Peripheral 360 Degree Retinotomy, Anterior
Flap Retinectomy, and Radial Retinotomy in the
Management of Complex Retinal Detachment
MUMIN HOCAOGLU, MURAT KARACORLU, ISIL SAYMAN MUSLUBAS, HAKAN OZDEMIR, SERRA ARF, AND
OMER UYSAL
I

PURPOSE: To compare the outcomes for patients with
rhegmatogenous retinal detachment (RRD) and patients
with retinal detachment (RD) following penetrating
injury after combined 360 degree retinotomy, anterior
flap retinectomy, and radial retinotomy for the manage-
ment of advanced proliferative vitreoretinopathy (PVR).

DESIGN: Retrospective, comparative, interventional
case series.

METHODS: Twenty-four eyes (60%) of 24 patients
diagnosed with RRD and 16 eyes (40%) of 16 patients
diagnosed with RD after penetrating injury whose sur-
gery involved 360 degree retinotomy, anterior flap reti-
nectomy, and radial retinotomy for the management of
advanced PVR (grade D) were included in the analysis.
The primary outcome was anatomic surgical success. Sec-
ondary outcomes were change in visual acuity (VA) and
postoperative complications.

RESULTS: The mean number of previous interventions
in the RRD and trauma groups were 1.04 and 1.31,
respectively (P [ .13). After 51.5 (± 52.7) months of
mean follow-up, the complete retinal reattachment rates
for the RRD and trauma groups were 79% (19/24) and
75% (12/16), respectively (P > .99). The final mean
VA was 2.2 logMAR (20/2000) in both groups, with
improvement in the RRD group (P [ .04). The most
common postoperative complications in the RRD and
trauma groups, respectively, were persistent hypotony
in 6 eyes (25%) and 5 eyes (31%) (P [ .73), corneal
damage in 8 eyes (29%) and 6 eyes (38%) (P [ .34),
and epiretinal membrane in 5 eyes (20.8%) and 4 eyes
(25%) (P > .99).

