Giant Retinal Tear Research Articles

Lack of Toxicity of Stainless Steel Retinal Tacks During 21 Years of Follow-Up

Retinal tacks were historically used in the repair of complex retinal detachment associated with giant retinal tear. The authors describe a patient with retinal detachment associated with giant retinal tear who was treated successfully with pars plana vitrectomy, use of stainless steel retinal tacks, endolaser photocoagulation, and gas-fluid exchange. Twenty-one years after treatment, the retina has remained attached, the tacks are in place, and best-corrected visual acuity is 20/30 in the operated eye. Although retinal tacks are no longer used, this case report suggests that intraocular stainless steel may cause minimal or no retinal toxicity during long-term follow-up.

MACULAR HOLE FORMATION AND CLOSURE AFTER CATARACT EXTRACTION AND Nd:YAG CAPSULOTOMY IN A VITRECTOMIZED EYE WITH AN EPIRETINAL MEMBRANE.

Vitreomacular traction and degeneration of the inner retinal layers of the fovea are considered contributing factors to idiopathic macular hole (MH) formation. This case report illustrates a rare scenario of MH formation and spontaneous closure associated with an epiretinal membrane (ERM) and perifoveal cystoid edema without anteroposterior traction from the vitreous in a previously vitrectomized eye. A case report following MH clinical progression with visual acuity and serial optical coherence tomography. A 47-year-old high myope underwent scleral buckle placement and pars plana vitrectomy for a macula-off, phakic, inferior retinal detachment with a giant retinal tear and proliferative vitreoretinopathy 2.5 years ago with eventual visual acuity of 20/20. Postoperatively, an ERM developed, and uncomplicated phacoemulsification cataract extraction was later performed. One week after Nd:YAG capsulotomy, a full-thickness MH formed (with perifoveal cystoid macular edema) that spontaneously resolved 2 months later with return of vision to 20/20. After vitrectomy, anteroposterior vitreofoveal traction no longer contributes to MH formation. Perifoveal cystoid macular edema as well as tangential traction from ERMs may contribute to MH formation.

Massive coats disease-like tumor after retinal detachment.

To describe two patients with peripheral Coats disease-like tumor reaction years after surgical repair for rhegmatogenous retinal detachment. Retrospective review of two clinical cases. Patient 1 presented with visual deterioration caused by a retinal angiomatous tumor and lipid exudates originating from telangiectatic vessels on the scleral buckle 8 years after vitrectomy and encircling band surgery for a giant retinal tear. In Patient 2, a vascularized retinal mass was detected during vitrectomy for a vitreous hemorrhage 24 years after scleral buckling procedures. Both patients were highly myopic and had no history of scleral perforation or angiomatous proliferation before surgery. They underwent vitrectomy and removal of the vascularized tumor. Histologic examination revealed wide lacunae filled with erythrocytes, connective tissue strands with inflammatory cells, and capillaries that showed thickened multilamellar basement membranes. Secondary Coats disease-like tumor reaction may occur as a late complication years after successful retinal detachment surgery and may be caused by a chronic ischemic and inflammatory stimulus induced by prominent buckling elements in highly myopic eyes.

Giant retinal pigment epithelial tear after laser photocoagulation for diabetic retinopathy

A 62-year-old man, who underwent focal laser photocoagulation in the left eye (OS) for diabetic retinopathy 2 years previously, complained of metamorphopsia OS. The left fundus had a semilunar retinal...

Bottle cork and cap injury to the eye: a review of 34 cases

To describe our series of bottle cork and cap injuries to the eye in order to report the visual impairment and clinical outcomes observed in 34 cases over an 8-year period. Retrospective review of the database of the Ophthalmology Institute of Modena from January 1999 to September 2007. All patients presented with closed-globe injury according to Kuhn et al.'s classification. All the cases were caused by sparkling wine: white in 24 cases and red in ten cases. The incidence varied between six and two cases a year (average 3.89). Bottle cork and cap injuries represent 11% of all injuries admitted to our department in the period considered in our series. In details: nine patients recovered totally, 22 patients recovered partially, three patients had a severe visual outcome (<grade 3 according to trauma classification system, BCVA < 0.2). Five patients needed a surgical procedure. The most frequent ocular lesion was hyphema; the worst was retinal detachment due to a giant retinal tear and two patients suffered very severe visual impairment. To our knowledge, this is the largest series of bottle cork and cap injuries to the eye published to date. This kind of injury can be potentially sight-threatening, leading to severe visual loss in a small percentage of cases. We highlight the need for preventative measures such as labelling or devices to regulate cork pressure.

