:30, 2:00, 7:00 10:30 6:30, 7:30, 9:00, 11:30 9:00, 11:00 12:00, 12:30, 1:30 1:00 1:30 12:00 9:00, 12:30, 2:00, 2:30 4:00 1:00 6:00, 7:00 12:00, 1:00 1:30, 6:30
1/4 1 1/2, 1/4 1/2, 1/4 1, 1/2
Equ
Macula
PreBCVA
Post-BCVA
Follow-up (mos)
P A A, A A, A A A, A, A E A, A, A A, A, E A, A, A A A, A E, A, A A, A A A A, A, E A A, A, A A A A A A A E A, A, A A A, A, A A A, A A, A, A A A A, A A A A A, A A, A, A A, A A A E A, A, A E, E, E A, A, A A A, A, A, A
Off On Off Off On On Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off Off On Off Off Off Off Off On On Off Off Off On Off Off Off On On Off Off Off Off Off Off Off On Off Off
HM 20/20 20/100 HM 20/20 20/20 20/200 20/400 CF HM CF CF HM 20/200 CF 20/200 20/400 HM HM HM 20/100 20/400 20/25 HM CF HM 20/50 CF 20/50 20/20 20/200 20/400 CF 20/32 20/100 20/400 20/400 20/25 20/40 CF CF 20/400 HM HM 20/400 HM 20/20 20/200 20/400
20/32 20/20 20/40 20/30 20/20 20/20 20/25 20/100 20/100 20/50 20/40 20/70 20/100 20/30 20/32 20/50 20/25 20/100 20/400 20/50 20/30 20/100 20/25 20/100 20/100 20/70 20/40 20/200 20/50 20/20 20/100 20/40 20/32 20/25 20/30 20/100 20/30 20/25 20/40 20/40 20/32 20/100 20/100 20/200 20/100 20/100 20/20 20/25 20/100
21.5 21.3 21.1 20.8 20.6 20.5 20.3 20 19.7 19.5 19.4 19.1 19 18.9 18.8 18.6 18.5 18.3 18.2 18.1 17.7 17.5 17.2 17.2 17.1 17 16.9 16.8 16.6 16.4 16.2 16 16 15.9 15.8 15.6 15.5 15.4 15.3 15.1 14.8 14.7 14.5 14.4 14.3 14.1 13.9 13.8 13.5
A, A A, A, A A A E A, E, A, A
Off Off On Off Off On
CF 20/400 20/40 CF HM 20/25
20/40 20/50 20/40 20/32 20/50 20/25
13.4 13.2 13.1 13 12.8 12.7
A A A, A E, A A, A
Off On Off Off Off
20/400 20/20 20/400 20/400 20/400
20/40 20/20 20/100 20/32 20/25
12.5 12.4 12.2 12.1 12.1
A ⫽ anterior; AH ⫽ atrophic hole; BCVA ⫽ best-corrected visual acuity; CF ⫽ counting fingers; E ⫽ equatorial; Equ ⫽ position of breaks in relation to the equator; F ⫽ female; HM ⫽ hand movements; HST ⫽ horeshoe tear; M ⫽ male; P ⫽ posterior; Qt ⫽ quadrants.
302.e1