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Файл:Ординатура / Офтальмология / Учебные материалы / Vitreoretinal Surgery Second Edition Springer.pdf
X
- •Preface
- •Contents
- •1.1.1 The Vitreous
- •1.1.1.1 Embryology
- •1.1.1.2 The Anatomy
- •1.1.1.3 Anatomical Attachments of the Vitreous to the Surrounding Structures
- •1.1.2 The Retina
- •1.1.2.1 Embryology
- •1.1.2.2 Anatomy
- •Retinal Pigment Epithelium (RPE)
- •Photoreceptor Layer
- •Intermediary Neurones
- •Ganglion Cells
- •Retinal Blood Vessels
- •Other Fundal Structures
- •1.1.3 The Physiology of the Vitreous
- •1.2 Clinical Examination and Investigation
- •1.2.1 Using the Database
- •1.2.2 Examination of the Eye
- •1.2.2.1 Examination Technique
- •Visual Acuity
- •1.2.2.2 The Slit Lamp
- •1.2.2.3 Binocular Indirect Ophthalmoscope
- •1.2.2.4 Using the Indenter
- •1.2.2.5 Ultrasonography
- •Posterior Vitreous Detachment (PVD)
- •Retinal Tear
- •Retinal Detachment
- •Subretinal Haemorrhage
- •Retinoschisis
- •Choroidal Elevation
- •Trauma
- •1.2.2.6 Optical Coherence Tomography
- •Time-Domain OCT
- •Colour Coding
- •Frequency-Domain OCT
- •Full-Field OCT
- •Scan Resolution
- •Images and Measurements
- •Performing the Scan
- •Macular Scan Patterns
- •Central Retinal Thickness
- •Inner Segment and Outer Segment Junction and External Limiting Membrane
- •1.2.3 Subjective Tests
- •1.2.4 The Preoperative Assessment
- •1.3 Summary
- •References
- •2: Introduction to Vitreoretinal Surgery
- •2.1 Introduction
- •2.2 Choice of Anaesthesia
- •2.3 Pars Plana Vitrectomy
- •2.3.1 Sclerotomies
- •2.3.2 Where to Place the Sclerotomies
- •2.3.3 Securing the Infusion Cannula
- •2.3.4 Checking the Infusion
- •2.3.6 The Superior Sclerotomies
- •2.3.6.1 Where to Place
- •2.3.7 Checking the View
- •2.3.8 The Independent Viewing System
- •2.3.9 Removing the Vitreous
- •2.4 Vitrectomy Cutters
- •2.5 Handling the Light Pipe
- •2.6 Use of Sclerotomy Plugs
- •2.7 The Internal Search
- •2.8 Endolaser
- •2.9 Using a Contact Lens
- •2.10 Maintaining a View
- •2.10.1 Microscope
- •2.10.3 Cornea
- •2.10.4 Blood in the Anterior Chamber
- •2.10.5 Condensation on an Intraocular Lens Implant
- •2.10.6 Cataract Formation
- •2.10.7 Pupillary Dilation
- •2.11 Closing
- •2.12 Peroperative Complications
- •2.12.1 Iatrogenic Breaks
- •2.12.1.1 Causes
- •2.12.2 Choroidal Haemorrhage
- •2.12.3 Haemorrhage from Retinal or Other Blood Vessels
- •2.12.4 Lens Touch
- •2.12.5 Hypotony
- •2.13 Postoperative Complications
- •2.13.1 Cataract
- •2.13.2 Endophthalmitis
- •2.13.3 Corneal Changes
- •2.13.4 Choroidal Haemorrhage
- •2.13.5 Raised Intraocular Pressure
- •2.13.6 Retinal Breaks and RRD
- •2.13.7 Hypotony
- •2.13.8 Scleritis
- •2.13.9 Sympathetic Uveitis
- •2.14 Adjustments for 20 Gauge Vitrectomy
- •2.14.1 Construction of Superior Sclerotomies
- •2.14.2 Priming
- •2.14.3 Self-Sealing Sclerotomies
