Pars Plana Vitrectomy in theManagement of RetinalDetachments Associated withDegenerative RetinoschisisSCOTI R. SNEED, MD, CHRISTOPHER F. BLODI, MD, JAMES C. FOLK, MD,THOMAS A.. WEINGEIST, MD, PhD, JOSE S. PULIDO, MD

Abstract: Pars plana vitrectomy and gas-fluid exchange were used to suc­cessfully reattach eyes of 12 patients who had symptomatic retinoschisis retinaldetachments (RDs) associated with large or posterior outer-layer holes. Visualacuity improved postoperatively in seven (58%) eyes, was unchanged in two(17%) eyes, and decreased in three (25%) eyes. Loss of vision was secondaryto a mild posterior subcapsular cataract in one eye and to epiretinal membranesin the other two. In two other eyes, cataracts developed that subsequentlyrequired an extracapsular cataract extraction (ECCE) and posterior chamberintraocular lens (PC IOL) implantation with 20/20 visual acuity in both eyes aftercataract surgery. All eyes with a macula-involved RD stabilized or improved invisual acuity . Surgical indications, techniques, and results in the managementof these retinoschisis RDs are discussed. Ophthalmology 1990; 97:470-474

Senile retinoschisis is a relatively common degenerativedisorder of the peripheral retina in patients 50 years ofage or older. Outer-layer breaks have been found in 10%1to 27%2 ofeyes with senile retinoschisis. Byer! found that56% ofeyes with outer-layer breaks had a non progressiveschisis detachment. Some patients, however, do have pro­gressive detachments and schisis. Several authors havereported the surgical treatment of these retinal detach­ments (RDs).3-9The use ofpars plana vitrectomy has beendescribed in the management of only two cases of schisisdetachments." We report 12 additional cases of symp­tomatic schisis RDs that were managed mainly with parsplana vitrectomy.

Originally received : March 8, 1989.Revision accepted: September 15, 1989.

From the Department of Ophthalmology, University of Iowa Hospitals andClinics, Iowa City.Dr. Sneed is currently affiliatedwith the W. K. Kellogg Eye Center. Universityof Michigan, Ann Arbor.

Supported in part by the Retina Research Fund of the University of Iowaand an unrestricted grant from Research to Prevent Blindness , New York,New York.

Reprint requests to Christopher F. Blodi, MD, Department of Ophthal­mology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

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MATERIALS AND METHODS

The medical records of 16 patients who were operatedon for retinoschisis RDs at the University of Iowa Hos­pitals and Clinics from January 1984 to December 1988were retrospectively analyzed. Four of these patients hadsmall to moderately sized peripheral outer retinal breaksand were treated successfully with traditional scleralbuckling procedures alone. When larger and more pos­terior outer-layer breaks were present, a pars plana vit­rectomy was included as an integral part of the operativeprocedure. There were 12 patients in this group (Table1). All patients were initially examined for symptomaticRDs. Ten patients had macular involvement causing vi­sualloss. The remaining two patients with macula-spareddetachments had noted visual field loss and had detach­ments well posterior to the equator. One to seven largeposterior outer-layer holes were identified in all instancesand inner-layer holes were found in 8 of the 12 eyes. Nopatients had tractional detachments, nor was focal vitreo­retinal traction present at the site of any inner retinalholes. However, the vitreous was usually attached overthe schisis cavity. Because ofthe size and location oftheseholes, they were treated with the following technique: first,

SNEED et al • SCHISIS DETACHMENT

Table 1. Summary of Retinoschisis/Retinal Detachment Cases Treated with Pars Plana Vitrectomy

Visual AcuityCase FOllow-up SurgicalNo. Age (yrs)/Sex Preoperative Postoperative (rnos) Typeof Surgery Result

1 50/F 20/100 20/20 23 PPV. laser, AFX~ A2 41 /M 20/25 20/30 30 1)Pneumatic retinopexy

