Retinal redetachment with PVR (Veckeneer, Belgium) скачать в хорошем качестве

Retinal redetachment with PVR (Veckeneer, Belgium)

Marc Veckeneer, Antwerp (Belgium) Case Description A 55 y/o male presented with an aggressive looking total retinal detachment (RD) with PVR in 4 quadrants 6 weeks post pseudophakic macula on RD treated with pars plana vitrectomy (PPV) and air. There were starfolds in 2 circumferential zones: first between posterior pole and equator, second anterior to equator near vitreous base (VB). There were no anterior PVR complications because ciliary body was free (complete vitrectomy was done during primary PPV) Surgical strategy Start peeling centrally, posterior membranes are most often purely epiretinal (ERMs) so they can be peeled/freed completely from the underlying retina. As your peeling extends towards VB, be careful because the membranes tend to have deeper intraretinal extensions anteriorly. Complete removal without additional breaks may be impossible: the zone where epiretinal becomes intraretinal will be the retinotomy site. So the goal is to free as large an area of central retina as possible from ERMs. A retinotomy (as last resort) releases/rescues the “conquered” and “healthy” central area from the anterior retina that is beyond repair due to intraretinal PVR. Understanding this fundamental difference between posterior ERMs (most likely originating from RPE seeding) and anterior (VB) membranes (rather Muller cell based) dictates surgical strategy. (1,2) Caveat: be patient, don’t look at the clock, just think this is your only case for today and you have the day off tomorrow!! Basic surgical setup: 23G 4-port (chandelier) PPV. Endgripping forceps, vertical scissors (very versatile: spatula, pick, scissors), soft tipped active backflush, membrane blue dual (trypan blue + brilliant blue). If this would have been a primary surgery with fresh PVR, an encircling buckle could have been an additional tool to try and avoid retinotomy in the acute phase. Surgical Procedure First, posterior ERMs were removed bimanually without retinal breaks. Fresh PVR membranes tend to stain poorly: repeat if necessary, preferably under air (despite high viscosity and density of the dye, in contracted retina with breaks, the dye tends to move subretinally: this can be toxic and it also reduces the contrast because everything tends to have a bluish hue afterwards) Caution: Do not re-stain after extensive peeling: trypan blue will stain tissue damage that you have caused inadvertently, making further peeling of the stained tissue rather perilous. As ERMs reach the VB they seem to be integrated intraretinally: you have reached the border between purely epiretinal and intraretinal PVR. Intraretinal PVR cannot be peeled without making breaks. Consequently the anterior traction can only be counteracted by broad indentation with an encircling buckle or with retinotomy. (3) Then, heavy liquid (PFCL) was injected (preferably perfluoroctane, as it is less heavy than decaline). It facilitated ERM engaging for additional peeling as the membrane is less “squashed”. Thus, using directional endo-light and PFCL, posterior ERMs were removed easier (better visualization than chandelier). It also makes anterior ERMs peeling easier, because PFCL functions as 3rd hand stabilizing central retina whilst anterior ERMs are removed with one hand indenting and the other using forceps. Afterwards, a relaxing retinectomy was performed to remove anterior ERMs and anterior-posterior traction due to retinal stiffness. Diathermy on large vessels was used at the border of the retinectomy (between peeled central retina and the redundant periphery). Retinectomy extension was calculated according to residual stiffness of the retina. Anterior retinal remnants were completely removed to prevent anterior retinal loop with hypotony or ischemia with rubeosis. Finally the retina was attached. Rather than laser under heavy liquid and perform direct PFCL/silicone oil exchange (PSX): a fluid/air exchange (FAX) was performed first because the retina would settle in a more relaxed central position. This is a fundamental difference with large retinotomy (as in full macular translocation (FMT) or giant tear (GRT) cases) without PVR, in these cases retinal slippage has to be avoided with direct PSX. Very limited laser was done, just to the retinotomy border or even no laser at all is a correct option because extensive laser at this point is not going to prevent recurrent PVR and is sacrificing healthier retina (4). Follow-up Retina remained attached without silicone oil.