Giant retinal tear after pneumatic retinopexy

Editor, M ost giant retinal tears are idiopathic (Wilkinson & Rice 1997). Males with pathological myopia are at risk. The second most common cause of giant retinal tears is blunt trauma. Surgical manipulation such as anterior vitrectomy can also be a cause (Wilkinson & Rice 1997). We report a case of giant retinal tear developed after pneumatic retinopexy and illustrate the pathogenesis of this rare and vision-threatening complication. A 54-year-old, non-myopic Chinese man presented with unprovoked floaters in the left eye. Visual acuity (VA) was 20 ⁄ 20 in both eyes. Anterior segments were unremarkable. Fundal examination of the left eye showed a superior rhegmatogenous retinal detachment extending from the 10 to the 2 o’clock position, with a small break and lattice degeneration at 12 o’clock. The right fundus was unremarkable. The patient underwent pneumatic retinopexy with cryopexy around the primary break and injection of 0.3 mL 100% C3F8 gas. Postoperatively, sitting upright with facedown posture was recommended. Ten days later, the superior retinal detachment was completely reattached. However, a giant retinal tear extending from 12 to 4 o’clock with pars plana detachment was noted (Figs 1 and 2). Scleral buckling, pars plana vitrectomy, perfluorocarbon liquid, endolaser, cryopexy and 20% SF6 gas)fluid exchange were performed. The retina remained flat with VA of 20 ⁄ 70 at 8 months postoperatively. There was mild nuclear sclerosis pending cataract extraction. Pneumatic retinopexy is a safe retinal reattachment procedure involving the transconjunctival injection of gas into the vitreous cavity, cryopexy or laser retinopexy, and posturing. Complications of this procedure are rare, and consist of new retinal break formation, subconjunctival gas, subretinal gas, gas entrapment at the pars plana, shift of detachment into previously attached macular and

LOW REDETACHMENT RATE DUE TO ENCIRCLING SCLERAL BUCKLE IN GIANT RETINAL TEARS TREATED WITH VITRECTOMY AND SILICONE OIL

The goal of this study was to identify risk factors for redetachment and to assess long-term anatomic and functional results of pars plana vitrectomy (PPV) for retinal detachment associated with giant retinal tears (GRT). In a retrospective study the authors analyzed 30 eyes which were operated with PPV for GRT retinal detachment in their clinic between March 1998 and August 2003. Redetachment rate after one vitrectomy procedure in this series of 30 eyes was 30% (n = 9), and ultimately, the retina was attached in 29 (96.7%) eyes. After multivariate analysis the absence of an encircling scleral buckle (P = 0.008) was significantly associated with redetachment. Visual acuity improved in 54% of the eyes. Vitrectomy with an encircling scleral buckle seems to be a preferred treatment for complicated retinal detachments due to GRT.

Prognostic Factors Associated with Outcomes after Giant Retinal Tear Management Using Perfluorocarbon Liquids

To identify prognostic factors for visual acuity and anatomic outcomes associated with giant retinal tear management using intraoperative perfluorocarbon liquids. All patients with giant retinal tears without proliferative vitreoretinopathy (PVR) who underwent management with intraoperative perfluorocarbon liquids between 1994 and 2005 were reviewed. The study included 115 patients (117 eyes), 93 (80.9%) males and 22 (19.1%) females, with a mean age of 30.3+/-15.2 years. Mean follow-up period was 29.7+/-26.7 months. Success rate with primary procedure was 78.6%, which increased to 94% with multiple surgeries. On univariate analysis, factors significantly associated with final visual acuity better than 20/200 included phakic/clear lens at presentation (p=0.0113), partial retinal detachment (p=0.0233), absence of all postoperative complications (p=0.0122), absence of recurrent retinal detachment (p=0.0406), and absence of postoperative PVR (p=0.0062). Logistic regression analysis highlighted that phakic/clear lens at presentation, unfolded flap of the giant tear, absence of postoperative cataract, and absence of postoperative PVR were associated with final visual acuity better than 20/200. On univariate analysis, use of gas tamponade was significantly associated with recurrent retinal detachment (p=0.0190). Logistic regression analysis highlighted that placement of an encircling scleral buckle and use of silicone oil tamponade were associated with anatomic reattachment with primary procedure. Encircling scleral buckling and silicone oil tamponade decrease the risk of recurrent retinal detachment.

