|Year : 1983 | Volume
| Issue : 7 | Page : 872-877
Pars plana vitrectomy and buckling in management of complex rhegmatogenous retinal detachment
Hemant Doshi, SS Badhinath
Sankara Nethralaya, Medical Research Foundation, 18 College Road Madras, India
Sankara Nethralaya, Medical Research Foundations 18 College Road, Madras-6
|How to cite this article:|
Doshi H, Badhinath S S. Pars plana vitrectomy and buckling in management of complex rhegmatogenous retinal detachment. Indian J Ophthalmol 1983;31:872-7
|How to cite this URL:|
Doshi H, Badhinath S S. Pars plana vitrectomy and buckling in management of complex rhegmatogenous retinal detachment. Indian J Ophthalmol [serial online] 1983 [cited 2013 May 22];31:872-7. Available from: http://www.ijo.in/text.asp?1983/31/7/872/29690
Vitreous surgery has become generally accepted and widely practised since 1970. The rapid growth of vitreous surgery as an established field results from the successful use of these techniques in treating various otherwise inoperable blinding disorders.
Prior to advent of vitreous surgery it was difficult to successfully manage cases of rhegmatogenous retinal detachment in the presence of massive periretinal retraction and vitreous traction, bands and membranes, vitreous haemorrhage, giant breaks. Vitrectomy with other intraocular manipulation has allowed us to increase the percentage of success in such complex cases.
This paper analyses the importance of vitrectomy in complex cases of rhegmatogenous retinal detachment.
| Material and methods|| |
65 patients compiling of 65 eyes, underwent pars plana vitrectomy combined with scleral buckling procedure at Sankara Nethralaya, Medical Research Foundation, Madras, between 1980 and 1982. 50 of the patients were male and 15 females.
The age group is shown in [Table - 1].
The pre-operative visual acuity in most of the cases was counting finger to light perception and projection. One eye had 6/9 visual acuity which was subjected to this procedure because of the presence of rhegmatogenous retinal detachment complicated by fibrovascular membrane proliferation in to the vitreous. The macula was spared. In another eye who had visual acuity of 6/12 with a partial rhegmatogenous retinal detachment sparing the macula and multiple breaks in different quadrants we were unable to re-attach the retina by two combined scleral buckling procedure. This eye was also subjected to vitrectomy and scleral buckling.
All the cases were characterised by the presence of rhegmatogenous retinal detachment associated with massive periretinal retraction, varying degree of vitreous traction, vitreous haemorrhage and giant tears. 19 of these eyes had already been subjected to various retinal detachment procedure elesewhere [Table - 2].
Associated features in some of these cases were traumatic cataract, senile cataract, after cataract and posterior subluxation of lens,
Fellow eye showed the feature listed in [Table - 3].
Pre-operative examination includes a careful history, ocular examination including visual function, muscle balance testing, pupillary response, slit lamp examination, vitreo-retinal examination is performed by using binocular indirect ophthalmoscope along with scleral depressor and slit lamp bimicroscopy with a three mirror Goldmann contact lens if the media are sufficiently clear. Additionally in 16 patients diagnostic ultrasound was done. Detailed and careful examination of the fellow eye.
Associated anterior segment surgery which was done is listed in [Table - 4].
360° peritomy done and bridle sutures passed under the four isolated rectus muscle. Three pars plana sclerotomies were made. I site for infusion cannula, II site for Ocutome/ Fragmatome and III site for fibreoptic endoillumination or accessory instruments. Removal of cataractous lens by conventional method or lensectomy or secondary membrane was done with Fragmatome prior to vitrectomy. Vitreous opacities, vitreous haemorrhage, bands, membranes were cut and removed with Ocutome probe. The posterior vitrectomy was done with the Luma lens on the corneal surface and all the membranes, vitreous traction bands close to the retinal surface were cut and removed carefully, At this time the suction was kept at a very low level. In cases of giant tears the folded retina was made mobilised and flattened.
Once the satisfactory clearing of the vitreous cavity was obtained the sclerotomy sites were'temporarily closed with scleral plugs.
Now the detail and careful examination of the retina is done and the visible breaks or tears ar ' localised and if new were detected they were also localised.
Cryopexy was done under direct visualization by indirect ophthalmoscope.
According to the situation and condition of the sclera, explant or implant is used. An explant or implant is temporarily secured to the sclera with a 4/0 nylon mattress suture and encircling hand is also secured in position in which it is used. We have used scleral explant in V cases and implant in 49 cases. We did 360° buckling in 27 cases and in remaining 38 cases we used encircling band along with the explant or implant
After release of the subretinal fluid through a proper site the fluid gas exchange or hydraulic dissection was done. In fluid gas exchange air is introduced through the Ocutome infusion system in place of fluid using the manually operated syringe. This gas bubble as it comes in to the eye displaces fluid which is more posterior. The Charles flute needle is held near the retina, deep to the surface of the meniscus, this allowing all the fluid to be removed from the eye. In our series hydraulic dissection was done in 10 cases and fluid gas' exchange in 13 cases.
