CH42 Management of Complicated Retinal Detachment

Z
Management of Complicated
R etinal Detachment
Jonx M. Lrvis G:r. W. Anr:xs J:xr C. Wrrxrr
the idea that dispersed retinal pigment epithelium cellsthat
settle on the inferior retina due to gravitational effectsplay
a prominent role in PVR formation.
Primary PVR can occur in a long-standing rheg-
matogenous retinal detachment. More commonly, it occurs
secondarily after scleral buckling, vitreoussurgery, or pneu-
matic retinopexy treatment for rhegmatogenous retinal
detachment, and is the leading cause of surgical failure and
redetachment of the retina. Experimental study has shown
that various factors associated with surgery, such as exten-
sive application of cryotherapy (14), brin formation (15),
and bloodretinal barrier breakdown may increase PVR
formation.
Surgical Anatomy
The severity and extent of PVR can be described accord-
ing to a classication system developed by the Retina
Society in 1983 (Table 42-1) (5) and updated in 1991
(Tables42-2 and 42-3) (6). Posterior PVR (posterior to the
equator) consistsof focal and diffuse retinal contractionsand
subretinal membranes, while anterior PVR (at or anterior
to the equator) consists of focal, diffuse, or circumferential
full-thickness folds, anterior retinal displacement, and sub-
retinal membranes. Focal contractionsare star folds, which
are caused by contraction of a localized epiretinal mem-
brane. Diffuse contractions involve four or more disk areas
and are induced by larger membranes (Fig. 42-2). Folds
without epiretinal membranes usually indicate the presence
of subretinal membranes.
Anterior PVR may result from deposition and pro-
liferation of pigment epithelial cellson the inferior periph-
eral retina along with contraction at the posterior edge of
the vitreous base (Fig. 42-3). These membranes induce cir-
cumferential contraction,shortening the circumference of the
C h a p t e r
42
Retinal detachments are considered complicated when
reparation requiresmore than a scleral buckle. Complicated
retinal detachments may be associated with vitreous hem-
orrhage, proliferative vitreoretinopathy (PVR), giant tears,
posterior holes or tears, choroidal detachments, ocular
inammatory diseases, trauma, and tractional retinal detach-
ments. Complicated retinal detachments associated with
giant retinal tears, ocular inammatory diseases, trauma, and
proliferative retinopathies such as diabetic retinopathy will
be discussed elsewhere.
RETINAL DETACHMENT WITH
PROLIFERATIVE VITREORETINOPATHY
Overview
PVR is the leading cause of failure in retinal detachment
surgery, occurring in approximately 7%of all retinal detach-
ments(1). During the past two decades, major advanceshave
been made both in the understanding of the pathogenesis
of PVR and in the surgical treatment of the disease (28).
PVR ischaracterized by the formation of cellular mem-
branes on the retinal surface, the retinal undersurface, and
in the vitreouscavity (Fig. 42-1) (9). Cellswithin the mem-
branes are derived from the retinal pigment epithelium
(10,11) and from retinal glial tissue (12,13).These cellsenter
the vitreous cavity or subretinal space via breaks in the
retina, undergo transformation to take on characteristics of
broblasts or macrophages, and proliferate in a sheet-like
conguration. Fibroblast-like transformed cells have con-
tractile properties, with the ability to pull collagen bersin
a hand-over-hand manner (2). Thus the proliferative cel-
lular membrane can insert into the vitreousand exert forces
leading to tractional retinal detachment. Involvement is
often most severe inferiorly; this nding is consistent with
531
HTH42 8/20/98 4:05 PM Page 531
retina at the posterior vitreousbase, which ispulled centrally.
The retina posterior to the vitreousbase developsradial folds,
while retina anterior to the posterior edge of the vitreous
base issmooth and pulled centrally (Fig. 42-4).With chronic-
ity, there may be contraction of the vitreousbase, which pulls
the retina posterior to it anteriorly toward the parsplana,thus
resulting in anterior retinal displacement. However, anterior
retinal displacement ismore commonly seen in eyesthat have
previously had a vitrectomy (Fig. 42-5). In these eyes, prolif-
erating cellsform a membrane on the surface of the remain-
ing peripheral vitreous, which contracts, pulling the retina
posterior to the vitreousbase anteriorly toward the parsplana
(Fig. 42-6A), the parsciliaris(Fig. 42-6B), or even the pos-
terior surface of the iris (Fig. 42-6C). In the most extreme
instances, the membranescan pull the retina to the edge of
the retracted pupil (Fig. 42-6D).
532 PART III Retinaand Vitreous Surgery
Z
A
B
C
Tabl e 42- 1. The Retina Society Classication of Retinal
Detachment with PVR
Grade Clinical Signs
A Minimal vitreoushaze
Vitreouspigment clumps
B Moderatewrinklingof theinner retinal surface
Rollededgeof retinal break
Retinal stiffness
Vessel tortuosity
C Markedfull-thicknessxedretinal folds
C1 Onequadrant
C2 Twoquadrants
C3 Threequadrants
D Massivexedretinal foldsinfour quadrants
D1 Widefunnel shape
D2 Narrowfunnel shape*
D3 Closedfunnel (opticnerveheadnot visible)
* Narrow funnel shape exists when the anterior end of the funnel can be seen by
indirect ophthalmoscope within the 45-degree eld of a 20 D condensing lens
(Nikon or equivalent).
FI GURE 42- 1. A. Mi grat i on of pi gment epi t hel i al and ot her
cel l s i nt o vi t reous cavi t y and subret i nal space. B. Proliferat ion and
cont ract i on of cel l s on ret i nal and vi t reous i nt erfaces. C. Fi xed fol ds
due t o cont ract i on of cel l ul ar membranes. (Adapt ed from Abrams
GW, Aaberg TM. Post eri or segment vi t rect omy. In: Wal t man SR (ed.).
Surgery of the eye. New York: Churchi l l -Li vi ngst one, 1988:
9031012.)
FI GURE 42- 2. Post eri or PVR: St arfol d (smal l arrow) (post eri or
t ype 1), di ffuse cont ract i on (l arge arrow) (post eri or t ype 2).
Cl assi cat i on i s CP12. (Repri nt ed by permi ssi on from Abrams GW,
Aaberg TM. Post eri or segment vi t rect omy. In Wal t man SR (ed.).
Surgery of the eye. New York: Churchi l l -Li vi ngst one,
1988:9031012.)
FI GURE 42- 3. Cont ract i on al ong post eri or edge of vi t reous
base wi t h cent ral di spl acement of ret i na. Peri pheral ret i na
st ret ched(* ); post eri or ret i na i n radi al fol ds() (ant eri or t ype 4).
(Repri nt ed court esy of Opht hal mi c Publ i shi ng Company, from
Machemer R, Aaberg TM, Freeman HM, et al . An updat ed
cl assi cat i on of ret i nal det achment wi t h prol i ferat i ve
vit reoret inopat hy. Am J Ophthalmol 1991;112:159165.)
HTH42 8/20/98 4:05 PM Page 532
Surgical Technique
Scleral Buckle vs. Vitrectomy
Primary retinal detachment associated with low-grade PVR
(grade A or B and limited grade C) can usually be managed
by retinal reattachment surgery with a scleral buckle (16).
In cases where retinal detachment is associated with higher
grades of PVR and in recurrent retinal detachment with
Chapter 42 Management of Complicated Retinal Detachment 533
Z
Tabl e 42- 3. Updated Classication of PVR:
Grade C PVR Described by Contraction Type
Type Location Features
1Focal Posterior Starfoldposterior tovitreousbase
2Diffuse Posterior Conuent starfoldsposterior to
vitreousbase
Opticdiskmaynot bevisible
3Subretinal Posterior Proliferationsunder retina:
or Anterior Napkin-ringarounddisk
Clotheslinemoth-eaten-
appearingsheets
4Circumferential Anterior Contractionalongposterior edgeof
vitreousbasewithcentral
displacement of theretina
Peripheral retinastretched
Posterior retinainradial folds
5Anterior displacement Anterior Vitreousbasepulledanteriorlyby
proliferativetissue
Peripheral retinal trough
Ciliaryprocessesmaybestretchedor
maybecoveredbymembrane
Irismayberetracted
Tabl e 42- 2. Updated Classication of PVR
Described by Grade
Grade Features
A Vitreoushaze
Vitreouspigment clumps
Pigment clustersoninferior retina
B Wrinklingof inner retinal surface
Retinal stiffness
Vessel tortuosity
Rolledandirregular edgesof retinal break
Decreasedmobilityof vitreous
C
CP112* Posterior toequator:
Focal,diffuse,or circumferential full-thicknessfolds
Subretinal strands
CA112 Anterior toequator:
Focal,diffuse,or circumferential full-thicknessfolds
Anterior displacement
Subretinal strands
Condensedvitreouswithstrands
* Expressed in the number of clock hours involved.
A B
C
FI GURE 42- 4. Prol i ferat i ve vi t reoret i nopat hy grade C. Type 4:
ci rcumferent i al cont ract i on wi t h prol i ferat i on i mmedi at el y behi nd
i nsert i on of t he post eri or hyal oi d pul l i ng ret i na cent ral l y, st ret chi ng
t he ret i na ant eri or t o i t , and creat i ng radi al fol ds post eri orl y.
Schemat i c drawi ng of si t uat i on i n nonvi t rect omi zed eye (left) and
vit rect omized eye (right). Arrowsshow direct ion of pull. (Adapt ed
court esy of Opht hal mi c Publ i shi ng Company, from Machemer R,
Aaberg TM, Freeman HM, et al . An updat ed cl assi cat i on of ret i nal
det achment wi t h prol i ferat i ve vi t reoret i nopat hy. Am J Ophthalmol
1991;112:159165.)
FI GURE 42- 5. Ant eri or ret i nal di spl acement i n PVR. A.
Prol i ferat i on of cel l s on vi t reous base and ret i na fol l owi ng vi t rect omy
and scl eral buckl e. B. Cont ract i on of cel l ul ar membranes pul l s ret i na
at post eri or vi t reous base ant eri orl y. C. Vi t reous base depressed i nt o
vi ew. Membrane exert i ng ant eri orpost eri or t ract i on i s sect i oned
wi t h vert i cal l y cut t i ng sci ssors. (Adapt ed from Abrams GW, Aaberg
TM. Post eri or segment vi t rect omy. In: Wal t man SR (ed.). Surgery of
the eye. New York: Churchi l l -Li vi ngst one, 1988:9031012.)
signicant PVR, or anytime when it isnot anticipated that
a scleral buckle will adequately relieve traction to reattach
the retina, vitreous surgery is usually indicated to relieve
tractional membranes and successfully reattach the retina.
HTH42 8/20/98 4:05 PM Page 533
Management with Scleral Buckle Only
When scleral buckling alone is judged adequate to treat a
retinal detachment associated with PVR, the general goals
of retinal reattachment surgery must be achieved, including
closure of all breaks and relief of vitreoretinal traction. The
techniques required are discussed in detail in Chapter 41,
but special considerations must be made in the presence
of PVR. With few exceptions, it is necessary to support
the vitreous base for 360 degrees by placing an encircling
element. Sometimes a fairly high degree of indentation is
necessary to relieve anterior traction adequately. The rec-
ommended width of the buckling element may vary with
the location of retinal breaksand the width of the vitreous
base.A narrower element will sufce if retinal breaksare rel-
atively anteriorly located and the vitreousbase isnot exces-
sively broad; however, a broader silicone tire or sponge
might be preferable if the vitreous base extends more pos-
teriorly. We use silicone tires or sponges varying from 5 to
7mm in width. Scleral sutures are usually placed 2mm
wider than the buckle, to increase scleral indentation and
buckle height. In general, placement of the buckle with its
anterior edge 2mm posterior to the muscle insertion ring
provides support for the posterior vitreous base and ante-
rior insertion of hyaloidal traction. Obviously, specic con-
ditions require modications of these general rules of
thumb, such aslong myopic eyeswith altered anatomic rela-
tionships. If a silicone tire and encircling band are used in
an eye with PVR, it isimportant that the tire be extended
throughout the inferior 180 degrees of the vitreous base,
and a conscious effort may be made to achieve greater
buckle height inferiorly by varying the width of the scleral
bites, since the inferior fundus is usually the most severely
involved with tractional membranes.
As in any retinal detachment repair, all retinal breaks
must be carefully identied and localized. Additional radial
buckling elements sutured in place beneath the encircling
element may sometimes be helpful in rhegmatogenous
retinal detachment with PVR that istreated by scleral buck-
ling alone. Breaksassociated with traction can sometimesbe
supported sufciently to relieve tractional forces.
Opening for Pars Plana Vitrectomy
When a vitrectomy is done for an eye with PVR, if no
scleral buckle is present, we recommend encircling the eye
with a scleral buckle to support the vitreous base and the
retina just posterior to the vitreous base. If the eye already
hasan encircling scleral buckle, we usually do not revise or
replace that element. Sometimes it is necessary to supple-
ment an existing scleral buckle, especially inferiorly, if there
is not adequate inferior support of the vitreous base. If the
eye haspreviously had only a radial scleral buckle, the radial
element isusually removed and an encircling scleral buckle
placed.
If the decision is made to perform a pars plana vitrec-
tomy, eyes with signicant PVR still require an encircling
element to support the vitreous base and relieve anterior
traction. Therefore, in eyes that do not have a preexisting
encircling element, a 360-degree conjunctival peritomy is
made just posterior to the limbus and the rectus muscles
isolated with 2-0 silk sutures.We often place the suturesfor
Z
A C
B D
E
FI GURE 42- 6. Ant eri or PVR: Ant eri or ret i nal di spl acement . Ret i na at post eri or aspect of vi t reous base i s drawn t o ant eri or vi t reous base (A),
t o ci l i ar y processes (B), t o post eri or i ri s (C), and t o pupi l wi t h i ri s ret ract i on (D). (E). Post eri or i nsert i on of t he vi t reous base drawn ant eri orl y creat i ng
ret i nal t rough. Fol ds t hat radi at e post eri orl y are caused by ci rcumferent i al cont ract i on. (Adapt ed from Lewi s H, Aaberg TM. Ant eri or prol i ferat i ve
vit reoret inopat hy. Am J Ophthalmol 1988;105:277.)
HTH42 8/20/98 4:05 PM Page 534
the scleral buckle prior to vitrectomy. At this time, the eye
is rmer and easier to place the sutures. We usually wait
until after the vitrectomy is completed to place the buck-
ling element around the eye. In most cases, we use a 4.5-
mm-wide encircling band to create a moderate buckle.
Some surgeons prefer to preplace scleral belt-loop inci-
sions, which may be technically easier prior to vitrectomy
when the eye is rmer. The disadvantage of preplacing
sutures or belt loops is that the surgeon loses the ability
to choose the type and placement of the buckle based on
the intraoperative ndings; however, in our experience
we rarely have to change the location or type of scleral
buckle following the vitrectomy. We feel that the 4.5-mm
encircling band will adequately support the vitreous base
in most cases of PVR following vitrectomy and that the
reduced volume of the band and reduced compression of
vortex veinsby the narrower element reduce complications
related to the scleral buckle in comparison with broader,
bulkier elements.
If the eye has an encircling element in place, it can be
left unaltered in most casesand conjunctival incisionsmade
in the usual fashion for a vitrectomy, exposing the tempo-
ral and superonasal sclera. Occasionally, modication of the
previousbuckle isdesirable.The buckling element islocated
by dissecting through itsbrouscapsule.Then the band can
be tightened, the buckle can be repositioned, additional
sutures can be placed to increase the height or location of
the buckle, or an additional scleral buckling element can
be placed. If, however, only a radial or segmental circum-
ferential element wasplaced at the time of previoussurgery,
it is usually best removed and replaced by an encircling
element.
Vitrectomy is most often performed via a 3-port pars
plana approach. Sclerotomy incisionsare made 3.0mm from
the limbusin aphakic and pseudophakic eyes, or when pars
plana lensectomy is planned. In the somewhat uncommon
circumstance in which the eye is to be left phakic (see
below), the incision is made 3.5mm from the limbus.
These distances must be modied if signicant anterior
displacement of the retina exists, in which case entry into
the vitreous cavity is made more anteriorly.
Incisions for the infusion and instruments are generally
made parallel to the limbus. When performing repeat vit-
rectomy, parallel incisions intended for the instruments
should be separated by at least 1mm from previousincisions
so the sclerotomies do not extend into the old sclerotomy
sitesduring vitrectomy and create large scleral defects. If the
sclera is thinned and macerated at the sites of the previous
sclerotomies, it may be advantageous to make radial inci-
sions, as these are less likely to extend into previous inci-
sions. The actual entry into the vitreous cavity must be
controlled, especially if the retina isbullous, to avoid retinal
perforation. In aphakic or pseudophakic eyes, the microvit-
reoretinal (MVR) blade should be inserted iris-parallel, and
the tip visualized in the pupil before it is withdrawn. The
infusion cannula is then inserted and tied permanently in
place. A 4-mm cannula is preferred in most cases, but in
caseswith severe anterior proliferative membranesand poor
visualization, a 6-mm cannula may facilitate entry into the
vitreouscavity. Before infusion to the eye isinitiated, the tip
of the cannula must be visualized through the pupil to
prevent subretinal infusion of uid. This can be done
through the operating microscope by grasping the base of
the cannula with nontoothed forceps and rotating the eye
until the tip comesinto view, or by using a beroptic light
probe externally and looking at the eye from an acute angle
(17). Once it has been positively ascertained that the tip of
the cannula isin the vitreouscavity and isfree of any mem-
branes or tissue, the infusion is turned on.