- •2.15 Adjustments for 23 and 25 Gauge Vitrectomy
- •2.15.1 Instrumentation
- •2.15.2 Surgical Technique
- •2.15.2.1 Vitrectomy Technique
- •2.15.3 Flexibility
- •2.15.4 Indentation
- •2.15.5 Flow Rates
- •2.15.6 Trochar Internal Protrusion
- •2.15.7 Silicone Oil
- •2.16 Complications
- •2.16.1 Peroperative
- •2.16.1.1 Extrusion of the Trochar on Removal of Instrumentation
- •2.16.1.2 Conjunctival Chemosis
- •2.16.1.3 Hypotony
- •2.16.1.4 Endophthalmitis
- •2.16.2 Postoperative Retinal Break Formation
- •2.17 Advantages and Disadvantages of 23 and 25 G Systems
- •2.18 Combined Cataract Extraction and PPV
- •2.18.1 How to Decide Whether to Perform Combined Surgery
- •2.18.1.1 Accommodation
- •2.19 Biometry
- •2.20 Chandelier Systems and Bimanual Surgery
- •2.20.1 Possible Complications
- •2.21 Dyes
- •2.22 Intravitreal Injections
- •2.22.1 Injection Medications
- •2.23 Slow Release Preparations
- •2.24 Summary
- •References
- •3: Principles of Internal Tamponade
- •3.1 Gases
- •3.1.1 Principles
- •3.1.1.1 Properties
- •3.1.1.2 A Safe Method for Drawing Up Gas
- •3.1.2 Complications
- •3.1.2.1 Vision
- •3.1.2.2 Refraction
- •3.1.2.3 Cataract
- •3.1.2.5 Loss of the Gas Bubble
- •3.1.2.6 Gas in the Wrong Place
- •3.1.3 Important Postoperative Information
- •3.1.3.1 Flying or Travel to High Altitude
- •3.1.3.2 General Anaesthesia
- •3.2 Silicone Oil
- •3.2.1 Properties
- •3.2.3 Complications of Silicone Oil
- •3.2.3.1 Refractive Changes
- •3.2.3.2 Cataract
- •3.2.3.5 Cornea
- •3.2.3.6 Macular Toxicity
- •3.2.3.7 Oil in the Wrong Place
- •3.2.3.8 Emulsion
- •3.2.3.9 IOLs
- •3.2.4 Silicone Oil Removal
- •3.2.4.1 Alternative Methods
- •3.2.4.2 Retinal Redetachment Rates After Oil Removal
- •3.2.5 Heavy Silicone Oils
- •3.2.6 Heavy Liquids
- •3.2.7 ‘Light’ Heavy Liquids
- •3.3 Summary
- •References
- •4: Posterior Vitreous Detachment
- •4.1 Introduction
- •4.1.1 Symptoms
- •4.1.1.1 Floaters
- •4.1.1.2 Flashes
- •Introduction
- •Clinical Characteristics
- •4.1.2 Signs
- •4.1.2.1 Detection of PVD
- •4.1.2.2 Shafer’s Sign
- •4.1.2.3 Vitreous Haemorrhage
- •4.1.2.4 Ophthalmoscopy
- •4.1.3 Retinal Tears
- •4.1.3.1 U Tears
- •4.1.3.2 Atrophic Round Holes
- •4.1.3.3 Other Breaks
- •4.1.3.4 Progression to Retinal Detachment
- •4.1.4 Peripheral Retinal Degenerations
- •4.2 Summary
- •References
- •5: Vitreous Haemorrhage
- •5.1 Introduction
- •5.2 Aetiology
- •5.3 Natural History
- •5.4 Erythroclastic Glaucoma
- •5.5 Investigation
- •5.6 Ultrasound
- •5.7 Management
- •5.8 Surgery
- •5.9 Vitrectomy
- •5.10 Summary
- •References
- •6: Rhegmatogenous Retinal Detachment
- •6.1 Introduction
- •6.1.1 Tears with Posterior Vitreous Detachment
- •6.1.2 Breaks Without Posterior Vitreous Detachment
- •6.1.3 Natural History
- •6.1.3.1 Chronic RRD
- •6.1.3.2 Risk to the Other Eye
- •6.2 Clinical Features
- •6.2.1 Anterior Segment Signs
- •6.2.2 Signs in the Vitreous
