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Retinal Physician

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Indications and Pearls for Relaxing Retinectomy

This procedure is a valuable tool in the surgeon's armamentarium.

By: Grant A. Justin, MD, Sharon Fekrat, MD, FASRS
Retinal Physician September 1, 2022 Vol 19, Issue September 2022 Page(s): 40-42, 44

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Relaxing retinectomy is performed when a detached retina is too short to be reattached to the wall of the eye. The most common causes of retinal foreshortening are retinal incarceration after trauma or contraction of the retina secondary to proliferative vitreoretinopathy (PVR), including star-fold (focal), diffuse, circumferential, anterior loop, or along the edge of a giant retinal tear.1 Other less common indications include proliferative vascular retinopathies, such as diabetic and sickle-cell retinopathies, or removal of the inner wall of retinoschisis.

Drs. Machemer and Charles described relaxing retinotomy and retinectomy for a giant retinal tear with a shrunken edge, removal of subretinal strands, and retinal incarceration after trauma in the late 1970s and early 1980s.2 Description by Zicojnovic et al3 of silicone oil as a long-term tamponade was an important evolution in complex retinal detachment (RD) management. However, due to the weaker surface tension and density of silicone oil compared to gas, often the inferior retina can remain detached and/or collect inflammatory material, resulting in PVR and redetachment (Figure 1). In the mid-1980s, surgeons including Haut et al4 began to describe inferior semicircular and circular retinectomies for complex traumatic detachments and the management of PVR detachments.

 

Figure 1. A patient underwent 2 surgeries for retinal detachment prior to referral. The first surgery was a vitrectomy with gas placement and the second was a scleral buckle, vitrectomy, and silicone oil placement. There was a silicone oil underfill with subsequent inferior proliferative vitreoretinopathy posterior to the buckle edge and redetachment (A). A vitrectomy, inferior retinectomy, and silicone oil placement was then performed, and the retina remained attached (B). Images courtesy of Xi Chen, MD, PhD.
Figure 1. A patient underwent 2 surgeries for retinal detachment prior to referral. The first surgery was a vitrectomy with gas placement and the second was a scleral buckle, vitrectomy, and silicone oil placement. There was a silicone oil underfill with subsequent inferior proliferative vitreoretinopathy posterior to the buckle edge and redetachment (A). A vitrectomy, inferior retinectomy, and silicone oil placement was then performed, and the retina remained attached (B). Images courtesy of Xi Chen, MD, PhD.

 

RETINECTOMY STEPS

Before a relaxing retinectomy is completed, a meticulous effort at peeling preretinal membranes should be performed. If a retinectomy is performed before all of the membranes are removed, then further peeling can be more technically challenging, and the retina may not reattach. Thoughtful consideration of scleral buckle placement is important, because buckling itself can relieve tractional forces, and then a retinectomy may not be necessary. Although there are associated risks with placing a scleral buckle, it may be associated with less morbidity than cutting retina, and in the case of subsequent retinectomy, a scleral buckle can support the horns and posterior edge of the retinectomy.

When planning a retinectomy, consider placing it as anteriorly as possibly to prevent secondary visual field loss. Judicious diathermy should be performed along the planned border of the retinectomy, particularly at the retinal blood vessels that would be transected during the maneuver (Figure 2A). Historically, the retina was cut with vertical and/or horizontal scissors; however, with smaller gauge vitrectomy systems, the vitrector is now more commonly used. The retina should be cut along the anterior edge or in the anterior third of the diathermy marks. Perfluorocarbon liquid (PFCL) is a critical adjunct in stabilizing the posterior retina during retinectomy (Figure 2B). Depending on the size of the retinectomy, extension into adjacent attached retina between 10° and 30° may be necessary. If the retinectomy needs to be extended into attached retina, then the attached retina can be detached using aspiration from the vitrector, scissors tips, a pick, or a soft silicone tip. Once the planned retinectomy is complete, the eye is filled with PFCL, and a fluid-air exchange is performed. If the retina does not flatten, check for residual membranes hampering reattachment. If none, then further retinectomy may be needed. Once the retina is flat, then 3 rows of laser can be applied, using a continuous laser setting, along the edge of the retinectomy under PFCL or air (Figure 2C).

 

Figure 2. In this patient with Stickler syndrome and associated high myopia, multiple recurrent retinal detachments with subsequent proliferative vitreoretinopathy and breaks along the edge of prior endolaser necessitated a 270° retinectomy. Intraoperative imaging shows the row of diathermy, the retinectomy location along the anterior third of the diathermized spots, and the adherent retina in an area of prior endolaser (A). Perfluorocarbon liquid was used to support the retina posteriorly (B; white arrowhead). A fluid-air exchange was performed, and confluent endolaser was applied (C). There is an oblique angle of the retinectomy toward the ora serrata. The retina anterior to the retinectomy noted in image A was removed. Images courtesy of Cynthia Toth, MD.
Figure 2. In this patient with Stickler syndrome and associated high myopia, multiple recurrent retinal detachments with subsequent proliferative vitreoretinopathy and breaks along the edge of prior endolaser necessitated a 270° retinectomy. Intraoperative imaging shows the row of diathermy, the retinectomy location along the anterior third of the diathermized spots, and the adherent retina in an area of prior endolaser (A). Perfluorocarbon liquid was used to support the retina posteriorly (B; white arrowhead). A fluid-air exchange was performed, and confluent endolaser was applied (C). There is an oblique angle of the retinectomy toward the ora serrata. The retina anterior to the retinectomy noted in image A was removed. Images courtesy of Cynthia Toth, MD.

