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Vincent S. Vincent S. ReppucciReppucci, MD, MDDirector Retina Service Director Retina Service Mount Sinai Mount Sinai -- St. LukeSt. Luke’’s Hospitals HospitalNew York, NYNew York, NYUSAUSA
How to Perform a How to Perform a RetinotomyRetinotomy(Properly)(Properly)
4th Thessaloniki International Vitreo-Retinal Summer SchoolMonday - Saturday, JUNE 16-21, 2014 Thessaloniki, Electra Palace Hotel
Define Define RetinotomyRetinotomy
Iatrogenic opening in retinaIatrogenic opening in retina•• Intentional or unintentionalIntentional or unintentional
DrainageDrainage SubSub--retinal accessretinal access Relaxing (Release of traction)Relaxing (Release of traction)
•• EnEn--blockblock
•• RetinectomyRetinectomy
SubSub--Retinal AccessRetinal Access
Submacular Hemorrhage Choroidal neovascularization Sub-retinal bands
SubretinalSubretinal HemeHeme
CNVCNV
Unintentional Unintentional RetinotomyRetinotomy
Unintentional Unintentional RetinotomyRetinotomy
Relaxing Relaxing RetinotomyRetinotomy
PVR and recurrent RD Chronic Diabetic Traction detachment Useful to reattach retina intraoperatively Long term reattachment is more critical
Can categorize, but every case is different Can categorize, but every case is different Visual and anatomic outcomes are variableVisual and anatomic outcomes are variable Removal of surface membranes is not a Removal of surface membranes is not a
problemproblem PVR failure due to PVR failure due to reproliferationreproliferation
PVR ObservationsPVR Observations
ObjectivesObjectives
Role of inferior vitreous base in PVR and Role of inferior vitreous base in PVR and recurrent detachmentrecurrent detachment Technique for resection of the inferior Technique for resection of the inferior
vitreous basevitreous base
Fairly strong Fairly strong vitreoretinalvitreoretinal attachment attachment including including oraora and and ciliaryciliaryepitheliumepithelium
Posterior and anterior Posterior and anterior insertion site is variableinsertion site is variable
Anterior attachment to Anterior attachment to ciliaryciliary processes and processes and lens capsulelens capsule
Vitreous BaseVitreous Base
Proliferative cells and Proliferative cells and chemotacticchemotactic factors settle factors settle inferiorly causing contractioninferiorly causing contraction
Insufficient inferior Insufficient inferior tamponadetamponade especially with especially with siliconesilicone
Opens iatrogenic breaks or create new breaksOpens iatrogenic breaks or create new breaks Especially acute with Especially acute with posteriorlyposteriorly positioned bucklepositioned buckle
Inferior Vitreous BaseInferior Vitreous Base
If shaved or If shaved or debulkeddebulked; ; leave residual scaffold leave residual scaffold for for reproliferationreproliferation
Leads to inferior Leads to inferior contractioncontraction
Only way to remove is Only way to remove is by dissection or by dissection or resectionresection
Inferior Vitreous BaseInferior Vitreous Base
Bimanual approach lighted pick; forcepsBimanual approach lighted pick; forceps Must first dissect Must first dissect hyaloidhyaloid anteriorlyanteriorly to vitreous to vitreous
basebase Dissect Dissect vitvit base base anteriorlyanteriorly, grasp, elevate, , grasp, elevate,
and mobilize and mobilize posteriorlyposteriorly
TractionalTractional RetinotomyRetinotomy
VitVit basebase
bimanualbimanual
IlmIlm peelpeel
pfopfo
Resection of VitreousResection of VitreousBaseBase
THIS IS NOT A SHORTCUT!!!!THIS IS NOT A SHORTCUT!!!! Risk of aggressive and extensive retinal Risk of aggressive and extensive retinal
lossloss Dissection is preferable to resectionDissection is preferable to resection ResectResect at least 4 clock hours at least 4 clock hours No No vitvit base or base or hyaloidhyaloid posterior to resectionposterior to resection
Resection of Vitreous Resection of Vitreous BaseBase
9 month period 5/98 to 1/99 9 month period 5/98 to 1/99 retrospective review consecutive PPV for retrospective review consecutive PPV for
PVRPVR 43 eyes in 43 patients43 eyes in 43 patients All 43 eyes prior All 43 eyes prior VxVx and 2.5 years followand 2.5 years follow--upup 9 eyes 9 eyes intraoperativeintraoperative resectionresection
ResultsResults
ResultsResults
Inferior Inferior ResectionResection
Non Non ResectionResection TotalTotal
# Eyes# Eyes 99 3434 4343
RecurrenceRecurrence 1(11%)1(11%) 10 (29.4%)10 (29.4%) 11(25.6%)11(25.6%)
Final Final AttachmentAttachment 9 (100%)9 (100%) 29 (85.3%)29 (85.3%) 38 (88.3%)38 (88.3%)
PhthisisPhthisis 00 3 (8.82%)3 (8.82%) 3 (6.9%)3 (6.9%)
ConclusionConclusion
RetinotomyRetinotomy can be useful in may situations.can be useful in may situations. Remove all traction surrounding the Remove all traction surrounding the retinotomyretinotomy Although helpful THIS IS NOT A SHORTCUTAlthough helpful THIS IS NOT A SHORTCUT Resection of the inferior vitreous base, when Resection of the inferior vitreous base, when
appropriate, may reduce the rate of appropriate, may reduce the rate of redetachmentredetachment in PVR surgery.in PVR surgery.