Management of complex retinal detachment with combined relaxing retinotomy and intravitreal perfluoro-n-octane injection

Macular changes after primary retinectomy for retinal detachment complicated by proliferative vitreoretinopathy

CLINICAL RELEVANCE

Primary retinectomy in eyes not previously vitrectomized has been previously rarely performed in a minority of cases, unlike non-primary retinectomies in vitrectomized eyes.

BACKGROUND

This paper aims to determine anatomical and functional outcomes of primary retinectomy, and to assess structural macular changes among successful cases.

METHODS

In this retrospective multicentre cohort-study, 35 primary retinectomies in eyes undergoing initial vitrectomy for rhegmatogenous retinal detachment complicated by proliferative vitreoretinopathy C or D between 2014 and 2021 were included. The mean follow-up duration was 48 ± 59.24 months among successes and 46.54 ± 20.99 months among unsuccesses (p = 0.483).

RESULTS

The anatomical success rate was 48.5% after one retinectomy and 60% after two retinectomies. Mean postoperative best corrected visual acuity (BCVA) was 1.85 ± 0.62 logMAR (6/425 Snellen equivalent). The difference from mean preoperative BCVA was not significant (p = 0.312). Final BCVA ≥ 6/60 was achieved in 17% of cases, and no cases gained ≥6/24. Final mean postoperative BCVA of successes was 1.69 ± 0.60 logMAR (6/294 Snellen equivalent) compared with 2.10 ± 0.57 logMAR (6/756 Snellen equivalent) of unsuccessful cases (p = 0.101). Post-operative macular optical coherence tomography was obtained from 95% of successes. Normal macular profile was found in 10% of cases, and the other cases demonstrated exudative maculopathy (60%), tractional maculopathy (20%) and macular atrophy (10%). Final BCVA was significantly higher in eyes with normal macular status compared to eyes with exudative maculopathy (p = 0.045) and macular atrophy (p = 0.025).

CONCLUSION

Primary retinectomy may be used for rhegmatogenous retinal detachment complicated with advanced proliferative vitreoretinopathy. Anatomical and functional outcome were inferior than non-primary retinectomies for grade C proliferative vitreoretinopathy. Functional outcome was influenced by macular status. Positive prognostic factors include final anatomical success and normal final macular anatomy.

Retinotomy and retinectomy in the management of rhegmatogenous retinal detachment associated with advanced proliferative vitreoretinopathy

Purpose:

To report the anatomical and functional outcomes of retinotomy and/or retinectomy for the management of rhegmatogenous retinal detachment (RRD) complicated by advanced proliferative vitreoretinopathy (PVR).

Methods:

In this retrospective study, the charts of patients who underwent pars plana vitrectomy with retinotomy and/or retinectomy for the management of RRD complicated by PVR were reviewed. Primary outcome measures were final best-corrected visual acuity (BCVA) and anatomical reattachment rate.

Results:

Sixty-one eyes of 61 patients with a mean age of 48.56 ± 15.92 were studied. The mean follow-up time was 21.38 ± 23.08 months. The mean angle of the retinotomy was 171.31° ± 79.15°. Thirty-two (52.5%) of them needed extensive (≥180°) retinotomy. In addition, simultaneous retinectomy was performed in 36.2% of the cases. The BCVA was 2.18 ± 0.63 and 1.85 ± 0.71 logMAR before the surgery and at the last visit, respectively (P = 0.001). The initial anatomical success was achieved in 45 eyes (73.8%) after retinotomy surgery. Sixteen eyes (26.2%) had recurrent RD and needed reoperation, which was performed 5.60 ± 4.01 months after the initial retinotomy surgery. At the last examination, the retina was attached in all patients.

Conclusion:

Retinotomy with/without retinectomy is an effective procedure in the majority of patients with RRD associated with advanced PVR; however, additional surgeries are needed in a significant number of eyes to achieve final anatomical success.

STRUCTURAL AND FUNCTIONAL MACULAR CHANGES AFTER RETINECTOMY FOR RETINAL DETACHMENT COMPLICATED BY PROLIFERATIVE VITREORETINOPATHY

PURPOSE

To report anatomical and functional outcomes of nonprimary retinectomy for rhegmatogenous retinal detachment with Grade C proliferative vitreoretinopathy, to assess the structural and functional macular changes in successful eyes.

METHODS

Retrospective single-center cohort study: one hundred-one consecutive retinectomies of 101 eyes affected by rhegmatogenous retinal detachment with C proliferative vitreoretinopathy between January 2014 and February 2020 were included.

RESULTS

The mean preoperative best-corrected visual acuity (BCVA) was 1.48 ± 0.71 logarithm of the minimal angle of resolution (20/604 Snellen equivalent). The anatomical success rate was 78.2% after one retinectomy and 83.1% after two retinectomies. The final BCVA ≥ 20/200 was achieved in 29% of cases, 8% gained ≥ 20/80. The final mean postoperative BCVA of successes with oil in situ was 1.68 ± 0.59 (20/957 Snellen equivalent) compared with 1.07 ± 0.63 logarithm of the minimal angle of resolution (20/235 Snellen equivalent) of successes after oil removal (P = 0.00005). Postoperative macular optical coherence tomography was obtained from 60/84 successes (71%). The normal macular profile was found in 3%, whereas majority demonstrated exudative maculopathy (51.5%), macular atrophy (22%), tractional maculopathy (21.5%), and macular disciform scar (2%). Bivariate linear relationship between final central foveal thickness and BCVA was statistically significant (P = 0.000013).

CONCLUSION

Satisfactory anatomical and functional outcome is possible after retinectomy for C proliferative vitreoretinopathy. Positive prognostic factors include the removal of oil without redetachment, normal macular status, and lower central foveal thickness. The functional outcome was influenced by macular changes, as final BCVA and central foveal thickness correlated.

Fully Automated Direct Perfluorocarbon Liquid-Silicone Oil Exchange

Purpose

To demonstrate a modified technique of fully automated direct perfluorocarbon liquid (PFCL)-silicone oil (SO) exchange.

Materials and Methods

This technique is indicated for cases that require direct PFCL-SO exchange as in giant retinal tear or large retinectomies to avoid retinal slippage. Pars plana vitrectomy (PPV) is carried out in standard fashion; then the dual active injection/extrusion mode is activated in the vitrectomy machine. The machine parameters are set at approximately 30–40 psi for SO injection and 150–250 mmHg for active PFCL aspiration. In this method, both the SO injection and the PFCL extrusion are simultaneously controlled by the foot pedal.

Results

We used this technique for a total of 24 cases: 6 cases of giant retinal tears and 18 retinectomies. We did not encounter any complications related to significant IOP spike during surgery or complete removal of the PFCL.

