Retinal Flap Research Articles

Surgical Treatment of Giant Retinal Tears with Inverted Posterior Retinal Flaps

We treated 23 consecutive cases of giant retinal tears with inverted retinal flaps. We used pars plana vitrectomy together with an intravitreal bubble to unfold the posterior retinal flap, combined with cryotherapy to cause a chorioretinal adhesion and a broad scleral buckle. The vitrectomy was done after applying cryotherapy so viable retinal pigment epithelial cells in the vitreous cavity could also be removed. Thirteen eyes had giant tears measuring 90 to 180 degrees (Group 1), eight eyes had giant tears measuring 180 to 270 degrees (Group 2), and two eyes had giant tears larger than 270 degrees (Group 3). The retina was successfully reattached in 11 of the 13 eyes in Group 1, each of the eight eyes in Group 2, and one of the two eyes in Group 3. We believe that vitrectomy and lavage of the vitreous cavity after applying cryotherapy was important in reducing the incidence of proliferative vitreoretinopathy and improving our success rate.

Surgical techniques for selected giant retinal tears.

Based on clinical experience, improved methods for treating giant retinal tears with an inverted retinal flap are described. In all cases a broad encircling scleral buckle is used in conjunction with a broad zone of peripheral chorioretinal adhesion produced by cryotherapy and, often, supplemented by postoperative photocoagulation. This virtually eliminates recurrent retinal detachment from an anterior location, if the retinal flap can be properly unfolded and the retina is initially reattached. Vitrectomy is done in all these cases, and an intraocular bubble is used to unfold and reposition the retinal flap during or after surgery. If the retinal flap is especially stiff or foreshortened, special techniques are used to incarcerate the edge of the retinal flap in the pars plana or the peripheral choroid, or transvitreal suturing techniques are used to secure the edge of the retinal flap to the eyewall before fluid-gas exchange is performed. This insures proper unfolding of the flap by the intraocular bubble. Applying retinal cryotherapy before performing the vitrectomy seems to reduce the occurrence of postoperative proliferative vitreoretinopathy (PVR), perhaps because retinal pigment epithelial cells in the vitreous cavity are removed during vitrectomy. Frequent, detailed examination during the first three weeks after surgery and use of postoperative photocoagulation to supplement the cryotherapy seem to prevent recurrent detachment from anterior leakage of subretinal fluid beneath the retinal flap or through other anterior retinal breaks.

Subtotal Open-Sky Vitrectomy for Severe Retinal Detachment Occurring as a Late Complication of Ocular Trauma

Subtotal open-sky vitrectomy was performed on 50 eyes with severe retinal detachment that developed as a late complication of ocular trauma. The retina was reattached in 32% of the eyes and vision was improved in 50% of the reattached cases. Two cases of giant retinal tear with massive preretinal retraction were successfully treated by suturing the retinal flap of the tear to the choroid. Subtotal open-sky vitrectomy may be helpful in cases in which closed vitrectomy has failed or would be likely to fail.

Broad Scleral Buckle in the Management of Retinal Detachments with Giant Tears

One of us (T.R.S.) operated on 24 patients with 26 retinal detachments caused by giant tears between 1969 and 1975 with the use of a broad silicone implant and diathermy. Minimum follow-up was six months. The technique included a scleral dissection extending at least three circumferential rows of diathermy posterior to the folded edge of the retinal flap, up onto the ora serrata, and two hours of the clock beyond each end of the tear. The retina was intentionally incarcerated on the buckle when subretinal fluid was drained. Sixty-nine percent of the cases were successfully reattached. If those patients with radial tears extending from the circumferential tears to the disk were excluded, the success rate rose to 75%. Seventeen percent of the successful reattachments required a second scleral buckle operation. Giant tears with radial tears extending to the disk, tears greater than 180 degrees, and immobile posteriorly everted flaps were poor prognostic signs. Thirty-five percent of the eyes with giant tears and a detachment had other holes or tears in the retina of that eye.

Fluorescein angiography of degenerative lesions of the peripheral fundus and rhegmatogenous retinal detachment.

