TWENTY-FIVE GAUGE PARS PLANA VITRECTOMY IN COMPLEX RETINAL DETACHMENTS ASSOCIATED WITH GIANT RETINAL TEAR

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1 TWENTY-FIVE GAUGE PARS PLANA VITRECTOMY IN COMPLEX RETINAL DETACHMENTS ASSOCIATED WITH GIANT RETINAL TEAR VINOD KUMAR, MS, DNB, MNAMS, FRCS (GLASG), DEVESH KUMAWAT, MD, ANJU BHARI, MBBS, PARIJAT CHANDRA, MD, DNB Purpose: To study the structural and functional outcomes of 25-gauge pars plana vitrectomy in giant retinal tear associated retinal detachments. Methods: Seventeen eyes of 17 patients with giant retinal tear, who underwent 25- gauge pars plana vitrectomy over a period of 15 months at a tertiary eye care center by a single surgeon, were recruited in this retrospective interventional study. Results: Giant retinal tears were mostly traumatic (35.3%) or associated with myopia (35.3%) and occurred in young (mean age 25.7 years) males (94.1%). Most eyes had bestcorrected visual acuity #20/1,200 (in 82.3%), foveal detachment (in 88.2%), and proliferative vitreoretinopathy #Grade B (in 82.3%). The giant retinal tear extent was more than 180 in 29.4% and the fellow eye was involved in 35.2% of eyes. All eyes underwent 25- gauge pars plana vitrectomy with encircling band in 41.1%, perfluorocarbon liquid use in 82.3%, and endotamponade with sulphur hexafluoride (23.6%) or silicone oil (76.4%). At mean follow-up of 10.2 months, reattachment rate was 88.2%. Only 35.2% of eyes achieved final visual acuity $20/80 with a cause of poor vision being cataract, secondary glaucoma, macular pucker, and corneal edema. Conclusion: Twenty-five gauge pars plana vitrectomy can achieve excellent attachment rates in eyes with giant retinal tear associated retinal detachment. It can be as efficient as larger-gauge vitrectomy, at the same time retaining all advantages of smaller-gauge surgery. RETINA 0:1 8, 2017 Agiant retinal tear (GRT) is a full-thickness retinal break which extends circumferentially for $3 clock hours ($90 ) in the presence of posteriorly detached vitreous. 1,2 Rhegmatogenous retinal detachment progresses rapidly in eyes with GRT and is often extensive. 3 Pars plana vitrectomy (PPV) has a higher success rate than previously attempted modes of surgical treatment and is the current treatment of choice for GRT-related retinal detachment. 4 6 Despite advances in the surgical techniques and endotamponade agents, GRTs pose significant challenge due to their complex anatomy, risk of retinal slippage, and high From the Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. None of the authors has any financial/conflicting interests to disclose. Reprint requests: Vinod Kumar, MS, DNB, MNAMS, FRCS (Glasg), 57, Sadar Apartments, Mayur Vihar Phase 1 extension, New Delhi , India; drvinod_agg@yahoo.com incidence of proliferative vitreoretinopathy (PVR). Redetachment has been reported to occur in as high as 45% of the cases. 7,8 Although initially reserved for simple vitrectomy, small-gauge vitrectomy (23-gauge) is now the accepted modality even for the treatment of complex vitreoretinal diseases. 9,10 Smaller-gauge vitrectomy has several advantages compared with conventional 20-G surgery, including lesser retinal mobility, easy and precise manipulation of tissues, improved wound anatomy, and reduced postoperative pain and inflammation Similarly, 25-gauge vitrectomy was initially performed only for simple vitrectomy and membrane peeling cases Newly developed second-generation 25-gauge instruments, forceps, directional endolaser, and wide-angle illumination have enabled peripheral vitreous dissection in more complex surgical cases, such as PVR, tractional retinal 1