Conclusion

This automated technique for direct PFCL-SO exchange maintains a controlled balance between SO injection and PFCL aspiration, that mitigates the risk of intraoperative IOP spikes. It is safe, quick, and can be performed without the need of an assistant or extra chandelier light or high-pressure viscous tubing.

Concept and application of relaxing radial retinectomy for retinal detachment with advanced proliferative vitreo-retinopathy

Purpose

To revisit the concept of retinectomy and the theory of mechanical forces on the retina occurring in rhegmatogenous retinal detachment (RRD) and to describe the potential application of radial retinectomy in RRD with advanced proliferative vitreoretinopathy (PVR).

Methods

A literature search was performed to identify all English language articles reporting the use of retinectomy for the management of RRD with PVR. We reviewed the theoretical background of mechanical forces occurring in RRD.

Results

Detachment of the retina from the retinal pigment epithelium (RPE)/choroid is influenced by disequilibrium of several physical forces: tangential forces on the epiretinal membrane \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( {T_{1} } \right)$$\end{document}T1 and radial traction on the retina \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_{R}$$\end{document}FR exceeding the retinal adhesion force to the RPE \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( {T_{1} \;\text{ + }F_{R} \;\text{ > }\;F_{A} } \right)\,\,$$\end{document}T1+FR>FA. PVR may exaggerate the amounts of tangential and radial forces (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( {T_{1} } \right)$$\end{document}T1 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_{R}$$\end{document}FR) that pull the retina off. Relaxing radial retinectomy, by the nature of its cutting pattern, may theoretically decrease the amounts of both forces, therefore restoring the equilibrium between tensile and adhesive forces on the retinal surface \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( {T_{1} \;\text{ + }F_{R} \;\text{ = }\;F_{A} } \right)\,\,$$\end{document}T1+FR=FA.

Conclusion

Relaxing radial retinectomy may potentially be applied in RRD with advanced PVR but has rarely been reported to date. Future studies are needed to evaluate its outcomes and long-term complications.

PPV, Retinectomy, and Silicone Oil Without Scleral Buckle for Recurrent RRD From Proliferative Vitreoretinopathy

BACKGROUND AND OBJECTIVE

To analyze the anatomic success rate of pars plana vitrectomy (PPV), retinectomy, and silicone oil (SO) tamponade without scleral buckle (SB) for repair of recurrent rhegmatogenous retinal detachment (RRD) associated with proliferative vitreoretinopathy (PVR).

PATIENTS AND METHODS

Retrospective, consecutive, single-surgeon case series of 28 eyes of 28 patients with PVR-associated RRD repaired with PPV, retinectomy, and SO tamponade without SB.

RESULTS

The single-procedure anatomic success rate was 85.2% at 3 months and 82.1% at 12 months. Final reattachment rate was 100.0%. There were no preoperative factors that predicted single procedure anatomic success. Mean logarithm of the minimal angle of resolution visual acuity (VA) was improved at 3 months (1.61 to 1.51, P = .732) and at 12 months (1.61 to 1.41; P = .271). VA outcome was related to preoperative macula and lens status.

CONCLUSION

The single-procedure anatomic success rate of PPV, retinectomy, and SO tamponade without SB for PVR-related recurrent RRD is comparable to prior reports of similar surgery incorporating SB. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e278-e287.].

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Bimanual 25-gauge chandelier technique for direct perfluorocarbon liquid-silicone oil exchange in retinal detachments associated with giant retinal tear

Direct perfluorocarbon liquid (PFCL)-silicone oil exchange presents its own set of challenges in the micro incision vitreous surgery era. We propose a simple bimanual technique to circumvent this problem. Thirteen eyes of patients with retinal detachment associated with giant retinal tears underwent vitrectomy followed by self-retaining endo illuminator (Chandelier) assisted direct PFCL-silicone exchange. No intra or postoperative complications related to the surgical technique were noted. All patients had attached retinas and satisfactory visual recovery at 6 months. Direct bimanual PFCL silicone oil exchange using a Chandelier seems to be a safe and effective technique.

RISK OF SILICONE OIL AS VITREOUS TAMPONADE IN PARS PLANA VITRECTOMY: A Systematic Review and Meta-Analysis

PURPOSE

The authors examined the differences between silicone oil and other vitreous tamponades or placebo in performing pars plana vitrectomy.

METHODS

This review and meta-analysis was conducted in accordance with the PRISMA guidelines. Seven databases and the reference lists of the retrieved randomized controlled trial articles were searched to identify eligible studies. The primary outcomes were the rate of redetachment after endotamponade removal, the rate of reoperation, and poor visual acuity. The secondary outcomes were adverse events and quality of life related to postoperative position.

RESULTS

Ten articles (12 trials) were included. There were no significant differences between silicone oil and other agents in most of the primary and second outcomes. Only the risk of hypotony was found to be significantly lower when filling with silicone oil, compared with other agents. No trial reported the quality of life related to postoperative position.

CONCLUSION

Based on the available studies, the authors conclude that there is no significant difference in the risk of poor outcomes between pars plana vitrectomy with silicone oil and that with other vitreous tamponades with different surgical histories.

Anatomical and functional outcomes of retinectomies in retinal detachments complicated by proliferative vitreoretinopathy

PURPOSE

To study anatomical and functional outcomes of retinectomies in rhegmatogenous retinal detachments complicated by proliferative vitreoretinopathy.

METHODS

This is a retrospective interventional consecutive case series of eyes with rhegmatogenous retinal detachments complicated by advanced proliferative vitreoretinopathy and managed by relaxing retinectomy over a period of seventeen years. Three-port pars plana vitrectomy included core vitrectomy and removal of all epi-retinal membranes. On failure to flatten, retina was cut and excised. Basal vitrectomy and removal of anterior flap of retina then followed. Silicone oil was used as temponade in majority of cases. The dependent variables were anatomical and functional outcomes. The statistical analysis was performed on SPSS 21.

RESULTS

Series included 370 eyes of 337 patients. Mean follow up was 39 months. Scleral explant was used in 90(24.39%) cases. Two hundred and nine (56.49%) eyes were operated with trans conjunctival sutureless vitrectomy technique. Procedure was bilateral in 33 patients (09.79%). Retina attached in 311(84.05%) eyes after initial surgery. Final re-attachment after one or more surgeries was achieved in 344(92.97%) eyes. Two hundred and eleven (57.02%) cases achieved visual acuity of 6/60 or better.

CONCLUSION

Relaxing retinectomies have good and encouraging anatomical and functional outcomes. This surgery can be effectively carried out with trans conjunctival sutureless vitrectomy technique.

The outcomes of scleral buckling versus re-vitrectomy for the treatment of recurrent inferior retinal detachment in silicone oil tamponade eyes

PURPOSE

In this retrospective study we evaluated the anatomic outcomes of scleral buckling (SB) versus re-vitrectomy for the treatment of recurrent inferior retinal detachment (RD) in silicone oil (SiO) tamponade eyes after primary vitrectomy.