Giant retinal tear management: an Asian experience

To report the management of giant retinal tears (GRT). Retrospective review of all patients who underwent surgery for GRT with at least 6 months follow-up. A total of 124 patients with 128 eyes were managed for GRT between 1991 and 2005. Of them, 99 eyes of 96 patients with at least 6 months follow-up were reviewed (mean follow-up 63.38 months). There were 113 men and the mean age was 39.6 years (8-72 years). Myopia was present in 81 eyes (63.3%) with mean myopia -7.56 dioptres sphere, DS (-1.00 to -27.00 DS). All eyes underwent pars plana vitrectomy. Scleral buckling was done in 90 eyes (70.3%) and lens removal in 49 of 95 phakic eyes (51.2%). Total 84 eyes (84.8%) were re-attached at 6 months after vitrectomy. This was achieved with one surgery in 71 eyes (71.7%). The mean number of surgeries for reattachment was 1.19 surgeries. At 6 months, 41 eyes (41.4%) regained 20/40 or better vision. A total of 47 vitreoretinal pathologies were seen in the fellow eyes of the 124 patients, including 4 with GRTs. Surgical success for GRT can be achieved with good visual outcome in 84.8% after a mean of 1.19 surgeries. The fellow eyes are however at risk of pathologies and should be followed-up in the long term.

Perfluoro-N-octane as Postoperative Vitreous Substitutes in Retinal Detachment: A Case Report

Purpose: To report a case of retinal detachment with a giant retinal tear, which was treated with perfluorocarbon liquid as an intraocular substitute. Case summary: A 37-year-old woman with a dislocated lens and a giant retinal tear underwent vitrectomy and lensectomy and was instructed to maintain a supine position after the operation. Perfluorocarbon liquid (Perfluoro-N-octane, C8F18) was used as a substitute in the vitreous cavity for 17 days. After 17 days, the perfluorocarbon liquid was removed and intraocular lens scleral fixation was performed. After removal of the perfluorocarbon liquid, the corneal endothelium was stable without other complications (including corneal edema, elevated intraocular pressure, ocular hypotony, macular pucker), and the best corrected visual acuity after intraocular lens scleral fixation was 0.4. Conclusions: Perfluorocarbon liquid is a useful surgical material in patients with a dislocated lens and retinal detachment with a giant retinal tear who have difficulty maintaining a prone position.

Postoperative giant retinal pseudotear.

To describe a case of an unusual vitreous membrane simulating detachment of a giant retinal tear after previous surgical repair. A 52-year-old man underwent vitrectomy for repair of a giant retinal tear. Six weeks later, a prominent vitreous membrane simulating recurrent detachment of the giant retinal tear was noted. Fundus photography, fluorescein angiography, and optical coherence tomography were used to characterize the membrane and its relationship to the contiguous retina. Fluorescein angiography and optical coherence tomography confirmed avascularity of the lesion and presence of retinal vessels and retinal tissue extending anterior to the membrane without distortion. Follow-up 8 months later demonstrated no progression, complete retinal attachment, and visual acuity of 20/20. Recognition of this condition is important to avoid unnecessary reoperation. Findings were consistent with a condensed hyaloidal membrane or organized postoperative fibrin membrane. The term "giant retinal pseudotear" is proposed.