2) PPV, PPL, laser, AFX~ A3 79/F HM 20/400 10 PPV, SSP, AFX~ A4 69/M 20/750 20/200 26 PPV, SSP. AFX~, ED A5 58/F 20/20 20/40 54 PPV, SSP, AFX~, ED A6 67/F CF CF 29 (1) SSP

(2) PPV. SSP, AFX~ A7 70/F 20/25 20/60 6 PPV, SSP, AFX~ A8 51 /M 20/50 20/25 8 PPV. SSP. laser, AFX~ A9 77/M HM 20/200 6 (1) PPV. SSP, AFX~

(2) PPL. PPV. MX. SSP.laser. AFX~ . ED A

10 74/M 20/300 20/50 37 (1) SEP(2) PPV. SSP. laser.

AFX~, ED A11 54/F HM 20/20 6 PPV, SSP, AFX~ . ED A12 67/M 20/500 20/500 6 PPV, SSP, AFX~ A

PPV = pars plana vitrectomy; AFX~ = air-fluid exchange; PPL = pars plana lensectomy; HM = hand motions; SSP = scleral buckling procedure;CF = counting fingers; ED = external drainage of subretinal fluid; A = attached; MX = posterior membranectomy.

Fig 1. Case I. Inferotemporal macula-involved schisis retinal detachment,left eye.

a standard three-port pars plana vitrectomy was per­formed. As much as possible, attached vitreous over theschisis cavity was removed. A plan ned retino tomy wascreated, usually with intraocular diathermy, in the innerschisis layer over a conveniently located outer-layer hole.If a large inner-layer break was already present, this wasused instead of creating a retinotomy. A soft-tipped 10 orconventional extrusion needle was placed through the in­ner-layer hole and also through or at least into the outer­layer hole. The cannula was inserted through the outer­layer hole to ensure drainage of both the RD and schisiscavity rathe r than the schisis cavity alone. A gas-fluid ex­change was then performed and the subretinal fluid and

the schisis cavity were drained and collapsed. If the RDwas completely flattened, endolaser was applied aroundthe outer layer hole(s). Alternatively, transscleral cryopexywas administered if a small amount of subretinal fluidpersisted. A long-acting gas (perfluoropropane or SF6) wasinjected into the vitreous cavity before closing the sclerot­omies. A scleral buckle was used to relieve peripheral vit­reous traction or to support more peripheral outer-layerholes. In many eyes, this buckle was an anterio r encirclingelement prophylactically placed without any attempt tosupport the outer-layer holes. Ten of 12 eyes had a scleralbuckle placed during the course oftreatment. In five eyes,we drained subretinal fluid by an external approach; how­ever, we now think this is more cumbersome and lesscontrolled than draining fluid under direct observationinternally, either through a preexisting hole or through asurgical retinotomy.

CASE REPORTS

Case 1. A 50-year-old white woma n noticed that her visionwas decreased in the left eye when she took a driver's licenseexamination. She was seen I month later at the University ofIowa (April 15, 1987). Visual acuity at that time was 20/20 inthe right eye and 20/70 in the left. Slit-lamp examination findingswere unremarkable. Dilated ophthalmoscopic examinationfindings of the right eye were significant only for a peripheralarea ofinferotemporal retinoschisis. An inferotemporal macula­involved RD was present in the left eye (Fig I). There wereseveral large posterior outer-layer holes below the macula (Fig2) and several small inner-layer holes. Argon laser photocoag­ulation was initially placed around the outer-layer hole in anattempt to increase subretinal fluid resorption and to seal the

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OPHTHALMOLOGY • APRIL 1990 • VOLUME 97 • NUMBER 4

Fig 2. Case I. Large outer-layer holes in retinoschisis inferotemporal tothe macula with associated retinal detachment, left eye.

hole. This was unsuccessful and the retina remained detachedwith a visual acuity of 20/100 (May 27, 1987). On May 28,1987, a pars plana vitrectomy was performed. A retinotomy wascreated in the inner layer of the schisis cavity. A gas-fluid ex­change was performed and the RD and schisis cavity were flat­tened using an extrusion needle placed through the retinotomy.Argon endolaser photocoagulation was placed around the outer­layer hole and a 20% mixture of perfluoropropane was injectedinto the eye. The retina remained attached (Fig 3) although shal­low peripheral retinoschisis persisted inferotemporally. A pos­terior subcapsular cataract developed postoperatively and byNovember 1988 visual acuity had diminished to 20/200. Anextracapsular cataract extraction (ECCE) with posterior chamberintraocular lens (PC IOL) implantation was performed on No­vember 9, 1988, and in January 1989 visual acuity was 20/20and the retina was attached.

