|Year : 2018 | Volume
| Issue : 1 | Page : 12-14
Anatomical and visual outcomes of retinectomy in eyes with advanced proliferative vitreoretinopathy
Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Web Publication||20-Aug-2018|
Prof. Amr Bessa
Ismail Serry Street, Sidi Gaber, Alexandria
Source of Support: None, Conflict of Interest: None
Background: Visual and anatomical success of inferior retinectomy in proliferative vitreoretinopathy complicating recurrent retinal detachment (RD). Aims: The aim of this study was to evaluate anatomical and visual outcomes of retinectomy in eyes with recurrent RD with advanced proliferative vitreoretinopathy. Settings and Design: Institutional, observational, cross-sectional retrospective study. Subjects and Methods: Records of 56 eyes of 56 patients with recurrent RD and proliferative vitreoretinopathy (PVR) were evaluated, three-port incision sclerotomies followed by standard vitrectomy were done. Retinal reattachment was achieved with the aid of perfluorocarbon and retinectomy. Retinectomy was performed at the time of surgery based on retinal shortening (inferior 180°). Silicon oil (SO) was used as a tamponade. Retinal attachment and visual acuity (VA) after 6 months were evaluated. Statistical Analysis Used: Chi-squared test. Results: In all 52 of 56 (93%) eyes, retinal reattachment was successful, with a mean follow-up of 25 months (range, 6–70 months). After retinal reattachment, VA improved or stabilized in 39 of 56 patients (70%). Conclusion: When combined with anterior base dissection, inferior retinectomy may be useful in the surgical treatment of complex PVR-related RD. It was found that with lensectomy, radical anterior base dissection, and inferior retinectomy, anatomic success rates are improved and visual function can be maintained.
Keywords: Complex retinal detachment, inferior retinectomy, proliferative vitreoretinopathy, recurrent retinal detachment, retinectomy
|How to cite this article:|
Bessa A. Anatomical and visual outcomes of retinectomy in eyes with advanced proliferative vitreoretinopathy. Egypt Retina J 2018;5:12-4
| Introduction|| |
Proliferative vitreoretinopathy (PVR) is a process of cellular proliferation which may follow retinal surgery with subsequent contractile membrane formation and retinal shortening that can lead to recurrent retinal detachment (RD). A complete pars plana vitrectomy is essential in the management of PVR. Meticulous vitrectomy with silicon oil (SO) tamponade can achieve good results as regards retinal attachment.
Residual traction or retinal shortening by surface or intraretinal fibrosis as seen in PVR usually leads to failure of retinal attachment. It may require additional dissection around a retinal tear or a limited peripheral relaxing retinotomy or even a circumferential or radial retinotomy with either vitreous scissors or, more conveniently, with the vitreous cutter to mobilize the retinal and achieve retinal flattening and reattachment., Machemer was the first to describe relaxing retinotomy in traumatic retinal incarceration. Relaxing retinotomies and retinectomies are used in the presence of retinal shortening as a result of retinal incarceration or fibrous, proliferation, and contraction that prevents attachment of the retina with the RPE., These relaxing retinotomies are considered essential to reattach the retina.
The aim of this study was to identify the visual and anatomical outcomes in eyes that underwent inferior retinectomy during pars plana vitrectomy for recurrent RD.
| Subjects and Methods|| |
The present study was conducted at Alexandria main university hospital between January 2009 and December 2015, Alexandria, Egypt. The present study adhered to the tenets of the Declaration of Helsinki. Institutional Review Board/Ethics Committee approval for human studies has been obtained.
Patients with PVR and retinal shortening with recurrent RD were eligible for enrollment. Fifty-six eyes of 56 patients with recurrent RD and PVR were enrolled in this observational retrospective study. A retrospective review of records over a 6-year period of patients treated with vitrectomy and inferior retinectomy was done. All patients were informed about the design of the study and the procedure involved, and all gave written informed consent. A complete patient's evaluation was performed, which included the patient's age and medical and ocular history. A detailed preoperative ophthalmic evaluation including slit-lamp examination, intraocular pressure (IOP) measurement with Goldmann applanation tonometry, and dilated fundus examination was performed. In addition, best-corrected visual acuity (BCVA) using Snellen acuity chart was examined and then converted to logMAR BCVA for statistical analysis. Color fundus photography (Topcon Retinal Camera, TRC50X, Japan) was performed for all patients.