- •6.2.3 Subretinal Fluid Accumulation
- •6.2.4 Retinal Break Patterns in RRD
- •6.2.5 Macula Off or On
- •6.3 Surgery
- •6.3.1 Flat Retinal Breaks
- •6.3.1.1 Retinopexy
- •6.3.1.2 Cryotherapy
- •6.3.1.3 Cryotherapy in the Clinic Setting
- •6.3.1.4 Laser
- •6.3.1.5 Laser in the Clinic Setting
- •6.3.2 Retinal Detachment
- •6.3.2.1 Principles
- •6.3.2.2 Break Closure
- •6.3.2.3 Relief of Traction
- •6.3.2.4 Alteration of Fluid Currents
- •6.3.2.5 Retinopexy
- •6.3.3 Pars Plana Vitrectomy
- •6.3.3.1 Introduction
- •6.3.3.2 Finding the Breaks
- •6.3.3.4 Draining Subretinal Fluid
- •6.3.3.5 When to Use Heavy Liquids
- •6.3.3.6 Removal of Heavy Liquid
- •6.3.3.7 Choice of Tamponade
- •6.3.3.8 Avoiding Retinal Folds
- •6.3.3.9 Inferior Breaks
- •6.3.3.10 Posterior Breaks
- •6.3.3.11 Multiple Breaks
- •6.3.3.12 Medial Opacities
- •6.3.3.13 Complications
- •6.3.3.14 Surgery for Eyes with No Breaks Found
- •6.3.3.15 Use of 360° Laser or Routine 360° Encirclage
- •6.3.3.16 Posturing
- •6.3.4.1 Operative Stages
- •6.3.4.2 Postoperative Care
- •6.3.4.3 Complications
- •6.3.4.4 Peroperative
- •6.3.4.5 Postoperative
- •6.3.5 Drainage Air Cryotherapy and Explant (DACE)
- •6.3.5.1 Subretinal Fluid (SRF) Drainage
- •6.3.5.2 Air Insertion
- •6.3.5.3 Complications
- •6.3.6 Pneumatic Retinopexy
- •6.3.6.1 Surgical Steps
- •6.3.6.2 Complications
- •6.4 Success Rates
- •6.5 Causes of Failure
- •6.6 Surgery for Redetachment
- •6.7 Secondary Macular Holes
- •6.8 Detachment with Choroidal Effusions
- •6.9 Removal of Explant
- •6.9.1 Diplopia
- •6.9.2 Erosion Through Conjunctiva
- •6.9.3 Infection
- •6.9.4 Cosmesis
- •6.9.5 Irritation
- •6.9.6 Surgery for Removal of the Explant
- •6.10 Summary
- •References
- •7.2 Atrophic Hole RRD with Attached Vitreous
- •7.3 Pseudophakic RRD
- •7.4 Aphakic RRD
- •7.5 Retinal Dialysis
- •7.5.1 Clinical Features
- •7.5.2 Surgery for Retinal Dialysis
- •7.5.2.1 Search
- •7.5.2.2 Cryotherapy
- •7.5.2.3 Marking the Break
- •7.5.2.4 Plombage
- •7.5.2.5 Checking the Indent
- •7.5.3 Complications
- •7.5.4 Giant Retinal Dialysis
- •7.5.5 Dialysis and PVR
- •7.5.6 Par Ciliaris Tear
- •7.6 Giant Retinal Tear
- •7.6.1 Clinical Features
- •7.6.2 Stickler’s Syndrome
- •7.6.3 Surgery for Giant Retinal Tear
- •7.6.3.1 Heavy Liquids
- •7.6.3.2 Retinopexy
- •7.6.3.3 Trans-scleral Illumination Technique
- •7.6.3.4 Silicone Oil Insertion
- •7.6.3.5 Choice of Endotamponade
- •7.6.3.6 Success Rates
- •7.6.3.7 Removal of the Silicone Oil
- •7.6.3.8 The Other Eye
- •7.7 Retinal Detachment in High Myopes
- •7.7.1 Clinical Features
- •7.7.2 Surgery
- •7.8.1 Clinical Features
- •7.8.1.1 Infantile Retinoschisis
- •7.8.1.2 Senile Retinoschisis
- •7.8.1.4 Retinal Detachment in Retinoschisis
- •7.8.2 Surgery
- •7.9 Juvenile Retinal Detachment
- •7.10 Atopic Dermatitis
- •7.11 Refractive Surgery
- •7.12 Congenital Cataract
- •7.13 Others
- •7.14 Summary
- •References
