Silvia Bopp,MD*, Klaus Lucke,MD Tagesklinik Universitätsallee, Bremen
The present review emphasizes indications and surgical techniques for retinotomies/retinectomies.
Retinotomies and Retinectomies are extreme surgical maneuvers for complex situations, in which vitrectomy and peeling techniques prove insufficient to achieve retinal reattachment. Major indications are severe postoperative and posttraumatic PVR, but also particular situations in advanced vasoproliferative diseases. Benefits and severe potential risks of retinoplastic procedures are not far apart. Furthermore, any cutting of retinal tissue is an absolutely irreversible surgical step. Based on extensive experience in vitreoretinal surgery over more than 15 years, guidelines for an adequate approach to these maneuvers are given.
Indications and Techniques: The rationales to cut the retina (retinotomy) and remove nonessential, functionless or peripheral 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 may be devastating, Most common complications are: intraoperative massive intraocular hemorrhages, retinal distorsion and shrinkage, large reopenings of retinal defects and postoperative redetachment along with voluminous subretinal silicone oil masses.
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 avoiding damage to the choroid (scissors / vitreous cutter),removal of tissue debris (drainage cannula), possibly removing peripheral functionless retinal tissue, complete reattachment of the retina (heavy liquids or air), confluent retinopexy of the retinotomy/retinectomy edges (endolaser), finally, application of a long-term intraocular tamponade.
With the technique described, the situation remains intraoperatively under control. 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 must have a sufficient extent. Both necessities must be considered, to spare the retina, but not to leave residual traction.
Based of these therapeutic concepts, a total of 441 procedures were carried out for PVR-detachment between January, 1998 and December, 2002 (5-year-period). 42% went without, but 58% received retinoplastic maneuvers. The majority of retinotomy procedures were performed during revision surgery (72%). However, 44% of eyes that underwent primary vitrectomy for PVR, also had retinal cuts. Final reattachment was achieved in 95% of cases.
From the surgical point of view, retinotomies/retinectomies are essential tools to achieve retinal attachment in advanced cases of PVR. Although the need for this surgical step indicates a severe underlying pathology, anatomic results are comparable to those without these special techniques.
Both, extensive peeling and retinotomies/retinectomies are of equal importance to counteract tractional forces and achieve anatomic success in complicated retinal detachments. Cutting the retina has potential devasting risks. Appropriate indications and careful techniques presumed, a high reattachment rate can be achieved and vision is not negatively affected.