Relaxing Retinectomy Research Articles

Direct Exchange of PerfluoroCarbon Liquid for Silicone Oil: A Surgical Technique to Control Pressure and Avoid Retinal Slippage.

Perfluorocarbon heavy liquid (PFCL) is used in vitreoretinal surgery to flatten the unsupported detached retina before insertion of silicone oil in cases of giant retinal tear or relaxing retinectomy. Direct exchange of PFCL for silicone oil is recommended to reduce retinal slippage when compared with fluid-air exchange, but it is commonly regarded as a difficult procedure. We describe our technique for direct PFCL-silicone oil exchange using a 20-gauge drainage cannula, reliably avoiding the complications of retinal slippage and high intraoperative intraocular pressure. We present a consecutive case series of patients undergoing PFCL-oil exchange and explain, using Poiseuille's equation for laminar fluid flow through a cannula, the rationale for using a 20-gauge drainage cannula rather than smaller gauges to avoid high intraocular pressure. Twenty-six patients underwent PFCL-oil exchange from February 1, 2019, to September 30, 2019. There was no intraoperative retinal slippage or pressure-related complications. Postoperatively 20 patients underwent oil removal. Six suffered retinal redetachment, and 14 remained attached. The vision postoil removal ranged from 6/6 to hand movements. We are confident that the PFCL-oil exchange technique described here is reliable and safe. The use of a 20-gauge drainage cannula is recommended regardless of vitrectomy gauge.

Complete manuscript title: role of sub-silicone oil application of triamcinolone acetonide (TA) drops on outcomes after 360° relaxing retinectomy: a pilot study.

To perform a pilot study to evaluate the role of sub-silicone oil Triamcinolone Acetonide (TA) crystal drops in complex Retinal Detachment (RD) with extreme proliferative vitreoretinopathy (PVR) requiring 360-degree relaxing retinectomy (RR). It was a retrospective pilot study. It was a retrospective case-control pilot study. TA-assisted 23G or 25G vitrectomy was done in 24 complex RDs with extreme PVR where 360 degree RR had to be performed. Group A (n = 13) included cases where additional TA crystal drops were applied, after settling the detached retina, over the site of RR under silicone oil (SO 5000 CSt) tamponade. In the control arm, group B (n = 11), additional TA crystals were not applied. Mean pre- and post-operative BCVA, ultra-widefield fundus photograph by Optos 200Tx, macular OCT and the propensity to remove silicone oil were measured. Mean pre-operative and post-operative BCVA at final follow-up were Log MAR 2.69 ± 0.41 and Log MAR 1.51 ± 0.90 (Mann-Whitney U test, p < 0.05), respectively, in Group A and Log MAR 2.9 and Log MAR 2.37 ± 0.86 (Mann-Whitney U test, p < 0.05), respectively, in group B. Visual improvement in group A was significantly better than group B (Wilcoxon W test, p < 0.025) with significantly less recurrence of RD (Fisher's Exact Test, p = 0.002). Silicone oil removal was done significantly more in group A (Fisher's Exact Test, p = 0.0017). Sub-silicone oil crystals application over sites of RR after 360-degree relaxing retinectomy leads to improved postoperative visual recovery as well as improved anatomical outcomes with fewer complications.

Coloboma associated retinal detachment: Anatomical and functional results in the era of microincision vitrectomy surgery with an evaluation of risk factors for a recurrence

