Combined Tractional-rhegmatogenous Retinal Detachment Research Articles

Surgical Treatment of Diabetic Combined Tractional-Rhegmatogenous Retinal Detachment

Diabetic macular edema, tractional retinal detachment (TRD) and combined rhegmatogenous retinal detachment (CTRRD) are important causes of vision loss in eyes with proliferative diabetic retinopathy. CTRRD is less common than TRD but has a worse prognosis. Therefore, the treatment of CTRRD is one of the issues that await solutions in current ophthalmology practice. In recent years, it has been shown that the risk of intraocular bleeding during and after the operation is reduced by the use of vascular endothelial growth factor inhibitors before the operation. In addition to bimanual surgery, there are current developments that enable the effective and safe application of segmentation and delamination of proliferative membranes with customized rapid cutters from vitreoretinal small incisions. In addition, the preference for silicone oil as an intraocular tamponade and intraoperative real-time follow-up of vitrectomy with optical coherence tomography has the potential to provide more successful anatomical and functional results.

Rhegmatogenous retinal detachment in choroidal melanoma: clinical features and surgical outcomes.

To describe the clinical features, prognostic factors, safety and rate of success of surgery and visual outcomes in patients with rhegmatogenous retinal detachment (RRD) and choroidal melanoma (CM). A retrospective, observational case-series of 21 patients with rhegmatogenous retinal detachment or combined tractional-rhegmatogenous retinal detachment in patients with choroidal melanoma over a period of 20 years. Nineteen patients were included in the final analysis. The mean elevation of CM was 4.0 mm and the mean largest diameter was 11.0 mm. RRD occurred after the CM treatment in 14 eyes at a mean interval of 44.2 months. The RRD was macula-on RRD in 6 eyes, there was posterior vitreous detachment (PVD) in 15 and PVR in 7 eyes. BCVA at presentation was 0.71 logMAR and final was 1.5 logMAR (p = 0.01). The primary surgical success rate was 59%. No intraocular or extraocular tumour dissemination occurred. Mean follow-up was 66 months. RRD in patients with CM is uncommon but requires multidisciplinary management. Anatomical results are favourable but visual outcomes are poor due to a combination of factors related to melanoma treatment, macular retinal detachment and PVR. Vitrectomy as a surgical intervention for RRD in treated CM appears to be safe in terms tumour dissemination.

Persistent subretinal fluid following diabetic tractional retinal detachment repair: risk factors, natural history, and management outcomes.

To study the natural history, anatomical and functional outcomes of persistent subretinal fluid (SRF) after pars plana vitrectomy (PPV) for diabetic tractional retinal detachment (TRD) and combined traction-rhegmatogenous retinal detachment (TRRD). Retrospective interventional case series of 43 patients (46 eyes) with persistent SRF following PPV for diabetic TRD or combined TRRD from January 2010 to December 2017 at single tertiary institution. Primary outcomes included best corrected visual acuity (BCVA) and central foveal thickness (CFT). Thirty-one eyes (67.4%) had macula-off TRD, 5 (10.9%) had fovea-threatening TRD and 10 (21.7%) had combined TRRD. The mean (± SD) duration of decreased vision was 48.0 ± 58.2weeks. The mean follow-up duration was 21 ± 13.2months. Residual macular SRF was detected by optical coherence tomography in all eyes at 3months and in 10 eyes (23.8%) at 12months after surgery. Only 3 eyes (6.5%) had persistent SRF at final follow up. The mean time to resolution was 10.6 ± 4.1months [range 6.0-23.0]. Thirteen eyes received additional intervention to address SRF. The mean CFT gradually improved until final follow-up (P-value < 0.001). The mean BCVA improved from 1.62 ± 0.88 LogMAR at presentation to 1.05 ± 0.76 LogMAR at final follow up. No statistically significant difference in final BCVA was found between eyes that had intervention and eyes that were observed (P value = 0.762). Persistent SRF after diabetic vitrectomy resolves slowly over time with gradual improvement in visual acuity. Additional drainage of persistent SRF may not be necessary.

INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY (OCT) GUIDANCE OF VITREORETINAL SURGERY

Background: Multiple studies have described the utility of intraoperative spectral-domain OCT (SD-OCT) with two dimensional (2D) B-scan imaging in the management of numerous vitreoretinal disorders including macular holes, vitreomacular traction disorders, epiretinal membranes and retinal detachment. Some of these studies also described post-processing of the 2D B-scans to obtain 3D images. With the advancement of intraoperative OCT technology, live volumetric (4D, i.e. 3D over time) visualization of different anterior and posterior segment surgeries has been described in recent studies using intraoperative swept-source microscope-integrated OCT (SS-MIOCT). Our study aims to explore the potential utility of SS-MIOCT during vitrectomy for complications of proliferative diabetic retinopathy. Aim of the work: To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated OCT (SS-MIOCT) in vitrectomy for proliferative diabetic retinopathy (PDR) complications.Patient and Methods: In this prospective study, we analyzed a subgroup of cases with PDR complications that required vitrectomy and that were imaged by the research SS-MIOCT system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy (DR)-associated pathologies and reviewing the intraoperatively documented surgeon feedback.Results: Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (TRD, 16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes) and vitreous hemorrhage (2 eyes). Useful, good quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple DR pathologies could be imaged. SS-MIOCT provided surgical guidance, e.g. in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%) acceptable images were captured, but they were not useful due to high TRD elevation which was challenging for imaging.Conclusion: SS-MIOCT can provide important guidance during surgery for PDR complications through intraoperative identification of different pathologies and facilitation of intraoperative decision making.

Current Management of Combined Traction/Rhegmatogenous Retinal Detachments

Due to proliferative diabetic retinopathy (PDR) and related complications, 25% of diabetic patients experience significant visual impairment. Panretinal argon laser photocoagulation (PRP) and the use of vascular endothelial growth factors (VEGF) in recent years have reduced the frequency of visual loss and tractional retinal detachment (TRD) and combined tractional/rhegmatogenous retinal detachment (CTRD). TRD and CTRD are the primary indications for vitreoretinal surgery related to PDR. TRD and CTRD which elevate macula less than 6 months, rapidly progressive and threatening macula are the other important indications to vitreoretinal surgery in diabetic retinopathy. CTRD, which was almost inoperable in previous years, now it takes place in the indications to vitreoretinal surgery by the development of new surgical equipment (vertical and horizontal scissors, light systems, diamond knives, trocar systems, etc.) and new surgical techniques (segmentation, visco-dissection, en-block dissection). Small calibered (23, 25, 27 Gauge) vitrectomy probes shortened the duration of vitreoretinal surgery in TRD and CTRD cases. Preoperative anti-VEGF treatment inhibits the fibrovascular tissue activation in this way facilitates and enables safe surgery. As long as the vitreoretinal surgery equipment and techniques improved, the functional and anatomical success in CTRD and TRD will increase.

Combined tractional rhegmatogenous retinal detachment in vascular occlusive disease

Цел: Да се представи рядък случай на пациент с комбинирано тракционно-регматогенно отлепване на ретината, свързано с венозна тромбоза, избрания терапевтичен подход и проследяване на резултата от лечението чрез ОСТ-ангиография. Материали и методи: Представя се 61-годишен мъж с внезапна загуба на зрението на едното око. Същото око е било лекувано неколкократно консервативно /медикаментозно и с лазер терапия/ по повод рецидивиращ хемофталм. Пациентът не приема медикаменти за системно заболяване. Терапевтичният подход беше оперативен: парс-плана витректомия, ендолазер и силиконова тампонада. Резултати: Интраоперативно се установи комбинирано тракционно-регматогенно отлепване на ретината с венозна оклузия. Направи се пан-ендолазер интраоперативно и се имплантира силиконово масло. Следоперативно зрителната острота се подобри значително в рамките на един месец. От 0.01 предоперативно до 0.4 на първи постоперативен ден и 0.8-1.0, месец по-късно. Обсъждане: Имайки предвид близостта на руптурата до оклузията, може да се предположи, че руптурата на ретината е следствие от витрео-ретиналната тракция, получена вследствие на оклузия, a не обратното. От водещо значение за зрителната острота е степента на ретинална исхемия и ангажирането на макулата от патологичния процес. Заключение: Комбинираното тракционно-регматогенно отлепване на ретината се среща рядко. Целта на оперативното лечение е да се отстранят тракциите и да се третира исхемията на ретината, чрез лазерна фотокоагулация. Важна е добрата колаборация с кардиолози и ендокринолози, с оглед спадане на рисковете за второто око на пациента. Навременното и адекватно лечение подобрява значително прогнозата за зрителната острота.

