Download peculiar complications of vitreoretina surgery

PECULIAR COMPLICATIONS OF
VITREORETINA SURGERY IN
SUBSAHARAN AFRICA
Olufemi Oderinlo
FRCSEd ,FWACS, DRCOphth.
Consultant Ophthalmologist and Vitreoretina Surgeon
EYE FOUNDATION HOSPITAL GROUP
• FINANCIAL DISCLOSURE: NO FINANCIAL
INTEREST IN MATERIAL PRESENTED
INTRODUCTION
• Sub-Saharan Africa contains less than 10% of the
world’s population, but 20% of the world’s blind.
• 1 ophthalmologist per million population
• African studies confirm patients with VR diseases
present late and with complex pathologies. 25 -40 % of
RDs have advanced PVR of > grade C-1 at presentation
• Frequent only eye presentations, sickle cell
retinopathy, complications of PDR, complications of
trauma from regional conflicts
• Prolonged surgery and less satisfactory visual outcome
Complications of VR surgery in2010
Cataract
Elevated IOP
Hyphaema
Band keratopathy
Rubeosis
Hyperoleum
Subretina fluid
Ant staphyloma
No post operative complicaction
Frequency
Percent
11
11.0
8
8.0
2
2.0
2
2.0
2
2.0
1
1.0
1
1.0
1
1.0
72
72.0
Timing of complication
Immediate (first 3 days)
Early (4 days to 6 weeks)
Late (more than 6 weeks)
Frequency
Percent
1
3.7
11
40.7
15
55.6
Cataract
• Incidence btw 50 and 95%
• Mechanism unclear :
antioxidant function of
vitreous, pre-existing
cataract, advancing age,
light toxicity from the
operating microscope,
diabetes, use of
intraocular gas or silicone
oil, and trauma to lens.
• duration of vitrectomy
does not increase the
risk.
Elevated IOP/ Glaucoma
• Incidence 6 – 8%
• Gas : improper mixture, better
to do mixture your self, pupil
block. Acute elevation
• Silicon oil (Chronically elevated
IOP was more prevalent in
silicone oil eyes than in C3F8
gas eyes) Silicon Study
• Ghost cell : intavitreal
bevacizumab and vitrectomy.
Aim to reduce inflammation
and IOP, paracentesis may be
helpful
• Inflammatory: trabeculitis.
• Steroid induced
Silicon oil and IOP
• Overfill of vitreous cavity
• Emulsification (Incidence equal for 1000cs and
5000cs) , Hyperoleum .
• Pupil block : absent andoiridectomy in
aphakia, closed iridectomy from fibrosis
• may require reopening andoiridotomy (Yag) or
sugical or oil exchange
Cataract + pupil block
Silicon oil complications
• Changes in refractive status :4 TO 8D change
• keratopathy: Punctate epithelial changes, cornea
epithelial defect, band keratopathy are all
reported
• The Silicone Study was the first study to
document that the postoperative incidence rates
of corneal abnormalities are equivalent between
oil and gas.
Popovic SS, Sikic J, Pokupec R. Intraocular pressure values
following vitrectomy with silicone oil tamponade. Acta Med
Croatica. 2005; 59: 143-6.
6. Quintyn JC, Genevois O, Ranty ML, et al. Silicone oil
migration in the eyelid after vitrectomy for retinal detachment.
Cornea complications
• Silicon oil Keratopathy
• Light microscopy : increased cellularity and
irregularity of collagen fibers of stroma.
• Endothelium degeneration with some oil
droplets noted
• More likely due to barrier effects of silicon
than direct toxicity
Subretina silicon oil
• Rare complication
• Can cause
redetachment or
migrate with time.
• Reduces visual function.
• Usually requires
reoperation,
retinotomy, relieve
residual traction .
• Optic chiasmal and brain migration of silicon
oil are reported (case reports).
Retained subretina PFCL
• retina toxicity may
occur from retained
perflourocarbon liquids
as well as scotomata
and elevated intraocular
pressures
• If very small bubble may
be ignored but large
bubbles shoud be
removed.
Hemorrhage
•
•
•
•
Vitreous
Retina
Suprachoroidal
Hyphema
Inflammation
• Severe inflammation is
rare
• Excessive retinopexy
esp. cryo, repeat
surgery.
• Periocular and systemic
steroids
Endophthalmitis
• An incidence of
between 0.023% and
0.039% is reported,
with staphylococcus
aureus more often
involved .