Case 2. A 40-year-old white man was initially seen at theUniversity ofIowa in October 1984. At that time, visual acuitywas 20/20 in the right eye and 20/15 in the left eye. Slit-lampexamination findings were unremarkable. Retinoschisis wasnoted bilaterally on dilated ophthalmoscopic examination (Fig4). Several large outer-layer holes were noted inferotemporallyin the right eye. No inner-layer or outer-layer holes were iden­tified in the left eye. No RD was present in either eye. The patientwas next seen on September 30, 1986. He had a 5-day historyof metamorphopsia and a nasal visual field defect in the left eye.Visual acuity was 20/20 in the right eye and 20/25 in the left.Dilated ophthalmoscopic examination findings of the right eyewere unchanged. In the left eye, a large posterior outer-layerhole was present temporal to the macula with multiple tiny inner­layer holes and an associated temporal RD (Fig 5). A pneumaticretinopexy was performed and laser was used to surround theouter-layer hole. Despite this procedure, the RD continued toprogress. On October 7, 1986, a pars plana vitrectomy was per­formed. Intraoperative cataractous lens changes required a parsplana lensectomy. A retinotomy was created in the inner layerand subretinal fluid and schisis fluid were removed with an ex­trusion needle during a gas-fluid exchange. The retina flattenedand endolaser was used to surround the outer-layer hole. A pro­phylactic encircling band was placed anteriorly. The postoper­ative course was unremarkable and when last seen 15 monthslater, the patient had visual acuity of 20/40 in the left eye withcontact lens correction. The retina was completely attached(Fig 6).

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Fig 3. Case I. Postoperative retinal reattachment and collapse of schisiscavity with inferior scarring secondary to laser photocoagulation, lefteye.

Fig 4. Case 2. Top and bottom, temporal retinoschisis, left eye, October1984.

Case 3. A 79-year-old white woman was initially seen at theUniversity of Iowa in July 1984. Visual acuity at that time was20/40 in the right eye and 20/30 in the left. Nuclear scleroticcataracts were present bilaterally. Retinoschisis was noted in-

SNEED et al • SCHISIS DETACHMENT

Fig 5. Case 2. Temporal retinal detachment with large outer-layer hole,left eye, September 1986.

Fig 6. Case 2. Postoperative retinal reattachment with temporal cho­rioretinal changes from laser photocoagulation, left eye.

ferotemporally in the dilated right eye on ophthalmoscopic ex­amination. Peripheral lattice degeneration was present in theleft eye. The patient was examined again on April 16, 1988. Shehad a 4-day history of decreased vision in the right eye. Visualacuity was limited to hand motions in the right eye and was 20/50 in the left eye. Results of slit-lamp examination detected 2+nuclear sclerosis in both eyes. Results of ophthalmoscopic ex­amination of the dilated right eye showed a bullous RD involvingthe inferotemporal periphery and macula. A large outer-layerhole was present temporally with an overlying inner-layer hole.A pars plana vitrectomy was performed on April 25, 1988. In­ternal drainage was performed through the preexisting inner­layer hole and the outer-layer hole with a cannulated extrusionneedle during a gas-fluid exchange. Cryopexy was used to sur­round the outer-layer hole and an encircling scleral buckle wasplaced to support the outer-layer hole. The patient was last seen7 months later with a visual acuity of 20/400 and a totally at­tached retina. Mild surface-wrinkling retinopathy was presentin the macula and there was a 2 to 3+ brunescent nuclear scle­rotic cataract.