If the pupil will not dilate adequately, we dilate the pupil
using mechanical pupillary stretching (Fig. 42-7). Our pre-
ferred pupillary stretching devices are small plastic hooks
placed through the limbus in four quadrants (18) (Flexible
Iris Retractors, Grieshaber, Inc., Kennesaw, GA). We lyse
synechiae and remove residual capsular material asmuch as
possible prior to placing the stretching hooks in order to
minimize iris trauma. Limbal openings are made parallel
with and just anterior to the irisplane with a Ziegler-type
blade. The small hooks are secured externally at the limbus
with a small locking device.
Lensectomy
The crystalline lens, if present, should be removed in most
cases with signicant PVR, even if clear. Visual rehabilita-
tion ismost critically related to the statusof the retina, and
therefore refractive concerns must be secondary. It is not
possible to do an adequate vitreous base dissection in the
phakic eye. Removal of the lensallowsmore complete dis-
section of the vitreous base and anterior membranes, and
removal of all capsular material may decrease the likelihood
Z
FI GURE 42- 7. Pupi l l ar y st ret chi ng usi ng exi bl e i ri s
ret ract ors.
HTH42 8/20/98 4:05 PM Page 535
of recurrent anterior PVR. In addition, with prolonged gas
tamponade, the lens will almost always develop a cataract.
Management in the postoperative period, including
the ability to do a uidgas exchange and to administer
postoperative laser photocoagulation, isfacilitated by remov-
ing the lens. If, on the other hand, a posterior chamber
intraocular lens (IOL) is already in place, it can usually
be left in place, as, in most cases, it does not hinder dis-
section of the vitreousbase and anterior membranes. Occa-
sionally, proliferative tissue adherent to the residual lens
capsule must be trimmed or removed with the vitreous
cutter to facilitate adequate visualization and surgical manip-
ulationsin the periphery. If it appearsexcessive membranes
are adherent to the peripheral lens capsule, or if the poste-
rior chamber IOL isunstable, we remove the IOL through
the limbus.
Anterior chamber IOLsare somewhat more problematic.
The optic may come in contact with and damage the
corneal endothelium if the lens is pushed forward by a gas
bubble postoperatively. Gasor silicone oil can easily prolapse
around the lens into the anterior chamber, degrading visu-
alization of the retina intraoperatively as well as postopera-
tively. For these reasons, many surgeons prefer to remove
anterior chamber IOLs. This step is completed via a limbal
incision after infusion has been established to the eye, but
with the infusion in a closed position. Sodium hyaluronate
or another viscoelastic material is used to maintain the
volume of the anterior chamber as well as to protect the
corneal endothelium during this procedure.
The crystalline lens is removed through the pars plana,
except in cases with extremely hard nuclei, in which case
the nucleusisremoved through the limbus. Following ultra-
sonic fragmentation of the nucleusand removal of the cor-
tical material, we recommend complete removal of the lens
capsule (19). An opening is made in the anterior capsule
with the vitrectomy instrument. One can then grasp the
peripheral capsule with vitreous forceps and exert enough
traction to expose the zonules in the pupil. While retract-
ing the capsule, the zonules can then be cut with a verti-
cally cutting scissor (we prefer the MPC scissor, Grieshaber,
Inc., Kennesaw, GA) placed through the opposite sclerotomy
site (Fig. 42-8).We feel complete removal of the lenscapsule
will reduce the likelihood of recurrent anterior PVR that
can sometimes present with membranes adherent to the
peripheral lens capsule. In addition, removal of the capsule
will prevent synechiae of the iristo the lenscapsule, which
can leave a distorted, retracted, xed pupil.
Vitrectomy
A lens ring to hold the contact lens can be placed follow-
ing placement of the pupillary stretching devices.We suture
a lensring in place and utilize several lensesasnecessary to
visualize the posterior and peripheral retina. We peel most
posterior membranes using a plano-concave lens, while
prism lenses are used in the periphery. A wide-angle lens
system with image inverter isalso used in selected situations
(20,21). The wide-angle lens is especially useful if there is
a constricted view due to a posterior chamber lens with
opacied peripheral capsule.
We remove the central vitreouswith the vitreouscutting
instrument, then remove gross peripheral vitreous. In most
casesa posterior vitreousdetachment will already be present
in cases of PVR. Rarely, in eyes with high myopia or vit-
reoretinal degenerations, there isincomplete or no posterior
vitreousseparation. In those cases, after the core vitrectomy
is completed, the posterior cortical vitreous should be
separated from the disk with the vitreous cutter, suction
catheter, or membrane pick, then peeled from the
retinal surface. If the vitreousistightly adherent to the pos-
terior retina such as seen in Stickler syndrome, vitreous
should be trimmed close to the adhesions and sectioned
as much as possible with automated vertically cutting
scissors.
If there is signicant anterior PVR, we delay extensive
shaving of the vitreous base and peripheral membrane dis-
section until after posterior membraneshave been removed,
because accessto and removal of these membranesare easier
once posterior membranes and midperipheral membranes
with adherent vitreous have been removed. In the absence
of anterior PVR, it isbest to excise or shave the vitreous
to the surface of the retina and pars plana at the vitreous
base area at thisstage of the case.The posterior membranes
xate the retina and reduce mobility of the anterior
retina, which makes peripheral viteous removal safer with
less risk of anterior retinal breaks. If at any point the
retina is excessively mobile during peripheral vitrectomy
and there isdanger of peripheral retinal damage, peripheral
vitrectomy can be delayed until posterior membranes have
been removed.Then peruorocarbon liquid (PFCL) can be
used to stabilize the retina during peripheral vitreous
removal.
Z
Central opening
in lens capsule
Forceps holding
lens capsule
Capsule
MPC scissors
cutting streched
zonules
FI GURE 42- 8. En bl oc removal of t he l ens capsul e fol l owi ng
phacofragment at i on and removal of t he nucl eus and cort ex of
t he l ens. Aft er openi ng i s made i n t he ant eri or l ens capsul e i n t he
pupi l l ar y area wi t h t he vi t rect omy cut t er, t he edge of t he cent ral
capsul ot omy i s grasped wi t h vi t reoret i nal forceps, and t he capsul e
i s ret ract ed t o expose t he zonul es i n t he pupi l . The zonul es are
sect i oned wi t h aut omat ed, vert i cal l y cut t i ng vi t reoret i nal sci ssors,
and t he capsul e i s removed t hrough t he scl erot omy si t e or wi t h t he
vit reous cut t er.
HTH42 8/20/98 4:05 PM Page 536
The vitreous base can be visualized with a standard lens
system (either hand held or with a sutured lensring) using
scleral depression, or by using a wide-angle system without
scleral depression. Using a standard lenssystem, we perform
anterior vitrectomy by two methods. In the rst method,
the vitreous cutter and the beroptic endoillumination
probe are both placed in the eye. An assistant depresses the
peripheral retina and vitreousbase into view asthe vitreous
is excised (Fig. 42-9). This method is especially useful for
removing vitreousin the inferior 140 degreesand the supe-
rior 100 degrees. Using thismethod, it isdifcult to excise
all of the peripheral vitreous in the horizontal meridians.
The second method, especially useful in the horizontal
meridians, utilizesexternal illumination (22).The vitrectomy
cutter is placed through a sclerotomy site. A plug is placed
in the opposite sclerotomy site, and the surgeon depresses
the retina and vitreous base in the area 180 degrees from
where the vitreous cutter has entered the eye. The assistant
holdsthe beroptic light probe in contact with the contact
lens, directing the light toward the area to be cut (Fig.
42-10). Because the light probe actually touchesthe contact
lens, there is no light reection, and the visualization is
similar to that seen with endoillumination. We have found
thismethod superior to that in which the microscope light
is used for peripheral visualization.
Scleral depression is not always required to visualize
and shave the vitreous base when using the 125-degree
wide-angle lens with an image inversion system. A bullet
light probe is used to disperse the light over a broad
area when using the wide-angle lens system. The vitreous
structure is more easily seen when using a standard
light probe held close to the vitreous, so we have found the
standard lens system with scleral depression most useful for
PVR.
Membrane Peeling
Posterior Membranes We begin epiretinal membrane dis-
section at the posterior pole. All membranes that can be
located are meticulously stripped from the retinal surface.
Posterior membranes are peeled from the surface of the
retina in a posterior-to-anterior fashion, so that greater force
is applied to the thicker posterior retina. The technique of
bimanual dissection, using an illuminated pick (Fig. 42-11)
Z
Cotton tip
applicator
retina
Retina pulled
forward as
vitreous is cut
Perfluorocarbon
liquid
Cotton tip
applicator
A
B
FI GURE 42- 9. Vit rect omy removal of ant erior vit reous in an
eye wi t h bul l ous ret i nal det achment . A. Ret i na i s ext remel y mobi l e
and i s pul l ed t oward t he vi t reous cut t er as vi t reous i s exci sed, ri ski ng
ant erior ret inal breaks. B. PFCL i s i nject ed t o at t en and st abi l i ze t he
post eri or ret i na. PFCL i s i nject ed t o t he post eri or edge of remai ni ng
vi t reous, hol ds ret i na i n pl ace, and reduces ret i nal mobi l i t y duri ng
peri pheral vi t rect omy.
FI GURE 42- 10. Li ght pi pe (L) hel d i n cont act wi t h cont act
l ens (C) i l l umi nat es vi t reous base pushed i nt o vi ew by scl eral
depressor (D). (Repri nt ed court esy of t he Ameri can Medi cal
Associ at i on, Chi cago, IL, from Murray TG, Bol dt HC, Lewi s H, et al .
A t echni que for faci l i t at ed vi sual i zat i on of t he vi t reous base, pars
pl ana, and pars pl i cat a. Arch Ophthalmol 1991;109:14581459.)
HTH42 8/20/98 4:05 PM Page 537
and vitreous forceps, is the most effective for this purpose.
There are several typesof forcepsthat can be used to grasp
membranes, but we have found that diamond-dusted forceps
(see Fig. 42-11) most reliably hold the membrane during
bimanual dissection.
Membrane peeling can be initiated by either of two
methods, depending on the characteristicsof the membrane:
thicker membranes with prominent edges can be directly
grasped with the forceps (Fig. 42-12), and atter, less dis-
tinct membranesare best elevated with the illuminated pick
prior to grasping with the forceps. Membranes can usually
be easily seen, but sometimes with extensive conuent
membranes, no edges can be identied. Signs of this type
of membrane include obscuration of portions of retinal
vessels by the membrane and a stiff, smooth, gray appear-
ance of the retina. Large retinal folds can be obscured by
the membranes. In thissituation, the pick isplaced in a fold
and gently pulled toward the center of the fold in order to
engage the membrane (Fig. 42-13A). Once the membrane
is engaged and the edge elevated, it is grasped with the
forceps for stripping (Fig. 42-13B). Some tightly adherent
membranescan be more easily engaged with a sharp-barbed
blade such as the MVR blade (Fig. 42-14).
When an edge of the membrane has been partially
elevated, it can be grasped with forceps and stripped ante-
riorly, with the pick used to separate adhesionsand stabilize
the retina (see Fig. 42-13B). During removal of midperiph-
eral membranes, the membrane isoften pulled centrally with
the forceps, and the blunt edge of the pick isplaced between
the membrane and the peripheral retina (Fig. 42-15).Asthe
membrane ispulled centrally, the blunt edge of the pick sep-
arates the membrane from the retina. When a tight adhe-
sion is encountered, excessive force should not be applied,
as a retinal tear is likely to occur. Rather, vertically cutting
automated scissors should be introduced to segment the
membrane from the retina at the adherent site. If any retinal
breaks do occur, they should immediately be marked with
intraocular diathermy.
Often, large membranes can be peeled in a single sheet
from the retinal surface. This is especially true in so-called
mature PVR, in which several weekshave passed and the
membranes have become fairly thick. In the past, some
experts recommended waiting for this point in the disease
process before intervening, allowing the proliferation to
mature to facilitate membrane removal. Thin immature
Z
FI GURE 42- 11. Inst rument s for membrane
removal i n PVR. Lef t : Di amond-dust ed vi t reoret i nal
forceps (Gri eshaber and Company, Fal l si ngt on, PA).
Ri ght : Il l umi nat ed pi ck (Escal on, Mukwanago, WI).
Bendi ng shaf t of pi ck 30 degrees away from t he
l i ght axi s gi ves a broader el d of i l l umi nat i on and
reduces t he shadow cast by t he pi ck.
FI GURE 42- 12. Graspi ng epi ret i nal membrane wi t h
vi t reoret i nal forceps. The forceps grasp t he body of t he membrane by
pi nchi ng t he surface or edge of t he membrane. Whi l e t he di amond-
dust ed vi t reoret i nal forceps (see Fi g. 42-11) wi l l engage membranes
wi t h t hi ckened edges, newer, ner, poi nt ed end-grabbi ng forceps are
superi or for t hi s maneuver. Once t he membrane i s grasped wi t h t he
forceps, t he i l l umi nat ed pi ck i s used t o appl y count er-t ract i on on t he
ret i na as t he membrane i s peel ed.
HTH42 8/20/98 4:05 PM Page 538
probably occurs because of incorporation of the posterior
hyaloid into membranesformed at the junction of the sep-
arated posterior vitreousand the vitreousbase (Fig. 42-17A).
With increasing and more posterior membrane formation,
we suspect that the vitreous is gradually pulled in by the
contracting membranesto give a relatively posterior adher-
ence of the posterior hyaloid, well posterior to the vitreous
base (Fig. 42-17B). It is important to strip the posterior
hyaloid anteriorly to itsinsertion into the vitreousbase.We
Z
Vitreous
Retina
Vitreous
Retina
A
B
FI GURE 42- 13. Bi manual membrane-peel i ng usi ng an
illuminat ed pick and vit reoret inal forceps. A. The edge of t he
membrane i s el evat ed wi t h t he i l l umi nat ed pi ck. If an edge i s not
apparent , t he t i p of t he pi ck i s pl aced i n t he t rough of a ret i nal fol d
and st ri pped t oward t he cent er of a st ar fol d unt i l t he membrane
i s engaged. The membrane i s usual l y engaged i n t he cent er of t he
st ar fol d. B. Aft er t he edge of t he membrane i s el evat ed wi t h t he
i l l umi nat ed pi ck, t he edge i s grasped wi t h t he di amond-dust ed
vi t reoret i nal forceps and pul l ed ant eri orl y. The bl unt , post eri or edge
of t he i l l umi nat ed pi ck i s pl aced agai nst t he ret i na adjacent t o t he
membrane t o hol d t he ret i na i n pl ace as t he membrane i s peel ed
from t he ret ina.
Epiretinal
membrane
Vessel tortuous
under membrane
Retinal
vessels
Stripping in
fold with MVR
blade
Retina
membranes are friable and more likely to fragment, leaving
residual islands of tissue that are difcult to remove and
a potential source of reproliferation. However, the dis-
advantage of waiting for membranes to mature is poten-
tial progression of photoreceptor degeneration, and most
authoritiesno longer delay surgery for thisreason.A helpful
technique for very immature membranes is to stroke them
with a silicone brush found on the tip of the backush
brush. Zivojnovic has found the retinal scratcher useful
for this technique. A new instrument, a diamond-dusted
silicone cannula, is now available that is useful for the
removal of small patches of thin epiretinal membranes
(Fig. 42-16) (23).
The posterior cortical vitreous is often adherent to
peripheral membranes posterior to the vitreous base. This
FI GURE 42- 14. Thi nner, t i ght membranes may be di fcul t
t o engage wi t h t he bl unt i l l umi nat ed pi ck, so t hese membranes are
somet i mes best engaged for peel i ng wi t h a sharp bl ade. We prefer
t he mi crovi t reoret i nal (MVR) bl ade. We barb t he t i p of t he bl ade pri or
t o membrane peel i ng. The barbed MVR bl ade i s pl aced i n a fol d
adjacent t o t he membrane and st ri pped t oward t he membrane.
Most membranes can be el evat ed i n t hi s fashi on.
FI GURE 42- 15. Separat i on of peri pheral membranes and
vi t reous from t he ret i na. The membrane or vi t reous i s grasped wi t h
di amond-dust ed vi t reoret i nal forceps and pul l ed cent ral l y. The bl unt
edge of t he i l l umi nat ed pi ck i s pl aced at t he junct i on of t he vi t reous
or membrane wi t h t he ret i na and t he t i ssue i s pul l ed over t he pi ck.
The membrane wi l l usual l y separat e, and vi t reous wi l l usual l y
separat e ant eri orl y t o t he post eri or edge of t he vi t reous base.