- •8: Proliferative Vitreoretinopathy
- •8.1 Introduction
- •8.2 Pathogenesis
- •8.3 Clinical Features
- •8.3.1 Introduction
- •8.3.2 Grading
- •8.3.3 Risk of PVR
- •8.4 Surgery
- •8.4.1 Mild PVR
- •8.4.2 Moderate PVR
- •8.4.3 Severe PVR
- •8.4.3.1 The Relieving Retinectomy
- •8.4.4 Radial Retinotomy
- •8.4.5 Silicone Oil Injection
- •8.4.6 Applying Laser
- •8.4.7 ROSO Plus
- •8.4.8 Very Severe PVR
- •8.4.9 Choice of Endotamponade
- •8.4.9.1 Silicone Oil or Perfluoropropane Gas
- •8.4.9.2 Heavy Oils
- •8.4.10 Removal of Subretinal Bands
- •8.4.11 Adjunctive Therapies
- •8.4.12 Success Rates
- •8.4.13 Postoperative Complications
- •8.5 Summary
- •References
- •9: Macular Hole
- •9.1 Introduction
- •9.2 Idiopathic Macular Hole
- •9.2.1 Clinical Features
- •9.2.1.1 Introduction
- •9.2.1.2 Watzke–Allen Test
- •9.2.1.3 Grading
- •9.2.1.4 Natural History
- •9.2.1.5 Optical Coherence Tomography
- •9.2.2 Secondary Macular Holes
- •9.2.3 Lamellar and Partial Thickness Holes
- •9.2.4 Surgery
- •9.2.4.1 Introduction
- •9.2.4.2 Surgery
- •9.2.4.3 Peeling the Posterior Hyaloid Membrane
- •9.2.4.4 ILM Peel and Other Adjunctive Therapies
- •9.2.4.5 Choice of Tamponade
- •9.2.4.6 Postoperative Posturing of the Patient
- •9.2.4.9 Visual Field Loss
- •9.2.5 Success Rates
- •9.2.6 Reoperation
- •9.3 Microplasmin
- •9.4 Summary
- •References
- •10.1 Clinical Features
- •10.1.1 Other Conditions
- •10.1.2 Secondary Macular Pucker
- •10.2 Surgery
- •10.3 Success Rates
- •10.5 Membrane Recurrence
- •10.6 Summary
- •References
- •11: Choroidal Neovascular Membrane
- •11.1 Age-Related Macular Degeneration
- •11.1.1 Clinical Features
- •11.1.2 Vitreous Haemorrhage and CNV
- •11.1.3 Pneumatic Displacement of Subretinal Haemorrhage
- •11.1.4 Surgery for Failed Anti-VEGF Therapy
- •11.1.4.1 Introduction
- •11.1.4.2 360° Macular Translocation
- •11.1.6 Success Rates
- •11.2 Choroidal Neovascular Membrane Not from ARMD
- •11.2.1 Introduction
- •11.2.2 Surgery
- •11.3 Summary
- •References
- •12: Diabetic Retinopathy
- •12.1 Introduction
- •12.2 Diabetic Retinopathy
- •12.2.1 Introduction
- •12.2.1.1 Diabetic Retinopathy Grading
- •12.2.2 Diabetic Vitreous Haemorrhage
- •12.2.3 Progression to Vitreous Haemorrhage and Tractional Retinal Detachment
- •12.2.3.1 Clinical Features
- •12.2.3.2 Surgery
- •12.2.4 Diabetic Retinal Detachment
- •12.2.4.1 Clinical Features
- •12.2.4.2 Surgery
- •12.2.4.3 Tractional Retinal Detachment
- •12.2.4.4 Peroperative Panretinal Photocoagulation
- •12.2.4.6 Bimanual Surgery
- •12.2.4.7 Dealing with Bleeding Vessels
- •12.2.4.8 Iatrogenic Breaks
- •12.2.4.9 Silicone Oil
- •12.2.4.10 Combined TRD and RRD
- •12.2.5 Postoperative Complications
- •12.2.5.1 Vitreous Haemorrhage
- •12.2.5.2 Rhegmatogenous Retinal Detachment
- •12.2.5.3 Iris Neovascularisation
- •12.2.5.4 Phthisis Bulbi
- •12.2.5.5 Maculopathy
- •12.2.5.6 Survival After Surgery
