PVR RD with napkin ring, subretinal membranes and subretinal clot (Martinez, Spain) скачать в хорошем качестве

PVR RD with napkin ring, subretinal membranes and subretinal clot (Martinez, Spain)

Jesus Ramon Garcia Martinez, Madrid. Case description A 65 y/o woman was referred from another hospital with a history of three failed retinal detachment (RD) surgeries in her left eye. She was previously treated with scleral buckle and vitrectomy + gas tamponade, but she developed RD with proliferative vitreoretinopathy (PVR). Vitreous base (VB) contraction and anterior retinal pulling due to anterior PVR in nasal quadrants with several retinal holes were observed, there were also peripapillary subretinal membranes in a napkin ring configuration and a subretinal clot in the superior quadrant. Her visual acuity (VA) was counting fingers at 50 cm in LE and 0,7 in RE. Slit lamp examination revealed corneal clouding, a posterior chamber intraocular lens (IOL) and posterior capsule fibrosis and opacification with atrophic iris. Surgery description Surgery was conducted under retrobulbar anesthesia and sedation. 23G transconjunctival pars plana vitrectomy (PPV) with and an accessory chandelier light was performed using a contact wide field viewing system (Landers wide field vitrectomy contact lens). At the beginning, corneal epithelium, IOL and fibrotic capsular bag were removed because they precluded a correct retinal visualization. Initially, heavy liquid (PFCL) was carefully injected to stabilize and fixate posterior retina and assess equatorial retina behavior. The retina at VB had a moth-eaten aspect and the anterior retinal tissue looked fibrotic at nasal and superior retinal quadrants, thus a circumferential relaxing/access retinotomy, posterior to the scarred retinal tissue was performed. Prior to performing the retinotomy, PFCL was aspirated to avoid PFCL bubbles migration into the subretinal space and diathermy was done, then the retina was cut with the vitreous cutter. The retinotomy was large enough to allow adequate access to subretinal membranes. The best way to remove subretinal membranes is bimanually. Forceps are used to grasp the membrane and gently pull it to determine whether it will strip free. A cannula, vitreous cutter, endolight or other forceps can be used to support the membrane tangentially and avoid traction on the retina. Once the subretinal membranes were extracted, the subretinal clot was lifted grasping it with forceps. Subretinal clot was attached strongly to the anterior retina and two forceps were needed to pull it out gently from the retina, then it was removed with the vitreous cutter. After all membranes were removed, the retina was reattached with PFCL, injecting it over the retinal edge, and 360º three-row laser photocoagulation was performed at the retinal edge under PFCL. After the retina was reattached silicone oil was chosen as a tamponade in this case with an almost 360º retinotomy. A direct PFCL-Silicone oil exchange was performed to prevent retinal slippage. Direct PFCL-silicone oil exchange (PSX) was set in the vitrectomy console. First, infusion line was disconnected and PFCL was injected until it passed through the disconnected infusion line. At this moment, silicone oil was injected through the temporal superior microcannula and PFCL aspirated with a soft tipped cannula through the other superior microcannula. At the end, the soft tip cannula was placed over the optic nerve or far away from the macula to remove all the PFCL. Follow-up Patient was instructed to avoid face-up position for the initial ten days after surgery. Complete attachment of the retina was achieved but visual acuity improvement was very poor due to corneal clouding and chronic macular edema. The patient refused further surgical interventions.