SILICONE OIL TAMPONADE IN 23-GAUGE TRANSCONJUNCTIVAL SUTURELESS VITRECTOMY

To describe 20 consecutive patients treated with 23-gauge transconjunctival sutureless vitrectomy and silicone oil tamponade for retinal detachments (RD) of different etiologies. Prospective case series. Twenty patients with complex retinal detachment were submitted to a primary 23-gauge transconjunctival pars plana vitrectomy: rhegmatogenous retinal detachment with proliferative vitreoretinopathy (RRD + PVR) in 7 cases, diabetic tractional retinal detachment (DTRD) in 5 cases, giant retinal tear (GRT) in 2 cases, RRD with multiple tears in 2 cases, GRT + uveitis in 1 case, RRD + uveitis in 1 case, DTRD + RRD in 1 case, and RRD + PVR with intraocular foreign body (IOFB) in 1 case. Length of postoperative follow up ranged from 3 to 14 months. Final visual acuity ranged from 20/25 to hand motion. Postoperatively, none of the 20 eyes had hypotony or leakage of silicone oil through the sclerotomies. Seventeen out of 20 (85%) had improved vision. Silicone oil tamponade was demonstrated to be a feasible option in conjunction with 23-g transconjunctival sutureless vitrectomy to treat complex retinal detachment.

Retinal Detachment and Prophylaxis in Type 1 Stickler Syndrome

To report the prevalence of retinal detachment (RD) and results of prophylaxis against detachment from a giant retinal tear in a large cohort of patients with type 1 Stickler syndrome. Retrospective study. Two hundred four type 1 Stickler syndrome patients. Pedigrees and individuals with type 1 Stickler syndrome were identified from the vitreous research clinic and divided into 3 groups. Group 1 consisted of patients who received no prophylaxis (control group). Group 2 consisted of patients who had bilateral 360 degrees prophylactic cryotherapy (study group). Group 3 consisted of patients referred with unilateral RD for surgical repair and who underwent prophylaxis in the fellow eye (mixed group). Retinal status after prophylaxis, with failure of prophylaxis being defined as the development of RD or retinal tears needing further retinopexy. Of 111 patients who had no prophylactic retinopexy (group 1; mean age, 49 years), 73% (81/111) suffered RD and 48% (53/111) were bilateral. Of 62 patients who had bilateral prophylactic cryotherapy (group 2; mean age, 21 years), 8% (5/62) suffered failure of prophylaxis. There were no cases of bilateral detachments. The mean follow-up period was 11.5 years. In 31 patients who had unilateral prophylactic cryotherapy to the fellow eye (group 3; mean age, 36 years), failure occurred in 10% (3/31) of cases with a mean follow-up of 15.5 years. The prevalence of failure of prophylaxis in treated patients was significantly less than prevalence of RD in untreated patients (chi2(1) = 119.2, P<0.001). Prophylactic cryotherapy substantially reduces the risk of RD in type 1 Stickler syndrome and, in this series, eliminated the risk of bilateral detachments.

Emulsification of Densiron-68 used in inferior retinal detachment surgery

To report the clinical features of eight patients presenting with emulsification of the heavier than water vitreous substitute, Densiron-68. Two patients underwent primary inferior retinal detachment (RD) surgery, two patients underwent giant retinal tear repair, three patients had repair of inferior RD complicated by proliferative vitreoretinopathy and one patient had inferior RD surgery following repair of a scleral rupture. All patients had insertion of Densiron-68. Significant emulsification of Densiron-68 was seen within 12 weeks of surgery in eight cases out of a total of 40 patients receiving Densiron-68. Despite adequate Densiron fills, emulsification necessitated its removal. Emulsified Densiron may have contributed to significant intraocular inflammation, epiretinal membrane formation and cystoid macular oedema. Without removal, prolonged presence of emulsified Densiron may lead to keratopathy, secondary glaucoma and retinal toxicity secondary to partitioning of perfluorohexyloctane. This has potentially significant implications on the indications for Densiron-68 use and warrants consideration before deciding on the optimal surgical intervention for inferior RDs.

