CONTINUOUS SCLERAL DRAINAGE IN VITRECTOMY FOR BULLOUS RETINAL DETACHMENT Keita Yamakiri, MD, Eisuke Uchino, MD, Taiji Sakamoto, MD
Scleral drainage was left unclosed and simultaneous infusion with a balanced salt solution done in vitrectomy for bullous retinal detachment. Subretinal fluid was drained through this site and the retina was kept flat through the vitrectomy, which greatly facilitated surgical maneuvers. Retinal reattachment was achieved in 10 of 10 eyes in a single operation per eye.
From the Department of Ophthalmology, Faculty of Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima, Japan.
gation is started to prevent reduced intraocular pressure. The infusion bottle is kept high enough to prevent retinal incarceration (usually 40 cm above eye level). Standard cataract surgery and intraocular lens implantation are done as needed. The bullous RD is thus flattened (Fig. 1, A and B). Central core vitrectomy is done, and the vitreous body is removed from the margins of breaks (Fig. 1, C and D). Treatment of retinal breaks is completed with a laser. No internal drainage is formed. Even if drainage is incomplete, additional drainage is not done as long as the original retinal break is treated sufficiently. Intraocular tamponade with SF6 gas or silicone oil is done.
P
ars plana vitrectomy (PPV), initially reserved for complicated retinal detachment (RD), is now used by many surgeons to treat primary uncomplicated RD.1 In PPV, bullous RD may cause safety problems; therefore, the retina should be flattened during surgery. Perfluorocarbon liquid sometimes used to do so, however, may cause complications, and its cost-effectiveness has been questioned.2– 4 We currently conduct scleral drainage and simultaneous irrigation with a balanced salt solution to flatten bullous RD during PPV, which greatly facilitates intraocular maneuvers. This report details surgical methods and results in recent cases.
Case Report Ten consecutive eyes with bullous RD in 10 patients were treated by this procedure and followed up at Kagoshima University Hospital (Kagoshima, Japan). The potential advantages and disadvantages of the treatment were explained to the patients, and fully informed consent was obtained. The study was conducted with the approval of the institutional review board and followed the ethical standards of the 1989 Declaration of Helsinki. Retinal attachment was achieved in all eyes with a single operation (Table 1). Even in severe proliferative vitreoretinopathy, this procedure flattened the funnel-shaped retina, rendering the use of perfluorocarbon liquid unnecessary. The drainage site could not be clearly identified during vitrectomy because a small amount of subretinal fluid usually remained even when surgery ended. Flattening of the retina confirmed the success of drainage. No sign or tendency toward retinal incarceration occurred. One eye had minimal subretinal hemorrhage that resolved spontaneously. After 1 month, two eyes showed depigmentation of the retinal pigment epithelium at the drainage site, but the drainage site could not be identified clearly in other eyes. All patients were observed for ⬎3 months.
Surgical Technique After opening the conjunctiva, three sclerotomies are formed, and an infusion cannula is attached; however, irrigation is not started. The sclera is incised radially with a surgical knife at the site of the bullous RD. To avoid direct connection between vitreous and subretinal space, the sclerotomy site is formed at a quadrant with the bullous RD distant from the retinal break, usually in the center of the ora serrata and equator. The choroid is cauterized sufficiently to close choroidal vessels, and a small hole is created with a surgical suture needle or a sharp electrode that is directed tangentially to avoid retinal damage. The sclerotomy site is left unclosed; then, intraocular irri-
Discussion
Reprint requests: Taiji Sakamoto, MD, Department of Ophthalmology, Faculty of Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 8908520, Japan; e-mail:[email protected]
Although scleral drainage is often used in buckling surgery, it is not commonly done in PPV. Simultaneous 104
CONTINUOUS SCLERAL DRAINAGE IN VITRECTOMY FOR BULLOUS RETINAL DETACHMENT
Fig. 1. Case 1. A, Intraoperative findings before scleral drainage. Note bullous retinal detachment before the scleral drainage hole is formed. Arrow, vitrectomy probe; arrowhead, retinal tear. B, Intraoperative findings after scleral drainage. After scleral drainage, the retina becomes flattened. Arrow, vitrectomy probe; arrowhead, retinal tear. C, Intraoperative findings. After scleral drainage, the retina is already flattened, and the vitreous body surrounding the retinal tear is easily resected. Arrow, vitrectomy probe. D, Intraoperative findings. Just before fluid–air exchange, the retina is reattached, and no internal drainage is necessary. Arrow, vitrectomy probe.
