Surgeon gives pearls on successful management of retinal detachment with PVR
WAIKOLOA, Hawaii — Recurrent retinal detachment with proliferative vitreoretinopathy can be effectively managed by vitrectomy, membrane peeling, retinectomy, laser and silicone oil, with the oil then removed 3 to 4 months later.
At Retina 2022, Carl D. Regillo, MD, FACS, gave pearls on how to deal with these complicated cases and achieve a high rate of success.
“No scleral buckle is needed with recurrent RD associated with significant PVR if you know that you’re going to be doing retinectomy and silicone oil tamponade,” he said.
Looking at the literature, the single surgery success rate of vitrectomy, retinectomy and silicone oil (SO) for retinal detachment (RD) with proliferative vitreoretinopathy (PVR) is in the 70% to 80% range, up to 90% for final reattachment. In Regillo’s case series of 28 consecutive cases, single surgery success, defined as fully reattached retina under oil at 3 months, was achieved in 85% of cases.
“It is a small series because I selected eyes with no previous [scleral buckle]. All patients had failed primary RD surgery with one to three prior vitrectomy procedures and significant PVR as the source of retinal redetachment,” Regillo said.
His basic approach entails first ensuring that the vitreous is totally removed.
“You need a good vitrectomy to begin with. If the previous vitrectomy was partial, make it complete,” he said.
Any detectable membranes should then be removed.
Retinectomy is a crucial part of getting the retina nicely and completely reattached, he said. “Removing the anterior retina (to the ora) when performing a peripheral retinectomy minimizes the risk of postoperative hypotony and neovascularization of the iris. Cut the inferior 180° or more, just posterior to the edge of the vitreous base, taking into account that retinectomy is rarely going to be adequate if it is less than 180°. To maintain a good hemostasis, apply light diathermy selectively to bleeding retinal vessels along the cut edge of retina,” Regillo said.
Perfluorocarbon liquid (PFCL) can be used at this point to flatten the retina and identify areas of residual traction. If complete retinal reattachment is not observed under PFCL, then the retinectomy will need to be enlarged. Two to three rows of contiguous light-medium intensity laser are applied along the edge of the retinectomy and any breaks elsewhere, aiming to preserve as much posterior retina as possible. Finally, PFCL-air-SO (or direct PFCL-SO) exchange is performed.
Adequate silicone oil fill is imperative to achieve sufficient intraocular tamponade.
“Remove any trapped air behind the lens-iris diaphragm to ensure a good fill of oil. With optimal silicone oil fill, you don’t need facedown positioning in these types of cases,” Regillo said. “Head elevated positioning should suffice if there is 90% or more SO fill.”
He uses 1,000 cs silicone oil and believes that 5,000 cs is not necessary. He recommended leaving the eye relatively soft at the end of the case after the SO instillation to minimize the risk for SO overfill and postop pressure elevation problems. All three sclerotomies must be sutured for SO cases.
Unless there is severe cataract, Regillo recommended preserving the crystalline lens.
“The lens technically does not get in the way of addressing anterior PVR or performing the inferior retinectomy. So, if the lens is clear enough, you should feel compelled to preserve it. However, if you are going to do a pars plana lensectomy, remove the lens entirely, including all of the capsule,” he said.
An inferior peripheral iridectomy will also be necessary if there is aphakia in a silicone oil case.
If complete retinal attachment under SO is achieved, and there is no significant recurrent PVR or residual traction and no significant hypotony after about 3 months or so, then it is best to proceed with PPV to remove the SO, and a standard limbal-based cataract extraction by phacoemulsification with posterior chamber IOL implantation can be performed at that time as a combination surgical procedure.
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Regillo CD. PVR surgery techniques and pearls. Presented at: Retina 2022; Jan. 15-21, 2022; Waikoloa, Hawaii.
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