CONCLUSIONS: Only 25% of the eyes (10/40) had VA
of 20/200 or better. The aim of peripheral 360 degree
retinotomy, anterior flap retinectomy, and radial retinot-
omy is to obtain retinal reattachment, which is otherwise
unachievable. (Am J Ophthalmol 2016;163:115–121.
Ó 2016 by Elsevier Inc. All rights reserved.)
Accepted for publication Dec 3, 2015.
From the Istanbul Retina Institute (M.H., M.K., I.S.M., S.A.); and the
Departments of Ophthalmology (H.O.) and Biostatistics (O.U.),
Bezmialem Vakif University, School of Medicine, Istanbul, Turkey.
Inquiries to Murat Karacorlu, Istanbul Retina Institute, Hakkı Yeten
Cad. Unimed Center No: 19/7, Fulya – Şişli, Istanbul 34349, Turkey;
e-mail: murat.karacorlu@istanbulretina.com
0002-9394/$36.00 Ó 2016 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2015.12.001
NTRARETINAL PROLIFERATION OF ALL NON-NEURONAL
cell types in the retina after retinal detachment
(RD) has been shown in experimental trials.1 Retinal
pigment epithelium (RPE) and Müller cells are the prin-
cipal cell types responsible for the formation of
abnormal cellular accumulations in the vitreous cavity
and subretinal space.2 Clinically, this condition is
known as proliferative vitreoretinopathy (PVR). The
PVR process is characterized by formation of periretinal
fibrocellular membranes, intraretinal fibrosis, and subre-
tinal bands.3
Treatment of RD in eyes with PVR is challenging and re-
quires complex vitreoretinal surgery. This may involve
scleral buckling, pars plana vitrectomy (PPV) with mem-
brane peeling, retinotomy, retinectomy, and intraocular
tamponade injection. Despite extensive peeling and
removal of membranes, in some cases intraoperative retinal
reattachment cannot be achieved.4 In these cases, there
seems to be some intraretinal fibrosis causing shortening
of the chronically detached retina. In severe cases, relaxing
retinotomy is often needed.5
Since being described by Machemer in 1979, retinotomy
has been used for the management of cases with
severe PVR.6 In 1985, 360 degree retinotomy was introduced
by Haut and associates.7,8 Such circumferential relaxing
retinotomy is helpful in the management of
anteroposterior retinal shortening in eyes with intraretinal
fibrosis secondary to chronic RD. However, it has been
proposed that it is not effective in the management of
circumferential shortening commonly found in more
advanced stages of PVR.
High anatomic success rates in patients with advanced
PVR were achieved by Lim and associates, who reported
performing combined circumferential retinectomy and
large radial retinotomy in 2009.9 A PubMed search
revealed no further information on the anatomic and func-
tional outcomes since the introduction of this surgical
technique.
In this retrospective study, we compared the anatomic
and functional outcomes of patients diagnosed with rheg-
matogenous retinal detachment (RRD) and patients with
RD after penetrating injury whose surgery involved 360 de-
gree retinotomy, anterior flap retinectomy, and radial reti-
notomy for the management of complex RD.
RIGHTS RESERVED. 115
 METHODS
THE MEDICAL RECORDS OF ALL PATIENTS WHO UNDERWENT
360 degree retinotomy, anterior flap retinectomy, and
radial retinotomy for complex RD at the Istanbul Retina
Institute between May 1, 2000 and April 1, 2015 were
reviewed. Sixty-six eyes of 63 patients were identified. Pa-
tients of all ages and grades of PVR (grade D1-3) were
included. Patients with previous retinotomy, inadequate
follow-up (less than 6 months), and incomplete data
were excluded. Therefore, 24 eyes of 24 patients with
RRD and 16 eyes of 16 patients with RD after penetrating
injury were included in the analysis. Informed consent was
obtained from all participants prior to every surgical proce-
dure. The study protocol was approved by the Institutional
Review Board of Sisli Memorial Hospital, Istanbul. The
study was in accordance with the principles of the Declara-
tion of Helsinki.
All patients underwent a comprehensive ophthalmo-
logic examination including best-corrected visual acuity
(BCVA), tonometry, slit-lamp biomicroscopy, and dilated FIGURE. Fundus photograph showing peripheral 360 degree
retinotomy, anterior flap retinectomy, and radial retinotomy.
funduscopic examination. Preoperative data included sex,
There was both anteroposterior and circumferential shortening.
laterality, refraction, Early Treatment Diabetic Retinop- This contraction is relieved by retinotomies. Edges of radial reti-
athy Study (ETDRS) visual acuity (VA), lens status, pa- notomy retracted owing to annular contraction and left almost
thology, duration of symptoms, number and details of 90 degrees of naked choroid. The naked choroid can also be
previous operations, and coexisting diseases. The PVR seen on previously inserted scleral buckle.
was graded intraoperatively using the Retina Society Clas-
sification System.10 Postoperative BCVA, intraocular pres-
sure (IOP), retinal reattachment, number and details of
reoperations, time of removal of silicone oil, and complica- The posterior hyaloid, if any, was routinely removed in
tions were recorded. Hypotony was defined as a persistent all cases.
IOP of 5 mm Hg or less. An IOP 25 mm Hg or higher Epiretinal membrane (ERM) peeling was done under
was considered elevated. perfluorocarbon liquid (DK-Line; Bausch and Lomb Inc,
All operations were performed by the same surgeon Waterford, Ireland), and retinal massage to flatten the
(M.K.) and all patients from both groups had macula- retina was applied. After the ERM removal and retinal
off RDs. Scleral buckling (silicone tire, style 286) was massage, and if the scleral buckle was considered insuffi-
performed during the same surgical procedure, prior to cient to relieve the retinal traction, 360 degree retinotomy
360 degree retinotomy and radial retinotomy in cases was created. Subretinal membrane peeling was performed
presenting with significant chronic disease. Although and retinal massage under perfluorocarbon liquid was
the surgical technique varied, in all cases it included 3- repeated.
port 20 gauge or 23 gauge PPV using the Associate If, despite all these procedures, the intrinsic retinal rigid-
2500 vitrectomy system (DORC, Zuidland, Netherlands) ity did not allow retinal reattachment, radial retinotomy
and removal of the vitreous up to the vitreous base. was performed. Radial retinotomies were localized mostly
Staining of posterior hyaloid with vital dyes during vit- in the nasal quadrant from the circumferential retinectomy
rectomy was not performed. For visualization of the resid- edge to 1 disc diameter from the optic disc margin (Figure).
ual vitreous (and the posterior hyaloid membrane in Retinotomy was completed usually using vertical scissors
some cases), after removal of the anterior and core vitre- and, infrequently, a vitreous cutter. To control hemorrhage
ous, 0.2–0.3 mL triamcinolone acetonide aqueous sus- during retinotomy, blood vessels were cauterized with
pension (40 mg/mL) was injected into the mid vitreous endodiathermy, and anterior flap retinectomy was usually
cavity. Induction of PVD was attempted by active aspira- completed without any bleeding. Bleeding during retinec-
tion with a vitreous cutter just anterior to the peripapil- tomy was not an issue in any of the cases. If any bleeding
lary retina. In cases with a thickened posterior hyaloid was observed, it was easily controlled with diathermy.
membrane, if PVD could not be induced by this proce- The retinectomy was extended circumferentially and as
dure, an end-gripping membrane forceps was used to much as possible of the peripheral anterior retinal flap
separate the posterior hyaloid from the retinal surface. was removed to minimize ischemia and its complications.

