Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

Non-Lasered Drainage Retinotomies for Repair of Primary Rhegmatogenous Retinal Detachments

Trevor S. Hodson, BS; Ryan F. Isom, MD; David Wilkin Parke III, MD

Abstract

BACKGROUND AND OBJECTIVE:

Drainage retinotomies are a technique used for treating rhegmatogenous retinal detachments (RRDs). These retinotomies are commonly surrounded by barricade laser. This paper aims to evaluate operative success of non-lasered drainage retinotomies during 25-gauge pars plana vitrectomy (PPV) for repair of primary RRD.

PATIENTS AND METHODS:

Retrospective review of a consecutive interventional case series. Study includes 45 eyes of 45 patients who underwent 25-gauge PPV with a non-lasered drainage retinotomy for primary RRD. Eyes with previous retinal detachments or less than 3 months of follow-up were excluded.

RESULTS:

All PPV with non-lasered drainage retinotomies were carried out by one surgeon (RFI); 25-gauge PPV instrumentation, a wide-angle viewing system, endolaser photocoagulation, and air or sulfur hexafluoride gas tamponade were utilized for each eye. Single surgery anatomical success was achieved in 42 out of 45 eyes (93%).

CONCLUSION:

Retinal detachment repair utilizing non-lasered drainage retinotomies had a high anatomic success rate comparable to that of standard retinal detachment repair.1,2

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:955–960.]

Abstract

BACKGROUND AND OBJECTIVE:

Drainage retinotomies are a technique used for treating rhegmatogenous retinal detachments (RRDs). These retinotomies are commonly surrounded by barricade laser. This paper aims to evaluate operative success of non-lasered drainage retinotomies during 25-gauge pars plana vitrectomy (PPV) for repair of primary RRD.

PATIENTS AND METHODS:

Retrospective review of a consecutive interventional case series. Study includes 45 eyes of 45 patients who underwent 25-gauge PPV with a non-lasered drainage retinotomy for primary RRD. Eyes with previous retinal detachments or less than 3 months of follow-up were excluded.

RESULTS:

All PPV with non-lasered drainage retinotomies were carried out by one surgeon (RFI); 25-gauge PPV instrumentation, a wide-angle viewing system, endolaser photocoagulation, and air or sulfur hexafluoride gas tamponade were utilized for each eye. Single surgery anatomical success was achieved in 42 out of 45 eyes (93%).

CONCLUSION:

Retinal detachment repair utilizing non-lasered drainage retinotomies had a high anatomic success rate comparable to that of standard retinal detachment repair.1,2

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:955–960.]

Introduction

Rhegmatogenous retinal detachments (RRDs) occur when the neurosensory retina separates from the retinal pigment epithelium (RPE) due to subretinal fluid (SRF) accumulation from one or more breaks. RRD affect about one person in 10,000 a year and, if left untreated, can lead to significant and permanent vision loss.3–5

Surgical interventions began in the 1950s with the introduction of the scleral buckle, followed by pneumatic retinopexy and, more recently, vitrectomy with or without a scleral buckle.6 Various techniques exist for draining subretinal fluid during vitrectomy for repair of RRDs. Three common techniques include drainage from a preexisting retinal break, perfluorocarbon liquids, and drainage retinotomies.

Each technique has its benefits and possible complications. The surgical approach often depends on surgeon preference, surgical setting, available equipment, and economic factors. Perhaps ideally, fluid is drained from an already present retinal break during a fluid-air exchange with complete flattening of the retina. This technique avoids the need to create additional retinal holes and the cost and possible complications of using perfluorocarbon liquids.

Draining through a peripheral break can be challenging due to residual vitreous around the break, difficulty of access in phakic eyes, and residual SRF. Significant amounts of residual SRF can lead to retinal folds, which have been reported in up to 3% of cases postoperatively in one series.7,8 Intraoperative head tilt can minimize residual posterior SRF. This makes the area of the break more dependent in order to pool the fluid closer to the break. Although the head tilt may compromise the view, a greater amount of fluid may be removed to decrease the risk of postoperative retinal folds.

