http://www.tvrs.gr/

1. Vincent S.Vincent S. ReppucciReppucci, MD, MD
Director Retina ServiceDirector Retina Service
Mount SinaiMount Sinai -- St. LukeSt. Luke’’s Hospitals Hospital
New York, NYNew York, NY
USAUSA
How to Perform aHow to Perform a RetinotomyRetinotomy
(Properly)(Properly)
4th Thessaloniki International Vitreo-Retinal Summer School
Monday - Saturday, JUNE 16-21, 2014 Thessaloniki, Electra Palace Hotel

2. DefineDefine 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

3. SubSub--Retinal AccessRetinal Access
 Submacular Hemorrhage
 Choroidal neovascularization
 Sub-retinal bands

4. SubretinalSubretinal HemeHeme

5. CNVCNV

6. UnintentionalUnintentional RetinotomyRetinotomy

7. UnintentionalUnintentional RetinotomyRetinotomy

8. RelaxingRelaxing RetinotomyRetinotomy
 PVR and recurrent RD
 Chronic Diabetic Traction detachment
 Useful to reattach retina intraoperatively
 Long term reattachment is more critical

9.  Can categorize, but every case is differentCan categorize, but every case is different
 Visual and anatomic outcomes are variableVisual and anatomic outcomes are variable
 Removal of surface membranes is not aRemoval of surface membranes is not a
problemproblem
 PVR failure due toPVR failure due to reproliferationreproliferation
PVR ObservationsPVR Observations

10. ObjectivesObjectives
 Role of inferior vitreous base in PVR andRole of inferior vitreous base in PVR and
recurrent detachmentrecurrent detachment
 Technique for resection of the inferiorTechnique for resection of the inferior
vitreous basevitreous base

11.  Fairly strongFairly strong
vitreoretinalvitreoretinal attachmentattachment
includingincluding oraora andand ciliaryciliary
epitheliumepithelium
 Posterior and anteriorPosterior and anterior
insertion site is variableinsertion site is variable
 Anterior attachment toAnterior attachment to
ciliaryciliary processes andprocesses and
lens capsulelens capsule
Vitreous BaseVitreous Base

12.  Proliferative cells andProliferative cells and chemotacticchemotactic factors settlefactors settle
inferiorly causing contractioninferiorly causing contraction
 Insufficient inferiorInsufficient inferior tamponadetamponade especially withespecially with
siliconesilicone
 Opens iatrogenic breaks or create new breaksOpens iatrogenic breaks or create new breaks
 Especially acute withEspecially acute with posteriorlyposteriorly positioned bucklepositioned buckle
Inferior Vitreous BaseInferior Vitreous Base

13.  If shaved orIf shaved or debulkeddebulked;;
leave residual scaffoldleave residual scaffold
forfor reproliferationreproliferation
 Leads to inferiorLeads to inferior
contractioncontraction
 Only way to remove isOnly way to remove is
by dissection orby dissection or
resectionresection
Inferior Vitreous BaseInferior Vitreous Base

14.  Bimanual approach lighted pick; forcepsBimanual approach lighted pick; forceps
 Must first dissectMust first dissect hyaloidhyaloid anteriorlyanteriorly to vitreousto vitreous
basebase
 DissectDissect vitvit basebase anteriorlyanteriorly, grasp, elevate,, grasp, elevate,
and mobilizeand mobilize posteriorlyposteriorly
TractionalTractional RetinotomyRetinotomy

15. VitVit basebase

16. bimanualbimanual

17. IlmIlm peelpeel

18. pfopfo

19. Resection of VitreousResection of Vitreous
BaseBase

20.  THIS IS NOT A SHORTCUT!!!!THIS IS NOT A SHORTCUT!!!!
 Risk of aggressive and extensive retinalRisk of aggressive and extensive retinal
lossloss
 Dissection is preferable to resectionDissection is preferable to resection
 ResectResect at least 4 clock hoursat least 4 clock hours
 NoNo vitvit base orbase or hyaloidhyaloid posterior to resectionposterior to resection
Resection of VitreousResection of Vitreous
BaseBase

21.  9 month period 5/98 to 1/999 month period 5/98 to 1/99
 retrospective review consecutive PPV forretrospective review consecutive PPV for
PVRPVR
 43 eyes in 43 patients43 eyes in 43 patients
 All 43 eyes priorAll 43 eyes prior VxVx and 2.5 years followand 2.5 years follow--upup
 9 eyes9 eyes intraoperativeintraoperative resectionresection
ResultsResults

22. ResultsResults
InferiorInferior
ResectionResection
NonNon
ResectionResection
TotalTotal
# Eyes# Eyes 99 3434 4343
RecurrenceRecurrence 1(11%)1(11%) 10 (29.4%)10 (29.4%) 11(25.6%)11(25.6%)
FinalFinal
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%)

23. ConclusionConclusion
 RetinotomyRetinotomy can be useful in may situations.can be useful in may situations.
 Remove all traction surrounding theRemove all traction surrounding the retinotomyretinotomy
 Although helpful THIS IS NOT A SHORTCUTAlthough helpful THIS IS NOT A SHORTCUT
 Resection of the inferior vitreous base, whenResection of the inferior vitreous base, when
appropriate, may reduce the rate ofappropriate, may reduce the rate of
redetachmentredetachment in PVR surgery.in PVR surgery.