Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6023_Библиотеки_им_академика_М_И_Перельмана.pdf
ab
11.4 Surgical Strategies forImproving Long-Term Outcomes inSevere PVR
245
11.4.3 Radial Retinotomy
Pioneered by Professor Xiaofeng Lin (China) in 2016, this technique addresses the
clinical dilemma of whether to excise or preserve severely contracted retinal tissue.
It provides an optimized “utilization” strategy, particularly for cases involving
advanced inferior PVR where retinal shortening is most pronounced.
This approach adopts a “using the problem to solve the problem” philosophy: by
leveraging the residual elasticity of the diseased retina, the creation of multiple
relaxing radial incisions effectively reduces overall retinal tension and enhances
pliability. This restoration of signicant retinal mobility enables complete anatomical reattachment during uid-air exchange or peruorocarbon liquid (PFCL) injection. Furthermore, the preserved retinal tissue between these incisions provides an
ideal substrate for endophotocoagulation, maximizing the potential for anatomical
success. Clinically, this technique avoids the extensive RPE exposure associated
with large-scale retinectomy—a known driver of recurrent PVR—and reduces the
risk of postoperative ocular hypotony (Fig.11.13).
11.4.4 Scleral Encircling andBuckling
The primary objective of scleral buckling in PVR management is to alleviate vitreous base traction. This approach is particularly effective for cases involving inferior
retinal breaks. However, from a pathophysiological standpoint, the success of buckling is predicated on the complete neutralization of retinal traction; as a standalone
procedure, it often fails to achieve stable anatomical reattachment in the presence of
advanced proliferative forces.
Fig. 11.13 Schematic diagram of radial retinotomy. (a) Multiple radial incisions made in the stiff,
shortened inferior retina. (b) Retinal reattachment achieved via heavy liquid injection or air-uid
exchange. Laser photocoagulation applied around the incisions to x the inferior retina. The area
of exposed RPE is signicantly reduced, maximizing retinal integrity
246
11 Prevention andManagement ofProliferative Vitreoretinopathy
11.5 Summary
“Persistence and precision are the twin pillars of surgical mastery.” For novice surgeons, the perioperative management of proliferative vitreoretinopathy (PVR) represents far more than a technical hurdle; it is a dening rite of passage that tests the
very core of one’s surgical foundation. The central mission of PVR surgery is the
comprehensive neutralization of retinal traction—a task that demands not only
steady hands but also a sophisticated level of clinical judgment. Intraoperative
decision-making is a multi-dimensional process that primarily involves the following critical aspects: (1)Anatomic mapping.Accurately identifying the precise location, morphology, and extent of both epiretinal and subretinal proliferation;
(2)Tissue preservation.Maximizing the protection of viable ocular structures while
minimizing iatrogenic trauma during highly invasive maneuvers; (3)Strategic intervention.Selecting the optimal surgical maneuvers—ranging from meticulous membrane peeling to relaxing retinotomies—required to effectively release tractional
forces; (4) Tamponade dynamics.Determining the appropriate timing and selection
of intraocular tamponades (gas vs. silicone oil) to provide sustained anatomical
support.
PVR is an enduring adversary that remains an inescapable reality throughout a
vitreoretinal surgeon’s career. Rather than viewing it with trepidation, beginners
should approach PVR with a sense of composure and resilience. By confronting its
complexities with rigorous scientic methodology and rened technical prociency,
surgeons can systematically overcome these challenges. The mastery of PVR management is not merely about achieving reattachment; it is about the relentless pursuit of excellence in the face of our most formidable surgical opponent.
Vitreoretinal Surgery inChildren
andAdolescents
Vitreoretinal surgery in the pediatric and adolescent population represents a formidable frontier, constituting a critical subspecialty within the eld. Its complexity
stems not only from the intricate and technically demanding nature of intraoperative
maneuvers but also from the diagnostic ambiguity and the prognostic uncertainty of
functional recovery. Effective management mandates a multidisciplinary approach,
requiring seamless collaboration across various medical specialties. In clinical practice, the surgical and perioperative challenges escalate in inverse proportion to the
patient’s age.
The rapid advancement of medical technology in China has inspired an increasing number of vitreoretinal surgeons to specialize in this demanding eld, driving
its continuous development and renement. When treating younger populations,
surgeons must proactively adapt both their clinical mindset and technical approach.
In this surgical context, the term ‘younger patients’ extends beyond chronological
age—including children and adolescents—to encompass any patient whose vitreous body remains in a ‘youthful’ state, characterized by minimal liquefaction and
signicant structural clarity.