Some surgeons prefer to use liquid perfluorocarbons routinely to avoid the need for posterior drainage retinotomies. Although perfluorocarbons have been a useful addition to the repair of retinal detachments, they remain expensive and carry the risk of retention in the pre- or subretinal space. One study found the rate of subretinal perfluorocarbon to be just over 11%; however, all cases of retained subretinal perfluorocarbon in that series involved retinectomies of over 120°.9

Drainage retinotomies usually achieve a more complete drainage of SRF because the surgeon can drain from the base of the accumulated fluid as opposed to draining from a peripheral retinal break. A more complete drainage of SRF decreases the risk of postoperative retinal folds.7,8 Other potential complications of posterior drainage retinotomies include visual field scotomas, subsequent epiretinal membrane (ERM) and proliferative vitreoretinopathy (PVR) formation, and subretinal choroidal neovascular membrane formation.10,11

Traditionally, drainage retinotomies are surrounded by barricade laser after a complete gas exchange in an effort to create a chorioretinal adhesion and prevent redetachment from the retinotomy site. We have utilized smaller and non-lasered drainage retinotomies and undertook this study to determine whether our technique would minimize the complications of retinotomies without affecting successful retinal reattachment.

There are several systems that help the retina remain attached: the negative pressure gradient between the vitreous and the choroid, the active pumping mechanism of the RPE, and the subcellular adhesive properties of the interphotoreceptor matrix of the RPE. These mechanisms work well except in the setting of focal vitreous traction at the edge of a peripheral retinal break. This is evidenced by the fact that macular holes are rarely the cause of RRDs, aside from in very myopic eyes. We hypothesize that these natural systems for retinal adhesion to the RPE, alongside removal of any vitreous traction during vitrectomy, would preclude non-lasered retinotomies from causing redetachment of the retina. Avoiding laser around the retinotomies would also decrease the size of potential visual scotomas.

This paper presents our single-surgery anatomical success rate for patients undergoing non-lasered drainage retinotomies between 2013 and 2016 as a follow-up to a case study previously presented by the surgeon in 2015.12

Optical coherence tomography image of non-lasered retinotomies.

Figure 1.

Optical coherence tomography image of non-lasered retinotomies.

Optical coherence tomography image of non-lasered retinotomies.

Figure 2.

Optical coherence tomography image of non-lasered retinotomies.

Color images of non-lasered retinotomies with accompanying optical coherence tomography images.

Figure 3.

Color images of non-lasered retinotomies with accompanying optical coherence tomography images.

Color images of non-lasered retinotomies with accompanying optical coherence tomography images.

Figure 4.

Color images of non-lasered retinotomies with accompanying optical coherence tomography images.

Patients and Methods

Retrospective analysis of 45 eyes of 45 patients was conducted upon reviewing surgical cases from August 23, 2013, to August 31, 2016. Consecutive cases involving 25-gauge PPV for RRD were selected. Postoperative notes were reviewed, and patient age, gender, preoperative and postoperative vision, and postoperative complications were recorded. Whether the detachment was macula-on or -off was also recorded. Any patients whose surgeries did not include non-lasered drainage retinotomies were excluded. Patients who had a previous history of vitrectomy and recurrent retinal detachment and patients with less than 3 months of follow-up were also excluded.

Each patient was administered a retrobulbar block following sedation by anesthesia. All vitrectomies were performed using a Constellation vitrectomy system (Alcon, Fort Worth, TX). A 25-gauge trocars and instrumentation were used. A BIOM noncontact widefield imaging system (Oculus, Munich, Germany) was used for visualization.

A core and peripheral vitrectomy were carried out, taking care to confirm separation of the posterior hyaloid and relieve traction at sites of retinal breaks and along detached retina. A drainage retinotomy was then created near the most posterior edge of the detached retina outside of the central macula and usually nasal to the optic nerve, using diathermy (Beaver-Visitec, Waltham, MA) to produce a nonperforated white spot on the retina. This spot was then perforated using the sharp tip of the diathermy.

Several methods exist to create a drainage retinotomy. The authors have found that cauterizing the retina briefly with diathermy to create a nonperforated white spot, followed by perforation with the sharp tip of the diathermy, can create a very small opening through which SRF may be removed during a fluid-air exchange. Prior removal of all viscous SRF through a peripheral break will further reduce the expansion of a retinotomy during a fluid-air exchange. Fluid-air exchange in our study was carried out through the drainage retinotomy with a soft-tip, backflush extrusion cannula (Alcon Laboratories, Fort Worth, TX). An endolaser probe was then used to apply laser around each retinal break except for the drainage retinotomy. Three hundred sixty degree peripheral laser was not routinely used.