2 2 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0 detachment, and pathologic myopia with vitreomacular traction. 17 Riemann et al described the use of 25-gauge PPV for complex vitreoretinal surgeries including 3 cases of GRT-associated retinal detachment. 18 Kunikata et al 19 found small-gauge PPV (23- and 25-gauge) feasible in the surgical management of GRT-associated retinal detachment and described 25-gauge PPV in five eyes with GRT. This study describes our experience in patients with GRT-associated retinal detachments undergoing 25- gauge PPV at a tertiary eye care center. The etiologies, clinical features, surgical technique, and outcomes are described. Materials and Methods Subjects It is a retrospective review of consecutive patients undergoing surgery for GRT-associated retinal detachment at a tertiary eye care center in North India. The study period ranged from January 2015 to May The study adhered to the Declarations of Helsinki. Informed consent was obtained from all the patients. Inclusion and Exclusion Criteria All patients with GRT-associated (irrespective of etiology) retinal detachment who underwent 25-gauge PPV were included in the study. Exclusion criteria were history of penetrating trauma, previous vitreoretinal surgery, and final follow-up less than 3 months. The eyes that had undergone vitrectomy before the study period with other gauge (23/20) were not included. Seventeen eyes of 17 patients met these criteria and were included in the study. Parameters Assessed/Outcome Measures Patient medical records were reviewed and the demographic data, preoperative and postoperative Snellen visual acuities, anterior segment and fundus examination, intraoperative and postoperative complications, and fellow eye status were noted. Special note was made of the surgical technique, including use of encircling band, use of perfluorocarbon liquids (PFCLs), direct versus indirect PFCL-silicone oil exchange, and endotamponade used. The Retina Society classification system was used to classify patients with PVR. 20 The functional outcome of surgery was evaluated by corrected distance visual acuity (CDVA) at the last follow-up. Anatomical success was primary retinal reattachment without any resurgery at the last follow-up. Any postoperative complication was recorded and analyzed as a secondary outcome. Visual acuities were converted to logarithm of the minimum angle of resolution equivalents, with counting fingers and hand motion vision corresponding to 2.0 and 3.0, respectively. 21 Surgical Technique All the eyes underwent 25-gauge PPV using a sutureless transconjunctival approach on Constellation Vision System (Alcon, Fort Worth, TX). A 240- style encircling band (Labtician ophthalmics, Ontario, Canada) was placed at the discretion of the operating surgeon. The crystalline lens, if clear, was spared. In cases where lens was opacified (enough to cause visualization problems during vitrectomy), pars plana lensectomy/phacoemulsification was performed. After removal of vitreous, PVR membranes, if present, were removed with an end-grasping forceps. Perfluorocarbon liquid (Aurooctane; Aurolabs, Madurai, India) was used in most cases to flatten the retina. After reattachment, three to four rows of confluent laser spots using a flex-tipped 25-gauge endophotocoagulation probe were applied around all GRTs. Near-confluent 360 endophotocoagulation was also performed from the posterior edge of the vitreous base to the ora serrata. Sparing few cases in which 25% sulphur hexafluoride gas was used, 1,000-centistoke silicone oil (Aurosil; Aurolabs) was used for tamponade. In a few cases, complete PFCL-air exchange was performed followed by silicone oil infusion, i.e., indirect PFCL-oil exchange was performed, whereas in others, direct PFCL-oil exchange was performed. For indirect exchange, a soft silicone tip extrusion cannula was used and positioned at the most posterior edge of tear. The globe was rotated to bring this point more posteriorly. Fluid was then aspirated at the edge of the break, at the air/pfcl interface, to prevent posterior slippage of the retina. Special care was taken to keep the anterior edge of GRT dry at all times. After PFCL-air exchange, airgas/silicone oil exchange was performed. For direct exchange, silicone oil was injected through an infusion cannula. A silicone soft-tip cannula was placed at the fluid-pfcl interface at the most posterior edge of tear as the oil continued to fill the vitreous cavity. The PFCL was removed passively with an extrusion cannula. Once oil interface descended enough to cover the edge of tear, further exchange was easily completed. Tightening of the encircling band was performed after the exchange to ensure complete silicone fill. Postoperatively, patients were instructed to maintain head positioning in accordance with the location of the GRT.

