Proliferative vitreoretinopathy (PVR) is usually seen as a complication of unsuccessful retinal detachment surgery. Early referral, risk stratification, and case selection can reduce the incidence of recurrent detachment and PVR after primary retinal detachment repair to less than 3%, as described by Alexander et al.1 However, PVR (and inferior PVR in particular) continues to represent a complex surgical challenge, despite the recent surgical advances in this area, including the introduction of heavy tamponades.
Internal tamponades (whether light or heavy) serve to maintain closure and apposition of retinal breaks to the underlying retinal pigment epithelium while the retinopexy matures to full strength. In this respect, with current conventional techniques, they are deployed toward the completion of the surgical intervention, solely as a tamponade. Single-port “oleodelamination,” a technique developed by Scott2–4 and further described by Snead,5 involves deploying silicone oil before vitrectomy, to delaminate retinal surface membranes, and then subsequently at single-port vitrectomy to enhance the tamponade effect beyond what is possible with conventional 3-port approaches using infusion and exchange.
In this article, we provide an updated description and video demonstration of single-port “oleodelamination” vitrectomy surgery, an effective alternative technique for managing retinal detachment complicated by PVR. A summary of the outcomes from a case series of 11 patients who underwent single-port vitrectomy and oleodelamination after unsuccessful conventional vitrectomy approaches (or in whom such approaches were deemed inoperable by another center) is presented.
A 360° peritomy is created, and the four rectus muscles are isolated on bridle sutures to assist in thorough examination under anesthesia and external release of subretinal fluid (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A655, which demonstrates the full oleodelamination technique). A single, standard 20-gauge vitrectomy port is fashioned. Preplacement of an absorbable suture facilitates closure at the end of the procedure. The subretinal fluid is released externally, and silicone oil (5,700 centistoke) is then slowly injected into the vitreous cavity under indirect ophthalmoscopic control (Figure 1). As the oil is injected and the subretinal fluid simultaneously drained, the detached retina begins to flatten, causing the proliferative, contractile membranes on its surface to be pulled taut. This creates tension in the relatively inelastic membrane which then splits preferentially as the oil herniates through to the preretinal space (Figure 2). Oil gradually accumulates between the neuroretina and the proliferative membrane and gently advances anteriorly along the plane of interface between these two structures, gently separating the surface membrane away from the retina en bloc (Figure 3).
Oleodelamination is thus particularly effective in cases of primary PVR, where the posterior hyaloid membrane (PHM) is intact. In secondary PVR cases, where previous vitrectomy has been undertaken, the silicone oil remains a useful instrument; although the PHM is no longer intact, the expanding oil bubble encourages the retina to flatten while assisting the delamination of the residual PHM that is still present in the same manner described above.
The progress of the membrane's separation is monitored continuously with the indirect ophthalmoscope. In cases where there is insufficient shortening of the PHM for complete “autodelamination,” a 23-gauge pick can be used to complete the oleodelamination of the PHM complex from the retinal surface.
Once the PHM complex has been completely separated from the retinal surface, it is then removed with the vitreous cutter through the same, single port, working through 360° in the vitreous space surrounding the silicone bubble to optimize the tamponade (Figure 4). Finally, retinopexy is applied to the causative tear(s). Silicone oil removal is performed as a planned second stage procedure once the retina is completely stabilized.
The entire vitrectomy procedure is monitored and completed using the head-mounted indirect ophthalmoscope. This instrument provides a generous depth of field and the ability to switch views instantaneously between the posterior segment, anterior segment, and external globe. The surgeon may vary the field of view and magnification using the 20D, 28D, or enhanced field 30D lenses as required. Furthermore, in comparison with the standard vitrectomy arrangement in which the surgeon is seated in a fixed position, the indirect ophthalmoscope provides the additional advantage of flexibility of approach, allowing the surgeon the freedom to move around the eye to better visualize the progress of the operation and to choose the position of the entry site sclerostomy to best access the pathology.
We review the results of a series of 11 patients who all underwent the above oleodelamination procedure at Addenbrooke's Hospital for management of retinal detachment complicated by PVR. The rate of retinal reattachment and subsequent oil removal were the primary outcomes measured.
The 11 cases treated by oleodelamination are enumerated in Table 1. Two of the patients were female and nine were male, with a mean age of 52.3 years (range 11–80 years). The patients had undergone a mean of 1.9 previous operations (range 0–4 operations). One case of total retinal detachment with grade “D” PVR, seen in an 11-year-old boy, had been deemed inoperable by standard wide-angle vitrectomy surgery at another vitreoretinal unit and had not undergone previous surgery.
At a mean follow-up interval of 2.7 years (range 0.5–10 years), the retina was fully attached in every case. In eight patients (73%), the silicone oil was successfully removed at a secondary procedure. Of the four patients in whom the oil was not removed, one was considered medically unfit for further surgery after a stroke and another opted to retain the silicone tamponade after a retinal detachment in his fellow eye.
Silicone oil is conventionally used solely as a tamponade at the completion of vitrectomy. This article and the accompanying video illustrate an alternative approach in which it is used first as an operative instrument, to provide a gentle delamination of retinal surface membranes, and subsequently as a tamponade. Silicone oil thus permits full retinal reattachment, even in cases where standard wide-angle vitrectomy approaches have previously been unsuccessful, thereby allowing its safe removal at a secondary planned procedure in most patients. In particular, the retina was successfully fully reattached in every case without the need for adjunctive heavy tamponades. Oleodelamination is thus the preferred method at our center for treating cases of retinal detachment with PVR at presentation or where secondary PVR has developed after unsuccessful primary surgery.
The “oleodelamination” technique takes full advantage of the wide field of view, versatility, and depth of focus of the indirect ophthalmoscope, a tool that is widely used in the clinic setting yet rarely used in operating theaters in most centers. The single-port approach described precludes bimanual surgery, yet oleodelamination can be performed efficiently and effectively through one port while also reducing the rate of port-related complications. Given the relatively basic instrument requirements, this technique could be used almost anywhere and has substantial potential for use in the developing world.
We hope that the excellent anatomical results achieved with this method, which has been used to successfully treat complex, “inoperable” retinal detachments, will encourage vitreoretinal surgeons to consider the benefits of adding this alternative technique to their arsenal.
The authors wish to acknowledge Mr Philip M. Ball, MA FMAA (Past Chairman, The Medical Artists' Association of GB. Photography and Illustration Manager, University of Cambridge) for preparing the illustrated figures and Mr Alan Lacey (W3 Media Ltd) for creating the animation included in the video accompanying this article.