Retinal detachment (RD) due to posterior paracentral retinal breaks is a rare condition. In contrary to macular hole associated retinal detachment (MHRD), which is mostly often observed primarily in highly myopic eyes, posterior paracentral retinal breaks are often secondary. These breaks are either paravascular or juxtapapillary breaks related to pathologic myopia [
To treat RD due to posterior breaks, pars plana vitrectomy with air fluid exchange, accompanied by laser retinopexy around the breaks and either gas or silicone oil tamponade nowadays, are mostly used [
The inverted internal limiting membrane (ILM) flap technique has been increasingly used for refractory macular hole (MH) [
This was a retrospective, consecutive case-series study conducted at Changhua Christian Hospital. The study was approved by the Ethics Committee and Research Board of Changhua Christian Hospital, and all procedures adhered to the Declaration of Helsinki. Informed consent was obtained from each patient.
We included patients with RD and posterior paracentral retinal breaks located within the equator from January 2017 to January 2018. Eyes with macular hole were excluded. All of the cases underwent standard pars plana vitrectomy using the ILM flap technique, accompanied by extended gas tamponade without laser retinopexy. All operations were performed by a single experienced vitreoretinal surgeon (SN Chen).
All of the patients underwent thorough ophthalmological examinations including slit lamp and indirect ophthalmoscopy examinations, color fundus photography, and spectral-domain optical coherence tomography (OCT) (Heidelberg Spectralis, Germany) preoperatively and postoperatively. Data including age, gender, and Snellen best-corrected visual acuity (BCVA) were recorded. Infrared-autofluorescence imaging (HRA, Retinal Angiograph; Heidelberg Engineering, Heidelberg, Germany) and spectral-domain OCT were used postoperatively to localize the retinal breaks. All of the patients were followed up at outpatient clinics for at least 3 months after the surgery.
Pars plana vitrectomy was performed in all patients with a 23-gauge vitrectomy probe using a constellation system (Alcon Laboratories, Inc., Fort Worth, TX). After core vitrectomy and trimming of peripheral vitreous, cortical vitreous stripping with or without triamcinolone acetonide assistance was performed within the arcade and around the breaks in all eyes. The ILM was then stained with indocyanine green (ICG) solution (25 mg ICG in 15 ml 5% glucose-water solution, final concentration = 1.7 mg/ml) followed by subretinal fluid drainage through the posterior breaks with soft tip until the retina was almost attached. The ILM flap was then prepared by first peeling ILM in a circular fashion to create an ILM island. The size of the ILM island was dependent on the size of retinal break, and the diameter of ILM island was at least twice than that of the break. ILM was peeled with a hinge attached to the break. Then, the inverted ILM flap was inserted into the breaks. Basically, total ILM peeling around the breaks was performed if possible but for those breaks with difficulty in peeling the surrounding ILM or peeling as an inverted flap, we harvest free ILM flap in a whole piece from other site within posterior pole. Then the free ILM flap was transplanted into the breaks.
An incomplete air-fluid exchange was then performed. Pan-retinal photocoagulation was performed in eyes with PDR. Sulfur hexafluoride (SF6) with a concentration from 20% to 40% was infused in seven eyes, and perfluoropropane (C3F8) with a concentration from 7% to 20% was infused in two eyes. The concentration of gas depended on the residual amount of subretinal fluid at the end of surgery. The patients were instructed to maintain a prone position after the operation for 1 week (see supplemental digital content for the video (available
Snellen BCVA was converted to the logarithm of minimal angle of resolution (LogMAR) for statistical analysis. Preoperative and postoperative BCVA values were compared using the Wilcoxon signed-rank test for nonparametric analysis. All analyses were performed using MedCalc software version 18 (MedCalc Software, Mariakerke, Belgium).
There were nine consecutive cases (five males and four females) with an average age of 56.89 ± 9.61 years (range, 45 to 74 years).