12
12.1 General Characteristics andUnique Challenges
In the pediatric and adolescent population, vitreoretinal conditions necessitating
surgical intervention are primarily categorized into three groups: (1) vasoproliferative disorders (Fig.12.1), including retinopathy of prematurity (ROP), familial exudative vitreoretinopathy (FEVR), and Coats disease; (2) parasitic infections, such as
ocular toxocariasis (Fig. 12.2); and (3) traumatic injuries, specically traumatic
retinal detachment.
Although the diagnosis of these conditions is often straightforward, their symptoms are insidious and frequently bilateral. Once the optimal treatment window is
missed, surgery becomes not only more difcult but also associated with a poorer
prognosis. Due to age and cognition, patients often cannot or will not express their
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_12
247
248
ab
cd
Fig. 12.1 Typical pediatric retinal detachment (a) Fundus photograph of stage 4A retinopathy of
prematurity (ROP) with plus disease (characterized by tortuous posterior pole vessels) in the right
eye. (b) Fundus photograph of stage 4B ROP with plus disease in the left eye. (c) Extensive retinal
detachment secondary to familial exudative vitreoretinopathy (FEVR) in the right eye. (d)
Fluorescein angiography of the fellow eye (left eye) of the patient in C shows peripheral avascular
retina and dye leakage
12 Vitreoretinal Surgery inChildren andAdolescents
concerns directly, but this invisible pressure is often expressed in the seemingly
tough and hopeful eyes of parents. From the beginner’s point of view, there is often
nothing that can be done due to the limitations of surgical experience and the objective conditions, which is a frequent dilemma for both doctors and patients.
While parasitic vitreoretinal diseases may show signs in the anterior segment,
symptoms are often subtle. Closely linked to hygiene and lifestyle—such as lack of
deworming in pets and poor hand hygiene—they are more common in remote rural
areas. Patients often present late with signicant vision loss, and recovery of useful
vision is generally limited. However, surgery can sometimes restore relatively normal intraocular structure.
Trauma-induced vitreoretinal lesions vary widely in form and severity. When
multiple ocular structures are involved, multidisciplinary teamwork and multiple
surgeries may be needed to partially restore vision. For beginners, advanced surgical management is challenging without adequate team support and trauma experience. However, the following less complex trauma-related conditions are more
manageable: ① dialysis of the ora serrata; ② lens dislocation into the vitreous cavity;
12.1 General Characteristics andUnique Challenges
Fig. 12.2 Tractional
retinal detachment in the
right eye secondary to
ocular toxocariasis, with a
white inammatory mass
noted inferiorly. At
presentation, the best-
corrected visual acuity was
0.06. Laboratory testing
revealed a markedly
elevated aqueous humor
toxocara IgG titer of
39.76U/L (normal <3U/L)
and a serum toxocara IgG
titer of 32.34U/L (normal
<9U/L). The patient had a
pet dog at home that had
not received regular
deworming treatment
249
③ rhegmatogenous retinal detachment without signicant proliferative changes; and
④ laser-induced traumatic macular hole. These conditions follow more predictable
surgical approaches, and standard vitreoretinal procedures often lead to favorable
outcomes.
Vitrectomy in children and adolescents presents several key characteristics:
1. Diagnosis often relies on imaging, genetics, molecular biology, or pathology,
especially to rule out retinoblastoma, unless clear causes or signs are present.
2. Preoperative and postoperative vision can vary signicantly and may not corre-
late closely with anatomical abnormalities, with assessment sometimes being
difcult.
3. The eye is not simply a smaller version of an adult eye—its structure and propor-
tions are still developing, requiring different surgical approaches.
4. Vitreous liquefaction or posterior detachment is often absent, making ade-
quatevitreous removal challenging.
5. Special tools like viscoelastic, intraocular scissors, or chandelier—not com-
monly used in adult surgery—may be needed to achieve oursurgical goals; and
choices for intraocular tamponade are more limited—for example, silicone oil is
usually avoided in ROP cases without iatrogenic breaks, while viscoelastic may
be used to separate membranes (though its use remains off-label). Additionally,
if retinal breaks exist at the inferior, tamponade with gas or silicone oil tends to
be less effective due to poor posturing compliance and may even worsen
proliferation.
