Relaxing Retinotomies and Retinectomies Surgical Results and Predictors of Visual Outcome Dennis P. Han, MD; Matthew T. Lewis, MD; Evelyn M. Kuhn, PhD; Gary W. Abrams, MD; William F. Mieler, MD; George A. Williams, MD; Thomas M. Aaberg, MD
\s=b\ Functional and anatomic success after relaxing retinotomy may be limited by recurrent retinal detachment or severe hypotony. Fifty-four consecutive eyes undergoing relaxing retinotomy for proliferative vitreoretinopathy (42 eyes) and trauma (12 eyes) were analyzed to determine whether perioperative factors, including size and location of the retinotomy, influenced visual or anatomic out\x=req-\ come. After 6 months' minimum follow-up, anatomic success (retina attached posterior to buckle and an intraocular pressure of 3 mm Hg or more) was achieved in 35 eyes (64%). Functional success (visual acuity of 5/200 or better) was achieved in 14 eyes (26%). Factors predicting functional success by stepwise logistic regression analysis included a preoperative visual acuity of hand motions or better and location of the retinotomy in the superior four clock hours of the fundus. Causes of anatomic failure included proliferative vitreoretinopathy (11 eyes) and severe hypotony or phthisis (8 eyes). Superior location of the retinotomy and visual acuity of hand motions or better favorably influenced visual outcome after relaxing retin-
otomy. (Arch Ophthalmol. 1990;108:694-697)
etinotomies are important adjuncts to vitreous surgery for pro¬ liferativi vitreoretinopathy (PVR) when periretinal traction is unrelieved by membrane dissection and scierai buckling.1"6 Retinal incarceration into a scierai wound after penetrating trauma may also require relaxing retinotomy to allow surgical reattachment of the retina and prevent poste-
"
Accepted for publication December 29,1989. From the Eye Institute, Department of Ophthalmology, Medical College of Wisconsin, Milwaukee.
Reprint requests to Department of Ophthalmology, Medical College of Wisconsin, 8700 W Wisconsin Ave, Milwaukee, WI 53226 (Dr Han).
rior retinal folds.7 Although anatomic reattachment rates after vitrectomy and relaxing retinotomy in unselected cases of PVR and trauma are good (40% to 80% ),4-6 reported rates of func¬ tional success (visual acuity of approx¬ imately 5/200 or better) are variable, ranging from 6.7% to 55% .2 6 Surgical results and visual outcome probably depend on factors relating to the pre¬ existing vitreoretinal disease, patient characteristics, operative factors, and the retinotomy itself. We determined whether such factors predicted visual outcome after vitrectomy and retinot¬ omy in 54 eyes with proliferative vit-
reoretinopathy
posterior segment trauma. Our surgical results and causes of failure relating to the retin¬ otomy are also presented. or
PATIENTS AND METHODS
We reviewed the clinical and operative
records of 54 consecutive eyes undergoing relaxing retinotomy or retinectomy at the Medical College of Wisconsin, Milwaukee, between January 1983 and June 1988. For¬ ty-two eyes had PVR grade C-2 or worse (as determined by the Retina Society Classifi¬ cation of PVR),8 and 12 eyes had posterior segment trauma and retinal detachment. Ten of the 42 eyes with PVR had a history of giant retinal tear. To assure that retinotomies were truly relaxing in nature, we excluded eyes in which retinotomies were made solely for the purpose of endodrainage or subretinal membrane removal. In no eyes had previous retinotomies or retinectomies been performed. All eyes underwent
Table 1.—Indications for
three-port pars plana vitrectomy with ar aspiration/cutting instrument and sepa¬ rate endoilluminator, followed by attempts at complete removal of periretinal proliferative membranes. Anterior PVR was man aged by techniques for juxtabasal vitreous dissection as previously described.2-9 De spite such juxtabasal dissection, however complete relief of anterior traction coulc not be achieved in all cases, requiring re¬ laxing retinotomy. In all cases, the follow
ing adjunctive techniques were performed intraocular gas or silicone oil tamponade scierai buckling with episcleral silicone im¬ plants (if insufficient or no previous sclera buckling had been performed), and endo-
photocoagulation on the scierai buckle anc
around retinal breaks. Retinotomies anc retinectomies (heretofore collectively re¬ ferred to as "retinotomies") were per¬ formed as previously described for PVR and trauma,7 the orientation and extent oí which were determined by the direction anc extent of persisting traction. Titanium ret¬ inal tacks were placed in a limited numbei of cases for fixation of the retinotomj
edge.10 Perioperative Factors Studied The
following perioperative factors were
determined from the clinical and operative records and were analyzed to determine ii they influenced the functional visual out¬
patient age and sex, preoperative di¬ agnosis, number of previous scleral-buckling procedures, number of previous vitreetomies, status of the lens, preoperative visual acuity (Snellen acuity if patient was capable of performing), severity of PVR as classified by the Retina Society Terminol¬ ogy Committee,8 number of relaxing retincome:
Relaxing Retinotomy
Indication Unremovable periretinal membranes "Intrinsic" retinal contraction* Anterior proliferative vitreoretinopathy Retinal incarceration Total
in 54
Eyes
No. of
Eyes
13
22 8 11
54
Intrinsic retinal contraction was defined as retinal contraction without clinically visible under the operating microscope.
