Retina Today - Tips and Tricks for Polishing Your Retinectomy Skills (May/June 2017)

摘要

Standard rhegmatogenous retinal detachments are typically straightforward to repair, but complex retinal detachments, such as those involving proliferative vitreoretinopathy (PVR), often require more advanced decision-making and technical prowess. If you are an avid reader of Retina Today, you may recall the insightful article by Charles C. Wykoff, MD, PhD, in the January/February issue on how to tackle recurrent retinal detachment due to PVR.1 In that article, Dr. Wykoff reviewed several concepts and tactics for managing these difficult cases. This article expands on the details of performing a retinectomy, providing some pearls to guide you and some pitfalls to avoid in order to ensure the best possible outcomes. AT A GLANCE • If a retinectomy is deemed necessary, try to identify the most anterior path because contracture inevitably results in less remaining retina than was anticipated. • Most circumferential retinectomies benefit from the use of heavy liquid (PFCL) as an adjuvant to flatten the retina. • Silicone oil is your friend in complex retinal detachment repair. PEARLS Pearl No. 1: Stay Anterior Assess the retinal detachment for the presence of both preretinal and subretinal membranes. Once you have completed your dissection, reassess for residual traction and intrinsic foreshortening of the retina that would prevent retinal flattening or could contribute to postoperative redetachment. If a retinectomy is deemed necessary to achieve the surgical goals, try to identify the most anterior path because contracture inevitably results in less remaining retina than was anticipated. Pearl No. 2: Do Not Undercut Although it is important to leave behind as much viable retina as possible, removing all areas of potentially problematic retina is equally crucial. Leaving behind significant preretinal membranes that cannot be peeled is often a mistake. If they do not involve the macula, they can be removed by including them in the retinectomized area. It is always best that the planned edge of the retinectomy be “fresh”—that is, free of any membranes, traction, or “rolling.” Another common error is failing to extend the retinectomy far enough. The inferior retina is the area most commonly involved in PVR and is also the area least supported by tamponade agents. Extending the edges of an inferior retinectomy superiorly will provide increased levels of support from gas or oil tamponades. Often, a 180º inferior retinectomy is necessary. Pearl No. 3: Leave a Razor-Sharp Edge My partner, who recently saw one of my retinectomy patients on postoperative day 1 asked me how I got such a razor-sharp edge on the retina. The answer is simple, and it involves two key steps. First, ensure that endodiathermy is used to create a well-defined line along the edge of where you want to perform the retinectomy. A line is preferable to a series of dots on the major vessels because the contiguous retinal whitening that is created becomes a stencil that can be followed with the vitrector. It also helps ensure complete hemostasis by avoiding capillary bleeding, as heme can contribute to future proliferation and contracture. You will find that the cauterized retina is easy to follow and remove with the vitrector. Second, make sure that you do not leave any retina anterior to the cautery line because this will add to the area requiring laser. Watch it Now Video 1. Recurrent PVR Under Oil A pseudophakic patient developed a recurrent inferior retinal detachment despite prior scleral buckle and vitrectomy with silicone oil placement. PFCL is placed to determine the ability of the retina to flatten. After membrane peel, a retinectomy is deemed necessary to achieve reattachment due to intrinsic retinal foreshortening. Pearl No. 4: Get Heavy Most circumferential retinectomies benefit from the use of heavy liquid (perfluorocarbon liquid, PFCL) as an