250
12 Vitreoretinal Surgery inChildren andAdolescents
12.2 Surgical Management ofROP
ROPwas rst clinically described in 1942. Between 1941 and 1953, an estimated
12,000 newborns worldwide were affected, many of whom suffered devastating
vision loss. Despite the rising incidence, the underlying etiology remained elusive
for nearly a decade. In 1951, the Australian pediatrician Kate Campbell (1899–1986)
made a landmark observation. Comparing two Melbourne hospitals, she noted that
the well-funded facility—which provided ample supplemental oxygen to premature
infants—had a higher incidence of ROP than the resource-limited hospital. Campbell
concluded that excessive oxygen concentration was a primary driver of the disease,
a causal link subsequently validated by rigorous clinical trials.As the complex
pathogenesis of ROP is extensively documented in existing literature, it is not
detailed here. Modern clinical management primarily involves three therapeutic pillars: (1)Pharmacological tntervention: Intravitreal anti-VEGF injections. (2)Laser
therapy: Indirect retinal laser photocoagulation performed under indirect ophthalmoscopy. (3) Surgical intervention: Advanced vitreoretinal surgery reserved for
stage 4 and stage 5 cases.
12.2.1 Overview oftheThird Edition ofROP Classification
(i) The Reason for the Upgraded Version
In 1984, the International Classication of Retinopathy of Prematurity (ICROP)
Committee was established, which led to the rst multicenter clinical study on
ROP.The results demonstrated that cryotherapy could effectively treat the condition, conrming that ROP is both preventable and manageable, with timely screening being a key measure for prevention and treatment. In 2021, the third edition of
the ICROP guidelines was published in Ophthalmology. The update was driven by
four main factors: ① certain aspects of the previous version were considered subjective; ② continuous advances in ophthalmic imaging technology; ③ the promise and
challenges introduced by anti-VEGF therapy; and ④ the earlier version did not fully
encompass the diverse disease presentations observed across different regions.
(ii) ROP Partition
The retina is divided into three concentric zones extending from the optic disc to the
ora serrata. The posteriormost extent of retinal vasculature or ROP lesions denes
the zone of involvement, and the extent of disease is recorded in clock hours
(Fig.12.3).
1. Zone I: This is the most posterior zone, dened as a circular area centered on the
optic disc with a radius equivalent to twice the distance from the disc center to
the center of the fovea.
2. Zone II: This is a concentric ring extending from the outer edge of Zone I to a
circular boundary whose radius is the distance from the optic disc center to the
nasal ora serrata. The peripheral portion of Zone II adjacent to Zone I—a band
12.2 Surgical Management ofROP
Fig. 12.3 The ICROP classication
251
approximately 2 disc diameters wide—is designated as posterior Zone II.ROP
in posterior Zone II is noted to potentially be more severe and requires closer
attention than disease in the more peripheral parts of Zone II.
3. Zone III: This is the remaining crescent-shaped, anterior retinal area outside
Zones I and II.
(iii) ROP Staging
1. Stage 1 (Demarcation line): A clear line separates the vascularized from the
avascular retina.
2. Stage 2 (Ridge): The demarcation line elevates, widens, and thickens to form
a ridge.
3. Stage 3 (Ridge with extraretinal brovascular proliferation): The ridge is accom-
panied by growth of brovascular tissue beyond the retinal surface (Fig.12.4).
4. Stage 4 (Partial retinal detachment): 4A is macula-on, and 4B is macula-off.
5. Stage 5 (Total retinal detachment): 5A is open funnel detachment, 5B is closed
funnel detachment with non-visible optic disc, and 5C is stage 5B with simultaneous abnormalities of the anterior segment of the eye.
(iv) Long-Term Sequelae
Infants with a history of prematurity may develop long-term complications even
without manifestations of ROP.This requires us to inquire about the medical history
252
ab
cd
Fig. 12.4 Fundus photographs of Stage 3 ROP (a) wedge-shaped avascular area is visible in the
peripheral retina of the right eye, with a ridge showing mild extraretinal brovascular proliferation,
accompanied by plus disease. (b) The left eye of the same infant also exhibits Stage 3 ROP with
Plus disease. (c, d) Fundus uorescein angiography (FFA) images of both eyes in the same patient
12 Vitreoretinal Surgery inChildren andAdolescents
when performing fundus examinations on adolescents, as these sequelae may only
manifest in adulthood. The main sequelae include the following aspects:
1. Delayed tractional, rhegmatogenous, or less commonly, exudative retinal
detachment.
2. Retinoschisis caused by chronic traction from regressed Stage 3 lesions, which
may involve the macula and impair visual eld and visual acuity without causing
retinal detachment.
3. Residual avascular retinal areas, which are prone to retinal thinning, holes, and
lattice degeneration, and may be associated with subsequent retinal detachment.
4. Macular abnormalities, including reduction in the size of the foveal avascular
zone and blunting or disappearance of the foveal depression.
5. Retinal vascular changes.
6. Patients with a history of ROP may develop secondary angle-closure glaucoma
in the later stage.
