grt repair, rd surgery

1. Giant retinal tear

2. Definition
 > 90’ circumferential tear

4. Urgency

5. Different from
giant dialysis

6. Etiology
 Idiopathic
 Traumatic – upper nasal and lower temporal
 males
 0.091 patients per 100,000
 High myopia
 Marfans, Stickler, Ehler-danlos, Lens coloboma,Aniridia
 ARN
 Iatrogenic

7. Etiology
 Pneumatic Retinopexy
 LASIK and phakic IOLs
 Barrage laser

8. PATHOGENESIS
 Central vitreous liquefaction with condensation in the vitreous base
 multiple horseshoe tears may coalesce to form a giant retinal tear
 (RPE) gains access to the vitreous cavity, increasing the risk of PVR

9. Management
 History
 retinal tacks or sutures
 fluid–air exchange in prone position
 PFCL

10. PREOPERATIVE
EVALUATION
AND
PLANNING
 Corneal and lens status
 IOP - low to very low IOP in recent GRT and +/- choroidal
-traumatic dialysis can have persistent high pressures
 posterior vitreous will be found to be detached
 In blunt injury, base avulsion is seen as a ropelike structure in periphery
 In perforating injury, the vitreous could be incarcerated in the wound –
GRT in opposite quadrant
 Pars plana may be detached
 Associated macular hole

11. USG
 discontinuity in retinal echo anteriorly and extending more than
one quadrant
 Double linear echo near the disc

12. Proliferative
Vitreoretinopathy
 base can contract circumferentially or anteroposteriorly involving
peripheral retina not involved in the giant retinal tear
 inverted flap of the retina can get adherent to the opposite
detached retina

13. Role of
treatment
other than
vitrectomy
 Laser barrage
 Outpatient Fluid–Gas Exchange Followed by Cryopexy or Laser
Photocoagulation
 SCLERAL BUCKLING

14. Vitrectomy
 Encircling band
 Lens management
The exact approach would depend on the
individual case,
the surgeon’s choice, and
the ability to be certain of the power of the IOL
 IOL placement would be avoided in eyes with severe PVR
 If silicone oil is planned, leave the eye aphakic and implant the IOL
at time of silicone oil removal

15. Vitrectomy
 Infuson cannula in vitreous cavity
 vitreous in the anterior segment – first remve it – allow retina to
fall back
 base is debulked to the maximum extent possible
 anterior retinal flap with adherent vitreous should be excised
 Any membrane, igment, pvr tried to be removed
 In eyes with PVR, post. Pole is cleared first, PFCL bubble is put
 combination of spatula, scratcher, and forceps would be needed

16.  If peripheral traction relieved, it is best to excise peripheral retina
along with the fibrosis
 edge of the GRT unfolded under the PFCL
 these edges are smoothed with the help of a spatula
 Fibrosed edges must be excised

17. PFCL
 transparency (can see and treat the retina underneath),
 Low viscosity (easy to inject and easy to remove),
 excellent tamponading effect (good retinal flattening), and
 a refractive index is different from the infusion fluid (visible interface).
 PFCLs are useful at several stages of the surgery:
(1) during membrane dissection to stabilize the posterior pole;
(2) for ILM removal around macular hole in detached retina;
(3) for reattachment of the mobilized retina without fear of
posterior slippage;
(4) For medium-term tamponade

18.  Forceful injection should be avoided - the jet of the liquid can tear
through
 The PFCL bubble is injected till it flattens the edge of the giant
retinal tear

19. Retinopexy
 Endolaser is the preferred
 about 3–4 rows of burns
 It is best to treat 360
 In phakic eyes, anterior treatment is done with LIO

20. PFCL–Air
Exchange
 This is the step when slippage of the retinal flap can occur
 edge of the tear should be dried frequently before removing the
main PFCL bubble

21. Internal
Tamponade
 long-acting gases such as 12–14% C3F8 or
 silicone oil
 SF6 and air are not suited

22. Additional
Steps
 In aphakic eyes, a PI is done inferiorly to reduce the pupillary block
 If IOL implantation planned, done just before PFCL–air or silicone
oil exchange or implant the IOL before itrectomy
 Macular hole – peeling under PFCL