Retinal detachment and proliferative vitreoretinopathy

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					              CHAPTE R

      21                                 Retinal detachment and proliferative
                                         Oh Woong Kwon, MD, PhD, Mi In Roh, MD, and Ji Hun Song, MD

                                                                                  RD occurs at a rate of 5–16 per 1000 cases following cataract surgery,
INTRODUCTION                                                                   and this comprises approximately 30–40% of all reported RD.4 The
                                                                               cumulative probability ratio of RD at 20 years after extracapsular cata-
Proliferative vitreoretinopathy (PVR) is a disease entity related to a         ract extraction or phacoemulsification is reported to be 1.58%, which is
number of intraocular diseases, including retinal detachment (RD).             four times higher than for patients not undergoing cataract extraction.5
Several studies have confirmed the hypothesis that PVR occurs as a              The risk factors associated with RD in cataract removal are accidental
reparative process induced by retinal breaks and excessive inflamma-            posterior capsule rupture at the time of surgery, young age, increased
tory reaction. A survey of recently published series suggested that the        axial length, a deep anterior chamber, RD in the fellow eye, and male
frequency of PVR remains largely unchanged in primary RD, with the             gender.6,7 While the incidence of RD after clear lens extraction in myopic
incidence ranging from 5.1 to 11.7%.1 PVR is the most common cause             eyes rises to 8.1%, the incidence of RD decreases to 2.7% with the intro-
of failed repair of rhegmatogenous RD and risk factors for PVR are             duction of small incision coaxial phacoemulsification.8,9
related to several, well-known pre-, intra-, and postoperative clinical           Approximately 10–20% of RD is associated with direct ocular trauma.
situations. Currently, surgery such as pneumatic retinopexy, scleral           Traumatic detachments are more common in younger people. Although
buckling, and pars plana vitrectomy (PPV) is the mainstream therapeu-          no studies have estimated the incidence of RD in contact sports, certain
tic modality for RD and PVR. The goal of surgery is to create chorioreti-      sports (e.g., boxing and bungee jumping) are associated with an
nal adhesion around all the retinal breaks and to relive all the tractional    increased risk of RD. There are also a few reports that Nd : YAG laser
force. Single-operation reattachment rates were 73% for pneumatic reti-        capsulotomy10,11 is associated with an increased risk of RD.
nopexy and 82% for scleral buckling after 6 months, and multiple-                 As for racial difference in the incidence of RD in pediatrics, while
operation reattachment rates at 2 years were 99% for pneumatic                 structural abnormalities (56%), previous surgery (51%), trauma (36%),
retinopexy and 98% for scleral buckling for RD. Surgical success rates         and uveitis (15%) were the main risk factors for RD in USA,12 high
for PVR have improved as techniques and instruments of vitrectomy              myopia (38%), trauma (31%), structural abnormalities (17%), and
evolved. The introduction of ancillary techniques such as longer-acting        previous surgery (5%) were the main risk factors in Asia.13
gases and long-term vitreous substitutes like silicone oil elevated the
success rate from 35–40% to approximately 60–75% at 6 months. Despite
these advances, more than one-fourth of initially successful cases results
in redetachment due to recurrent retinal traction. Furthermore, visual         INCIDENCE OF PROLIFERATIVE
results are less satisfactory and only 40–80% of cases with anatomic           VITREORETINOPATHY
success achieve ambulatory vision. As a result, PVR remains a difficult
problem to manage and continuing efforts have been made to develop             Published series through the 1990s to early 2000 suggest that the
other forms of therapy to inhibit the pathologic response causing trac-        frequency of PVR remains largely unchanged in primary RD, with
tion. Recent efforts have been directed toward the chemical inhibition         the incidence ranging from 5.1 to 11.7%.
of cellular proliferation and membrane contraction in PVR.

                                                                               PATHOGENESIS OF PROLIFERATIVE
INCIDENCE OF RETINAL DETACHMENT                                                VITREORETINOPATHY
In normal eyes, RD occurs at a rate of approximately 5 per 100 000             PVR is the result of growth and contraction of cellular membranes
people per year in the USA, and the age-adjusted incidence of                  within the hyaloids, retina, and retinal surface.14 These membranes
idiopathic RD is approximately 12.5 cases per 100 000 per year, or about       exert traction and may cause tractional RD that opens otherwise suc-
28 000 cases per year.2,3                                                      cessfully treated retinal breaks, creating new retinal breaks, or promot-
                                                                               ing proliferation at the posterior vitreous base and anterior cortical
                                                                               vitreous. This in turn causes anteroperipheral traction on the retina with
                                                                               displacement of the peripheral retina toward the pars plana. Membrane
ETIOLOGY AND RISK FACTORS FOR                                                  contraction on the inner retina causes distortion and folding, resulting
RETINAL DETACHMENT                                                             in starfolds at the inferior quadrant (Figure 21.2).