 

When selecting retinectomy location, place the horns of the retinectomy above the horizontal meridian, or supported by a scleral buckle (Figure 3). Because the circumferential retinectomy relieves anterior-posterior traction, if the horns of the retinectomy are angled obliquely and toward the ora serrata, this reduces circumferential traction (Figures 2C, 3B). Removing the residual anterior retina not only removes the ischemic stimulus for anterior-segment neovascularization but also prevents anterior loop PVR with contraction on the ciliary body and the horns of the retinectomy. Proliferative vitreoretinopathy can also pull up the edges of the retinectomy, resulting in retinal redetachment. If the retinectomy will be greater than 270°, then extension to 360° should be completed, and if there is a small bridge of intact retina between 2 retinectomies, then that bridge of tissue should be removed.

 

Figure 3. This patient had a history of multiple retinal detachment repairs with vitrectomy, endolaser, and silicone oil placement. Note the superonasal peripheral exudative hemorrhagic chorioretinopathy lesions. Recurrent inferotemporal retinal detachment was noted from about 3 o’clock to 7 o’clock positions with prior dense laser (A). Due to the dense laser, a complete 180° inferior retinectomy could not be achieved (B). A scleral buckle was placed to support the inferior horn at approximately the 6 o’clock position. Note the oblique angle of the temporal horn of the retinectomy. Images courtesy of Xi Chen MD, PhD.
Figure 3. This patient had a history of multiple retinal detachment repairs with vitrectomy, endolaser, and silicone oil placement. Note the superonasal peripheral exudative hemorrhagic chorioretinopathy lesions. Recurrent inferotemporal retinal detachment was noted from about 3 o’clock to 7 o’clock positions with prior dense laser (A). Due to the dense laser, a complete 180° inferior retinectomy could not be achieved (B). A scleral buckle was placed to support the inferior horn at approximately the 6 o’clock position. Note the oblique angle of the temporal horn of the retinectomy. Images courtesy of Xi Chen MD, PhD.

 

MANAGEMENT OF RETINAL INCARCERATION

Relaxing retinectomy is often necessary if retinal incarceration occurs following an open-globe injury. The retina may become incarcerated due to extrusion of intraocular contents at the time of injury or due to fibrovascular proliferation at the wound site.5 Vitrectomy, posterior vitreous detachment (PVD) induction with removal of vitreous hemorrhage, and careful membrane peeling should be completed. Then, if the scleral wound is relatively recent, using a pick or forceps, the retina may be gently teased from the incarceration site. Of note, the sclera at the site of the injury usually requires 4 to 7 days to heal following injury.5 In cases of an impact or exit site from an intraocular foreign body (IOFB), a circumferential retinotomy can be considered. If there is significant retinal foreshortening and fixed folds that do not improve after PVR membrane peeling, a larger relaxing retinectomy may be necessary (Figure 4).

 

Figure 4. This patient had a retained metallic intraocular foreign body, and the impact site can be seen posteriorly (A; red circle). Due to a contracted edge that developed at the impact site, a scleral buckle was placed, and a temporal retinectomy was performed instead of a circumferential retinotomy (B). The inferior horn of the temporal retinectomy was supported by the scleral buckle. Images courtesy of Lejla Vajzovic, MD.
Figure 4. This patient had a retained metallic intraocular foreign body, and the impact site can be seen posteriorly (A; red circle). Due to a contracted edge that developed at the impact site, a scleral buckle was placed, and a temporal retinectomy was performed instead of a circumferential retinotomy (B). The inferior horn of the temporal retinectomy was supported by the scleral buckle. Images courtesy of Lejla Vajzovic, MD.

 

If a suprachoroidal hemorrhage leads to retinal incarceration into an anterior-segment wound or if a larger penetrating laceration with retinal incarceration occurs, a larger 360° retinectomy may be needed. Perfluorocarbon liquid can be an extremely helpful adjunct in these cases because it can stabilize the posterior retina, open the funnel of the RD, and reattach the retina prior to endolaser application.

COMPLICATIONS

There are a range of complications and sequelae that can occur with retinectomy: retinal or choroidal hemorrhage, hypotony, subretinal PFCL, inability to unfold and reattach retina, visual field loss, fibrous proliferation from PVR, and epiretinal membrane formation, among others.

Retinal hemorrhage during retinectomy can be minimized with the strategic use of diathermy. The presence of a chronic RD can result in the development of retinal neovascularization from secondary retinal ischemia. Postoperative vitreous hemorrhage, particularly under silicone oil, can also contribute to fibrous proliferation. Further, choroidal hemorrhage due to iatrogenic trauma from the scissors or vitrector during the creation of the retinectomy can result in significant hemorrhage (Figure 5). Raising the intraocular pressure and further cauterization with diathermy may slow or stop the bleeding. If needed, forceps can be used to grab a piece of the anterior residual retina, and this tissue can even be used to press against the bleeding vessel to attempt to tamponade it.

