- Email: [email protected]
Results of Conventional Vitreous Surgery for Proliferative Vitreoretinopathy
Results of Conventional Vitreous Surgery for Proliferative Vitreoretinopathy Paul Sternberg, Jr., M.D., and Robert Machemer, M.D.
During a five-year period (1978 through 1982), we used conventional vitreous surgery techniques to treat patients who had recurrent retinal detachment as the result of proliferative vitreoretinopathy. At a six-month follow-up, 24 (33%) of 72 patients achieved total retinal reattachment; 14 patients regained ambulatory vision (5/200 or betted after one operation. Only 12 patients were reoperated on; four achieved retinal reattachment. Anatomic success correlated with a lesser grade of proliferative vitreoretinopathy and an absence of detectable retinal breaks. Creation of iatrogenic retinal tears and broad scleral buckling and an extended interval between the initial detachment and vitreous surgery did not improve the prognosis.
success rate in these patients. In this study, we report the results of 72 consecutive cases of proliferative vitreoretinopathy treated with "conventional" vitreous surgical techniques between 1978 and 1983. In most cases, intervention was limited to one operation. The results of this study should provide a background for future evaluations of newer techniques.
SUbjects and Methods We examined the records of 95 patients who underwent vitreous surgery here by one surgeon (R.M.) for recurrent retinal detachment caused by proliferative vitreoretinopathy from 1978 through 1983. Each patient's age, sex, race, and ocular history were recorded. The causes of the proliferative vitreoretinopathies were classified as follows: (1) rhegmatogenous retinal detachment, (2) giant retinal tear, (3) trauma, (4) diabetes mellitus, or (5) other. The date of the initial retinal detachment, the number of operations before referral, and the interval between initial retinal detachment and vitrectomy were noted. Patients who had undergone vitrectomy before referral were identified. Data regarding the anatomic and functional status of the eye before vitreous surgery were summarized on the basis of findings that had been recorded during an initial evaluation, as well as by the review of fundus photographs and retinal drawings made preoperatively. These data included the following characteristics: (1) visual acuity of the involved and second eye; (2) lens status, including the degree of cataract, aphakia, or pseudophakia; (3) the presence and amount of agueous flare; (4) the presence and amount of vitreous hemorrhage; (5) the presence of vitreous membranes; and (6) the degree of retinal detachment. The degree of retinal detachment was assessed by (a) the number of quadrants detached, (b) the number of preexisting retinal holes, and (c) the number of quadrants with fixed retinal folds. The amount of massive periretinal proliferation or proliferative vitreoretinopathy was
PROLIFERATIVE VITREORETINOPATHY is a leading cause of failure in retinal detachment surgery. In the past, surgical intervention in these cases was generally limited to scleral buckling techniques. With the advent of vitrectomy, these procedures were supplemented by the removal of the vitreous intraocular segmentation and the removal of transvitreal and epiretinal membranes. In 1978, Machemer and Laqua' reported a 36% success rate using vitreous surgery techniques for the treatment of recurrent retinal detachment secondary to proliferative vitreoretinopathy. Since then, these techniques have been refined. Recently, however, additional techniques, including silicone oil injection.v' argon laser panphotocoagulation, 5 planned retinotomy and retinectomy, 4,5 and antimetabolite therapy.P" have been introduced in an effort to improve the anatomic and visual
From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. This study was supported by National Eye Institute Grant No. EY02903, Research to Prevent Blindness, Inc., and the Helena Rubinstein Foundation, New York. Dr. Sternberg was a Heed Ophthalmic Foundation Fellow (1983-1984). Reprint requests to Robert Machemer, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
©AMERICAN JOURNAL
OF
OPHTHALMOLOGY
100:141-146,
JULY,
1985
141
142
July, 1985
AMERICAN JOURNAL OF OPHTHALMOLOGY
then classified using both the Machemer classification" and the Retina Society classification. 10 Details of all primary and subsequent surgical procedures were recorded. These included the difficulty of membrane peeling, the number of iatrogenic breaks, the presence of large iatrogenic breaks, the degree of scleral buckling, the width of scleral buckle placed, the amount of cryotherapy placed, and whether or not a lensectomy was performed. In addition, the use of scleral resection, intravitreal sodium hyaluronate, and intravitreal air or gasbubble placement were noted. The number of postoperative fluid gas exchanges and the use of postoperative photocoagulation or cryotherapy were recorded. Follow-up data were obtained from the outpatient charts and from the referring ophthalmologist if the patient was followed up elsewhere after surgery. Data were recorded regarding (1) the length of follow-up, (2) the final best corrected visual acuity, and (3) the anatomic status of the eye, including the percentage of retina attached, the number of quadrants with persistent or recurrent membrane formation, and whether or not the macula was attached. The data were analyzed statistically using Fisher's exact test and the X2 test for trends to identify correlations among various features of the retinal detachment, surgical intervention, and final visual and anatomic outcome. For statistical analyses of data regarding the final anatomic and functional result, only cases with a minimum of six months of follow-up were evaluated. Surgical method-After a 360-degree conjunctival peritomy, the sclera was carefully exposed and bridle sutures were placed under the insertions of the recti muscles. The sclera was perforated with a myringotome 3 to 3.5 mm from the corneoscleral limbus in the superotemporal and superonasal quadrants. A cannula was placed into each opening by means of a small trocar. Vitreous was removed by means of a twoinstrument technique, with the vitreous-infusion suction cutter introduced through the superotemporal cannula and a 19-9auge fiberoptic probe introduced through the superonasal cannula. The central vitreous and the posterior surface of the vitreous where it was detached were removed. Epiretinal membranes were approached with a hooked 22-gauge needle. We attempted to engage the membrane posteriorly and dissect it toward the periphery. Often these membranes were difficult to identify. Typically they were found overlying the fixed folds. They often had a variable amount of pigment on their surface. The hooked needle was used to engage the membrane by digging into the preretinal tissue. The surgeon had to be careful to avoid damaging the retina with the sharp tip. The