Selection of a tamponade agent depended on location of retinal breaks, elevation of the patient's residence, need for travel in the near future, and need for travel over high mountain passes to return home. Sulfur hexafluoride (SF6) and air were both utilized, although SF6 gas was used in 75% of cases. The concentration of SF6 ranged from 20% to 30% depending on the same criteria as above.

Face-down positioning was used in all macula-off detachments and some macula-on detachments. Duration of counseled face-down positioning varied from a minimum of 1 day to a maximum of 1 week. Patients were counseled to sleep on their side at night.

Results

Forty-five eyes of 45 patients were included in this study. There were 19 women and 26 men whose ages ranged from 44 years to 89 years, with a median age of 61.5 years. All patients received follow-up for a minimum of 3 months with a median follow-up of 11 months. Presurgical visual acuity (VA) ranged from 20/25 to LP. Post-surgery VA ranged from 20/15 to 20/400+1.

Single-surgery anatomical success was 93% (42 out of 45 eyes). Of the three recurrent detachments, all were attributed to new peripheral retinal breaks, and none redetached from the non-lasered retinotomy. Air was used as a tamponade in two of these patients, with both developing new inferior retinal breaks. The third patient had SF6 as a tamponade and developed a new retinal break in a non-lasered area. No PVR nor ERM were noted in any of the three patients.

Discussion

The techniques employed to repair retinal detachments continue to vary and improve over time. Drainage of SRF from a primary break is ideal, but in cases of persistent posterior fluid, a drainage retinotomy may decrease the risk of postoperative retinal folds. As compared to perfluorocarbon liquids, retinotomies decrease the cost and time of surgery and do not have the risk for retained perfluorocarbon bubbles. This series suggests that retinotomies may be left unlasered in most routine cases without adversely affecting the reattachment rate.

Surgeons should use caution in using drainage retinotomies in young patients or in cases of inflammation or trauma due to concern for promoting PVR. If there is intraoperative or postoperative concern for PVR, drainage retinotomies should be lasered to prevent redetachment from the site. It should be emphasized that patients in this series were selected for non-lasered retinotomies by the surgeon, and that individuals at elevated risk for PVR usually received laser around retinotomies in the standard fashion.

One limitation to our study is that many patients who received non-lasered drainage retinotomies were not included in the study because they did not return for a full 3 months of follow-up. Due to our geographic location and referral base, many patients travelled several hours for surgical repair and were subsequently followed by their local general ophthalmologist or optometrist. Of 32 excluded patients, eight patients received only 2 months of direct follow-up by the surgeon, and 24 received less than 2 months follow-up from the surgeon and were then cared for by their local provider. Additionally, visual field testing was not performed postoperatively; thus, further study is needed to determine the efficacy of this technique at minimizing visual field loss. Finally, a limitation of this study is that with only 3 months of follow-up, it is possible that some patients experienced retinal detachment after the follow-up period.

Further evaluation is required to determine whether this technique has any effect on the rate of post-surgery ERM formation and size of any perceptible scotoma. At this point, it does appear from this series that good anatomic success with reattachment of the retina can be achieved using non-lasered retinotomies at time of vitrectomy.

References

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  12. Isom R. Drainage Retinotomy Sans Laser. Retina Specialist website. http://www.retina-specialist.com/article/drainage-retinotomy-sans-laser. Accessed March 5, 2017.
Authors

From Retina and Vitreous Surgeons of Utah, Provo, Utah (TSH, RFI); VitreoRetinal Surgery, Minneapolis (DWP); University of Utah School of Medicine (RFI); and The Ohio State University College of Medicine, Columbus, Ohio (TSH).

The authors report no relevant financial disclosures.

Address correspondence to Ryan Isom, MD, Retina and Vitreous Surgeons of Utah, 1055 N 300 W, #210, Provo, UT 84604; email: ryanisom@gmail.com.

Received: April 25, 2018
Accepted: October 03, 2018

10.3928/23258160-20181203-08

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