A Critical Analysis of Postoperative Outcomes in Rhegmatogenous Retinal Detachment Associated with Giant Tears: A Consecutive, Multicenter Study

Background: Currently there remains controversy in the surgical management of rhegmatogenous retinal detachment (RRD) due to giant retinal tears (GRTs), a potentially blinding condition. To clarify which surgical technique is better depending on the origin and magnitude of the giant tear this study aimed to analyze the anatomical and functional outcomes. To analyze trans- and postoperative surgical complications, we used long-term final postoperative structural, optical coherence tomography (OCT) and correlated the results with the final postoperative best-corrected visual acuity (BCVA) in three different groups of eyes.Methods: Seventy-six consecutive eyes of 66 patients from three participant institutions were recruited and classified according to the degree of GRT-associated RRD extension as follows: group 1, 42 eyes with GRT-associated RRD extension < 180°; group 2, 23 eyes with GRT-associated RRD extension = 180°–270°; and group 3, 11 eyes with GRT-associated RRD extension > 270°. Structural and functional outcomes were compared across groups.Results: Of the 76 eyes analyzed, 63 were phakic, and 13 were pseudophakic. The mean age of the patients was 43.0 ±13.0 years (range, 19–76 years); 36 females, and 40 males. The mean preoperative time for GRT surgery was 1.8 weeks, the mean preoperative and postoperative BCVA was 1.87 logMAR and 0.35 logMAR, respectively (p<0.05), and the mean postoperative follow-up was 28.1 months. Five patients (6.57%) had bilateral GRT-associated RRD, 61 patients (80.26%) had a monocular condition, and 21 eyes (27.63%) had a BCVA ≥20/40. Proliferative vitreoretinopathy resulted in multiple surgeries in 31.57% of the eyes. Postoperative OCT yielded abnormal retinal thickness in all groups, ellipsoid band disruptions, and external limiting line discontinuities in all groups, predominantly in macula-off GRTs requiring multiple surgeries. Conclusions: Multiple structural alterations in spectral-domain OCT biomarkers were observed. Eyes that developed secondary epiretinal membrane (ERM) proliferation showed significantly improved BCVA after proliferation, and the internal limiting membrane was removed. This study presents the severe consequences of macular structure and function. The structural findings correlated with the BCVA allow us to conclude severe consequences of the macular structure and that, despite a fully reattached retina without ERM proliferation, GRTs-associated RRD has a guarded functional prognosis.

Limbal Approach Phacovitrectomy to Treat Cataract with Clinically Significant Asteroid Hyalosis—Presentation of the Technique and Preliminary Results

Purpose: To assess preliminarily the efficacy and safety of a relatively new surgical modification of phacovitrectomy in eyes with cataract and visually significant asteroid hyalosis (AH). Materials and methods: Prospective, noncomparative, interventional case series of six eyes of six patients (mean age 75.6 years; 1 woman, 5 men) with cataract and visually significant AH treated with a novel surgical technique—a phacoemulsification with anterior vitrectomy through posterior capsulorhexis and intraocular lens (IOL) implantation. Main outcome measures were: best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, complications. Mean follow-up was 39.17 ± 4.31 months. Results: The mean BCVA (Snellen) improved from 0.26 ± 0.18 to 0.73 ± 0.33 at the end of the follow-up. IOP was in the normal range, and no problems with IOL fixation were observed at the end of the follow-up. No post-operative complications, retinal detachment, retinal tears, macular edema or prolonged inflammation were observed. Conclusions: The presented new surgical technique seems to be a safe and efficacious method to treat cataract with visually significant asteroid hyalosis.