Finally the explant or implant sutures are tightened to create a moderate buckle.
All the 65 cases had a follow-up duration of less than 1 months to 2 years time. The followup of duration of 30 cases who had anatomical attrachment is shown in [Table - 5].
| Observation and results|| |
The 65 cases have been divided into five different groups according to the vitreo retinal pathology for which closed vitrectomy through pars plana was performed.
Group I: Massive peri-retinal retraction Group - II: Vitreous membranes, bands and traction
Group III: Vitreous haemorrhage
Group IV: Giant tears
Group V: Oral dialysis.
The reason for doing vitrectomy in these two cases was that there was associated traumatic subluxation of the lens in the vitreous cavity. Both these cases were successfully attached after removal of the lens and vitrectomy.
Total we had 30 cases in which we were able to achieve anatomical attachment [Table - 11]
The final visual acuity which in all the successful cases is achieved is shown in [Table - 12].
Total 22 cases showed definite improvement in post-operative visual acuity than their pre-operative vision. In the group below 6/60 but better than pre-operative vision, some cases had little visual function improvement but the result was gratifying because this was the patients only functioning eye.
| Discussion|| |
The important role of the vitreous in the aetiology of the retinal detachment is indisputed.
Massive peri-retinal retraction is one of the most common cause of failure in retinal detachment surgery. It presents one of the most challenging problem in the field of retinal detachment Among our 27 cases in this group those who have been subjected for the surgery only 9 had anatomical attachment. About 60% of these cases already had once or more conventional scleral buckling procedures. In most of the cases the retina was highly elevated and fixed folds by trans vitreal traction. In these cases we did the vitrectomy to remove the intravitreal proliferation so as to provide an access to the retina and if the membranes are present they are pelled away with the help of illuminated membrane pic. At the end of the procedure we used the intraocular air injection in these cases to provide an additional force to re-attach the retina. The main cause for the failure in the cases is recurrence of vitreous retraction and development of star folds.
Visual results in this group are not so good but we do not regret as these cases were with massive vitreous retraction.
II group of cases those who had rhegmatogenous retinal detachment with vitreous haemorrhage showed very good visual prognosis. As when it is known that retinal breaks are responsible for vitreous haemorrhage then it must be treated soon. If the haemorrhage was large then we did the pre-operative ultrasonography to confirm the diagnosis.
In most cases in which a vitreous haemorrhage is caused by retinal detachment bleeding occur from a retinal vessel bridging a retinal break generally a large tear or a horse shoe shaped tear. The advantage of doing vitrectomy in these cases is that it prevents one to clear the opacity and to identify the retinal breaks and perform the appropriate scleral buckling during the same operation.
In third group i.e. those cases of rhegmatogenous retinal detachment with vitreous membranes, traction and bands. The main aim of doing vitrectomy in such cases is to cut bands and sheets causing vitreoretinal traction and remove certain epiretinal membrane causing disturbance or immobilization of the retina. When vitreous traction prevents settling of the retina by conventional scleral buckling technique, vitrectomy can be used to relive the traction and allow the retina to settle. In our series we had total 20 cases in this group and out of which 13 cases had anatomical attachment of the retina. Group IV cases with giant tears, vitrectomy can be of much help. Vitreous opacities are removed in these cases to improve visibility, vitreous behind the retina is removed eliminating an obstruction to retinal reattachment. We did surgery for 5 cases in this group but we had only one anatomical attachment. In one case the retina was immobile, so we had to abandon the procedure. While in 3 cases we had retina attachment on the table but later on the retina got redetached.
In group V two cases had oral dialysis. Routinely vitrectomy is not necessary for the oral dialysis, but in these cases we had traumatic dislocated lens in the vitreous cavity. So we did the vitrectomy, lensectomy and buckling. Both these cases had successful anatomical attachment
The main causes which attributed for the failure in surgery in general were recurrent MVR, presence of fixed folds, immobile flap, presence of hole posterior to buckle edge.
The poor visual acuity attained by the patient may be explained by severe vitreoretinal pathological abnormalities. The main causes which we have seen in our series for the poor visual acuity are macular pucker and dragging of the macula, pre-retinal fibrosis, long standing retinal detachment manifesting as presence of large amount of exudates in the subretinal space; presence of pigments at the posterior pole, intraretinal fibrosis and preretinal membrane formation.
| Summary|| |
This report is based on the observation of 65 cases of complicated rhegmatogenous retinal detachment seen in two years period. Vitreous surgery technique combined with scleral buckling procedure, provides important new capability to treat selected retinal detachment that have a poor prognosis. The paper presents the technique, results and advantages of pars plana vitrectomy done in conjunctiva with conventional scleral buckling procedure.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11], [Table - 12]