HTH42 8/20/98 4:05 PM Page 539
have found it useful to grasp the edge of the posterior
hyaloid with the vitreousforceps, place the blunt portion of
the illuminated pick at the junction between the hyaloid
and the peripheral retina, and pull the hyaloid centrally to
allow the pick to separate the hyaloid from the retina
(similar to the method described in Fig. 42-15). This tech-
nique also identies the point of permanent adherence of
the hyaloid to the posterior border of the vitreous base.
Once the peripheral hyaloid is separated to the vitreous
base, it is excised with the vitrectomy instrument. If the
retina becomes excessively mobile, PFCL can be injected
over the posterior pole to stabilize the retina during vitrec-
tomy (see Fig. 42-9; see also below) (24).
Anterior Membranes If anterior PVR ispresent, peripheral
membranes must be dissected. Membranes may be focal,
diffuse, or subretinal (see Tables 42-1 and 42-2; Figs.
42-342-6). Focal and diffuse membranes are peeled in a
fashion similar to posterior membrane peeling, although vit-
reousisoften adherent to the membranes. Subretinal mem-
branesmay not be apparent until after epiretinal membranes
have been removed. The most difcult form of anterior
PVR to manage is anterior retinal displacement, in which
the retina at the posterior vitreous base or even more pos-
teriorly ispulled anteriorly by contracting anterior vitreous
and membranes (see Fig. 42-6) (4,25). A circumferential
trough of variable depth and area may be present at the
vitreousbase formed between the anteriorly displaced retina
and the anterior retina and pars plana. Initially, the type of
anterior PVR must be identied.
Sometimes, in advanced forms of anterior PVR, it is
difcult to see a peripheral trough, and the surgeon might
erroneously believe that no anterior retinal displacement is
present. The only sign of anterior retinal displacement may
be obscuration of the ora serrata and the nding of a brous
circumferential membrane adherent to the pars plana or
ciliary processes. Usually, however, a peripheral trough can
be seen peripheral to a circumferential fold of anteriorly
displaced retina. The membrane that bridges from the
anteriorly displaced retina toward the anterior structures
must be cut (Fig. 42-18). It isoften easiest to initially open
this membrane with the sharp tip of the MVR blade
(Fig. 42-18A). Then vertically cutting vitreoretinal scissors
can be inserted to section the membrane circumferentially
(Fig. 42-18B). The membrane should be circumferentially
sectioned throughout the extent of anterior displacement
of the retina.
Z
Retinal break
Separated vitreous
Vitreous loosely
laying on retina
RPE cells
Vitreous fused
to retina
A
B
FI GURE 42- 16. Di amond-dust ed membrane cannul a.
The t apered si l i cone t i p has been dust ed wi t h di amonds t o creat e
a sur face t hat wi l l engage and peel di aphanous, i mmat ure
membranes.
FI GURE 42- 17. Reat t achment of peri pheral separat ed
vi t reous t o t he ret i na post eri or t o t he vi t reous base i n PVR.
A. Rhegmat ogenous ret i nal det achment wi t h post eri or vi t reous
separat i on and l arge ret i nal break. Rel eased pi gment epi t hel i al
cel l s i n t he vi t reous cavi t y set t l e on t he i nferi or ret i na bet ween t he
det ached ret i na and t he vi t reous. As membranes form, t he vi t reous
at t aches t o t he membranes t hat are at t ached t o t he ret i na. B. PVR
wi t h vi t reous now fused wi t h t he peri pheral ret i na post eri or t o t he
vi t reous base. As membranes are peel ed, t he vi t reous shoul d be
separat ed ant eri orl y t o t he post eri or aspect of t he vi t reous base.
HTH42 8/20/98 4:05 PM Page 540
When the membrane issectioned, the anterior-posterior
element of traction is relieved, and the anteriorly displaced
retina will fall posteriorly. Remnants of the membrane can
exert circumferential traction and sometimescan be excised
with the vitrectomy instrument. If membrane remnants are
tightly adherent, then a bimanual technique isused in which
the membrane is xated with an illuminated pick or illu-
minated forceps as it is cut with the vertically cutting scis-
sors (Fig. 42-18C). If possible, the whole extent of the
membrane should be eliminated, but if this is not possible,
remnants should be sectioned vertically in multiple areas
along its circumference in order to eliminate circumferen-
tial traction.Vitreousin the trough should be trimmed back
to the surface of the pars plana and peripheral retina with
the vitreous cutter.
The techniques of peripheral vitreous removal utilizing
scleral depression or a wide angle viewing system are
described above. Retinal breaks are sometimes created
during the dissection process. Breaks should be identied,
and all traction relieved around the area of these breaks. In
some cases, it is not possible to relieve anterior contraction
adequately with dissection so a peripheral relaxing reti-
notomy is necessary (see below). Because it is difcult to
remove posterior and peripheral membranes after an
extensive retinotomy, we wait until all of the posterior
and peripheral membranes have been removed before
proceeding with retinectomy.
Once the posterior and peripheral membraneshave been
removed, the retina becomes quite mobile. The pars plana
isoften detached, and any remaining vitreousiseasily incar-
cerated in the sclerotomy sites. There is risk of peripheral
retinal incarceration in the sclerotomy sites. The retina can
be stabilized and further peripheral vitreous removal and
membrane dissection can be facilitated by the use of PFCL
(Fig. 42-19; see also Fig. 42-9). An initially small volume of
PFCL (usually about 1mL) isinjected over the optic nerve.
We usually wait until posterior membraneshave been com-
pletely removed before injecting the PFCL. While a small
posterior retinal break is not a contraindication to the use
of PFCL, we usually do not use PFCL in the presence of
large breaks. Excessive traction on the retina in the presence
of even a small retinal break may also cause PFCL to go
through the break. It is important not to inject the PFCL
directly over a break asthe stream of PFCL will go beneath
the retina. Initially, only enough PFCL is injected to stabi-
lize the posterior retina and improve the ability to remove
peripheral vitreous and membranes. Injection of too much
PFCL may cover and compress the remaining vitreous.
Additional PFCL can be injected to further atten the retina
as the dissection is carried anteriorly.
Subretinal Membranes
Subretinal membranes are less common in PVR than
epiretinal membranes, and even when present, often do not
interfere with successful retinal reattachment (26). In these
cases they can be left in place. In some cases, subretinal
membranesthat appear to be elevating the retina will break
or stretch during uidgas exchange or after injection of
PFCL, leading to release of traction (see below).
In cases in which subretinal membranes prevent retinal
reattachment after uidgasexchange or injection of PFCL,
of if they are felt by an experienced surgeon to be
signicant, the traction from these membranes must be
relieved (27). If a single subretinal strand is tenting the
Z
C B A
FI GURE 42- 18. Management of ant eri or ret i nal di spl acement i n PVR. A ci rcumferent i al membrane has formed on t he peri pheral vi t reous
and, wi t h cont ract i on, has pul l ed t he ret i na at t he post eri or aspect of t he vi t reous base ant eri orl y t o t he ant eri or pars pl ana. The membrane
obscures a t rough of redundant ret i na creat ed by t he ant eri or di spl acement of t he ret i na. A. The membrane i s sect i oned ci rcumferent i al l y wi t h
an MVR bl ade. B. Once an openi ng i s made i n t he membrane wi t h t he MVR bl ade, t he aut omat ed, vert i cal l y cut t i ng vi t reoret i nal sci ssors use used
t o sect i on t he membrane t hroughout i t s ext ent . Ant eri or ret i nal di spl acement i s most commonl y found i n t he i nferi or 180 degrees of t he ret i na.
C. The t rough has opened up and t he ret i na has rel axed post eri orl y. If a ci rcumferent i al membrane remai ns on t he post eri or aspect of t he vi t reous
base, i t shoul d be removed or radi al l y sect i oned. An i l l umi nat ed pi ck or i l l umi nat ed forceps can be used t o xat e t he membrane for removal or
sect i oni ng wi t h aut omat ed, vert i cal l y cut t i ng vi t reoret i nal sci ssors. The arrowpoi nt s at an area t hat has been radi al l y sect i oned, whi l e t he forceps
hol ds t he edge of t he membrane and exposes i t for di ssect i on wi t h t he sci ssors.
HTH42 8/20/98 4:05 PM Page 541
retina, it can be cut with scissors after creating an adjacent
retinotomy with diathermy and will often retract back,
allowing the retina to settle (Fig. 42-20). If not, or if mul-
tiple subretinal strandsor a large sheet ispresent, the retinot-
omy isenlarged to allow the insertion of microforceps.The
membrane should be grasped and gentle traction applied in
a back and forth motion, breaking adhesions and attach-
ments, while both ends are observed to ensure that the
retina isnot torn at a remote site (Fig. 42-20C). In rare cases
of extensive subretinal brosis with a so-called napkin ring
conguration, where the membranes completely encircle
the optic nerve in the subretinal space, a large peripheral
retinotomy must be made (see below), usually on the order
of 90 degrees or more, and the retina folded over to allow
complete removal of the membrane. A bimanual technique
is required, with a lighted pick or similar instrument used
to elevate and hold the inverted retina, while scissors are
used to section the membrane. Then microforceps are
used to grasp, tease, and regrasp the membrane until it is
completely free (Fig. 42-21).
Scleral Buckle
When all membranes have been removed from the surface
of the retina, it should be mobile and ready to be reattached.
In eyes that do not already have an encircling band, this is
an appropriate time to place a scleral buckle. Determination
of the appropriate position of the scleral buckle follows
many of the same considerations discussed previously. If
removal of all anterior membranesand most of the anterior
vitreous was accomplished, a 3.5- or 4.5-mm encircling
element is usually adequate to support the vitreous base. If
continued peripheral vitreoretinal traction is present, espe-
cially if this traction extends postequatorially, a broader
buckle isrequired.A 7-mm-wide solid silicone element will
provide broad support in this situation.
One disadvantage of placing a buckle at thisstage in the
procedure is that the subretinal uid makes it difcult to
assess buckle height. However, after retinal reattachment
with PFCL injection or uidgas exchange, buckle height
can be reassessed and adjusted if need be.
Relaxing Retinotomies and Retinectomies
Some eyes with severe PVR, particularly those undergoing
reoperation and those with anterior PVR, have areas of
retinal shortening that make reattachment impossible,
despite meticulousremoval of membranes. In such instances,
raising the height of the scleral buckle can sometimes ade-
quately relieve persistent traction. If this maneuver is not
successful, or if the surgeon decides against revising the
scleral buckle, retinotomy with or without retinectomy is
necessary to reattach the retina (28,29). Sometimes this
determination isnot made until air or PFCL isinjected into
the eye (see below) and isnoted to go subretinally through
a break associated with elevated retina.
Relaxing retinotomy is usually done because of retinal
contraction due to anterior PVR, with anterior retinal
displacement being the most common indication. How-
ever, any type of contraction, especially when chronic, can
sometimes require retinotomy to relieve traction. Rarely, a
focal area of posterior contraction cannot be relieved by
removal of membranes, and a focal retinotomy must be
performed.
For anterior contraction, after all other membranes have
been removed, diathermy isapplied posterior to the area of
Z
A B C
FI GURE 42- 19. Use of PFCL for PVR. A. Fol l owi ng removal of post eri or membranes, a smal l vol ume of PFCL i s i nject ed over t he post eri or
ret i na. The PFCL reduces ret i nal mobi l i t y duri ng removal of peri pheral membranes. B. Aft er t he membranes have been removed, t he ret i na i s
reat t ached by i nject i ng more PFCL. Subret i nal ui d drai ns i nt o t he vi t reous cavi t y from t he ant eri or ret i nal break. C. More PFCL has been i nject ed t o
reat t ach t he ret i na. Somet i mes a smal l amount of subret i nal ui d wi l l remai n ant eri or t o t he PFCL. Tr y t o avoi d i mmersi ng t he i nf usi on cannul a i n
t he PFCL, because bubbl es wi l l obst ruct t he vi ew and smal l bubbl es can go t hrough l arge open breaks.
HTH42 8/20/98 4:05 PM Page 542
contraction (Fig. 42-22). For focal contraction, diathermy is
used to encircle the area to be excised. It is important to
treat all vessels with heavy diathermy to prevent hemor-
rhage. The retinotomy should extend beyond the area of
contraction into normal retina. The actual retinotomy is
usually made with automated vertically cutting vitreousscis-
sors (see Fig. 42-22A). Cutting the retina with the vitreous
cutter is less controlled and can lead to hemorrhage and
inadvertent excision of larger areas of the retina than
desired. For anterior retinal contractions, circumferential
retinotomiesare usually performed. Radial retinotomiesare
rarely indicated. Radial retinotomies tend to extend poste-
riorly into the posterior pole and often inadequately relieve
traction. Retinotomies in the posterior pole, which involve
more functionally important retina, should also be avoided.
Use of a partial ll of PFCL will stabilize the retina during
performance of the retinotomy and prevent folding and
inversion of the ap of the now giant tear after the retina
is cut. If the retinotomy extends into attached retina, the
retina should be carefully separated from the underlying
retinal pigment epithelium with the tip of the scissors or a
membrane pick before cutting, to avoid damage to the
choroid.The endsof the retinotomy may be angled toward
the ora serrata to relieve residual traction present in these
regions (Fig. 42-22B). In most cases, we prefer to remove
the anterior ap of devascularized retina to decrease the
Z
B
Subretinal
strand
Extraction of
subretinal strand
through retinotomy
C
FI GURE 42- 20. A. Branchi ng subret i nal st rand. B. Sect i oni ng
of subret i nal st rand t hrough peri pheral ret i not omy. Sci ssors are
pl aced t hrough a smal l ret i not omy creat ed adjacent t o t he
membrane wi t h di at hermy. If t he membrane i s not adherent t o t he
ret i na or choroi d, t he ends of t he membrane shoul d ret ract af t er
sect i oni ng. C. Ext ract i on of subret i nal st rand t hrough ret i not omy.
The membrane i s grasped wi t h forceps and removed wi t h a gent l e,
si de-t o-si de mot i on. If t he membrane i s st rongl y adherent t o ret i na
or choroi d, i t shoul d be sect i oned. (A. Court esy of Hi l el Lewi s, MD,
Cl evel and Cl i ni c Fandat i on, Cl evel and, OH; B, C. Adapt ed from
Abrams GW. Ret i not omi es and ret i nect omi es. In: Ryan SJ (ed.).
Retina. vol . 3. St . Loui s: CV Mosby, 1989:317346.)
A A
A B
FI GURE 42- 21. A,B. Subret i nal napki n ri ng membrane
(post eri or t ype 3). C. Membrane sect i oned and removed t hrough
peri pheral ret i not omy. (A. Court esy of Hi l el Lewi s, MD, Cl evel and
Cl i ni c Fandat i on, Cl evel and, OH; B,C. Adapt ed from Abrams GW.
Ret i not omi es and ret i nect omi es. In Ryan SJ (ed.). Retina. vol . 3. St .
Loui s: CV Mosby, 1989:317346.)
HTH42 8/20/98 4:05 PM Page 543
likelihood of reproliferation and possibly lower the risk of
rubeosis. This procedure is accomplished with the vitreous
cutter, again with care taken to avoid damage to the
choroid.
A retinotomy greater than 90 degrees in circumference
creates the problem of management of a giant retinal tear.
The best method for reattaching the retina in the presence
of a giant tear isthe use of a PFCL (discussed below) (30).
PFCLshave the advantage of ease of use and do not require
manipulation of the ap under gas or silicone oil.
If a large relaxing retinotomy (90 degrees) isperformed
to treat an eye with PVR, careful consideration should be
made of the type of retinal tamponade to use. Eyes under-
going retinotomy and retinectomy are more likely to have
postoperative hypotony, which suggeststhat silicone oil may
be preferred in such eyes (31).
Reattachment of the Retina with PFCL
If PFCL was used to stabilize the retina during membrane
removal or retinotomy, additional PFCL is injected to reat-
tach the retina (24). If PFCL was not used, the retina can
be reattached pneumatically with air or with PFCL, accord-
ing to the characteristicsof the retina. If a large retinotomy
has created a giant tear, PFCL should be used to reattach
the retina (30). If there is no giant break and a posterior
break exists, pneumatic reattachment can be performed,
using the posterior break to simultaneously drain subretinal
uid. More often, however, breakswill be fairly anterior, and
reattachment of the retina isperformed with PFCL prior to
uidair exchange.
When PFCL is to be used, the surgeon should make
quite sure that all traction has been removed from around
retinal breaks. If breaks with elevated edges are present, the
PFCL can pass through the break and move subretinally,
requiring further manipulations to remove it, even includ-
ing a retinotomy.
We prefer a PFCL with an index of refraction allowing
good visibility such as peruoro-n-octane (32). The PFCL
can be injected manually with a syringe or with a surgeon-
controlled automated uid injector. We inject the PFCL
through a silicone-tipped cannula and start injection over
the optic disk. Once a large enough bubble of PFCL is
present over the optic nerve, the tip of the silicone cannula
can be inserted into the PFCL during subsequent injection
to ensure that a single bubble isproduced (see Fig. 42-19A).
