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Complex Retinal Detachment

Proliferative Vitreoretinopathy and Giant Retinal Tears

Proliferative vitreoretinopathy (PVR) is a condition in which retinal scar tissue, or “membranes” form; this may occur with a retinal detachment. A key risk factor for developing PVR is a giant retinal tear—a large tear that involves at least 25% of the retina. When PVR or a giant retinal tear is present, a retinal detachment is classified as “complex.”

What is the retina?

Symptoms

Many patients with PVR report symptoms of retinal traction (pulling), such as floaters or flashes of light. Accumulation of fluid underneath the retina results in a loss of peripheral (side) vision.

When the detachment involves the center of the retina, called the macula, central vision loss will occur. Patients with chronic retinal detachment may also develop problems such as elevated pressure in the eye and inflammation.

Some patients experience no symptoms, particularly:

  • Younger patients
  • Cases where the macula is not involved
  • Patients whose detachment has progressed slowly

But, most often, patients will have some visual symptoms.

Causes

Figure 1. A patient with complex retinal detachment due to PVR in the left eye. A retinal “star fold” is present in the inferior macular with associated subretinal fluid. (Photo courtesy Carl Regillo, MD)
Figure 1. A patient with complex retinal detachment due to PVR in the left eye. A retinal “star fold” is present in the inferior macular with associated subretinal fluid. (Photo courtesy Carl Regillo, MD)

Complex retinal detachments due to PVR are associated with retinal scar tissue or membranes; these ultimately contract, pull, and stretch the retina, causing retinal tears or stretch holes. When the detached retina contracts, so-called “star folds” often develop (Figure 1).

The reason these membranes form is uncertain, but it is thought to be due to cells growing on the retinal surface. Passage of liquefied vitreous gel through a retinal tear or hole results in an accumulation of fluid under the retina (subretinal fluid) and progression of the retinal detachment.

PVR most commonly occurs after a previous (primary) retinal detachment repair surgery. PVR is the most common cause of primary retinal detachment surgery failure, occurring in approximately 5% to 10% of all retinal detachments. Retinal detachment with a giant retinal tear, however, is relatively uncommon.

Risk Factors

Many risk factors for PVR have been identified, including:

  • Large or multiple retinal tears
  • Giant retinal tears
  • Vitreous hemorrhage—a leakage of blood into the gel that fills the eye cavity
  • Choroidal detachment—separation of the choroid from the sclera (the white of the eye)
  • Eye trauma (injury)
  • Multiple previous surgical procedures

Diagnostic Testing

Figure 2. B-scan ultrasound of a patient with PVR-related retinal detachment. A fixed retinal fold (yellow arrow) is seen with a cone-shaped retinal detachment. (Photo courtesy of Yale Fisher, MD. Retina Image Bank, © American Society of Retina Specialists.)
Figure 2. B-scan ultrasound of a patient with PVR-related retinal detachment. A fixed retinal fold (yellow arrow) is seen with a cone-shaped retinal detachment. (Photo courtesy of Yale Fisher, MD. Retina Image Bank, © American Society of Retina Specialists.)

Viewing the retina with an indirect ophthalmoscope while the doctor applies gentle pressure to the eye (scleral depression) is the primary method for diagnosing retinal detachment. When view of the retina is obscured (blocked) by blood or dense cataract, B-scan ultrasonography can be used to determine the location and extent of a retinal detachment (Figure 2). To confirm whether there is subretinal fluid in the macula, optical coherence tomography (OCT) may be used.

Treatment and Prognosis

The only treatment option for complex retinal detachment is retinal surgery. Patients may undergo pars plana vitrectomy with peeling of membranes, a scleral buckling procedure, or both. Use of special retinal detachment repair strategies, including retinectomy or perfluorocarbon liquid, may be necessary in patients with complex retinal detachments.

Laser is also used in combination with the vitrectomy to seal the retinal breaks. Your surgeon will decide which procedure is best depending on the nature of your detachment. At the end of surgery, most patients with complex retinal detachment due to PVR or a giant retinal tear will receive a long-acting gas bubble or silicone oil filling into the vitreous cavity of the eye to hold the retina in position while the eye heals.

Research is being conducted to find a medical therapy to prevent and treat PVR, but to date, none has proven effective in most patients.

Authors

Thank You To The Retina Health Series Authors

Sophie J. Bakri, MD
Audina Berrocal, MD
Antonio Capone, Jr., MD
Netan Choudhry, MD, FRCS-C
Thomas Ciulla, MD, MBA
Pravin U. Dugel, MD
Geoffrey G. Emerson, MD, PhD
Roger A. Goldberg, MD, MBA
Darin R. Goldman, MD
Dilraj S. Grewal, MD

Larry Halperin, MD
Vincent S. Hau, MD, PhD
Suber S. Huang, MD, MBA
Mark S. Humayun, MD, PhD
Peter K. Kaiser, MD
M. Ali Khan, MD
Anat Loewenstein, MD
Mathew J. MacCumber, MD, PhD
Maya Maloney, MD
Hossein Nazari, MD

Oded Ohana, MD, MBA
George Parlitsis, MD
Jonathan L. Prenner, MD
Gilad Rabina, MD
Carl D. Regillo, MD, FACS
Andrew P. Schachat, MD
Michael Seider, MD
Eduardo Uchiyama, MD
Allen Z. Verne, MD
Yoshihiro Yonekawa, MD

Editor

John T. Thompson, MD

Medical Illustrator

Tim Hengst

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Copyright 2016 The Foundation of the American Society of Retina Specialists. All rights reserved.