3 Table 1. Characteristics of Eyes Undergoing 25-Gauge Vitrectomy for GRT-Associated Retinal Detachments Patient Age, Years Sex Eye Time, Days Cause Extent, Macular Status PVR Grade IOP (NCT) Lens Status 1 6 M OS 10 Trauma 90 Off C1 11 PSC 2 28 M OD 15 Idiopathic 120 On B 14 PCIOL 3 48 M OS 30 Trauma 210 Off B 14 PCIOL 4 8 M OS 3 High myopia 210 Off B 6 Clear 5 70 F OS 20 PCR 180 Off B 6 Aphakic 6 16 M OD 30 Trauma 90 Off B 14 Clear 7 23 M OD 30 Trauma 120 On A 14 Clear 8 8 M OD 5 High myopia 210 Off B 6 Clear 9 4 M OD 60 High myopia 120 Off B 8 PCIOL M OD 180 Idiopathic 120 Off C1 4 PCIOL 11 8 M OS 1 High myopia 150 Off B 18 Clear M OD 30 Trauma 120 Off B 12 Clear M OD 15 High myopia 210 Off B 8 Clear M OS 10 High myopia 210 Off B 4 PSC 15 9 M OS 30 Idiopathic 150 Off B 8 PCIOL M OS 15 Idiopathic 180 Off B 14 PCIOL M OD 30 Trauma 120 Off C2 6 PSC Patient Fellow Eye Status Fellow Eye Al, mm Baseline LogMAR (Snellen) CDVA Surgical Procedure 1 NAD (20/600) SB + PPV + C3F8 2 RRD 0.3 (20/40) SB + PPV + PFCL Use PFCL Exchange Follow-up, Months Status on Last Follow-up Final LogMAR (Snellen) CDVA Y Indirect 7 Attached 0.6 (20/80) Y Direct 8 Attached 0.48 (20/60) Cause of Poor Vision 3 NAD (HMCF) PPV + Y Direct 8 Attached 1.48 (20/600) Persistent epithelial defect 4 NAD (HMCF) SB + PPV + Y Direct 7 Attached 1 (20/200) Amblyopia 5 NAD (HMCF) PPV + Y Direct 7 Attached 1 (20/200) Corneal edema 6 NAD (FCCF) SB + PPV + Y Indirect 7 Attached 0.78 (20/120) Cataract 7 NAD (20/30) PPV + SF6 N 9 Attached 0.18 (20/30) 8 RRD 1.78 (20/1,200) PPV + Y Direct 8 Attached 0.6 (20/80) 9 RRD 3 (HMCF) PPV + Y Indirect 10 Detached 1.78 (20/1,200) Redetachment 10 RRD 3 (HMCF) PPV + Y Indirect 11 Attached 0.6 (20/80) 11 RRD 3 (HMCF) SB + PPV + Y Indirect 12 Detached 1.78 (20/1,200) Redetachment 12 NAD (HMCF) PPV + SF6 N 11 Attached 0.78 (20/120) Cataract 13 RRD 3 (HMCF) SB + PPV + Y Direct 12 Attached 0.78 (20/120) Cataract (continued on next page) 25-GAUGE VITRECTOMY FOR GIANT RETINAL TEAR KUMAR ET AL 3

4 4 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0 Table 1. (Continued) Cause of Poor Vision Final LogMAR (Snellen) CDVA Status on Last Follow-up Follow-up, Months PFCL Exchange PFCL Use Surgical Procedure Baseline LogMAR (Snellen) CDVA Fellow Eye Al, mm Fellow Eye Status Patient Y Indirect 13 Attached 0.6 (20/80) 14 NAD (HMCF) PPV + + PPL Y Direct 14 Attached 1.3 (20/400) Glaucoma 15 NAD (HMCF) SB + PPV + 16 NAD (HMCF) PPV + SF6 N 16 Attached 0.78 (20/120) Cataract 17 NAD (HMCF) PPV + + Y Indirect 13 Attached 1.3 (20/400) Glaucoma* PPL C3F8, perfluoropropane; FCCF, finger counting close to face; HMCF, hand movement close to face; IOP, intraocular pressure; logmar, logarithm of the minimum angle of resolution; NAD, no abnormality detected; NCT, Noncontact tonometry; OD, right eye; OS, left eye; RRD, rhegmatogenous retinal detachment; SB, scleral buckling; SF6, sulphur hexafluoride; PSC, posterior subcapsular cataract; PCIOL, posterior chamber intraocular lens. Follow-up Follow-up examinations were performed at 1 day and 1 week postoperatively followed by monthly examination. Silicone oil removal was performed at 3 to 6 months postoperatively. Repeat surgery, if required, was performed within a week of presentation with redetachment. Statistics SPSS 20 software was used for analysis after data entry. The qualitative data were expressed as frequency and percentages. Groups having nonparametric data (data with large variation) were subjected to the Mann Whitney test and to assess the changes in this group over a period of time the Wilcoxon signed-rank test was used. P value,0.05 was deemed statistically significant. Results The detailed patient characteristics are shown in Table 1. The median age of the patients was 16 years, range being 