YAG-laser retinotomy in the complex treatment of horseshoe tear and rhegmatogenous retinal detachment

Horseshoe-shaped retinal tear leads to rhegmatogenous retinal detachment (RRD) in 61-83% of cases. Vitreoretinal traсtion is the main factor in the development of horseshoe tears and RRD. In this aspect, YAG-laser retinotomy is promising, which makes it possible to eliminate the traction component by excision area of the horseshoe tear with vitreoretinal adhesion (VRA). Purpose. To analyze the results of YAG-laser retinotomy in the treatment of patients with complicated horseshoe tears and rhegmatogenous retinal detachment. Material and methods. The study included 97 patients (100 eyes). Of these, 54 patients (57 eyes) with complicated horseshoe retinal tears and 43 patients (43 eyes) with local RRD. Patients with complicated horseshoe tears underwent YAG-laser retinotomy at the base of the horseshoe tear. Patients with local RRD underwent a combined laser-surgical technology, which included YAG-laser retinotomy of the horseshoe tear area with vitreoretinal adhesion, pneumatic retinopexy and barrier laser photocoagulation. Results. In the group of patients with complicated horseshoe tears, complete retinal attachment was achieved in 15 eyes (58%), partial retinal attachment - in 7 eyes (27%). In the group of patients with local RRD complete retinal attachment was achieved in 40 patients (93%). There was a stable anatomical result and no changes in functional parameters. Conclusion. YAG-laser retinotomy eliminates vitreoretinal traction in the area of horseshoe tear and prevents the development of rhegmatogenous retinal detachment. Application of YAG-laser retinotomy as the first step of a microinvasive combined laser-surgical technology for the treatment of RRD makes it possible to obtain a high anatomical result, reduce the risk of retinal redetachment, and also preserve the initially high visual functions of patients.

Vitreous hemorrhage of unknown origin in adult non-diabetic non-traumatic eyes: a retrospective analysis and the lessons we learn from it

Objective: To analyse the causes of vitreous hemorrhage (VH) of unknown origin in non-diabetic nontraumatic eyes and evaluate the results regarding the underlying cause and time of surgery. Methods and Analysis: Retrospective analysis of 125 eyes with a dense VH of unknown origin, who underwent vitrectomy at a varied time point. Preoperative and postoperative data were compared between the groups with the three major causes of VH as well as between the eyes with an early (≤5 days after presentation) and a late (>5 days after presentation) vitrectomy. Results: Most common causes of VH were retinal vessel occlusion (RVO; 39/125; 31.1%), retinal tears (36/125; 28.8%) and submacular hemorrhage (34/125; 27.2%). Postoperative visual acuity improved significantly in all eyes (2.14 vs. 1.04 logMAR, p<0.01) with better outcome in eyes with retinal tears. Early vitrectomy group had better functional outcome regardless of underlying cause (p=0.02). Final visual outcome correlated significantly with the underlying cause of VH (p<.001) and time to treatment in the retinal tear group (p<.001). Conclusion: We encourage performing early minimal invasive vitreoretinal surgery in cases of non-diabetic, non-traumatic VH. More than three of four of the cases are caused by retinal tear/retinal detachment, submacular hemorrhage and RVO. Early surgical treatment had better functional outcome on the longer run.

Primary rhegmatogenous retinal detachment: evaluation of a minimally restricted face-down positioning after pars plana vitrectomy and gas tamponade

AIM: To evaluate the safety and efficacy of a minimally restricted face-down postoperative positioning following pars plana vitrectomy (PPV) with gas tamponade for primary rhegmatogenous retinal detachment (RRD). METHODS: Patients with primary RRD treated with PPV and gas tamponade and followed up for at least 6mo were selected for the study. All phakic eyes underwent simultaneous cataract surgery. The patients were required to be in a postoperative position that prevented downward flow of retinal tears. Patients with macular detachment were positioned face-down for only a couple of hours. The patients were assessed for preoperative and postoperative best-corrected visual acuity (BCVA), anatomical retinal reattachment rate, and postoperative complications. RESULTS: In total, 40 eyes of 39 patients with primary RRD were included in the study. A single tear was present in 30 eyes (75.0%), multiple retinal tears were present in nine eyes (22.5%), and oral dialysis was present in one eye (2.5%). The anatomical success rate was 90.0% (36 cases) after the primary surgery, and the final anatomical success rate was 100%. The BCVA improved significantly (P<0.001) from 0.75 logarithm angle of resolution (logMAR) preoperatively to 0.12 logMAR at the final visit. Postoperative complications included intraocular pressure elevation (≥25 mm Hg) in 11 patients (27.5%), fibrin formation in two patients (5.0%), pupillary capture of the intraocular lens in two patients (5.0%), and posterior synechia in one patient (2.5%). CONCLUSION: A minimally restricted face-down and flexible postoperative positioning after PPV and gas tamponade for primary RRD is effective and safe.