amount of pulling that the retina could tolerate was variable. In general, the posterior retina was less likely to tear than the thinner, often atrophic, peripheral retina. Often the epiretinal membranes extended into the far periphery, with persistent traction at the vitreous base. Concentric traction was attacked through the use of a broad scleral buckle. However, this was not always adequate, and the surgeon had to make an attempt to open the ring of circumferential scar tissue. This was best done with microscissors such as the membrane peeler-cutter. Work in the periphery was simplified greatly by having the assistant indent the sclera. Work at the vitreous base was more difficult in phakic patients. When the surgeon believed the operation would fail if inadequate segmenting or peeling was performed at the vitreous base and that this procedure was impeded by the presence of the lens, a lensectomy was performed. Throughout the case, the surgeon identified all preexisting or created retinal breaks. This was assured by whitening the retina with transvitreal diathermy applications to mark the breaks. Attention was paid to relieving any residual traction on the retinal tear. After finishing the vitrectomy, the retinal breaks were sometimes treated with transvitreal cryotherapy. Usually the sclerotomy sites were closed with 7-0 absorbable sutures and external cryotherapy was applied. A circumferential or radial buckle was placed or revised. All suspected or actual retinal holes were closed. We often atttempted to create high and broad buckles. Silicone tires (as wide as 11 mm) were often used, and were pulled very tightly with an overlying silicone band. In cases where the retina was believed to be too short because of excessive shrinking, a scleral resection was performed for at least 180 degrees, with a scleral bed of 5 to 7 mm. The bed was treated with diathermy before the anterior and posterior ends of the resection were sutured together. Drainage of subretinal fluid was generally unnecessary. Air or sulfur hexafluoride was injected into the vitreous cavity at the end of the operation to help close the retinal holes and eliminate the need for drainage of subretinal fluid. The conjunctiva was carefully sutured to avoid exposure of the scleral buckle. In some eyes, when the retina was attached the next day because of absorption of subretinal fluid, loose-scatter photocoagulation was performed, usually just posterior to the buckle.
Results In 75 of the 95 patients in this study, the proliferative vitreoretinopathy was a result of a rhegmatoge-
Vol. 100, No. 1
Surgery for Vitreoretinopathy
nous retinal detachment. Five patients with proliferative vitreoretinopathy resulting from a giant retinal tear, 12 cases with trauma, one case with diabetic retinopathy, and two cases with inflammatory problems were excluded. A six-month follow-up was available on 72 of the 75 patients in whom the proliferative vitreoretinopathy resulted from rhegmatogenous retinal detachments. These 72 patients formed the basis for further data analysis. Of the 72 patients, 47 were men and 25 were women. The average age was 54 years. The right eye was involved in 39 patients; the left eye was involved in 33 patients. Thirty-two patients were aphakic, thirty-five were phakic, and five were pseudophakic. The patients had undergone an average of 1.5 operations before their referral. Eleven patients had undergone vitrectomy before their referral here. Fourteen patients had visual acuity worse than 5/200 in their uninvolved eye, and were classified as one-eyed patients. Using the Machemer classification" of massive periretinal proliferation, 16 patients had preretinal proliferation in one or two quadrants and were classified as 4A or 45, 43 had three to four quadrants involved and were graded 4C, and 13 had a closed funnel (4D). When the Retina Society classification'? of proliferative vitreoretinopathy was used, 16 patients had preretinal proliferation in one or two quadrants and were classified as Cl or C2, 13 had proliferation in three quadrants (C3), 18 had involvement of all four quadrants with a wide-open funnel (Dl), 12 shared a narrow funnel (D2), and 13 had a closed funnel (D3). Anatomic success was defined as complete reattachment of the retina posterior to the scleral buckle. The overall rate of successful anatomic reattachment was 33%, with 24 of the 72 patients achieving this end. The success rate was 69% (11 of 16) in those eyes with only one or two quadrants involved, but decreased as the amount of proliferative vitreoretinopathy increased when subgrouped by either classification (Table 1). The X2 test results
TABLE1 ANATOMIC SUCCESS VS DEGREE OF PROLIFERATIVE VITREORETINOPATHY ANATOMIC
ANATOMIC
MACHEMER
SUCCESS/NO. OF
RETINA SOCIETY
SUCCESS/NO.
GRADE
PATIENTS ("!o)
GRADE
OF PATIENTS ("!o)
C1/C2 C3 01 02 03
11/16(69) 2/13 (15) 6/18 (33) 3/12 (25) 2/13 (15) 24/72 (33)
4A14B 4C
11/16 (69) 11/43 (26)
40
2/13 (15) '24/72 (33)
Total
143
for trend were significant (P=.0016 with the Machemer classification" and P = .086 using the Retina Society classiflcation"), indicating that as the amount of proliferation increases, the success rate decreases. Of the 24 patients with anatomic success, 18 had final visual acuity of finger counting or better, with 11 patients achieving visual acuity of 20/200 or better. Four of the 14 one-eyed patients achieved anatomic success. Reoperations were performed on 12 patients, with four achieving ultimate anatomic success (a 33% success rate) (Figure). No patients had more than one reoperation. Various aspects of the patients' preoperative status and surgical intervention were evaluated using the Fisher's exact test to determine their effect on anatomic outcome. The presence of preoperative anterior chamber flare was not significant. We believed that increased flare might indicate a more active proliferative process and reflect a poorer prognosis, but this was not the case. The patients' lens status was not significant, with 28% success in aphakic patients (nine of 32) and 34% success among phakic patients (12 of 35). The interval between initial detachment and vitreous surgery did not affect prognosis, as shown in Table 2. The presence of preexisting open retinal breaks on preoperative examination was statistically significant (P=.003), with a 58% success rate (14 of 24) in those patients in whose retinas no holes were seen, as opposed to a 21% success rate (ten of 48) in those cases in which retinal breaks were observed before surgery. Retinal breaks were created at the time of surgery in 31 patients. These patients carried an equivalent prognosis to those patients without iatrogenic retinal breaks (35% [11 of 31] vs 32% [13 of 41]). In 40 cases, membrane peeling was described in the operative note as being "difficult." In those patients, there was a 30% anatomic success rate (12 of 40), as opposed to a 38% success rate in patients in whom the membrane peeling was less difficult (12 of 32), but this difference was not statistically significant. Although preoperative lens status did not seem to affect prognosis, 20 phakic patients required lerisectomy as part of their surgical procedure. These patients had a 15% success rate (three of 20), as opposed to a 60% success rate (nine of 15) in the 15 phakic patients who did not require lensectomy (P=.Oll). The amount of cryotherapy did not seem adversely to affect the prognosis, with a 41% success rate (14 of 34) in those patients who received 360 degrees cryotherapy, vs 28% (eight of 29) in those patients with only local cryotherapeutic applications and 22% (two of nine) in those patients who did not receive cryotherapy. The placement of a broad encircling element (defined as greater than 7 mm in diameter) did not improve prognosis, with only a 22% success rate (six of 27) in these patients. In most cases, such an element was
144
AMERICAN JOURNAL OF OPHTHALMOLOGY
July, 1985
NLP
>t::
HM-LP
II
20/300-FC
••
a.. 20/50-20/200
•
::l
~
••
.J
~
s
a..