- •12.2.6 Success Rates
- •12.2.7 Diabetic Maculopathy
- •References
- •13: Other Vascular Disorders
- •13.1 Introduction
- •13.2 Retinal Vein Occlusion
- •13.2.1 Chorioretinal Anastomosis
- •13.2.2 Arteriovenous Decompression
- •13.2.3 Radial Optic Neurotomy
- •13.2.4 Intravitreal Steroid and Anti-VEGF Agents
- •13.2.5 Tissue Plasminogen Activator
- •13.3 Sickle-Cell Disease
- •13.3.1 Introduction
- •13.3.2 Types of Sickle-Cell Disease
- •13.3.3 Systemic Investigation
- •13.3.4 Inheritance and Race
- •13.3.5 Systemic Manifestations
- •13.3.6 Ophthalmic Presentation
- •13.3.7 Laser Therapy
- •13.3.8 Surgery
- •13.3.9 Visual Outcome
- •13.3.10 Screening
- •13.3.11 Survival
- •13.4 Retinal Vasculitis
- •13.5 Central Retinal Artery Occlusion
- •13.6 Summary
- •References
- •14: Trauma
- •14.1 Introduction
- •14.3 Contusion Injuries
- •14.3.1 Clinical Presentation
- •14.3.2 Types of Retinal Break
- •14.3.2.1 Dialysis
- •14.3.2.2 Pars Ciliaris Tears
- •14.3.2.3 Ragged Tear in Commotio Retinae
- •14.3.2.4 Giant Retinal Tears
- •14.3.3 Surgery
- •14.3.4 Visual Outcome
- •14.4 Rupture
- •14.4.1 Clinical Presentation
- •14.4.2 Surgery
- •14.4.3 Visual Outcome
- •14.5 Penetrating Injury
- •14.5.1 Clinical Presentation
- •14.5.1.1 Endophthalmitis
- •14.5.1.2 Retinal Detachment
- •14.5.2 Surgery
- •14.5.3 Visual Outcome
- •14.6 Trauma Scores
- •14.7 Intraocular Foreign Bodies
- •14.7.1 Clinical Presentation
- •14.7.1.1 Diagnostic Imaging
- •14.7.2 IOFB Materials
- •14.7.3 Surgery
- •14.7.4 The Primary Procedure
- •14.7.5 PPV: The Anterior Segment
- •14.7.5.1 The Lens
- •14.7.6 PPV: The Posterior Segment
- •14.7.7 The Magnet
- •14.7.8 Visual Outcome
- •14.7.9 Siderosis
- •14.8 Perforating Injury
- •14.9 Sympathetic Ophthalmia
- •14.10 Proliferative Vitreoretinopathy
- •14.11 Phthisis Bulbi
- •14.12 When Not to Operate
- •14.12.1 At Presentation
- •14.12.2 Postoperatively
- •14.13 Summary
- •References
- •15.1 Introduction
- •15.2 Dropped Nucleus
- •15.2.1 Clinical Features
- •15.2.2 Surgery
- •15.2.2.1 Primary Management
- •15.2.2.2 Vitrectomy Surgery
- •15.2.2.4 Success Rates
- •15.3 Intraocular Lens Dislocations
- •15.3.1 Clinical Presentation
- •15.3.2 Surgery
- •15.3.2.1 Removal of the IOL
- •15.4 Surgical Options for the Aphakic Eye
- •15.4.1 McCannell Sutured IOL
- •15.4.2 Iris-Clip IOL
- •15.4.3 Haptic Capture Method
- •15.4.4 Anterior Chamber IOL
- •15.4.5 Sutured Posterior Chamber IOLs
- •15.4.6 The Aphakic and Aniridic Eye
- •15.5 Postoperative Endophthalmitis
- •15.5.1 Clinical Features
- •15.5.2 Surgery
- •15.5.2.1 Vitreous Tap
- •15.5.2.2 Vitreous Biopsy
- •15.5.3 Infective Organisms
- •15.5.4 Antibiotics
- •15.5.5 The Role of Vitrectomy
- •15.5.6 Success Rates
- •15.6 Chronic Postoperative Endophthalmitis
- •15.7 Needlestick Injury
- •15.7.1 Clinical Features
- •15.7.2 Surgery
- •15.8 Intraocular Haemorrhage
- •15.9 Retinal Detachment