105
related to ocular hypotension. Only one eye had minimal subretinal hemorrhage. The scleral drainage site was not closed, but no postoperative hypotension, bleeding, or infection occurred. Retinal herniation at the drainage site was not seen in any eyes, probably because irrigation pressure was comparatively low and subretinal fluid exited the eyeball very slowly. Although no incarceration of the retina was found in this small series, it may pose a possible problem in larger series. Further evaluation is thus necessary. It is difficult to conclude which is superior in flattening the retina, simultaneous use of perfluorocarbon liquid or the present method. Perfluorocarbon liquid may be superior in cases of RD with giant tears,2 but our method appears to be superior in appropriate cases in view of potential complications and financial considerations. No definitive conclusion is yielded by such a small case series, but our method offers advantages in flattening the detached retina and in facilitating surgical maneuvers in bullous RD. Key words: proliferative vitreoretinopathy, implant, retinal drainage, subretinal fluid, vitreous body. References
external subretinal fluid drainage and intravitreal gas injection previously reported5,6 had advantages similar to our method (e.g., drainage retinotomy was not needed for retinal reattachment). Our method has the notable advantage of retina flattening during vitrectomy, which greatly facilitates surgical PPV maneuvers in bullous RD. Pressure in the subretinal space was likely lower than that in the vitreous space due to continuous subretinal drainage through the sclera. Indeed, even if the retina sometimes floated up due to surgical manipulation during PPV, it flattened again spontaneously within a few seconds, greatly facilitating surgical maneuvers. The most serious complication of this procedure is
1. 2.
3. 4.
5.
6.
Barrie T. Debate overview. Repair of a primary rhegmatogenous retinal detachment. Br J Ophthalmol 2003;87:790. Chang S, Lincoff H, Zimmerman NJ, Fuchs W. Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch Ophthalmol 1989;107:761–766. Lesnoni G, Rossi T, Gelso A. Subfoveal liquid perfluorocarbon. Retina 2004;24:172–176. Foster RE, Smiddy WS, Alfonso EC, Parrish 2nd RK. Secondary glaucoma associated with retained perfluorophenanthrene. Am J Ophthalmol 1994;118:253–255. Meyers SM, FitzGibbon EJ. Simultaneous external subretinal fluid drainage and intravitreal gas injection. Arch Ophthalmol 1985;103:1881–1883. McLeod D. Monitored posterior transscleral drainage of subretinal fluid. Br J Ophthalmol 1985;69:433–434.
Table 1. Characteristics of 10 Cases of Scleral Drainage in Vitrectomy Case
Diagnosis
Sex
Age (y)
Preoperative VA
Final VA
Tamponade
1 2 3 4 5 6 7 8 9 10
RD MHRD PVR-A PVR-D PVR-A PVR-A RD PVR-B RD RD
M F M F F M M F M M
60 60 58 55 56 58 61 55 56 57
20/50 4/400 20/25 HM 20/63 4/100 20/20 20/200 20/50 20/63
20/32 4/150 20/20 4/200 20/25 20/25 20/20 20/63 20/25 20/25
SF6 SF6 SF6 Silicone SF6 SF6 SF6 SF6 SF6 SF6
Complication None Subretinal hemorrhage None None None None None None None None
VA, visual acuity; RD; retinal detachment; MHRD, macular hole RD; PVR, proliferative vitreoretinopathy; PVR-A, -B, and -D; PVR grades A, B, and D, respectively; HM, hand motion at 30 cm.