METHODS

There were 103 patients (103 eyes) enrolled in this study. All patients had recurrent inferior RD in the SiO-filled eyes within 6 months after the primary vitrectomy, and were treated by either SB or re-vitrectomy. Patients were divided into two groups based on different surgical procedures: the SB group (49 eyes) and the re-vitrectomy group (54 eyes). Anatomic reattachment of the retina was measured after reoperation. Based on different retinal proliferation states in different postoperative periods after primary vitrectomy, we also compared the anatomic outcomes of the two surgical procedures in two specific postoperative periods, early period (≤1 month) and late period (1-6 months).

RESULTS

The SB and re-vitrectomy groups exhibited similar retinal reattachment rate (65.3% versus 72.2%, p = 0.449) after reoperation. In the re-vitrectomy group, the retinal reattachment rate was similar in the early period and the late period (70.8% versus 73.3%, p = 0.839). However, the retinal reattachment rate was significantly higher in the early period than that of the late period (80.8% versus 47.8%, p = 0.016) in the SB group. In the early surgery groups, the retinal reattachment rate was similar in the SB group compared to the re-vitrectomy group (80.8% versus 70.8%, p = 0.411). While in the late surgery groups, retinal reattachment rate was trended higher in the re-vitrectomy group compared to the SB group (73.3% versus 47.8%, p = 0.058).

CONCLUSION

For recurrent inferior RD in SO-filled eyes, SB surgery provides similar therapeutic effectiveness with satisfactory anatomic outcomes compared to the re-vitrectomy. For eyes with recurrent inferior RD in the early period (≤1 month) after primary vitrectomy, SB surgery may be a better choice since it causes less complication; while in the late period (1-6 months) after primary vitrectomy, re-vitrectomy may be recommended, especially for the eyes with severe anterior proliferative vitreoretinopathy and retinal foreshortening.

Retinal Detachment in Down Syndrome: Characteristics and Surgical Outcomes

Purpose. To determine the functional and anatomic outcomes of rhegmatogenous retinal detachment (RRD) surgery in patients with Down syndrome. Methods. A retrospective chart review was performed of patients with Down syndrome who had undergone surgery for RRD at King Khalid Eye Specialist Hospital between 1995 and 2014. Results. A total of 245 patients with Down syndrome were evaluated during the study period. Eighteen eyes of 15 patients (6.1%) with RRD were identified. Three out of 15 patients (20%) presented with bilateral retinal detachment. All eyes presented with macula off retinal detachment. The retina was successfully reattached in 16/18 (88.8%) eyes after a mean follow-up of 48 months. The final postoperative visual acuity ranged from light perception to 20/125 (median: hand motion) (11/18 eyes). Conclusions. The anatomic success rate of retinal reattachment surgery in patients with Down syndrome is comparable to the general population. Patients with Down syndrome should undergo regular ophthalmic examinations for early diagnosis. Despite late diagnosis and the presence of proliferative vitreoretinopathy (PVR) in some patients, favorable anatomical outcomes can be achieved.

Soft shell technique during vitrectomy for proliferative vitreoretinopathy

PURPOSE

To determine whether ophthalmic viscoelastic devices (OVDs) can be used during vitrectomy to prevent perflorocarbon liquid (PFCL) from leaking into the subretinal space through retinal tears in eyes with proliferative vitreoretinopathy (PVR). The OVDs are adhesive materials that can temporally close retinal breaks. We introduce a "soft shell technique", which allows the unfolding of the retina by PFCL.

METHODS

We studied five eyes of five patients with proliferative vitreoretinopathy that underwent vitrectomy using the soft shell technique. After removing the core vitreous, the OVDs were carefully injected over the area where confluent retinal folds were formed with possible retinal breaks. This created a soft shell shield on the retina that can prevent the intravitreal PFCL from leaking into the subretinal space.

RESULTS

The soft shell technique still allowed the PFCL to unfold the retina even if iatrogenic breaks are present. The high viscosity of OVDs sealed the iatrogenic retinal breaks and thus prevented the PFCL from leaking into the subretinal space during the vitrectomy. All patients had an improvement of the visual acuity, and four eyes had a reattachment of the retina.

CONCLUSIONS

Although only five eyes were examined, the success of the soft shell technique indicates that it can be used with PFCL, which facilitates the unfolding of the contracted retina.

Rhegmatogenous retinal detachment--an ophthalmologic emergency

BACKGROUND

Rhegmatogenous retinal detachment is the most common retinological emergency threatening vision, with an incidence of 1 in 10 000 persons per year, corresponding to about 8000 new cases in Germany annually. Without treatment, blindness in the affected eye may result.

METHOD

Selective review of the literature.

RESULTS

Rhegmatogenous retinal detachment typically presents with the perception of light flashes, floaters, or a "dark curtain." In most cases, the retinal tear is a consequence of degeneration of the vitreous body. Epidemiologic studies have identified myopia and prior cataract surgery as the main risk factors. Persons in the sixth and seventh decades of life are most commonly affected. Rhegmatogenous retinal detachment is an emergency, and all patients should be seen by an ophthalmologist on the same day that symptoms arise. The treatment consists of scleral buckle, removal of the vitreous body (vitrectomy), or a combination of the two. Anatomical success rates are in the range of 85% to 90%. Vitrectomy is followed by lens opacification in more than 70% of cases. The earlier the patient is seen by an ophthalmologist, the greater the chance that the macula is still attached, so that visual acuity can be preserved.

CONCLUSION

Rhegmatogenous retinal detachment is among the main emergency indications in ophthalmology. In all such cases, an ophthalmologist must be consulted at once.

Comparison of anatomic and functional results after retinotomy for retinal detachment in pediatric and adult patients

PURPOSE

We investigated characteristics and treatment outcomes of pediatric vs adult retinal detachment managed by retinotomy and retinectomy.


METHODS

This was a retrospective, nonrandomized, interventional study involving 20 pediatric patients and 25 adult patients operated with vitrectomy and retinectomy due to retinal detachment. Outcome measures included preoperative and postoperative visual acuity at 6 months and at final visit, postoperative proliferative vitreoretinopathy, silicone oil removal, final intraocular pressure (IOP), and final anatomic success, defined as complete retinal reattachment.


RESULTS

Reattachment was observed in 60% (12/20) of pediatric patients and 88% (22/25) of adults at final visit (p=0.041). Statistically significant improvement in visual acuity was observed in adults (p<0.001) but not in children (p=0.360) due to large proportion of anatomic failure. Children required a higher number of further reoperations (p=0.008). Postoperative proliferative vitreoretinopathy was significantly more frequent in pediatric eyes (p=0.003). 