During injection, uid is allowed to escape from the
sclerotomy site. As the bubble of PFCL slowly increases in
size, the posterior pole should be noted to atten, and the
choroidal pattern should become apparent. The PFCL is
injected slowly and the peripheral retina assessed during
injection.Thisprocedure isparticularly important if a giant
retinotomy hasbeen created, because the edge can become
folded beneath the peruorocarbon.
In addition, it is important to observe if the peripheral
retina attens during PFCL injection. If the retina remains
elevated, injection should be stopped. PFCL should be
removed to at least the posterior aspect of the remaining
traction and the traction relieved. A wide-angle viewing
system is ideal for observation of the entire fundus during
this process. Injection is continued until the PFCL extends
well onto the scleral buckle anteriorly (see Fig. 42-19C).Try
to avoid immersing the tip of the infusion port in the PFCL,
because multiple bubbles of PFCL are created by the uid
ow. These bubbles may obstruct the view and go beneath
the edge of a large break. In most cases, uid will drain from
known or unrecognized anterior retinal breaks, and the
contour of the buckle will be apparent. Occasionally, uid
will accumulate anteriorly, obscuring the outline of the
buckle (Fig. 42-23A). In such cases, tipping the eye so that
the PFCL forcesthe uid toward a known retinal break will
sometimes atten the retina (Fig. 42-23B). Occasionally,
however, intraocular diathermy must be used to create an
anterior drainage retinotomy over the buckle in an area of
nonvascular retina.Thisretinotomy should be made asante-
riorly as possible to avoid trapping subretinal uid anterior
to the retinotomy (Fig. 42-23C).
At this point, the entire posterior retina should be re-
attached. Areas of persistent retinal elevation beneath the
PFCL indicate persistent traction, which must be relieved if
surgery isto be successful. Most remaining epiretinal mem-
branescan be removed beneath the PFCL. If it isnecessary
to remove the PFCL, it should be carefully aspirated into a
syringe for reuse later in the case. Further membrane peeling
can then be performed, or retinotomy and retinectomy can
Z
RPE
B
A
FI GURE 42- 22. A. Inferior relaxing ret inot omy t o relieve
t ract i on i n cont ract ed ret i na. The ret i na t o be cut i s di at hermi zed,
pri mari l y by di at hermi zi ng bl ood vessel s, ext endi ng i nt o normal
ret i na on each end of cont ract ed ret i na. Cut i s made wi t h vert i cal l y
cut t i ng sci ssors al ong t he post eri or edge of cont ract ed ret i na.
B. Ret i na reat t ached fol l owi ng rel axi ng ret i not omy. Ret i not omy i s
ext ended ant eri orl y t o ora serrat a or ci l i ar y body (i f pars pl ana i s
i nvol ved). The ant eri or ret i na i s exci sed. (Adapt ed from Abrams GW.
Ret i not omi es and ret i nect omi es. In: Ryan SJ (ed.). Retina. vol . 3.
St . Loui s: CV Mosby, 1989:317346.)
HTH42 8/20/98 4:05 PM Page 544
be carried out asdiscussed above if separation of membranes
is not possible.
Occasionally, retinal reattachment under PFCL is pre-
vented by subretinal strands or membranes. In many cases,
the retina will reattach despite such tissues. Sometimes the
weight of the PFCL acting over time will relax the traction
applied by subretinal membranes, and the surgeon may wish
to wait for several minutes to reassess the retinal status. If
there appearsto be lessretinal elevation, more PFCL can be
injected and further observation for retinal attening carried
out. If the PFCL does not overcome the traction from the
subretinal membranes, the PFCL should be removed by
aspirating it back into the same syringe, for reuse later
in the case, and the subretinal membranes dealt with as
discussed above.
Laser Endophotocoagulation
The PFCL affords an excellent view for application of
laser endophotocoagulation to the now reattached retina,
although the eld of view islessthan with a gas-lled eye.
All retinal breaks, previously marked with diathermy, are
surrounded with conuent laser spots(Fig. 42-24). Laser can
then be applied over the scleral buckle for 360 degrees,
using the prism funduscontact lensor a wide-angle viewing
system (Fig. 42-25). Peripheral laser is facilitated by raising
the level of the PFCL well onto the buckle, to ensure that
no subretinal uid is present. An angled laser probe is also
helpful for treating superior retina. Laser burnsshould be of
moderate intensity and placed for two to three rows, with
a separation between spotsof approximately one burn width
(Fig. 42-26). Conuent and overly intense peripheral pho-
tocoagulation (Fig. 42-27) can occasionally lead to stasis of
venous return from the ciliary body to the vortex system.
Occasionally, visualization of the periphery is difcult, and
photocoagulation of this region is delayed until the eye is
lled with air. We treat any posterior retinal breaks with
laser, but do not perform scatter treatment posterior to the
scleral buckle.
Removal of PFCL
On completion of laser endophotocoagulation, an inferior
peripheral iridectomy is made if silicone oil is to be used
in an aphakic eye (see below) (33). Then, uid/ PFCLair
exchange is carried out. We prefer active suction with an
Z
A B C
PFCL PFCL PFCL
Retinal
break
Sharp
diathermy
probe
Hole in
retina
FI GURE 42- 23. A. Fl ui d t rapped ant eri or t o ret i nal break fol l owi ng ret i nal reat t achment wi t h PFCL. B. Eye t i l t ed so PFCL wi l l force subret i nal
ui d out of ret i nal break. C. If unabl e t o force subret i nal ui d out by t i l t i ng t he eye, an ant eri or drai nage ret i not omy i s made wi t h endodi at hermy t o
al l ow drai nage of subret i nal ui d (arrow). Inject i on of more PFCL wi l l now at t ach t he ant eri or ret i na.
Retinal
break
Laser
FI GURE 42- 24. Laser endophot ocoagul at i on. Treat ed ret i nal
breaks wi t h one or t wo rows of conuent l aser. (Adapt ed from
Abrams GW. Ret i not omi es and ret i nect omi es. In: Ryan SJ (ed.).
Retina. vol . 3. St . Loui s: CV Mosby, 1989:317346.)
HTH42 8/20/98 4:05 PM Page 545
reappears. This process is continued until all the uid is
removed from the eye.
In the presence of a giant retinotomy (usually 180
degrees or more), there is a risk of retinal slippage during
the exchange of PFCL for air.Thiscan be prevented by ade-
quate drying of the edge of the retinotomy during the air
exchange (24), accomplished by lling the vitreous cavity
anterior to the ap of the giant retinotomy with air,
then aspirating uid from beneath the anterior edge of the
retinotomy before removing the PFCL (Fig. 42-29). The
anterior edge of the retina can be visualized during uidair
exchange with a wide-angle viewing system or, alternatively,
with an indirect ophthalmoscope. If uid is left behind the
edge of the retinotomy, as PFCLair exchange proceeds,
Z
FI GURE 42- 25. Laser endophot ocoagul at i on usi ng a wi de-
angl e syst em. The wi de-angl e vi ew al l ows vi sual i zat i on of t he
peri pheral ret i na duri ng endophot ocoagul at i on. Treat ment i s
appl i ed usi ng a scat t er t echni que on t he ret i na support ed by t he
scl eral buckl e. The bul l et l i ght probe i s used wi t h t he wi de-angl e
vi ewi ng syst em t o gi ve wi de el d i l l umi nat i on. (Adapt ed from
Abrams GW, Glazer LC. Proliferat ive vit reoret inopat hy. In: Freeman
WR (ed.). Practical atlas of retinal disease and therapy. 2nd ed.
Phi l adel phi a: Li ppi ncot t -Raven, 1997:303323.)
FI GURE 42- 26. One burn wi dt h bet ween l aser appl i cat i ons
during scat t er t reat ment . (Adapt ed from Abrams GW, Glazer LC.
Prol i ferat i ve vi t reoret i nopat hy. In: Freeman WR (ed.). Practical atlas
of retinal disease and therapy. 2nd ed. Phi l adel phi a: Li ppi ncot t -
Raven, 1997:303323.)
FI GURE 42- 27. Excessi ve l aser t reat ment t o peri pheral ret i na
on scl eral buckl e.
aspiration silicone-tipped cannula for this purpose. Alterna-
tive instruments preferred by some surgeons are backush
brushes or extrusion needles, providing passive egress of
PFCL and intraocular uid from the eye. In the phakic or
pseudophakic eye, a biconcave contact lensisplaced on the
cornea to overcome the higher refractive power of the
air-lled eye. With the aspiration cannula and beroptic
light probe in the eye, the infusion line is switched from
uid to air, with the pressure of the air pump typically set
at approximately 40mmHg. Preliminary aspiration is per-
formed just behind the iris plane, until air lls the anterior
vitreous cavity. Then the silicone cannula tip is placed near
the peripheral retina at the level of the PFCLuid inter-
face, so that an airPFCL interface is achieved and there is
minimal risk of reaccumulation of subretinal uid. Next the
cannula ispositioned over the optic nerve, and the remain-
der of the PFCL is aspirated. As the eye lls with air, the
uid level can be safely determined by the dipping
maneuver.The silicone cannula isinserted toward the optic
nerve head until the bright reex disappears, indicating that
the tip of the cannula has reached the uid (Fig. 42-28).
Aspiration is initiated and continued until the reex
HTH42 8/20/98 4:05 PM Page 546
uid forced posteriorly during the exchange will allow pos-
terior slippage of the edge of the tear. If PFCL goesbeneath
the retina, it must be removed, which may require relling
the eye with uid. Once uid is removed from behind the
anterior edge of the retina, PFCLair exchange iscompleted
and all PFCL is removed from the eye.
Peruoro-n-octane is easily seen and removed, and
because of the high vapor pressure, remaining small bub-
bles will evaporate in air at body temperature. How-
ever, peruorodecalin and peruorophenanthrene, two other
commonly used liquid PFCLs, are less easily seen, have a
lower vapor pressure, and will not evaporate in air (32), so
we recommend dripping approximately 0.1 to 0.3mL of
balanced saline onto the posterior retina to identify any
remaining PFCL (which will coalesce into more easily seen
bubbles in the balanced saline) to facilitate removal.
The optical properties of a gas-lled eye allow a wider
eld of view than those of liquid, and usually a more com-
plete view of the periphery is obtained after uidair
exchange. If inadequate laser treatment of the periphery was
accomplished under PFCL, particularly laser treatment of
retina overlying the scleral buckle, more complete endopho-
tocoagulation can now be performed in many cases. In
pseudophakic eyes, condensation of uid on the IOL can
impede visualization, as discussed below.
Reattachment of the Retina Without PFCL
If PFCL isnot used, we reattach the retina with a uidair
exchange. All retinal breaks should be marked with endo-
diathermy prior to uidair exchange so they can be seen
Z
FI GURE 42- 28. A. Fl ui dai r exchange. The t i p of t he suct i on
needl e i s hel d just ant eri or t o t he break. Not e t he ui d meni scus
(arrow) on shaf t of drai nage needl e. B. Removi ng nal bi t of ui d
over opt i c ner ve. The needl e t i p i s repeat edl y di pped i nt o ui d at
t he ret i nal break and over t he opt i c di sk. A l i ght reex i s seen t o
di sappear as t he needl e t i p cont act s t he ui d meni scus. (Adapt ed
from Abrams GW, Aaberg TM. Post eri or segment vi t rect omy. In:
Wal t man SR (ed.). Surgery of the eye. New York: Churchi l l -
Li vi ngst one, 1988:9031012.)
A
B
FI GURE 42- 29. Unfol di ng ap of gi ant t ear or l arge
ret i not omy wi t h PFCL. A. PFCL i s i nject ed over t he post eri or pol e t o
unfol d ap of gi ant t ear. Wi t h ret i na st abi l i zed wi t h PFCL, removal of
ant eri or vi t reous and ant eri or di ssect i on are made easi er. PFCL can
be i nject ed t o t he l evel of t he ant eri or edge of t he gi ant t ear af t er al l
membranes are removed. B. PFCLai r exchange. The space ant eri or
t o t he PFCL i s l l ed wi t h ai r. The edge of t he t ear i s dri ed t o prevent
sl i ppage. Fl ui d behi nd t he edge i s aspi rat ed wi t h t he sof t -t i p needl e
unt i l t he edge i s compl et el y at . C. PFCLai r exchange i s compl et ed.
Al l PFCL i s removed wi t h t he sof t -t i p needl e. (Adapt ed from Abrams
GW, Gl azer LC. Prol i ferat i ve vi t reoret i nopat hy. In: Freeman WR (ed.).
Practical atlas of retinal disease and therapy. 2nd ed. Phi l adel phi a:
Li ppi ncot t -Raven, 1997:303323.)
HTH42 8/20/98 4:06 PM Page 547
and treated through the air bubble. Before switching from
uid to air, the decision of whether to use gas or silicone
oil tamponade must be made, because if silicone oil isto be
used, it is preferable to create an inferior peripheral iridec-
tomy in a uid-lled eye (see below). Air issupplied by the
air pump and uid is usually removed with an aspiration
soft siliconetipped needle, just as described above for
removal of PFCL.There isusually a posterior or peripheral
retinal break available for removal of subretinal uid. If a
posterior break ispresent, then it isused for subretinal uid
drainage (Fig. 42-30). If no posterior break is present, we
do not usually make a posterior drainage retinotomy.
Drainage through a peripheral break isfacilitated by the use
of the extendable cannulated extrusion needle in which the
soft-silicone tube can be extended through the peripheral
break into the subretinal space posteriorly (Fig. 42-31) (34).
In most cases, a simple nonextendable, soft-tipped cannula
will sufce for the same purpose. If there is no accessible
break for drainage, we usually make a drainage retinotomy
with the endodiathermy probe in the peripheral retina in
an area to be supported by the scleral buckle.
Once the retina is reattached under air, conuent laser
endophotocoagulation is applied to surround all breaks,
identication of which is facilitated by previous labeling
with diathermy as discussed above. If a retinal burn is not
noted despite adequate power and laser application interval,
residual subretinal uid islikely present at the margin of the
break, and further aspiration should be performed.Treatment
of all breaks is followed by peripheral laser treatment over
the scleral buckle as described above in conjunction with
PFCL.
Not uncommonly, visibility will deteriorate after uid
air exchange due to the appearance of corneal striae, or
due to condensation of uid on the IOL in pseudophakic
eyes, occasionally to the point where completion of
endolaser treatment becomes difcult or impossible. Use
of a wide-angle viewing system can often improve fundus
visualization.The posterior surface of the IOL can be more
evenly wetted by application of a soft-tipped cannula in
a sweeping fashion. Another maneuver that is often helpful
is the application of sodium hyaluronate to the corneal
endothelium. A small amount of viscoelastic injected
onto the endothelial surface often dramatically improves
visibility.
Silicone IOLs may create signicant problems during
uidair exchange (35). Because of the hydrophobic nature
of the silicone, condensation will reoccur during uidair
exchange, even if it is wiped away with a silicone-tipped
cannula, obscuring the view of the retina in the air-lled
eye. It may be possible to dry the posterior surface with a
steady stream of air from the air pump via a needle held
against the posterior surface of the IOL during uidair
exchange (36).
Z
Air insufflation
Soft tip
needle
Air
Subretinal fluid
aspiration
FI GURE 42- 30. Fl ui dai r exchange. Subret i nal ui d
i s aspi rat ed t hrough t he post eri or ret i nal break as t he eye i s
si mul t aneousl y l l ed by t he ai r pump. (Adapt ed from Abrams GW.
Ret i not omi es and ret i nect omi es. In: Ryan SJ (ed.). Retina. vol . 3. St .
Loui s: CV Mosby, 1989:317346.)
FI GURE 42- 31. Fl ui dai r exchange usi ng a peri pheral ret i nal
break. Drai nage ret i not omy i s creat ed ant eri orl y over t he scl eral
buckl e. Ext endabl e sof t si l i cone t ubi ng of t he cannul at ed ext rusi on
needl e i s passed t hrough t he ret i not omy i nt o t he post eri or subret i nal
space for ui dai r exchange. (Adapt ed from Abrams GW, Gl azer LC.
Raven, 1997:303323.)
HTH42 8/20/98 4:06 PM Page 548
AirGas Exchange
Following laser treatment, two sclerotomy sites are closed,
usually with 7-0 polyglycolic acid sutures. At least 25mL of
a nonexpansile mixture of C
3
F
8
gas(12%to 14%) are ushed
through the eye (37).We have shown experimentally that a
predictable gas concentration can be obtained using this
method.The gasmixture isinsufated through the infusion
port and allowed to egress through a 27-gauge,
1
/2-inch-
length needle inserted through the parsplana and vented to
atmosphere. A tuberculin syringe with the plunger removed
can be used as a handle for the needle. Following the gas
ush, the needle is removed, then the infusion port is
removed and that site closed. We then reform the eye to a
normal pressure with the gasmixture via a 30-gauge needle
through the pars plana. We try to leave the intraocular
pressure at approximately 10mmHg at the completion of
surgery.
