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Retinal Tacks
Retinal Tacks Eugene de Juan, [r., M.D., Dyson Hickingbotham, and Robert Machemer, M.D.
An improved retinal tack and applicator can be used to fix the retina to the wall of the eye mechanically. The system consists of a small (1 x 2.7 mm) stainless steel tack with a blade-like tip and a forked applicator that can grasp the tack securely from any position. Two eyes with complex detachments with fixed rolled retinas could not have been repaired without the help of retinal tacks. The advantages of the retinal tack system over other methods include ease of handling, insertion, and removal.
A major problem in the vitreoretinal surgery of giant retinal tears, especially when the retina is stiff, is to keep the unfolded retina attached to the wall of the eye. Various techniques of retinal incarceration':" or suturingt" of the retina have been proposed. These are complex procedures and are susceptible to major complications. We were intrigued by the proposal of Ando and Kondo" to use tacks in the treatment of folded and fixed giant retinal tears. Their basic idea is to nail the retina against the wall of the eye by using small plastic tacks pierced through the retina into the choroid-sclera. We believed that a special instrument needed to be developed with which one could guide the tack safely into the eye and place it without the danger of losing it. Also, we wanted to be able to remove such a tack from the eye once it was no longer needed instead of leaving it as proposed by Ando and Kondo. We have successfully used the new tack system during the repair of two complicated retinal detachments.
Accepted for publication Dec. 4, 1984. From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. This study was supported by grants EY02903 and EY05741 from the National Eye Institute and grants from Research to Prevent Blindness, Inc., and the Helena Rubinstein Foundation. Reprint requests to Eugene de Juan, [r., M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
272
Material and Methods Our system consists of a small stainless steel tack (diameter, 1 mm; length, 2.7 mm) (Fig. 1, top). The sharp blade at the end of the tack allows easy insertion through the retina and choroid into the sclera and a collar holds the retina in place. The applicator is a L-mm (19-gauge) steel tube into which the forked holder can retract, firmly securing the tack during placement or removal (Fig. 1, bottom). When the tack is secured in the applicator, it can be placed through a small sclerotomy into the eye. The retina is then engaged and moved where desired. We have found that the most effective method for inserting the tack into the sclera is a slow steady motion using a sharp tack so as not to distort the eye wall. Too much pressure has to be avoided to prevent
Fig. 1 (de Juan, Hickingbotham, and Machemer). Top, Scanning electron micrograph showing retinal tack and forked applicator. The fork can be retracted by spring action. The tack is 2.7 mm in length. Bottom, Retinal tack held by applicator ready for placement.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
99:272-274,
MARCH,
1985
Vol. 99, No.3
Retinal Tacks
pushing the tack through the retina. Once the tack is in appropriate position, the forked holder is released by sliding the finger rest which in turn disengages the tack. One must be careful to avoid sudden movements during insertion to prevent retinal tears around the tack. Bleeding h~ not been a problem during either placement or removal of the tacks.
Case Reports Case 1 A 24-year-old woman suffered severe lacerations to both globes during an automobile accident. After primary repair, visual acuity was light perception in her right eye and no light perception in her left eye. She had undergone corneal transplantation in the right eye during the early post-injury period. Examination of the right eye six months after the initial injury disclosed a clear corneal transplant with 360-degree iris incarceration in the corneal wound. The lens was absent and the vitreous cavity was opaque with blood. Ultrasound showed a fixed total retinal detachment. A vitrectomy was performed and an inferior giant retinal tear was found. The edge of the tear was incarcerated in a superior scleral wound, thus folding the retina over on itself and exposing the underside of the retina to the surgeon. The retina was cut free from the wound superiorly and extensive preretinal and subretinal proliferation was re-
273
moved. This allowed a narrow funnel of retina to open. However, the retina would not remain unfolded. Four tacks were placed at equal intervals along the inferior retinal edge. It was then possible to perform a fluid-gas exchange with internal drainage of subretinal fluid while the patient remained in the supine position. This allowed the retina to flatten nicely. Silicone oil was then injected into the eye. Two rows of endocryopexy were placed along the equator for 360 degrees. The tacks were then removed. A small amount of bleeding occurred during removal of the nasal tack. Visual acuity had improved to 4/200 one month after surgery. The retina has since remained attached and vision stabilized. Case 2 A 58-year-old man suffered blunt trauma to his only eye (the right). He underwent primary repair of the globe. Postoperatively retinal incarceration into the scleral wound was found. A vitrectomy combined with retinectomy was performed. This resulted in a small mass of detached retinal tissue centered around the optic nerve head. The patient was referred here for examination and possible treatment five months after his initial injury. Visual acuity was light perception; an examination disclosed a clear cornea and a partially missing iris. The vitreous cavity was empty and without inflammation. The retina was totally detached and curled onto itself, resulting in an appearance of a small (3 x 3 disk diameters) mass centered over the
Fig. 2 (de Juan, Hickingbotharn, and Machemer). Left, Intraoperative photograph shows remnant of folded posterior retina centered at the optic nerve head. Right, Postoperative appearance of a small island of retina with tacks in place. Visual acuity is hand motions at 5 feet.
