A comprehensive account on the current management trends of giant retinal tears

1. GIANT RETINAL
TEARS
DULEEPA BARANAGE
Senior Registrar in Vitreo-Retinal Surgery

2. INTRODUCTION
• Full thickness, circumferential tears of more than
90⁰ of retina
• Associated with vitreous detachment
• Can occur spontaneously, but often associated with
number of conditions

4. INCIDENCE / AEITIOLOGY
• 1.5% of RRDs
• Average age – 42 years
• Males 72%
• Causes
• Idiopathic - 54%
• High myopia – 25%
• Hereditary conditions – 14%
• Mafans’s, Stickler-Wagner, Ehrler Danlos Xd
• Trauma – 12.3%
• Bilateral in 12.8%
• Incidence – 0.05/100,000 per year

5. PATHOGENESIS
• Liquefaction of central vitreous
• Peripheral vitreous condensation
• Concomitant traction at the vitreous base
• The neurosensory retina tears circumferentially in
the area of the posterior vitreous base
• Vitreous gel attached to the anterior flap
• Posterior flap moves freely and can fold upon itself
[In retinal dialyses the vitreous is adherent to the
posterior aspect of the retinal tear, therefore the
retina is not very mobile – laser/ scleral buckle]

6. MANAGEMENT
• Perfluorcarbon liquids were described by Stanely
Chang in 1987
• Increased the primary attachment rate from 58% to
over 94% (inverted surgical beds/ retinal tracks/
sutures..)
• Options…
• Laser photocoagulation
• Scleral buckle
• Primary vitrectomy with PFCL
• Vitrectomy + buckle
• Combined phaco/ vitrectomy

7. • Laser
• When the retina is attached
• Edge of the tear is treated with 2-4 rows of
photocoagulation
• Particularly the radial edges of the tear, treat anteriorly
up to the ora serrata
• Scleral buckle
• If the edge is not inverted
• Good option in children (lens protection/ positioning)
• Support of the edges + cryo/laser
• PPV + PFCL + gas/SiO tamponade
• To unroll and reposition a folded retina
• PPV + buckle
• In PVR

8. 25-gauge vitrectomy…
• ADVANTAGES
• Less trauma
• Smaller incisions
• Reduced sclerotomy complications
• Shortened surgical times
• CHALLENGES
• Slower removal of vitreous
• Some difficulty reaching the anterior retina and vitreous
near the ora serrata
• Flexible instruments
• More prolonged aspiration time during the air/ fluid
exchange (crucial to prevent retinal slippage)

9. SURGICAL TECHNIQUES

10. 1. Removal of all the
vitreous posteriorly
and injection of
perfluoro-octane
liquid over the optic
nerve
• Done slowly with a
dual bore cannula
(to prevent trauma
and IOP elevation)
• PFCL as a single
bubble (prevent fish
eggs)

11. 2. Once the retina is
stabilized posteriorly,
the anterior vitreous
and the anterior
retinal flap are
removed
• Chandelier illumination
and scleral depression
aid in the visualization
• Paramount to remove all
the vitreous, esp. the
corners (to prevent
redetachment)

13. 3. More PFCL is
added to further
flatten the retina over
the level of the edge
of the tear
• Keep the PFCL level
below the infusion to
avoid the formation of
fish eggs
• Retina can be unfolded
with forceps, with a
soft-tip cannula or with
a vitreous rake loop

14. 4. All of the anterior flap and vitreous need to be
thoroughly removed
• Especially all possible vitreous traction on the corners
since this is the area where any residual vitreous
traction can cause proliferation, traction and
redetachment

15. 5. If epiretinal
membranes, star
folds, or macular
holes are present,
membranes and
the ILM can be
peeled through
the PFCL
• Staining can be
done prior to
injecting PFCL

16. 6. Laser is applied
to the corners and
edge of the tear
• Two to three rows
up to the ora serrata
• Using a curved laser
probe
• Rest of the retina
should be checked
for small breaks etc..

17. 7. Fluid – Air Exchange
• Aspiration of all fluid
anterior to the PFCL
meniscus with a soft tip
cannula
• To prevent retinal
slippage
• Residual PFCL aspirated
over the optic nerve
• Eye filed with minimally
expanding conc. of gas
• If SiO used direct
PFCL/SiO exchange
preferred to prevent
retinal slippage

18. PHAKIC EYES
1. PRESERVE THE LENS
• Chandelier illumination – scleral depression can be used
to remove the anterior flap without causing trauma to
the lens
• Advantage- accurate lens calculations/ risk of losing
pupillary dilatation from lens removal is avoided
• Disadvantage – technically difficult to clear the anterior
vitreous and retinal flap
2. PHACOEMULSIFICATION / PARS PLANA
LENSECTOMY
• Concomitant / secondary IOL
• Advantage – easier access to anterior vitreous
• Disadvantage – extra procedures / imprecise lens
calculation / poor visibility due to pupillary miosis

19. PROLIFERATIVE VITREORETINOPATHY
• Not uncommon in GRT
• RPE dispersion + VH
• Occur in 45%
• More in trauma / chronic
• Pre-placing an encircling silicone scleral buckle
(#41/#42)
• Removal of all fibrous proliferation on both surfaces of
the retina
• Subretinal before and on the surface after PFCL injection
• Scleral buckle is placed and vitrectomy done as
described above
• Scleral buckle NOT ROUTINELY RECOMMENDED in eyes
without PVR
• Creation of retina redundancy > guttering > retinal slippage

20. COMPLICATIONS
• Retinal slippage during PFCL removal
• Retinal folds associated with slippage, SB or high
myopia
• Residual PFCL
• Cataract progression
• Recurrent RD with PVR
• Re-detachment Causes :
• Anterior traction and re-proliferation at the corners
• Missed breaks away from the tear
• Concomitant macular holes
• PVR (old/ blood/ pre-existing membranes/ pre-existing
PVR)

21. RESULTS
• Rate of reattachment following single procedure is
80 - 90%
• Final reattachment rate 94-100%
• In PVR – visual prognosis poor (despite
reattachment and anatomical success)

22. OTHER EYE
• 12.8% develop bilateral GRTs
• High risk in:
• High myopes
• White without pressure
• Vitreous condensation
• Peripheral pathology should be treated with laser
• Prophylactic buckle – controversial