Giant Retinal Tears. He Said... She Said...
A discussion on treating giant retinal tears presented at the first annual meeting of the Vit-Buckle Society in Miami.
At the first meeting of the Vit-Buckle Society, R. Ross Lakhanpal, MD, FACS, and Geeta Lalwani, MD, led a discussion session on the management of giant retinal tears (GRTs). Drs. Lakhanpal and Lalwani took extreme sides regarding questions about videos that were shown with specific types of cases, to look at different treatment approaches.
Case No . 1 . Fresh GRT With No Proliferative Vitreoretinopathy
By Manish Nagpal, MS, DO, FRCS(UK)
Dr. Lakhanpal: This patient had a GRT with no proliferative vitreoretinopathy (PVR). The question is whether or not a scleral buckle is indicated. My feeling on this is that I think a scleral buckle is helpful. It doesn’t take very long to do, and a buckle sup- ports the vitreous base where GRTs originate. Additionally, a buckle addresses any periph- eral pathol- ogy that may come into play during the repair process. It also stabilizes the areas of attached retina during the repair process.
I also believe that if a patient is pseudophakic, a buckle is indicated because there is a higher risk of peripheral reti- nal breaks in this setting. The only exception for placing a scleral buckle would be if the GRT was 360o, which, in my opinion, is a contraindication for a creating a buckle.
Dr. Lalwani: I think that in cases such as this, a buckle is not always necessary. The flap of the tear has already been freed, and if the edge can be kept flat, I do not think a sig- nificant amount of traction will result. If the eye is phakic, I will be most comfortable using a gas bubble.
Case No . 2 . GRt using a chandelier
By María H. Berrocal, MD
Dr. Lakhanpal: The second case, performed by María H. Berrocal, MD, is of a GRT for which a chandelier was used as an adjunct for visualization.
Is it necessary to have a chandelier in such a case?
In my opinion, a chandelier may be helpful, but for local- ized GRTs that are smaller than 6 clock hours, I don’t believe it’s necessary, as long as there is adequate visualization.
On the other hand, if there is PVR that requires a bimanual approach, a chandelier is warranted; however, this is relatively uncommon in my practice. Of all the GRT surgeries that I have performed, 15% to 20% have required a bimanual approach due to the degree of PVR.
Dr. Lalwani: In this case, in which 25-gauge instrumenta- tion was used without first placing a buckle, you see the light from the light pipe and the chandelier.
I typically use a chandelier for GRTs, because it allows me to depress the periphery without an assistant, providing me total control of the case. I am able to laser the edge with a curved laser probe and see it laying flat. It is important to make sure that the edge of the flap is completely dry so that it lasers well without slippage.
María H. Berrocal, MD: It is not possible to depress completely without a chandelier. If the eye is phakic, I depress so that I can laser the edge with a curved laser probe, preserving the crystalline lens so that cataract extraction with accurate biometry can be achieved later when the retina is attached.
Dr. Lalwani: Dr. Berrocal, do you use 25-gauge or 23-gauge instrumentation for GRTs?
Dr. Berrocal: I perform most of my procedures using 25 gauge. For GRTs, the most important thing is to dry the edges of the tear well, and for this, larger 23-gauge instrumentation actually provides a slight advantage. I have had some cases with 25 gauge in which the edges of the tear are slow to dry, resulting in some slippage. I would like to know if Dr. Chang uses a buckle in GRTs.
Stanley Chang, MD: I buckle selectively. If I can see well in the periphery, particularly in pseudophakic eyes with clear peripheral capsules, I might perform the case without a buckle. In a 1-eyed patient who had failed GRT surgery, I consider placing a buckle simply out of principle, but there’s really no good evidence that it’s worthwhile. What’s important is to do the surgery well, clear up the peripheral vitreous, and laser the horns well. Visualization is a key part of doing a good job.
Dr. Lalwani: Dr. Chang, what buckle do you use when you use one?
Dr. Chang: If I use a buckle, it will be a low encircling buckle such as a type-41 band.
Case No. 3. GRT Using a Chandelier and PFCL
By María H. Berrocal, MD
Dr. Lalwani: Dr. Lakhanpal, what do you think about using perfluorcarbon liquid (PFCL)?
Dr. Lakhanpal: I think PFCL is indispensable in GRTs. I want to be sure that the tear is pushed back and flattened out, and I think PFCL works well for this. When the surgery is performed correctly, there is a low risk of retained subretinal PFCL.
Dr. Lalwani: I don’t think PFCL is always needed, and I don’t use it in all of my cases. This is something people who operate in an ambulatory surgery center (ASC) have to think about because PFCL is quite expensive.