274
March, 1985
AMERICAN JOURNAL OF OPHTHALMOLOGY
optic nerve head (Fig. 2, left). Bare choroid was visible for 360 degrees. A membrane-peeling procedure was used to unfold the contracted retina. However, the retina always refolded. Therefore, a small area of retina was flattened and secured with a retinal tack. A total of five tacks were finally placed, resulting in an unfolded retina. This was followed by fluid-gas exchange and silicone oil injection. Endocryopexy was placed in one row for 360 degrees around the edge of the remaining retina. No bleeding occurred. The tacks were left in the eye for later removal so the retina would stay sealed against the pigment epithelium. Postoperatively the patient's visual acuity quickly improved to hand motions at several feet with a tiny island of attached retina (Fig. 2, right). His vision has remained stable and retina attached in the postoperative period.
We believe that the improved version of tack and applicator, combined with the use of silicone oil, will allow treatment of extremely difficult cases of retinal detachment that otherwise would not be considered operable. The twin grip of the retractable fork of the applicator allows secure insertion of the tack into the sclera even under pressure. Because the applicator holds the tack by spring action rather than relying on continued manual pressure, the surgeon's hands do not get tired during insertion, aiming, and application. The round head of the tack allows it to be engaged by the applicator at angles of as much as 60 degrees off the axis. Thus, a misplaced tack can be regrasped and reinserted. If the tack should slide out of the wound and fall into the posterior part of the eye, the tack can easily be scooped off the vitreal surface by the forked applicator. The tacks consist of high-quality steel which does not rust if the tacks have to be left in the eye for a limited period of time.
Discussion Retinal detachments associated with loss of retinal tissue and extensive periretinal proliferation resulting in fixed and folded retina are among the most difficult detachments to treat. These patients are often referred because they have only one eye with useful vision. It is in these patients where rather extreme measures are needed and justified to salvage any vision. The conventional techniques of scleral buckling with or without vitrectomy and gas injection are often effective in treating giant tears that are not associated with fixed and folded retina. However, when the retina remains immobile despite membrane-peeling attempts, various methods of retinal fixation have been employed. These include retinal incarceration.P retinal suturing, 3,~ and tacks.' We have found uses for all of the above methods but find multiple retinal tacks combined with silicone oil injection the most versatile and effective. A special advantage of the new tack and applicator is that the tack has a sharp cutting tip and therefore slides into the sclera without deforming the globe.
References 1. Fung, W. E., Hall, D. L., and Cleasby, G. W.: Combined technique for a 355 0 traumatic giant retinal break. A case report. Arch. Ophthalmol. 93:264, 1975. 2. Heimann, K: Zur Behandlung Komplizieter Riesenrisse der Netzhaut. Klin. Monatsbl. Augenheilkd. 176:491, 1980. 3. Scott, J. D,: A new approach to a vitreous base. Mod. Probl. Ophthalmol. 12:407,1974. 4. Hirose, T., Schepens, C. L., and Lopansri, c.: Subtotal open-sky vitrectomy for severe retinal detachment occurring as a late complication of ocular trauma. Ophthalmology 88:1, 1981. 5. Federman,). L., Shakin,). L., and Lanning, R. c.: The microsurgical management of giant retinal tears with transscleral retinal sutures. Ophthalmology 89:832, 1982. 6. Michels, R. G., Rice, T. A., and Blankenship, G.: Surgical techniques for selected giant retinal tears. Retina 3:139, 1983. 7. Ando, F., and Kondo, J.: A plastic tack for the treatment of retinal detachment with giant tear, letter. Am. J. Ophthalmol. 95:260, 1983.
