Program list

SYMPOSIUM: STRATEGIES
SECTION: To manage complicated cases of PVR
Moderators: Didier Ducournau, Murat Oncel
Tuesday, September 16th, 2003 ;9:50 - 12:00

ENDOSCOPY ASSISTED VITRECTOMY FOR TREATMENT OF ESTABLISHED PVR AND CYCLITIC MEMBRANES
Claude Boscher
Paris, France

Purpose : to evaluate endoscopic 360° high magnification evaluation of Anterior Vitreous Base, hyaloidocapsulozonulociliary dissection, and removal of pigmented and white clumps deposited from the ciliary margin to the vitreoretinal juncture, with internal tamponade in the treatment of established PVR.
Methods : prospective consecutive pilot study of 43 eyes (15 phakic, 7 aphakic, 21 pseudophakic) with rhegmatogenous Retinal Detachment(RD) and PVR grade C at preoperative examination (from C P3 to P12, and /or C A3 to A12 , with subretinal strands in 30 % and giant tear in 12 % eyes), enrolled between september 1999 and december 2002. Duration of RD was inferior to 1 month in 10% eyes , between 1 and 3 months in 61% , more than 3 months in 29% . A history of trauma was found in 19 % of eyes ; impairment of visualization (keratoplasty / keratoprosthesis /corneal degeneration, cataract) was present in 19% of eyes ; 8 (19%) patients were monocular . Eav was performed primarily in 46% eyes , after failure of previous conventional surgery(ies) in 54% eyes . Neither (additional) buckling nor lens removal in phakic eyes were performed; relaxing retinotomy(ies)/retinectomy(ies) were performed in 56% eyes ; gas tamponade was used in 28% eyes , silicone oil in 72% eyes). Follow up ranges from 4 to 42 months (mean 22).
Results : retina was reattached intraoperatively in all but 1 eye . Recurrence occured in 16 (37%) eyes (after gas resorption in 3 eyes, (re)proliferation within 1 to 3 months under oil in 6 eyes , intraoperative peripheral redetachment during silicone oil removal in 4 eyes, redetachment within 1 to 3 months after silicone oil removal in 3 eyes).14/16 eyes with recurrence were reoperated . Final overall anatomical success is obtained in 36(84%) eyes, with silicone oil left in place in 9 cases; stable anatomical success after 1 operation is 60%, after 1 reoperation is 81%.1 eye operated after failure of 2 previous conventional vitrectomies has hypotony despite stable retinal reapplication. Retinal reapplication after primary EAV without buckle is 80% after 1 operation and 85% after 1 reoperation.
Conclusion: EAV and primary EAV might improve the success rate of surgery for PVR; primary EAV might suppress the need for scleral buckle ; primary EAV might prevent hypotony . Adjuvants against (re)proliferation might improve results of EAV.

Purpose : to establish clinicoanatomical correlations and to evaluate therapeutical benefit of endoscopy in cyclitic membranes associated to PVR.
Patients and Methods : retrospective consecutive study involving 13 eyes (6 pseudophakic, 7 aphakic) (4 monocular patients), operated between april 2000 and april 2003. Preoperative anatomical condition were : corneal obturing opacification in 6/13 eyes , iris retraction in 5/13 eyes , with rubeosis in 3, hypotony (2 to 4) in 9/13 eyes, retina attached in 6/13 eyes (under silicone oil in 3 eyes), persistent RD after multiple surgeries in 5 , primary RD with anterior PVR and cyclitic membrane in 2 eyes.
Endoscopy was exploratory only in 1 eye . Surgical videorecords were analysed in all eyes.
Results : cyclitic membranes were composed of three different layers agglomerated at the surface of the ciliarybody and in continuity on a variable amount of surface of pars plana, and of anterior retina (or anterior flap of a retinectomy) ; the underlying condition of the ciliary processes was variable: normal, elongation, discolouration, atrophy. In 4/13 eyes, the membranes were neovascularized . Full ciliary body dissection could not be achieved in 2 eyes. Endoscopy disclosed subretinal silicone oil in 3/9 eyes . Hypotony resolved in 8/9 eyes, in 2 cases delayed over 10 months after surgery ; silicone oil is still in place in 6/13 eyes.
Conclusion : endoscopy provides a unique evaluation and treatment capacity in cyclitic membranes ; hypotony complicating PVR may be reversible ; prolonged follow up is necessary to evaluate results. Improvements of technology are necessary (bimanual surgery, superior viewing).