Dr. Lakhanpal: In my opinion, it is worth the expense. The only reason I would not use PFCL is when I have a case with a tear of 3 clock hours with no PVR in only 1 quadrant.
Dr. Lalwani: I disagree. If you carefully remove the fluid from the edge as you slowly switch to air, this works fine. Derek Kunimoto, MD, has told me that he typically does not use PFCL.
Dr. Lakhanpal: Dr. Kunimoto, what is your opinion on using PFCL?
Derek Kunimoto, MD: I frequently work in an ASC, so in general, I don’t use PFCL for GRTs. Rather, I switch to air slowly, and begin extruding from the edges. If the edge starts flipping over, this is an indication of PVR. The edge, however, usually lies flat because these are fresh tears and the patients present quickly, so PFCL is most often unnecessary.
Dr. Lakhanpal: I think the real issue is what is essential and what is nonessential. For me, PFCL is essential, and a chandelier is nonessential.
Dr. Lalwani: I think that there is learning curve but that many GRTs can be repaired with air alone. If you don’t try it, you’re not going to learn how to do it.
Case No. 4. 360º GRT
By R. Ross Lakhanpal, MD, FACS
Dr. Lakhanpal: Is a buckle necessary to appropriately fix a 360º GRT? During our discussion, the consensus was that no, a buckle is not necessary. In most cases such as this, there is some degree of PVR, and it is my position that, although a buckle may not be necessary, PFCL is.
Additionally, a bimanual approach is also necessary, making chandelier illumination essential. The other important factor in 360º GRT surgery is that a direct PFCL/silicone oil exchange may be necessary to prevent slippage.
Dr. Lalwani: Because there is significant PVR in this case, PFCL and a bimanual approach with a chandelier are advantageous. PFCL provides good countertraction, allowing the surgeon to peel everything backward starting at the nerve. One must be careful, however, because this is the type of case in which PFCL can leak to the subretinal space through a small hole induced while peeling the membranes. Continuous laser can be used to paint the edges flat.
Case No. 5. GRT With PVR
By Manish Nagpal, MS, DO, FRCS(UK)
Dr. Lakhanpal: Many cases of GRT with PVR, as in this surgery performed by Manish Nagpal, MS, DO, FRCS(UK), can be challenging because PFCL must be used, and there is a risk, as in the previous case of 360º GRT, of developing subretinal PFCL when membranes are being picked apart and removed to flatten the retina. Small buttonholes and holes within the retina often occur during this process. Small PFCL that get under the retina can be a challenging scenario during the PFCL-air exchange, and often, 1 or 2 PFCL bubbles are retained under the retina if the surgeon is not completely aware of the situation.
One ways to avoid developing subretinal PFCL is to use valved cannulas.
Dr. Lalwani: For this type of case, I would also use PFCL both to flatten the retina, as well as to provide countertraction. If the PVR membranes could not be removed, I would consider retinectomy to relieve all traction and prevent recurrent retinal detachment.
Additionally, I believe that silicone oil should also be used, which can be achieved via a direct exchange with PFCL or following an air-PFCL exchange. In this case, the laser was applied to the periphery in numerous rows in an attempt to keep the retina flat.
Case No. 6. Bubble Wrap GRT
By R. Ross Lakhanpal, MD
Dr. Lakhanpal: This was an extreme case of GRT, which I called “bubble wrap GRT” due to its appearance after nearly 360º GRT with extreme PVR.
These types of cases are fairly rare, but they are extremely challenging, requiring bimanual surgery, chandelier illumination, PFCL, and in my opinion, direct PFCL/silicone oil exchange. Additionally, it is important to be steadfast in picking all the PVR membranes to flatten the retina.
If the PVR is unable to be peeled, retinectomy should be performed in that quadrant. I also believe that PFCL is important during the peeling process, even though there is a risk of subretinal PFCL bubbles. Surgeons should be cautious in terms of peeling membranes to avoid this possible complication.
Once the retina flattens well with PFCL, direct PFCL-air exchange can be performed, and the patient should do very well.
R. Ross Lakhanpal, MD, FACS, is a Partner at Eye Consultants of Maryland and is the Vice President of the Vit-Buckle Society. He may be reached at email@example.com or at GVoice (443) 684-2020.
Geeta Lalwani, MD, is owner and physician at Rocky Mountain Retina Associates, Boulder, CO. Dr. Lalwani is a consultant for Genentech, Synergetics, and Thrombogenics. She may be reached at (303) 900-8507; or at firstname.lastname@example.org.
Thomas Albini, MD, is an Associate Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute. He specializes in vitreoretinal diseases and surgery and uveitis. He is membership chair of the VBS and a member of the New Retina MD Editorial Board. He may be reached at (305) 482-5006; or at email@example.com.