116 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2016

 TABLE 1. Preoperative Characteristics of the Patients TABLE 2. Surgical Procedures Performed Prior to 360
Undergoing 360 Degree Retinotomy, Anterior Flap Degree Retinotomy and Radial Retinotomy for the
Retinectomy, and Radial Retinotomy for the Management of Management of Complex Retinal Detachment
Complex Retinal Detachment
RRD RD After Penetrating
RRD RD After Penetrating Type of Prior Procedure (N ¼ 24)a Injury (N ¼ 16)a
Characteristics (N ¼ 24) Injury (N ¼ 16) P
No prior operations, n (%) 3 (13) 0 (0)
Age (y) Scleral buckle, n (%) 5 (20.8) 3 (18.8)
Mean (SD) 44.2 (14.8) 26.3 (13.0) <.001 Pars plana vitrectomy, n (%) 21 (87.5) 5 (31.3)
Range 19–72 7–51 Lensectomy, n (%) 7 (29.2) 9 (56.3)
Sex, n (%) Repair of penetrating injury, n (%) 0 (0) 16 (100)
Male 15 (63) 12 (75) .41
Female 9 (37) 4 (25) RD ¼ retinal detachment; RRD ¼ rhegmatogenous retinal
VA before surgery (logMAR) detachment.
a
Mean (SD) 2.46 (0.78) 2.56 (0.73) .67 Several procedure were performed in most of the cases.
Median 3.0 3.0
Range 3.0–2.0 3.0–2.0
Intraocular pressure (mm Hg)
need for lensectomy, and the incidence of hypotony,
Mean (SD) 13.4 (7.47) 13.0 (5.51) .85
elevated IOP, keratopathy, and other postoperative com-
Median 11.50 11.00
plications.
Range 4–43 5–29
Elevated IOP, n (%) 1 (4.2) 0 (0) 1.0
Hypotony, n (%) 1 (4.2) 1 (6.3) 1.0

STATISTICAL ANALYSIS: Data were analyzed using
Number of prior operations independent-sample t tests to compare subgroups’ mean
Mean (SD) 1.04 (0.55) 1.31 (0.48) .13 values and Pearson x2 test or Fisher exact test to evaluate
Median 1.0 1.0 categorical cross-distributions. Wilcoxon signed rank test
Range 0–2 1–2 was used to compare within groups and Mann-Whitney
Lens status, n (%) test between groups for non-normal, ordinal, or integer var-
Phakic 10 (41.6) 6 (37.5) .24 iables. P < .05 was considered statistically significant. Sta-
Pseudophakic 7 (29.2) 1 (6.3)
tistical analyses used SPSS version 20.0 (SPSS, Inc,
Aphakic 7 (29.2) 9 (56.2)
Chicago, Illinois, USA).
High myopia (>6 D), n (%) 11 (45.8) 1 (6.3) .01