CONCLUSIONS

The clinical features and prognosis for pediatric retinotomies and retinectomies are different from those for adults. When a decision to perform retinotomy in children is made, we can anticipate significantly lower anatomic success than in adults. Even though the overall visual acuity was worse in children than in adults, 25% of pediatric eyes achieved 5/50 or better vision.

Retinotomy with retinal turnover to remove subretinal membranes under direct visualization for proliferative vitreoretinopathy

Purpose

The purpose of the study was to report the outcomes for cases of proliferative vitreoretinopathy (PVR) that received retinotomy and removal of subretinal proliferative tissue under direct visualization using retinal turnover.

Methods

Nineteen eyes with posterior and/or anterior grade C1–12 PVR that had undergone retinotomy and retinal turnover were reviewed. Main outcomes included the retinal reattachment rate, final best-corrected visual acuity (BCVA), postoperative intraocular pressure, extent of retinotomy, and complications.

Results

Final retinal reattachment rates with silicone oil tamponade were 100%. The mean logarithm of the minimal angle of resolution (logMAR) BCVA was significantly improved (P = 0.001). Positive correlation was found between the extent of retinotomy and both preoperative logMAR BCVA (r = 0.663, P = 0.002) and postoperative logMAR BCVA (r = 0.619, P = 0.005). There was no correlation between the extent of retinotomy and the change in preoperative and postoperative logMAR BCVA (r = −0.267, P = 0.268). Negative correlation was found between preoperative logMAR BCVA and the change in logMAR BCVA (r = −0.587, P = 0.008). There was no correlation between the extent of retinotomy and the intraocular pressure at the final visit (r = −0.316, P = 0.188). Corneal decompensation due to silicone oil in the anterior chamber occurred in one eye.

Conclusion

Removal of subretinal proliferative tissue with retinal turnover seems to be an effective procedure.

Internal limiting membrane peeling as prophylaxis of macular pucker formation in eyes undergoing retinectomy for severe proliferative vitreoretinopathy

BACKGROUND

The purpose of this was to analyze the effect of internal limiting membrane (ILM) peeling on the anatomical and functional outcomes in patients undergoing retinectomy for proliferative vitreoretinopathy-related retinal detachment, especially regarding the postoperative development of macular pucker.

METHODS

In all, a consecutive and prospective series of 84 eyes of 84 patients were included in the study. All eyes underwent retinectomy with silicone oil tamponade for retinal detachment because of proliferative vitreoretinopathy. In Group A (33 eyes), the ILM was also peeled; in Group B (51 eyes), the ILM was left intact. Each patient gave consent to be included in the study, and no patient was lost to follow-up. Postoperatively, careful slit-lamp examination with a contact lens was used to determine whether primary ILM peeling was effective in preventing macular pucker formation. Various statistical methods were used to analyze the significance of the results with a P value of ≤ 0.05 interpreted as significant.

RESULTS

In Group A, the mean age of the patients was 57.2 ± 12.8 years and in Group B 54.6 ± 14.5 years. Median follow-up in Group A was 28.2 ± 7.2 months and in Group B 27.4 ± 6.5 months. The mean time interval between the last retinectomy and silicone oil removal was 9.2 ± 6.1 months in Group A and 8.8 ± 3.0 months in Group B. The mean follow-up after silicone oil removal was 17.4 ± 10.3 months in Group A and 15.1 ± 9.3 months in Group B. The mean logarithm of the minimum angle of resolution visual acuity at the final follow-up visit was 1.89 ± 0.87 in Group A and 1.85 ± 0.83 in Group B (P = 0.6, t-test). Extramacular epiretinal cellular proliferation occurred in 3 eyes (9%) in Group A in the first month after retinectomy and in 3 eyes (5.8%) in Group B (P = 0.27, Fisher exact test). These epiretinal membranes, extending to the edge of the retinotomy, were stable during the follow-up period. No case of macular pucker was observed in Group A, but macular pucker was observed in 9 eyes (17.6%) in Group B at the final examination (P = 0.008, Fisher exact test).

CONCLUSION

Primary peeling of the ILM allowed complete removal of all the epiretinal membranes and successfully prevented the development of macular pucker. Retinectomy and silicone oil tamponade proved an effective treatment modality for eyes with retinal detachment due to proliferative vitreoretinopathy.

[Perfluorocarbon liquids and vitreoretinal surgery in 2011]

Perfluorocarbon liquids (PFCLs) are one of the most innovative recent tools for vitreoretinal surgery. PFCLs are characterized by their number of carbon atoms, which has an impact on the density, viscosity, surface tension, vapor pressure, the boiling point, and the refraction index. PFCLs are routinely used because of their high gravity (double that of water) and their low viscosity. Furthermore, they are immiscible in water, optically clear with refraction indices similar to that of water, allowing visualization of an interface between the PFCL and saline. The use of intravitreally injected liquid PFCLs as adjunctive agents to vitreoretinal surgery plays an important role in facilitating retinal reattachment, especially in cases of giant retinal tear, trauma, and/or proliferative vitreoretinopathy. PFCLs are also used as intraoperative instruments to re-establish intraocular volume, assist in separating membranes adherent to the retina (in proliferative diabetic retinopathy, for example), and manage the dislocated crystalline lens and intraocular lens.

360° retinectomy for the treatment of complex retinal detachment

PURPOSE

To review the anatomical and functional outcomes of eyes that underwent 360° retinectomy for a variety of indications and compare them with previously published results.

METHODS

Retrospective case series. We reviewed the data of 40 patients (41 eyes) who underwent pars plana vitrectomy and 360° retinectomy. The principal indication for surgery in this series was retinal detachment after penetrating trauma (26 of 41 eyes [63%]). Anatomical success was defined as complete retinal reattachment or attachment posterior to the scleral buckle, if present.

RESULTS

Thirty of the 41 eyes (73%) had follow-up of at least 6 months after 360° retinectomy, and of these, 11 eyes (37%) had recurrent retinal detachment. Seven of the latter eyes underwent repeat pars plana vitrectomy with anatomical success in 6 eyes (86%). Overall, anatomical success was achieved in 25 of 30 eyes (83%) with follow-up of ≥ 6 months after ≥ 1 operations (including 360° retinectomy). Visual results were limited with only 4 of 35 eyes (11%) in which visual acuity could be tested achieving ambulatory vision, which may reflect the preponderance of posttraumatic retinal detachments in this series.

CONCLUSION

The anatomical results of this series are comparable with those in the reported literature and indicate that vitrectomy with 360° retinectomy can be beneficial in the management of complex retinal detachments in otherwise unsalvageable eyes.

Anatomy and function of the macula after surgery for retinal detachment complicated by proliferative vitreoretinopathy

PURPOSE

To investigate the macular changes following silicone oil removal after surgery for complicated retinal detachment (RD) with proliferative vitreoretinopathy (PVR).

