PROLIFERATIVE VITREORETINOPATHY

Dr. Swati Ramteke

INTRODUCTION

 Proliferative vitreoretinopathy (PVR) - clinical syndrome associated with retinal traction

and detachment in which cells with proliferative potential multiply and contract on retinal
surfaces and in the vitreous compartment.
 Spectrum of severity
 Can occur in untreated RD,VH,prolonged inflammation,after trauma and after RD sugery.
 Most common cause of failure in retinal detachment surgery.
 Some degree of PVR is found in up to 10 % of retinal detachments.
PATHOPHYSIOLOGY

 An inappropriate excess wound-healing response.

 Vitreous compartment is normally almost devoid of cellular content
 Protected by ILM and blood retinal barrier.Any disruption in them results in invasion of
circulatory inflammatory cells.
 In retinal tears with RD,RPE cells migrate onto retinal surface,vitreous and vitreous base.
 Proliferation,transdifferentiate and contract.Its self propogating cascade.
 4 to 12 weeks for PVR to develop.

CLASSIFICATION
nw2013-retinaldetachment-47-638.webp
GRADE A
SHAFFER’ SIGN – PRESENCE OF
VITREOUS CELLS
 GRADE A
Retinal detachment with
vitreous clumps
 GRADE B
Retinal wrinkling with
rolled edges of retinal
break.
GRADE B
 GRADE C
Full thickness fixed retinal folds
 GRADE C

C1 C7
 GRADE D

D1Wide funnel
 GRADE D
D2 Narrow funnel
 GRADE D
D3 - Closed funnel
SURGERY FOR PVR

Clinical severity is variable – surgery is planned accordingly.

Urgent if the macula is still attached or salvageable.
If the macular vision is not salvageable, inflammation is active – wait and quiten the eye with
corticosteroids.
Mostly should be operated soon.
Goals – 1. permanently support the retina from any ongoing traction.
2. to close any open retinal breaks.
 Scleral Buckle - 360° encircling scleral buckle remains a fundamental requirement.
 Reasons -
 Vitreous base,inferiorly, becomes fibrocellular in PVR and continues to contract even after
a formal vitrectomy.
 Supports the vitreous base against further traction.
VITRECTOMY –
To remove all vitreous gel, cellular and inflammatory material, blood, and fibroblastic
membranes.
To relieve all traction and to remove as much of VB.
To release the tractional effect on scarred shortened retina.
 Complete vitrectomy and division and peeling or delamination of fixed membranes.
 Heavy fluorocarbons may be needed to flatten the retina.
 Relaxing retinotomy is required to fully relieve traction
 Rarely subretinal membranes need to be removed
 Internal drainage of subretinal fluid and fluid–air exchange of the vitreous compartment.
 Persistent retinal elevation after fluid–air exchange means that complete release of traction
or retinal shortening has not been achieved.
 Reattached retina and open retinal breaks are sealed with endolaser photocoagulation or
cryotherapy
 Tamponade – SO is mostly preferred .
 Face-down in the prone position for at least the first 24 hours after gas or light SO. 7 to 10
days if inferior breaks.
 Raised IOP should be monitored and addressed.
COMPLICATIONS

 Early –
 Iop rise in 10 to 15 %
 Postoperative inflammation
 Incomplete fill of SO with associated fluid inferiorly
 Endophthalmitis
 LATE –
 Regrowth of surface retinal membranes leading to retinal detachment, tractional retinal
tears,macular pucker.
 Hypotony – if ciliary body membranes
 Retinotomy or retinectomy cut edge may fibrose and retract back to the posterior pole
 Migration of SO with development of new tears.
 Early cataract,Emulsification of SO,band shaped keratopathy and late secondary glaucoma.
 Scleral buckle infection.
 Wound-healing sequence of PVR matures over 3 months.atleast kept for this period.
 Significant risk of redetachment after SOR.
 Indications of SOR