D ¼ diopter; IOP ¼ intraocular pressure; RD ¼ retinal detach-

ment; RRD ¼ rhegmatogenous retinal detachment; VA ¼ visual
acuity.
If the retina was incarcerated in a scleral wound, it was
released.
Upon completion of the retinectomy, the retina was flat-
tened with intravitreal injection of perfluorocarbon liquids.
Laser photocoagulation was then applied along the poste-
rior retinotomy and radial retinotomy edge. Perfluoro-
carbon was exchanged with silicone oil (1000 cs or 5000
cs). Because peripheral retinotomy extended over 360 de-
grees, a direct perfluorocarbon–silicone oil exchange was
performed, avoiding retinal slippage in all of the cases.
A lensectomy was performed if lens opacity was limiting
intraoperative visualization or if the lens was found to
impede adequate dissection of the anterior PVR. Intravi-
treal or posterior sub-Tenon steroids were not given after
surgery. Topical steroid drops were used routinely during
postoperative follow-up.
The primary outcome was anatomic surgical success.
Secondary outcomes were change in VA, the number of op-
erations required for complete retinal reattachment, the
number of operations undergone before retinotomy, any
RESULTS

PREOPERATIVE CHARACTERISTICS: Preoperative char-
acteristics and earlier procedures are presented in Table 1
and Table 2, respectively. For all patients, the mean age
was 37.1 (6 16.3) years (range, 7–72 years). The youngest
patients in the RRD and trauma groups were aged 19 and 7
years, respectively. Patients were not selected according to
age.
Twenty-seven patients were male (68%) and 13 were fe-
male (32%). For all patients, the mean preoperative
logMAR visual acuity was 2.5 (6 0.76), ranging from 3.0
to 1.0. The mean preoperative IOP for all patients was
13.2 (6 6.7) mm Hg, ranging from 4 to 43 mm Hg. Baseline
characteristics did not differ between the groups, but there
was a trend for the trauma group to be younger than the
RRD group (P < .001). All of the 16 eyes in the trauma
group had undergone primary repair following perforating
eye injury a mean 5.5 months (range 1–18 months) prior
to the 360 degree retinotomy and radial retinotomy proce-
dure. PPV and silicone oil injection in 2 eyes and PPV,
scleral buckle, and silicone oil injection in 3 eyes had
been performed in the trauma group following a diagnosis