0
UJ
0:
Figure (Sternberg and Machemer). Scattergram of preoperative and postoperative visual acuities of eyes treated for proliferative vitreoretinopathy. Open circles indicate cases with full reattachment (anatomic success) of the retina; closed circles, failures.
20/20-20/40
20/20 20/50 20/300 -20/40 -201200 -FC
HM -LP
NLP
POST OP VISUAL ACUITY
placed when inadequate membrane removal could be performed peripherally and the intraoperative prognosis seemed poor. Scleral resection was performed in 14 cases; none of these procedures resulted in successful anatomic reattachment. Silicone oil injection was used in two patients undergoing reoperation. One of these patients achieved anatomic success.
Discussion In recent years, surgery for retinal reattachment has been extremely successful, exceeding 90% in most series. Most failed cases result from contraction of membranes that grow on both the inner and outer TABLE 2 RATE OF ANATOMIC SUCCESS VS AGE OF PROLIFERATIVE VITREORETINOPATHY BETWEEN RETINAL DETACHMENT AND VITRECTOMY
OPERATION AGE (MOS)
ANATOMIC SUCCESSI NO. OF PATIENTS (%)
1
6/14 (43)
2
5/18 (28) 2/11 (18)
3 4 5
5/12 (42) 6/17 (35)
surfaces of the retina and on the posterior hyaloid surface. Vitreous surgery provided a new approach to this disease, whereby transvitreal bands and epiretinal membranes could be segmented and removed. After failure in 28 initial cases," Machemer achieved a 36% success in a series of 47 consecutive patients operated on between 1973 and 1977.9 In this study, we report the results of vitreous surgery in 72 consecutive patients during the subsequent five-year period, in which an overall 33% anatomic success rate was achieved. It is difficult to compare these results with those obtained by other surgeons because of differences in classification and case selection. The former problem has been addressed recently by the Retina Society Terminology Committee" and will perhaps lead to a better ability to compare results. Nonetheless, Grizzard and Hilton 12 achieved a 35% success rate in 46 patients, with at least one quadrant of fixed retinal folds treated with scleral buckling alone. Ratner and associates" reported a 42% successrate in 69 patients who underwent vitreous surgery for severe proliferative vitreoretinopathy. Recently [alkh and colleagues" reported a 59.3% anatomic success rate in 410 eyes treated with a closed vitrectomy, membrane peeling, scieralbuckling, and intraocular air injection during an eight-year period. It is unclear from the paper how the grade of proliferative vitreoretinopathy was determined retrospectively. In addition, these investigators failed to indicate the
Vol. 100, No. 1
Surgery for Vitreoretinopathy
number of reoperations required to achieve reattachment. It is surprising that they could achieve such significantly higher success rates than other groups using similar surgical techniques during a similar time period. Havener" reported an 84% success rate in a series of 189 patients but provided no classification of these patients to allow adequate correlation. The conditions of all of the patients in our series were believed to be untreatable by scleral buckling alone. This is emphasized by the large percentage of patients with proliferative vitreoretinopathy in at least three quadrants (5p Of 72, or 78%). We evaluated a number of aspects of the preoperative status of the eye, as well as the surgical technique employed, in an effort to determine those factors that best correlated with success. As seen in the previous series of patients, the rate of anatomic reattachment decreased with increased retinal involvement with proliferative vitreoretinopathy. This was best demonstrated using the Machemer classification," but was also apparent when the patients were categorized by the system devised by the Retina Society Terminology Committee" (Table 1). Severity of the disease as measured by the number of quadrants involved was clearly the most important aspect correlating with anatomic success. Although the success rate was 69% in the patients who had one or two quadrants with proliferative vitreoretinopathy, it dropped to 23% when three or four quadrants were involved. Similarly, Grizzard and Hilton" had a 48% success rate in the less severe (one to two quadrants) cases and a 19% success rate in the more severe (three to four quadrants) cases. Ratner and colleagues" did not provide a classification of their patients. The absence of preoperatively visible retinal breaks was a second aspect that correlated with anatomic success. One should remember that breaks were usually closed during preceding operations and that small breaks often escape preoperative recognition in the heavily folded retina. However, the presence of easily identified open retinal breaks in cases of prominent proliferative vitreoretinopathy may signify an increased severity of the disease. It is interesting that the presence of iatrogenic retinal holes did not adversely affect the prognosis. This is a tribute to compulsive identification of these breaks and the effective use of transvitreal and transscleral cryopexy along with gas bubbles. Preoperative aphakia did not seem to alter the prognosis significantly. However, the phakic patients who underwent lensectomy had significantly less. successful outcomes. Presumably, these cases had marked persistent vitreous-base traction requiring combined scleral depression and lens removal for effective treatment. Often, this traction could not be eliminated effectively. However, lensectomy was not
145
