Scleral buckling and lens-sparing vitrectomy are the two preferred methods of treatment for stage 4 retinopathy of prematurity (ROP). Both have some disadvantages, so the authors modified the lens-sparing vitrectomy method to create the local relaxing vitrectomy technique. The core vitreous is not cut as in the lens-sparing vitrectomy, but the organized vitreous is directly dissected with the vitrectomy probe. Two cases of stage 4 ROP were successfully treated using this method. The local relaxing vitrectomy may be a better treatment choice for some cases of stage 4A ROP.
Long-Term Follow-Up of Local Relaxing Vitrectomy for Stage 4 Retinopathy of Prematurity
From the Department of Ophthalmology, People’s Hospital, Peking University, Beijing, People’s Republic of China.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Jiang YanRong, MD, Department of Ophthalmology, People’s Hospital, Peking University, No. 11 South Avenue of XiZhiMen, XiCheng District, Beijing, People’s Republic of China.
Accepted: March 09, 2009
Posted Online: March 09, 2010
There are currently two techniques to treat stage 4 retinopathy of prematurity (ROP): scleral buckling1 and lens-sparing vitrectomy.2,3 We improved the lens-sparing vitrectomy method and successfully treated two cases of stage 4 ROP with local relaxing vitrectomy.
The patient was a premature male infant born at 31 weeks’ gestational age with a birth weight of 1,400 g. He was diagnosed as having stage 3 ROP at 41 weeks of postnatal age, and both eyes had laser photocoagulation immediately. Thirty days later, the retinopathy had progressed when rechecked. He was referred to our department for further treatment.
The anterior segment was benign in both eyes. The dilated fundus examination of both eyes revealed a normal optic disc and moderate temporal dragging of the macula. There were tractional stage 4A retinal detachments for three clock hours from the 2-o’clock to 5-o’clock positions in the left eye (Fig. 1) and from the 8-o’clock to 11-o’clock positions in the right eye. The diagnosis was stage 4 ROP in both eyes after photocoagulation.
Figure 1. Case 1. Photograph of the Left Eye 1 Hour Before Vitrectomy Shows Progressive Retinopathy and Localized Traction Retinal Detachment at the Temporal Area.
The surgical technique involved standard three-port vitrectomy sclerotomy placed 1.5 mm posterior to the limbus. A standard 20-gauge infusion light pipe and vitreous cutter were used for vitrectomy. Unlike in lens-sparing vitrectomy,2,3 we did not cut the core vitreous but directly dissected the organized vitreous with the vitrectomy probe (Fig. 1). Then we performed transscleral cryotherapy to the avascular detached retina where the photocoagulation was not enough.
Six days after the operation, the traction was relieved. After 23 months of follow-up, the lenses were clear and the retinas were attached without dragging (Fig. 2). After 43 months of follow-up, the retinas were still attached without dragging. Visual acuity with correction (−3.00 + 0.50 × 30, right eye; −3.25 + 0.75 × 45, left eye) using the Early Treatment Diabetic Retinopathy Study chart was 25/40 in the right eye and 25/40 in the left eye.
Figure 2. Case 1. Photograph of the Left Eye 18 Months After Vitrectomy Shows that the Retina is Reattached and there are Laser Burn Scars at the Temporal Avascular Area.
The second patient was a premature male infant born at 33 weeks’ gestational age with a birth weight of 2,050 g. He was diagnosed as having stage 3 ROP with plus disease at 41 weeks of postnatal age, and both eyes had laser photocoagulation immediately. Twenty-five days later, the retinopathy had progressed when rechecked. The dilated fundus examination revealed tractional stage 4A retinal detachments in the left eye (Fig. 3) and an attached retina in the right eye. The diagnosis was stage 4A ROP after photocoagulation in the left eye. The surgery was performed as in case 1.
Figure 3. Case 2. Photograph of the Left Eye 1 Hour Before Vitrectomy Shows Progressive Retinopathy and Localized Traction Retinal Detachment at the Temporal Area.
Two weeks after surgery, the traction was relieved. After 9 months of follow-up, the lenses were clear and the retinas were attached (Fig. 4). Visual acuity using Teller Acuity Cards was 6 cpd (equal to 20/100 of Snellen acuity) in the right eye and 6 cpd in the left eye.
Figure 4. Case 2. Photograph of the Left Eye 2 Weeks After Vitrectomy Shows that the Retina is Reattached and there are Laser Burn Scars at the Temporal Avascular Area.
When reviewing treatment options for stage 4 ROP, we considered the following goals: (1) to relieve the traction and reattach the retina; (2) to prevent complications, such as cataract, proliferative vitreoretinopathy, and total retinal detachment; (3) to maintain the original refraction; and (4) to serve as a shortcut and be more convenient. Because it is difficult to create posterior vitreous detachment and easy to form proliferative vitreoretinopathy,3 we just perform the local relaxing vitrectomy and do not dissect the core vitreous. The table compares lens-sparing vitrectomy and local relaxing vitrectomy.
Table: Lens-Sparing Vitrectomy Versus Local Relaxing Vitrectomy
The subtotal vitrectomy cuts the organized vitreous. Because the retinal detachment is caused by the traction of organized vitreous, this vitrectomy prevents retinal detachment and treats the local retinal detachment, as our case showed. Because our local relaxing vitrectomy seldom disturbs the vitreous, it causes less proliferation compared with traditional lens-sparing vitrectomy. We believe it is of great benefit to the prevention of retinal detachment after surgery, reduction of proliferation, and protection of the lens. The local relaxing vitrectomy may be a better treatment option, at least for some cases of stage 4A ROP.
- Hinz BJ, de Juan E Jr, Repka MX. Scleral buckling surgery for active stage 4a retinopathy of prematurity. Ophthalmology. 1998;105:1827–1830. doi:10.1016/S0161-6420(98)91023-5 [CrossRef]
- Capone A Jr, Trese MT. Lens-sparing vitreous surgery for tractional stage 4A retinopathy of prematurity retinal detachments. Ophthalmology. 2001;108:2068–2070. doi:10.1016/S0161-6420(01)00809-0 [CrossRef]
- Lakhanpal RR, Sun RL, Albini TA, Holz ER. Anatomic success rate after 3-port lens-sparing vitrectomy in stage 4a or 4b retinopathy of prematurity. Ophthalmology. 2005;112:1569–1573. doi:10.1016/j.ophtha.2005.03.031 [CrossRef]
Lens-Sparing Vitrectomy Versus Local Relaxing Vitrectomy
|Procedure||Lens-Sparing Vitrectomy||Local Relaxing Vitrectomy|
|Cut the core vitreous||Yes||No|
|Order of vitrectomy||(1) Ridge/retina to lens/anterior hyaloid face, (2) ridge to ridge, (3) ridge to nerve, (4) ridge to vitreous base, and (5) circumferential along the ridge||Directly dissect the organized vitreous|
|Tamponation (C3F8 or silicone oil)||Sometimes||No|