Rhegmatogenous RD develops with: (1) the existence of liquefied vitre-
ous gel; (2) tractional force resulting in retinal breaks; and (3) the pres-
ence of a retinal break (Figure 21.1). The most common worldwide               RISK FACTORS FOR PROLIFERATIVE
etiological factors associated with RD are myopia, cataract removal, and       VITREORETINOPATHY
trauma. Approximately 40–50% of all patients with RD have myopia.
RD related to myopia tends to occur in patients aged 25–45 years, while        Although PVR is the most common cause of failed repair of rhegmatog-
nonmyopia RD tends to occur in older individuals. Patients with high           enous RD, risk factors for PVR are related to several, well-known pre-,
myopia (>6 D), which is more common in males than females, have a              intra-, and postoperative clinical situations. A number of factors
5% lifetime risk of RD.                                                        can increase the risk of PVR, including the preoperative extent of
                                                                            Vitreous gel
                                                                                                                                                                                                                   Vitreous gel
CHAPTER 21 • Retinal Detachment and Proliferative Vitreoretinopathy

                                                                           Anterior flap                                                                                                                      Operculum
                                                                         and retinal tear
                                                                         with persistent
                                                                                 traction                                                                                                                     Retinal hole

                                                                       Dispersed retinal                                                                                                                      Retina
                                                                        epithelium cells
                                                                        A                                                                           B

                                                                      Figure 21.1 Retinal tears due to vitreoretinal traction. Persistent traction frequently causes retinal detachment (A). If the traction results in a
                                                                      break that is not associated with persistent vitreoretinal traction (B), the tear will act as a retinal hole and detachment is unlikely.

                                                                                                                                                     There are three major wound-healing phases that occur after tissue
                                                                                                                                                  injury: inflammation, proliferation, and scar modulation.20 After a
                                                                                                                                                  retinal break occurs, inflammation proceeds with the breakdown of the
                                                                                                                                                  blood–retinal barrier. This enables platelets to migrate to the lesion site
                                                                                                                                                  and release growth factors. Concurrently, extracellular matrix is pro-
                                                                                                                                                  duced using fibrin and fibronectin.21 These processes act as chemotactic
                                                                                                                                                  factors for attracting monocytes. Cells involved in the inflammatory
                                                                                                                                                  process during wound healing in RD include retinal pigment epithelial
                                                                                                                                                  (RPE) cells, macrophage-like cells, glial cells, and fibroblast-like cells,
                                                                                                                                                  and this process triggers the onset of PVR.22 Of these cell types, RPE
                                                                                                                                                  cells, which are present in almost all epiretinal membranes, are the key
                                                                                                                                                  factor in triggering PVR development.21 RPE cells have a wide range of
                                                                                                                                                  activities, and can act like fibroblasts and participate in fibrosis,23 release
                                                                                                                                                  factors similar to those of glial cells, promote extracellular matrix con-
                                                                                                                                                  traction24 and synthesize collagen types 1, 2, and 3.25
                                                                                                                                                     Soluble mediators such as growth factors and cytokines26 play a role
                                                                                                                                                  in producing membranes which occur in PVR, and the extracellular
                                                                                                                                                  matrix components (most importantly, collagen and the elastic fiber
                                                                                                                                                  family) play a critical role in cellular events, including proliferation,
                                                                                                                                                  migration, tissue contraction, and tissue remodeling.25,27 Among the
                                                                                                                                                  soluble mediators, fibroblast growth factor induces the proliferation of
                                                                                                                                                  fibroblasts, which synthesize the extracellular matrix, leading to the
                                                                                                                                                  formation of intravitreal and periretinal membranes. In the final process,
                                                                                                                                                  membrane contraction occurs, leading to tractional RD.

