New retinotomy technique reduces retinal surgery complications, improves recovery

Tarek S. Hassan, MD, a professor of ophthalmology at Oakland University, presents a groundbreaking approach to managing proliferative vitreoretinopathy (PVR) through serial relaxing retinotomies.

"I was given the opportunity to present a series of patients and a concept that we've been working on using serial, relaxing retinotomies in the management of PVR; rather than using a more traditional approach of a circle, linear retinectomy, where we remove several clock hours of retina, make large cuts in the retina," Hassan said.

"Historically, we've thought of relieving tangential traction in cases of PVR as something we have to cut a lot of retina to achieve. And the problem is, our assumption has been that the intrinsic retinal scarring–or foreshortening–that occurs creates lines of traction that go from the periphery to the optic nerve or to attached retina somewhere posteriorly. But in fact, intraretinal scarring, which begins as early as 1 day after retinal detachment, and gets sequentially worse. That intraretinal scarring is fibroblastic glial tissue that proliferates in all directions within the retina, so there are no lines of traction that specifically go from the periphery to the nerve."

Historically, surgeons would remove several clock hours of retina to relieve tension, but Hassan's technique focuses on making small, strategically placed retinotomies. After removing epiretinal and subretinal fibrous tissue, he creates tiny holes the size of a soft tip, which effectively relieve traction in a 360-degree circular pattern.

"So rather than making large circum linear retinectomies, we've been exploring the idea that if, after you've relieved all epiretinal fibrous tissue cause traction through membrane peeling and any sub retinal proliferation through peeling, then now you're left with the retina that is still foreshortened because of the intrinsic scarring," he said. "Typically, people would make a retinectomy of at least several clock hours, then cut the anterior retina, and then flatten the retina and laser. You're left with a large separation of bare RPE, rather than doing so if there is no further anterior traction–or epiretinal traction–with just foreshortening, we make regularly spaced small retinotomies the size of a soft tip that then relieve the traction, very, very well placed, circular retina retinotomies that relieve traction 360 degrees from the small retinotomy."

This innovative method offers multiple advantages: it removes significantly less retinal tissue (potentially 1/50 or 1/100 of traditional approaches), reduces the risk of re-detachment, prevents long retinal edges from curling, and allows for faster patient recovery.

By flattening the retina under air and using a scattered laser technique, surgeons can achieve the same anatomical goals with minimal intervention. In the past year, multiple surgeries have been performed using this technique, reporting no recurrent PVR, no hypotony, and improved patient outcomes.

"when we're talking about stimulating recurrent PBR beyond that operation, certainly cutting less is more when we're trying to achieve the best anatomic outcome," Hassan said.