Hassan Mortada (Cairo, Egypt), Grazia Pertile (Verona, Italy)

Introduction:

PVR is a clinical entity characterized by migration and proliferation of cells, mainly retinal pigment epithelium, glial cells and inflammatory cells, with subsequent formation of non-vascularized membranes on both retinal surfaces, vitreous base and vitreous gel, after a RRD. The cells have contractile properties and can exert traction directly on the retina or through the vitreous gel leading to retinal breaks and retinal traction. Traction is a key feature in the pathogenesis of PVR. The location, extent and severity of traction vary considerably. Breakdown of the blood-ocular barrier is another key feature associated with PVR. This causes increased cytokine release in the vitreous and often precedes clinically recognizable PVR. The PVR process is self-propagating which contributes to more inflammation and worsening breakdown of the blood-ocular barrier.
The 1983 Retina Society classification was modified in 1989 by the Silicone Study Group whose classification differentiates between posterior and anterior forms of PVR and recognize 3 patterns of proliferation: diffuse, focal and subretinal The anterior form has a worse prognosis than the posterior form, and its treatment requires more complex surgical procedures
PVR is the most common complication of RRD, occurring in about 8 – 10% of patients undergoing primary repair of RRD. PVR is still the most common cause of failure of surgery for RRD, despite the substantial effort that has been devoted to better understanding and managing this condition during the past 25 years.
Since the introduction of pars plana vitrectomy (PPV), several advances have resulted in improved PVR surgical outcomes. These advances include introduction of perfluorocarbon liquids, wide-field non-contact viewing systems, use of relaxing retinotomies, transconjunctival microincisional vitrectomy systems, improved illumination and high-speed cutters.

Synopsis:

This course will highlight recent trends and techniques used for management of various components and severity of PVR.
In didactic format, controversial issues like timing of vitrectomy, role of scleral buckle, management of the crystalline lens or intraocular lenses, choice of vitrectomy gauge and choice of intraocular tamponde, will be intensely discussed.
Many videos will be used to demonstrate the appropriate sequence for management of this complicated form of RD including: combining phacoemulsification and implantation of posterior chamber IOL with PPV, management of small pupil, removal of vitreous gel, role of Triamcinolone and Tano scrapper to detect residual cortical vitreous, instrumentation and techniques used for posterior epiretinal membrane dissection, use of PFCL to open retinal folds helping in stabilizing the posterior retina, detection of more epiretinal membranes and allowing ILM peeling.
Emphasizing the importance of dealing with basal vitreous gel and anterior PVR, Videos will be used to demonstrate how to perform scleral indentation, use of high speed cutters to trim the basal vitreous gel, unimanual and bimanual dissection of anterior epiretinal proliferation. The indications, timing and techniques of relaxing retinotomy/retinectomy will be demonstrated.
The course will course will also highlight indications, timing and techniques for dealing with different forms of subretinal proliferation, including Napkin ring.
Finally, the course will demonstrate how to achieve safe complete retinal reattachment using PFCL, endolaser photocoagulation and exchange with the appropriate tamponade.
Avoidance and management of intraoperative complications (subretinal PFCL bubbles, bleeding, iatrogenic tears) as well as postoperative complications will be discussed.

Objectives:

At the end of the course, attendees will be able to:
1. Make up their minds regarding controversial issues in management of PVR.
2. Decide which vitrectomy gauge system, instrumentation, visualization system, vitrectomy machine parameters and illumination are appropriate for management of PVR.
3. Learn different techniques and tricks.
4. Organize a strategy for dealing with this challenging surgical situation with various complicated components.
5. Deal with different intraoperative challenging situations and complications
6. Attempt to reduce the incidence of postoperative recurrence of PVR and RD.