4 to 70 years. Children (age #16 years) constituted 52.9% of the cases (n = 9/17). All patients except one were males. The right eye was affected with GRT in nine of the cases, whereas in eight cases, the left eye was affected. The median duration of presentation to our center after the initiation of vision loss was 20 days, range being 1 to 180 days. Fifteen of the patients (88.2%) presented within a month of symptom initiation. The GRTs were mostly posttraumatic (35.3%, n = 6/ 17) or associated with myopia (35.3%, n = 6/17). One case had iatrogenic trauma due to vitreous manipulation during posterior capsular rent in manual small Table 2. Details of Surgery in Eyes With GRT-Associated Retinal Detachments Surgical Aspect Total Eyes (n) SB + PPV Group (n) Only PPV Group (n) 25-gauge PPV Lensectomy PFCL use PFCL exchange Direct Indirect Tamponade Silicone oil SF C3F * C3F8, perfluoropropane; SB, scleral buckling; SF6, sulphur hexafluoride.

5 25-GAUGE VITRECTOMY FOR GIANT RETINAL TEAR KUMAR ET AL 5 Fig. 1. Fundus photograph of the left eye of patient 14 (A) showing 210 superior GRT. After 25-gauge PPV, the retina is attached (B). incision cataract surgery. In rest 4 cases, no cause could be identified and hence were labeled idiopathic. The majority of the children had high myopia as the cause of GRT (n = 5/9), whereas in adult eyes, either predisposing trauma was present or no cause could be ascertained (3 eyes each). The extent of GRT was between 90 and 120 (47.0%, n = 8/17) and involved the inferotemporal quadrant in 10 eyes. The extent was more than 180 in 5 eyes, of which 4 were myopic and 1 had trauma. The retinal detachment involved the macula in 88.2% of eyes (n = 15/17). Most eyes had PVR Grade B (76.5%, n = 13/17). Three eyes had focal fixed retinal folds posterior to the equator, and one eye had PVR Grade A. Most of the eyes were phakic (58.8%, n = 10/17) with cataract in three eyes. Six eyes were pseudophakic. Notably, all four idiopathic GRTs occurred in pseudophakic eyes. One eye in which GRT occurred after small incision cataract surgery was aphakic and had lens nucleus in the subretinal space. Fellow eyes of six patients had rhegmatogenous retinal detachment at the presentation. The fellow eye was involved in 44.4% of children (n = 4/9), whereas only 25% adults had affected fellow eyes as well (n = 2/8). Rest of the fellow eyes had no peripheral lesion. The mean preoperative intraocular pressure was 9.8 ± 4.3 mmhg. The mean baseline logarithm of the minimum angle of resolution CDVA was 2.45 ± 0.96 units. Only 4 eyes had visual acuity $20/1,200. Summary of the operative characteristics is shown in Table 2. Encircling band was used in seven eyes. Two eyes underwent lensectomy along with PPV. Indirect PFCL exchange was performed in the initial cases (n = 7/ 14). Direct PFCL-oil exchange was performed in rest of the cases (n = 7/14). Silicone oil was used as intravitreal tamponade in majority of eyes (n = 13/17). Gas was used in eyes with fresh retinal detachment due to superior GRT. Intraoperatively, none of the eyes had complications like tear extension, subretinal PFCL/silicone oil, and flap slippage. Postoperative Outcomes The mean follow-up was 10.1 months, range being 7 to 16 months. Primary retinal reattachment was attained in all eyes (Figures 1 and 2). Anatomical success (retinal reattachment at the last follow-up) was achieved in 88.2% of eyes (n = 15/17). The mean logarithm of the minimum angle of resolution CDVA Fig. 2. Fundus photograph of the right eye of patient 7 in the series showing superotemporal 120 GRT (A). After 25-gauge PPV with sulphur hexafluoride gas, the retina is attached at 1-week follow-up with gas still visible (B). At 1 month, the retina is attached and gas has absorbed (C).