The conjunctiva can be closed with absorbable suture
such as 6-0 plain gut, bringing the ap of conjunctiva to
the limbus and assuring that all sclerotomies are well
covered. In eyes that have undergone multiple prior surgi-
cal procedures, thiscan be quite difcult and time consum-
ing, but must be done in careful fashion. If the conjunctiva
is retracted, it can sometimes be released by making multi-
ple small circumferential cutsin the undersurface of Tenons
capsule with a sharp, rounded blade, and drawn closer to the
limbus. Subconjunctival injection of an antibiotic, while of
unproven value, is standard practice, as is subconjunctival
corticosteroid injection, usually with dexamethasone. Place-
ment of ointment in the palpebral ssure and an eye patch
completes the procedure.
Silicone Oil
The Silicone Study found that visual and anatomic results
in eyes with PVR were similar in most analyses regardless
of whether silicone oil or C
3
F
8
gas was used as the intra-
ocular tamponade and both modalitieswere superior to SF
6
gas (3840). While the surgeon and patient will jointly
decide on the tamponade to use in most cases, some factors
will contribute to the decision. Gas may be preferred over
silicone oil if it is likely that silicone oil will herniate into
the anterior chamber and contact the cornea, such aswhen
the iris diaphragm is not intact or when an IOL is present
without an intact iris-capsular-IOL diaphragm. Oil may be
preferred for patients unable to maintain prone positioning
such aschildren or mentally or physically impaired patients.
Silicone oil is associated with a lower incidence of postop-
erative hypotony and ispreferred in certain cases, including
eyes with preoperative hypotony and eyes with rubeosis or
requiring extensive anterior dissection of membranes, as
these eyes are at greater risk of postoperative hypotony.
Silicone oil may be preferred in the face of a giant tear or
retinotomy, which will also more likely have postoperative
hypotony. Silicone oil is preferred if the patient must travel
by air or if the patient must travel to a higher elevation.
Silicone oil ispreferred over gasin the presence of residual
vitreous or choroidal or large subretinal hemorrhage. An
obvious disadvantage of silicone oil as a means of intraoc-
ular tamponae isthe need for a second operation if silicone
oil is eventually removed.
When silicone oil is to be used, an inferior iridectomy
should be created in the aphakic eye (Fig. 42-32) (33).The
vitreous cutter is inserted behind the inferior peripheral
iris at its base, with the vitrectomy instrument facing the
iris, then the iris is engaged. Excision of iris tissue must
be controlled, and care must be taken to conne the iri-
dectomy to near the iris base and not to extend it to
the pupillary margin. As partial thickness iris is removed,
Z
FI GURE 42- 32. Inferi or i ri dect omy. A. Wi t hout i nferi or
i ri dect omy, si l i cone oi l herni at es i nt o t he ant eri or chamber due t o
pupi l l ar y bl ock mechani sm. B. Inferi or i ri dect omy al l ows access of
aqueous i nt o t he ant eri or chamber, rel i evi ng pupi l l ar y bl ock so t hat
aqueous no l onger forces si l i cone oi l i nt o t he ant eri or chamber.
C. Inferior iridect omy. (Adapt ed from Abrams GW, Glazer LC.
Raven, 1997:303323.)
Silicone
oil
A
Silicone
oil
B
C
HTH42 8/20/98 4:06 PM Page 549
the surgeon begins to see the tip of the vitreous cutter
through the thin residual anterior irisstroma and can in this
manner guide placement of the instrument to complete the
process.
If the retina has been reattached with air, then silicone
oil can be infused into the air-lled eye at the end of the
case. Alternatively, a uidsilicone exchange or PFCL
silicone oil exchange can be performed. When infusing
silicone oil into the air-lled eye, the 5000-centistoke oil
that ismost commonly used hashigh viscosity and requires
high pressure tubing if injected through the infusion port.
We usually inject silicone oil into the air-lled eye in the
following manner. With the infusion port in place and the
air pump engaged to the infusion port tubing, we close one
sclerotomy site and preplace a suture in the other site. We
inject the silicone oil through an 18- or 20-gauge angio-
cath that has been trimmed to approximately 10mm in
length.Asthe silicone oil isinjected, the pressure isadjusted
and maintained at the present pressure by the air pump,
which remainsattached to the infusion tubing. In phakic or
pseudophakic eyes, injection of silicone oil is continued
until the oil just reaches the posterior lens. The syringe
is removed and the preplaced sclerotomy suture closed.
The infusion cannula can then be removed and the nal
sclerotomy closed. A small amount of oil will escape during
suturing of the nal sclerotomy, helping to ensure that the
eye is not overlled with silicone oil.
In aphakic eyes, injection iscontinued until the oil level
isat the level of the infusion cannula.The silicone syringe is
removed from the eye, and the preplaced superotemporal
sclerotomy suture isclosed.Then, after clamping the air line,
the infusion cannula can be removed from the eye and the
tip of the silicone oil syringe inserted into the infusion scle-
rotomy.To maintain the appropriate intraocular pressure and
allow the escape of air from the eye, a 30-gauge needle can
be attached to the air pump (still set at 15mmHg) and
inserted into the anterior chamber through the limbus.Injec-
tion is continued until the silicone oil just reaches the iris
plane.Then the silicone oil syringe and needle are removed
from the eye, and the nal sclerotomy isclosed.Again, a small
amount of oil will escape, helping to prevent an overll of
silicone oil. Regardlessof the phakia statusof the eye, it may
be prudent to place a plug in the sclerotomy before closing
it and measure the intraocular pressure.A pressure reading of
above 20mmHg may indicate an overll, and a small amount
of silicone oil should be removed through the open sclerot-
omy and the pressure remeasured.We try to leave the closing
pressure at approximately 10mmHg. The anterior chamber
is left at normal depth. If the anterior chamber shallows, a
small amount of oil isremoved and the anterior chamber is
reformed with air injected through the limbus. It isimpor-
tant that the intraocular pressure be left at a low-normal level
so as not to inadvertently overll or underll the eye with
silicone oil.
If a posterior chamber IOL ispresent with an intact iris-
capsular-IOL diaphragm, we do not make an inferior iri-
dectomy. If the diaphragm is not intact and/ or silicone oil
herniates around the IOL into the anterior chamber, an
inferior iridectomy will sometimes keep the silicone oil
out of the anterior chamber; however, sometimesthe oil will
go into the anterior chamber in spite of the iridectomy.
Residual capsular material can obstruct an iridectomy, so
patency should be conrmed at surgery. If the iridectomy
is open and oil has gone into the anterior chamber, the
oil can be pushed posteriorly with viscoelastic material
injected into the anterior chamber. If the eye is making
adequate aqueous, it may be necessary to remove the IOL
and capsule and reopen the iridectomy in order to keep the
silicone oil out of the anterior chamber. A stable anterior
chamber lens can be left in place if an adequate inferior
iridectomy ismade. Unstable anterior chamber lensesshould
be removed.
After all sclerotomiesare closed, the eye isirrigated copi-
ously with saline solution to remove residual silicone oil,
and the conjunctiva is closed as described above.
If the pressure iswithin a normal range and the retina is
stable, the silicone oil can be removed 2 months or more
following surgery. It is often possible to remove recurrent
epiretinal membranes at the time of silicone oil removal.
The Silicone Study found that approximately 20%of retinas
detach following silicone oil removal (41).
In the presence of hypotony, it is probably best to leave
the silicone oil in the eye. Hypotonouseyesusually end up
with corneal decompensation in the presence of silicone
oil, because the silicone oil herniates forward and touches
the corneal endothelium. Unfortunately, with silicone oil
removal, these eyes often become phthisical. Whereas
the visual prognosis is poor in either situation, the eye will
probably remain more stable with silicone oil remaining in
the eye than otherwise.
Early Postoperative Management
Eyes with PVR require signicant postoperative manage-
ment. Early postoperative management is directed toward
1) careful control of the intraocular pressure (IOP), 2)
adequate retinal tamponade, 3) control of inammation, 4)
elimination of hemorrhage and brin, and 5) detection and
management of recurrent retinal detachment.
Han et al (42) found that 36%of patients developed an
intraocular pressure of 30mmHg or more following vitrec-
tomy. Patients undergoing surgery for PVR have many of
the risk factors for elevation of IOP: scleral buckle, lensec-
tomy, scatter endophotocoagulation, and sometimesa brin
pupillary membrane postoperatively.We monitor IOP care-
fully in the postoperative period. We normalize IOP at the
end of the case, and if the patient haspreexisting glaucoma
or other factorsindicating high risk for elevation of the IOP
(e.g., scleral buckle and scatter photocoagulation), we give
topical ocular antihypertensive medications. We check the
IOP approximately 2 to 4 hoursfollowing surgery, then re-
check as needed. We treat elevated IOP medically in most
Z
HTH42 8/20/98 4:06 PM Page 550
cases, but extreme elevation of pressure sometimes requires
paracentesis of uid or gas.
We ensure that the gasbubble isadequate to tamponade
all retinal breaks and laser treatment postoperatively. We
prefer to have the eye at least 80%lled with gas in the
postoperative period. If the gas bubble is inadequate post-
operatively, assometimesoccurs, we do a uidgasexchange
to top up the gas bubble. For uidgas exchange in the
aphakic eye, we prepare the eye with 5%povidine-iodine
solution to the lidsand the conjunctival cul-de-sac.We make
a limbal incision with a disposable Ziegler-type blade.Then,
with the patient prone, we inject gas into the eye through
a 30-gauge needle inserted through the limbal incision
(Fig. 42-33). As gas is injected, uid will run out around
the shaft of the needle through the limbal opening. The
limbal incision is self-sealing and usually leaves a relatively
normal IOP.We usually use a 15%mixture of C
3
F
8
for the
postoperative uidgas exchange.
In a phakic eye or in an eye with a posterior chamber
implant, we perform the uidgas exchange through the
parsplana.We use a two-needle technique.With the patient
placed on his or her side, we insert a 30-gauge needle
attached to a 10-cc syringe lled with the selected
gas mixture (usually 14%C
3
F
8
gas) through the pars plana
in the most superior position and into the vitreous cavity.
We then insert a 27-gauge needle attached to a 10-cc
syringe through the pars plana at the most dependent
position. We usually place the needle for air insufation
(which is now superior) nasally, and the needle for uid
aspiration (which is now dependent, inferiorly) temporally
(Fig. 42-34).
We aspirate uid from the dependent syringe as we
simultaneously ll the eye with air from the superior
syringe. We sequentially equalize the volume of uid aspi-
rated through the dependent syringe with the amount of
gas injected through the superior syringe. Usually, we
sequentially aspirate 0.5mL of uid then inject 0.5mL of
gas, until the uid is replaced with gas. As we ll the
eye with air, we turn the head toward a more prone
position so we can aspirate more uid. We aspirate as the
needle is slowly withdrawn to remove as much uid as
possible.
To control inammation, we give subconjunctival
Decadron (510mg) at the conclusion of surgery. We also
treat with frequent topical corticosteroids postoperatively.
We usually give the topical corticosteroidsevery hour while
awake for the rst few daysof the postoperative period.We
usually do not give systemic corticosteroids because of the
potential systemic risksinvolved and because the benet has
not been clearly demonstrated.
If signicant postoperative brin formation causespupil-
lary block, interfereswith postoperative uidgasexchange,
or interfereswith the view to the extent that it complicates
postoperative evaluation and management, we lyse the brin
Z
Gas bubbles
Fluid flows
out of eye
FI GURE 42- 33. Post operat i ve ui dgas exchange i n t he
aphaki c eye. A sel ect ed gas mi xt ure (5 t o 10 mL) i s i nsufat ed i nt o
t he eye t hrough a 30-gauge needl e pl aced t hrough a l i mbal i nci si on
made wi t h a Zi egl er-t ype bl ade. Because t he sel f-seal i ng l i mbal
i nci si on i s l arger t han t he di amet er of t he needl e, ui d wi l l drai n out
of t he i nci si on as t he gas i s i nject ed. Smal l bubbl es wi l l coal esce i n
t he rst hours af t er t he exchange.
FI GURE 42- 34. Post operat i ve ui dgas exchange i n t he
phaki c or pseudophaki c eye. The superi or (nasal ) syri nge cont ai ns
ai r or gas mi xt ure. The i nferi or (t emporal ) syri nge i s for aspi rat i on of
ui d i n t he vi t reous cavi t y. Exchange i s done by sequent i al l y i nject i ng
0.5 mL of ai r or gas and aspi rat i ng t he same vol ume of ui d unt i l t he
ui d i n t he vi t reous cavi t y i s exchanged for t he ai r or gas. We use a
30-gauge needl e for i nject i on and 27-gauge needl e for aspi rat i on.
HTH42 8/20/98 4:06 PM Page 551
with tissue plasminogen activator (tPA) (4345).We usually
wait 48 to 72 hoursfollowing surgery to administer tPA in
order to minimize the possibility of intraocular hemorrhage.
We recommend injecting 3g of tPA in 0.1mL of balanced
saline with a 30-gauge needle through the limbus. In the
presence of severe brin formation and/ or hemorrhage, we
usually do a uidgasexchange to clear the brin products
and/ or hemorrhage after lysis with the tPA.
We closely monitor patients for the development of
recurrent retinal detachment. Retinal detachment is most
easily seen by looking around (not through) a gas bubble.
We usually examine the patients every 1 to 2 weeks
until the gas bubble has resolved. If retinal detachment is
detected, we look for the cause. Usually retinal detachment
indicates the presence of an untreated retinal break and/ or
excessive retinal traction. The most common cause of
recurrent retinal detachment isresidual anterior traction that
opensan anterior break. Eyeswith anterior contraction can
sometimesbe reattached successfully with a repeat uidgas
exchange.
After the retina is attened, laser treatment is applied in
several rowsto the retina over the scleral buckle and some-
times 360-degrees posterior to the scleral buckle. We have
found that postoperative laser photocoagulation in the air-
lled eye is most easily administered using a laser with a
long wavelength, such as krypton red or diode laser, and a
panfunduscopic contact lens.
Although some degree of retinal detachment anterior to
the scleal buckle may remain, often uid can be demarcated,
and the posterior retina will remain attached. This is com-
patible with long-term stability and recovery of functional
visual acuity in some cases; however, some caseswith ante-
rior retinal detachment will become hypotonus. If there is
signicant retinal contraction posterior to the scleral buckle,
we do not recommend doing a uidair exchange
because of the risk of further contraction and posterior
tear formation. With posterior contraction, we recommend
reoperation.
Eyeswith silicone oil can have unique postoperative con-
siderations, including herniation of the silicone oil into the
anterior chamber and pupillary block glaucoma due to the
silicone oil. Both problems usually result from closure of
the peripheral iridectomy. Sometimes, however, the oil will
be in the anterior chamber in the rst few days following
surgery in spite of an open iridectomy. If the eye is pro-
ducing adequate aqueous, the silicone oil will recede behind
the pupil as ow of aqueous is established through the
peripheral iridectomy. Keeping the patient in an upright
position with the face tilted forward will help establish the
proper aqueous ow. If the eye is not making adequate
aqueous, the oil will continue to herniate forward. Usually,
if the silicone oil haspushed the irisforward with shallow-
ing of the anterior chamber following surgery, simply posi-
tioning the patient upright with the face tilted forward or
having the patient lie prone will cause it to recede to its
normal position.
Fibrin can close a peripheral iridectomy and cause pupil-
lary block with shallowing of the anterior chamber and
glaucoma or herniation of the silicone oil into the anterior
chamber. Sometimesthe brin will resolve with topical cor-
ticosteroids, but if it persists more than 48 to 72 hours, we
inject tPA (3g) to lyse the brin. If postoperative brin
formation hascaused adherence of the peripheral iristo the
cornea, surgically reforming the anterior chamber may be
necessary. In the surgical suite, we inject viscoelastic to
reform the anterior chamber. Removing a small amount of
silicone oil may occasionally be necessary.
Results
There has been slow, steady improvement in the surgical
results of PVR management in the past 25 years. Grizzard
and Hilton (16) used a high encircling scleral buckle tech-
nique and reported a 35%retinal reattachment rate in eyes
with the equivalent of C1 to D2 PVR (Retina Society
classication). Machemer and Norton (46) found vitrectomy
alone was not successful for PVR, but Machemer and
Laqua (3) combined membrane peeling techniqueswith vit-
rectomy and their retinal reattachment rate at 6 months
increased to 36%.
Early surgical techniques of vitrectomy and membrane
peeling were effective in managing posterior membranesin
PVR.The major cause of failure wasanterior retinal prolif-
eration and contraction. Charles(47) rst described anterior
displacement of the retina in PVR. Lewis and Aaberg (4)
described the pathoanatomy, and Elner and colleagues (25)
showed the histopathology of anterior PVR. Aaberg (48)
correlated the chronology of surgical advances and under-
standing of the pathoanatomy of PVR with improvement
in results and management of PVR.
There has been continued improvement in both
anatomic and visual resultsin management of PVR. Lewis,
Aaberg, and Abrams (7) reported complete retinal reattach-
ment in 73 (90%) of 81 eyes that had not undergone a
previous vitrectomy. Of the eyes that were completely
reattached, 85%(62/ 73) obtained a visual acuity of 5/ 200
or better. Lewisand Aaberg (8) reported complete anatomic
reattachment in 27 (73%) of 37 eyes that had undergone a
previous vitrectomy for PVR, with visual acuity of 5/ 200
or better in 67%(18/ 27) of eyeswith complete attachment.
