Three-step program may have better success for PVR after retinal detachment

VIENNA, Austria — Proliferative vitreoretinopathy after retinal detachment is better managed by a three-step program of operations in the most severe cases, according to one surgeon speaking at the Euretina Congress here.

"Unfortunately, PVR can be quite a frequent complication of retinal detachment if the access to health care is delayed. The rate varies from 5% when retinal detachment is detected promptly to as much as 53% when this is delayed of 2 or more months," Tom H. Williamson, MD, said.

He emphasized that the key to successful PVR surgery is timing. The temptation is to achieve a completely flat retina as soon as possible, for example by early relaxing retinectomy.

"Operating on an eye with active PVR can result in a proliferation of membrane formation because the surgical procedure increases the stimuli for PVR," Dr. Williamson said. "PVR must be in a quiescent state before retinectomy is performed, but this requires at least partial reattachment of most of the retina to minimize the release of cytokines and growth hormones from breakdown of the blood-retinal barrier."

For this reason, a three-step program was designed to allow reattachment of the majority of the retina with consequent reduction of PVR stimuli, delaying retinectomy for 3 to 6 months later before proceeding to silicone oil removal.

"At the first operation, vitrectomy is performed and the eye is filled with silicone oil, which in most circumstances flattens two-thirds of the retina, leaving the inferior retina detached because of its shortening. With the macula in place, the retina is left for 3 to 6 months for the PVR process to become quiescent," Dr. Williamson said.

At a second operation, the inferior retina is cut as far peripherally as possible to perform a relaxing retinectomy. Diathermy to the visible peripheral retinal blood vessels is applied to avoid bleeding. The retina is cut with vertical cutting scissors to fashion the retinectomy, cutting through the diathermy points. The vitreous cutter is used to remove the redundant anterior retina, and radial cuts are performed in case of retinal folds. Silicone oil is inserted, and laser retinopexy is performed.

At a third stage, after 3 to 6 months, silicone oil is removed and the retina is inspected.

In a study including 27 patients with PVR, 25 (93%) achieved a flat retina, with removal of the silicone oil in 81% of the cases.

Success rate is usually low in patients with PVR, approximately 62% to 65%, despite the variety of methods used.

"This program appears to provide a high chance of reattached retina and silicone oil removal," Dr. Williamson said. "Visual acuity remains low, but this reflects the damage to the macula from the PVR process and the retinal detachment."