performed in those cases in which peripheral membrane peeling was unnecessary, implying a better prognosis. The role of cryotherapy in the development of proliferative vitreoretinopathy is often debated, with recent studies suggesting that the treatment may disperse viable retinal pigment epithelial cells into the vitreous cavity." Minimal cryotherapy has been advocated in routine retinal detachment surgery to reduce the incidence of proliferative vitreoretinopathy. Surprisingly, extensive cryotherapy did not adversely affect the prognosis in this study. Broad and high scleral buckles were used in cases in which peripheral vitreous-base traction could not be adequately treated. Because these patients had a poorer prognosis does not incriminate the use of broad buckles, but rather identifies a group of patients with a poorer rate of anatomic success. We carefully examined the relationship of the interval between detachment and vitreous surgery to anatomic success. By doing so, we hoped to identify an optimal time for intervention, and particularly to determine whether it is advantageous to "let the proliferation burn out." There was no benefit to operating on older patients, given the rather small number of cases in the various interval groups, but this question remains unanswered. This study has provided a summary of the results following conventional vitreous surgery for complex recurrent retinal detachments due to proliferative vitreoretinopathy. We want to emphasize that, in most cases, intervention was limited to one intraocular procedure because we felt that the stress on the patient who had undergone multiple operationsthe reduced visual prognosis after repeated failures -did not justify the surgeon's longing for a "success." Also, the number of one-eyed patients in whom there would be a greater incentive to pursue reoperation was very low. It was our goal to provide a reasonably large pool of patients for this study who were treated under similar conditions. It is difficult in a rapidly changing field to maintain identical surgical techniques for an extended period of time. To remain consistent, we have avoided, until recently, pursuing newer adjuvant methods of therapy such as silicone oil Injection;'? Patients in this study have basically been treated with careful vitrectomy and membrane peeling, buckling, and treatment of retinal holes. We can state with some confidence that one of three patients with proliferative vitreoretinopathy has a chance for a complete retinal reattachment, with visual improvement in 21 % of the cases. We know that the success rate is higher if only one or two quadrants are involved (nearly 70%), and that it decreases with
146
AMERICAN JOURNAL OF OPHTHALMOLOGY
increasing severity of the disease. This contradicts the findings of our previous study." It is important to emphasize that the retinas of patients who achieve anatomic success will permanently reattach, and the patients will not require reintervention later on. The use of silicone oil by us has increased the success rate considerably;'? but since it has other major drawbacks, we recommend that this type of surgery only be tried when conventional vitrectomy techniques have been exhausted.
References 1. Machemer, R., and Laqua, H.: A logical approach to the treatment of massive periretinal proliferation. Ophthalmology 85:584, 1978. 2. Gonvers, M.: Temporary use of intraocular silicone oil in the treatment of detachment with massive periretinal proliferation. Ophthalmologica 184:210, 1982. 3. Grey, R. H. B., and Leaver, P. K.: Silicone oil in the treatment of massive periretinal retraction. I. Results in 105 eyes. Br. J. OphthalmoI. 63:355, 1979. 4. Zivojnovic, R., Mertens, D. A. E., and Baars, M. A.: Das flussige Silikon in der Amotiochirurgie. II. Bericht uber 280 Faile, weitere Entwicklung der Technik. Klin. MonatsbI. Augenheilkd. 181:444, 1982. 5. Parke, D. W., II, and Aaberg, T. M.: Intraocular argon laser photocoagulation in the management of severe proliferative vitreoretinopathy. Am. J. OphthalmoI. 97:434, 1984. 6. Blumenkranz, M.S., Ophir, A., Claflin, A. J., and Hajek, A.: Fluorouracil for the treatment of massive periretinal proliferation. Am. J. Ophthalmol. 94:458, 1982.
July, 1985
7. Weiss, J. F., and Belkin, M.: The effect of penicillamine on posttraumatic vitreous proliferation. Am. J. OphthalmoI. 92:625, 1981. 8. Tano, Y., Chandler, D., and Machemer, R.: Treatment of intraocular proliferation with intravitreal injection of triamcinolone acetonide. Am. J. OphthalmoI. 90:810, 1980. 9. Machemer, R.: Pathogenesis and classification of massive periretinal proliferation. Br. J. OphthalmoI. 62:737, 1978. 10. Retina Society Terminology Committee: The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 90:121, 1983. 11. Machemer, R.: Subtotal vitrectomy through the pars plana. Trans. Am. Acad. OphthalmoI. OtolaryngoI. 77:198, 1973. 12. Grizzard! W. 5., and Hilton, G. F.: Scleral buckling for retinal detachments complicated by periretinal proliferation. Arch. OphthalmoI. 100:419, 1982. 13. Ratner, C. M., Michels, R. G., Auer, c., and Rice, T. R.: Pars plana vitrectomy for complicated retinal detachments. Ophthalmology 90:323, 1983. 14. Jalkh, A. E., Avila, M. P., Schepens, C. 1., Azzolini, C., Duncan, J. E., and Trempe, C. 1.: Surgical treatments of proliferative vitreoretinopathy. Arch. OphthalmoI. 102:1135, 1984. 15. Havener, W. 1.: Massive vitreous retraction. Int. OphthalmoI. Clin. 16:135, 1976. 16. Campochiaro, P. A., Kaden, I. H., Vidaurri-Leal, J., and Glaser, B.: Cryotherapy enhances intravitreal dispersion of viable retinal pigment epithelial cells. Arch. Ophthalmol., in press. 17. McCuen, B. W., Landers, M. B., and Machemer, R.: The use of silicone oil following failed vitrectomy for retinal detachment with advanced proliferative vitreoretinopathy. Ophthalmology, in press.
