Lens-sparing pars plicata vitrectomy for stage 4 ...

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5. Williams JD. Spectrum of activity of azithromycin. Eur J Clin. Microbiol Infect Dis 1991;10:813-20. Lens-sparing pars plicata vitrectomy for stage 4 retinopathy ...

[Downloaded free from http://www.ijo.in on Wednesday, September 28, 2016, IP:] Letters to Editor May - June 2010 3. Paller AS. Genetic immunodeficiency diseases. In: Freedburg IM, Eisen AZ, Wolff K, Frank Austen K, Goldsmith LA, Katz SI, editors. Fitz Patrick's Dermatology in general medicine. 6th ed. New York: McGraw-Hill; 2003. p. 1125-6. 4. Grimbacher B, Schäffer AA, Holland SM, Davis J, Gallin JI, Malech HL, et al. Genetic linkage of hyper-IgE syndrome to chromosome 4. Am J Hum Genet 1999;65:735-44. 5. Williams JD. Spectrum of activity of azithromycin. Eur J Clin Microbiol Infect Dis 1991;10:813-20.

Lens-sparing pars plicata vitrectomy for stage 4 retinopathy of prematurity Dear Editor, We read with interest the article by Bhende et al.[1] We would like to make the following comments: 1. The title of the article mentions pars plana vitrectomy. We feel that in these young eyes the pars plana is still not developed and the sclerotomies are actually through the pars plicata. 2. Not all cases of Stage 4A retinopathy of prematurity (ROP) require surgery. Some of these remain stable and some get better spontaneously. Only those eyes which are progressing in spite of good laser or unlasered late referrals with vascular activity should be operated upon. 3. It is commendable that in spite of having iatrogenic breaks in three cases, two had a favorable anatomical and visual outcome. In our experience,[2] all the eyes with iatrogenic break did badly. In fact we have even concluded that aggressive peeling in Stage 4B should be avoided for the same reason. 4. With the advent of 23 and 25-gauge systems, lens-sparing vitrectomy (LSV) has become more popular. The small instruments allow the surgeon easy access to anterior membranes in peripheral detachments in these small eyes.[3] However, the sclerotomies should be sutured at the end of the surgery. 5. Triamcinolone acetonide-assisted vitrectomy has been useful in adults. It has also been used in Stage 5 ROP.[4] We are of the opinion that in the future it may become a very useful adjuvant in LSV for Stage 4 ROP too.

Parag K Shah, V Narendran, N Kalpana Pediatric Retina and Ocular Oncology Department, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India Correspondence to: Dr. Parag K. Shah, Department of Pediatric Retina and Ocular Oncology, Aravind Eye Hospital, Avinashi Road, Coimbatore- 641 014, Tamil Nadu, India. E-mail: [email protected]

References 1. Bhende P, Gopal L, Sharma T, Verma A, Biswas RK. Functional and anatomical outcomes after primary lens-sparing pars plan vitrectomy for stage 4 retinopathy of prematurity. Indian J Ophthalmol 2009;57:267-71.


2. Shah PK, Narendran V, Kalpana N, Tawansy KA. Anatomical and visual outcome of stages 4 and 5 retinopathy of prematurity. Eye 2009;23:176-80. 3. Gonzales CR, Boshra BS, Schwartz SD. 25-guage pars plicata vitrectomy for stage 4 and 5 retinopathy of prematurity. Retina 2006;26:S42-6. 4. Lakhanpal RR, Fortun JA, Chan-Kai B, Holz ER. Lensectomy and vitrectomy with and without intravitreal triamcinolone acetonide for vascularly active stage 5 retinal detachments in retinopathy of prematurity. Retina 2006;26:736-40. DOI: 10.4103/0301-4738.62661 

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Authors' reply Dear Editor, The authors wish to thank Shah et al.[1] for their keen interest in our article,[2] which extends the discussion on the particular matter. We appreciate the comments and suggestions written by them regarding the surgical management of Stage 4 and 5 retinopathy of prematurity (ROP). We would like to discuss the issues raised regarding the subject. 1. We completely agree that the term ‘pars plicata vitrectomy’ is more aptly applied to these small eyes, in which the pars plana is incompletely developed.[3] 2. Stage 4A only indicates attached macula and may have a localized traction along the ridge in the periphery, or may have extensive proliferation with tractional component all along the ridge. Stage 4A eyes require surgical intervention only when the retinal detachment progresses, or when there is no desired response despite adequate laser ablation.[4] All our study eyes with Stage 4A ROP had progressive disease. 3. Iatrogenic break formation during the vitreoretinal surgery in ROP generally carries a poor prognosis in terms of anatomical success. Of the three eyes with iatrogenic breaks in our series, two had a break in previously lasered retina. In both these eyes, additional retinopexy was performed during the surgery. Third eye was noted to have a break nasal to the disc and reported with retinal detachment at two months follow-up. Subsequently it underwent resurgery with successful outcome. 4. Authors fully agree that the 23- or 25-gauge systems have made life easier with much improved maneuverability of instruments in these small eyes. Suturing of sclerotomies can be left to the surgeon’s discretion.[5] The majority of our cases reported in this series were operated before 23G or 25G systems were established in clinical practice. Presently, nearly all the lens-sparing vitrectomies for Stage 4 and some of the Stage 5 ROP in our institute are being carried out with the smaller gauge instruments. We routinely suture the 23G sclerotomies including overlying conjunctiva. However, we leave the 25G sclerotomies unsutured, and have never had a postoperative hypotony or sclerotomyrelated complications in these eyes. 5. Triamcinolone was used at the end of the surgery by Lakhanpal et al. for vascularly active Stage 5 ROP eyes for limiting the postoperative inflammation and reproliferation, and not for the better visualization of vitreous during the surgery.[6] In Stage 5 ROP, generally there is extensive proliferation and vitreous membranes without much gel, which does not need additional dye for

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