Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Post-Traumatic Giant Retinal Tear Without Posterior Vitreous Detachment: A Case Series

Alfonso Savastano, MD; Francesco Barca, MD; Ruggero Tartaro, MD; Tomaso Caporossi, MD; Stanislao Rizzo, MD

Abstract

BACKGROUND AND OBJECTIVE:

To investigate the vitreal condition in retinal detachment (RD) related to giant retinal tears (GRT) after ocular blunt trauma.

PATIENTS AND METHODS:

Retrospective, observational study conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy. The institutional review board and ethics committee approved the study. Records of 23 eyes of 23 patients affected by traumatic RD associated with a GRT were evaluated. A total of four eyes had RD related to blunt trauma, in which the authors performed 25-gauge vitrectomy and silicone oil was used as a endotamponade.

RESULTS:

Three out of four eyes did not display a posterior vitreous detachment at the B-scan, and this was confirmed during surgery. The three eyes had a mean visual acuity of 20/32 1 month after silicone oil removal.

CONCLUSIONS:

Posterior vitreous detachment may not be present in RD associated with GRT after blunt trauma. This knowledge could result in modified intraoperative management to improve postoperative outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:686–690.]

Abstract

BACKGROUND AND OBJECTIVE:

To investigate the vitreal condition in retinal detachment (RD) related to giant retinal tears (GRT) after ocular blunt trauma.

PATIENTS AND METHODS:

Retrospective, observational study conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy. The institutional review board and ethics committee approved the study. Records of 23 eyes of 23 patients affected by traumatic RD associated with a GRT were evaluated. A total of four eyes had RD related to blunt trauma, in which the authors performed 25-gauge vitrectomy and silicone oil was used as a endotamponade.

RESULTS:

Three out of four eyes did not display a posterior vitreous detachment at the B-scan, and this was confirmed during surgery. The three eyes had a mean visual acuity of 20/32 1 month after silicone oil removal.

CONCLUSIONS:

Posterior vitreous detachment may not be present in RD associated with GRT after blunt trauma. This knowledge could result in modified intraoperative management to improve postoperative outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:686–690.]

Introduction

A giant retinal tear (GRT) is a full-thickness neurosensory retinal break that extends circumferentially around the retina for 3 or more clock hours. Although a GRT may arise spontaneously, approximately 25% occur in association with different types of ocular trauma.1

To date, the presence or absence of posterior vitreous detachment (PVD) is considered the main difference between GRT and giant retinal dialysis (GRD) related to retinal detachment (RD), and the surgical approach may differ according to this finding.2

On the other hand, the vitreous relationship to the retinal break is not the only distinction between GRT and dialysis. GRT is diagnosed when retinal tissue is visibly attached to the ora serrata, whereas in retinal dialysis, we have the anterior border of the break detached from the ora serrata.

Penetrating/perforating traumas may also be associated to GRT development; in the case of blunt traumas, the pathogenesis is related to PVD formation and, furthermore, the development of hemorrhagic necrotic retinal areas due to anteroposterior force and vitreous base expansion has also been hypothesized.3–5 In the case of penetrating/perforating trauma, it is the vitreous loss that causes a PVD and the GRT formation.

Here, we describe a case series in which three eyes affected by RD related to GRT without PVD were evaluated before surgery by ultrasound and confirmed during surgery.

Patients and Methods

This study was not funded by any specific grant from public, commercial, or nonprofit sectors. This was a single-center, retrospective, observational report that adhered to the tenets of the Declaration of Helsinki, and proper written informed consent was not necessary from the patients due to the retrospective nature of the study. The institutional review board and ethics committee approved the study.

We observed 23 eyes affected by RD related to GRT in the previous 3 years. Of these, only eyes with a history of ocular blunt trauma were selected for the present study (Figure 1). All data were extrapolated through the electronic medical record system at Azienda Ospedaliero Universitaria Careggi, Florence, Italy.

Pie chart showing the overall percentage of retinal detachment related to giant retinal tear. PVD = posterior vitreous detachment

Figure 1.

Pie chart showing the overall percentage of retinal detachment related to giant retinal tear. PVD = posterior vitreous detachment

B-scan examination was performed prior to surgery for all eyes according to the internal protocol of our eye clinic.

All eyes were subjected to 25-gauge pars plana vitrectomy (PPV) with a complete vitrectomy and shaving of the vitreous base. Cataract phacoemulsification or lensectomy and intraocular lens (IOL) implantation were planned concomitantly for phakic eyes. According to the choice of the surgeon, intraoperative triamcinolone acetonide was used. Perfluorocarbon was applied to resolve the RD, and silicone oil (1,300 centistokes [cs]) was used to tamponade the retina at the end of surgery. In all cases, silicone oil was maintained for an average of 3 months before its removal. Patients were evaluated clinically on days 1, 15, 30, 60, and 90 after surgery.

