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   Table of Contents      
ARTICLES
Year : 1983  |  Volume : 31  |  Issue : 7  |  Page : 872-877

Pars plana vitrectomy and buckling in management of complex rhegmatogenous retinal detachment


Sankara Nethralaya, Medical Research Foundation, 18 College Road Madras, India

Correspondence Address:
Hemant Doshi
Sankara Nethralaya, Medical Research Foundations 18 College Road, Madras-6
India
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Source of Support: None, Conflict of Interest: None


PMID: 6544275

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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, Suppl S1:872-7

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 2020 May 24];31, Suppl S1:872-7. Available from: http://www.ijo.in/text.asp?1983/31/7/872/29690

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Table 12

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Table 11

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Table 5

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Table 2

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Table 1

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Table 1

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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 Top


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].

Surgical Technique:

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 Top


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 Top


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 Top


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.



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11], [Table - 12]



 

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