Two cases had primary rhegmatogenous retinal detachment (RRD) (cases 1 and 2, Figure
A 67-year-old male patient (case 1) with shadow vision in the left eye for 1 week with a corrected visual acuity of 20/60. Primary rhegmatogenous retinal detachment (RRD) of the posterior pole of the left eye was noted at our clinic (a). The break was located within vascular arcade, near the inferior temporal vessel and well identified by preoperative optical coherence tomography (OCT, b). He underwent vitrectomy with inverted internal limiting membrane (ILM) flap technique, accompanied by 30% sulfur hexafluoride infusion. Two weeks postoperatively after the absorption of air, the retina was well attached (c). Magnified OCT showed that the break had sealed, the presence of the ILM flap, and absorption of the subretinal fluid (d). His visual acuity improved to 20/40 (see supplemental digital content of the video (available
Three had secondary RRD after membrane peeling for either macular pucker or foveoschisis (cases 3, 8, and 9; Figure
A 46-year-old highly myopic male patient (case 8) had a previous history of vitrectomy, internal limiting membrane (ILM) peeling, and semicircular ILM flap over the fovea for foveoschisis in his right eye. He developed retinal detachment over his right eye 2 months later (a). Preoperative optical coherence tomography (OCT) showed a small break located temporally within the posterior pole (b). After vitrectomy, an inverted ILM flap was made and inserted into the small break with 24% sulfur hexafluoride gas tamponade. The retina was found to be reattached 2 weeks later, and infrared autofluorescence imaging showed a hyperfluorescent spot of the ILM plug corresponding to the previous retinal break (c). Postoperative OCT confirmed ILM tissue at the site of the previous break (d).
Two had intraoperative iatrogenic breaks during the surgery for TRD (cases 4 and 6, Figure
A 57-year-old male patient (case 6) with proliferative diabetic retinopathy underwent vitrectomy for vitreous hemorrhage and tractional retinal detachment. During surgery, an iatrogenic break was made during the delamination process. After internal limiting membrane (ILM) peeling, a free ILM flap was inserted into the break, followed by panretinal retinal photocoagulation without using the laser around the break, and 24% sulfur hexafluoride gas tamponade. Two weeks later, fundus photography showed that the retina was attached (a). Follow-up optical coherence tomography and infrared autofluorescence photography showed ILM tissue over the break area (b, c).
One had CTRRD (case 5), and one had recurrent RD with PVR (case 7). Table
Demographic data of patients.
Case/age/sex/eye | Retinal detachment type | Tamponade | Best-corrected visual acuity in LogMAR | Duration of follow-up (months) | |
---|---|---|---|---|---|
Initial | Final | ||||
1/67/M/OS | Primary RRD | 30% SF6 | 0.5 | 0.3 | 6 |
2/74/M/OD | Primary RRD (high myopia) | 40% SF6 | 2 | 0.7 | 3 |
3/51/F/OS | Secondary RRD (post ILM peeling) | 40% SF6 | 0.7 | 0 | 5 |
4/45/F/OD | PDR + TRD + iatrogenic intraoperative break | 7% C3F8 | 0.8 | 1.3 | 3 |
5/63/M/OS | CTRRD (PDR) | 24% SF6 + blood | 1 | 0.7 | 6 |
6/57/M/OS | PDR + TRD + iatrogenic intraoperative break | 22% SF6 | 1 | 0.4 | 3 |
7/54/F/OS | Recurrent RRD with PVR | 20% C3F8 | 2 | 1.3 | 6 |
8/46/M/OD | Secondary RRD (post ILM peeling) | 24% SF6 + blood | 1.6 | 1.3 | 8 |
9/55/F/OD | Secondary RRD (post ILM peeling) | 24% SF6 | 1 | 0.7 | 8 |
C3F8: perfluoropropane; CTRRD: combined tractional and rhegmatogenous retinal detachment; F: female; ILM: internal limiting membrane; M: male; PDR: proliferative diabetic retinopathy; PVR: proliferative vitreoretinopathy; RRD: rhegmatogenous retinal detachment; SF6: sulfur hexafluoride; TRD: tractional retinal detachment.