12.2 Surgical Management ofROP
253
12.2.2 Anti-VEGF Intraocular Injection
(i) Comparison with Retinal Laser Photocoagulation
Intravitreal injection of anti-VEGF provides a relatively simple and feasible option
for the timely treatment of ROP.Current research focuses on comparing the advantages and disadvantages between anti-VEGF and retinal laser photocoagulation,
with no consensus reached in many aspects. However, in terms of operation by
physicians and medical institutions, anti-VEGF has higher universality. Nevertheless,
we should pay more attention to its limitations. The following table compares the
advantages and disadvantages of anti-VEGF and laser in several major aspects
(Table12.1).
Table 12.1 Comparison of the advantages and disadvantages of anti-VEGF and laser therapy for ROP
Anti-VEGF Laser
Treatment
success rate
Surgical
difculty
Intraoperative
complications
Recurrence
and follow-up
Favorable
outcome
Vision Intact visual eld Reduced visual eld and
Refractive
changes
Retinal
detachment
Systemic side
effects
Higher success rate
for zone I lesions
Lower requirements
for equipment and
operator prociency;
lower requirements
for anesthesia and
monitoring
Lower, decreasing to
a lower level with
increased operational
experience
Increased recurrence
and prolonged
follow-up
High Reduced due to difcult
Lower chance of
developing high
myopia
Short term: low risk
Long term: unknown
There is no clear
report; it is only a
theoretical
speculation
The success rate of zone II
lesions is on par with
anti-VEGF
Higher requirements for
equipment and operator
prociency; longer learning
curve; higher requirements
for anesthesia and
monitoring
Higher, but decreasing to a
lower level with increased
operational experience
Low recurrence and short
follow-up
laser photocoagulation
myopia
Higher chance of
developing high myopia
Short term: low risk
Long term: unknown
No systemic effect Both are equivalent
Preferred option
Anti-VEGF
Anti-VEGF
Anti-VEGF
Laser
Anti-VEGF
Anti-VEGF
Anti-VEGF
Theoretically, and taking
into account the residual
avascular area of the
retina, the laser has a
stronger preventive effect
on retinal detachment
254
12 Vitreoretinal Surgery inChildren andAdolescents
(ii) Injection Technique
1. Dosage: The axial length of a newborn’s eye is approximately 16–17mm, while
that of a normal adult eye is about 23–24mm. In addition, the lens accounts for
a larger proportion of the newborn’s eye. A rough estimate shows that the vitreous cavity volume of a newborn is about 1/5 to 1/3 that of an adult. Theoretically,
if the adult dosage is used (e.g., 0.5mg of ranibizumab for treating AMD), the
intravitreal concentration of anti-VEGF in newborns may be 3–5 times higher
than that in adults.
Although there is no clear medical evidence that adult dosage leads to higher
postoperative complications, considering that higher anti-VEGF may hinder the
normal development of retinal blood vessels and may affect the vasculardevelopment inother organs, the actual applied dosage should be slightly lower than
that for adults.
Many studies have also explored the differences between different doses in
terms of therapeutic effectiveness and re-injection rates, and the more consistent
conclusion is that retinal neovascularization can be signicantly inhibited at
lower doses, but the number of re-injections also increases accordingly. In practice, more attention should be paid to the precise control of the dose than in adult
surgery. The recommended dose is 0.02mL of ranibizumab.
2. Preinjection preparation: If under topical anesthesia, 1–2 trained nurses should
be available to assist in xing the child’s trunk and head (which is crucial for
surgical safety). The skin around the surgical eye should be disinfected in the
iodine to be instilled into the conjunctival sac (left for at least 1min). After placing a pediatric eyelid speculum, rinse the povidone-iodine thoroughly with
salinesolution.
3. Eyeball xation: The surgeon holds serrated forceps in one hand to grasp the
conjunctiva at the limbus. Thehand should have astable support to avoid tremor.
4. Injection site: Use a caliper to select the injection site 1–1.5mm posterior to
the limbus.
5. Injection: This is the most difcult step. Beginners are advised to complete the
drug injection with the assistance of a nurse. After the operator xes the position
of the syringe, ask the nurse to gently inject the drug. Due to the large proportion
of the lens in the infant’s eye, following the method in adult surgeryis likely to
damage the lens (this phenomenon is not uncommon). Unlike adults, if the child
has been lying at and xed, the injection direction should be nearlyperpendicular to the ground, and attention should also be paid to the depth of needle that
into the vitreous cavity (Fig. 12.5). The usage of a microscopes is
recommended.
6. Eye patching and postoperative local medication are basically the same as those
for adults.
same way as in adults. Before the injection,we recommend that5% povidone-