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Triamcinolone-assisted removal of the posterior hyaloid to repair retinal detachment due to macular hole in high myopia

Akifumi Ueno¹,Hiroshi Enaida¹ Yasuaki Hata¹, Takao Nakamura¹, Toshio Hisatomi¹, Kimihiko Fujisawa¹, Toshiaki Kubota¹,Taiji Sakamoto², Tatsuro Ishibashi¹
[1] Dept of Ophthalmology, Faculty of Medicine, Kyushu University Graduate School of Medical Science, 3-1-1 Maidashi,
Higashi-ku, Fukuoka 812-8582 Japan
[2] Department of Ophthalmology, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan

Correspondence to: Tatsuro Ishibashi, Department of Ophthalmology, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-82, Japan Email: ishi{at}eye.med.kyushu-u.ac.jp

Accepted for publication:  August 1, 2004

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Introduction

Although the exact pathogenesis of retinal detachment resulting from macular hole in a highly myopic eye is still unclear, tangential macular traction, posterior staphyloma, and retinal pigment epithelial atrophy are thought to be major factors.¹ Vitrectomy with peeling of macular epiretinal membrane and/or internal limiting membrane (ILM) to remove tangential traction has been reported to be an effective treatment.¹ In preoperative examinations, we often observe a glial ring in retinal detachment resulting from highly myopic eyes. However, the visibility of posterior hyaloid, epiretinal membrane, and the ILM is poor in most cases of retinal detachment, which thus makes this surgical procedure a difficult one. In order to solve this problem, indocyanine green (ICG) staining has been used recently to visualize the ILM.¹ However, the possible toxicity of ICG on retina is of concern for surgeons.²

Recently, intravitreous injection of triamcinolone acetonide (TA) during vitrectomy was reported not only to reduce inflammation but also to improve the visibility of the vitreous body and residual vitreous cortex. ³ In this study, we report the usefulness of this technique for retinal detachment caused by macular hole in highly myopic eyes. A thick posterior hyaloid present on highly myopic eyes can be more easily visualized and removed using the method described here.

 

Patients and Surgical Technique

A TA-assisted pars plana vitrectomy with the removal of the posteriorhyaloid was performed on 12 eyes from 11 consecutive highly myopic patients with extensive retinal detachment resulting caused by macular hole, in the absence of peripheral holes. All surgeries were performed at Kyushu University Hospital from March 2001 to December 2001. The present study was approved by the appropriate institutional review board, and informed consent was obtained from all patients.

The TA suspension was made using a previously described method.³

Briefly, a triamcinolone aqueous suspension (Kenakolot-A®, Bristol Pharmaceuticals KK, Tokyo, Japan) was left standing for 30 min and the vehicle was discarded. The remaining TA (40 mg) suspension was mixed with 2.5 ml of balanced salt solution (BSS, Santen, Osaka, Japan).

A standard three-port pars plana vitrectomy and phacoemulsification without intraocular lens implantation was performed on 11 eyes that had cataract, while a vitrectomy alone was performed on one pseudophakic eye. Scleral indentations were performed in all eyes to cut the vitreous to the peripheral vitreous base. After a prior core vitrectomy, a TA suspension (0.5 ml) was injected into the vitreous cavity with a 27-gauge needle followed by the aspiration of TA granules with a surgical probe. The posterior hyaloid membrane thereafter appeared as a white-colored gel attached to the retinal surface. The hyaloid was then removed using a silicon-tipped aspiration needle, ILM forceps, or a diamond-dusted membrane scraper (DDMS, DORC, Phoenix, USA). After this procedure, the ILM was confirmed to be intact using ICG staining in ten eyes as previously described.3

Subretinal fluid was drained through the macular hole and no coagulative treatment was used around the macular hole. After an air-fluid exchange with the injection of SF₆ gas (20%) or C3F8 gas (15%), the patients were instructed to remain in a prone position from one to two weeks. Three of 12 eyes received a silicone oil injection instead of a gas injection. Two cases had difficulty maintaining a prone position postoperatively (one was mentally retarded and the other had a spine problem). In addition, a suprachoroidal hemorrhage occurred intraoperatively in one case.

The initial surgical results showed eight of 12 eyes to be successfully treated with macular hole closure, and retinal reattachment throughout the follow-up period, which ranged from 6 to 16 months. Retinal reattachment was achieved in 9 of 12 eyes during the follow-up period. The best corrected visual acuity improved by 2 lines or more in 8 of 12 eyes.

The resected tissue from the posterior hyaloid was submitted for a pathologic examination using transmission electronmicroscopy, revealing collagen fibers with glial cells without ILM tissue (not shown). We would like to demonstrate the surgical procedures of a representative case in this video.

 

Comment

A thick posterior hyaloid was clearly observed intraoperatively in all 12 eyes. TA greatly improves the visibility of the posterior hyaloid, facilitating its removal. Tractional forces generated by this thick posterior hyaloid (probably with various cells contained in this gel structure) may be a major factor in the pathogenesis of macular hole retinal detachment, supported by the fact that the present technique reattached the retina succesfully without peeling of the ILM. Furthermore, the residual TA may inhibit post-operative inflammation.
 

References

1. Kadonosono K, Yazama F, Itoh N, et al. Treatment of retinal detachment resulting from myopic macular hole with internal limiting membrane removal. Am J Ophthalmol 2001: 131; 203-207

2. Enaida H, Sakamoto T, Hisatomi T, Goto Y, Ishibashi T. Morphological and functionl damage of the retina caused by intravitreous indocyanine green in rat eyes. Graefes. Arch Clin Exp Ophthalmology 2002; 240: 209-213.

3. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinolone-assisted pars plana vitrectomy improves the surgical procedures and decreases the post-operative blood-ocular barirer breakdown. Graefes Arch Clin Exp Ophthalmology 2002; 240: 423-429.