Purpose:To analyze the anatomical and visual outcomes of microincision vitrectomy surgery (MIVS) with silicone oil tamponade in eyes having coloboma-related retinal detachment (RD) and evaluate the risk factors for recurrence of RD.Methods:This was a retrospective, multicentric analysis of eyes having coloboma RD undergoing MIVS with silicone oil tamponade between March 2010 and July 2018.Results:We evaluated 148 eyes of 144 patients. The mean age of presentation was 17.4 ± 9.8 years (range: 2–65 years) and the mean follow-up duration was 13.1 ± 13.8 months (range: 3–84 months). The single operation success rate was 88.5% (131 eyes), with an overall successful outcome achieved in 90.5% (134 eyes). Recurrence of RD occurred in 17 eyes (11.5%) over a mean duration of 2.59 ± 3 months. The risk of recurrence was found to be higher in eyes where relaxing retinectomy (RR) was performed (odds ratio [OR]: 3.22; P = 0.05). A statistically significant improvement in vision was noted in the majority of cases from logMAR 1.85 ± 0.34 preoperatively to logMAR 1.33 ± 0.6 post-surgery (P = 0.002).Conclusion:MIVS with silicone oil tamponade provided an anatomical success rate of 90.5% in eyes with coloboma RD with a significant improvement in visual acuity. Eyes in which RR was performed were susceptible to higher rates of re-detachment.

Management of inadvertent scleral penetration during retinal detachment surgery

We report the management of a case of inadvertent full-thickness scleral penetration during rhegmatogenous retinal detachment (RRD) surgery in a 14-year-old high myope while making partial-thickness scleral tunnel for the passage of the 240 silicone band. Sudden and gross hypotony with subretinal hemorrhage were noted post-penetration. Hypotony was immediately addressed by suturing the penetration site with a 7-0 vicryl suture. Subretinal blood was removed by performing 360° relaxing retinotomy and retinectomy and the retina was attached. This case report highlights the possible reasons for the full-thickness scleral penetration and one of the various methods to handle the same.

Unfolding falciform folds and their consequences - To touch or not to touch.

Background:Falciform folds are congenital tractional retinal folds due to strong contractile forces and hyperextensibility of retina resulting in temporal dragging of the macula and often associated with familial exudative vitreoretinopathy and retinal detachment (RD). Retinologists are reluctant to treat these entities in view of their poor visual recovery.Purpose:To describe a novel surgical technique to unfold the falciform folds.Synopsis:This video demonstrates innovative surgical techniques to remove both pre-retinal and sub-retinal adhesions and unfold these folds, managing its consequences and visual recovery. We describe cases of congenital falciform folds with poor visual acuity, where we did vitrectomy, membrane adhesion removal, peeling of the internal limiting membrane (ILM) the macula, mechanical stretching of the folded retina by Tanno scraper or Finesse flex loop, then sub-retinal injection of balanced salt solution (BSS) by 38 gauge sub-retinal needle o create multiple blebs around the folded retina and finally sulphur hexafluoride tamponade. Post-operative macular hole with RD can be a complication. When this falciform fold is complicated by RD, there is risk of intraoperative subretinal migration of infusion cannula and therefore the need for peripheral relaxing retinectomy for redundant retinal fold as well as silicone oil as endotamponade. Vision improved in all our patients after the surgery.Highlights:Both long-standing pre-retinal adhesions as well as sub-retinal adhesions are responsible for he tformation of congenital falciform folds. For pre-retinal adhesions, vitrectomy with removal of all the adhesions along with peeling of the sticky ILM and then mechanical stretching of folded retina by Tanno scraper or Finesse flex loop are necessary. To remove sub-retinal adhesions, sub-retinal injection of BSS is necessary to stretch the folded retina from behind, but it should be done away from the retina to avoid formation of macular hole.Online Video Link: https://youtu.be/9h8IE3abKIM