DESIGN

Retrospective interventional case series.

METHODS

setting: Vienna, Austria. study population: Thirty-nine patients with attached retina after silicone oil removal following previous vitrectomy and silicone oil tamponade for complicated RD and PVR grade C3 and worse. observation procedures: Examination of macular anatomy with biomicroscopy, optical coherence tomography (OCT), and fluorescein angiography (FA). Macular function was tested by assessing logMAR distance visual acuity (VA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and reading acuity and reading speed using a standardized test (Radner charts). main outcome measures: Macular anatomy, VA, reading acuity, and reading speed.

RESULTS

The macula was clinically normal in five patients (12.8%). Retinal pigment epithelium (RPE) irregularities were found in nine patients (23.1%). Eight patients (20.5%) had macular pucker, seven (18.0%) had cystoid macular edema (CME), and 10 (25.6%) had subretinal fibrosis. The mean VA of all patients was logMAR 0.67 +/- 0.68 (range, -0.1 to 3.0). Six eyes did not achieve reading acuity. The distance VA of the remaining 33 eyes was logMAR 0.44 +/- 0.29 and their mean reading acuity was logRAD 0.62 +/- 0.35, with a reading speed ranging from 55 to 240 words per minute.

CONCLUSIONS

We found macular changes in 87% of the patients, one-third thereof being eligible for further treatment (macular pucker or CME). Thus, the majority of these patients do not seem to be eligible for a further improvement of anatomic or functional outcome.

Closed funnel-shaped proliferative vitreoretinopathy in patients with cognitive disabilities

BACKGROUND AND OBJECTIVE

To report severe proliferative vitreoretinopathy (PVR) cases in patients with cognitive disabilities treated with vitrectomy.

PATIENTS AND METHODS

This retrospective study included 10 eyes of 9 consecutively enrolled patients with cognitive disabilities. The severity of PVR was grade C type 2345 with widespread preretinal and subretinal proliferation in all cases. The surgical management was vitrectomy with scleral buckling, retinotomy, removal of preretinal and subretinal proliferation, and silicone oil tamponade. Mandatory prone positioning and limb restraint were not indicated. Postoperative anatomic and functional success were studied. The follow-up ranged from 3 to 62 months (mean: 25.8 months).

RESULTS

The retina was attached in 10 eyes (100%) at the final examination. Functional success, based on an improvement in patient daily activity, was achieved in 4 patients (44%). No severe complications were noted.

CONCLUSIONS

Treatment with vitrectomy was effective to manage severe PVR in patients with cognitive disabilities and contributed to improve daily life.

Functional outcome and prognostic factors in 304 eyes managed by retinectomy

BACKGROUND

This study was undertaken to relate the anatomic and functional results of patients who underwent retinectomy for complex retinal detachment (RD) to preoperative prognostic variables.

METHODS

Three hundred and four eyes of 302 patients whose surgery involved retinectomy were included in the analysis. All eyes had established proliferative vitreoretinopathy (PVR grade C). The main outcome measures were (1) postoperative visual acuity of 6/24 or better, (2) status of the retina at the end of follow-up, and (3) incidence of hypotony whilst under review.

RESULTS

PVR was secondary to rhegmatogenous RD in 237 eyes (78%), posterior trauma in 51 eyes (16.8%), tractional RD in vasoproliferative vasculitides in 12 eyes (4%), acute retinal necrosis in 2 eyes and endophthalmitis in 2 eyes. Complete reattachment rate after one operation was 51%, with final complete reattachment success rate of 72%. The visual acuity improved in 138 eyes (45%), remained the same in 73 eyes (24%) and became worse in 89 cases (29%). Postoperative visual acuity of 6/24 or better was significantly associated with preoperative vision, the duration of silicone oil tamponade, silicone oil removal and retinectomy size. There was also some evidence of association between visual outcome and the number of clock hours of retinal detachment. Final retinal attachment was significantly associated with silicone oil removal and preoperative vision, and final hypotony was significantly associated with silicone oil removal. The incidence of sympathetic ophthalmia in our study was 0.09% (one case).

CONCLUSIONS

Good functional outcome is possible following retinectomy surgery despite advanced pathology and often multiple surgical procedures. Retinal redetachment as a result of reproliferation and hypotony appear to be the main reasons for anatomical and functional failure. The clinical features we have identified as good indicators for improved final visual acuity such as shorter tamponade duration, removal of silicone oil, smaller retinectomy size, fewer previous operations and better preoperative vision are surrogate markers of less advanced PVR and should prompt retinal surgeons to consider retinectomy at an earlier stage in the process of PVR development. Clinicians should be aware of the small risk of sympathetic ophthalmia from complex retinal surgery.

Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial

OBJECTIVE

To compare the anatomical and functional outcome of scleral buckle (SB) surgery with that of pars plana vitrectomy (PPV) alone in the treatment of primary rhegmatogenous pseudophakic retinal detachment (RD).

METHODS

In this prospective, randomized clinical trial, 150 eyes of 150 patients with pseudophakic RD and proliferative vitreoretinopathy (PVR) stage B or less were randomized to SB surgery (75 eyes) or primary PPV (75 eyes). SB surgery involved break localization, cryotherapy, placement of a circumferential 240 style 2.5-mm solid silicone band, combined with a local buckle when indicated, and transscleral drainage of subretinal fluid. PPV included extensive vitreous removal, perfluoro-n-octane injection or endodrainage of subretinal fluid to flatten the retina, cryopexy treatment of breaks, and fluid/air exchange with injection of 20% SF6. Postoperative follow-up was 1 year. Break diagnosis, operating time, intraoperative and postoperative complications, retinal reattachment rate for single as well as multiple surgeries, axial length changes, and best-corrected visual acuity at 1 year after surgery were the main outcome measures.

RESULTS

The number of eyes that were diagnosed with additional breaks inter-operatively was higher in the PPV group (P=0.004, chi test). Mean operating time was significantly less (P=0.0001, t-test) in the PPV group. With a single surgery, the retina was reattached in 62 eyes (83%) in the SB surgery group and in 71 eyes (94%) in the PPV group (P=0.037, Fisher exact test). With subsequent surgeries, final anatomical reattachment was achieved in 71 cases in the SB surgery group and in 74 cases in the PPV group (P=0.37, Fisher exact test). Mean axial length change at 1 year was 0.95 mm in the SB surgery group and 0.1 mm in the PPV group (P=0.0001, t-test). Mean final best-corrected visual acuity (logMAR) was 0.40 in the SB surgery group and 0.33 in the PPV group (P=0.26, t-test).

