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COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 10  |  Page : 2158-2159

Commentary: Management of proliferative vitreoretinopathy in recurrent retinal detachment


Department of Vitreo-retinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Naresh Babu
Department of Vitreo.retinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_641_20

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How to cite this article:
Babu N, Kohli P. Commentary: Management of proliferative vitreoretinopathy in recurrent retinal detachment. Indian J Ophthalmol 2020;68:2158-9

How to cite this URL:
Babu N, Kohli P. Commentary: Management of proliferative vitreoretinopathy in recurrent retinal detachment. Indian J Ophthalmol [serial online] 2020 [cited 2020 Oct 31];68:2158-9. Available from: https://www.ijo.in/text.asp?2020/68/10/2158/295749



Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent rhegmatogenous retinal detachment (RRD) after surgical repair. It is characterized by cellular proliferation leading to the formation of contractile preretinal membranes, intraretinal fibrosis, and subretinal bands. The usually used postoperative tamponading agents, like silicon oil and gas, used after RD surgery are lighter than water. This causes compartmentalization of the vitreous cavity and the migrated retinal pigment epithelium (RPE) cells get collected along with aqueous humor in the inferior vitreous, leading to PVR changes in the inferior retina.[1]

Several authors have described relaxing retinectomy as a successful technique for the treatment of eyes with recurrent RD caused due to PVR. Various types of retinectomies like circumferential retinectomy, 360-degree retinectomy, radial retinectomy, and their combinations have been described.[2],[3] However, retinectomies are also associated with a number of intra- and postoperative complications. Intraoperative complications include retinal and choroidal bleeding as well as slippage of retina. These bleeds can sometimes be difficult to control, not only making the surgery difficult but also lead to postoperative inflammation and PVR. Postoperative complications, including hyphema, hypotony, keratopathy, macular pucker, and PVR, have been reported in as high as 50% of eyes undergoing retinectomy.[2],[3],[4],[5],[6],[7],[8]

Banerjee et al. described a case series of five nondiabetic patients who developed neuropathic corneal ulcer following retinectomy.[7] Retinectomies expose a large area of RPE to the vitreous cavity, thus increasing the chances of further PVR. Bueste et al. described the various forms of PVR causing recurrent retinal detachment after retinectomy. These include posterior focal or diffuse contraction, macular pucker causing detachment at the posterior pole, fibrosis of the retinectomy edge, severe inferior folding of the retina (SIRF), anterior PVR in the nonretinectomized area, and beyond-the-edge proliferation (BTEP).[4] SIRF has been defined as the severe contraction of the inferior retina which overcomes the strength of adhesion provided by retinopexy leading to upward retraction of the inferior retina.[4],[8] BTEP has been described as the proliferation anterior to and continuous to the retinectomy edge.[4],[6]

We try and avoid retinectomy as much as possible. We prefer to reserve it for third surgery in case of recurrent RD. One of the most common causes of recurrent RD is incomplete vitreous removal. RRD is often associated with vitreoschisis and a layer of cortical vitreous is often left behind. We regularly stain using triamcinolone acetate to look for the presence of a remnant layer of vitreous sheet. In case of the presence of any vitreous membranes, it is meticulously removed. The perfluoro-n-octane-assisted Mega Weiss-Ring technique described by our group is helpful in removing the posterior vitreous cortex.[9] The second step is removing all the anterior PVR membranes. Caution should be made not to create a retinotomy while dealing with such membranes. Tabandeh described the use of two membrane scrapers to gently stretch the retina–PVR complex and create a plane of dissection for the primary management of RRD associated with severe PVR.[5]

Shroff et al. have described the “Tug of war” technique using end-gripping forceps for the release of traction in a relatively atraumatic manner, thus avoiding the need for retinectomy.[10] The authors are correct in proposing that pulling the membranes in opposite directions till they visibly snap reduce the risk of causing iatrogenic retinal tears and in case of tears, they will generally be smaller compared to the large relaxing retinotomies. Extreme care has to exercised in phakic eyes due to the risk of lens touch.

The best method of managing such eyes is the prevention of postoperative PVR. Short- and intermediate-term postoperative perfluorocarbon liquid tamponade has shown promising results for the treatment of complicated RRD apparently due to its high density which reduces the empty space available in the inferior vitreous cavity, thus preventing the resultant PVR changes.[1] Various intravitreal pharmacological agents like 5-fluorouracil, heparin, daunomycin, colchicine, retinoids and methrotrexate have been tried with mixed success for the prevention of PVR and resultant recurrent RD.[11]



 
  References Top

1.
Sigler EJ, Randolph JC, Calzada JI, Charles S. 25-gauge pars plana vitrectomy with medium-term postoperative perfluoro-n-octane tamponade for inferior retinal detachment. Ophthalmic Surg Lasers Imaging Retina 2013;44:34-40.  Back to cited text no. 1
    
2.
Lim AK, Alexander SM, Lim KS. Combined large radial retinotomy and circumferential retinectomy in the management of advanced proliferative vitreoretinopathy. Retina 2009;29:112-6.  Back to cited text no. 2
    
3.
Banaee T, Hosseini SM, Eslampoor A, Abrishami M, Moosavi M. Peripheral 360 degrees retinectomy in complex retinal detachment. Retina 2009;29:811-8.  Back to cited text no. 3
    
4.
Beuste T, Rebollo O, Parrat E, Guigou S, Mérité PY, Meyer F, et al. Recurrences of retinal detachment after retinectomy: Causes and outcomes. Retina 2019. [Epub ahead of print].  Back to cited text no. 4
    
5.
Tabandeh H. A surgical technique for the management of retinal detachment associated with severe proliferative vitreoretinopathy. Retina 2017;37:1407-10.  Back to cited text no. 5
    
6.
Denion E, Coffin-Pichonnet S, Degoumois A, Barcatali MG, Beuste T, Lux AL. Beyond-the-edge proliferation after relaxing retinectomy. J Fr Ophtalmol 2016;39:26-30.  Back to cited text no. 6
    
7.
Banerjee PJ, Chandra A, Sullivan PM, Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: A case series. JAMA Ophthalmol 2014;132:750-2.  Back to cited text no. 7
    
8.
Gupta B, Mokete B, Laidlaw DA, Williamson TH. Severe folding of the inferior retina after relaxing retinectomy for proliferative vitreoretinopathy. Eye (Lond) 2008;22:1517-9.  Back to cited text no. 8
    
9.
Babu N, Kumar J, Kohli P, Ramasamy K. Perfluoro-n-octane-assisted mega weiss-ring technique for posterior vitreous detachment induction in retinal detachment. Indian J Ophthalmol 2019;67:1463-5.  Back to cited text no. 9
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10.
Shroff D, Saha I, Bhatia G, Dutta R, Gupta C, Shroff CM. Tug of war: A bimanual technique for anterior circumferential proliferative vitreoretinopathy in recurrent retinal detachment. Indian J Ophthalmol 2020;68:2155-8.  Back to cited text no. 10
  [Full text]  
11.
Falavarjani KG, Hadavandkhani A, Parvaresh MM, Modarres M, Naseripour M, Alemzadeh SA. Intra-silicone oil injection of methotrexate in retinal reattachment surgery for proliferative vitreoretinopathy Ocul Immunol Inflamm 2019;1-4. doi: 10.1080/09273948.2019.1597894.  Back to cited text no. 11
    




 

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