Macular Hole–Related Retinal Detachment in Children with Knobloch Syndrome

To describe the findings and the management of macular hole (MH)-related retinal detachment (RD) in children with Knobloch syndrome. Retrospective interventional case series. Patients with Knobloch syndrome who presented with MH-related RD. Retrospective chart review of patients with Knobloch syndrome who presented with MH-related RD from January 2012 to December 2018. Interventions included pars plana vitrectomy and silicone oil tamponade with or without scleral buckle, drainage retinotomy, or relaxing retinectomy. MH characteristics and surgical anatomical outcome. The study included 9 eyes of 5 patients (age range 2 months to 5 years; median age 5.5 months). Presenting symptoms were poor fixation and nystagmus. The fellow eye of 1 patient had RD due to peripheral breaks. The MH was clinically visible in 8 eyes and detected only by OCT in 1 eye. The RD was shallow and extended to the anterior equator in 7 eyes and localized to a punched-out atrophic lesion in 1 eye. Seven eyes underwent surgical repair. At the last follow-up examination (follow-up range 11 to 42 months; mean 24 months, standard deviation 11.8 months), retinal reattachment with MH closure was achieved in 5 eyes along with marked improvement in fixation. Patients with Knobloch syndrome may develop MH-related RD as early as infancy. The condition may be easily overlooked in children but should be suspected in the setting of high myopia, vitreoretinal degeneration, and encephalocele.

Intravitreal methotrexate for the treatment of proliferative vitreoretinopathy

Background/aimsPreventing and treating proliferative vitreoretinopathy (PVR) remain a serious challenge for vitreoretinal surgeons. PVR is a devastating complication of retinal detachment that results in recurrent detachment and limits visual recovery....

Outcomes of 25-Gauge Vitrectomy With Relaxing Retinectomy for Retinal Detachment Secondary to Proliferative Vitreoretinopathy

The aim of this study is to evaluate visual and anatomic outcomes of 25-gauge vitrectomy with relaxing retinectomies for complex retinal detachment (RD) secondary to proliferative vitreoretinopathy (PVR). A single-center, retrospective case series of 44 patients who had undergone a 25-gauge vitrectomy with a relaxing retinectomy for the treatment of combined RD and PVR was performed. Pre-operative characteristics, intraoperative techniques, and outcomes were analyzed. The rates of attachment, complications, and visual acuity were analyzed. Institutional Review Board/Ethics Committee approval was obtained and the described research adhered to the tenets of the Declaration of Helsinki. At the final follow-up, 27 eyes (61%) had attachment after one surgery, 41 eyes (93%) ultimately had attached retinas, 3 eyes (7%) had hypotony, 3 eyes had become phthisical (7%), and 24 eyes (56%) had improved visual acuity. After stratifying by visual outcomes, 20/400 or better BCVA was not associated with age (p=0.66), RD etiology (p=0.61), pre-operative hypotony (p=0.60), nor size of retinectomy (p=0.48). Patients achieving 20/400 vision or better were statistically more likely to be pseudophakic (p=0.024) and have silicone oil removal (p<0.0001). The use of 25-gauge vitrectomy and relaxing retinectomy provides a high rate of reattachment and improved visual acuity.

Outcomes of relaxing retinectomy in patients with proliferative vitreoretinopathy

Outcomes of relaxing retinectomy in patients with proliferative vitreoretinopathy

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

PurposeTo study anatomical and functional outcomes of retinectomies in rhegmatogenous retinal detachments complicated by proliferative vitreoretinopathy. MethodsThis 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. ResultsSeries included 370 eyes of 337 patients. Mean follow up was 39months. 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. ConclusionRelaxing retinectomies have good and encouraging anatomical and functional outcomes. This surgery can be effectively carried out with trans conjunctival sutureless vitrectomy technique.

INCIDENCE OF LENS TOUCH DURING PARS PLANA VITRECTOMY AND OUTCOMES FROM SUBSEQUENT CATARACT SURGERY.

