S. Bopp, K. Lucke Bremen, Germany

Introduction:

Retinotomies and Retinectomies are surgical maneuvers for complex situations, in which conventional vitrectomy and peeling techniques prove insufficient to achieve retinal reattachment. Advanced forms of PVR including posterior segment trauma, but also complications secondary to vasoproliferative diseases are the major indications. Benefits and severe potential risks of retinoplastic procedures are not far apart. Furthermore, any cutting of retinal tissue is an absolutely irreversible surgical step. The present review emphasizes indications and surgical techniques for retinotomies/retinectomies. Guidelines for adequate treatment are given.

Material/Methods:

The concepts presented are based on extensive experience in vitreoretinal surgery over more than 15 years.

Results:

The rationales to cut the retina (retinotomy) and remove functionless retinal tissue (retinectomy) are:
• to get access to the subretinal space (e.g. removal of subretinal strands)
• to treat localized traction areas (e.g. retinal incarceration)
• to relieve persistent vitreoretinal traction despite of extensive membrane peeling
• to counteract intractable retinal foreshortening (e.g. long-standing PVR)

The decision to perform retinoplastic maneuvers should be done only after considering any other less invasive technique. Inadequately performed, consequences for the intra- and postoperative course can be devastating, Most common complications are:
• intraoperative massive intraocular hemorrhage
• retinal distorsion and shrinkage and
• large re-openings postoperatively that lead to redetachment and movement of voluminous silicone oil masses under the retina.

Having achieved a maximal mobilization of the retina by conventional techniques, the surgical steps to perform a retinotomy/retinectomy include:
• thorough hemostasis (endodiathermy)
• careful incision of the retinal tissue (by scissors or vitreous cutter) avoiding damage to the choroid
• removal of tissue debris (drainage cannula)
• possibly removing peripheral functionless retinal tissue
• complete reattachment of the retina (perfluorocarbon liquids, air)
• confluent laser of the retinotomy/retinectomy edges and
• finally, application of a long-term intraocular tamponade.

With the technique described, the situation remains under control intraoperatively. However, for the final outcome, location and size of the retinotomies/retinectomies are of utmost importance. This decision is based on the surgeon’s experience. Basically, retinal cuts should be located as peripherally as possible, but they should have a sufficient extent. A compromise must be found between sparing the retina and leaving no residual traction.
On the basis of these therapeutic concepts, 246 procedures were carried out for PVR-detachment be¬tween January, 1998 and December, 2000 (3-year-period).  35% went without, but 65% received retino¬plastic maneuvers. The majority of procedures were performed during revision surgery (68%). However, 32% of eyes that underwent primary vitrectomy for PVR, also had retinotomies/retinectomies. Final reattachment was achieved in approximately 95%.
In the same period, 726 diabetic vitrectomies were performed, 287 for advanced cases with traction retinal detachment. 23% of them (66 operations) underwent surgery with retinotomies/retinectomies; proportionally retinoplastic maneuvers during primary diabetic vitrectomies and revision surgery were equal. Control of retinopathy was achieved in 90% of eyes with and without retinotomy/retinectomy.

Conclusions:

From the surgical point of view, retinotomies/retinectomies are essential tools to achieve retinal attachment in advanced cases of proliferative disease. Although the need for this surgical step indicates an advanced underlying pathology, results are encouraging and do not differ significantly from surgery without these specific techniques.