The Surgical Maneuvers Tip of the Month enewsletter from Retinal Physician focuses on current surgical techniques and efficiencies, which can impact the effective operations of an ophthalmology practice. Each article features a different physician who shares surgical pearls or tips. Many of the issues also include a link to a surgical video provided by the contributing physician.
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July 2019

Detachments Are Like Onions

Peeling off the layers of complex retinal detachments

By David RP Almeida, MD, MBA, PhD

Complex retinal detachments secondary to proliferative vitreoretinopathy, proliferative diabetic retinopathy, and uveitis represent challenging cases for the vitreoretinal surgeon. These complicated retinal detachments are analogous to onions with layers of pathology that need to be addressed. Successful outcomes in these cases require that, much as one would “peel” an onion, surgeons “peel” or remove each layer of pathology. Conceptually, there are three planes or layers — with respect to the neurosensory retina — to be addressed:
  • Above: preretinal adherent posterior hyaloid
  • In: proliferative membranes, epiretinal membranes and internal limiting membrane
  • Below: subretinal bands
ABOVE THE RETINA: Posterior hyaloid removal
  • Not uncommonly, a triamcinolone-stained residual layer of vitreous can be found over the posterior pole and peripheral retina in many eyes with complex retinal detachments; this include some eyes with a preexisting posterior vitreous detachment or Weiss ring.
  • Utilizing a Tano diamond-dusted membrane scraper (Figure 1A), forceps, or the vitreous cutter on aspiration (Figure 1B), the adherent posterior hyaloid needs to be removed.
  • The adherent posterior hyaloid is likely part of a spectrum of proliferative pathology related to incomplete posterior vitreous detachment, vitreoschisis, and immature membrane formation.
Watch Video
Figure 1A                                                                     Figure 1B

IN THE RETINA: Epiretinal membranectomy and internal limiting membrane removal
  • Frank membrane formation, in the form of epiretinal membranes, leads to traction and foreshortening of the retina; consequently, these need to be removed as the presence of epiretinal membrane is 8.00 times (crude odds ratio, 95% CI: 1.43 - 44.92, p = 0.0182) more likely to have proliferative membrane formation.
  • Presence of cystoid macular edema in complex retinal detachment is 8.33 times (crude odds ratio, COR, 95% CI: 1.23 - 56.67, p = 0.0302) more likely to have subsequent membrane formation. Internal limiting membrane removal can minimize occurrence of cystoid macular edema.
  • Membranectomy can be efficiently achieved with forceps (Figure 2) or small-gauge vitrector handpiece on aspiration.
  • One of my favorite techniques is to use end-grasping (ILM-type) forceps and, in the closed position, abrade the retina to engage epiretinal membranes; then, membranes can be removed with tangential peeling in the usual manner (See related video below).
Watch Video
Figure 2
BELOW THE RETINA: Subretinal bands
  • Contrary to proliferative epiretinal membranes, not all subretinal bands need to be removed. Specifically, subretinal bands involving the macula or limiting your ability to re-attach the retina need to be removed. A small retinotomy with endothermy followed by forceps-assisted removal is a straightforward approach.
GRATIS
If a scleral buckle has not been placed previously, I recommend placing one in during complex retinal detachment cases. Even if only an encircling band (e.g., 41 band), this will provide support of the vitreous base and act as a barrier to anterior retinal contracture in cases where subsequent anterior membrane formation occurs.
 
Watch Video
Dr. Almeida repairs a complex retinal detachment.

Reference(s):
1. Chin EK, Almeida DR, Folk JC. Posterior hyaloid removal. Ophthalmic Surg Lasers Imaging Retina. 2015;46(4):404.
2. Almeida DR, Chin EK, Roybal CN, Elshatory Y, Gehrs KM. Multiplane peripheral dissection with perfluoro-n-octane and triamcinolone acetonide. Retina. 2015;35(4):827-828.
3. Xu K, Chin EK, Mahajan VB, Almeida DR. Intravitreal foscarnet with concurrent silicone oil tamponade for rhegmatogenous retinal detachment secondary to viral retinitis. Retina. 2016;36(11):2236-2238.
4. Xu K, Chin EK, Almeida DR. Five-port combined limbal and pars plana vitrectomy for infectious endophthalmitis. Case Rep Ophthalmol. 2016;7(3):289-291.
5. Kuriakose RK, Xu K, Chin EK, Almeida DR. Proliferative Vitreoretinopathy (PVR) Update: current surgical techniques and emerging medical management. J VitreoRetin Dis. 2017;1(4):261-269.
6. Xu K, Chin EK, Bennett SR, et al. Predictive factors for proliferative vitreoretinopathy formation after uncomplicated primary retinal detachment repair. Retina. E-pub ahead of print: May 21, 2018.
7. Xu K, Chin EK, Parke DW, Almeida DR. Epiretinal membrane and cystoid macular edema as predictive factors of recurrent proliferative vitreoretinopathy. Clin Ophthalmol. 2017;11:1819-1824.

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