The IOP was less than 5mmHg in 4 of their 5 cases with
recurrent anterior retinal detachment.The cause of surgical
failure wascellular reproliferation and traction with anterior
PVR present in 9 of 12 cases that developed a recurrent
retinal detachment.
The Silicone Study wasa multicenter, randomized, con-
trolled clinical trial funded by the National Eye Institute
comparing silicone oil and gases in the management of
PVR.The surgical method included vitrectomy, removal of
posterior membranes, dissection for anterior PVR if present,
and reattachment of the retina with air, followed by ran-
domization to 1000-centistoke silicone oil or gas. An infe-
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HTH42 8/20/98 4:06 PM Page 552
rior iridectomy wascreated in silicone oil eyes.There were
two groupsof eyes: group 1 eyeshad not undergone a pre-
vious vitrectomy; group 2 eyes had undergone a previous
unsuccessful vitrectomy with gasfor retinal detachment.The
study involved a 36-month follow-up on most eyes ran-
domized to silicone oil or C
3
F
8
gas, and long-term follow-
up, up to 72 months, on many of the eyes with attached
maculas at 36 months.
Eyes were randomized to silicone oil or 20%SF
6
gas in
the initial portion of the study and silicone oil or 14%C
3
F
8
gas in the major portion of the study. While results with
silicone oil were superior to SF
6
(38), there was little
difference between silicone oil and C
3
F
8
gas (2). Thus,
both silicone oil and C
3
F
8
gas produced better results than
SF
6
gas.
At 36 months, C
3
F
8
eyes had a higher rate of complete
retinal attachment posterior to the scleral buckle than sili-
cone oil eyes(approximately 80%versus60%, p 0.05) in
group 1 (no previous vitrectomy) (40). No such difference
was found in group 2 (previous vitrectomy) eyes. Between
55%and 65%of oil and gas eyes with complete posterior
attachment in both group 1 and group 2 had visual acuity
of 5/ 200 or better (no signicant difference). Although
hypotony was more common in gas eyes than oil eyes, the
difference was not signicant among eyes with complete
posterior attachment in either group 1 or group 2.
There was no difference in keratopathy in eyes with com-
plete posterior attachment.
On long-term follow-up (up to 72 months) of all eyes
with attached maculas at 36 months, regardless of gas used
or previous vitrectomy status, there was no signicant dif-
ference between gasand oil in anatomic or visual outcome
or in the incidence of keratopathy. In contrast, signicantly
more gaseyeshad hypotony than did oil eyes(approximately
18% versus 5%, p 0.001). Further analyses compared
gas-treated, oil-retained, and oil-removed eyes.
1. Oil-retained versus oil-removed eyes: Oil-removed eyes
had a higher rate of complete posterior retinal
attachment, a higher percentage of eyes with visual
acuity of 5/ 200 or better, and a lower rate of
keratopathy. There was no difference in hypotony.
2. Gas-treated versus oil-removed eyes: There was no
difference in complete posterior retinal attachment,
but oil-removed eyes had a higher percentage of
eyes with visual acuity of 5/ 200 or better at 60
months, less keratopathy at 48 months, and a lower
rate of hypotony.
3. Gas-treated versus oil-retained eyes: Gas-treated eyes
had a higher rate of complete posterior attachment
and visual acuity of 5/ 200 or better. There was no
difference in hypotony, but oil-retained eyes showed
a trend toward more keratopathy (not signicant).
Oil-removed eyeshad a better outcome than oil-retained
and gas-treated eyes in this study. However, silicone oil
removal was at the surgeons discretion, and oil was more
likely to be removed in eyes with attached retinas, better
visual acuities, and fewer complications. Oil-removed eyes
also had fewer reoperations than oil-retained eyes, so
surgeon biasmakesit difcult to determine if it isbetter to
remove or retain oil. An earlier Silicone Study report
attempted to remove surgeon bias from the analysis (41).
Silicone oil was removed from 100 (45%) of 222 eyes that
received silicone oil in the study. In a matched-pairs analy-
sis, eyeswith silicone oil removed were more likely to expe-
rience improvement in visual acuity and suffer retinal
detachment than eyes with silicone oil retained.
A number of subgroup analyses were reported in the
Silicone Study. There was no difference in retinal reattach-
ment or visual acuity between group 1 and group 2 eyes
(49). Though uncommon, elevated IOP (25mmHg) was
more prevalent in silicone oil eyes (8%) than in C
3
F
8
eyes
(2%) (p 0.05) (50). Chronic hypotony (IOP 5mmHg)
was1) more prevalent in eyesrandomized to C
3
F
8
gasthan
in those randomized to silicone oil (31%versus 18%; p
0.05), 2) more prevalent in eyeswith anatomic failure (48%
versus 16%; p 0.01), and 3) correlated with poor post-
operative vision (p 0.001) and retinal detachment (p
0.001). Diffuse contraction of the retina anterior to the
equator was an independent factor prognostic of chronic
hypotony.
Relaxing retinotomies were more commonly done in
group 2 eyes(42%) than in group 1 eyes(20%) (p 0.0001)
(31). The incidence of hypotony (IOP 5mmHg) was
greater in gas eyes than silicone oil eyes undergoing relax-
ing retinotomies. Relaxing retinotomies were done more
commonly in eyeswith anterior PVR than in eyeswithout
anterior PVR.Visual acuity and the retinal reattachment rate
were better in eyes without relaxing retinotomies than in
eyes with relaxing retinotomies.
Eyes with posterior PVR had a better outcome at 6
months than eyes with anterior PVR (51). For eyes
with anterior PVR, signicant predictorsof poor (5/ 200)
visual acuity were a preoperative PVR grade of D1 or
worse (Retina Society Classication) and the use of
C
3
F
8
gas as the intraocular tamponade. Eyes with anterior
PVR and clinically signicant posterior PVR changes
had a better visual prognosisif silicone oil wasused instead
of gas.
In eyes with attached maculae, the incidence of corneal
abnormalities at 24 months was 27% and did not
differ signicantly between silicone oil and gas groups
(52). Corneal abnormalities were correlated with poor
visual acuity and hypotony. Factors predictive of corneal
abnormalities were iris neovascularization, aphakia or
pseudophakia, postoperative aqueousare, and reoperations.
The overall prevalence of macular pucker among eyes
with attached maculae was 15%(53). There was no differ-
ence in the prevalence of postoperative macular pucker in
eyes randomized to gas versus silicone oil or between
group 1 and group 2 eyes. Postoperative macular pucker
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HTH42 8/20/98 4:06 PM Page 553
was three times as likely to develop in eyes that were
preoperatively aphakic or pseudophakic than in eyes
preoperatively phakic.
Recent improvements such as PFCL and wide-angle
viewing were not available for the Silicone Study. The
impact of these advances on the results of the study are
unknown.We expect further technical advancesto improve
our ability to manage PVR. In spite of the excellent surgi-
cal resultsin PVR management, many problemswith recur-
rent proliferation remain. Whereas an increased percentage
of casescan be reattached with surgery, inhibition of repro-
liferation with pharmacologic agents to prevent subsequent
retinal detachment has been sought by many investigators
for over 20 years and counting. There are ve major areas
of investigation into reducing cellular proliferation in PVR:
anti-inammatory therapy (54), direct inhibition of cellular
proliferation (5560), prevention of attachment of prolifer-
ating cells to collagen (61), immunotoxin therapy (62), and
gene therapy (involving the suicide gene) (63). Addition-
ally, there are new modalities under development, such as
sustained release devices, to better deliver drug therapy to
the eye.These avenuesof research offer hope that PVR can
be prevented from occurring in most cases, and cured if it
does occur.
RETINAL DETACHMENT ASSOCIATED
WITH VITREOUS HEMORRHAGE
Overview
Vitreoushemorrhage most commonly occursdue to retinal
tears associated with posterior vitreous separation. The
patient frequently has photopsia and oaters followed by
visual loss. Retinal detachment may also be associated with
postsurgical hemorrhage, or hemorrhage may be present fol-
lowing a failed retinal reattachment procedure.
Vitreous hemorrhage can obscure the retina. However,
peripheral tears and retinal detachment can sometimes be
visualized with the indirect ophthalmoscope in spite of a
dense vitreoushemorrhage because the area of the vitreous
base may not be obscured. Visualization is sometimes
obtained following bed rest and head elevation.
Ultrasound may reveal a retinal detachment.Areasof vit-
reoretinal adhesion may be identied, and larger aps of
horseshoe tears may be seen with ultrasound. Mapping the
extent and degree of elevation of the retinal detachment is
usually possible with ultrasound.
If vitreous hemorrhage prevents adequate visualization
for a scleral buckling procedure, vitrectomy is indicated.
Sometimes peripheral visualization is adequate to permit
a scleral buckling procedure, and visualization may be
improved by bed rest, bilateral patching, and head elevation.
We proceed to vitrectomy if a retinal detachment ispresent;
the risk of PVR may be increased by delaying surgery in
the presence of vitreous hemorrhage.
If a denite acute retinal tear without retinal detachment
is detected by ultrasound, and visualization is not adequate
for treatment, vitrectomy is indicated. However, a trial of
bed rest with head elevation and bilateral patching is indi-
cated for 48 to 72 hours to see whether the hemorrhage
will settle enough to permit visualization and treatment
without vitrectomy.
Surgical Anatomy
Posterior vitreousseparation ispresent in most cases. Retinal
tears are usually located at the posterior edge of the vitre-
ous base that is the anterior extent of the posterior vitre-
ousseparation.The retinal detachment may be quite bullous;
sometimes there is little separation between the posterior
hyaloid and the retina.
Surgical Technique
The eye is prepared for vitrectomy in the usual manner. If
a scleral buckle is planned, a 360-degree conjunctival inci-
sion is made, and the muscles are isolated with sutures. If a
preexisting buckle is not to be revised, transconjunctival
suturesare placed through the rectusmusclesand a limited
conjunctival approach is used. Entrance into the eye is in
the usual manner. If the pars plana is detached, openings
should be made more anteriorly than usual.We use a 4-mm
infusion port. Care must be taken if a longer infusion port
is used, so that it does not impact the equator of the lens
or the retina over the scleral buckle. For this reason, we
rarely use the long infusion ports in phakic eyes or in eyes
with anteriorly located scleral buckles.
The central vitreous is removed, then the posterior
hyaloid isincised over attached retina if possible. If the retina
is completely detached, then a less bullous area is selected.
Preoperative ultrasound is helpful, but the conguration of
the retinal detachment may change at surgery. The hyaloid
is incised posteriorly over the optic nerve if the retina is
totally detached, because the retina isat at the edge of the
optic disk. If the posterior hyaloid is separated from the
retina and the vitreous is collapsed anteriorly, the cutting
port is directed anteriorly and the vitreous and posterior
hyaloid face may curl around the instrument tip into the
port during vitrectomy. It is usually necessary to face the
cutting port parallel with a collapsed hyaloid, or directly
toward a thickened or taut hyaloid, in order to incise the
hyaloid.
Once the hyaloid is incised, the instrument tip is placed
through the opening and the cutting port is directed away
from the detached retina toward the edge of the hyaloid.Low
suction isapplied, and the retina iskept in view during vit-
rectomy. Vitreous is cut in a centrifugal fashion, eventually
excising the vitreous to the surface of the vitreous base. In
the periphery,there isdanger of suctioning bullousretina into
the cutting tip. The vitreous should be cut over detached
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HTH42 8/20/98 4:06 PM Page 554
retina with lower levels of suction and with the vitreous
cutter facing away from the detached retina. PFCL (see
above) injected over the posterior retina will stabilize the
retina during excision of peripheral vitreous and reduce
the likelihood of retinal damage. The PFCL should be
injected so the meniscusremainsposterior to the vitreousin
the periphery, thusavoiding compression of the vitreousand
allowing it to be engaged with the vitreouscutter.Vitreous
iscut back to the periphery asfar ascan be safely done.
The posterior retina should be examined closely for the
presence of epiretinal membranes. Membranes should be
removed in the same manner done for PVR. If the retina
is mobile, without any folds or membranes, then the retina
can be reattached. Prior to reattaching the retina, plugs
should be placed in the sclerotomy sites and the peripheral
retina thoroughly examined with the indirect ophthalmo-
scope. All retinal breaks should be identied and localized.
Peripheral retinal breaks can be treated with either laser or
cryotherapy. Cryotherapy can be performed at this time or
after reattachment of the retina with air or PFCL, but breaks
should be marked with diathermy if possible so they can be
identied when the retina is reattached. Laser is performed
after the retina is reattached.
If peripheral retinal breaks are present, an appropriate
encircling scleral buckle is usually placed to support the
breaksand vitreousbase area.The suturesand scleral buckle
are usually placed at thistime, although some surgeonsplace
the buckle after reattachment of the retina. If scatter treat-
ment on the buckle is anticipated, it is best to have the
buckle in place prior to insufating air, because sometimes
the pupil will become miotic in the aphakic eye or with
uctuation of IOP in the air-lled eye. If a posterior retinal
break is present, uidair exchange is performed as
described above for PVR. If a posterior break isnot acces-
sible for endodrainage, we usually reattach the retina with
PFCL as described above.
When the retina is reattached, laser endophotocoagula-
tion is applied to all accessible retinal breaks. Laser is most
easily applied through PFCL, but can also be done through
air. Breaks should be surrounded with conuent laser. In
aphakic and pseudophakic eyes, laser endophotocoagulation
can be used to treat both posterior and anterior breaks, but
in phakic eyes, there is a risk of damage to the lens with
the endoprobe when treating peripheral breaks. Delivery of
the laser by the indirect ophthalmoscope (indirect laser pho-
tocoagulation) isoften preferred for peripheral breaks. In the
absence of PVR, if vitreous traction has been satisfactorily
relieved, only the retinal breaksare treated with laser or cry-
oretinopexy. However, if there is signicant traction, laser
scatter treatment should be placed on the peripheral retina
supported by the scleral buckle in two to three rows, with
at least one burn width between laser spots. If PFCL is in
the eye, it should be exchanged for air as described above.
An airgas exchange is done if a long-acting gas is to be
used.
Results
Ratner et al (64) reported retinal reattachment in 21 (50%)
of 42 eyes with retinal detachment and vitreous hemor-
rhage. Of the 42 eyes, 18 (43%) obtained visual acuity of
5/ 200 or better. A more recent study using more modern
techniques reported retinal reattachment in 55 (89%) of 62
eyes with preoperative vitreous hemorrhage (65). The
authors found no difference in the incidence of posto-
perative PVR between eyes with and without preoperative
vitreous hemorrhage.
Surgical failure in these eyes may result from complica-
tions of the vitrectomy. Eyes with preexisting rhegmatoge-
nousretinal detachment have a higher incidence of entrance
site problems, including dialysis, subretinal infusion, and
retinal incarceration. Iatrogenic tears are easily created in
detached retina. Other causesof failure to reattach the retina
include failure to identify tears and PVR. Tears may be
hidden in the hemorrhagic vitreous base. A broad buckle
covering the area from the ora serrata to near the equator
will close most peripheral tears. PVR probably occursmore
rapidly in eyes with vitreous hemorrhage. For that reason,
we recommend surgery soon after the onset of hemorrhage
if retinal detachment occurs. Eyeswith vitreoushemorrhage
should be followed closely with ultrasound to detect retinal
detachment at an early stage. Poor visual function following
retinal reattachment may be due to macular dysfunction
from longstanding retinal detachment, PVR, or epiretinal
membrane formation.
POSTERIOR RETINAL BREAKS
Overview
Posterior breaksmay lead to retinal detachment in a variety
of conditions. Macular holes may be idiopathic or associ-
ated with high myopia, or may follow trauma (6670). Most
do not lead to retinal detachment beyond the immediate
margin of the macular hole, and management of macular
holes without extensive retinal detachment is described in
Chapter 52. Posterior breaks may be associated with pro-
liferative retinopathies (diabetic retinopathy or branch
vein occlusion), posterior lattice degeneration, or uveal
colobomas. Retinal detachments due to posterior breaks
usually do not extend to the ora serrata, and peripheral
breaks are usually not present.
A scleral buckle may reattach the retina in some eyes
with breakswell posterior to the equator.Variousprocedures
using slings, straps, scleral pockets, or permanent or tempo-
rary radial scleral buckling elements have been reported
(7174). However, there isrisk of damage to the optic nerve,
macula, vortex veins, and posterior ciliary vessels in the
treatment of far posterior tears, and a scleral buckling pro-
cedure carries the risk of scleral perforation or rupture or
choroidal hemorrhage in highly myopic eyes.Those eyesnot
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HTH42 8/20/98 4:06 PM Page 555
easily and safely managed by a scleral buckling procedure
are candidates for vitrectomy.