• A recent large series
study reported no
difference in incidence
of End. after 20G and
23G vitrectomy.
Parolini B, Romanelli F, Prigione G, Pertile G. Incidence of endophthalmitis in a large series of 23gague and 20-gague transconjuntival pars plana vitrectomy. Graefes Arch Clin Exp Ophthalmol.
2009;247:895–8. [PubMed]
Endophthalmitis
• Outcomes are usually poor with greater than 67%
having NPL vision.
• organisms other than coagulase-negative staphylococci
tend to have poor visual prognosis.
• EVS results used as guide only
• Systemic antibiotics (fourth generation
flouroquinolones ), Intravitreal antibiotics (vancomycin,
ceftazidime, amikacin) silicon oil exchange.
• intravitreal quinupristin/dalfopristin Q/D( recently
developed streptogramin antibiotic in 3/7 combination
ratio)
Am J Ophthalmol. 2004 Nov;138(5):799-802.
Endophthalmitis after pars plana vitrectomy: Incidence, causative organisms, and visual acuity outcomes.
Eifrig CW, Scott IU, Flynn HW Jr, Smiddy WE, Newton J
Iatrogenic retina breaks
• Incidence 1-2%
• Peeling highly adherent ERM, PVR membranes
• Insertion and removal of instruments from the
eye can cause peripheral retina breaks.
• Maximize use of each instrument before
removal
• Remove peripheral vitreous as much as
possible before instruments
Wound leaks and hypotony
• Advent of small gauge vitrectomy raised some
concern about wound leaks
Avoiding complications such as wound leak,
hypotony, choroidal detachment and
endophthalmitis through optimal surgical
technique is critical.
Proper wound construction and closure are both
necessary to ensure tight self-sealing wounds.
• Partial or complete air-fluid exchange, thorough
peripheral vitrectomy, and subconjunctival
antibiotics are supplemental steps that may also
help ensure successful surgical outcomes
• Other factors that contribute to wound leakage,
such as increased surgical duration and
nonmacular diagnosis, may be indirect
measurements of extensive trocar rotation,
causing wound leakage .
CHRONIC HYPOTONY
• Chronic hypotony was more prevalent in C3F8
gas eyes than in silicone oil eyes. (The silicon
study)
• ? Retinectomy
Retina toxicity
• from ICG, Aminoglycosides and fiberoptic light
are reported
• Phototoxic lesions caused by the endoilluminator
are similar to lesions caused by the operating
microscope but are usually larger in size and have
less well-delineated borders.
• The wavelength of light used, the power of the
light source and the duration of use determine
the amount of ocular damage in phototoxicity.
Aminoglycoside toxicity
• Can cause acute, toxic ischaemic retinopathy
• Severe retina vasc occlusion and optic
neuropathy.
• Prevention is crucial.
Scleral buckle
• Retina hemorrhage
from drainage of
subretina fluid.
• Drainage safer on both
sides of horizontal recti
and highest level of
subretina fluid.
Extrusion of buckle
• Incidence 3.5 to 24% with silicon sponge
• Incidence0.6 to 1.2% with solid silicon
Anisometropia
• Increase in axial length
• Lens can become thicker and displaced
anteriorly
• 2 – 3 D myopic shift
• Cornea steepening leading to astigmatism
Strabismus
• Incidence 3 – 30%
• Exotropia, esotropia, hypertropia and
cyclotorsional changes
• Many times removal of buckle does not
resolve deviation
• MRI of orbit useful
• Squint surgery may be required
• Generally complication rates after vitreoretina
surgery is low and most can be prevented by
paying attention to detail and being
meticulous.
THANK YOU
REFERENCES
• Foos RY, Simons KB, Wheeler NC. Comparison
of lesions predisposing to rhegmatogenous
retinal detachment by race of subjects. Am J
Ophthalmol 1983; 96: 644–649
• D Yorston and S Jalali .Retinal detachment in
developing countries Eye (2002) 16, 353–358.
doi: 10.1038/sj.eye.6700188
• Lin, Albert L B; Ghate, Deepta A ; Robertson, Zachary M ;
O'sullivan, Patrick Sean ; May, Warren L ; Chen, Ching-Jygh
Factors Affecting Wound Leakage in 23-Gauge Sutureless Pars
Plana Vitrectomy Retina: June 2011 - Volume 31 - Issue 6 - pp
1101-1108