Scleral drainage was left unclosed and simultaneous infusion with a balanced salt solution done in vitrectomy for bullous retinal detachment. Subretinal fluid was drained through this site and the retina was kept flat through the vitrectomy, which greatly facilitated surgical maneuvers. Retinal reattachment was achieved in 10 of 10 eyes in a single operation per eye.
From the Department of Ophthalmology, Faculty of Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima, Japan.
gation is started to prevent reduced intraocular pressure. The infusion bottle is kept high enough to prevent retinal incarceration (usually 40 cm above eye level). Standard cataract surgery and intraocular lens implantation are done as needed. The bullous RD is thus flattened (Fig. 1, A and B). Central core vitrectomy is done, and the vitreous body is removed from the margins of breaks (Fig. 1, C and D). Treatment of retinal breaks is completed with a laser. No internal drainage is formed. Even if drainage is incomplete, additional drainage is not done as long as the original retinal break is treated sufficiently. Intraocular tamponade with SF6 gas or silicone oil is done.
P
ars plana vitrectomy (PPV), initially reserved for complicated retinal detachment (RD), is now used by many surgeons to treat primary uncomplicated RD.1 In PPV, bullous RD may cause safety problems; therefore, the retina should be flattened during surgery. Perfluorocarbon liquid sometimes used to do so, however, may cause complications, and its cost-effectiveness has been questioned.2– 4 We currently conduct scleral drainage and simultaneous irrigation with a balanced salt solution to flatten bullous RD during PPV, which greatly facilitates intraocular maneuvers. This report details surgical methods and results in recent cases.
Case Report Ten consecutive eyes with bullous RD in 10 patients were treated by this procedure and followed up at Kagoshima University Hospital (Kagoshima, Japan). The potential advantages and disadvantages of the treatment were explained to the patients, and fully informed consent was obtained. The study was conducted with the approval of the institutional review board and followed the ethical standards of the 1989 Declaration of Helsinki. Retinal attachment was achieved in all eyes with a single operation (Table 1). Even in severe proliferative vitreoretinopathy, this procedure flattened the funnel-shaped retina, rendering the use of perfluorocarbon liquid unnecessary. The drainage site could not be clearly identified during vitrectomy because a small amount of subretinal fluid usually remained even when surgery ended. Flattening of the retina confirmed the success of drainage. No sign or tendency toward retinal incarceration occurred. One eye had minimal subretinal hemorrhage that resolved spontaneously. After 1 month, two eyes showed depigmentation of the retinal pigment epithelium at the drainage site, but the drainage site could not be identified clearly in other eyes. All patients were observed for ⬎3 months.
Surgical Technique After opening the conjunctiva, three sclerotomies are formed, and an infusion cannula is attached; however, irrigation is not started. The sclera is incised radially with a surgical knife at the site of the bullous RD. To avoid direct connection between vitreous and subretinal space, the sclerotomy site is formed at a quadrant with the bullous RD distant from the retinal break, usually in the center of the ora serrata and equator. The choroid is cauterized sufficiently to close choroidal vessels, and a small hole is created with a surgical suture needle or a sharp electrode that is directed tangentially to avoid retinal damage. The sclerotomy site is left unclosed; then, intraocular irri-
Discussion
Reprint requests: Taiji Sakamoto, MD, Department of Ophthalmology, Faculty of Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 8908520, Japan; e-mail:[email protected]
Although scleral drainage is often used in buckling surgery, it is not commonly done in PPV. Simultaneous 104
CONTINUOUS SCLERAL DRAINAGE IN VITRECTOMY FOR BULLOUS RETINAL DETACHMENT
Fig. 1. Case 1. A, Intraoperative findings before scleral drainage. Note bullous retinal detachment before the scleral drainage hole is formed. Arrow, vitrectomy probe; arrowhead, retinal tear. B, Intraoperative findings after scleral drainage. After scleral drainage, the retina becomes flattened. Arrow, vitrectomy probe; arrowhead, retinal tear. C, Intraoperative findings. After scleral drainage, the retina is already flattened, and the vitreous body surrounding the retinal tear is easily resected. Arrow, vitrectomy probe. D, Intraoperative findings. Just before fluid–air exchange, the retina is reattached, and no internal drainage is necessary. Arrow, vitrectomy probe.