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periretinal membranes
Type
—
No.
No. of
of
Retinotomies Radial alone Circumferential alone Combined Total
Success Rate of Circumferential Retinotomies
Table 3.
Table 2.—Types and Extent of Retinotomies Performed
Eyes 16
Degrees
Total No. of
30°
Eyes
Anatomic Success
90°-120°
7
54
otomies performed, number of iatrogenic retinal breaks other than for relaxation, orientation of the retinotomy (radial vs circumferential), number of clock hours of circumferential retinotomy, posterior ex¬ tent of radial retinotomy, most inferior ex¬ tent of retinotomy, presence of scierai buckle support of retinotomy, evidence of residual retinal fractional elevation after retinotomy (incomplete relief of traction), placement of retinal tacks, type of tamponade (gas vs silicone oil), occurrence of in¬ traoperative complications, and presence of residual hemorrhage at the retinotomy margin at the end of the procedure. Followup examination was obtained at least 6 months after the most recent procedure in all cases, and the following information was obtained: final visual acuity (tested in the same manner as preoperatively), attach¬ ment status of the retina, and the presence of globe atrophy or phthisis.
Functional Success
(30) (31) 2(28) 1 (12)
(80) 8 (62) 5(71) 5 (62)
8
10
33 5
(%) of Eyes
Table 4.—Functional and Anatomic Success Rates
3 4
by Diagnosis*
No./Total No. (%) of Eyes
Diagnosis vitreoretinopathy
_Anatomic
Success
Functional Success
11/42(26) 29/42(69) Posterior segment trauma 3/12(25) 6/12(50) 14/54(26) 35/54(65) Overall success rate * Anatomic success was defined as the retina entirely attached posterior to the scierai buckle and atrophy or severe hypotony. Functional success was defined as a visual acuity of 5/200 or better. Proliferative
no
globe
Statistical Analysis
We defined functional success as a visual acuity at the final follow-up visit of 5/200 or better. We defined anatomic success as complete attachment of the retina posterior to the scierai buckle, and absence of globe
atrophy
or severe
pressure
\s=b\ Functional and anatomic success after relaxing retinotomy may be limited by recurrent retinal detachment or severe hypotony. Fifty-four consecutive eyes undergoing relaxing retinotomy for proliferative vitreoretinopathy (42 eyes) and trauma (12 eyes) were analyzed to determine whether perioperative factors, including size and location of the retinotomy, influenced visual or anatomic out\x=req-\ come. After 6 months' minimum follow-up, anatomic success (retina attached posterior to buckle and an intraocular pressure of 3 mm Hg or more) was achieved in 35 eyes (64%). Functional success (visual acuity of 5/200 or better) was achieved in 14 eyes (26%). Factors predicting functional success by stepwise logistic regression analysis included a preoperative visual acuity of hand motions or better and location of the retinotomy in the superior four clock hours of the fundus. Causes of anatomic failure included proliferative vitreoretinopathy (11 eyes) and severe hypotony or phthisis (8 eyes). Superior location of the retinotomy and visual acuity of hand motions or better favorably influenced visual outcome after relaxing retin-
otomy. (Arch Ophthalmol. 1990;108:694-697)
etinotomies are important adjuncts to vitreous surgery for pro¬ liferativi vitreoretinopathy (PVR) when periretinal traction is unrelieved by membrane dissection and scierai buckling.1"6 Retinal incarceration into a scierai wound after penetrating trauma may also require relaxing retinotomy to allow surgical reattachment of the retina and prevent poste-
"
Accepted for publication December 29,1989. From the Eye Institute, Department of Ophthalmology, Medical College of Wisconsin, Milwaukee.