To determine the incidence of lens touch during pars plana vitrectomy (PPV) and evaluate cataract surgery complications after lens touch. One thousand three hundred and ninety nine phakic patients who underwent PPV during the period from 2001 to 2013 were included in the study. Data of the PPV and lens touch (excluding lens bite) complications were reviewed from an electronic database (VITREOR). Subsequent cataract surgery data and intraoperative complications were reviewed. A control group consisted of 149 cases of phakic patients who underwent PPV with no lens touch then subsequent cataract surgery. All surgeries were performed by senior surgeons, and no cataract was present before the PPV. The incidence of lens touch was 3.7% (52 of 1,399 phakic patients). The Demographics and presenting complaints of the patients were not significantly associated with lens touch, but retinal detachment with proliferative vitreoretinopathy, the use of silicone oil and use of relaxing retinectomy were associated with more lens touch. Cataract developed in 49 patients of whom 45 underwent cataract surgery. Nuclear sclerosis developed in 22 patients, 16 had posterior subcapsular, 8 had mixed lens opacities, and 3 had white cataract. The median duration between PPV and cataract surgery was 4 months in the lens touch group, which was significantly shorter than the median of 8 months in the control group (P = 0.001). During the subsequent cataract surgery in the lens touch group, 5 patients (11%) had a posterior capsule rupture, whereas the control group had only 2 cases of posterior capsule rupture 1.4% (P = 0.008). Final visual acuity was 0.3 LogMar or better in 22 patients (44%). Lens touch is a frequent complication of PPV in a phakic eye. It is more common in patients having surgery for proliferative vitreoretinopathy. Care should be taken when performing subsequent cataract surgery on an eye with lens touch as it carries a significantly increased chance of posterior capsule rupture.

Beyond-the-edge proliferation after relaxing retinectomy

To report beyond-the-edge proliferation (BTEP) after relaxing retinectomies (RR) i.e. fibrous sheets stretched between the RR edge and the far periphery; to evaluate the tractional potential and report the long-term course of BTEP. Retrospective review of the medical records of 83 patients having undergone a RR between January 2009 and December 2014 to identify patients with BTEP. Six patients aged 31 to 76 were identified. Retinectomy had been performed for traumatic retinal incarceration in one case and anterior PVR in 5 cases. BTEP occurred within weeks of the RR (earliest: 5 weeks). It was discovered intraoperatively in two patients with silicone oil tamponade, at 7 weeks and 6 months respectively after RR. It recurred over a few months after excision in 5 patients, causing inferior tractional retinoschisis in 4 patients and inferior tractional retinal detachment in two patients. BTEP is an unusual form of proliferative vitreoretinopathy developing despite the absence of the usual vitreo-retinal support (excised during RR), probably through compartmentalization and cell migration along the inferior interface between silicone oil or gas and the aqueous humour. BTEP can cause serious retinal traction, develops over weeks after the RR and recurs frequently a few months after excision.

Spontaneous resolution of subfoveal perfluorocarbon

Perfluorocarbon liquids (PFCL) have transformed the surgical approach to complex retinal detachments, but their use can be complicated by subretinal retention. Migration of peripherally located subretinal PFCL towards the fovea is well established, but spontaneous resolution of subfoveal PFCL without surgical evacuation or displacement has rarely been described. We present a case of a large single retained subfoveal PFCL droplet following vitrectomy with membrane peeling, inferior relaxing retinectomy, and silicone oil tamponade that demonstrated spontaneous resolution 3 weeks postoperatively, with subsequent anatomic and visual improvement. No residual subretinal PFCL was noted, and we hypothesize that the PFCL droplet spontaneously extruded through a transient hole created in the thinned retina overlying the droplet, which subsequently closed spontaneously. Further understanding of the mechanisms of PFCL migration and resolution may facilitate improved treatments for this complication.

Outcomes of Relaxing Retinectomy in Patients with Proliferative Vitreoretinopathy