105
related to ocular hypotension. Only one eye had minimal subretinal hemorrhage. The scleral drainage site was not closed, but no postoperative hypotension, bleeding, or infection occurred. Retinal herniation at the drainage site was not seen in any eyes, probably because irrigation pressure was comparatively low and subretinal fluid exited the eyeball very slowly. Although no incarceration of the retina was found in this small series, it may pose a possible problem in larger series. Further evaluation is thus necessary. It is difficult to conclude which is superior in flattening the retina, simultaneous use of perfluorocarbon liquid or the present method. Perfluorocarbon liquid may be superior in cases of RD with giant tears,2 but our method appears to be superior in appropriate cases in view of potential complications and financial considerations. No definitive conclusion is yielded by such a small case series, but our method offers advantages in flattening the detached retina and in facilitating surgical maneuvers in bullous RD. Key words: proliferative vitreoretinopathy, implant, retinal drainage, subretinal fluid, vitreous body. References
external subretinal fluid drainage and intravitreal gas injection previously reported5,6 had advantages similar to our method (e.g., drainage retinotomy was not needed for retinal reattachment). Our method has the notable advantage of retina flattening during vitrectomy, which greatly facilitates surgical PPV maneuvers in bullous RD. Pressure in the subretinal space was likely lower than that in the vitreous space due to continuous subretinal drainage through the sclera. Indeed, even if the retina sometimes floated up due to surgical manipulation during PPV, it flattened again spontaneously within a few seconds, greatly facilitating surgical maneuvers. The most serious complication of this procedure is
1. 2.
3. 4.
5.
6.
Barrie T. Debate overview. Repair of a primary rhegmatogenous retinal detachment. Br J Ophthalmol 2003;87:790. Chang S, Lincoff H, Zimmerman NJ, Fuchs W. Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch Ophthalmol 1989;107:761–766. Lesnoni G, Rossi T, Gelso A. Subfoveal liquid perfluorocarbon. Retina 2004;24:172–176. Foster RE, Smiddy WS, Alfonso EC, Parrish 2nd RK. Secondary glaucoma associated with retained perfluorophenanthrene. Am J Ophthalmol 1994;118:253–255. Meyers SM, FitzGibbon EJ. Simultaneous external subretinal fluid drainage and intravitreal gas injection. Arch Ophthalmol 1985;103:1881–1883. McLeod D. Monitored posterior transscleral drainage of subretinal fluid. Br J Ophthalmol 1985;69:433–434.
Table 1. Characteristics of 10 Cases of Scleral Drainage in Vitrectomy Case
Diagnosis
Sex
Age (y)
Preoperative VA
Final VA
Tamponade
1 2 3 4 5 6 7 8 9 10
RD MHRD PVR-A PVR-D PVR-A PVR-A RD PVR-B RD RD
M F M F F M M F M M
60 60 58 55 56 58 61 55 56 57
20/50 4/400 20/25 HM 20/63 4/100 20/20 20/200 20/50 20/63
20/32 4/150 20/20 4/200 20/25 20/25 20/20 20/63 20/25 20/25
SF6 SF6 SF6 Silicone SF6 SF6 SF6 SF6 SF6 SF6
Complication None Subretinal hemorrhage None None None None None None None None
VA, visual acuity; RD; retinal detachment; MHRD, macular hole RD; PVR, proliferative vitreoretinopathy; PVR-A, -B, and -D; PVR grades A, B, and D, respectively; HM, hand motion at 30 cm.