Reprint requests to Department of Ophthalmology, Medical College of Wisconsin, 8700 W Wisconsin Ave, Milwaukee, WI 53226 (Dr Han).
rior retinal folds.7 Although anatomic reattachment rates after vitrectomy and relaxing retinotomy in unselected cases of PVR and trauma are good (40% to 80% ),4-6 reported rates of func¬ tional success (visual acuity of approx¬ imately 5/200 or better) are variable, ranging from 6.7% to 55% .2 6 Surgical results and visual outcome probably depend on factors relating to the pre¬ existing vitreoretinal disease, patient characteristics, operative factors, and the retinotomy itself. We determined whether such factors predicted visual outcome after vitrectomy and retinot¬ omy in 54 eyes with proliferative vit-
reoretinopathy
posterior segment trauma. Our surgical results and causes of failure relating to the retin¬ otomy are also presented. or
PATIENTS AND METHODS
We reviewed the clinical and operative
records of 54 consecutive eyes undergoing relaxing retinotomy or retinectomy at the Medical College of Wisconsin, Milwaukee, between January 1983 and June 1988. For¬ ty-two eyes had PVR grade C-2 or worse (as determined by the Retina Society Classifi¬ cation of PVR),8 and 12 eyes had posterior segment trauma and retinal detachment. Ten of the 42 eyes with PVR had a history of giant retinal tear. To assure that retinotomies were truly relaxing in nature, we excluded eyes in which retinotomies were made solely for the purpose of endodrainage or subretinal membrane removal. In no eyes had previous retinotomies or retinectomies been performed. All eyes underwent
Table 1.—Indications for
three-port pars plana vitrectomy with ar aspiration/cutting instrument and sepa¬ rate endoilluminator, followed by attempts at complete removal of periretinal proliferative membranes. Anterior PVR was man aged by techniques for juxtabasal vitreous dissection as previously described.2-9 De spite such juxtabasal dissection, however complete relief of anterior traction coulc not be achieved in all cases, requiring re¬ laxing retinotomy. In all cases, the follow
ing adjunctive techniques were performed intraocular gas or silicone oil tamponade scierai buckling with episcleral silicone im¬ plants (if insufficient or no previous sclera buckling had been performed), and endo-
photocoagulation on the scierai buckle anc
around retinal breaks. Retinotomies anc retinectomies (heretofore collectively re¬ ferred to as "retinotomies") were per¬ formed as previously described for PVR and trauma,7 the orientation and extent oí which were determined by the direction anc extent of persisting traction. Titanium ret¬ inal tacks were placed in a limited numbei of cases for fixation of the retinotomj
edge.10 Perioperative Factors Studied The
following perioperative factors were
determined from the clinical and operative records and were analyzed to determine ii they influenced the functional visual out¬
patient age and sex, preoperative di¬ agnosis, number of previous scleral-buckling procedures, number of previous vitreetomies, status of the lens, preoperative visual acuity (Snellen acuity if patient was capable of performing), severity of PVR as classified by the Retina Society Terminol¬ ogy Committee,8 number of relaxing retincome:
Relaxing Retinotomy
Indication Unremovable periretinal membranes "Intrinsic" retinal contraction* Anterior proliferative vitreoretinopathy Retinal incarceration Total
in 54
Eyes
No. of
Eyes
13
22 8 11
54
Intrinsic retinal contraction was defined as retinal contraction without clinically visible under the operating microscope.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/21/2015
periretinal membranes
Type
—
No.
No. of
of
Retinotomies Radial alone Circumferential alone Combined Total
Success Rate of Circumferential Retinotomies
Table 3.
Table 2.—Types and Extent of Retinotomies Performed
Eyes 16
Degrees
Total No. of
30°
Eyes
Anatomic Success
90°-120°
7
54
otomies performed, number of iatrogenic retinal breaks other than for relaxation, orientation of the retinotomy (radial vs circumferential), number of clock hours of circumferential retinotomy, posterior ex¬ tent of radial retinotomy, most inferior ex¬ tent of retinotomy, presence of scierai buckle support of retinotomy, evidence of residual retinal fractional elevation after retinotomy (incomplete relief of traction), placement of retinal tacks, type of tamponade (gas vs silicone oil), occurrence of in¬ traoperative complications, and presence of residual hemorrhage at the retinotomy margin at the end of the procedure. Followup examination was obtained at least 6 months after the most recent procedure in all cases, and the following information was obtained: final visual acuity (tested in the same manner as preoperatively), attach¬ ment status of the retina, and the presence of globe atrophy or phthisis.
Functional Success
(30) (31) 2(28) 1 (12)
(80) 8 (62) 5(71) 5 (62)
8
10
33 5
(%) of Eyes
Table 4.—Functional and Anatomic Success Rates
3 4
by Diagnosis*
No./Total No. (%) of Eyes
Diagnosis vitreoretinopathy
_Anatomic
Success
Functional Success
11/42(26) 29/42(69) Posterior segment trauma 3/12(25) 6/12(50) 14/54(26) 35/54(65) Overall success rate * Anatomic success was defined as the retina entirely attached posterior to the scierai buckle and atrophy or severe hypotony. Functional success was defined as a visual acuity of 5/200 or better. Proliferative
no
globe
Statistical Analysis
We defined functional success as a visual acuity at the final follow-up visit of 5/200 or better. We defined anatomic success as complete attachment of the retina posterior to the scierai buckle, and absence of globe
atrophy
or severe
pressure