                                                                      Figure 21.2 Starfold from proliferative vitreoretinopathy. Contraction      SIGNS, SYMPTOMS, AND DIAGNOSIS
                                                                      of a focal retinal surface membrane (arrow) has resulted in the
                                                                      formation of a starfold.                                                    Rhegmatogenous RD presents as an accumulation of subretinal fluid
                                                                                                                                                  with one or more retinal breaks. Symptoms such as photopsia and/or
                                                                      detachment exceeding two quadrants, giant, large, multiple, or unde-        increased vitreous floaters with acute posterior vitreous detachment
                                                                      tected retinal breaks,15 aphakia status, vitreous hemorrhage,16 preopera-   may indicate the development of a retinal break. In symptomatic eyes,
                                                                      tive choroidal detachment, previous failed attempts at reattachment,        retinal tears associated with persistent vitreoretinal traction indicate a
                                                                      the presence of signs of uveitis, and the preoperative presence of PVR      high risk for RD which may present with decreased visual acuity and/
                                                                      grades A and B.17 In giant retinal tears, the PVR incidence varies from     or restriction of the visual field. The most common presentation of PVR
                                                                      16 to 41%, while in penetrating ocular traumas the incidence is 10–45%      is epiretinal membrane proliferation causing traction, with retinal folds
                                                                      with a mean of 25%.1 In eyes with rhegmatogenous RD with grade B            on the retina in an eye with rhegmatogenous RD. Other presentations
                                                                      PVR, the incidence of severe PVR after surgery was reported to be           include multiple retinal breaks, a vitreoretinal traction ring, and con-
                                                                      25.8% when using cryotherapy and 2.2% when using argon laser pho-           traction of the vitreous base.
                                                                      tocoagulation.18 Intraocular hemorrhage during or after surgery, use of        It is difficult to diagnose PVR when there is media opacity due to
                                                                      air or sulfur hexafluoride (SF6), excessive cryotherapy, diathermy or        corneal, lenticular, or vitreous opacities. In such cases, ultrasonographic
                                                                      photocoagulation,19 repeated surgical procedures, loss of vitreous          characteristics showing funnel-shaped RD with the opposition of the
                                                                      during drainage of subretinal fluid, and the use of vitrectomy are also      posterior retina or the presence of an anterior membrane bridging the
                                                                      intraoperative risk factors that increase the incidence of PVR.             mouth of the funnel28 can provide evidence for a diagnosis (Figure 21.3).

                                                                                                                                                                       SECTION 3 • Retinal Diseases Amenable to Pharmacotherapy


Figure 21.3 Ultrasonograph of an eye with rhegmatogenous reitinal
detachment with proliferative vitreoretinopathy.                                   Figure 21.4 Correct position of scleral buckle for flap retinal tear.

 Table 21.1 Classification of proliferative vitreoretinopathy (PVR) used in the silicone study

 Type no.             Type of contraction                   Location of PVR              Summary of clinical signs
 1                    Focal                                 Posterior                    Starfold
 2                    Diffuse                               Posterior                    Confluent irregular retinal folds in posterior retina; remainder of
                                                                                         retina drawn posteriorly; optic disc may not be visible
 3                    Subretinal                            Posterior                    “Napkin ring” around disc or “clothesline” elevation of retina
 4                    Circumferential                       Anterior                     Irregular retinal folds in the anterior retina; series of radial folds
                                                                                         more posteriorly; peripheral retina within vitreous base
                                                                                         stretched inward
 5                    Perpendicular                         Anterior                     Smooth circumferential fold of retina at insertion of posterior
 6                    Anterior                              Anterior                     Circumferential fold of retina at insertion of posterior hyaloid
                                                                                         pulled forward; trough of peripheral retina anteriorly; ciliary
                                                                                         processes stretched with possible hypotony; iris retracted

 Reprinted with permission from Lean J, Irvine A, Stern W, et al. Classification of proliferative vitreoretinopathy used in the silicone study. The Silicone study
 group. Ophthalmology 1989;96:765–771.

