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
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
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
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.