Ординатура / Офтальмология / Английские материалы / Retinal and Vitreoretinal Diseases and Surgery_Boyd, Cortez, Sabates_2010

Controlling the local biological environment has already been translated into therapeutic application,114,115,116,117,118,119,120 but the potential of interfering with the biological equilibrium in a clinical setting is as yet not predictable. Therefore, the way to their clinical application may as yet be long. Targeting chronic ischemia has not systematically been addressed but ascorbic acid has been applied in physiological concentrations in vitro in order to re-constitute the environmental situation in the vitreous after retinal detachment.121 More recently, evidence has been reported that statins may have therapeutic potential in the prevention of posterior vitreal detachment and inhibit the progression of PVR.122,123 Further work will thus have to go on in search of the optimal adjunctive treatment, which may be a combination treatment for the management of PVR.63,124,125

With respect to adjunctive treatment, selection of the cases that would benefit from such treatment has remained an unsolved problem.125 The evolution of drug delivery systems may carry a currently not predictable beneficial potential in the next future for successful prevention of proliferation and reproliferation after surgery for PVR,58,5 but its clinical suitability namely in the combination with the different tamponades has as yet not been assessed.

Inconclusion,basingoncurrentknowledge, preventive strategies remain a keystone for success, beyond these in the first place surgical experience126 and strategies to minimize surgical trauma.69,20

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Summary and Perspective

The anatomical success after treatment of PVR has improved remarkably within the last decades, namely with introduction of vitrectomy and the use of silicone oil tamponade, which contrasts with a sometimes surprisingly poor functional outcome. This may be related to the induction of biological cicatrising and remodelling processes in consequence of separation of the neuroretina from the retinal pigment epithelium, which may proceed even after successful reattachment of the retina. Therefore a more profound pathophysiological understanding of the biological and biochemical processes involved and a preoperative recognition of cases at risk has to be reinforced in order to allow selection of eyes which take advantage from a primary prophylaxis of PVR at the time of or prior to retinal reattachment surgery. In cases where the development of PVR cannot be prevented successfully, a sustained drug delivery and the introduction of therapies influencing the biological cicatrising process carries promising potential and may realistically be expected within the next 5 to 10 years. Technical evolution has grown to such a high level that the keystone of technical success nowadays is surgical experience, but microrobotic systems to remove existing vitreoretinal adhesions and epiretinal membranes and apply drugs are under development,127,128 which may further improve the anatomical outcomes. After introduction of chromovitrectomy129 including the use of triamcinolone to improve the visualisation of residual

vitreous cortex and epiretinal membranes,130 the next step to improve the completeness of vitrectomy, which is a hallmark of surgical success, may be achieved by enzymatic vitreolysis, which is already on a good way and close to routine clinical application.131 A reconstitution of the properties of the vitreoretinal environment, namely a rebalancing of cytokines and growth factors after occurrence of retinal redetachment may be an option at the horizon of preventive strategies. A better understanding of the factors controlling PVR and visual outcome will remain important fields of clinical research in PVR.

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