Sequenced approach offers effective retinectomy with less complications

February 26, 2018

A retinectomy performed under air using a sequenced approach can improve outcomes.

By Vanessa Caceres;Reviewed by Steve Charles, MD

Using a sequence-based approach can help surgeons perform a retinectomy more effectively with fewer complications, according to Steve Charles, MD.

Dr. Charles, Charles Retina Institute, Germantown, TN, outlined his pearls and shared the reattachment sequence that he follows during a retinectomy.

Dr. Charles recommends that surgeons not perform a retinectomy under balanced salt solution (BSS) or under perfluoro-N-octane (PFO). In fact, at the various retina meetings he attends, Dr. Charles said there always seems to be a complication presented that is related to sub-foveal PFO. The only way to avoid such complications is by not using it in the first place, he said.

Dr. Charles will use oil only if oil is already present and then preforms retinectomy under oil.

Typically, he performs a retinectomy under air. This helps avoid complications, such as an unnecessary or excessive retinectomy or excessive retinal movement when performed under BSS and subretinal PFO when performed under PFO, Dr. Charles said.

Retinectomy sequence

When performing a retinectomy, Dr. Charles follows the sequence below:

  • Start draining the subretinal fluid, then fluid-air exchange (FAX[VC1] );
  • Perform a pars plana vitrectomy under air if residual vitreous traction;
  • Perform the epiretinal membrane (ERM) peel under air if ERM noted at this stage;
  • Remove the subretinal band under air if retinal contour changing band noted at this stage;
  • Perform incremental retinectomy under air.

“Vitrectomy under air is a big part of this concept,” Dr. Charles said. “It works very well. There are some optics changes at the interface, but I’ve often thought I removed all the vitreous. I found during this step I didn’t. You have to be very careful because of where you are.”

Dr. Charles also advocates for ERM peeling under air instead of putting PFO in the eye at this stage. “Peeling under air works very well,” he said. “If the retina continues to move back and is hung up by a subretinal band, then do a punch-through retinotomy, again, under air.”

It is important for surgeons to assess as they proceed with the surgical steps how much a retinectomy is needed, Dr. Charles cautioned. Dr. Charles has had times when he thought a patient needed a retinectomy, but it turned out they did not, and times when it turns out they did need it unexpectedly. That is the reason he believes a retinectomy should be thought of as a sequence of events rather than performing all steps in all cases.

“This controlled method eliminates the retina from moving around,” Dr. Charles said.

Different laser approach

One thing Dr. Charles does differently compare with other surgeons is that he applies laser confluently versus using rows and rows of laser spots.

“I should probably use diathermy a little more,” Dr. Charles said. “Occasionally, I get a little bleed. If you do get a bleed, air confines it. I can continue to work on it.”

Another pearl that Dr. Charles shared is how he excises everything anterior to the cut, as data have shown, this leads to less hypotony and less anterior segment vascularization than Machemer’s relaxing, retinotomy technique.

Steve Charles, MD

e: scharles@att.net

This article was adapted from a presentation that Dr. Charles delivered at the Retina Subspecialty Day prior to the 2017 American Academy of Ophthalmology meeting. Dr. Charles has no disclosures relevant to his talk.