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Brit. J. Ophthal. (1976) 60, 756
Management of persistent hyperplastic
by pars plana vitrectomy
primary
vitreous
GHOLAM A. PEYMAN, DONALD R. SANDERS, AND KRISHAN C. NAGPAL
From the Department of Ophthalmology, University of Illinois Eye and Ear Infirmary, Chicago, Illinois
In the past the surgical treatment of persistent
hyperplastic primary vitreous (PHPV) has been
mainly carried out via an anterior segment approach.
With the newly developed vitreous cutting and
aspirating instruments, pars plana vitrectomy may
be a workable surgical alternative (Smith and
Maumenee, I974; Michels, Machemer, and
Mueller-Jensen, 1975; Peyman and Sanders, 1975).
We describe two cases of PHPV handled by pars
plana surgerv.
Patients
CASE I
A 3-month-old Black boy was noted to have leucocoria
Address for reprints: Gholam A. Peyman, MD, University of
Illinois Eye and Ear Infirnary, I855 W. Taylor Street, Chicago,
Illinois 6o6I2, USA
in the right eye at two months of age. Prenatal and
developmental histories were unremarkable. There was
no family history of ocular abnormalities. Physical
examination showed only an easily reducible right
inguinal hernia.
The child's left eye was normal, with corneal diameter
of I I 5 x I VI 5 mm. He had a deviation in the right eye
with a constant 24 degrees of right esotropia. The right
eye was normal externally with a corneal diameter of
I I X I I mm. Intraocular pressure by Schiotz tonometry
was 24 mmHg in the left eye and 21 mmHg in the right.
Gonioscopy showed normal angles in both eyes. A
posterior polar cataract in the right eye spared the
periphery of the lens, through which was visible a large
fibrovascular stalk (Fig. I) with prominent vessels
emanating from the optic disc. Surrounding the base
of the stalk was a localized central tractional retinal
detachment. There was no evidence of elongated ciliary
processes at the periphery of the lens.
FIG. I. Preoperative appearance
of patient's right eye demonstrating
cataract and intravitreal
fibrovascular stalk (arrow)
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Persistent hyperplastic primary vitreous 757
Surgical technique
Under general anaesthesia with four 4-o silk bridle
sutures under the rectus muscles, a no. 15 Bard-Parker
blade cut a 3-5 mm long limbus-parallel sclerotomy
down to the choroid, 2-5 mm posterior to the corneoscleral limbus in the inferotemporal quadrant. The
ends of a 5-0 Dexon mattress suture, placed through
the sclerotomy lips, were tied loosely. Toothed forceps
grasping the sclerotomy lips stabilized the eye while a
radiofrequency diathermy probe (Peyman and Dodich,
I972), inserted through the sclerotomy, coagulated the
large vessels of the intravitreal stalk without complication.
A no. 52S Beaver blade inserted into the equator of the
lens created a track through the sclerotomy for the
vitrectomy instrument. The lens fragmenter unit
(Peyman, Huamonte, and Goldberg, 1975) of the
vitrophage broke up the lens, which was removed
together with the posterior polar cataractous plaque
and the anterior portion of the fibrovascular stalk, with
the wide-angle cutting unit of the vitrophage (Peyman,
1976). An anterior vitrectomy was performed with the
same unit. The vitrophage was removed, and the 5-0
Dexon mattress suture was tied and reinforced centrally
with an interrupted suture of 5-o Dexon. Sutures of
5-0 catgut closed the peritomy, and the eye received
atropine and an antibiotic corticosteroid preparation
topically.
Two weeks after operation the eye was quiet, and only
a slight vitreous haze clouded the media (Fig. 2). The
stump of the fibrovascular stalk appeared retracted,
and the tractional retinal detachment was somewhat
flattened. Ocular examination has remained unchanged
after being followed-up for six months.
CASE 2
A 4-month-old White boy was noted to have leucocoria in the left eye at approximately six weeks of age.
Prenatal and developmental histories were noncontributory. At three months of age the child was
FIG. 3 Preoperative view demonstrating cataractous lens
noted to have, in the left eye, a small cornea, shallow
anterior chamber, small cataractous lens, and a white
retrolental mass with elongated ciliary processes nasally.
Intraocular pressure (Schi6tz) was I7 mmHg and the
fundus could not be visualized. X-ray films of the orbit
revealed no intraocular calcifications, and ultrasonography revealed a slightly microphthalmic eye with a
thickening at the posterior lens capsule. The patient
was then referred to us for treatment.