- •15.10 Chronic Uveitis
- •15.11 Postoperative Cystoid Macular Oedema
- •15.12 Postoperative Vitreomacular Traction
- •15.13 Postoperative Choroidal Effusion
- •15.13.1 External Drainage
- •15.14 Summary
- •References
- •16: Uveitis and Allied Disorders
- •16.1 Introduction
- •16.2 Non-infectious Uveitis of the Posterior Segment
- •16.2.2 Retinal Detachment
- •16.2.3 Cystoid Macular Oedema
- •16.2.4 Hypotony
- •16.2.5 The Vitreous Biopsy
- •16.2.6 Sampling at the Beginning of a PPV
- •16.2.6.1 Special Situations
- •16.3 Acute Retinal Necrosis
- •16.3.1 Clinical Features
- •16.3.2 Surgery
- •16.3.2.1 For Diagnosis
- •16.3.2.2 For Treatment
- •16.3.3 Visual Outcome
- •16.4 Cytomegalovirus Retinitis
- •16.4.1 Clinical Features
- •16.4.2 Surgery
- •16.4.2.1 For Diagnosis
- •16.4.2.2 For Treatment
- •16.4.3 Visual Outcome
- •16.5 Fungal Endophthalmitis
- •16.5.1 Clinical Features
- •16.5.2 Surgery
- •16.5.2.1 For Diagnosis
- •16.5.2.2 For Treatment
- •16.5.3 Visual Outcome
- •16.6 Other Infections
- •16.6.1 Clinical Features
- •16.6.2 Surgery
- •16.6.2.1 For Diagnosis
- •16.6.2.2 Chorioretinal Biopsy
- •16.6.2.3 For Treatment
- •16.6.3 Visual Outcome and Survival
- •16.7 Paraneoplastic Retinopathy
- •16.8 Summary
- •References
- •17: Miscellaneous Conditions
- •17.1 Vitrectomy for Vitreous Opacities
- •17.2 Vitreous Anomalies
- •17.2.1 Persistent Hyperplastic Primary Vitreous
- •17.2.2 Asteroid Hyalosis
- •17.2.3 Amyloidosis
- •17.3 Retinal Haemangioma and Telangiectasia
- •17.4 Optic Disc Anomalies
- •17.4.1 Optic Disc Pits and Optic Disc Coloboma
- •17.4.2 Morning Glory Syndrome
- •17.5 Retinochoroidal Coloboma
- •17.6 Marfan’s Syndrome
- •17.7 Retinopathy of Prematurity
- •17.8 Uveal Effusion Syndrome
- •17.8.1 Clinical Features
- •17.8.2 Surgery
- •17.9 Terson’s Syndrome
- •17.10 Disseminated Intravascular Coagulation
- •17.11 Retinal Prosthesis
- •17.12 Summary
- •References
- •Glossary of Abbreviations
- •Others in Database
- •Appendices
- •Useful Formulae and Rules
- •Cryotherapy
- •Fluids (i.e. Both Gases and Liquids)
- •Gases
- •Liquids
- •Ultrasound
- •Diffusion and Viscosity
- •Visual Acuity
- •Diffusion
- •Fick’s Law
- •Stokes-Einstein
- •Darcy’s Law
- •Starling’s Law
- •Index
7.6 Giant Retinal Tear |
171 |
|
|
Fig. 7.13 See previous figure
Fig. 7.15 A retinal tear near lattice in Stickler’s syndrome
Fig. 7.16 A retinal tear in Stickler’s syndrome
7.6.3 Surgery for Giant Retinal Tear
Fig. 7.14 Some vitreoretinal surgeons claim that there is a form of Stickler’s syndrome which does not have optically clear vitreous but has a membrane in the anterior vitreous as in this image
Vitrectomy has been used for many years for giant retinal tears (Vidaurri-Leal et al. 1984; Leaver et al. 1984; Peyman et al. 1984; Michels et al. 1983; Federman et al. 1982; Scott 1979), but recent innovations have considerably facilitated the manipulation of the retina.