An improved retinal tack and applicator can be used to fix the retina to the wall of the eye mechanically. The system consists of a small (1 x 2.7 mm) stainless steel tack with a blade-like tip and a forked applicator that can grasp the tack securely from any position. Two eyes with complex detachments with fixed rolled retinas could not have been repaired without the help of retinal tacks. The advantages of the retinal tack system over other methods include ease of handling, insertion, and removal.
A major problem in the vitreoretinal surgery of giant retinal tears, especially when the retina is stiff, is to keep the unfolded retina attached to the wall of the eye. Various techniques of retinal incarceration':" or suturingt" of the retina have been proposed. These are complex procedures and are susceptible to major complications. We were intrigued by the proposal of Ando and Kondo" to use tacks in the treatment of folded and fixed giant retinal tears. Their basic idea is to nail the retina against the wall of the eye by using small plastic tacks pierced through the retina into the choroid-sclera. We believed that a special instrument needed to be developed with which one could guide the tack safely into the eye and place it without the danger of losing it. Also, we wanted to be able to remove such a tack from the eye once it was no longer needed instead of leaving it as proposed by Ando and Kondo. We have successfully used the new tack system during the repair of two complicated retinal detachments.
Accepted for publication Dec. 4, 1984. From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. This study was supported by grants EY02903 and EY05741 from the National Eye Institute and grants from Research to Prevent Blindness, Inc., and the Helena Rubinstein Foundation. Reprint requests to Eugene de Juan, [r., M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
272
Material and Methods Our system consists of a small stainless steel tack (diameter, 1 mm; length, 2.7 mm) (Fig. 1, top). The sharp blade at the end of the tack allows easy insertion through the retina and choroid into the sclera and a collar holds the retina in place. The applicator is a L-mm (19-gauge) steel tube into which the forked holder can retract, firmly securing the tack during placement or removal (Fig. 1, bottom). When the tack is secured in the applicator, it can be placed through a small sclerotomy into the eye. The retina is then engaged and moved where desired. We have found that the most effective method for inserting the tack into the sclera is a slow steady motion using a sharp tack so as not to distort the eye wall. Too much pressure has to be avoided to prevent
Fig. 1 (de Juan, Hickingbotham, and Machemer). Top, Scanning electron micrograph showing retinal tack and forked applicator. The fork can be retracted by spring action. The tack is 2.7 mm in length. Bottom, Retinal tack held by applicator ready for placement.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
99:272-274,
MARCH,
1985
Vol. 99, No.3
Retinal Tacks
pushing the tack through the retina. Once the tack is in appropriate position, the forked holder is released by sliding the finger rest which in turn disengages the tack. One must be careful to avoid sudden movements during insertion to prevent retinal tears around the tack. Bleeding h~ not been a problem during either placement or removal of the tacks.
Case Reports Case 1 A 24-year-old woman suffered severe lacerations to both globes during an automobile accident. After primary repair, visual acuity was light perception in her right eye and no light perception in her left eye. She had undergone corneal transplantation in the right eye during the early post-injury period. Examination of the right eye six months after the initial injury disclosed a clear corneal transplant with 360-degree iris incarceration in the corneal wound. The lens was absent and the vitreous cavity was opaque with blood. Ultrasound showed a fixed total retinal detachment. A vitrectomy was performed and an inferior giant retinal tear was found. The edge of the tear was incarcerated in a superior scleral wound, thus folding the retina over on itself and exposing the underside of the retina to the surgeon. The retina was cut free from the wound superiorly and extensive preretinal and subretinal proliferation was re-
273
moved. This allowed a narrow funnel of retina to open. However, the retina would not remain unfolded. Four tacks were placed at equal intervals along the inferior retinal edge. It was then possible to perform a fluid-gas exchange with internal drainage of subretinal fluid while the patient remained in the supine position. This allowed the retina to flatten nicely. Silicone oil was then injected into the eye. Two rows of endocryopexy were placed along the equator for 360 degrees. The tacks were then removed. A small amount of bleeding occurred during removal of the nasal tack. Visual acuity had improved to 4/200 one month after surgery. The retina has since remained attached and vision stabilized. Case 2 A 58-year-old man suffered blunt trauma to his only eye (the right). He underwent primary repair of the globe. Postoperatively retinal incarceration into the scleral wound was found. A vitrectomy combined with retinectomy was performed. This resulted in a small mass of detached retinal tissue centered around the optic nerve head. The patient was referred here for examination and possible treatment five months after his initial injury. Visual acuity was light perception; an examination disclosed a clear cornea and a partially missing iris. The vitreous cavity was empty and without inflammation. The retina was totally detached and curled onto itself, resulting in an appearance of a small (3 x 3 disk diameters) mass centered over the
Fig. 2 (de Juan, Hickingbotharn, and Machemer). Left, Intraoperative photograph shows remnant of folded posterior retina centered at the optic nerve head. Right, Postoperative appearance of a small island of retina with tacks in place. Visual acuity is hand motions at 5 feet.