During a five-year period (1978 through 1982), we used conventional vitreous surgery techniques to treat patients who had recurrent retinal detachment as the result of proliferative vitreoretinopathy. At a six-month follow-up, 24 (33%) of 72 patients achieved total retinal reattachment; 14 patients regained ambulatory vision (5/200 or betted after one operation. Only 12 patients were reoperated on; four achieved retinal reattachment. Anatomic success correlated with a lesser grade of proliferative vitreoretinopathy and an absence of detectable retinal breaks. Creation of iatrogenic retinal tears and broad scleral buckling and an extended interval between the initial detachment and vitreous surgery did not improve the prognosis.
success rate in these patients. In this study, we report the results of 72 consecutive cases of proliferative vitreoretinopathy treated with "conventional" vitreous surgical techniques between 1978 and 1983. In most cases, intervention was limited to one operation. The results of this study should provide a background for future evaluations of newer techniques.
SUbjects and Methods We examined the records of 95 patients who underwent vitreous surgery here by one surgeon (R.M.) for recurrent retinal detachment caused by proliferative vitreoretinopathy from 1978 through 1983. Each patient's age, sex, race, and ocular history were recorded. The causes of the proliferative vitreoretinopathies were classified as follows: (1) rhegmatogenous retinal detachment, (2) giant retinal tear, (3) trauma, (4) diabetes mellitus, or (5) other. The date of the initial retinal detachment, the number of operations before referral, and the interval between initial retinal detachment and vitrectomy were noted. Patients who had undergone vitrectomy before referral were identified. Data regarding the anatomic and functional status of the eye before vitreous surgery were summarized on the basis of findings that had been recorded during an initial evaluation, as well as by the review of fundus photographs and retinal drawings made preoperatively. These data included the following characteristics: (1) visual acuity of the involved and second eye; (2) lens status, including the degree of cataract, aphakia, or pseudophakia; (3) the presence and amount of agueous flare; (4) the presence and amount of vitreous hemorrhage; (5) the presence of vitreous membranes; and (6) the degree of retinal detachment. The degree of retinal detachment was assessed by (a) the number of quadrants detached, (b) the number of preexisting retinal holes, and (c) the number of quadrants with fixed retinal folds. The amount of massive periretinal proliferation or proliferative vitreoretinopathy was
PROLIFERATIVE VITREORETINOPATHY is a leading cause of failure in retinal detachment surgery. In the past, surgical intervention in these cases was generally limited to scleral buckling techniques. With the advent of vitrectomy, these procedures were supplemented by the removal of the vitreous intraocular segmentation and the removal of transvitreal and epiretinal membranes. In 1978, Machemer and Laqua' reported a 36% success rate using vitreous surgery techniques for the treatment of recurrent retinal detachment secondary to proliferative vitreoretinopathy. Since then, these techniques have been refined. Recently, however, additional techniques, including silicone oil injection.v' argon laser panphotocoagulation, 5 planned retinotomy and retinectomy, 4,5 and antimetabolite therapy.P" have been introduced in an effort to improve the anatomic and visual
From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. This study was supported by National Eye Institute Grant No. EY02903, Research to Prevent Blindness, Inc., and the Helena Rubinstein Foundation, New York. Dr. Sternberg was a Heed Ophthalmic Foundation Fellow (1983-1984). Reprint requests to Robert Machemer, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
©AMERICAN JOURNAL
OF
OPHTHALMOLOGY
100:141-146,
JULY,
1985
141
142
July, 1985
AMERICAN JOURNAL OF OPHTHALMOLOGY
then classified using both the Machemer classification" and the Retina Society classification. 10 Details of all primary and subsequent surgical procedures were recorded. These included the difficulty of membrane peeling, the number of iatrogenic breaks, the presence of large iatrogenic breaks, the degree of scleral buckling, the width of scleral buckle placed, the amount of cryotherapy placed, and whether or not a lensectomy was performed. In addition, the use of scleral resection, intravitreal sodium hyaluronate, and intravitreal air or gasbubble placement were noted. The number of postoperative fluid gas exchanges and the use of postoperative photocoagulation or cryotherapy were recorded. Follow-up data were obtained from the outpatient charts and from the referring ophthalmologist if the patient was followed up elsewhere after surgery. Data were recorded regarding (1) the length of follow-up, (2) the final best corrected visual acuity, and (3) the anatomic status of the eye, including the percentage of retina attached, the number of quadrants with persistent or recurrent membrane formation, and whether or not the macula was attached. The data were analyzed statistically using Fisher's exact test and the X2 test for trends to identify correlations among various features of the retinal detachment, surgical intervention, and final visual and anatomic outcome. For statistical analyses of data regarding the final anatomic and functional result, only cases with a minimum of six months of follow-up were evaluated. Surgical method-After a 360-degree conjunctival peritomy, the sclera was carefully exposed and bridle sutures were placed under the insertions of the recti muscles. The sclera was perforated with a myringotome 3 to 3.5 mm from the corneoscleral limbus in the superotemporal and superonasal quadrants. A cannula was placed into each opening by means of a small trocar. Vitreous was removed by means of a twoinstrument technique, with the vitreous-infusion suction cutter introduced through the superotemporal cannula and a 19-9auge fiberoptic probe introduced through the superonasal cannula. The central vitreous and the posterior surface of the vitreous where it was detached were removed. Epiretinal membranes were approached with a hooked 22-gauge needle. We attempted to engage the membrane posteriorly and dissect it toward the periphery. Often these membranes were difficult to identify. Typically they were found overlying the fixed folds. They often had a variable amount of pigment on their surface. The hooked needle was used to engage the membrane by digging into the preretinal tissue. The surgeon had to be careful to avoid damaging the retina with the sharp tip. The