RESULTS

All retinas were successfully reattached using pars planavitrectomy as part of the surgical procedure. Data on sur­gical technique and results are listed in Table 1. Beforethe vitrectomy, scleral buckling alone was unsuccessfulin two eyes (cases 6 and 10) and a pneumatic retinopexywas unsuccessful in an eye with multiple inner-layer holes(case 2). One eye that initially had 0-2 proliferativevitreoretinopathy!' required two surgical procedures be­fore successful retinal reattachment (case 9). Final post­operative visual acuity improved in seven (58%) eyes, wasunchanged in two (17%) eyes and decreased in three (25%)eyes. Loss of vision was caused by a mild posterior sub­capsular cataract in one eye (case 7) and an epiretinalmembrane in two eyes (cases 2 and 5). All eyes with amacula-involved retinal detachment showed improve­ment or stabilization of visual acuity after surgery.

DISCUSSION

Schisis detachments may be associated with large pos­terior outer-layer holes that are technically difficult to ap­proach with a standard scleral buckling procedure. Evenif a scleral buckling procedure can be performed, posteriorscleral buckles may cause significant macular distortionand some may need to be removed' Sulonen and others"described two cases ofschisis detachments with large pos­terior outer-layer holes that were successfully treated witha pars plana vitrectomy approach. Recently, Ambler etal" have had good results with a technique simply usingdrainage of the subretinal fluid externally with simulta­neous insufflation of an expansile gas. One of the six eyesin their series had failed a scleral buckling procedure beforeundergoing external subretinal fluid drainage and insuf­flation ofan expansile gas, and one patient failed the initialprocedure after 9 months and required a scleral bucklingprocedure for successful reattachment. External drainageof subretinal fluid with insufflation of an expansile gasalone was successful in four of their six cases and appearsto be an alternative approach to the treatment of thesedetachments. From schematic drawings in Ambler's ar­ticle, it appears that most of their patients had outer-layerholes that were smaller and more peripheral than thoseseen in our patients.

From the experience with our 12 patients, we feel mostcomfortable approaching eyes with schisis detachmentsand large or posterior outer-layer holes with a pars planavitrectomy technique. Although external drainage is pos­sible, we prefer the more controlled internal drain usingthe cannulated extrusion needle that can be positionedthrough a preexisting inner-layer hole or intentional ret­inotomy and then through the outer-layer hole to drainthe schisis cavity and the subretinal fluid. A vitrectomywith internal drainage reduces the chance of sequentialretinal tear development that has been described after

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pneumatic retinopexy and eliminates the complicationsof external subretinal fluid drainage. Expansile gases arecommonly needed to maintain larger gas bubbles neces­sary to tamponade posterior or inferior retinal breaks.

The only complication we have encountered with thissurgical technique was the intraoperative formation of acataract necessitating its removal in one instance (case 2).A posterior subcapsular cataract developed postopera­tively in one patient (case 7), which dropped visual acuityfrom 20/25 preoperatively to 20/60 postoperatively. Intwo eyes (cases 1 and 5), postoperative cataracts developedthat subsequently required ECCE and PC IOL implan­tation. Postoperative visual acuity in these two eyes was20/20. An epiretinal membrane developed in two patients(cases 2 and 5) postoperatively, perhaps from the surgicalprocedure. Other, more severe, complications of parsplana vitrectomy and internal drainage were not noted.These include new retinal breaks, endophthalmitis, intra­ocular hemorrhage, and gas-related intraocular pressureelevation.

Schisis detachments, although uncommon, should betreated if the patient has symptoms. Asymptomatic RDsassociated with degenerative retinoschisis have been ob­served to be nonprogressive over years and do not warranttreatment. 1 Standard scleral buckling procedures may besuccessful in eyes that have peripheral outer-layer holes.Pars plana vitrectomy should be considered for treatingsymptomatic schisis detachments, especially in eyes thathave large or posterior outer-layer holes.

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