The inverted ILM flap could only be performed in two eyes (cases 1 and 8). Free ILM flap was performed in the other 7 eyes, because the inverted ILM flap could not be achieved in the following conditions: first, for eyes with previous ILM peeling, there is no ILM around the breaks (cases 3 and 9). Second, for a highly myopic eye with peripapillary break and extremely adherent vitreous around the breaks, the vitreous could be peeled (case 2), and third, eyes of TRD with iatrogenic breaks (cases 4 and 6) or for eyes of CTRRD 9 (cases 5 and 7), in which the retina surface is rigid and uneven around the breaks, an inverted ILM flap is impossible to be obtained. The free ILM flaps were harvested within the macular area in 5 eyes (cases 2–7). In the other 2 eyes (cases 3 and 9), because of the previous extensive ILM peeling within the arcade, the free ILM flaps were harvested at an area outside the arcade, where residual ILM was feasible. The retina was successfully reattached in all eyes, and fundus examinations and OCT confirmed that the retinal breaks had been sealed. No major complication was observed postoperatively. The average visual acuity in LogMAR statistically significantly improved from 1.18 ± 0.55 preoperatively to 0.74 ± 0.47 postoperatively (
Several methods had been proposed to manage RD due to posterior retinal breaks, including pars plana vitrectomy with silicone oil or gas tamponade, macular buckles [
In this study, we found that it is not always possible to peel ILM as an inverted flap around the retinal breaks. Thus, most cases in our series have free ILM flap transplantation. Recently, we demonstrated that in cases with MHRD, multiple pieces of free ILM flap insertion into macular hole could efficiently close the macular hole and reattach the retina without the assistance of perfluorocarbon liquid [
In this study, we used larger ILM flap and then inserted the flap to plug into the breaks without the assistance of perfluorocarbon. This proved to be effective, as infrared autofluorescence localization and OCT showed that the ILM flaps stayed in place during subsequent follow-up in all of our cases. Instead of silicone oil tamponade, either sulfur hexafluoride or perfluoropropane was used in our cases which was reabsorbed spontaneously within 2 weeks. It indicated that the glial tissue would grow over the flap to seal those paracentral breaks within weeks and only gas tamponade is sufficient.
We also noted in some cases that ILM peeling or even cortical vitreous removal around the retinal breaks is not applicable. It is quite different from the previous reported methods in treating MHRD, in which ILM peeling around macular hole was always performed, regardless of using the inverted ILM technique or the free ILM flap technique. In our cases of using free ILM flaps due to difficulty in peeling cortical vitreous and ILM around the breaks, we found the breaks could still be closed. It may indicate that healing of retinal paracentral breaks assisted by free ILM flaps may be strong enough to counteract the tractional force of the remaining ILM and cortical vitreous.
In this study, incomplete air-fluid exchange was used to prevent the residual subretinal fluid gaining access into intravitreal space, pushing and displacing the inverted or free ILM flap away from the retinal breaks. Therefore, gas with expansile concentration was used dependenting on the amount of residual subretinal fluid. The most common postoperative complication in this study was ocular hypertension. Four eyes (cases 1–3 and 7) had transient IOP elevations several days after the surgery due to gas expansion. The elevated IOP returned to normal within 2 weeks after onset.
Recently, Park et al. [
The limitation of this study includes the retrospective nature, small number of cases, and short period of follow up. In addition, there are several limitations to this technique. First, this technique could only be used for small retinal breaks. It is more technically challenging to harvest a large sheet of ILM as a whole piece on detached retina. Second, it is sometimes difficult to harvest enough ILM tissue in eyes with previous ILM peeling. Third, although there are good surgical outcome in our study, we did not compare the different ILM methods in the break closure rate owing to the small number of case using the inverted ILM flap. A larger number of cases and a longer follow-up period are necessary to elucidate the efficacy and potential complications in long-term follow-up.
In conclusion, using ILM flap offers some advantages over traditional laser retinopexy, by recovering anatomical structure and preventing complications from laser photocoagulation. Overall, the surgical outcome by using the ILM flap in management retinal detachment due to posterior paracentral retinal breaks is satisfying, with significant visual acuity improvement.
No data were used to support this study.
This retrospective chart review study was approved by IRB review. It should be noted that this article does not contain any personal medical information about an identifiable living individual.
The authors declare that there are no conflicts of interest regarding the publication of this article.
Supplementary material 1: this video demonstrated the surgical procedure of using internal limiting membrane (ILM) flap for rhegmatogenous retinal detachment of our patient (case 1). After vitrectomy, the break and associated retinal detachment was well identified. Indocyanie green (ICG) staining and ILM peeling in an inverted flap fashion were performed. The ILM inverted flap was then inserted into the break, and the correct position of the flap was confirmed after air-fluid exchange. No laser retinopexy for the break was performed. Then, 30% sulfur hexafluoride (SF6) was infused. The patients were instructed to maintain a prone position after the operation for 1 week.