172 |
7 Different Presentations of Rhegmatogenous Retinal Detachments |
|
|
Table 7.2 Difficulty rating of PPV for GRT
Difficulty rating |
Moderate |
Success rates |
High |
Complication rates |
Medium |
When to use in training |
Middle |
Additional surgical steps
1.Insert heavy liquids.
2.Apply laser retinopexy under heavy liquid tamponade.
3. Exchange silicone oil (air then gas if a small, 90–180°, superior GRT is present) for heavy liquid.
4. Apply further retinopexy as required.
7.6.3.1 Heavy Liquids
Insert heavy liquids (perfluorocarbon liquids) into the eye to unfold the flap of retina and to stabilise the retina (Kreiger and Lewis 1992; Glaser et al. 1991; Chang et al. 1989; Millsap et al. 1993; Mathis et al. 1992; Scott et al. 2002; Chang 1987). Advance the heavy liquid up to the posterior edge of the tear: Advancing over the tear risks allowing a droplet of heavy liquid to enter under the retina; however, if there is no traction on the edge of the tear, this is unlikely. Use of heavy liquid minimises the risk of slippage of the retina (to 7 % in one study (Meffert and Peyman 1999)). Search 360° in case there are satellite U tears that need treatment as well. If the giant retinal tear is relatively posterior, you may be able to flatten the retina with the heavy liquids and apply laser therapy under heavy liquids. This will provide slightly improved optical properties over trying to do this under the silicone oil. However, occasionally, the giant retinal tear is very anterior, and to fill the eye fully with heavy liquids runs the risk of leaving bubbles of heavy liquid at the vitreous base. These will be seen by the patient postoperatively when lying supine (the bubbles sink onto the fovea) and may enter the anterior chamber and be seen as droplets lying in the inferior angle.
Fig. 7.17 Heavy liquids placed onto the retina can be rolled (arrow) with the eye to unfold a GRT
7.6 Giant Retinal Tear |
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Fig. 7.18 The GRT can be flattened by the heavy liquid |
Fig. 7.19 In a phakic patient, cryotherapy with indentation can be |
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used to seal the ends of the tear |
7.6.3.2 Retinopexy
Apply endolaser to the posterior edge of the giant retinal tear and around the ends and anteriorly if the tear is posterior. If the tear is very anteriorly placed, apply laser to the edge, around the ends and up to the ora serrata, without applying laser to the anterior flap. Check that you have reached the ora serrata by indenting the retina after the laser.
The ends of the giant retinal tear and the anterior edge may be more difficult to treat because most of these patients are phakic.
There are three options that can be employed.
•One is to apply cryotherapy to the ends in the same manner as a retinectomy (one or two burns at each end should be enough). The cryotherapy probe has the advantage of allowing simultaneous indentation to push the peripheral retina into view. Its use as always should be kept to a minimum to avoid excessive dispersion of retinal pigment epithelial cells into the vitreous cavity thereby risking PVR (Glaser et al. 1993).
•Use a curved laser probe and ask an assistant to indent the peripheral retina. This runs the risk of the assistant moving the indent during your retinopexy resulting in a retinal
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Fig. 7.20 Laser is applied to the posterior edge of the GRT |
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• Alternatively perform trans-scleral illumination. |
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