amount of pulling that the retina could tolerate was variable. In general, the posterior retina was less likely to tear than the thinner, often atrophic, peripheral retina. Often the epiretinal membranes extended into the far periphery, with persistent traction at the vitreous base. Concentric traction was attacked through the use of a broad scleral buckle. However, this was not always adequate, and the surgeon had to make an attempt to open the ring of circumferential scar tissue. This was best done with microscissors such as the membrane peeler-cutter. Work in the periphery was simplified greatly by having the assistant indent the sclera. Work at the vitreous base was more difficult in phakic patients. When the surgeon believed the operation would fail if inadequate segmenting or peeling was performed at the vitreous base and that this procedure was impeded by the presence of the lens, a lensectomy was performed. Throughout the case, the surgeon identified all preexisting or created retinal breaks. This was assured by whitening the retina with transvitreal diathermy applications to mark the breaks. Attention was paid to relieving any residual traction on the retinal tear. After finishing the vitrectomy, the retinal breaks were sometimes treated with transvitreal cryotherapy. Usually the sclerotomy sites were closed with 7-0 absorbable sutures and external cryotherapy was applied. A circumferential or radial buckle was placed or revised. All suspected or actual retinal holes were closed. We often atttempted to create high and broad buckles. Silicone tires (as wide as 11 mm) were often used, and were pulled very tightly with an overlying silicone band. In cases where the retina was believed to be too short because of excessive shrinking, a scleral resection was performed for at least 180 degrees, with a scleral bed of 5 to 7 mm. The bed was treated with diathermy before the anterior and posterior ends of the resection were sutured together. Drainage of subretinal fluid was generally unnecessary. Air or sulfur hexafluoride was injected into the vitreous cavity at the end of the operation to help close the retinal holes and eliminate the need for drainage of subretinal fluid. The conjunctiva was carefully sutured to avoid exposure of the scleral buckle. In some eyes, when the retina was attached the next day because of absorption of subretinal fluid, loose-scatter photocoagulation was performed, usually just posterior to the buckle.
Results In 75 of the 95 patients in this study, the proliferative vitreoretinopathy was a result of a rhegmatoge-
Vol. 100, No. 1
Surgery for Vitreoretinopathy
nous retinal detachment. Five patients with proliferative vitreoretinopathy resulting from a giant retinal tear, 12 cases with trauma, one case with diabetic retinopathy, and two cases with inflammatory problems were excluded. A six-month follow-up was available on 72 of the 75 patients in whom the proliferative vitreoretinopathy resulted from rhegmatogenous retinal detachments. These 72 patients formed the basis for further data analysis. Of the 72 patients, 47 were men and 25 were women. The average age was 54 years. The right eye was involved in 39 patients; the left eye was involved in 33 patients. Thirty-two patients were aphakic, thirty-five were phakic, and five were pseudophakic. The patients had undergone an average of 1.5 operations before their referral. Eleven patients had undergone vitrectomy before their referral here. Fourteen patients had visual acuity worse than 5/200 in their uninvolved eye, and were classified as one-eyed patients. Using the Machemer classification" of massive periretinal proliferation, 16 patients had preretinal proliferation in one or two quadrants and were classified as 4A or 45, 43 had three to four quadrants involved and were graded 4C, and 13 had a closed funnel (4D). When the Retina Society classification'? of proliferative vitreoretinopathy was used, 16 patients had preretinal proliferation in one or two quadrants and were classified as Cl or C2, 13 had proliferation in three quadrants (C3), 18 had involvement of all four quadrants with a wide-open funnel (Dl), 12 shared a narrow funnel (D2), and 13 had a closed funnel (D3). Anatomic success was defined as complete reattachment of the retina posterior to the scleral buckle. The overall rate of successful anatomic reattachment was 33%, with 24 of the 72 patients achieving this end. The success rate was 69% (11 of 16) in those eyes with only one or two quadrants involved, but decreased as the amount of proliferative vitreoretinopathy increased when subgrouped by either classification (Table 1). The X2 test results
TABLE1 ANATOMIC SUCCESS VS DEGREE OF PROLIFERATIVE VITREORETINOPATHY ANATOMIC
ANATOMIC
MACHEMER
SUCCESS/NO. OF
RETINA SOCIETY
SUCCESS/NO.
GRADE
PATIENTS ("!o)
GRADE
OF PATIENTS ("!o)
C1/C2 C3 01 02 03
11/16(69) 2/13 (15) 6/18 (33) 3/12 (25) 2/13 (15) 24/72 (33)
4A14B 4C
11/16 (69) 11/43 (26)
40
2/13 (15) '24/72 (33)
Total
143
for trend were significant (P=.0016 with the Machemer classification" and P = .086 using the Retina Society classiflcation"), indicating that as the amount of proliferation increases, the success rate decreases. Of the 24 patients with anatomic success, 18 had final visual acuity of finger counting or better, with 11 patients achieving visual acuity of 20/200 or better. Four of the 14 one-eyed patients achieved anatomic success. Reoperations were performed on 12 patients, with four achieving ultimate anatomic success (a 33% success rate) (Figure). No patients had more than one reoperation. Various aspects of the patients' preoperative status and surgical intervention were evaluated using the Fisher's exact test to determine their effect on anatomic outcome. The presence of preoperative anterior chamber flare was not significant. We believed that increased flare might indicate a more active proliferative process and reflect a poorer prognosis, but this was not the case. The patients' lens status was not significant, with 28% success in aphakic patients (nine of 32) and 34% success among phakic patients (12 of 35). The interval between initial detachment and vitreous surgery did not affect prognosis, as shown in Table 2. The presence of preexisting open retinal breaks on preoperative examination was statistically significant (P=.003), with a 58% success rate (14 of 24) in those patients in whose retinas no holes were seen, as opposed to a 21% success rate (ten of 48) in those cases in which retinal breaks were observed before surgery. Retinal breaks were created at the time of surgery in 31 patients. These patients carried an equivalent prognosis to those patients without iatrogenic retinal breaks (35% [11 of 31] vs 32% [13 of 41]). In 40 cases, membrane peeling was described in the operative note as being "difficult." In those patients, there was a 30% anatomic success rate (12 of 40), as opposed to a 38% success rate in patients in whom the membrane peeling was less difficult (12 of 32), but this difference was not statistically significant. Although preoperative lens status did not seem to affect prognosis, 20 phakic patients required lerisectomy as part of their surgical procedure. These patients had a 15% success rate (three of 20), as opposed to a 60% success rate (nine of 15) in the 15 phakic patients who did not require lensectomy (P=.Oll). The amount of cryotherapy did not seem adversely to affect the prognosis, with a 41% success rate (14 of 34) in those patients who received 360 degrees cryotherapy, vs 28% (eight of 29) in those patients with only local cryotherapeutic applications and 22% (two of nine) in those patients who did not receive cryotherapy. The placement of a broad encircling element (defined as greater than 7 mm in diameter) did not improve prognosis, with only a 22% success rate (six of 27) in these patients. In most cases, such an element was
144
AMERICAN JOURNAL OF OPHTHALMOLOGY
July, 1985
NLP
>t::
HM-LP
II
20/300-FC
••
a.. 20/50-20/200
•
::l
~
••
.J
~
s
a..
