Retinectomy for treatment of intractable glaucoma: long term results

Abstract

Aim: To report long term efficacy and complications of retinectomy as an intraocular pressure lowering procedure for intractable glaucoma.

Methods: This was a consecutive interventional case series. In 44 consecutive eyes (39 patients, 22 men and 17 women) retinectomy was performed to lower the intraocular pressure (IOP) in patients with uncontrolled IOP (>35 mm Hg for more than 4 months) despite conventional filtering surgery and drug treatment. Pars plana vitrectomy was performed and the peripheral retina was surgically excised to various degrees. The procedure was concluded by an intraocular gas tamponade of 20% C(3)F(8). Included were patients with neovascular glaucoma (12 eyes), infantile and juvenile glaucoma (three eyes), secondary glaucoma due to aphakia (13 eyes), severe ocular trauma (seven eyes), uveitis (seven eyes), and glaucoma in Ehlers-Danlos syndrome (two).

Results: All patients underwent successful surgical retinectomy. All patients were followed for 5 years. Mean postoperative IOP after 4 years was 15.7 (SD 9.4) mm Hg, representing a decrease of IOP by 61% compared to the preoperative level (41.2 (9.4) mm Hg). In 52.3% of eyes long term regulation of IOP could be achieved without complications. Retinectomy was least effective in neovascular glaucoma because of central retinal vein occlusion (CRVO). Eyes with glaucoma secondary to uveitis showed a tendency towards low IOP levels with subsequent phthisis bulbi. The initial visual acuity of all patients was lower than 20/50 (mean 1.8 (0.8) logMAR) in the treated eye. Final visual acuity was 2.3 (0.6) logMAR. 21 out of 44 cases developed retinal complications (retinal detachment or proliferative vitreoretinopathy (PVR)) after surgery, requiring silicone tamponade in 11 eyes (52%) either for persistent low IOP or for PVR. Nine eyes developed phthisis, seven of which were enucleated during the follow up.

Conclusions: Long term results after retinectomy demonstrate its efficacy in otherwise intractable glaucoma. Efficacy and safety of retinectomy are dependent on the underlying disease.

Figure 1

(A) Intraocular pressure, mean and standard deviation in all patients. Eyes which are outside the 95% and 98% percentile are displayed with their respective numbers (1–44) (circles and stars respectively)—for example, it is seen, that IOP in eye no 32 remains higher from 3 months to 12 months. Apart from these exceptions, there is a significant and persistent pressure lowering effect after retinectomy. (B) Individual IOP development in patients with glaucoma secondary to uveitis. Each line represents a single eye. One of the eyes (dark green line) was enucleated because of phthisis bulbi, two other eyes remained permanently hypotonic with IOP levels below 7 mm Hg. (C) Individual IOP development in patients with neovascular glaucoma after central vein occlusion. Each line represents a single eye. One eye (blue line) was removed from the follow up after 1 year because of painful phthisis.

Figure 2

(A) Individual development of visual acuity in patients with glaucoma secondary to uveitis. Each line represents a single eye. One of the eyes (green line) was enucleated because of phthisis bulbi, two other eyes remained permanently hypotonic with IOP levels below 7 mm Hg. (B) Individual development of visual acuity in patients with neovascular glaucoma after central vein occlusion. Each line represents a single eye. One eye (blue line) was removed from the follow up after 1 year because of phthisis.

Figure 3

Clinical composite image of retinectomy.