Vincent S. Vincent S. ReppucciReppucci, MD, MDDirector Retina Service Director Retina Service Mount Sinai Mount Sinai -- St. LukeSt. Luke’’s Hospitals HospitalNew York, NYNew York, NYUSAUSA

How to Perform a How to Perform a RetinotomyRetinotomy(Properly)(Properly)

4th Thessaloniki International Vitreo-Retinal Summer SchoolMonday - Saturday, JUNE 16-21, 2014 Thessaloniki, Electra Palace Hotel

Define Define RetinotomyRetinotomy

Iatrogenic opening in retinaIatrogenic opening in retina•• Intentional or unintentionalIntentional or unintentional

DrainageDrainage SubSub--retinal accessretinal access Relaxing (Release of traction)Relaxing (Release of traction)

•• EnEn--blockblock

•• RetinectomyRetinectomy

SubSub--Retinal AccessRetinal Access

Submacular Hemorrhage Choroidal neovascularization Sub-retinal bands

SubretinalSubretinal HemeHeme

CNVCNV

Unintentional Unintentional RetinotomyRetinotomy

Unintentional Unintentional RetinotomyRetinotomy

Relaxing Relaxing RetinotomyRetinotomy

PVR and recurrent RD Chronic Diabetic Traction detachment Useful to reattach retina intraoperatively Long term reattachment is more critical

Can categorize, but every case is different Can categorize, but every case is different Visual and anatomic outcomes are variableVisual and anatomic outcomes are variable Removal of surface membranes is not a Removal of surface membranes is not a

problemproblem PVR failure due to PVR failure due to reproliferationreproliferation

PVR ObservationsPVR Observations

ObjectivesObjectives

Role of inferior vitreous base in PVR and Role of inferior vitreous base in PVR and recurrent detachmentrecurrent detachment Technique for resection of the inferior Technique for resection of the inferior

vitreous basevitreous base

Fairly strong Fairly strong vitreoretinalvitreoretinal attachment attachment including including oraora and and ciliaryciliaryepitheliumepithelium

Posterior and anterior Posterior and anterior insertion site is variableinsertion site is variable

Anterior attachment to Anterior attachment to ciliaryciliary processes and processes and lens capsulelens capsule

Vitreous BaseVitreous Base

Proliferative cells and Proliferative cells and chemotacticchemotactic factors settle factors settle inferiorly causing contractioninferiorly causing contraction

Insufficient inferior Insufficient inferior tamponadetamponade especially with especially with siliconesilicone

Opens iatrogenic breaks or create new breaksOpens iatrogenic breaks or create new breaks Especially acute with Especially acute with posteriorlyposteriorly positioned bucklepositioned buckle

Inferior Vitreous BaseInferior Vitreous Base

If shaved or If shaved or debulkeddebulked; ; leave residual scaffold leave residual scaffold for for reproliferationreproliferation

Leads to inferior Leads to inferior contractioncontraction

Only way to remove is Only way to remove is by dissection or by dissection or resectionresection

Inferior Vitreous BaseInferior Vitreous Base

Bimanual approach lighted pick; forcepsBimanual approach lighted pick; forceps Must first dissect Must first dissect hyaloidhyaloid anteriorlyanteriorly to vitreous to vitreous

basebase Dissect Dissect vitvit base base anteriorlyanteriorly, grasp, elevate, , grasp, elevate,

and mobilize and mobilize posteriorlyposteriorly

TractionalTractional RetinotomyRetinotomy

VitVit basebase

bimanualbimanual

IlmIlm peelpeel

pfopfo

Resection of VitreousResection of VitreousBaseBase

THIS IS NOT A SHORTCUT!!!!THIS IS NOT A SHORTCUT!!!! Risk of aggressive and extensive retinal Risk of aggressive and extensive retinal

lossloss Dissection is preferable to resectionDissection is preferable to resection ResectResect at least 4 clock hours at least 4 clock hours No No vitvit base or base or hyaloidhyaloid posterior to resectionposterior to resection

Resection of Vitreous Resection of Vitreous BaseBase

9 month period 5/98 to 1/99 9 month period 5/98 to 1/99 retrospective review consecutive PPV for retrospective review consecutive PPV for

PVRPVR 43 eyes in 43 patients43 eyes in 43 patients All 43 eyes prior All 43 eyes prior VxVx and 2.5 years followand 2.5 years follow--upup 9 eyes 9 eyes intraoperativeintraoperative resectionresection

ResultsResults

ResultsResults

Inferior Inferior ResectionResection

Non Non ResectionResection TotalTotal

# Eyes# Eyes 99 3434 4343

RecurrenceRecurrence 1(11%)1(11%) 10 (29.4%)10 (29.4%) 11(25.6%)11(25.6%)

Final Final AttachmentAttachment 9 (100%)9 (100%) 29 (85.3%)29 (85.3%) 38 (88.3%)38 (88.3%)

PhthisisPhthisis 00 3 (8.82%)3 (8.82%) 3 (6.9%)3 (6.9%)

ConclusionConclusion

RetinotomyRetinotomy can be useful in may situations.can be useful in may situations. Remove all traction surrounding the Remove all traction surrounding the retinotomyretinotomy Although helpful THIS IS NOT A SHORTCUTAlthough helpful THIS IS NOT A SHORTCUT Resection of the inferior vitreous base, when Resection of the inferior vitreous base, when

appropriate, may reduce the rate of appropriate, may reduce the rate of redetachmentredetachment in PVR surgery.in PVR surgery.