0
UJ
0:
Figure (Sternberg and Machemer). Scattergram of preoperative and postoperative visual acuities of eyes treated for proliferative vitreoretinopathy. Open circles indicate cases with full reattachment (anatomic success) of the retina; closed circles, failures.
20/20-20/40
20/20 20/50 20/300 -20/40 -201200 -FC
HM -LP
NLP
POST OP VISUAL ACUITY
placed when inadequate membrane removal could be performed peripherally and the intraoperative prognosis seemed poor. Scleral resection was performed in 14 cases; none of these procedures resulted in successful anatomic reattachment. Silicone oil injection was used in two patients undergoing reoperation. One of these patients achieved anatomic success.
Discussion In recent years, surgery for retinal reattachment has been extremely successful, exceeding 90% in most series. Most failed cases result from contraction of membranes that grow on both the inner and outer TABLE 2 RATE OF ANATOMIC SUCCESS VS AGE OF PROLIFERATIVE VITREORETINOPATHY BETWEEN RETINAL DETACHMENT AND VITRECTOMY
OPERATION AGE (MOS)
ANATOMIC SUCCESSI NO. OF PATIENTS (%)
1
6/14 (43)
2
5/18 (28) 2/11 (18)
3 4 5
5/12 (42) 6/17 (35)
surfaces of the retina and on the posterior hyaloid surface. Vitreous surgery provided a new approach to this disease, whereby transvitreal bands and epiretinal membranes could be segmented and removed. After failure in 28 initial cases," Machemer achieved a 36% success in a series of 47 consecutive patients operated on between 1973 and 1977.9 In this study, we report the results of vitreous surgery in 72 consecutive patients during the subsequent five-year period, in which an overall 33% anatomic success rate was achieved. It is difficult to compare these results with those obtained by other surgeons because of differences in classification and case selection. The former problem has been addressed recently by the Retina Society Terminology Committee" and will perhaps lead to a better ability to compare results. Nonetheless, Grizzard and Hilton 12 achieved a 35% success rate in 46 patients, with at least one quadrant of fixed retinal folds treated with scleral buckling alone. Ratner and associates" reported a 42% successrate in 69 patients who underwent vitreous surgery for severe proliferative vitreoretinopathy. Recently [alkh and colleagues" reported a 59.3% anatomic success rate in 410 eyes treated with a closed vitrectomy, membrane peeling, scieralbuckling, and intraocular air injection during an eight-year period. It is unclear from the paper how the grade of proliferative vitreoretinopathy was determined retrospectively. In addition, these investigators failed to indicate the
Vol. 100, No. 1
Surgery for Vitreoretinopathy
number of reoperations required to achieve reattachment. It is surprising that they could achieve such significantly higher success rates than other groups using similar surgical techniques during a similar time period. Havener" reported an 84% success rate in a series of 189 patients but provided no classification of these patients to allow adequate correlation. The conditions of all of the patients in our series were believed to be untreatable by scleral buckling alone. This is emphasized by the large percentage of patients with proliferative vitreoretinopathy in at least three quadrants (5p Of 72, or 78%). We evaluated a number of aspects of the preoperative status of the eye, as well as the surgical technique employed, in an effort to determine those factors that best correlated with success. As seen in the previous series of patients, the rate of anatomic reattachment decreased with increased retinal involvement with proliferative vitreoretinopathy. This was best demonstrated using the Machemer classification," but was also apparent when the patients were categorized by the system devised by the Retina Society Terminology Committee" (Table 1). Severity of the disease as measured by the number of quadrants involved was clearly the most important aspect correlating with anatomic success. Although the success rate was 69% in the patients who had one or two quadrants with proliferative vitreoretinopathy, it dropped to 23% when three or four quadrants were involved. Similarly, Grizzard and Hilton" had a 48% success rate in the less severe (one to two quadrants) cases and a 19% success rate in the more severe (three to four quadrants) cases. Ratner and colleagues" did not provide a classification of their patients. The absence of preoperatively visible retinal breaks was a second aspect that correlated with anatomic success. One should remember that breaks were usually closed during preceding operations and that small breaks often escape preoperative recognition in the heavily folded retina. However, the presence of easily identified open retinal breaks in cases of prominent proliferative vitreoretinopathy may signify an increased severity of the disease. It is interesting that the presence of iatrogenic retinal holes did not adversely affect the prognosis. This is a tribute to compulsive identification of these breaks and the effective use of transvitreal and transscleral cryopexy along with gas bubbles. Preoperative aphakia did not seem to alter the prognosis significantly. However, the phakic patients who underwent lensectomy had significantly less. successful outcomes. Presumably, these cases had marked persistent vitreous-base traction requiring combined scleral depression and lens removal for effective treatment. Often, this traction could not be eliminated effectively. However, lensectomy was not
145