CONCLUSIONS

Primary PPV offers potential advantages over SB surgery in the treatment of pseudophakic RD, including less operating time, accurate diagnosis of breaks, higher reattachment rate with a single surgery, and no postoperative axial length changes. Retinal reattachment rate with multiple surgeries and final visual acuity at 1 year were similar for SB surgery and PPV.

RISK FACTORS FOR RETENTION OF SUBRETINAL PERFLUOROCARBON LIQUID IN VITREORETINAL SURGERY

PURPOSE

To analyze factors that may lead to inadvertent subretinal retention of perfluorocarbon liquid (PFCL) after vitreoretinal surgery and compare surgical outcomes and complications associated with these events.

DESIGN

Consecutive retrospective study.

METHODS

The authors retrospectively reviewed the charts of 72 vitreoretinal surgeries using intraoperative PFCL and its removal through fluid-air exchange and subsequent tamponade. Indications for surgery included trauma, retinal detachment, giant retinal tear, and submacular hemorrhage. Most interventions studied had significant amounts of proliferative vitreoretinopathy and were required after failed or complicated previous vitreoretinal surgery.

MAIN OUTCOME MEASURES

Analysis was focused on the occurrence of subretinal retention of PFCL during different surgical procedures and techniques, indications, anatomic and visual results, and complications.

RESULTS

At the last follow-up, the retina was completely attached in 97% of eyes treated with PFCL after 1 or 2 vitrectomies. Subretinal PFCL was found in 8 (11.1%) eyes. There was no statistical difference in the retention rate for perfluorodecalin and perfluoro-n-octane. The factor most significantly associated with subretinal retention of PFCL was the presence and large size of a peripheral retinotomy. All cases of subretinal PFCL had a retinotomy of 120 degrees or larger. The average retinotomy size in these cases was 259 degrees . Subretinal PFCL was found in 40% of eyes with a 360 degrees retinotomy. Small and medium-sized retinal breaks were not associated with PFCL retention. Another surgical procedure that correlated significantly with subretinal PFCL was lack of saline rinse during fluid-air exchange. Only 1 of the 23 eyes that were rinsed had subretinal PFCL, although many had large retinotomies.

CONCLUSION

Subretinal PFCL retention is most likely to occur in eyes with large peripheral retinotomies, especially if 360 degrees . Saline rinse seems to be useful in the prevention of subretinal PFCL. The presence of subretinal PFCL does not seem to affect visual and anatomic success when located outside the macula, at least during an intermediate period of follow-up.

Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks

PURPOSE

To evaluate the efficacy of pars plana vitrectomy in conjunction with intraoperative perfluoro-n-octane (PFO) use as initial treatment of retinal detachment (RD) with multiple breaks located at various distances from the ora serrata.

METHODS

Twenty-two consecutive eyes (15 phakic, 2 aphakic, and 5 pseudophakic) presenting with RD with multiple breaks and tears underwent primary pars plana vitrectomy, PFO retinal reattachment, transcleral cryopexy or endolaser treatment of breaks, PFO/air exchange, and final injection of 18% perfluoropropane (C3F8). Scleral buckles were not used. The mean follow-up period was 29 months.

RESULTS

Temporary PFO utilization attached the posterior retina and facilitated the safe removal of vitreous at its base and around the retinal tears. Intraoperative complications included new breaks (3 eyes), enlargement of breaks (2 eyes), and a small bubble of subretinal PFO (1 eye). Postoperatively, the retina remained attached during follow-up in 19 eyes. Cataract developed or progressed in 13 phakic eyes.

CONCLUSIONS

Pars plana vitrectomy in conjunction with intraoperative PFO utilization is effective as initial treatment of RDs with multiple breaks. The main limitation of this technique is the postoperative progressive cataract formation in phakic eyes.

Outcomes of surgery for retinal detachment associated with proliferative vitreoretinopathy using perfluoro-n-octane: a multicenter study

PURPOSE

To report visual acuity and anatomical outcomes, as well as complications, of management of complex retinal detachment with proliferative vitreoretinopathy using pars plana vitrectomy and intraoperative perfluoro-n-octane (PFO), and to investigate clinical features associated with anatomical and visual acuity outcomes.

DESIGN

Prospective, noncomparative, interventional multicenter study.

METHODS

The study included 555 patients (555 eyes) 15 months of age or older who underwent pars plana vitrectomy for complex retinal detachment associated with proliferative vitreoretinopathy with intraoperative PFO at 24 study sites between April 1994 and February 1996. Main outcome measures included visual acuity and rates of retinal reattachment, reoperation, retained PFO, corneal edema, elevated intraocular pressure ([IOP] > 25 mm Hg), hypotony (IOP < 5 mm Hg), and cataract. All outcome measures were assessed at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively and at the last examination.

RESULTS

The study included 555 eyes of 555 patients followed up at a median of 5.6 months. Visual acuity of 20/200 or better was recorded in 51 (10%) patients preoperatively and 85 (24%) at 6 months postoperatively. Among the 465 eyes with both preoperative and final visual acuities available, postoperative visual acuity improved in 274 (60%) eyes, remained stable in 106 (23%), and worsened in 85 (18%) eyes. Six-month follow-up data were obtained for 356 (65%) eyes; the retina was attached in 279 (78%) eyes and retained PFO was noted in 20 (6%). Throughout follow-up, 238 of 555 (43%) eyes underwent reoperation for recurrent retinal detachment. At 6 months, corneal edema, elevated IOP, and hypotony were noted in 26 of 356 (7%), 6 of 356 (2%), and 48 of 356 (15%) eyes, respectively. Of the 114 phakic eyes without significant cataract preoperatively, 105 (92%) developed a significant cataract or underwent cataract surgery during study follow-up. Operative factors significantly (P <.05) associated with recurrent retinal detachment include female gender, creation of a relaxing retinotomy, and the use of sulfur hexafluoride (SF(6)) gas tamponade, air tamponade, or no tamponade (compared with perfluoropropane [C(3)F(8)] or silicone oil tamponade). Factors significantly associated with final vision of 20/200 or better include first operation anatomic success, prior scleral buckling procedure, no diabetes mellitus, no prior vitrectomy, no silicone oil retinal tamponade, and no relaxing retinotomy. Cases that require relaxing retinotomy generally represent more severe cases of complex retinal detachment and, therefore, relaxing retinotomy is likely associated with a poorer visual outcome owing to the nature of the cases selected for this procedure.

CONCLUSIONS

In the management of complex retinal detachment associated with proliferative vitreoretinopathy, pars plana vitrectomy and use of intraoperative PFO was associated with retinal reattachment and preserved visual acuity in most eyes.

