Fig. 16.2 Postoperative fundus photograph of the left eye of case 1. Silicone oil is present in the vitreous cavity. Thin subretinal hemorrhage is present in the macula

subretinal hemorrhage in addition to the premacular hemorrhage in this case, and this is clearly shown in Fig. 16.2. Subsequently the subretinal blood resolved, the silicone oil was removed from the eye, and the final visual acuity was 20/200 (Fig. 16.3).a

16.2Case 2: Bilateral Proliferative Diabetic Retinopathy with Acute Vitreous Hemorrhage in One Eye and a Chronic Traction Retinal Detachment in the Other Eye

A 48-year-old man with type 1 diabetes for 35 years and hypertension for 15 years presented with chronic poor vision in left eye and new acute loss of vision in right eye. He reported being able to read and drive with the right eye before the sudden visual loss. The left eye visual acuity was light perception and by history had been this way for 6 months. This was the first time he had been examined by an ophthalmologist and there were no other details from the past, but there had been no previous laser treatment. The left eye had an intraocular pressure of 15 mmHg, was phakic, and had no iris neovascularization. Fundus photographs of the left disk and midperipheral fundus are shown (Figs. 16.4 and 16.5). Figure 16.4 shows a thick, florid neovascular plaque overlying the disk that has contracted and has raised the peripapillary retina into a funnel. The far peripheral retina was attached (not shown). Figure 16.6 portrays the anatomic situation. The right eye had a visual acuity of counting fingers with disk neovascularization much less severe than that present in the left eye and a new dispersed vitreous hemorrhage without traction retinal detachment.

Fig. 16.3 Postoperative fundus photograph of case 1, 4 months after the fundus photograph shown in Fig. 16.2. The subretinal hemorrhage in the macula has resolved leaving pigmentary mottling. The oil was uneventfully removed and the final visual acuity was 20/200

a Discussed by David J. Browning MD, PhD

Fig. 16.4 Appearance of the left eye of case 2 at presentation. A thick neovascular plaque overlies the disk and has pulled the peripapillary retina into a tight funnel

Fig. 16.5 A fundus photograph of more peripheral retina in case 2 at presentation. The far peripheral retina is attached. The midperipheral retina is detached, as shown, and no previous panretinal photocoagulation has been administered

Question: How would you manage this patient? If part of your response involves surgery of the left eye, please be detailed in the technical aspects of your approach.

16.2.1 Discussion

The four ophthalmologists who reviewed this case agreed that the management priority was

to rehabilitate the right eye known to have reading vision in the recent past. This would involve a pars plana vitrectomy with panretinal laser photocoagulation. In addition, efforts should be spent to educate the patient about the importance of regular ophthalmic monitoring and care in the future, a factor missing in his past history.

The controversy in this case revolves around what to do about the left eye. One reviewer commented, ‘‘The left eye has a very poor prognosis based on poor acuity, type 1 diabetes, and long duration of traction retinal detachment, as well as the absence of panretinal photocoagulation. It is comfortable and I would like to keep it that way, so I would not operate this eye.’’ There is ample support in the literature for this perspective. Macular traction retinal detachments present for more than 1 month have been shown to have poorer prognosis when repaired, and when the macula has been detached for greater than 6 months, older publications conclude that the

risks of surgery outweigh the possible benefits.13–16

Counterbalancing this reasoning, it is certain that the left eye cannot improve without intervention, and it may advance to neovascular glaucoma and phthisis if observed. Unfortunately, the natural history of such eyes is not well studied, and one does not know what the spontaneous rate of progression

Fig. 16.7 Fundus photograph of the left eye of case 3. Neovascularization is present on the temporal disk margin. The macula is edematous with many intraretinal hemorrhages, a few lipid exudates, and a patch of neovascularization inferotemporally

to no light perception, neovascular glaucoma, and phthisis bulbi is in such eyes, but the consensus opinion of the authors is that it is relatively common. Reliable operative outcome statistics in such a case are also in short supply, and would depend on the individual surgeon’s expertise. Rates of 8.7– 18.6% of similar eyes progressing to no light perception after vitreous surgery and 24–67% achieving ambulatory vision have been published.17–20 In

more recent case series, it appears that vitreoretinal surgeons are more willing to operate on chronic

traction macular detachments documented to be present for as long or longer than 1 year.13,21 In

view of the patient’s young age, the unstable status of the right eye (better eye), and the patient’s demonstrated failure to access the health care system previously, three of the four co-authors reviewing this case considered that the natural history of the left eye would probably be worse than the outcome with surgical intervention. Therefore, surgical intervention for the left eye was recommended by these co-authors after educating the patient thoroughly regarding the significant risks of surgery and possible progression to neovascular glaucoma and/or phthisis bulbi even if surgery is attempted. There were some differences in their technical approaches, however, as manifest from the following comments.

16.2.2 Opinion 1

1.Use 25 gauge instruments first and convert to 20 gauge if the membranes cannot be adequately cut with the 25 gauge instrument.

2.Use intravitreal triamcinolone to assist in visualizing the posterior hyaloid and facilitate its complete removal.

Fig. 16.10 Fundus photograph from case 4 showing 2 clock hours of a peripheral retinal detachment delimited by previously placed panretinal photocoagulation for proliferative diabetic retinopathy

3.Make no intentional retinotomies and if no intraoperative break occurs, use perfluoron to move the subretinal fluid peripherally and allow panretinal photocoagulation. If iatrogenic, unintended breaks occur intraoperatively, flatten the

retina with subretinal fluid drainage through one of them, apply panretinal laser photocoagulation, and use silicone oil as a tamponade.

16.2.3 Opinion 2

1.Do not inject intravitreal bevacizumab before vitrectomy.

2.Apply panretinal photocoagulation to the attached peripheral retina in the office a few weeks before the vitrectomy.

3.Use 20 gauge instrumentation and horizontal curved scissors for membrane delamination.

4.Create a drainage retinotomy, and flatten the retina before applying panretinal photocoagulation.

5.Finish with a gas/fluid exchange using 28% sulfur hexafluoride.

16.2.4 Opinion 3

1.Inject intravitreal bevacizumab 1.25 mg 1–4 days before surgery.