VISUALIZATION FROM INTRAOPERATIVE SWEPT-SOURCE MICROSCOPE-INTEGRATED OPTICAL COHERENCE TOMOGRAPHY IN VITRECTOMY FOR COMPLICATIONS OF PROLIFERATIVE DIABETIC RETINOPATHY

To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated optical coherence tomography in vitrectomy for proliferative diabetic retinopathy complications. In this prospective study, we analyzed a subgroup of patients with proliferative diabetic retinopathy complications who required vitrectomy and who were imaged by the research swept-source microscope-integrated optical coherence tomography system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy-associated pathologies and reviewing the intraoperatively documented surgeon feedback. Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes), and vitreous hemorrhage (2 eyes). Useful, good-quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple diabetic retinopathy complications could be imaged. Swept-source microscope-integrated optical coherence tomography provided surgical guidance, e.g., in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%), acceptable images were captured, but they were not useful due to high tractional retinal detachment elevation which was challenging for imaging. Swept-source microscope-integrated optical coherence tomography can provide important guidance during surgery for proliferative diabetic retinopathy complications through intraoperative identification of different complications and facilitation of intraoperative decision making.

Pars plana vitrectomy to repair retinal detachment following brachytherapy for uveal melanoma

AimsRetinal detachment can develop following brachytherapy for uveal melanoma. This complication may result in substantial visual loss and poses a significant therapeutic dilemma due to the required surgical intervention for...

Posterior Subtenon Triamcinolone Acetonide in Gas-filled Eyes as an Adjunctive Treatment for Complicated Proliferative Diabetic Retinopathy

PurposeTo evaluate the effect of adjunctive subtenon injection of triamcinolone acetonide (TA) in gas-filled eyes after vitrectomy for complicated proliferative diabetic retinopathy (PDR).MethodsThis nonrandomized comparative study included 27 patients (27 eyes) who underwent pars plana vitrectomy and gas tamponade for treatment of PDR with tractional or combined tractional-rhegmatogenous retinal detachment and who received subtenon injection of TA (40 mg) at the end of surgery. The study group was compared with the control group (29 eyes), which was matched with the study group for preoperative and intraoperative parameters, but underwent pars plana vitrectomy and gas tamponade without a subtenon injection of TA.ResultsRetinal reattachments without reoperation were achieved in 25 eyes (92.6%) and 26 eyes (89.7%) at 6 months (p = 1.000) in the study and control groups, respectively. The study group and the control group did not differ significantly in the frequency of postoperative proliferative vitreoretinopathy, retinal redetachment rate, reoperation rate, macular pucker formation, postoperative vitreous hemorrhage, gain in visual acuity, intraocular pressure, and intraocular inflammation (p > 0.05).ConclusionsThe clinical results of pars plana vitrectomy for complicated PDR are not improved significantly by an adjunctive subtenon TA injection in gas-filled eyes.

Surgical management of the late complications of proliferative diabetic retinopathy

The late complications of proliferative diabetic retinopathy (PDR) comprise vitreous haemorrhage, tractional retinal detachment, combined tractional-rhegmatogenous retinal detachment, and severe fibrovascular proliferation (including macular distortion or dragging, tractional macular oedema, and media opacity due to fibrovascular tissue). This article will review the indications, techniques, and outcomes of vitrectomy surgery to treat these conditions. A careful assessment of the surgical anatomy, with particular attention to the configuration of vitreoretinal attachments, is important when determining the precise surgical procedure required. The surgical outcome after diabetic vitrectomy has steadily improved with advances in vitreoretinal surgical instrumentation and technique. Significant post-operative complications may, however, occur including cataract formation, recurrent vitreous cavity haemorrhage (early or delayed), rhegmatogenous retinal detachment, and neovascular glaucoma. Most patients will regain or retain useful vision after diabetic vitrectomy, although the visual outcome does remain unpredictable. The development of adjunctive pharmacotherapy should enable further improvements in visual outcome in the future.