Surgical Anatomy
Macular holes usually do not lead to extensive retinal
detachment. The incidence is extremely low in nonmyopic
eyes with macular holes but is not uncommon if myopia
of 6.00 diopters (D) or greater is present (Fig. 42-35A, B)
(7576). Retinal detachment is usually associated with vit-
reoretinal adhesion and traction. Gass believes that macular
holesare the result of tangential retinal traction, and that the
vitreousremainsattached to the retina surrounding the hole
in most cases. It isthe combination of the macular hole and
the associated vitreous traction that leads to both the
common localized and the less common extensive retinal
detachment. In cases of proliferative retinopathy, posterior
lattice degeneration, and uveal coloboma, traction is nearly
always present. These breaks are usually the result of partial
posterior vitreous separation, with vitreous traction on the
ap of the tear and often on the adjacent retina. In most
retinal detachmentsassociated with posterior holes, vitreous
traction is necessary for the retinal detachment to occur.
Exceptionsare highly myopic eyeswith posterior staphylo-
mas in which the retina may detach even though a com-
plete posterior vitreousseparation occurs. In these eyes, the
retina isprobably relatively shortened in comparison to the
conguration of the deep staphyloma, and the retinal
pigment epithelium may function inadequately to pump out
subretinal uid.
Surgical Technique
A scleral buckle is usually not performed. Preparation and
vitrectomy are the same as described above. Frequently,
vitreous adhesions not identied preoperatively are
recognized at surgery. Adhesions are initially recognized
when the retina moves and is pulled toward the vitreous
as the adherent vitreous is cut. Sometimes it is necessary
to strip vitreous and/ or associated epiretinal membranes
from the retinal surface. We use an illuminated pick or
barbed needle or a blade to strip the vitreous. Sometimes
the vitreous is best grasped near the retina with vitreous
forceps, then in a bimanual technique, the retina isheld back
with the blunt side of the illuminated pick and the vitre-
ous is stripped free. Alternatively, the pick can be used to
bluntly separate adhesionsasthe vitreousisheld under trac-
tion. If vitreous is tightly adherent and will not strip free,
it is cut near the retinal surface, then adhesions are cut
with automated vertically cutting scissors. All adhesions
are cut, and remaining vitreousistrimmed back toward the
vitreous base.
Macular Hole Without Staphyloma
After all vitreous adhesions have been released and vitrec-
tomy is completed, we inspect the peripheral retina for
retinal breaks. If no breaks are seen, the retina is reattached
with a uidair exchange. Fluid can be drained through the
macular hole to reattach the retina. The subretinal uid is
aspirated with gentle suction with a soft-tipped needle.
Alternatively, a backush brush can be used if care is taken
that the air pressure is somewhat lower than for a routine
uidgas exchange, so the extrusion pressure is not too
high. It isimportant not to suction the retina into the orice
of the aspirating needle. Usually, the subretinal uid will
stream out of the hole when low suction is applied while
the soft-tipped needle is held just anterior to the hole.
Too much suction will sometimes enlarge the hole by
stretching the edgesasthe uid traversesthe hole. If chronic
subretinal uid hasbecome proteinaceous, the uid iseasily
Z
FI GURE 42- 35. The ri ght eye of a pat i ent wi t h hi gh myopi a who had a l ocal i zed rhegmat ogenous ret i nal det achment due t o a macul ar
hol e. A. Preoperat i ve fundus phot ograph. B. Appearance of t he macul a 10 days af t er pars pl ana vi t rect omy and ui dgas exchange, wi t h no di rect
t reat ment appl i ed t o t he macul ar hol e. There i s st i l l a part i al gas l l i n t he vi t reous cavi t y. The ret i na i s reat t ached.
A B
HTH42 8/20/98 4:06 PM Page 556
visualized as it streams out of the hole into the aspirating
needle.
At the end of the uidair exchange, we do not aggres-
sively aspirate uid at the hole when the retina is at. We
remove as much intraocular uid as possible by waiting
approximately 15 minutes to let more uid accumulate in
the posterior pole, then aspirate the accumulated uid. We
do not treat the macular hole with laser or other adhesive
modality.The air is exchanged for a nonexpansile gas (12%
to 14% C
3
F
8
). We ask the patient to stay in the prone
position for the rst two weeks following surgery. If
retinal detachment recurs postoperatively, a repeat uidgas
exchange isperformed (77).Then, when the macula isat,
the hole is treated with external laser.
Macular Hole with Posterior Staphyloma
Initial management isthe same asfor macular hole without
posterior staphyloma. Most macular holes associated with
staphylomas will require treatment; nevertheless, we gener-
ally do not treat these tears initially. If retinal detachment
recurs postoperatively, we atten these tears with repeat
uidgas exchange and treat with laser.
Posterior (Nonmacular) Break
After vitrectomy and release of all traction from the break,
the margins of the break are marked by whitening
with endodiathermy. Fluidair exchange is performed with
drainage through the posterior break by an aspirating
soft-tipped needle. The break is treated with two rows of
surrounding laser endophotocoagulation. The patient is
in a prone position postoperatively for approximately
1 week to keep the tear closed while air or gas remains in
the eye.
Results
Binder and Riss(78) compared 27 eyeswith macular holes
and retinal detachments treated with nonvitrectomy tech-
niquesfrom 1972 until 1977 with 18 eyestreated with vit-
rectomy and gas insufation from 1978 until 1981 at the
same eye clinic.The anatomic reattachment rate washigher
in the vitrectomy group (17 of 18) than in the nonvitrec-
tomy group (16 of 27). No eyesin the nonvitrectomy group
had better than 6/ 60 vision, while one-third of eyes that
underwent vitrectomy had visual acuity of 6/ 12 to 6/ 48.
Poorer vision in the nonvitrectomy group wasdue to buck-
ling of the macula or sometimes repeated treatment of the
macula. In 3 casestreated with vitrectomy, no treatment was
applied to the macular hole.
Gonvers and Machemer (79) treated 6 cases of retinal
detachment due to macular holes with vitrectomy and
uidgas exchange and positioning. No treatment was
applied to the breaks. Of the 6 eyes, 5 remained attached,
but one required a repeat uidair exchange. Also, 5 of 6
eyeswere highly myopic. Final vision ranged from 3/ 200 to
20/ 100.
Several authors have also attempted treatment of retinal
detachment due to macular hole by performing gas injec-
tion without parsplana vitrectomy. Blankenship and Ibanez-
Langlois exchanged liquid vitreous with an intravitreal gas
bubble and achieved successful reattachment in 15 of 19 eyes
(80). One patient required repeated exchange and 3 required
vitrectomy. Visual acuity of 20/ 400 was obtained in 9
patients. Miyake reported successful reattachment after gas
injection in 15 of 18 eyes, with follow-up from 4 to 32
months (81). Another study compared vitrectomy and gas
injection with gas injection alone in 43 eyes, and found
similar nal attachment rates (82).
Complicationsare the same asfor vitrectomy surgery in
general. Because the intraocular maneuvers are limited and
the procedures short, a low incidence of complications is
found in this group of eyes. However, redetachment rates
are high, and the need for reoperation is not uncommon.
Residual epiretinal tissue over the posterior retina causing
tangential traction is thought to be the cause of recurrent
detachment in some cases (83,84). Complications may be
less with vitrectomy than with scleral buckling for some
highly myopic eyes.
NONDIABETIC TRACTION
RETINAL DETACHMENT
Most retinal detachments result from vitreous traction.
However, we differentiate traction retinal detachmentsfrom
other retinal detachments by the presence of either direct
vitreoustraction that preventsthe retina from contacting the
retinal pigment epithelium, or direct vitreous traction that
preventsa retinal break from settling on an adequately posi-
tioned scleral buckle. Traction retinal detachment requires
parsplana vitrectomy to adequately relieve vitreoretinal trac-
tion and reattach the retina. Common etiologiesof traction
retinal detachment such asproliferative diabetic retinopathy,
advanced proliferative vitreoretinopathy, retinopathy of pre-
maturity, and penetrating trauma are discussed elsewhere in
the text. Other etiologies include vitreous incarceration in
a surgical wound, lower gradesof PVR, vitreomacular trac-
tion syndrome, and complicated branch retinal vein occlu-
sion and associated diseases. While other conditions can
also cause traction retinal detachments, the principles of
treatment of the above conditions can be used for most
other etiologies.
Vitreous Incarceration in a Surgical Wound
Overview
Vitreous incarcerated in a cataract wound can cause direct
vitreous traction on the retina. Incarceration may result
from vitreous loss from a broken posterior capsule during
phacoemulsication or from a limited choroidal hemorrhage
in which vitreousisextruded from the wound (Fig. 42-36A).
Thismay result in traction retinal detachment with vitreous
Z
HTH42 8/20/98 4:06 PM Page 557
strandsbridging between the wound and the retina (Fig. 42-
36B). These detachments may occur soon after surgery if a
great deal of vitreouswaslost at surgery or if a retinal break
occurred at the time of cataract surgery. Alternatively, the
retinal detachment may occur weeksto monthsafter surgery
if brousproliferation at the wound caused additional trac-
tion. A similar picture can sometimesbe seen following vit-
rectomy if inadequate vitreous was removed and vitreous
traction from the sclerotomy wound is transmitted to the
retina (Fig. 42-37A). In addition, vitreousincarceration in a
scleral drain site during a scleral buckling procedure can lead
to signicant vitreoustraction.We have seen traction retinal
detachment following resolution of a postoperative, nonex-
pulsive choroidal hemorrhage following glaucoma ltration
surgery. In thiscase, vitreouswasextruded through the lter
site into the subconjunctival space.
Surgical Anatomy
Characteristically, these retinal detachmentsare rhegmatoge-
nousand have horseshoe retinal breakswith highly elevated
retinal aps, though occasionally the retinal detachmentsare
purely tractional. Vitreous can usually be seen bridging
between the wound and the retina.
Surgical Technique
We initiate pars plana vitrectomy as described above.Vitre-
oustraction isusually directed toward the vitreousbase, and
the posterior vitreous is often separated. If posterior vitre-
ous separation has not occurred, then vitreous is separated
from the optic disk and retina with suction, picks, and/ or
vitreous forceps as necessary. Vitreous strands from the
wound to the retina are severed with the vitrectomy cutter
(Fig. 42-37B). If the vitreousisorganized, it may be neces-
sary to cut the membraneswith scissors, though thisisrare.
We remove vitreous attached to aps of retinal breaks and
strip any epiretinal membranes present. The vitreous is
shaved to the surface of the peripheral retina at the vitre-
ous base using scleral depression or a wide-angle viewing
system.
If the retina becomes bullous as traction is released,
then PFCL can be used to stabilize the retina asperipheral
vitreous or membranes are removed. If a posterior break
is present, a uidair exchange will reattach the retina. If
breaksare only peripheral, the retina can be reattached with
PFCL. We usually treat retinal breaks with laser endopho-
tocoagulation, although indirect laser photocoagulation or
cryotherapy can be used alternatively. No gastamponade or
scleral buckle is required if there are no retinal breaks and
traction has been released. We usually place an encircling
scleral buckle to support peripheral retinal breaks.
Results
Kreiger (85) reported on 4 patients who developed retinal
detachments secondary to tears caused by traction from
incarcerated vitreous at a sclerotomy site, and who under-
went reoperation. All detachments were successfully re-
paired, although visual outcome waspoor in 1 eye in which
silicone oil was required because of severe PVR.
Vitreous Traction on Retinal
Breaks Following Scleral Buckle
Overview
Most retinal detachments with lower grades of PVR are
managed with a scleral buckle. With grades A and B (see
Table 42-1), there can be vitreous contraction induced by
Z
Vitreous
wound
Open cataract wound
Iris incarcerated
inwound
Haemorrhage in
supra choroidal
space A B
Retinal detachment
Taut vitreous
to wound
Retinal
detachment
FI GURE 42- 36. An i nt raoperat i ve choroi dal hemorrhage l eadi ng t o a t ract i onal ret i nal det achment . A. An eye wi t h an i nt raoperat i ve
choroi dal hemorrhage duri ng cat aract surger y. The mass effect of t he choroi dal hemorrhage di spl aces vi t reous i nt o t he open cat aract wound.
B. Wi t h resol ut i on of t he choroi dal hemorrhage, t he band of i ncarcerat ed vi t reous appl i es t ract i onal force t o t he ret i na, l eadi ng t o t ract i onal
ret i nal det achment .
HTH42 8/20/98 4:06 PM Page 558
proliferative cells. Vitreous traction on a retinal break can
sometimes prevent the retinal break from making contact
with the retinal pigment epithelium on a scleral buckle and
prevent reattachment of the retina (Fig. 42-38A). In addi-
tion, some large posterior retinal breaks, even in the absence
of PVR, can sh-mouth and not close on a scleral buckle.
If the retinal break isin the superior 180 degrees, injection
of an air or gas bubble will usually tamponade the break,
except for extreme levels of traction. Inferior retinal breaks
are problematic because of the difculty of tamponading
with air or gas. Sometimes elevating the height of a scleral
buckle or adding a radial element will close the retinal
break, but it is less traumatic to the eye to directly relieve
traction with a vitrectomy in some cases.
Surgical Anatomy
In PVR, ndings include pigmented vitreous cells and
reduced mobility of the vitreous on eye movement. Breaks
are often large, and vitreouscan be seen tenting the ap of
the tear.
Surgical Technique
The central vitreous is removed with the vitreous cutter.
Vitreous attachments to the ap of the retinal tear should
be cut (Fig. 42-38B). Scleral depression or a wide-angle
viewing system may be necessary to visualize the retinal
break. We recommend shaving the peripheral vitreous to
the surface of the anterior retina. If there is signicant
mobility of the anterior retina, PFCL can be used to
stabilize the retina. We usually reattach the retina with
PFCL, then apply laser photocoagulation to the retinal
breaks. We use laser endophotocoagulation in aphakic and
pseudophakic eyes and indirect laser photocoagulation in
phakic eyes. In reoperation of eyeswith early PVR, we rec-
ommend scatter laser photocoagulation 360 degrees to the
retina supported by the scleral buckle, because of the risk
of anterior retinal traction in the postoperative period. We
leave air or gas in the eye for postoperative tamponade of
the retinal breaks.
Results
Friedman and DAmico treated 9 patients who had recur-
rent retinal detachentsdue to persistent vitreoustraction on
retinal breaks after scleral buckle surgery (86). All patients
were treated with vitrectomy, relief of traction on the retinal
break, and gas tamponade. Long-term reattachment was
achieved with 7 of the 9 patients with a single operation,
and in 1 additional patient after two vitrectomies.
Vitreomacular Traction Syndrome
Overview
Vitreomacular traction syndrome classically hasvitreoretinal
traction on the posterior pole causing visual loss.While most
cases do not have retinal detachment, sometimes traction
retinal detachment of the macula and even a larger area of
the posterior pole evolveswhen vitreousseparatesfrom the
retina, except at the macula and optic disk area.
Z
Vitrectomy
insrument
Old sclerotomy
with vitreous
incarceration
Subretinal
fluid
Optic nerve
head
Border of
retinal
detachment
A B
FI GURE 42- 37. Vi t reous i ncarcerat i on i n a scl erot omy wound af t er pars pl ana vi t rect omy l eads t o a ret i nal det achment . A. Vit reous
st reams from t he scl erot omy si t e i n t he pars pl ana t o t he vi t reous base, produci ng peri pheral t ract i on on t he ret i na, wi t h a resul t ant ret i nal break
format i on and a t ract i on/ rhegmat ogenous ret i nal det achment . B. Rel ease of vi t reous t ract i on wi t h vi t rect omy.
HTH42 8/20/98 4:06 PM Page 559
Surgical Anatomy
On examination, the vitreous is seen to bridge in a taut
fashion from the posterior pole adherence to the vitreous
base, separated from the midperipheral retina. There is
epiretinal membrane that fuses the posterior cortical vitre-
ous to the retina in the posterior pole, and there is often
brous tissue at the optic disk where the vitreous remains
attached (Fig. 42-39). The contractile elements in the
epiretinal and epipapillary brous tissue may be the cause
of the taut antero-posterior traction between the vitreous
base and the posterior pole that results in traction retinal
detachment.
Surgical Technique
At vitrectomy, the vitreousattachmentsto the posterior pole
are cut, relieving antero-posterior traction.Then the epireti-
nal membranes are stripped with a membrane pick and
forceps. If no retinal breaksare discovered after the vitreous
is removed to the vitreous base area, air or gas tamponade
is not necessary.
Results
Melberg and colleagues (87) reported on the results of vit-
rectomy in 9 patients who had vitreomacular traction syn-
drome with macular detachment (87). Macula reattachment
was achieved in 7 eyes (78%), and visual acuity was
improved in 4 eyes and stable in 4 eyes. Visual acuity was
thought to be limited in some cases by chronic macular
detachment, premacular brosis, cystoid macular edema, and
macular schisis.These resultsare not asfavorable asfor eyes
undergoing vitrectomy for vitreomacular traction without
macular detachment, a condition for which one seriesfound
vision improvement of two or more linesin 12 (80%) of 15
eyes (88).
Retinal Branch Vein Occlusion
and Associated Diseases
Overview
Traction retinal detachments arising from other causes are
fairly rare. However, retinal branch vein occlusion can be
complicated by retinal neovascularization occasionally
leading to traction retinal detachment (Fig. 42-40) (89,90).