After diagnosis, PVR should be classified according to the commonly                 be caused by fibrosis and/or altering the action of the rectus muscles.
used system presented in Table 21.1. This system distinguishes between             Other complications include infection, extrusion, or intrusion of the
anterior and posterior forms of PVR, and identifies proliferation as                buckling element, anterior-segment ischemia, and choroidal detach-
diffuse, focal, or subretinal. While this system provides information on           ment. Pneumatic retinopexy is a possible alternative to scleral buckling,
the anatomical construction of PVR, it does not indicate the biological            and may be used to treat rhegmatogenous RD with retinal breaks in the
activity or prognostic factors.1                                                   superior two-thirds of the retina. This procedure involves injecting a gas
                                                                                   bubble into the vitreous cavity and positioning the patient’s head such
                                                                                   that the retinal breaks can be closed by the bubble, while laser photoco-
                                                                                   agulation or cryotherapy is used for retinopexy. However, the possibility
TREATMENT OPTIONS                                                                  of overlooking an existing retinal break, or creating a new break, could
                                                                                   be higher for pneumatic retinopexy compared to scleral buckling.
Currently available surgical options for RD management are pneumatic                  PPV was previously considered a second-line treatment for primary
retinopexy, scleral buckling, and PPV. There remains no consensus                  RD. However, a growing number of surgeons choose primary vitrec-
regarding the optimal surgical management option, and the choice is                tomy for rhegmatogenous RD, in part due to the rapid advances in
generally based on many factors, including the characteristics of the              instrumentation. The major advantage of primary vitrectomy is that it
retinal breaks, lens status, various patient factors (e.g., expected compli-       allows a direct approach to the release of vitreous traction. Vitrectomy
ance with postoperative positioning), and surgeon preference.29                    can also remove media opacities, and therefore improve intraoperative
   The principles of surgical management consist of sealing all retinal            visualization and control internal drainage of subretinal fluid. The
breaks by making permanent scars, and relief of vitreoretinal traction.            greatest problem with primary vitrectomy is the possibility of causing
Scleral buckling, including an encircling element and subretinal fluid              new retinal breaks and cataract formation. Furthermore, vitrectomy
drainage in some cases, relieves the vitreous traction on the retina and           may be a more expensive procedure because it requires more special-
displaces some subretinal fluid from the breaks, resulting in an approxi-           ized operating room equipment and instrumentation.30
mation of a neurosensory retina and RPE (Figure 21.4). Complications                  Early surgical failures are mostly the result of failure to seal all retinal
of scleral buckling surgery include refractive change, which is typically          breaks, and/or failure to relieve vitreous traction adequately. In con-
axial myopia induced by encircling elements, and strabismus, which may             trast, late surgical failures are usually due to PVR, which accounts for
                                                                                                                                                  applied to the edges of the retinotomy site with the addition of long-
                                                                                                                                                  term tamponades. Most severe cases involving advanced anterior PVR
                                                                                                                                                  have used a posterior 360° retinotomy combined with an extensive
                                                                                                                                                  peripheral retinectomy and silicone oil tamponade.34 However, the
                                                                                                                                                  results have not been encouraging due to reproliferation causing recur-
                                                                                                                                                  rent macular detachment. Surgical means to reduce the risk of PVR
                                                                                                                                                  include removal of vitreous collagen, which is the stratum to cell attach-
                                                                                                                                                  ment, using wide-angle viewing systems and heavy liquids, and appli-
                                                                                                                                                  cation of dyes which aim at a more thorough and less traumatic removal
                                                                                                                                                  of vitreous and periretinal membranes.35 In addition, recent efforts have
CHAPTER 21 • Retinal Detachment and Proliferative Vitreoretinopathy

                                                                                                                                                  been directed toward the pharmacological inhibition of cellular prolif-
                                                                                                                                                  eration and membrane contraction in PVR.