performed in those cases in which peripheral membrane peeling was unnecessary, implying a better prognosis. The role of cryotherapy in the development of proliferative vitreoretinopathy is often debated, with recent studies suggesting that the treatment may disperse viable retinal pigment epithelial cells into the vitreous cavity." Minimal cryotherapy has been advocated in routine retinal detachment surgery to reduce the incidence of proliferative vitreoretinopathy. Surprisingly, extensive cryotherapy did not adversely affect the prognosis in this study. Broad and high scleral buckles were used in cases in which peripheral vitreous-base traction could not be adequately treated. Because these patients had a poorer prognosis does not incriminate the use of broad buckles, but rather identifies a group of patients with a poorer rate of anatomic success. We carefully examined the relationship of the interval between detachment and vitreous surgery to anatomic success. By doing so, we hoped to identify an optimal time for intervention, and particularly to determine whether it is advantageous to "let the proliferation burn out." There was no benefit to operating on older patients, given the rather small number of cases in the various interval groups, but this question remains unanswered. This study has provided a summary of the results following conventional vitreous surgery for complex recurrent retinal detachments due to proliferative vitreoretinopathy. We want to emphasize that, in most cases, intervention was limited to one intraocular procedure because we felt that the stress on the patient who had undergone multiple operationsthe reduced visual prognosis after repeated failures -did not justify the surgeon's longing for a "success." Also, the number of one-eyed patients in whom there would be a greater incentive to pursue reoperation was very low. It was our goal to provide a reasonably large pool of patients for this study who were treated under similar conditions. It is difficult in a rapidly changing field to maintain identical surgical techniques for an extended period of time. To remain consistent, we have avoided, until recently, pursuing newer adjuvant methods of therapy such as silicone oil Injection;'? Patients in this study have basically been treated with careful vitrectomy and membrane peeling, buckling, and treatment of retinal holes. We can state with some confidence that one of three patients with proliferative vitreoretinopathy has a chance for a complete retinal reattachment, with visual improvement in 21 % of the cases. We know that the success rate is higher if only one or two quadrants are involved (nearly 70%), and that it decreases with
146
AMERICAN JOURNAL OF OPHTHALMOLOGY
increasing severity of the disease. This contradicts the findings of our previous study." It is important to emphasize that the retinas of patients who achieve anatomic success will permanently reattach, and the patients will not require reintervention later on. The use of silicone oil by us has increased the success rate considerably;'? but since it has other major drawbacks, we recommend that this type of surgery only be tried when conventional vitrectomy techniques have been exhausted.
References 1. Machemer, R., and Laqua, H.: A logical approach to the treatment of massive periretinal proliferation. Ophthalmology 85:584, 1978. 2. Gonvers, M.: Temporary use of intraocular silicone oil in the treatment of detachment with massive periretinal proliferation. Ophthalmologica 184:210, 1982. 3. Grey, R. H. B., and Leaver, P. K.: Silicone oil in the treatment of massive periretinal retraction. I. Results in 105 eyes. Br. J. OphthalmoI. 63:355, 1979. 4. Zivojnovic, R., Mertens, D. A. E., and Baars, M. A.: Das flussige Silikon in der Amotiochirurgie. II. Bericht uber 280 Faile, weitere Entwicklung der Technik. Klin. MonatsbI. Augenheilkd. 181:444, 1982. 5. Parke, D. W., II, and Aaberg, T. M.: Intraocular argon laser photocoagulation in the management of severe proliferative vitreoretinopathy. Am. J. OphthalmoI. 97:434, 1984. 6. Blumenkranz, M.S., Ophir, A., Claflin, A. J., and Hajek, A.: Fluorouracil for the treatment of massive periretinal proliferation. Am. J. Ophthalmol. 94:458, 1982.
July, 1985
7. Weiss, J. F., and Belkin, M.: The effect of penicillamine on posttraumatic vitreous proliferation. Am. J. OphthalmoI. 92:625, 1981. 8. Tano, Y., Chandler, D., and Machemer, R.: Treatment of intraocular proliferation with intravitreal injection of triamcinolone acetonide. Am. J. OphthalmoI. 90:810, 1980. 9. Machemer, R.: Pathogenesis and classification of massive periretinal proliferation. Br. J. OphthalmoI. 62:737, 1978. 10. Retina Society Terminology Committee: The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 90:121, 1983. 11. Machemer, R.: Subtotal vitrectomy through the pars plana. Trans. Am. Acad. OphthalmoI. OtolaryngoI. 77:198, 1973. 12. Grizzard! W. 5., and Hilton, G. F.: Scleral buckling for retinal detachments complicated by periretinal proliferation. Arch. OphthalmoI. 100:419, 1982. 13. Ratner, C. M., Michels, R. G., Auer, c., and Rice, T. R.: Pars plana vitrectomy for complicated retinal detachments. Ophthalmology 90:323, 1983. 14. Jalkh, A. E., Avila, M. P., Schepens, C. 1., Azzolini, C., Duncan, J. E., and Trempe, C. 1.: Surgical treatments of proliferative vitreoretinopathy. Arch. OphthalmoI. 102:1135, 1984. 15. Havener, W. 1.: Massive vitreous retraction. Int. OphthalmoI. Clin. 16:135, 1976. 16. Campochiaro, P. A., Kaden, I. H., Vidaurri-Leal, J., and Glaser, B.: Cryotherapy enhances intravitreal dispersion of viable retinal pigment epithelial cells. Arch. Ophthalmol., in press. 17. McCuen, B. W., Landers, M. B., and Machemer, R.: The use of silicone oil following failed vitrectomy for retinal detachment with advanced proliferative vitreoretinopathy. Ophthalmology, in press.