OUTCOMES OF TRANSCONJUNCTIVAL SUTURELESS 25-GAUGE VITRECTOMY WITH SILICONE OIL INFUSION

To evaluate the outcomes and complications of surgical management with 25-gauge pars plana vitrectomy (PPV) and silicone oil (SO) tamponade in complex vitreoretinal diseases. Retrospective review of a consecutive, interventional case series at a single center. Thirty-five eyes of 35 patients were included in the study. The indications for vitrectomy included tractional retinal detachment (11 eyes), macular hole (6 eyes), proliferative vitreoretinopathy or recurrent retinal detachment (9 eyes), neovascular glaucoma (3 eyes), giant retinal tear (3 eyes), and pathologic myopia with epiretinal membrane or macular hole (3 eyes). All patients underwent 25-gauge PPV with either 1,000-centistoke (n = 31) or 5,000-centistoke (n = 4) SO tamponade infused through a 24-gauge angiocatheter. No intraoperative complications were noted. The median preoperative visual acuity was counting fingers (range, 20/50 to light perception). The median postoperative visual acuity after a median follow-up of 6 months (range, 1-19 months) was 20/200 (range, 20/30 to light perception). A small subconjunctival SO bleb was identified in two patients. Recurrent retinal detachment occurred in three patients. No significant complications relating to the use of SO in the setting of 25-gauge PPV occurred. Advances in 25-gauge PPV instrumentation have enabled expanding indications for 25-gauge PPV. 25-Gauge PPV with SO tamponade is safe and efficient and can be considered in the surgical management of complex vitreoretinal disease.

Prevention and control of proliferative vitreoretinopathy: primary retinal detachment surgery using silicone oil as a planned two-stage procedure in high-risk cases

For rhegmatogenous retinal detachment, reattachment with a single procedure is associated with better visual outcomes. In the past, silicone oil has been used mostly as a last resort following failed primary surgery. This study evaluates a novel approach to patients at high risk of primary failure, using silicone tamponade as the primary stage of a planned two-stage procedure. We report a series of 140 eyes that underwent primary surgery for rhegmatogenous retinal detachment. Patients at higher risk of surgical failure (eg giant retinal tear, inability to posture, poor view, uncertainty of location of primary break, primary proliferative vitreoretinopathy (PVR), multiple tears with rolled posterior edges, retinoschisis/detachment, staphyloma with macular hole) were managed by a planned staged procedure using primary silicone oil tamponade. This was followed by silicone removal at a later date. Fifty-four eyes underwent scleral buckling alone, with primary success in 52/54 (96%). Fifty-three eyes underwent vitrectomy and gas, achieving primary success in 50/53 (94%). Thirty-three eyes were classified high risk and managed with primary silicone. Silicone was safely removed in 22/25. In eight eyes, silicone was retained without attempt at removal. In total, primary retinal reattachment was achieved in 128 of 140 eyes (91.4%). Of these, 124 (97%) did not require long-term tamponade. Only four eyes (2.9%) developed PVR. A planned two-stage approach to highrisk cases of retinal detachment using primary silicone oil tamponade followed by silicone removal can achieve a high primary reattachment rate with less than 3% incidence of PVR.

Secondary proliferations in heavy silicone oil endotamponade.

To describe postoperative complications in a patient with a giant retinal tear and heavy silicone oil endotamponade. Case report. A 16-year-old girl with a giant retinal tear underwent 20-gauge three-port pars plana vitrectomy with scleral buckling and heavy silicone oil endotamponade (Oxane HD; Bausch & Lomb, Toulouse, France). During follow-up, early emulsification of the silicone oil and severe secondary membrane proliferation within the silicone oil and retinal interface were detected. Exchange of silicone oil (5,000 centistokes) and membrane removal were performed. Histologic evaluation revealed fibrosis and a foreign body-type reaction. Secondary proliferations may become a provoked inflammatory response to heavy silicone oil; therefore, further controlled clinical trials should be performed to evaluate these potential side effects before heavy silicone oil is routinely used as a temporary vitreous substitute in eyes with complicated retinal detachments.