                                                                                                                                                  PROGNOSIS WITH THE VARIOUS
                                                                                                                                                  TREATMENT OPTIONS
                                                                                                                                                  It appears that the surgical success rates for pneumatic retinopexy are
                                                                                                                                                  either similar to or slightly lower than those for scleral buckling, and the
                                                                                                                                                  risk of late redetachment is similar for pneumatic retinopexy and scleral
                                                                                                                                                  buckling.30 In a 2-year follow-up study, single-operation reattachment
                                                                                                                                                  rates were 73% for pneumatic retinopexy and 82% for scleral buckling
                                                                                                                                                  after 6 months, and multiple-operation reattachment rates at 2 years
                                                                                                                                                  were 99% for pneumatic retinopexy and 98% for scleral buckling.36
                                                                                                                                                     More recently, a few prospective randomized trials revealed that
                                                                                                                                                  there was no statistically significant difference in single-operation
                                                                                                                                                  success rates or visual outcomes when comparing primary vitrectomy
                                                                                                                                                  with scleral buckling for the treatment of rhegmatogenous RD.37,38
                                                                                                                                                  However, faster foveal reattachment may be an advantage of PPV. In
                                                                                                                                                  a nonrandomized series of 33 cases of macular-off RD, serial optical
                                                                                                                                                  coherence tomography examinations showed no primary vitrectomy
                                                                                                                                                  patients had subfoveal fluid while approximately one-third of scleral
                                                                                                                                                  buckling patients had subfoveal fluid after the operation.39
                                                                                                                                                     Surgical success rates for PVR have improved as vitrectomy tech-
                                                                                                                                                  niques and instruments have evolved. The introduction of ancillary
                                                                                                                                                  techniques such as longer-acting gases and long-term vitreous substi-
                                                                                                                                                  tutes like silicone oil have elevated the success rate from 35–40% to
                                                                                      B                                                           approximately 60–75% at 6 months.40,41 Despite these advances, more
                                                                                                                                                  than 25% of initially successful cases result in redetachment due to
                                                                      Figure 21.5 Ability of perfluorocarbon liquids to reattach                   recurrent retinal traction. Furthermore, visual results are less satisfac-
                                                                      mechanically posterior retina in proliferative vitreoretinopathy.           tory and only 40–80% of cases with anatomic success achieve ambula-
                                                                      Epiretinal membranes cause folding and shortening of the retina in          tory (5/200 or better) vision.42 As a result, PVR remains a major problem,
                                                                      both anteroposterior and circumferential directions (A). After              and continuing efforts have been made to develop other forms of
                                                                      performing membranectomy on posterior region of the retina,                 therapy to inhibit the pathological response causing traction. Recent
                                                                      perfluorocarbon liquid may be used to reattach the posterior retina          efforts have been directed towards chemical inhibition of cellular pro-
                                                                      and aid in removal of peripheral epiretinal membrane (B).                   liferation and membrane contraction for PVR.

                                                                      the majority of failures following RD surgery. Surgical procedures used
                                                                      to repair RDs associated with PVR include scleral buckling, vitrectomy,     ADJUNCTIVE THERAPIES
                                                                      membrane peeling, relaxing retinotomies, the use of liquid perfluoro-
                                                                      carbons, and internal tamponade with gas or silicone oil (Figure 21.5).31   Although PVR is currently primarily managed surgically, ongoing
                                                                      In the early stages of PVR, buckling and encircling procedures may          efforts seek to identify adjuvant therapies that might inhibit PVR devel-
                                                                      close all retinal breaks with release of circumferential traction caused    opment. No matter how thoroughly vitrectomy is performed, it is virtu-
                                                                      by the vitreous base.17 A moderately wide, broad silicone band (5–7 mm)     ally impossible to prevent some level of cell adhesion and pathological
                                                                      extending from the ora serrata to the equator is required to reduce the     change. Control of the biological processes involved in proliferation
                                                                      vitreous traction.13 In addition, retinopexy with cryotherapy, diathermy,   and wound-healing would improve the success rate of surgery for
                                                                      and photocoagulation can be used to treat definite retinal breaks, thus      primary RD and PVR.
                                                                      minimizing further RPE cell dispersion, postoperative inflammation,             Daunorubicin was the first adjunct agent to be studied in a random-
                                                                      and breakdown of the blood–retinal barrier. While there is no standard-     ized controlled trial for the management of PVR, and was found to
                                                                      ized approach to PVR treatment, types 1 and 2 affecting fewer than two      reduce the number of reoperations within 1 year.43 Recent advances in
                                                                      quadrants (classification system by the Silicone Oil study) can be suc-      the sustained release of daunomycin achieved by a single intravitreal
                                                                      cessfully treated using buckling procedures.                                application of liposome encapsulation44 may be very useful for future
                                                                         PPV is indicated in cases with no definite retinal breaks with trac-      treatment strategies.
                                                                      tional membranes causing RD, or in cases where the retinal breaks              A randomized controlled trial in the UK reported that adjuvant
                                                                      cannot be sealed by scleral buckling alone.14 However, in complex PVR       5-fluorouracil and heparin prevented PVR. In that study, the combina-
                                                                      cases, it is necessary to perform a vitrectomy with membrane peeling        tion treatment resulted in a significant reduction in the rate of postopera-
                                                                      and a gas or silicone oil tamponade.32 Moreover, a relaxing retinotomy      tive PVR development.45 However, subsequent studies failed to show
                                                                      and retinectomy may be required to attach the retina to the RPE in such     any benefit of this combination treatment, and indeed one of the study
                                                                      complex cases.33 Once all traction is relieved, photocoagulation is         results showed worse outcomes in macula-sparing RDs patients.46,47
   Many drugs, such as colchicine, corticosteroids, retinoids, and                18. Bonnet M, Guenoun S. Surgical risk factors for severe postoperative
heparin, might be useful for inhibiting PVR development at specific                    proliferative vitreoretinopathy (PVR) in retinal detachment with grade B
                                                                                      PVR. Graefes Arch Clin Exp Ophthalmol 1995;233:789–791.
stages. More detailed understanding of the pathophysiology underly-                                              ,
                                                                                  19. Jaccoma EH, Conway BP Campochiaro PA. Cryotherapy causes extensive
ing PVR may lead to the development of effective prophylactic and/or                  breakdown of the blood–retinal barrier. A comparison with argon laser
adjunct therapies. Further work is necessary to identify optimal adjunct              photocoagulation. Arch Ophthalmol 1985;103:1728–1730.
therapies for the management of RD and PVR.                                                          ,
                                                                                  20. Wiedemann P Weller M. The pathophysiology of proliferative
                                                                                      vitreoretinopathy. Acta Ophthalmol Suppl 1988;189:3–15.
                                                                                  21. Casaroli Marano RP Vilaro S. The role of fibronectin, laminin, vitronectin
                                                                                      and their receptors on cellular adhesion in proliferative vitreoretinopathy.
                                                                                      Invest Ophthalmol Vis Sci 1994;35:2791–2803.
SUMMARY AND KEY POINTS                                                                                         ,
                                                                                  22. Baudouin C, Hofman P Brignole F, et al. Immunocytology of cellular