The child's right eye was normal with corneal
diameters of I I X II -5 mm. There was unsteady fixation
in the left eye with a variable deviation. The left eye
appeared microphthalmic with corneal diameters of
10-25 X I0-25 mm. Intraocular pressure (Schi6tz) was
17 mmHg (4/5-5). A distinct dense pupillary membrane
extended from collarette to collarette; in addition, an
intact tunica vasculosa lentis and a retrolental mass
extended into the lens (Fig. 3). A red reflex could be
elicited temporally around the retrolental mass. The
operative procedure was identical to that in Case I
except that the intravitreal stalk was not diathermized.
There were no operative or postoperative complications
and on the first postoperative day the conjunctiva was
mildly hyperaemic, the cornea was clear, and retinal
fundus detail could be seen with a hand-light. At two
weeks postoperatively only mild conjunctival hyperaemia
was noted (Fig. 4), and at examination three months
postoperatively there was no evidence of inflammation,
the ocular media were clear, and the retina was normal
(Fig. 5).
FIG. 2 Appearance of eye Io days postoperatively
demonstrating clear pupillary opening with no evidence of
ocular inflammation
Discussion
Most surgical approaches to the treatment of
PHPV have been via an anterior segment approach
(Collins, I908; Wolfe, 1954; Reese, 1955; Acers
and Costen, I967; Gass, I970; Smith and
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758 British Journal of Ophthalmology
of macular aplasia, tractional detachments and
deprivation amblyopia, removal of the antero..:..posterior traction caused by the hyperplastic
primary vitreous allows the eye to grow and to
.achieve reasonable cosmesis.
:.
... .
.
._umm.ar_yX
Two children with persistent hyperplastic primary
(PHPV) underwent vitrectomy and lensectomy via the pars plana to remove the fibrovascu~~lar stalk. Postoperatively the eyes were quiet,
only a slight vitreous haze obscured the fundus
view in the immediate postoperative period, and
the stumps of the stalks retracted. Early surgical
treatment of PHPV may prevent later serious
vitreous
........
complications.
FIG. 4
Postoperative view demonstrating wide and clear
pupillary opening
Maumenee, I974); either a discission or excision of
the retrolenticular tissue through a large corneo-i
scleral limbal incision followed an aspiration
procedure. Nevertheless, this large incision provides
poor operative exposure for removal of retropupillary
tissue.
Michels and Ryan (1975) reported two cases of
PHPV among ioo vitrectomy cases although the
operative technique and postoperative results were
not specified. Michels and others (I975) have saidthat they prefer to use an incision at the limbus
rather than at the pars plana in these microphthalmic
eyes. We advocate early surgical intervention in
these cases before complications such as bleeding
into the lens or vitreous or traction on the ciliary
body occurs or becomes worse. With development
of the cataract, a lens-induced fiat anterior chamber
and secondary glaucoma may develop. Although
the visual prognosis in these cases is poor because
:
,
FIG. 5 Fundus view: note clarity of the media. Arrow
indicates retracted vascular stalk
References
ACERS, T. E., and COSTEN, T. 0. (I967)
Amer. J. Ophthal., 64, 734
COLLINS, E. T. (I908) J. Amer. med. Ass., 5I, 105I
GASS, J. D. M. (1970) Arch. Ophthal., 83, I63
MICHELS, R. G., MACHEMER, R., and MUELLER-JENSEN, K. (1975) Ophthal. Surg., 5
, and RYAN, S. J., JR. (I975) Amer. Y. Ophthal., 8o, 24
(4), 13
PEYMAN, G. A. (1976) Ophthal. Surg. (in press)
and DODICH, N. A. (I972) Ibid., 3, 32
HUAMONTE, F., and GOLDBERG, M. F. (I975) Amer. Y. Ophthal., 8o, 30
and SANDERS, D. R. (1975) 'Advances in Uveal Surgery, Vitreous Surgery and the Treatment of
Endophthalmitis'. Appleton-Century-Crofts, New York
REESE, A. B. (I955) Amer. J. Ophthal., 40, 317
SMITH, R. E., and MAUMENEE, A. E. (1974) Trans. Amer. Acad. Ophthal. Otolaryng., 78, 9I
WOLFE, 0. R. (I954) J. int. Coll. Surg., 21, 650
Downloaded from http://bjo.bmj.com/ on May 2, 2017 - Published by group.bmj.com
Management of persistent
hyperplastic primary vitreous by
pars plana vitrectomy.
G A Peyman, D R Sanders and K C Nagpal
Br J Ophthalmol 1976 60: 756-758
doi: 10.1136/bjo.60.11.756
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