Svasti-Salee CR, Dawkins RCH, Poulson AV, Snead MP. Single-Port Vitrectomy and “Oleodelamination” for the Management of Retinal Detachment Complicated by Proliferative Vitreoretinopathy. Retina. 2019;39 Suppl 1:S125-S128.
Open Access Video Link: https://d047c2cddb.site.internapcdn.net/permalink/iae/a/iae_2017_04_20_snead_216-1031_sdc1.mp4
In this surgical technique special edition of RETINA: The Journal of Retina and Vitreous Diseases, Svasti-Salee et al. present an extremely interesting method for the surgical management of retinal detachment complicated by proliferative vitreoretinopathy (PVR). The technique is best understood by watching the video included above in the open-access link.
To briefly summarize, the technique consists of a conjunctival peritomy, followed by the creation of a single 20-gauge pars plana sclerotomy which is advantageous for intraocular manipulation. Next, external drainage using a 23-gauge needle is performed. Following external drainage, and prior to performing any vitrectomy, silicone oil (SO) (5,700 centistoke utilized herein) is injected into the vitreous cavity under direct visualization using an indirect ophthalmoscope and condensing lens. As the silicone oil fills the vitreous cavity, subretinal fluid continues to externally drain. As the retina flattens more, the relatively inelastic PVR membranes and posterior hyaloid membrane are stretched taut. Ultimately, these preretinal PVR membranes reach their maximum point of stretch and preferentially split, allowing SO to herniate into the sub-hyaloid, pre-retinal space.
As SO continues to be injected (now occupying the sub-hyaloid and sub-PVR membrane space), the PVR membranes are ultimately separated from the surface of the retina in an en-bloc fashion. In this way, SO is used primarily as a surgical instrument and secondarily as an intraocular tamponade. The preretinal PVR membranes and posterior hyaloid face can then be removed en bloc through the single port using a pick, cutter, or forceps. Single port vitrectomy can then be performed around the silicone oil bubble with optimization of SO fill.
Retinopexy of the retinal breaks is then performed, typically using cryotherapy as illustrated in the video. in this series, the authors report single surgery success (full retinal attachment) in 11 out of 11 cases (at a mean of 2.7 years follow up) presenting with retinal detachment complicated by PVR, most of which had undergone prior unsuccessful surgeries. In 8 out of 11 patients (73%), the SO was successfully removed at a secondary procedure.
This technique is likely most advantageous in cases of primary PVR where the posterior hyaloid membrane is intact. One should also be aware of the possibility of subretinal SO migration.
While the technique of single-port vitrectomy and “oleodelamination” utilizing the indirect ophthalmoscope, a condensing lens, silicone oil, and a single port may not be ideal for all surgeons, it certainly inspires thought regarding surgical innovation and how we can continue to develop new techniques for optimizing patient outcomes.
Edward H. Wood, MD
The Byers Eye Institute at Stanford University
Palo Alto, CA