274
March, 1985
AMERICAN JOURNAL OF OPHTHALMOLOGY
optic nerve head (Fig. 2, left). Bare choroid was visible for 360 degrees. A membrane-peeling procedure was used to unfold the contracted retina. However, the retina always refolded. Therefore, a small area of retina was flattened and secured with a retinal tack. A total of five tacks were finally placed, resulting in an unfolded retina. This was followed by fluid-gas exchange and silicone oil injection. Endocryopexy was placed in one row for 360 degrees around the edge of the remaining retina. No bleeding occurred. The tacks were left in the eye for later removal so the retina would stay sealed against the pigment epithelium. Postoperatively the patient's visual acuity quickly improved to hand motions at several feet with a tiny island of attached retina (Fig. 2, right). His vision has remained stable and retina attached in the postoperative period.
We believe that the improved version of tack and applicator, combined with the use of silicone oil, will allow treatment of extremely difficult cases of retinal detachment that otherwise would not be considered operable. The twin grip of the retractable fork of the applicator allows secure insertion of the tack into the sclera even under pressure. Because the applicator holds the tack by spring action rather than relying on continued manual pressure, the surgeon's hands do not get tired during insertion, aiming, and application. The round head of the tack allows it to be engaged by the applicator at angles of as much as 60 degrees off the axis. Thus, a misplaced tack can be regrasped and reinserted. If the tack should slide out of the wound and fall into the posterior part of the eye, the tack can easily be scooped off the vitreal surface by the forked applicator. The tacks consist of high-quality steel which does not rust if the tacks have to be left in the eye for a limited period of time.
Discussion Retinal detachments associated with loss of retinal tissue and extensive periretinal proliferation resulting in fixed and folded retina are among the most difficult detachments to treat. These patients are often referred because they have only one eye with useful vision. It is in these patients where rather extreme measures are needed and justified to salvage any vision. The conventional techniques of scleral buckling with or without vitrectomy and gas injection are often effective in treating giant tears that are not associated with fixed and folded retina. However, when the retina remains immobile despite membrane-peeling attempts, various methods of retinal fixation have been employed. These include retinal incarceration.P retinal suturing, 3,~ and tacks.' We have found uses for all of the above methods but find multiple retinal tacks combined with silicone oil injection the most versatile and effective. A special advantage of the new tack and applicator is that the tack has a sharp cutting tip and therefore slides into the sclera without deforming the globe.
References 1. Fung, W. E., Hall, D. L., and Cleasby, G. W.: Combined technique for a 355 0 traumatic giant retinal break. A case report. Arch. Ophthalmol. 93:264, 1975. 2. Heimann, K: Zur Behandlung Komplizieter Riesenrisse der Netzhaut. Klin. Monatsbl. Augenheilkd. 176:491, 1980. 3. Scott, J. D,: A new approach to a vitreous base. Mod. Probl. Ophthalmol. 12:407,1974. 4. Hirose, T., Schepens, C. L., and Lopansri, c.: Subtotal open-sky vitrectomy for severe retinal detachment occurring as a late complication of ocular trauma. Ophthalmology 88:1, 1981. 5. Federman,). L., Shakin,). L., and Lanning, R. c.: The microsurgical management of giant retinal tears with transscleral retinal sutures. Ophthalmology 89:832, 1982. 6. Michels, R. G., Rice, T. A., and Blankenship, G.: Surgical techniques for selected giant retinal tears. Retina 3:139, 1983. 7. Ando, F., and Kondo, J.: A plastic tack for the treatment of retinal detachment with giant tear, letter. Am. J. Ophthalmol. 95:260, 1983.