Retina Today - Treating Recurrent Retinal Detachment Due to PVR (January/February 2017)

摘要

Rhegmatogenous retinal detachment (RRD) is the most common form of retinal detachment, and treatment of patients with RRD is one of the most common indications for vitreoretinal surgery. Ideally, RRD is repaired with a single surgical intervention; however, despite excellent skill and impeccable technique, surgeons are sometimes required to perform additional interventions to ultimately repair an RRD. Proliferative vitreoretinopathy (PVR) that developsas a complication of RRD can be a frustrating clinical encounter. Indeed, management of recurrent RRD dueto associated PVR can be a humbling experience. Over the years I have collected several helpful tactics formanaging recurrent RRD caused by PVR, and I share these below. AT A GLANCE • Before treating recurrent RRD caused by PVR, be sure to thoroughly discuss the clinical situation and network. • A variety of vital dyes can be used to aid in the removal of tractional PVR membranes. • When performing retinectomy, stay as far anterior and peripheral as possible, and consider leaving temporary “spokes” to maintain the retina in suspended form until the procedure is complete. TIPS AND TRICKS FOR TREATING RRD RELATED TO PVR Patient Education and Chair Time I thoroughly discuss the patient’s clinical situation and prognosis with the patient and his or her support network. Be sure to distinguish between visual and anatomic prognoses. Give them ample opportunity to ask questions, and make sure your answers are understood. Take Your Time in the OR In an era that rewards efficiency and speed, I make an effort to slow down. I do not let the scrub nurse, the clock, or an afternoon clinic rush me. Dean Eliott, MD, gave me this advice early in my career for approaching PVR cases, and it has served me and my patients well. I take my time, peeling every possible membrane thoroughly and deliberately to relieve as much PVR-associated traction on tissues as possible. Buckle Up If a scleral buckle was not placed during the previous surgery, I have a low threshold for placing an encircling scleral buckle at the time of reoperation if an extensive relaxing retinectomy is not planned to address the risk of subsequent tractional redetachment. Harry W. Flynn Jr, MD, taught me this, and I have never placed a scleral buckle during a reoperation that I subsequently regretted. Remove All Tractional PVR Membranes In order to carefully remove all tractional PVR membranes, I use various stains liberally. Triamcinolone is excellent for identifying residual vitreous; trypan blue is decent for staining PVR-associated tissues, if given sufficient contact time; and indocyanine green (ICG) is my go-to stain for ILM. If the membranes are not readily grasped with forceps, a flexible loop instrument can be useful to peel PVR-associated tissues. Try using a gentle sweeping motion from posterior to anterior in the midperiphery in regions containing membranes you wish to peel. Peel the ILM I typically peel ILM in all PVR reoperations unless there is good reason not to do so. The ILM can serve as a scaffold for PVR. I prefer to use ICG to visualize the ILM. I both apply it and remove it under air to minimize subretinal migration. I peel ILM as far into the periphery as possible—even beyond the edge of a planned retinectomy, if this is practical. Do all peeling before you begin a retinectomy. Not All Subretinal Bands Need to Be Removed If subretinal bands (SRBs) are extrafoveal and the retina reattaches evenly without tractional points and without removal of SRBs, consider leaving the SRBs in place. However, if the SRBs cause obvious retinal traction, remove them during an extramacular retinotomy. With PFO, Use Valved Trocars and Lower the IOP When I was in fellowship, Timothy G. Murray, MD, MBA, demonstrated the difference in fluidics between valved and nonvalved trocars when perfluoro-n-octane (PFO) liquid is used. I ad