                                                                                                                                                                        SECTION 3 • Retinal Diseases Amenable to Pharmacotherapy
                                                                                      components in vitreous and subretinal fluid from patients with proliferative
                                                                                      vitreoretinopathy. Ophthalmologica 1991;203:38–46.
Current methods of surgical management of RD and PVR are pneu-                    23. Lee SC, Kwon OW, Seong GJ, et al. Epitheliomesenchymal
matic retinopexy, scleral buckling, and PPV. The principles of surgical               transdifferentiation of cultured RPE cells. Ophthalmic Res 2001;33:80–86.
management consist of sealing all retinal breaks and relief of vitreoreti-        24. Glaser BM, Cardin A, Biscoe B. Proliferative vitreoretinopathy. The
                                                                                      mechanism of development of vitreoretinal traction. Ophthalmology
nal traction. However, although surgical success rates for PVR have                   1987;94:327–332.
improved as vitrectomy techniques and instruments have evolved,                                 ,
                                                                                  25. Hiscott P Sheridan C, Magee RM, et al. Matrix and the retinal pigment
more than 25% of initially successful cases result in retinal redetach-               epithelium in proliferative retinal disease. Prog Retin Eye Res
ment due to recurrent tractional proliferation. This of course, results in            1999;18:167–190.
                                                                                  26. Wiedemann P. Growth factors in retinal diseases: proliferative
suboptimal visual results as well.                                                    vitreoretinopathy, proliferative diabetic retinopathy, and retinal
   Recent efforts have therefore been directed toward pharmacologic                   degeneration. Surv Ophthalmol 1992;36:373–384.
inhibition of cellular proliferation and membrane contraction with                27. Jerdan JA, Pepose JS, Michels RG, et al. Proliferative vitreoretinopathy
drugs such as daunorubicin, 5-fluorouracil, and heparin. Pharmacologic                 membranes. An immunohistochemical study. Ophthalmology
inhibition of the pathologic response involved in cell adhesion, prolif-          28. Fuller DG, Laqua H, Machemer R. Ultrasonographic diagnosis of massive
eration, and membrane contraction would most likely improve the                       periretinal proliferation in eyes with opaque media (triangular retinal
surgical success rate for RD. Moreover, better understanding of the                   detachment). Am J Ophthalmol 1977;83:460–464.
processes leading to retina damage after detachment, and knowledge                29. Schwartz SG, Flynn HW. Primary retinal detachment: scleral buckle or pars
                                                                                      plana vitrectomy? Curr Opin Ophthalmol 2006;17:245–250.
of how to protect or rehabilitate such retinas, may ultimately result in          30. Saw SM, Gazzard G, Wagle AM, et al. An evidence-based analysis of
better visual outcomes, even in relatively long-standing macular-off                  surgical interventions for uncomplicated rhegmatogenous retinal
retinal detachments.                                                                  detachment. Acta Ophthalmol Scand 2006;84:606–612.
                                                                                  31. Pastor JC. Proliferative vitreoretinopathy: an overview. Surv Ophthalmol
                                                                                  32. Ryan SJ. Traction retinal detachment. XLIX Edward Jackson Memorial
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