OSLI Retina: Strategic planning ensures surgical success in cases of proliferative vitreoretinopathy

For this Practical Retina column, Dr. Ross Lakhanpal from Baltimore was asked to comment on the current state of thinking and management options for proliferative vitreoretinopathy (PVR) after retinal detachment (RD) surgery.

We are all aware that PVR continues to be an important cause of recurrent RD after successful repair. This feared complication has been reported to occur in up to 8% of patients after undergoing RD repair. Despite the historic progress made in managing various vitreoretinal diseases over the past decade, most retina specialists will agree that an unmet need remains in this landscape. Fortunately, advances in various surgical technologies such as instrumentation, lighting, and visualization have improved the outcomes after PVR management.

Dr. Lakhanpal discusses causes of PVR, management goals, surgical techniques, and pearls to avoid complications after managing PVR. His experience working in an urban tertiary surgical retina practice enables him to offer insights that will be highly valued by our community.

Seenu M. Hariprasad, Practical Retina Co-editor

The most common and dreaded complication after primary retinal detachment (RD) repair is proliferative vitreoretinopathy (PVR), which occurs in approximately 7% to 8% of patients.1,2 In my tertiary retina practice, PVR is present in 25% to 30% of patients.

What is PVR?

The hallmark of PVR is overzealous cellular proliferation from glial cells and retinal pigment epithelial (RPE) cells stemming from the presence of partial or full-thickness retinal breaks or holes. These cells form membranes on and/or beneath the retinal surface, creating epiretinal and subretinal membranes and fibrosis. Contracture and shortening of the retina mark the next pathologic step. The shortening, in turn, distorts and holds open the retinal breaks and can lead to persistent or progressive RD.1 Chronic RD, numerous or large retinal breaks, giant retinal tears, trauma, aphakia, previous intraocular surgery, vitreous hemorrhage, and uveitis are significant risk factors for PVR in RD. Another factor is patient age. The proliferative healing response is more aggressive in younger patients, and a young patient with trauma has an even greater potential for developing PVR. This proliferative process can occur in untreated eyes or eyes that have undergone primary RD repair. In either case, PVR management and repair are challenging and require strategic planning before surgical intervention.

Management goals

My main goals for managing a case of RD with PVR are the following: (1) locate and mark all the offending retinal holes; (2) relieve all the traction from the PVR epiretinal and subretinal membranes; (3) in extreme PVR scenarios, relieve all foreshortening; (4) reattach and flatten the retina; (5) determine and implement the best tamponade required. To avoid failure, all of these steps must be successfully implemented. In my experience, inability to relieve the foreshortening of the retina is the most common cause of failure. This should be remembered when peeling the membranes, because removing all the visible scar tissue may be inadequate if one fails to adequately relax the retina. In numerous instances, the retina may be reattached intraoperatively but re-detaches during the postoperative period, most likely from the areas that are foreshortened and not adequately supported.

Click here to read the full article published in Ophthalmic Surgery, Lasers and Imaging Retina, February 2015.