6 6 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0 Table 3. Comparison of Clinical Features and Surgical Outcomes With 25-Gauge Vitrectomy in GRT-Associated Retinal Detachments Between Children and Adults Variable Children Adult P (Mann Whitney Test) Time of presentation, days 15 (1 60) 25 (10 180) 0.32 Extent, 150 ± ± Intraocular pressure, mmhg 9.4 ± ± Baseline LogMAR (Snellen) CDVA* 2.58 (20/7,600) ± (20/4,080) ± Final LogMAR (Snellen) CDVA 1.1 (20/250) ± (20/108) ± *CDVA. logmar, logarithm of the minimum angle of resolution. at the last follow-up was 0.93 ± 0.45 units. Only 6 eyes had CDVA $20/80. All the eyes underwent silicone oil removal at 3 to 6 months postoperatively. Retinal redetachment due to PVR was noted in two eyes after silicone oil removal, two and three months after initial surgery, respectively. Both the patients were children. Inferior traction persisted in one of these eyes after repeat PPV with silicone oil reinsertion, and further surgery was not planned. The second patient with inferior detachment required inferior retinectomy with repeat injection of silicone oil to settle the retina. Comparison of clinical features and outcomes between children and adults is shown in Table 3. Persistent corneal epithelial defect and corneal decompensation developed in one eye each. Secondary glaucoma developed in two eyes. Posterior subcapsular cataract developed in four eyes. Cataract surgery was performed in these eyes at the time of silicone oil removal at 3 months postoperatively. None of the eyes had endophthalmitis or macular pucker. One eye had poor visual gain due to ametropic amblyopia arising out of untreated high myopic refractive error. The etiology and extent of GRT did not have any association with final postoperative visual acuity (Table 4). Similarly, eyes that underwent encircling band along with PPV had similar final visual acuity as compared to eyes undergoing only PPV. Statistical analysis between the oil and gas subgroups could not be performed because of inadequate sample size within the groups. Discussion Giant retinal tears pose numerous surgical challenges, including flap manipulation, extensive PVR membranes, tear extension, subretinal PFCL or silicone oil, and flap slippage. Conventional 20-G vitrectomy with PFCL use has been reported to have up to 94% final attachment rates in GRT-associated RD. 6 Smaller-gauge vitrectomy has evolved over time and has several advantages compared with conventional 20-G surgery, including lesser retinal mobility, lesser vitreous traction, easy manipulation of tissues, and PVR management apart from improved wound anatomy and reduced postoperative pain and inflammation Outcomes of transconjunctival sutureless 25-gauge PPV in GRT have been reported scarcely in the past. 19,22 Single surgery anatomical success rate of 88% and 92% has been reported in GRT with 23-G PPV by Pitcher et al 23 and Kunikata et al, 19 respectively (mean Table 4. Variables and Their Relation to Attachment Rate and Visual Outcome in GRT-Associated Retinal Detachments Variable No. of Eyes n (% of Total) Anatomical Success n (% of Subgroup) Final Median Visual Acuity (Snellen) P (Mann Whitney Test) Encirclage 0.84 Used 7 (41.1) 6 (85.7) 20/120 Not used 10 (58.9) 9 (90) 20/120 Silicone oil Sample size inadequate Used 13 (76.5) 11 (84.6) 20/200 Not used 4 (23.5) 4 (100) 20/98 Etiology 0.51 Trauma 6 (35.3) 6 (100) 20/120 High myopia 6 (35.3) 4 (66.7) 20/155 Extent 0.92, (58.9) 8 (80) 20/120 $180 7 (41.1) 7 (100) 20/120