25-gauge vitrectomy under topical anesthesia

Dear Editor, We read with interest, the article by Raju et al.1 We must congratulate the authors for the excellent article but we would like to make a few points which would make the article more relevant. The total time required for each of the surgeries was not mentioned anywhere. After practicing as a vitreoretinal surgeon for the last 12 years and having carried out hundreds of retinal procedures, I (first author) know that several patients experience pain after a variable amount of time ranging from 1h onwards even after full peribulbar block. These patients require supplemental parabulbar or subtenon anesthesia to make them comfortable. The surgeries under topical anesthesia would have to be really quick to prevent this problem even though the authors have mentioned that with the 25-G vitrectomy system there is minimal touching of the sclera or the choroid. What do the authors mean by no inadvertent movements were noted during surgery? Do they mean that the eyes did not move at all? It has been well documented that topical and even subtenon anesthesia allows significant movement of the eye.2 The authors have mentioned one case of epiretinal membrane removal; any inadvertent movement at this stage can lead to disasters as we are working on the macula. The authors have not mentioned whether the retinal periphery was examined with indirect ophthalmoscope and depression at the end of the procedure to rule out retinal breaks or dialyses induced by insertion of instruments through the sclerotomies. If yes then did the patients get pain or were they restless? Incidence of retinal breaks is as high as 8% in pars plana vitrectomies3 and should be identified and treated at the time of surgery to prevent retinal detachment in future. We assume a BIOM was used during surgery but even with wide-angle viewing systems it is many a time difficult to see up to the ora and an examination with an indirect ophthalmoscope and depression would be advisable. If there are any iatrogenic breaks or any preexisting peripheral lattice/breaks a cryo would be necessary which would again cause considerable pain. Endo laser or laser indirect ophthalmoscopy are not always possible due to a variety of reasons. Vitrectomies are sometimes quite unpredictable and there have been times where I (first author) have had to do additional unplanned buckling procedures for dialyses or giant retinal tears occurring during so-called routine vitrectomies - we wonder how the authors would have managed such cases. One case involved removal of the intraocular lens (IOL) in an eye with endophthalmitis together with vitrectomy. Was intracameral lignocaine used in this case? Handling of the normal iris results in considerable pain and we would assume an inflamed iris would be very sensitive. And of course, not pertinent to this discussion - why was the IOL removed? Some cases were labeled as fungal and intravitreal Amphotericin was given. Was the microbiological diagnosis made prior to the surgery or was the drug used empirically? I (first author) would prefer to switch to topical anesthesia for vitrectomy but we feel the surgeon's comfort, both physical and mental, is necessary for a successful surgical outcome.4 The only vitreous surgery which is totally predictable is vitreous surgery for endophthalmitis but even in these eyes the inflammation may result in greater than normal pain as we have noted even during intravitreal injections.

Traitement des décollements de rétine par déchirure géante: Étude rétrospective à propos de 23 cas

Report of anatomic and functional results of retinal detachment with giant retinal tear. Retrospective study of 23 cases of retinal detachment resulting from retinal tear of 90 degrees or more: five had a history of ocular trauma, 14 had myopia, and six had no risk for giant retinal tear. Episcleral surgery was performed on cases of giant retinal tear less than 180 degrees , with no advanced proliferative vitreoretinopathy and no inversion of the retinal flap. A vitrectomy was performed on other cases. Scleral buckle was associated with vitrectomy in cases of advanced vitreoretinopathy. The degree of success in the primary surgery was 50% in vitreoretinal surgery, 75% in vitreoretinal surgery with an encircling scleral buckle, and 86.4% in episcleral surgery. Of the seven failed cases, six patients underwent second-intention surgery: vitrectomy in four cases (primary surgery: the first case, episcleral surgery; the next two cases, vitrectomy; and in the fourth, vitrectomy with an encircling scleral buckle). In the last two cases, vitrectomy with scleral buckle was used (the primary surgery in both cases was vitreoretinal surgery). The final success rate was 78.2%, and the average follow-up was 32 months. Through the last test, postsurgery acute vision improved in 16 cases. Vitrectomy is often recommended to repair retinal detachment with giant retinal tear. However, episcleral surgery can be used if the giant tear is less than 180 degrees , the proliferative vitreoretinopathy is not advanced, and the retina flap is not inverted. The scleral buckle must be associated with the vitrectomy in cases of inferior giant retinal tear even if the proliferative vitreoretinopathy is not advanced.

Idiopathic retinal holes in monozygotic twins

It remains controversial whether there is a significant genetic contribution to the pathogenesis of idiopathic giant retinal tears or retinal dialysis. In contrast, the underlying molecular genetic basis of several inherited vitreoretinal dystrophies is now well established, with also an increasing recognition of genetic factors in the development of myopia. We describe asymptomatic female monozygotic twins who were identified as having identical retinal holes. These cases represent the first evidence to our knowledge of a potential role of inherited factors in the causation of idiopathic peripheral retinal holes. This observation raises the need to examine the twin of any patient presenting with a retinal break(s).