Pars plana vitrectomy revealed Toxocara canis organism

The Toxocara organism may cause direct injury to the eye, but most commonly, host inflammatory reactions are responsible for the resulting compromise. The inflammatory response created by the ocular involvement may result in epiretinal membrane formation, tractional or combined tractional-rhegmatogenous retinal detachment. The treatment of choice is pars plana vitrectomy (PPV), which also has diagnostic significance. We report a pediatric case in which PPV recovered the Toxocara canis organism. For the total tractional retinal detachment diagnosed after the cataract surgery, PPV, preretinal and subretinal membrane peeling, 180 degrees retinotomy, silicone oil injection were performed. The fibrous membrane specimen obtained during PPV recovered the Toxocara canis organism. The intense postoperative inflammatory reaction had to be managed surgically, also. Retinal reattachment was achieved with subsequent improvement of the visual acuity. The importance of vitreous biopsy examination following PPV, in eyes in which etiology is uncertain and the intense antiinflammatory therapy applied within and following vitreoretinal surgery is emphasized.

Tractional retinal detachment after branch retinal vein occlusion: Influence of disc neovascularization on the outcome of vitreous surgery

Objective This study aimed to investigate the influence of disc neovascularization on the outcome of vitreous surgery for tractional retinal detachment (TRD) after branch retinal vein occlusion (BRVO). Design The study design was a retrospective case series. Participants Twenty-two eyes of 22 patients who had undergone vitrectomy for TRD after BRVO at the Osaka National Hospital (Osaka, Japan) or the Surugadai Hospital of Nihon University (Tokyo, Japan) between 1985 and 1995 participated. Seven (32%) of 22 eyes had a TRD secondary to neovascularization of the optic disc (NVD) and neovascularization elsewhere (NVE; group I), and 15 (68%) had a TRD with NVE without NVD (group II). Main outcome measures Visual acuities and retinal reattachment rates were measured. Results Sixteen (73%) of the 22 study eyes showed severe vitreous hemorrhage before surgery, and 11 eyes (50%) had received laser photocoagulation treatment before surgery. Fourteen (64%) of the study eyes achieved total retinal reattachment after initial vitrectomy, and 19 eyes (86%) were reattached completely at final examination. Thirteen eyes (59%) achieved a visual acuity of better than 0.1. Group I patients had a significantly higher rate of recurrent combined traction rhegmatogenous retinal detachment ( P = 0.01) and a significantly worse final visual outcome ( P = 0.01). Conclusions Better surgical results are expected in eyes without NVD than with NVD among patients who undergo vitrectomy for TRD after BRVO. Although the authors were unable to determine the reason for this difference in the current study, they speculate that the degree of retinal nonperfusion, diffusible angiogenic factors, and distance of the site of occlusion from the disc may each affect visual and anatomic outcomes in these eyes.

Cytokeratin-containing cells in proliferative diabetic retinopathy membranes.

Immunohistochemical techniques were used to investigate the relation between retinal pigment epithelial cells (RPE), traction retinal detachment (TRD) membranes, and combined traction rhegmatogenous retinal detachment (CTR) membranes in proliferative diabetic retinopathy. Seven CTR and five TRD membranes were obtained during closed microsurgery. Six of the seven CTR membranes and one of the five TRD membranes contained RPE. Eleven of the 12 diabetic membranes incorporated glial cells. The findings emphasise that the intravitreal membranes of proliferative diabetic retinopathy contain a diversity of cell types and indicate that RPE tend to contribute to CTR, rather than TRD, membranes. The histopathological appearance of CTR membranes is that of a hybrid between TRD and proliferative vitreo-retinopathy membranes.