Retinal detachments do not only necessitate a medical emergency; they can cause permanent vision loss if not promptly treated. During the retinal detachment session at the recently held Asia-Paciﬁc Academy of Ophthalmology (APAO 2017) meeting in Singapore, vitreoretinal surgeons shared clinical pearl in the management of complex retinal detachments
It is well known that on average, about 70% of retinal detachments are complicated by proliferative vitreoretinopathy (PVR). This is due to the proliferation or contraction of the cellular membranes that are in the hyaloid of the retina or on the surface of the retina. In fact, although surgeons achieve anatomical success in more than 90% of retinal detachments, primary prevention of PVR remains an issue.
“These tractional forces then result in reopening retinal breaks, creating new breaks or distorting the retina. It has been described as a scaring process ampliﬁed by the inﬂammation,” said Dr. Lee Shu Yen, MBBS, MMed(Ophth), FRCS(Ed), FAMS, Senior Consultant, Surgical Retina Department, Singapore National Eye Centre.
At risk of complex retinal detachments, highlighted Dr. Lee, are basically eyes that have giant or large breaks, multiple breaks, eyes of patients that have a history of uveitis, patients presenting with vitreous hemorrhage, and patients presenting with choroidal detachment.
“Sometimes as you wait for the massive choroidal detachment to subside, this may result to surgery later. Or when a patient has a history of penetrating trauma…in such cases, we need quite a lot of work to undo all these,” she added.
Meanwhile, presenting cases of retinal detachments associated with trauma and intraocular foreign bodies, Dr. Paisan Ruamviboonsuk, M.D., Immediate Past President, The Royal College of Ophthalmologists of Thailand; Regional Secretary, APAO; Council Member, APVRS; Secretary General, ASEAN Ophthalmology Society; Previous President, Thai Retina Society (2009-2014), agreed that such cases which can lead to penetrating trauma pose quite a challenge to surgeons.
Furthermore, secondary PVR, emphasized Dr. Lee, is a “hot” retinal detachment case “because you thought you have done a good job and then one to two months later the retina re-detaches,” she explained.
“You have to be aware of these eyes that have already presented with some form of low grade PVR, vitreous hemorrhage or history of uveitis, because sometimes you will miss the break. The problem is, successful sealing of all retinal breaks does not always give protection against PVR because it is quite common that you see re-detachment one month later,” shared Dr. Lee.
Also, Dr. Lee noted the importance of “completing” surgery in retinal detachments. “Otherwise there would be a scaffold that the harvest process will continue on to,” she said.
“You need to address the issues of the vitreous space, you need to remove all the surface membranes that are exerting tractional forces. In terms of retinal foreshortening you need a good broad buckle. Sometimes you need to do a relieving retinectomy if the broad buckle is not good enough. And sometimes you need to ﬂip the retina over to remove the sub-retinal bonds that are tending the retina up,” Dr. Lee shared.
Adding to the clinical experiences shared by Dr. Lee and Dr. Ruamviboonsuk, Dr. Andrew Chang, MBBS(Hons), PhD (Syd), FRANZCO, FRACS, Associate Clinical Professor, University of Sydney and Medical Director of Sydney Retina Clinic and Day Surgery in Australia, reported that heavy liquid tamponade is of good use in treating complex retinal detachments.
“It’s heavy and so pushes the retina down. It is clearer so we can see what we are doing within the eye. It has a moderate surface tension and low viscosity, therefore easy to handle,” explained Dr. Chang. He then presented a few surgical videos in treating retinal detachment using heavy liquid tamponade and concluded that based on his clinical experience, short-term heavy liquid tamponade is useful in treating complex retinal detachments.