Purpose: To report the outcomes of relaxing retinectomy for retinal detachment in patients with proliferative vitreoretinopathy (PVR). Methods: Sixty-four cases of relaxing retinectomy for PVR with a minimum follow-up of 6 months were retrospectively reviewed. The outcomes included achievement of complete retinal reattachment, PVR recurrence, the mean number of additional operations, visual acuity and incidence of postoperative complications. We analyzed the influence of intraoperative factors including lens status, retinectomy extent, additional scleral buckling, and tamponade agent on primary retinal reattachment. Results: Complete retinal reattachment was achieved in 47 eyes (74.3%) without an additional surgery. PVR recurred in 19 eyes (29.7%) and an additional operation was performed in 17 eyes (26.6%). Fifty-seven (89.1%) eyes showed complete retinal reattachment and 40 eyes (62.5%) had visual acuity of 0.02 or more at the final follow-up visit. Hypotony was the major complication and developed in 10 eyes (15.6%). Eyes undergoing smaller (< 180 ) retinectomy or silicone oil tamponade had higher primary anatomical success rates than larger (≥ 180 ) retinectomy or gas tamponade (p = 0.043 and 0.013, respectively). Conclusions: Relaxing retinectomy is a useful technique for retinal detachment with PVR, but risk of recurrent proliferation or hypotony should be considered. J Korean Ophthalmol Soc 2015;56(6):900-905

Severe inferior retinal folding after retinectomy: an uncommon form of posterior proliferative vitreoretinopathy

AbstractPurpose Relaxing retinectomy is a surgical procedure commonly used in the presence of a retinal shortening in retinal detachments with severe proliferative vitreoretinopathy (PVR. Severe inferior retinal folding (SIRF) is an uncommon form of posterior PVR observed after retinectomy. This rare complication has been described in a single publication so far.Methods A 49‐year‐old woman presented with a 180° giant retinal tear with diffuse posterior PVR.Results She was treated with pars plana vitrectomy, retinectomy, internal limiting membrane peeling, endolaser and silicone oil tamponnade. A week after the retina was completely attached. Visual acuity was counting fingers. Twenty seven days after the intervention, a recurrent PVR detachment involving the lower hemi‐retina was observed. The lower retinal edge had retracted upwards away from the retinopexy scar (SIRF). Six months after the patient underwent silicone oil removal, epi‐retinal membrane peeling, repeat inferior retinectomy, endolaser and C2F6 tamponnade. The spared retina remained attached. Visual acuity was “hand motion”.Conclusion SIRF consists in an inferior widespread epi‐retinal membrane whose massive retraction capacity overcomes retinopexy adhesion. The inferior retina ends up retracted upwards like a Venetian blind, away from the retinopexy scars. SIRF is rare. It has been described only in 5 of 254 patients after relaxing retinectomy over a 9‐year period in Gupta et al. study.

Relaxing retinectomy for tractional retinal detachment with retinal capillary hemangiomas in genotypically confirmed von hippel-lindau disease.

To report the outcome of tractional retinal detachment with retinal capillary hemangiomas after pars plana vitrectomy (PPV) and relaxing retinectomy in genotypically confirmed von Hippel-Lindau disease (VHL). Interventional case report of a 28-year-old patient with multiple and large retinal capillary hemangiomas underwent PPV combined with relaxing retinectomy. Over the next several weeks, the retina recovered to reattachment and remained this way for 2 years. In excised angiomas, the finding of a missense Arg167Trp mutation and immunohistochemistry staining confirmed the diagnosis of VHL. Patients with tractional retinal detachment with hemangiomas secondary to VHL may benefit from PPV with relaxing retinectomy.

Planned Delayed Relaxing Retinotomy for Proliferative Vitreoretinopathy

A program involving three operations-the first to reattach most of the retina under silicone oil, the second to reattach the remaining retina by planned delayed relaxing retinectomy (PDRR), and the third to remove silicone oil-was tested. Review of electronic records of patients receiving PDRR for proliferative vitreoretinopathy (PVR). The primary end point was reattached retina without silicone oil. Eighty-seven patients had PVR and 27 received PDRR (mean age: 66.6 years; mean follow-up: 2.3 years). Ten patients had grade B PVR, 8 had CP1 to CP6, and 7 had CA2 to CA6. Twenty-four (89%) patients achieved a reattached retina without silicone oil. Mean logarithm of the minimum angle of resolution visual acuities were 1.41 (standard deviation = 0.67) at presentation and 1.21 (standard deviation = 0.58) at final follow-up. Four patients had glaucoma and 1 had scleromalacia. The overall success rate for all patients with PVR was 85% reattached retina without oil tamponade. PDRR contributes to a high chance of reattached retina and oil removal in PVR.