 

Figure 5. An iatrogenic choroidal hemorrhage (yellow circle) was caused by the vitrector when trying to lift and cut attached retina. The intraocular pressure was raised to 60 mmHg for one minute, and the bleeding stopped. Images courtesy of Cynthia Toth, MD.
Figure 5. An iatrogenic choroidal hemorrhage (yellow circle) was caused by the vitrector when trying to lift and cut attached retina. The intraocular pressure was raised to 60 mmHg for one minute, and the bleeding stopped. Images courtesy of Cynthia Toth, MD.

 

Postoperative hypotony is not uncommon after a large retinectomy, and historically, retinectomy has been proposed for treatment of intractable glaucoma. Hypotony occurs due to ciliary body detachment or cyclitic membrane formation, and/or a large area of exposed RPE, resulting in increased absorption of intraocular fluid. Surgical management can be considered if the patient has symptomatic hypotony maculopathy. An endoscopic approach and peeling of the cyclitic membranes can be attempted. Alternatively, silicone oil can be placed, which may help maintain intraocular pressure and possibly delay phthisis.

Subretinal PFCL can occur, particularly with larger relaxing retinectomies. Having a closed vitrectomy system with valved cannulas helps prevent the formation of multiple small PFCL bubbles that could slip into the subretinal space. If subretinal PFCL is noted postoperatively, the decision to remove it is based on its size and location.

In rare cases, the retina cannot be fully unfolded and reattached. Filling the eye entirely with PFCL or a fluid-air exchange is performed to judge if the retina will lay flat. If not, then further retinectomy is required. However, the more posteriorly the retinectomy is located, the greater the visual field loss. In rare cases due to the proximity to the macula or optic nerve, further retinectomy must be abandoned (Figure 6).

 

Figure 6. A patient presented with a metallic intraocular foreign body with a posterior impact site adjacent to the optic nerve inferonasally. An intraoperative image (A) shows that there was still contraction along the inferior edge of the retinectomy under perfluorocarbon liquid but due to the proximity to the optic nerve and macula, the decision was made not to remove additional retina posteriorly. Postoperatively, the patient had significant fibrosis along this edge, but the retina remained attached under oil (B). Images courtesy of Durga Borkar, MD.
Figure 6. A patient presented with a metallic intraocular foreign body with a posterior impact site adjacent to the optic nerve inferonasally. An intraoperative image (A) shows that there was still contraction along the inferior edge of the retinectomy under perfluorocarbon liquid but due to the proximity to the optic nerve and macula, the decision was made not to remove additional retina posteriorly. Postoperatively, the patient had significant fibrosis along this edge, but the retina remained attached under oil (B). Images courtesy of Durga Borkar, MD.

 

During retinectomy, particularly under silicone oil, hemorrhage may result in significant fibrous proliferation and redetachment due to PVR. With large areas of exposed RPE cells, pigment can migrate and cause PVR membranes away from the retinectomy. Development of an epiretinal membrane is common after retinectomy and retinal reattachment; therefore, internal limiting membrane peel at the time of surgery to decrease the risk of epiretinal membrane formation may be considered.

CONCLUSION

Relaxing retinectomy is a useful technique in a retinal surgeon’s armamentarium for complex retinal detachment surgeries. RP

Grant A. Justin, MD, is a vitreoretinal surgery fellow at Duke University Eye Center in Durham, North Carolina. He reports no relevant disclosures. Sharon Fekrat, MD, FASRS, is a retina surgeon and professor of ophthalmology at Duke University Eye Center. She reports no relevant disclosures. Reach Dr. Fekrat at sharon.fekrat@duke.edu.

REFERENCES

  1. Abrams GW, Garcia-Valenzuela E, Nanda SK. Retinotomies and retinectomies. In Schachat AP, ed. Ryan’s Retina. Sixth edition. Edinburgh; New York: Elsevier. 2018;2052-2072.
  2. Machemer R. Retinotomy. Am J Ophthalmol. 1981;92(6):768-774. doi:10.1016/s0002-9394(14)75627-2
  3. Zivojnović R, Mertens DA, Peperkamp E. [Liquid silicone in amotio surgery (II). Report on 280 cases - further development of the technic]. Klin Monbl Augenheilkd. 1982;181(6):444-452.
  4. Haut J, Seigle P, Larricart P, Flamand M, Vachet JM. Circular subtotal retinectomy and inferior semicircular retinotomy: preliminary report. Ophthalmologica. 1985;191(2):65-74. doi:10.1159/000309556
  5. Abrams GW, Topping TM, Machemer R. Vitrectomy for injury: the effect on intraocular proliferation following perforation of the posterior segment of the rabbit eye. Arch Ophthalmol. 1979;97(4):743-748. doi:10.1001/archopht.1979.01020010395025

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