Results

An overall analysis confirmed that the RD related to GRT after blunt trauma represented 17% of the cases (four eyes). Contrary to our expectations, although RD related to GRT was distinctly detectable in three eyes, no clear PVD was found. Even if a GRT could be observed in the superotemporal quadrant of each eye, the posterior retinal flap was not rolled back on itself as is generally observed in classic RD related to GRT. The absence of PVD is more typical of RD related to GRD; however, a clear anterior retinal flap was observed in our cases (Figure 2). Dynamic B-scan evaluation of these three eyes revealed incomplete separation of the vitreous from the posterior pole or from the posterior edge of the GRT (Supplemental Video 1, below). During surgery, the PVD was mechanically induced (Supplemental Video 2, below). In some cases, triamcinolone acetonide was used for better visualization of the vitreous body. All clinical features of these three eyes are presented in the Table.



B-scan image showing the posterior vitreous still attached to the posterior pole.

Figure 2.

B-scan image showing the posterior vitreous still attached to the posterior pole.

Clinical Features of the Three Eyes With Retinal Detachment Related to GRT After Blunt Trauma With No Posterior Vitreous Detachment Observable

Table:

Clinical Features of the Three Eyes With Retinal Detachment Related to GRT After Blunt Trauma With No Posterior Vitreous Detachment Observable

Patient 1

Patient 1 was a 36-year-old female with RD in the right eye with GRT of 3 to 4 clock hours in the superotemporal quadrant that occurred 13 days after a blunt trauma due to a domestic injury. The preoperative visual acuity (VA) was 20/200, and the macula was involved in the detachment (macula-off). The preoperative B-scan suggested an attached posterior hyaloid.

The patient underwent 25-gauge PPV and phacoemulsification with IOL implantation.

PVD was induced with gentle suction using the vitrector. Perfluorodecalin (Fluoron / Geuder AG, Heidelberg, Germany) was used to flatten the retina and triamcinolone was injected to facilitate vitreous shaving. A 360° laser retinopexy was conducted and 1,300 cs silicone oil (Oxane; Bausch + Lomb, Rochester, NY) was used as endotamponade at the end of surgery. The patient was asked to keep a left-side position for 2 weeks.

After 1 month, VA improved to 20/80 and the retina was attached. For this reason, 15 days later the silicone oil was removed. One month after oil removal, VA was 20/32.

Patient 2

Patient 2 was a 28-year-old male with RD in the left eye with GRT of 5 clock hours in the superotemporal quadrant that occurred 23 days after a blunt trauma due to a sports injury. The preoperative VA was count fingers, and the macula was involved in the detachment (macula-off). The preoperative B-scan suggested an attached posterior hyaloid.

The patient underwent 25-gauge PPV and phacoemulsification with IOL implantation.

PVD was induced after triamcinolone injection with gentle suction using the vitrector. Perfluorodecalin was used to flatten the retina. A 360° laser retinopexy was conducted and 1,300 cs silicone oil was used as endotamponade at the end of surgery. The patient was asked to keep a right-side position for 2 weeks.

After 1 month, VA improved to 20/100 and the retina was attached. For this reason, 15 days later the silicone oil was removed. One month after the oil removal, VA was 20/40.

Patient 3

Patient 3 was a 50-year-old male with RD in the right eye with GRT of 3 to 4 clock hours in the superotemporal quadrant that occurred 24 days after a blunt trauma due to a domestic injury. The preoperative VA was light perception, and the macula was involved in the detachment (macula-off). This patient had already had cataract surgery the year before (phacoemulsification) and IOL implantation. The preoperative B-scan suggested an attached posterior hyaloid.

The patient underwent 25-gauge PPV. PVD was induced using the vitrector after triamcinolone injection. Perfluordecaline was used to flatten the retina. A meticulous vitreous shaving was conducted using triamcinolone to facilitate vitreous visualization. A laser retinopexy around the tear was carried out and 1,300 cs silicone oil was used as endotamponade at the end of surgery. The patient was asked to keep a right-side position for 2 weeks.

After 1 month, VA improved to 20/80 and the retina was attached. For this reason, 15 days later the silicone oil was removed. One month after the oil removal, VA was 20/25.