Since the number of cases for each of the conditions in our study was small, only preliminary conclusions can be made; in order to establish the fluorescein pattern of each of these peripheral retinal lesions, additional studies will be required. The following summarizes our preliminary observations. 1. Areas of retinal white-with-pressure or without and peripheral retinal cystoid degeneration did not reveal remarkable fluorescein angiographic findings. One exception was in an area of pigment epithelial disturbance characterized by atrophy and proliferation, which showed a "window and masking" effect of choroidal fluorescence. 2. Fluorescein angiography of areas of the fundus with lattice retinal degeneration showed little or no findings in early or mild cases. In severe or advanced cases, the affected retina revealed poor or absent perfusion caused by vascular occlusion. The retinal and choroidal circulation was devoid of fluorescein leakage. Advanced lesions displayed choroidal hypofluorescence in areas of pigment proliferation and hyperfluorescence in areas of pigment atrophy. 3. In advanced cases, occlusive vascular changes over areas of acquired retinoschisis were observed. There was intraretinal leakage of the dye from deep capillaries and pooling of the dye in cystic cavities near the margin of the retinoschisis. 4. There was no perfusion of the choroid and retina in the area of the hole and in the retina surrounding it. This finding suggests choroidal and retinal ischemia in the pathogenesis of a retinal hole. 5. Fluorescein angiography of retinal tears revealed fluorescein leakage along the edge of the tear and absent perfusion of the retinal flap. The retinal and choroidal circulation-around the tear was otherwise unremarkable. The choroidal fluorescein underlying the retinal flap was not visible, perhaps because it was masked by the retinal flap. 6. Our fluorescein angiographic findings in cases of rhegmatogenous retinal detachment confirmed those of others [7, 8, 10]. Transit of fluorescein through the retinal circulation was sluggish. The retinal capillaries were dilated. 7. In cases of rhegmatogenous retinal detachment which had become reattached surgically, areas treated with diathermy or cryoapplications showed absent or diminished choroidal and retinal perfusion. Leakage of the fluorescein from capillaries in the optic disc and retina in the posterior pole was sometimes persistent several months postoperatively.

IV. Intraocular Balloon: Clinical Application

A vitreous probe with an inflatable latex balloon at its tip is described, as well as the technique of its use. This instrument was used as an adjunct in the management of 16 cases of giant retinal breaks with a bound down inverted posterior retinal flap. The adhesions between the flap and the underlying retina were broken in 11 cases so that the flap could be unfolded. With the retinal flap mobilized, the case was made operable. Of the 16 cases, four patients have had reattachment of the retina with useful vision. Results obtained with the instrument to mobilize a bound down retinal flap and to reattach a retina with a tear of 270° are illustrated in a case report.

Silicone injection in retinal detachment.

Silicone injection was used to treat 100 cases of retinal detachment: 68 eyes with massive preretinal retraction (MPR); 25 with a giant retinal break and MPR; and 7 with a giant retinal break, without MPR, whose posterior retinal flap could not be unrolled. Anatomically successful reattachment of the retina was obtained in six (9%) of the 68 eyes, two (8%) of the 25, and three (43%) of the 7. Improvement of visual function in these successes was equivocal. Preoperative examination, surgical techniques, and postoperative appearance of silicone are described. Recurrent retinal detachment, proliferation, and opacification of preretinal membranes around the silicone bubble, cataract formation, and corneal opacification were frequent late complications.

A POWER-DRIVEN MULTIPOSITIONAL OPERATING TABLE.

The use of positioning and head exercises to unfold the inverted edge of a giant retinal break has been reported briefly. 1 The inverted retinal flap of a superior giant break may unfold when the patient's head is lowered, as in the Trendelenburg position. In cases where complete unfolding is not accomplished with positioning, the addition of head exercises may achieve the desired result. Positioning and exercises generally are less effective when the patient is supine. They can be very effective when the patient is prone because the vitreous gel moves away from the inverted retinal flap and does not impede its unfolding. Once the retinal flap has unfolded, incarceration of the retina behind the posterior edge of the giant break before scleral buckling seems to be the best method of preventing reinversion and redetachment. It is necessary to incarcerate the retina with the patient in the most favorable position