Perfluorohexyloctane (F6H8) induces structural modifications and increases apoptosis in rat primary retinal cultures

The effects of perfluorohexyloctane (F6H8), recently investigated as a long-term artificial vitreous substitute, were studied in vitro, with the use of rat retinal cultures seeded on microporous inserts that allow the cell layer to be in contact with the material to be tested, on the apical side, and with the nutrient medium, on the basal side. After 72 h of treatment with F6H8, retinal cultures lost the characteristic two-layered organization with glial cells at the bottom and neuronal cells on top of them. They appeared to be composed of only one layer of polyhedrical, flattened, and disconnected cells. TUNEL assay revealed an evident increase in the percentage of apoptotic cells in F6H8-treated cultures (30.1 +/- 4.5), compared to control (10.3 +/- 2.6) and perfluoroctane-treated cultures (10.1 +/- 1.7). Immunolabeling of MAP-2, a protein of neuronal cytoskeleton, evidenced a marked loss of neurites. The results suggest that F6H8 is harmful to retinal cells in vitro and can therefore be potentially noxious to the retina as an artificial vitreous substitute.

Outcomes and complications associated with giant retinal tear management using perfluoro-n-octane

OBJECTIVE

To report visual acuity and anatomic outcomes, as well as complications, associated with giant retinal tear management using intraoperative perfluoro-n-octane and to investigate clinical features associated with anatomic and visual acuity outcomes.

DESIGN

A prospective, noncomparative, observational, multicenter study.

PARTICIPANTS

Two hundred twelve patients (212 eyes) > or =15 months of age who underwent giant retinal tear management with intraoperative perfluoro-n-octane at 24 study sites between April 1994 and February 1996. Giant retinal tear was defined as a retinal tear extending > or =90 degrees.

INTERVENTION

Vitrectomy with perfluoro-n-octane intraoperative retinal tamponade.

MAIN OUTCOME MEASURES

Visual acuity and rates of retinal reattachment, reoperation, retained perfluoro-n-octane, corneal edema, elevated intraocular pressure (IOP > 25 mmHg), hypotony (IOP < 5 mmHg), and cataract. All outcome measures were assessed at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively and at the last examination.

RESULTS

The study included 212 eyes of 212 patients followed a median of 3.5 months. Visual acuity > or =20/200 was measured in 56 (27%) patients preoperatively and 67 (47%) patients at 6 months. Postoperative visual acuity improved in 107 (59%) eyes, remained stable in 44 (24%) eyes, and worsened in 29 (16%) eyes (percentages are based on the number of patients for whom the data were available at these time points). Of the 124 patients with visual acuity < or =5/200 preoperatively, 94 (76%) had improved visual acuity at 6 months postoperatively. At 6 months, the retina was attached in 108 (76%) eyes, and retained perfluoro-n-octane was noted in 8 (6%) eyes. Throughout follow-up, 64 (30%) eyes underwent reoperation for recurrent retinal detachment. At 6 months, corneal edema, elevated IOP, and hypotony were noted in 5 (4%), 4 (3%), and 12 (9%) eyes, respectively. Of the 72 phakic eyes without cataract preoperatively, 61 (85%) had a cataract or underwent cataract extraction during study follow-up. Factors significantly (P < 0.05) associated with recurrent retinal detachment include female gender, younger age, preoperative proliferative vitreoretinopathy, prior vitrectomy, larger size of giant retinal tear, lack of scleral buckle placement, and relaxing retinotomy. Multivariate analysis demonstrated that female gender, larger size of giant retinal tear, and prior vitrectomy were significantly associated with recurrent detachment. Factors significantly associated with vision >or =20/200 include male gender, no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy. After adjusting for recurrent detachment, factors significantly associated with vision > or =20/200 include no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy.

CONCLUSIONS

Retinal reattachment and preserved visual acuity were achieved in most eyes that underwent giant retinal tear management with intraoperative perfluoro-n-octane. Significant risk factors for recurrent retinal detachment include size of retinal tear, age, prior vitrectomy, and female gender. After adjusting for recurrent detachment, significant predictors of postoperative vision >or =20/200 include no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy.

Biocompatibility assessment of silicone oil and perfluorocarbon liquids used in retinal reattachment surgery in rat retinal cultures

The effects of silicone oil and perfluorocarbon liquids used in retinal reattachment surgery were studied in vitro using rat retinal cultures seeded on microporous inserts. These inserts allow the cell layer to be in contact with the material to be tested on the apical side and with the nutrient medium on the basal side. The materials tested were silicone oil, the perfluorocarbons perfluorophenanthrene and perfluoroctane, and hydroxypropylmethylcellulose. Perfluorophenanthrene, the heaviest of the compounds, induced a very precocious detachment of the cell layer. All the other tested biomaterials were compatible with cell survival and did not alter the structural organization of the retinal cultures, as revealed by scanning electron microscopy. By immunocytochemical techniques we evaluated the cell composition and the differentiation state of each of the cultures. In both control and treated samples, neuronal cells were well preserved. The expression of microtubule-associated protein 2, a marker of differentiated neuronal cytoskeleton, was not affected. Amacrine neurons, immunolabeled for gamma-aminobutyric acid, still were detectable after treatment. Synapses, marked by immunoreactivity for synapthophysin, were equally preserved. Vimentin-positive glial cells did not show modifications. The apoptotic rate, as determined by the terminal transferase-mediated dUTP-biotin nick end-labeling assay, was similar in treated and control samples. The results confirm that the use of biomaterials with a specific gravity close to intraocular fluids is compatible with retinal cell survival and differentiation in vitro.

Biodegradable scleral plugs for vitreoretinal drug delivery

Intraocular controlled drug release is one way to facilitate drug efficacy and decrease side effects that occur with systemic administration. Vitreoretinal drug delivery with the biodegradable scleral plug has been investigated. The scleral plug, which is made of biodegradable polymers and drugs, can be implanted at the pars plana using a simple procedure, and it gradually releases effective doses of drugs with polymer biodegradation for several months. The release profiles of the drugs were dependent on the kind of polymers used, their molecular weights, and the amount of drug in the plug. The plugs are effective for treating vitreoretinal diseases such as proliferative vitreoretinopathy. The implantation site was replaced with connective tissue. Electroretinography and histologic studies revealed little retinal toxicity. This implantable scleral plug was supposed to be advantageous for diseases such as cytomegalovirus retinitis that respond to repeated intravitreal injections and for vitreoretinal disorders that require vitrectomy.

The expanding role of primary pars plana vitrectomy in the treatment of rhegmatogenous noncomplicated retinal detachment

The surgical management of rhegmatogenous retinal detachment has evolved dramatically during the past 2 decades. Investigators have introduced and refined alternative techniques to scleral buckling surgery including pneumatic retinopexy and primary pars plana vitrectomy (PPV). Rapid parallel developments in instrumentation, including wide-angle viewing systems, perfluorocarbon liquids, novel vitrectomy machines, intraocular tamponades, and endolaser photocoagulators have led to increasing sophistication in primary PPV surgical techniques for the treatment of rhegmatogenous uncomplicated retinal detachment. However, the precise role of primary PPV in new uncomplicated retinal detachment remains debatable owing to the lack of controlled randomized trials. This article examines primary vitrectomy treatment for rhegmatogenous uncomplicated retinal detachment and presents the specific types of retinal detachments for which primary PPV may be optimal, according to personal and reported results, the surgical instrumentation and technique, as well as the complications and limitations of this surgical method.

Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair

OBJECTIVE

To compare rates of perfluorocarbon liquid (PFCL) intraocular retention, anatomic and visual acuity outcomes, and complications associated with intraoperative perfluoro-n-octane (Perfluoron) versus perfluoroperhydrophenanthrene (Vitreon) in retinal detachment repair.

DESIGN

Retrospective noncomparative consecutive case series.

PARTICIPANTS AND METHODS

Records of consecutive patients who underwent retinal detachment repair with intraoperative Perfluoron (n = 78) or Vitreon (n = 84) at the Bascom Palmer Eye Institute between November 1, 1991, and October 31, 1994, were retrospectively reviewed.

MAIN OUTCOME MEASURES

Comparison of PFCL intraocular retention rates, retinal reattachment rates, visual acuity outcomes, and postoperative complication rates between the Perfluoron and Vitreon groups at postoperative day 1, week 1, month 1, month 3, and month 6. To assess the study's generalizability, the Perfluoron data obtained in the current study were compared with results of the Perfluoron Multicenter Clinical Study.

RESULTS

Retained Perfluoron was noted less frequently (P < 0.03) than retained Vitreon at each postoperative visit assessed. At 6 months postoperatively, the cumulative rate of retained PFCL (noted at any of the study postoperative visits) was 7.8% of patients in the Perfluoron group and 38.3% in the Vitreon group (P < 0.001). No significant difference was found between the groups in retinal reattachment rates; at 6 months postoperatively, the retina was attached in 45 of 61 (74%) patients in the Perfluoron group and 36 of 57 (63%) patients in the Vitreon group (P = 0.2). There was a trend (P = 0.055) toward better 6-month visual acuity in the Perfluoron group compared with the Vitreon group. The incidence of corneal abnormality at any study visit was 46.7% in the Perfluoron group and 77.4% in the Vitreon group (P < 0.001). At 6 months postoperatively, the cumulative rate of elevated intraocular pressure (>25 mmHg) was 13 +/- 4% and 37 +/- 5%, respectively (P = 0.004). No significant difference was found between the groups in rates of postoperative hypotony. Results of this study are comparable with those observed in the Perfluoron Multicenter Clinical Study.

CONCLUSIONS

In this study, Perfluoron was retained intraocularly less frequently than Vitreon. Although no significant difference was found between groups in retinal reattachment rates, Perfluoron is associated with slightly better 6-month visual acuity and lower rates of corneal abnormality and elevated intraocular pressure compared with Vitreon.

Perfluorocarbons and semifluorinated alkanes

The introduction of perfluorocarbons (PFCs) and, more recently, semifluorinated alkanes (SFAs) has greatly facilitated vitreoretinal surgery. A distinction is made between the use of these substances as intraoperative tools and internal tamponade agents. This article reviews the physical and chemical properties of PFCs and SFAs and discusses the indications, results, and complications. The effectiveness of these substances as internal tamponade agents is discussed with reference to the specific gravity, contact angle, viscosity and ability to fill model eye chambers and the vitreous cavity. The evidence for the toxicity in animal and human is examined.

Implantable biodegradable polymeric device in the treatment of experimental proliferative vitreoretinopathy

We investigated the use of a scleral plug of biodegradable polymer implanted at the pars plana to create a controlled drug-delivery system in the vitreous. We evaluated the efficacy of a plug containing doxorubicin hydrochloride to treat experimental proliferative vitreoretinopathy (PVR) in pigmented rabbits. An implantable device on the sclera, which imitates a scleral plug, containing 1% doxorubicin, was prepared with poly(lactic acid) (molecular weight, 20,000). The release of doxorubicin in phosphate-buffered saline was evaluated by spectro-photometry. After pars plana vitrectomy and plug implantation, concentrations of doxorubicin in the vitreous humor of the rabbits were measured by high performance liquid chromatography. The release profiles were evaluated during 5 weeks in vitro and 4 weeks in vivo. Cultured homologous fibroblasts were injected into the vitreous space to induce experimental PVR after gas compression of the vitreous. The scleral plugs were implanted at the pars plana in treatment animals (n = 11). Control rabbits (n = 11) were followed up without implantation after PVR induction. All eyes of the control group developed tractional retinal detachment at day 28, while the incidence of retinal detachment was decreased to 64% in the treated eyes. (P = 0.002). The implantation of the scleral plug effectively inhibited intravitreous proliferation of fibroblasts. This study demonstrated that the scleral plug of biodegradable polymers may have potential as a treatment modality for PVR.

Perfluorocarbon liquid in the management of retinal detachment with proliferative vitreoretinopathy

PURPOSE

To describe the techniques and results of perfluoro-N-octane used during vitrectomy for managing retinal detachment with severe proliferative vitreoretinopathy (PVR).

METHODS

The authors retrospectively studied 223 consecutive patients who underwent vitreoretinal surgery for severe PVR (93% D1-D3). Patients underwent an average of 1.72 prior vitreoretinal surgeries. Perfluoro-N-octane was used intraoperatively to flatten the retina, avoiding posterior drainage retinotomy, to identify areas of residual retinal traction and periretinal membranes, to stabilize the peripheral retina during dissection of anterior PVR, and to help determine the extent and location of relaxing retinotomies. Extended-term gas tamponade was used in 91% of eyes. All patients were followed for a minimum of 6 months.

RESULTS

Seventy-eight percent of the retinas were reattached posterior to the scleral buckle after a single vitreoretinal surgery and 96% were reattached after multiple surgeries. An average of 1.24 vitrectomy surgeries were required. The final visual acuity was 20/400 or better in 74% of eyes and 20/80 or better in 30% (P = 0.004). Preoperative hypotony (intraocular pressure < or = 5 mmHg) and multiple prior vitreoretinal surgeries were associated with a poor final visual acuity (P = 0.01 and 0.02, respectively). Preoperative hypotony (intraocular pressure < or = 5 mmHg) was associated with a greater frequency of relaxing retinotomies (P = 0.02). Retained perfluoro-N-octane was observed postoperatively in the vitreous cavity in 1.3% and subretinal perfluoro-N-octane in 0.9%.

CONCLUSION

Experience with perfluoro-N-octane has demonstrated its usefulness both diagnostically and therapeutically as an intraoperative tool and improved the anatomic and visual outcome for retinal detachment complicated by severe PVR.