Discussion

PVD is considered the “primum movens” implicated in the development of idiopathic and traumatic GRT. However, we discovered a very unusual condition in three out of four eyes affected by RD related to GRT after a blunt ocular trauma where a PVD was not observed. This finding was confirmed during surgery. The implication that this finding will have on the pathogenesis of GRT formation is unclear; it may be that the GRTs were caused by the formation of retinal necrotic hemorrhagic areas that were a result of the antero-posterior force of the blunt trauma.3–5 However, in our opinion, it is more likely that the formation of a GRT is related to the presence of a weak peripheral retinal area on which there is abnormal vitreous traction. Many rhegmatogenous or nonperipheral retinal alterations can cause GRT, which explains why RD related to GRT most commonly arises spontaneously. Nevertheless, RD related to GRT following ocular trauma, especially blunt ocular trauma, most commonly occurs at different times after the trauma. Sometimes it can be associated with massive vitreous bleeding, so that the RD and GRT can only be observed using a B-scan. When a GRT occurs after a blunt trauma and causes RD, it is often located in the inferotemporal or superonasal quadrant and can be found alone or in association with retinal tears.

The fact that the GRT after a blunt trauma is often localized in the superonasal or inferotemporal quadrants supports this idea of GRT formation due to the formation of hemorrhagic necrotic areas because the antero-posterior force is directed toward the opposite pole of the impact area, and these quadrants are the most exposed to direct contact.3–5

Trauma, an important risk factor for the development of GRT, causes 16.1% of RD according to the British Giant Retinal Tear Epidemiology Eye Study (BGEES), although different incidence rates can be found in literature.6,7

In a study by Sohelian et al., the most common cause of traumatic GRT was blunt trauma (57.5%), followed by penetrating trauma (25.6%), perforating injury (25%), and globe rupture (14.7%).8 Contrarily, Yoston et al. reported an incidence rate of 8.3% of RD related to GRT among people living in East Africa.9

Different classifications have been proposed for GRT according to the location or etiology.10,11 Rare conditions, such as lens coloboma, retinitis pigmentosa, aniridia, acute retinal necrosis, endophthalmitis and the Jarisch-Herxheimer reaction, can be followed by the formation of GRTs.12,13

The reason why we decided to perform PPV directly in our patients was because even if the retina was not rolled-up on itself, the retina resulted largely detached and the vitreous showed a large amount of “tobacco dust” and a vitreous hemorrhage that could have developed in proliferative vitreoretinopathy (PVR) if not removed. Even though, usually, a scleral buckle is our first choice dealing with retinal detachment in general, in these cases, we preferred vitrectomy for the explained reasons.

The most common surgical procedure in the case of GRT is PPV with or without cataract phacoemulsification. PPV plus scleral encircling has been described in some series for GRT greater than 3 clock hours with PVR in order to reduce epiretinal tractions at the vitreous base. From the literature it emerges that the bigger the tear is, the higher the surgical difficulty and the complications are. At the end of surgery, the eye can be tamponed with silicone oil, heavy liquid (short-term postoperative tamponade, off-label procedure), or gas according to the surgeon choice.14–16

One of the worst complications of GRT is retinal slippage without complete reattachment; moreover, it can be associated with a higher possibility of PVR development, which can cause RD recurrence.

To summarize, an awareness of the vitreous condition prior to surgery is useful for to plan the appropriate surgery and improve the post-operative success rate. In fact, leaving the vitreous attached during the operation is a possible error and may bring about the development of complications such as RD recurrence and PVR. PVD should always be evaluated during vitrectomy for RD and mechanically induced if not present, even in cases of RD related to GRT.

References

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Clinical Features of the Three Eyes With Retinal Detachment Related to GRT After Blunt Trauma With No Posterior Vitreous Detachment Observable

Patient 1 (Right Eye) Patient 2 (Left Eye) Patient 3 (Right Eye)
Male or Female F M M
Age (Years) 36 28 50
Axial Length (mm) 28 25 26
Lens Status Phakic Phakic Pseudophakic
Extension / Localizationof GRT 3 to 4 clock hours / superotemporal quadrant 5 clock hours / superotemporal quadrant 3 to 4 clock hours / superotemporal quadrant
Presence of PVD at the B-Scan Negative Negative Negative
Presence of PVD During the Surgery Negative Negative Negative
Months After Silicone Oil Was Removed 3 2 3
BCVA (logMAR) Before Surgery +1.0 Count fingers Light perception
BCVA (logMAR) 1 Month After Surgery +0.6 +0.7 +0.6
BCVA (logMAR) 1 Month After Silicone Oil Removal +0.2 +0.3 +0.1
Authors

From Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (AS, FB, TC, SR); and Università Degli Studi di Firenze, Florence, Italy (RT, SR).

The authors report no relevant financial disclosures.

Address correspondence to Alfonso Savastano, MD, Department of Ophthalmology, University Hospital Careggi – Florence, Via Largo Palagi 1, 50139, Florence, Italy; email: asavastano21@gmail.com.

Received: December 22, 2017
Accepted: August 03, 2018

10.3928/23258160-20180831-06

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