A novel technique to avoid intraoperative giant tear slippage: the bimanual double aspiration technique

Background The aim of this paper is to present a novel bimanual double aspiration technique to avoid intraoperative giant tear slippage. The major problem of giant retinal tears (GRT) surgery is the mobility of the posterior flap (slippage), which has been classically solved by the use of intraoperative perfluorocarbon liquid (PFCL). However, avoiding slippage of the posterior flap can be a serious technical challenge when the PFCL is removed, especially when a GRT circumference is > 180°. Methods Conventional three-port 23-gauge pars plana vitrectomy (PPV) plus chandelier was performed in three patients with giant retinal tears (GRT), using the “bimanual double aspiration technique” with non-contact wide field viewing systems. All surgeries were performed by the same surgeon. Results None of the three cases presented with a retinal slippage after the bimanual aspiration technique. Discussion GRT are full thickness retinal tears that extend circumferentially more than 90° of the retina. Management of GRT is a challenge for the vitreoretinal surgeons because the higher risk of proliferative vitreoretinopathy (PVR), re-detachment and increased risk of retinal slippage; this last can occur intraoperative or postoperative. Retinal slippage is not uncommon but far under-reported and can lead to various complications such as hypotony, retinal folds, and may exacerbate PVR formation. We performed bimanual double aspiration technique to avoid intraoperative giant tear slippage. We believe that this maneuver may avoid slippage by drying the posterior edge of the GRT. There were no complications related with the technique, and no additional equipment was needed. Conclusion In summary, “bimanual double aspiration technique”, is a simple, effective, safe and economic maneuver that could be a good option to avoid intraoperative slippage in giant retinal detachment surgery, thus achieving the stabilization of the posterior retinal flap.

Parsplana vitrectomy alone versus parsplana vitrectomy combined with phacoemulsification for the treatment of rhegmatogenous retinal detachment: a randomized study

Background To compare parsplana vitrectomy (PPV) with and without phacoemulsification to treat rhegmatogenous retinal detachment (RRD). Methods Subjects aged 48–65 years with RRD in a phakic eye due to superior retinal tears with an overall extension of retinal breaks < 90° underwent to PPV alone (group A); or PPV plus phacoemulsification (phacovitrectomy, PCV, group B). Post-operative follow-up visits occurred at 1 week, 1 month (m1), 3 months (m3), and 6 months (m6) after surgery. The main outcome was the rate of retinal reattachment. Secondary outcomes included best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), and cataract progression (in the lens-sparing [PPV-alone] group). Results In this initial phase of the study a total of 59 patients (mean age: 55 years, 59 eyes) were enrolled: 29 eyes in group A and 30 eyes in group B. Both groups had similar gas tamponade. During the follow-up there were three cases of RRD recurrence in group A and one in group B. The relative risk of recurrence in group A was 3.22 times higher but the difference was not significant (p = 0.3). The two groups were also similar in terms of BCVA and IOP variation. At m3, CMT was significantly higher in group B (p = 0.014). In group A, cataract progression was significant at m6 (p = 0.003). Conclusions In a cohort of RRD patients selected according to their preoperative clinical characteristics, PPV was comparable to PCV in terms of the rate of retinal reattachment after 6 months. Trial registration ISRCTN15940019. Date registered: 15/01/2021 (retrospectively registered).