Other rare causes of traction or combined tractional-
rhegmatogenous retinal detachments include sickle cell
disease (91), Coats disease (92), and angiomatosis retinae
(92), which are managed in a fashion similar to that for
venous occlusive disease.
Surgical Anatomy
As in proliferative diabetic retinopathy, traction retinal
detachment is associated with both anterior-posterior trac-
tion due to vitreous adherence to epiretinal brovascular
membranes, and tangential traction caused by contraction
of these membranes. If retinal breaks are present, the
detachment istermed a combined traction-rhegmatogenous
detachment.
Z
A B
FI GURE 42- 38. Recurrent rhegmat ogenous ret i nal det achment af t er scl eral buckl e surger y due t o vi t reous t ract i on on a preexi st i ng ret i nal
break. A. A band of vi t reous el evat es t he i nferi or ret i nal break, l eadi ng t o subret i nal ui d overl yi ng t he buckl e and ext endi ng post eri orl y t o i nvol ve
t he macul a. B. Rel ease of vi t reous t ract i on wi t h vi t rect omy al l ows t he ret i na t o be reat t ached.
HTH42 8/20/98 4:06 PM Page 560
Surgical Technique
The usual indication for vitrectomy in traction retinal
detachment due to venous occlusive disease is detachment
involving or threatening the macula, or a progressive extra-
macular traction-rhegmatogenous retinal detachment. The
technique issimilar to that used in vitrectomy for diabetic-
related retinal detachments, detailed above.
To summarize briey, a three-port parsplana vitrectomy
isperformed, starting with a core vitrectomy and removal of
vitreousopacities, which are often signicant. Starting at the
optic nerve head, brovascular membranesare segmented or
delaminated with intraocular scissorsand forceps.Vitreousis
separated from the retinal surface asfar anteriorly aspossible,
with particular care taken to make sure all vitreoustraction
isrelieved from around any retinal breaks.Then, pneumatic
reattachment is performed, with simultaneous aspiration of
subretinal uid via a silicone-tipped cannula through a pre-
existing or iatrogenic posterior retinal break. If no posterior
break ispresent, PFCL can be used to reattach the retina in
a manner similar to that described for PVR.Then, all retinal
breaks are treated with endophotocoagulation. Scatter laser
endophotocoagulation isalso applied to the peripheral retinal
areas drained by obstructed vessels. An encircling band is
placed in selected cases to decrease traction from the ante-
rior vitreous, and parsplana lensectomy isperformed when
cataract obscuresvisualization of the fundus.
Results
A recent study of pars plana vitrectomy for traction retinal
detachment after retinal branch vein occlusion revealed a
nal anatomic successrate of approximately 86%, with 59%
of eyes achieving visual acuity of 20/ 200 or better (93).
Complications in this study included iatrogenic retinal
breaks in 23% of eyes, and recurrent retinal detachment
requiring additional surgery occurred in 36%.
Less frequent complications include recurrent vitreous
hemorrhage, cataract progression, epimacular membrane
formation, corneal opacication, and neovascular glaucoma.
COMBINED RHEGMATOGENOUS
RETINAL DETACHMENT AND
CHOROIDAL DETACHMENT
Overview
Rhegmatogenousretinal detachment presenting with simul-
taneouschoroidal detachment in the absence of trauma and
recent eye surgery is considered rare (94). In one series
of 1000 consecutive retinal detachments, simultaneous
choroidal detachment was present preoperatively in only 4
cases(95).The condition isseen most commonly in highly
myopic individuals with chronic rhegmatogenous detach-
ments. There appears to be an increased incidence among
Asians, which may be related to the preponderance of
high myopia among these individuals. The presence of a
choroidal detachment hasbeen associated with an increased
incidence of postoperative PVR formation and redetach-
ment (96) [although there is conicting evidence in the
literature regarding this assertion (97)], leading to a
poorer prognosis than for simple rhegmatogenous retinal
detachment.
The pathogenesis of combined retinal and choroidal
detachment is theorized to be related to hypotony. A
Z
Vitreous
base
Vitreous
Vitreous
seperated
from
midperipheral
retina
Macula
Subretinal
fluid
FI GURE 42- 39. The vi t reomacul ar t ract i on syndrome
associ at ed wi t h det achment of t he macul a. The vi t reous i s separat ed
from t he mi dperi pheral ret i na, and part i al l y separat ed from t he
post eri or pol e, but remai ns at t ached at t he di sk and t he macul a.
The vi t reous has become t aut and exert s ant eri orpost eri or t ract i on
bet ween t he post eri or pol e and t he vi t reous base, l eadi ng t o
el evat i on of t he macul a and subret i nal ui d. A brous ri ng and
i nt raret i nal edema are of t en present i n t he macul a.
FI GURE 42- 40. Fundus phot ograph of a t ract i onal
ret i nal det achment secondar y t o a branch ret i nal vei n occl usi on.
Fi brovascul ar membranes run from t he opt i c di sk al ong t he superi or
t emporal vascul ar arcades, ari si ng from NVE and NVD. As t hese
membranes prol i ferat e and cont ract , t ract i on i s exert ed on t he
ret i na, l eadi ng t o a det achment i nvol vi ng t he macul a.
HTH42 8/20/98 4:06 PM Page 561
rhegmatogenous retinal detachment occurs rst, and it
may be initially unnoticed or ignored by the patient. Eyes
harboring retinal detachments are known to be subject to
hypotony, which may be due to decreased aqueous pro-
duction and/ or increased activity of the retinal pigment
epithelium pump. Highly myopic, hypotonous eyes may be
predisposed to development of a choroidal effusion, because
of anatomic and physiologic features such as the poor
support of the anterior uveal veins. With time, a signicant
choroidal detachment develops, which may be associated
with signicant anterior chamber reaction. Laser are-cell
meter measurements have shown the aqueous protein level
to be 70 times higher in eyes with combined retinal and
choroidal detachment than in eyes with simple retinal
detachment (98).
Surgical Anatomy
Fundus examination often reveals a fair degree of vitreous
haze and debris. Because of its chronic nature, the detach-
ment is usually quite bullous, and multiple breaks are
common. PVR may be present.
Surgical Technique
Traditionally, combined retinal and choroidal detachment
hasbeen treated with scleral buckling and external drainage
of subretinal uid, sometimes combined with drainage
of suprachoroidal uid. If there is signicant ocular
inammation, some authorities recommend treatment
with topical and/ or systemic anti-inammatory medi-
cations, delaying surgery until anterior chamber reaction is
reduced in the hope of decreasing the risk of postoperative
PVR.
More recently, initial repair of combined retinal and
choroidal detachment using parsplana vitrectomy combined
with scleral buckling hasbeen reported (99). One potential
advantage with this technique is drainage of suprachoroidal
uid via the instrument and infusion sclerotomies, eliminat-
ing the need for a separate scleral cut-down. A possible dis-
advantage of vitrectomy would be the potentially increased
risk of postoperative PVR formation.
Prior to performing surgery, the severity of the choroidal
detachment should be evaluated with indirect ophthal-
moscopy and possibly echography. From this information,
an area with a lower choroidal elevation can be chosen for
the infusion cannula site.There isrisk of retinal damage and
hemorrhage during creation of the sclerotomy sites, so
the tip of the blade should not contact the elevated retina
and choroid.There isalso risk of suprachoroidal infusion, so
it is important to visualize the tip of the infusion port
within the eye prior to opening the infusion. As noted,
suprachoroidal uid will usually drain when sclerotomiesare
made for the instrument ports. Surgery then proceeds in a
fashion similar to that for retinal detachment with PVR,
with removal of the vitreous, membrane peeling, encircling
scleral buckle placement, endolaser treatment, and gas or
silicone oil tamponade.
Results
Results in the literature are limited, but in a recent small
series of patients with rhegmatogenous retinal detachment
and choroidal detachment treated with pars plana vitrec-
tomy, 90%achieved retinal reattachment without reopera-
tion after 6 months of follow-up (99).
RETINAL DETACHMENT IN
OCULAR INFLAMMATORY DISEASE
Overview
Patients with uveitis may develop retinal detachments due
to several mechanisms. Retinal detachments can be exuda-
tive, tractional, or rhegmatogenous.There are often tractional
elements to the rhegmatogenous retinal detachments.
Exudative retinal detachments are treated medically, while
tractional and rhegmatogenous retinal detachments usually
require surgery.
Fibrous proliferation secondary to intraocular inamma-
tion may cause abnormally strong vitreoretinal adhesions
posterior to the vitreous base, resulting in retinal breaks
when a posterior vitreous separation occurs. Surgical repair
often requires vitrectomy as well as a scleral buckle.
There is a signicant risk of recurrent retinal detachment
with PVR following repair of retinal detachments in
uveitis. Factors linked to a high propensity to develop
PVR, such as breakdown of the blood-ocular barrier,
inux of inammatory cells and macrophages, and stim-
ulation of growth factors, are present in active ocular
inammatory disease. Cataracts and hypotony are often
found in patients with uveitis and further complicate
surgical management.
Certain formsof uveitisare more prone to retinal detach-
ment than others. In an older series of 44 eyes with rheg-
matogenous retinal detachments (1.7%of a large series of
consecutive retinal detachments), the causes of the
inammatory disease were classied asfollows: toxoplasmo-
sis, 36%; pars planitis, 25%; and ocular toxocariasis, 7%. In
32%of the eyes, no cause could be established (100). Retinal
detachmentsare common following viral retinitis, and these
retinal detachments are covered elsewhere.
Surgical Anatomy
Foci of retinal inammation and inammation-induced
neovascularization may cause scarring and vitreoretinal
adhesions. In nonrhegmatogenous traction retinal detach-
ment, there is vitreous traction on areas of viteoretinal
adhesion, which causes the retinal detachment. When a
retinal break occurs in an area of adhesion, a traction-
rhegmatogenous retinal detachment may occur. Retinal
Z
HTH42 8/20/98 4:06 PM Page 562
breaksat the vitreousbase due to posterior vitreoussepara-
tion may cause retinal detachmentsin patientswith uveitis.
These may be complicated and difcult to repair because of
vitreoushaze and cataract. Epiretinal membranesseen before
surgery can lead to xed foldsand recurrent retinal detach-
ment with PVR. Even without preexisting epiretinal mem-
branes, retinal detachments in uveitis are more likely to
develop recurrent retinal detachment and PVR. In pars
planitis, retinal breaksassociated with peripheral brovascu-
lar proliferation at the vitreousbase may cause complicated
retinal detachments.The peripheral retinal traction createsa
picture similar to anterior PVR. In toxocariasis, there may
be extensive vitreous, retinal, and subretinal proliferation that
leads to retinal breaks and detachment.
Additional anatomic problems these patients develop
include cyclitic membranes with anterior retinal dis-
placement and ciliary body traction. Hypotony may lead
to phthisis bulbi even in the face of successful retinal
reattachment.
Surgical Techniques
Eyes with uveitis and retinal detachment are prone to
develop severe inammation postoperatively. Preoperative
treatment with periocular or systemic corticosteroids may
reduce inammation. Machemer hasshown that administra-
tion of corticosteroidsprior to surgery ismore effective than
postoperative administration (54). Pretreatment with corti-
costeroids may induce synthesis of intracellular effector
proteins that inhibit the inammatory cascade. While treat-
ment with corticosteroids for 5 to 7 days prior to surgery
will best inhibit inammation, it is not always best to wait
that long to repair a recent rhegmatogenousretinal detach-
ment. In that case, pretreatment the day prior to surgery
may still help to reduce the postoperative inammatory
reaction. Patients with toxoplasmosis should be treated
with the full regimen for toxoplasmosis in addition to
corticosteroids.
In eyeswith peripheral retinal breakswithout PVR, and
in which the media are clear enough to permit adequate
peripheral retinal examination, the retinal detachment
can usually be repaired using a scleral buckle without vit-
rectomy. Cryotherapy should be minimized, because it may
incite further inammation.
Eyeswith cataract or media hazy enough to prevent ade-
quate peripheral retinal examination will require a vitrec-
tomy, as will eyes with signicant retinal traction or PVR.
The entrance sites for vitrectomy should be well planned
preoperatively. Sclerotomy sites should be moved more
anteriorly in eyes with the anterior retinal displacement
sometimesfound in parsplanitisand PVR. Sclerotomy sites
should be moved away from peripheral granulomasand areas
of brosis. Preoperative ultrasound is sometimes useful in
planning sclerotomy placement.
Eyes with cataracts will require lensectomy. Extensive
posterior synechiae are often present and complicate lensec-
tomy. After placing the infusion port, sclerotomies are
created nasally and temporally. If the cataract prevents
inspection of the infusion port to see if it has penetrated
the pars plana epithelium, the port should not be opened
to uid infusion until penetration is visually conrmed.
During lensectomy and the initial posterior vitrectomy pro-
cedure, infusion can be with a handheld 20-gauge infusion
needle as described above. We usually break posterior
synechiae prior to lensectomy by sweeping the synechiae
with a small blunt cannula on a syringe of viscoelastic.The
viscoelastic will maintain anterior chamber depth, clear
the anterior surface of the lens, and partially dilate the
pupil after sweeping the synechiae. Iris retractors may be
necessary to dilate the pupil, but should be avoided if
possible because they can potentially incite more inam-
mation. The lens should be removed with ultrasound
phacofragmentation, and the lens capsule removed, as
described above, to reduce the likelihood of anterior brosis
and traction.
Vitrectomy techniques are similar to those described
above for traction retinal detachment, vitreoushemorrhage,
and PVR. Membranes can be extremely thick and tena-
cious, and it is sometimes best to section membranes if
they do not readily peel from the retina. Extensive brosis
associated with toxocariasis may require sectioning as well
as membrane peeling. Retinal traction should be released
and the vitreous shaved to the surface of the peripheral
retina at the vitreous base, using scleral depression. We
apply only enough laser to treat retinal breaks, except for
PVR cases, where we recommend peripheral scatter treat-
ment on the retina, supported by a scleral buckle.We utilize
gas for most retinal detachments; however, when the eye is
hypotonous, silicone oil may be preferred. Postoperative
periocular and/ or systemic corticosteroidsshould be admin-
istered in most cases. We give subconjunctival Decadron
(510mg) at the end of all cases, and posterior subtenons
(posterior to the equator) triamcinolone acetonide in some
cases.
Results
Hagler and colleaguesreported the resultsof surgery for 44
retinal detachments associated with uveitis (100). In this
1978 study, 38 eyes were treated with scleral buckle and
cryotherapy and only 2 eyes were treated with vitrectomy.
The retina was reattached in 91% of eyes, and vision
improved in 57%. Compared to a large series of retinal
detachmentsin eyeswithout uveitis, retinal detachmentsfol-
lowing ocular inammatory disease had a longer duration
of the retinal detachment, fewer observable retinal breaks, a
higher incidence of visible vitreous membranes and preop-
erative macular puckers, a younger age distribution, and a
higher incidence of phakic patients. No signicant differ-
ence in the presence or types of retinal folds, the rate of
operative complications, or the rate of reattachment at six
months was shown.
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HTH42 8/20/98 4:06 PM Page 563
Thumann and colleagues reported the results of vitrec-
tomy in 50 eyes with uveitis (101). The indications for
surgery were opaque media, retinal detachment, and cyclitic
or preretinal membranes. Eyes with preoperative retinal
detachment had a worse visual outcome (mean visual acuity
of 0.2) than those without preoperative retinal detachment
(mean visual acuity of 0.5). Persistent hypotony following
surgery was found in 7 eyes.
Retinal detachment followsparsplanitisin 22%(102) to
51%(103) of eyes. In mild to moderate formsof the disease,
retinal breaksmay form on the posterior edge of the orga-
nized peripheral brosis. Most of these detachmentscan be
managed with a scleral buckle. However, severe forms of
pars planitis have extensive neovascularization and brous
proliferation with vitreoretinal traction and xed folds, and
a picture similar to anterior PVR.These eyesusually require
vitrectomy (104).
Small et al (105) reported the resultsof vitrectomy for 12
eyeswith tractional macular detachment due to Toxocara canis.
Traction retinal detachments were found in 10 eyes, and
2 eyes had combined traction-rhegmatogenous retinal
detachments. Granulomaswere located peripherally in 9 eyes
and in the posterior pole in 3 eyes. One eye had a central
macular granuloma.The authorsfound that membraneswere
difcult to peel from the retina and were best sectioned or
delaminated from their retinal and optic nerve attachments.
With a minimum of 6 months follow-up, the retina was
completely attached in 10 eyes(83%).Visual acuity improved
in 7 eyes. Poor postoperative visual acuity correlated with
large foldsthrough the macula identied preoperatively.
Morse and McCuen (106) used vitrectomy and silicone
oil injection to treat 5 eyes with profound hypotony asso-
ciated with loss of vision complicating bilateral chronic
uveitis. Uveitiswasdue to toxoplasmosisin 2 eyes, psoriatic
arthritisin 1 eye,Vogt-Koyanagi-Harada disease in 1 eye, and
an undetermined cause in 1 eye. Visual acuity and IOP
improved in 3 of the 5 eyesat 6 months, but vision declined
later in 2 of the 3 with initial improvement.
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