Tractional Retinal Detachment Treatment & Management

Updated: Sep 20, 2018
  • Author: Lihteh Wu, MD; Chief Editor: Hampton Roy, Sr, MD  more...
  • Print
Treatment

Medical Care

Currently, no role exists for medical care in the treatment of TRD.

Next:

Surgical Care

Depending on the underlying cause and extent of the TRD, surgical intervention is offered to patients. For instance, a patient with TRD secondary to PDR that does not threaten the macula probably can be monitored closely. The main surgical goal in all these cases is to relieve vitreoretinal traction. Traction may be relieved with scleral buckling techniques and/or with vitrectomy.

In certain cases, combined RRD and TRD may be present. Usually, the retina becomes detached from the vitreoretinal traction. With further traction, small breaks may occur causing a combined TRD-RRD. In these cases, the surgical goal is to identify all the breaks and to close them in addition to the relief of vitreoretinal traction.

Tractional Retinal Detachment Due to Proliferative Vitreoretinopathy

In TRD secondary to PVR, usually a broad circumferential element, such as a 287 buckle, is placed. A decision is made whether the crystalline lens needs to be sacrificed. A complete vitrectomy follows. Inside-out (posterior to anterior) forceps (not pick) membrane peeling is the preferred dissection method with or without perfluorocarbon liquid injection. Perfluorocarbon liquid may be injected at the surgeon's discretion to stabilize the posterior retina. If residual traction remains, subretinal membranes may need to be excised if causing traction. If necessary, a relaxing retinectomy is created. A fluid-air exchange is performed. Endophotocoagulation is followed by either air-silicone oil exchange or air-gas exchange. If perfluorocarbon liquids are not used, the dissection starts anteriorly and proceeds posteriorly.

A randomized controlled clinical trial of a perioperative infusion of 5-fluorouracil and low molecular weight heparin was not able to demonstrate a better surgical outcome in eyes with established PVR. There has been a recent interest in using methotrexate as an antiproliferative agent. [11, 12]

Tractional Retinal Detachment Due to Proliferative Diabetic Retinopathy

In TRD secondary to PDR, several surgical techniques have been developed. A scleral buckle usually is not used unless anterior breaks are present.

A central vitrectomy is performed with the vitrector clearing the axial opacities and the cortical vitreous gel. A large opening is created in the posterior hyaloid until vitreoretinal adhesions are encountered. Segmentation and/or delamination of these adhesions (as described by Charles) are used for virtually all diabetic TRD.

Delamination refers to the separation of the retina from the extraretinal proliferation. This dissection proceeds from posterior to anterior. Fibrovascular tissue often bridge separate retinal zones. Segmentation refers to cutting of the fibrovascular tissue bridge into small separate islands of tissue.

Care must be given to create as few iatrogenic breaks as possible. If breaks are identified, usually fluid-air exchange with photocoagulation reattaches the retina. Breaks should be marked with diathermy, so they are identified easily in the air-filled eye. The incidence of RRD in patients who underwent vitrectomy for PDR has been reported to be 4.3%. Intraocular bleeding also must be monitored closely. Diathermy to active neovascular fronds may be necessary.

Other techniques include the en bloc dissection. En bloc is a name applied to outside-in delamination where the vitreous is used to pull on the epiretinal membrane. Outside-in causes more retinal breaks than inside-out, making it a dangerous maneuver.

Recent advances in small-gauge instrumentation have facilitated the peeling of membranes in these cases, in many cases obviating the need for intraocular picks and scissors. [13, 14, 15, 16, 17, 18]

Intravitreal bevacizumab has been reported as a preoperative adjunct in vitrectomy for PDR. Bevacizumab seems to reduce the bleeding associated with the segmentation and delamination of fibrovascular membranes. However, in eyes with severe ischemia, the neovascularization regresses rapidly, but the resulting fibrous scar tissue may lead to the development or progression of TRD. Therefore, caution should be exercised when injecting these eyes, and patients should be scheduled for surgery days, and not weeks, after the injection.

Anti-VEGF agents such as bevacizumab have been used as adjuncts to vitrectomy. The advantages of using preoperative bevacizumab includes faster surgery and reduced risk of intraoperative bleeding, which facilitates membrane dissection. [19, 20, 21, 22] Care must be taken because it has been reported that, in very ischemic eyes, TRD may occur or progress shortly following intravitreal bevacizumab. [20, 21] It is speculated that rapid neovascular involution with accelerated fibrosis and posterior hyaloidal contraction as a response to decreased levels of VEGF is responsible for this phenomenon. In this retrospective series, the time from injection to TRD was a mean of 13 days, with a range of 3-31 days. [20] Therefore, the time between bevacizumab injection and vitrectomy should not exceed 3 days.

Tractional Retinal Detachment Due to Retinopathy of Prematurity

The treatment of TRD secondary to ROP depends on the stage of the disease.

Although many vitreoretinal surgeons advocate an encircling band for stage 4A ROP, no scientific evidence is available that supports its efficacy. In stage 4B, vitrectomy is recommended. It is currently unclear if lens-sparing vitrectomy has any advantages over lensectomy.

For stage 5 ROP, visual and anatomical results have been disappointing, making some surgeons abandon surgery for these cases. Others have tried vitrectomy and lensectomy with or without scleral buckling. In these cases, a 2-port vitrectomy technique is recommended since the small size of the eye and orbit limits ocular manipulation if a 3-port technique is used. The use of intravitreal triamcinolone as a postoperative adjuvant might improve the rate of retinal reattachment after vitrectomy.

A recent case series of aggressive posterior ROP suggested that early vitrectomy with lensectomy in these cases is effective in preventing TRD.

Special attention must be given to avoid iatrogenic retinal breaks because of the poor prognosis associated with this complication. The goal of surgery is to obtain macular reattachment.

Previous
Next:

Consultations

Patients with TRD should be referred to an experienced vitreoretinal surgeon for further management.

Previous
Next:

Prevention

Proliferative vitreoretinopathy

Extensive cryotherapy, cryotherapy over bare RPE, and scleral depression after cryotherapy should be avoided because this will disperse RPE cells into the vitreous cavity. Cryotherapy also causes breakdown of the blood-ocular barrier, allowing serum (containing various growth factors believed to be stimulatory to the formation of PVR) to enter the eye.

A double-masked, prospective, randomized, placebo-controlled clinical trial reported that adjuvant therapy with 5-fluorouracil and low molecular weight heparin does not improve anatomical and visual success rates in retinal detachments with preexisting PVR. Furthermore, it is associated with worse visual outcomes in cases with macula-sparing retinal detachment.

Proliferative diabetic retinopathy

Patients with diabetes should be monitored closely and treated with aggressive panretinal photocoagulation when indicated.

Retinopathy of prematurity

Screening protocols should be monitored, and patients should be treated with laser or cryotherapy as indicated.

Previous
Next:

Further Outpatient Care

Certain eyes that undergo vitreoretinal surgery have an intraocular gas bubble to serve as internal tamponade. Depending on the gas used and the location of the breaks, the surgeon instructs the patient to maintain a certain head position for a limited time.

Previous
Next:

Further Inpatient Care

Most vitreoretinal procedures currently are performed in an ambulatory setting.

Previous
Next:

Inpatient & Outpatient Medications

Postoperative medications usually include a topical corticosteroid, a topical cycloplegic, and a topical antibiotic. The intraocular pressure is monitored and controlled accordingly.

Previous