7 25-GAUGE VITRECTOMY FOR GIANT RETINAL TEAR KUMAR ET AL 7 follow-up of 17 and 12 months, respectively). Randolph et al 22 reported anatomical success rate of 91.3% with 25-gauge PPV with medium-term PFCL endotamponade in GRT (mean follow-up 33 months). Despite high proportion of posttraumatic and pediatric cases, which are a high risk factor for PVR, final anatomical success in our study is similar to these studies (88.2%). Randolph et al reported a final mean CDVA of 1.08 ± 0.81 logarithm of the minimum angle of resolution units with visual improvement in 48% of eyes. In our study, 88.2% of eyes gained Snellen lines, whereas 2 eyes with macula on status preoperatively did not have any visual gain. Previous studies report that larger the extent of GRT, higher is the risk of redetachment. 8 However, in our study, the extent of GRT did not have any association with postoperative attachment status and visual acuity. Pediatric retinal detachments are known to be mostly related to trauma, have late presentation with poor visual acuity, 27 high incidence of bilateral involvement, poor visual outcomes, and lower anatomical success rates, 24,28 as compared to adult cases. However, pediatric GRT-associated retinal detachments have not been compared with adult cases in the past. In our study, most children had high myopia as the etiology and a similar duration of presentation as in adults. Baseline visual acuity was comparable in both the groups. Although the final visual acuity was lower in children than that in adults, the difference was statistically insignificant. This suggests that the poor visual outcome as reported in the past studies in children occurs likely due to the chronic nature of detachment. Redetachment occurred in two eyes of two pediatric patients in our study because of inferior PVR. High rates of PVR-associated redetachment have been reported previously in pediatric eyes because of high intraocular cellular activity. 29,30 Chronic retinal detachment due to late presentation also increases the likelihood of PVR in such eyes. The use of encircling scleral band in GRT is controversial. Some studies have reported higher redetachment rates with encircling due to redundant retinal folds, fishmouthing, and increased posterior retinal slippage, 11,13,20 whereas others report a lack of encircling band to be associated with a higher rate of redetachment. 10,31 In our study, the use of encircling band did not affect the attachment rate and postoperative visual acuity. The anatomical success has been previously reported to increase with the use of PFCL in GRT. 4 In this study, PFCL was used in most eyes (n = 14/17, 82.3%) for unrolling of the inverted GRT flap. Perfluorocarbon liquid exchange was performed with slow removal of the fluid at the edge of tear by a soft-tipped extrusion cannula at PFCL-air interface in indirect exchange and at PFCL-oil interface in direct exchange. Slippage may occur in indirect exchange when residual fluid at the air-pfcl interface gets trapped posteriorly by descending air bubble, causing the retina to slide. 32 Perfluorocarbon liquid oil exchange is less likely to cause slippage than PFCL-air exchange, as both PFCL and silicone oil being hydrophobic extrude fluid at the PFCL-oil interface. Direct exchange is useful in cases where the surgeon is unsure of dryness of the tear edge and completeness of vitreous base shaving. Direct exchange is quicker, more controlled, and leads to complete vitreous cavity fill as compared to indirect exchange. No slippage of the tear flap was noted intraoperatively in our study, as the exchange was performed meticulously as described in the surgical technique. The eyes were rotated as needed to place the tear at most dependent position and almost complete aspiration of fluid was performed to make the tear edge dry before proceeding to the center to aspirate PFCL. Also, the tightening of sclera buckle was performed after exchange to ensure complete oil fill. This study was limited by a relatively small sample size and short follow-up. A larger cohort needs to be followed for a longer duration to assess the long-term attachment rates in patients with GRT-associated retinal detachment when treated with 25-gauge PPV. To conclude, 25-gauge PPV can achieve excellent retinal reattachment rates in GRT-associated retinal detachments without significant intraoperative and postoperative complications. Key words: giant retinal tears, perfluorocarbon liquid, PFCL-oil exchange, 25-gauge, pars plana vitrectomy. References 1. Freeman HM. Fellow eyes of giant retinal breaks. Trans Am Ophthalmol Soc 1978;76: Kanski JJ. Giant retinal tears. 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