Managing challenges in giant retinal tear re-attachment

Mexico City-Giant retinal tears pose outsize challenges for physicians, including the risks of hemorrhage, heavy fluid droplets, and macular holes, according to Gerardo Ledesma-Gil, MD.

Dr. Ledesma-Gil, a retina fellow at the Instituto de Oftalmología Fundación Conde de Valenciana in Mexico City, Mexico, presented his team’s experience during Retina Subspecialty Day at the 2015 meeting of the American Academy of Ophthalmology.

“These surgeries are complicated and you have to take your time,” Dr. Ledesma-Gil said. “If something goes wrong, be calm and make another plan.”

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Video courtesy of Gerardo Ledesma-Gil, MD

Giant retinal tears are rare, Dr. Ledesma-Gil pointed out.

In 2010, the British Giant Retinal Tear Epidemiology Eye Study (Invest. Ophthalmol. Vis. Sci. 2010;51(9):4781-4787) found an incidence of 0.094 retinal tears per 100,000 people. Although retinal attachment was achieved in 94.7% of patients, only 42.1% achieved vision of 20/40 or better.

Dr. Ledesma-Gil’s patient was a 29-year-old man who underwent phacoemulsification in 2009 as treatment for injuries from blunt trauma to the eye.

Five years later, the man presented with a giant retinal tear and retinal detachment. The surgeons began their treatment with PPV. They used perfluorocarbon heavy liquid to flatten the retina, allowing them to observe its anterior edge.

After an air fluid exchange, they tried to reattach the anterior edge. During this procedure, a subretinal hemorrhage occurred. However, the surgeons were able to control it and remove all the clots.

“I think in that part of the surgery the heavy liquids came under the retina incidentally,” Dr. Ledesma-Gil said.

When the surgeons noticed the heavy liquid under the retina, they drained it surgically and performed another air fluid exchange.

Using an endoprobe to deliver laser, they reattached the retina, then infused silicone oil as a long-acting tamponade.

During a follow-up

During a follow-up to this surgery, the surgeons noticed two elevations on the retina. Investigating with optical coherence tomography, they found one subfoveal perfluorocarbon droplet and one under the nasal region of the retina.

Fearing that the droplets could damage the retina, the surgeons performed a PPV revision, giving them a clear view of the droplets.

Using a 42-gauge needle, they made a small hole in the area surrounding the droplet under the macula to attempt its removal, but were fearful of making the hole too close to the fovea. As a consequence, they could not reach the droplet with the needle and had to use a silicon-tipped cannula to move the droplet to the needle. After several attempts, they succeeded in draining the droplet.

They made a second hole and drained the second droplet from the nasal area of the retina. Finally, they used gas for a temporary tamponade and achieved complete macular attachment.

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However, in a postoperative exam the patient’s final visual acuity in the affected eye was 20/400. Although this was an improvement over his vision before the surgery, it was disappointing, Dr. Ledesma-Gil said.

Using optical coherence tomography, the surgeons confirmed that they had completely removed the droplets. And though they found a macular hole, they decided to take no further action.

“It was probably the droplet itself and the retinotomy that made the hole,” Dr. Ledesma-Gil said. “I think a combination of factors led to the hole formation.”

If he had to do the procedure over, he said, he would take a slightly different approach, perhaps using gas to move the droplet rather than a cannula.

The physicians explained to the patient what happened, and because he has good vision in his other eye, he is satisfied, Dr. Ledesma-Gil said.