Retina Today - RETINA PEARLS: Bimanual Vitreoretinal Surgery for Tractional Retinal Detachment Due to Proliferative Diabetic Retinopathy (July/August 2011)

摘要

In this issue of Retina Today, Elliott Sohn, MD, provides surgical pearls for performing bimanual vitreoretinal surgery for tractional retinal detachment due to proliferative diabetic retinopathy using 20- or 23-gauge instrumentation. We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Ingrid U. Scott, MD, MPH (iscott@psu.edu); or Dean Eliott, MD (dean_eliott@meei.harvard.edu). We look forward to hearing from you. a??Ingrid U. Scott, MD, MPH; and Dean Eliott, MD Managing eyes with tractional retinal detachment (TRD) due to severe proliferative diabetic retinopathy (PDR) can be challenging for vitreoretinal surgeons (Figure 1). TRD from PDR, resulting from contraction of epiretinal fibrovascular proliferative membranes, requires surgery when it involves or threatens the macula or has a combined rhegmatogenous retinal detachment (RRD) component. In bimanual vitreoretinal surgery, two instruments are used simultaneously to manipulate the same tissue inside the eye. This concept typically excludes the use of a single- function light pipe as one of the instruments, although this too can be used for manipulation. Due to the complexity of TRDs from PDR requiring surgery, bimanual technique can be advantageous to permit optimal visualization and to facilitate creation of dissection planes between the retina and fibrovascular membranes (FVMs) to reduce bleeding and iatrogenic complications. For most TRDs with focal vitreoretinal adhesions (pegs), a light pipe and a curved scissors (Figure 2A), horizontal scissors (Figure 2B), or vertical membrane peeler-cutter (MPC) scissors (Figure 2C), an instrument that combines automated vitreous scissors and a hooked needle (Figure 2C), are usually adequate. For the most complex cases in which there are extensive FVMs, particularly broad sheets that are tightly adherent to detached, mobile, and atrophic retina prone to breaks, I typically employ bimanual surgery with a cutting device in one hand (vitrector or vertical, curved, or horizontal scissors) and a lighted instrument in the other (three-function tissue manipulator [Figure 2D], illuminated forcep, or illuminated pick). This article discusses some tools and techniques to perform bimanual vitreoretinal surgery using either 20- or 23-gauge instrumentation. My experience is primarily with technology manufactured by Alcon Laboratories, Inc. (Fort Worth, TX); however, the principles should apply to any platform. Notably, many diabetic vitrectomies do not require bimanual vitreoretinal surgery because FVMs can often be removed with the cutter, curved or horizontal scissors used for delamination, and/or vertical scissors used for segmentation. These techniques depend on the surgical case, but I tend to use a combination of these instruments for the most difficult cases. PEARLS FOR TRD SURGERY In TRD surgery, it is important to 1) remove as much hyaloid and FVM from the retina as possible to eliminate associated vitreoretinal traction; 2) dissect a plane separating the retina and FVM to reduce the risk of iatrogenic breaks and bleeding; and 3) use just enough light to visualize the dissection but limit phototoxicity. PEARLS FOR 20-GAUGE SURGERY Vitreoretinal surgery with 20-gauge instrumentation is the traditional method for repairing TRDs. The range of instruments available for 20-gauge surgery is the broadest, as this modality has been around the longest. The larger caliber instruments allow increased stability for devices such as the reusable vertical MPC scissors and three-function tissue manipulator (endoillumination, cautery, irrigation, and aspiration all in one handpiece; Figure 2D). Although it requires a trained assistant to control the partially filled balanced salt solution (BSS irrigating solution, Alcon Laboratories, Inc.) syringe manually, the tissue manipulator is us