All operations were performed by the same surgeon (AS) under general anesthesia. Dilating drops in the form of phenylephrine 2.5% and tropicamide 1% of eye drops were instilled before surgery. After anesthesia and draping, the surgical technique included 360° peritomy to insert sclera buckle after muscle suspension with silk and three-port incision sclerotomies after which standard vitrectomy was done. Peeling of posterior hyaloid was assisted by the use of intravitreal preservative-free triamcinolone acetonide. Retinal flattening was achieved with the aid of perfluorocarbon (PFC) liquid and retinectomy. Retinectomy was performed under PFC after diathermy at its site at the time of surgery based on retinal shortening (inferior 180°). Silicon PFC exchange was done. For all cases, 5000-centistokes SO was used as a tamponade.
Immediately after surgery, moxifloxacin 0.5% eye drop was prescribed five times a day for 1 week together with prednisolone acetate 1% eye drop five times a day with a one drop/week taper over 5 weeks.
Patients were examined on the postoperative days 1, 7, and 30 and then regularly every month. Postoperative hypotony was defined as IOP ranging from 0 to 5 mmHg. Patients who did not complete 6 months of follow-up were excluded from the study. SO was removed after a minimum of 6 months in patients with no signs of recurrent PVR or persistent RD.
Postoperative evaluation included patient history regarding any ocular complaint, Snellen visual acuity (VA), slit-lamp examination, IOP measurement, and fundus examinations. Evaluation was based on anatomical retinal reattachment at the end of the 6 postoperative months, as well as improvement or stabilization in BCVA as indicated by Snellen acuity test.
Statistical analysis was performed using SPSS software (Statistical Package for the Social Sciences, version 9.0, SPSS Inc., Chicago, III, USA).
| Results|| |
In 52 of 56 (93%) eyes, retinal reattachment was successful, with a mean follow-up of 25 months (range, 6–70 months). [Figure 1] and [Figure 2] causes of reaatachment failure were severe epiretinal gliosis and subretinal bands which were encounteredin four eyes. After retinal reattachment, VA was improved or stabilized in 39 of 56 patients (70%). The mean number of operations for RD before the diagnosis of PVR requiring retinectomy was 1.8 (range, 1–5) [Table 1].
|Figure 1: The retina before and after attachment in 55-year-old patient with recurrent retinal detachment|
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|Figure 2: Another 62-year-old patient with severe proliferative vitreoretinopathy with recurrent retinal detachment, attachment was achieved after the surgery|
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Of the 56 patients, nine (16%) had one or more of the following complications: SO-induced keratopathy requiring penetrating keratoplasty (4 eyes), glaucoma requiring aqueous shunt device (3 eyes), and hypotony which was managed with either parching or addressing any leaking sclerotomy (3 eyes). SO removal was performed in 26 of 45 patients (58%) before the last follow-up visit, with a one in 26 (4%) redetachment rate which was managed with vitrectomy and SO reinjection and it was feasible as it occurred early.
| Discussion|| |
PVR is the main cause of recurrence of RD following successful retinal attachment following RRD surgery. Relaxing retinectomy is an essential step during vitrectomy when retinal flattening is not possible, even after membrane removal. Previous studies reported recurrent RD after 180°–360° retinectomies from 17% to 48%. The present study showed a 3.8% rate of recurrent RD following SOR and a seven percentage rate of failed attachment at the primary surgery most probably due to the use of heavy silicon.,
Eyes with advanced PVR who undergo retinectomy are more likely to develop postoperative PVR due to retinal pigment epithelium exposure, proliferation, and migration of inflammatory cells on the retinal surface., In the current study, all patients were classified as PVR greater than C3. Few studies in the literature have reported the efficacy of retinectomy in eyes with PVR Grade C3 because most studies include PVR Grade C1–C2 only. The final reattachment rate of 92.8% was greater than reports in the other studies for severe PVR cases.,
In this study, following retinal reattachment, VA was improved or stabilized in 70% of patients. This figure is much higher than other literature as they report only a small number of patients achieved ambulatory vision after a large retinectomy. This high percentage of visual gain or stabilization in the current study may be attributed to the limited inferior retinectomy, in addition to the advance in vitreoretinal surgery techniques.
Postoperative hypotony is one of the complications following retinectomy. Only 5.3% of eyes showed this complication in the present study. This low figure in the current study may be related to the use of SO as a tamponade as it is believed that the use of SO can prevent hypotony and phthisis after vitrectomy.,
The current study has some limitations. This is a retrospective study, and the small number of patients is the main limitation of this study. Moreover, lack of a control group for comparison is another disadvantage for this study. However, to the best of the authors' knowledge, the studies that evaluate retinectomy in eyes with recurrent RD often exclude eyes with advanced PVR.,
| Conclusion|| |
When combined with anterior base dissection, inferior retinectomy may be useful in the surgical treatment of complex PVR-related RD. It was found that with lensectomy, radical anterior base dissection, and inferior retinectomy, anatomic success rates are improved, and visual function can be maintained.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]