Severe folding of the inferior retina after relaxing retinectomy for proliferative vitreoretinopathy

Proliferative vitreoretinopathy (PVR) is a severe complication of retinal detachment, which can be treated surgically by relaxing retinectomy. In this study, we describe patients with severe inferior retinal folding after this surgical intervention (SIRF). A retrospective review of the electronic patient records of 254 patients who received relaxing retinectomies was performed to identify patients with SIRF. Five patients (1.97% of those with retinectomy) were identified with SIRF, mean age, 51.4 years; mean follow-up, 36 months. Three patients had rhegmatogenous retinal detachment (RRD) with PVR, one had a dropped nucleus with RRD and PVR and one with giant retinal dialysis from ocular trauma. SIRF was noted from a mean 4.2 months after the retinectomy. All involved the macula and visions were hand movements or perception of light. SIRF is an uncommon but devastating complication of relaxing retinectomy with a poor visual outcome. This is the first description of this condition that we are aware of.

Triamcinolone Acetonide in Silicone-Filled Eyes as Adjunctive Treatment for Proliferative Vitreoretinopathy: A Randomized Clinical Trial

To evaluate the effect of adjunctive intraocular triamcinolone acetonide (TA) in silicone-filled eyes on outcomes of vitreoretinal surgery for proliferative vitreoretinopathy (PVR). Prospective, randomized, controlled clinical trial. Seventy-five eyes with rhegmatogenous retinal detachment and PVR grade C (posterior, anterior, or both) undergoing vitrectomy combined with silicone oil tamponade were included. Of these, 38 eyes were assigned randomly to the adjunctive treatment, whereas 37 eyes served as controls. All eyes underwent pars plana vitrectomy, membrane peeling, and silicone oil exchange, with or without relaxing retinotomy or retinectomy. In the treatment group, 4 mg TA was injected into the silicone-filled vitreous cavity at the end of the procedure. Silicone oil was removed 3 months after surgery in eyes with attached retinas. The primary outcome measure was retinal reattachment rate at 6 months. Secondary outcome measures included visual acuity, rate of recurrent PVR, reoperation rate, and rise of intraocular pressure. Retinal reattachment without any reoperation was achieved in 32 eyes (84.2%) and 29 eyes (78.4%) in the adjunctive treatment and control groups, respectively, at 6 months (P = 0.5). No statistically significant difference was observed between the 2 groups in terms of any of the secondary outcome measures (P>0.05). The outcomes of vitreoretinal surgery for established PVR are not improved significantly by adjunctive TA injection in silicone-filled eyes.

Repair of Retinal Detachments Due to Herpes Varicella-Zoster Virus Retinitis in Patients with Acquired Immune Deficiency Syndrome

Purpose: The authors characterize surgical techniques and report results for repair of retinal detachments due to varicella-zoster retinitis in patients with acquired immune deficiency syndrome (AIDS).Background: Varicella-zoster virus (VZV) retinitis is a distinctly aggressive infection in patients with AIDS. Retinal detachments occur in the majority of such patients, and contribute to their poor visual prognosis.Methods: A case series of five eyes in four patients with AIDS and retinal detachments due to VZV retinitis is presented, highlighting surgical technique and results. Pars plana vitrectomy, silicone oil tamponade, and endolaser photocoagulation were used in all cases.Results: Apparent contraction of the necrotic retina was observed, requiring large relaxing retinectomies to achieve retinal attachment in three of the five eyes. Follow up after surgery was 4, 6, 15, 29, and 30 months. Four eyes maintained ambulatory vision and the retinas remained attached.Conclusion: Vitrectomy with silicone oil tamponade may be used to preserve ambulatory vision in carefully selected patients with AIDS and retinal detachments due to VZV retinitis. Relaxing retinectomy is a useful technique to achieve and maintain retinal attachment.