Giant retinal tear is defined as a full-thickness circumferential break in the retina extending more than three clock hours or 90 degrees.1,2 GRTs arise from liquefaction of central vitreous and peripheral vitreous condensation with concomitant traction at the vitreous base. As a result, the retina tears circumferentially at the posterior vitreous base.3
For GRTs, the vitreous gel remains attached to the anterior flap of the retina, while the posterior retina moves freely and can fold upon itself.3 An important distinguishing factor between GRTs and dialyses is the status of the vitreous. In a dialysis, the
vitreous is attached; in GRTs, the posterior vitreous is detached.
The incidence of GRTs is about 0.05: 100,000 per year.4 GRTs are mostly idiopathic; however, they can occur in the setting of trauma, cataract surgery, young age, high myopia, aphakia, pseudophakia or genetic mutations.2,5–10 The incidence of GRTs is estimated at 1.5 percent of rhegmatogenous retinal detachments (RRD),3 and proliferative vitreoretinopathy (PVR) may occur in cases of GRTs causing surgical failure or vision loss.
In 1962, Charles L. Schepens, MD, and colleagues were among the first to report on the difficulties of managing RD with GRT and the importance of performing timely surgery to minimize PVR.11 Despite advancements of surgical instruments and techniques, the management of RD with GRT is still a surgical challenge because of the technical difficulties and associated complications. In this article, we describe our opinions related to surgical management for RD with GRT.
Currently, pars plana vitrectomy is considered to be the conventional and standard procedure to repair RD with GRT.12 Unfolding GRTs can be achieved by using PPV followed by intraoperative perfluorocarbon liquid.
Figure 1. Preoperative wide-angle color photograph shows a retinal detachment with a giant retinal tear in a 66-year-old pseudophakic man. He experienced a shadow in the vision of his right eye for a week. Visual acuity was 20/30 OD, 20/25 OS. Optical coherence tomography preoperatively shows that the fovea is still attached.
For pseudophakic eyes without PVR, PPV without scleral buckling is commonly used for RD with GRT. Without a scleral buckle, meticulous vitreous base trimming with scleral indentation and appropriate tamponade are usually adequate for vitreous-base dissection and GRT reapposition in cases with no significant PVR.6,13,14
During PPV, a thorough vitrectomy is necessary. Pay attention to remove all the vitreous and traction to the retinal break. You can use PFCL to flatten the retina by using a dual-bore cannula. You can safely remove the anterior vitreous using the vitrectomy probe with the assistance of a scleral depressor when the posterior retina is stabilized. Incomplete removal of the anterior vitreous around the GRT might lead to redetachment and occurrence of PVR.
The fluid-air exchange is crucial in GRT vitrectomy. It’s important to remove the fluid anterior to the PFCL to prevent the slippage of the retina before the removal of PFCL. At the conclusion of the surgery, the eye can be filled with either gas or oil.
To add a buckle or not
We don’t recommend performing a lensectomy in a phakic GRT case because the modern small-gauge cutters can facilitate a thorough vitrectomy while respecting the crystalline lens.
Dr. Papakostas demonstrates the key steps in his technique for repairing a giant retinal tear.
Reports on adjuvant scleral buckle
The literature has shown a trend for higher anatomical success rates for patients who had adjuvant scleral buckle compared to those who had PPV only.16–22 However, these studies haven’t shown an advantage to using an encircling buckle in addition to PPV in terms of anatomical or visual acuity outcomes for RD with GRT.2,20 In addition, the reoperation rates were higher in cases with encircling buckles23,24 compared to those without encircling buckles.24,25
These studies generally had small sample sizes, and it’s difficult to compare these results due to the difference in the clinical characteristics of the study subjects and surgical techniques or procedures. More recently, John D. Pitcher, MD, and colleagues reported that adding a buckle did not significantly alter the success rates in GRT associated RDs.26
Gas or oil?
We usually use long-acting gas (14% C3F8) as a tamponade agent. Silicone oil can be used in cases of PVR or during a direct PFCL-SO exchange in cases of retinal slippage. David G. Charteris, MD, and his group at Moorfields Eye Hospital reported that eyes with gas as tamponade achieved better vision, had fewer postoperative complications and there was no difference in final attachment rates when compared to the eyes that received silicone oil.27
Figure 2. Six months postoperatively, photography and optical coherence tomography show the retina is attached. Visual acuity is 20/25.
Role of prophylactic laser
The use of laser in these cases is controversial because of the lack of evidence. One study from Italy with long-term follow-up showed that the group that received prophylactic laser had a higher incidence of tears with localized pre-equatorial RD and lower incidence of macula-off GRT RDs compared to the observation group.28 To get an unequivocal answer to this question would require a randomized trial consisting of 645 eyes in each group with a minimum follow-up of five years.
The bottom line
The prognosis of managing GRTs has improved over the recent years with better instrumentation and surgical visualization. Surgical advances include small-gauge PPV for managing RD with GRT.29–31
From our perspective, vitreoretinal surgeons should pay attention to the key steps of vitrectomy to increase the surgical success, including complete removal of the anterior vitreous and release of the traction on the retinal breaks, identifying and treating all breaks, and prevention of slippage of the retina. Although adjuvant buckling is associated with good anatomical success rates, emerging research has shown high anatomical success rates using PPV alone in managing RD with GRT.6,14,16,26,32
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