VOL. 163 MANAGEMENT OF RETINAL DETACHMENT WITH RADIAL RETINOTOMY 117

 procedure, 4 eyes (4/24; 17%) of the RRD group and 5
TABLE 3. Postoperative Characteristics of the Patients eyes (5/16; 31%) of the trauma group (P ¼ .44). Scleral
Undergoing 360 Degree Retinotomy, Anterior Flap buckling was performed during the same surgical proce-
Retinectomy, and Radial Retinotomy for the Management of
dure, prior to 360 degree retinotomy and radial retinotomy
Complex Retinal Detachment
in cases presenting with significant chronic disease. Eight
RD After eyes (20%) had lens removal, 5 eyes (5/24; 21%) of the
RRD Penetrating P RRD group and 3 eyes (3/16; 19%) of the trauma group
Characteristics (N ¼ 24) Injury (N ¼ 16) Value
(P ¼ .34). Silicone oil endotamponade was used in all
Follow-up (mo) cases. In 3 patients in this case series, higher-viscosity sili-
Mean (SD) 57.8 (58.19) 42.0 (43.14) .80 cone oil (5000 cs) was used to provide long-term internal
Median 18.0 25.0 tamponade and was removed after 3 months. In 2 of 3 pa-
Range 6–152 6–136 tients the retina remained attached until the last visit, and
Final VA (logMAR) 2 patients developed persistent hypotony. One pseudo-
Mean (SD) 2.2 (0.92) 2.2 (0.89) .99
phakic eye in the RRD group and 1 in the trauma group
Median 2.0 2.0
had IOL extraction. The retina was reattached intraopera-
Range 3.0–0.5 3.0–0.4
Final change in logMAR
tively in all 40 eyes.
Mean (SD) 0.3 (0.62) 0.41 (0.88) .98
Final IOP (mm Hg)
POSTOPERATIVE DATA: Table 3 summarizes the postop-
Mean (SD) 10.6 (6.44) 13.1 (8.24) .32 erative data for the 2 groups. The mean follow-up time for
Median 10.5 13.5 all patients was 51.5 (6 52.7) months (range, 6–
Range 2–30 5–29 152 months). Final anatomic success was achieved in 31
Elevated IOP at any time, n (%) 5 (20.8) 4 (25) >.99 eyes (78%), with no significant statistical difference be-
Persistent elevated IOP, n (%) 2 (8.33) 2 (12.5) >.99 tween groups: 19 eyes (19/24; 79%) in the RRD group
Persistent hypotony, n (%) 6 (25) 5 (31.3) .73 and 12 eyes (12/16; 75%) in the trauma group (P > .99).
Corneal damage, n (%) 7 (29.2) 6 (37.5) .34
Two eyes (8%) in the RRD group and 1 eye (6%) in the
Epiretinal membrane, n (%) 5 (20.8) 4 (25) >.99
trauma group developed recurrent RD underneath the sili-
Lens status, n (%)
Phakic 1 (4.2) 0 (0) .01
cone oil and required a second surgery with silicone oil in-
Pseudophakic 9 (37.5) 1 (6.2) jection. At last visit, there was a recurrent RD underneath
Aphakic 14 (58.3) 15 (93.8) the silicone oil in 2 of the 3 cases and 1 patient had RD after
Scleral buckle, n (%) 9 (37.5) 8 (50) .43 silicone oil was removed. At final follow-up there were 5
Final anatomic success, n (%) 19 (79.2) 12 (75) >.99 (21%) failures in the RRD group and 4 (25%) failures in
Duration of SO (mo) the trauma group in which patients refused reoperation or
Mean (SD) 5.0 (2.76) 4.8 (2.12) .96 reoperation was not recommended. Two patients (1 patient
Median 4.0 3.5 in each group) had recurrent RD underneath the silicone
Range 3–12 3–12 oil. In the other 7 patients, the retina redetached after
Silicone oil at final 1 (4.2) 1 (6.2) >.99
the silicone oil was removed. For all patients, the mean
examination, n (%)
postoperative logMAR visual acuity was 2.2 (6 0.9),
IOP ¼ intraocular pressure; RD ¼ retinal detachment; RRD ¼ ranging from 0.4 to 3.0. The improvement in VA in the
rhegmatogenous retinal detachment. RRD group was significant (P < .04). Functional VA
(>
_20/200) was achieved in 6 eyes (25%) from the RRD
group and 4 eyes (25%) from the trauma group (P > .99).
of RD a mean 2.2 months (range 2–4 months) prior to the For all patients, the mean intraocular pressure at final ex-
procedure. In the RRD group, 17 eyes had undergone 1 amination was 12.0 (6 7.2) mm Hg, ranging from 2 to
PPV operation a mean 6.0 months (range 2–23 months) 30 mm Hg. The decrease in IOP in the RRD group
prior; 4 patients had had 2 PPV operations, the last measured at the final examination was significant
performed a mean 2.3 months (range 2–4 months) earlier; (P ¼ .04).
and 3 patients had had symptoms for a mean of 3 months We removed the silicone oil in almost all cases. Removal
and no prior operation. Five cases from this group had of the silicone oil was not regarded as additional surgery.
had scleral buckling. Silicone oil had been used as a tampo- The mean silicone oil tamponade duration for all patients
nading agent except in 4 cases, in which C3F8 gas had been was 4.9 (6 1.7) months (range, 3–12). There was no signif-
used. Removal of the silicone oil was not regarded as addi- icant difference in the duration of tamponade between the
tional surgery. groups. Only 1 eye (1/24; 4%) from the RRD group and 1
eye (1/16; 6%) from the trauma group still had silicone

ADDITIONAL PROCEDURES PERFORMED DURING SUR- oil tamponade at the last follow-up. There was no signifi-
GERY: A scleral buckle was placed in 9 eyes (23%) during cant difference between the groups in the incidence of
the 360 degree retinotomy and radial retinotomy postoperative complications.

118 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2016

 DISCUSSION
ACCEPTABLE REATTACHMENT RATES HAVE BEEN ACHIEVED
using relaxing retinotomy in the management of RD
complicated by advanced grades of PVR.4,11–15 However,
circumferential retinotomy alone is not so effective in
the management of the circumferential retinal shortening
and immobility present in more advanced PVR cases. In
such challenging cases, Lim and associates proposed the
use of combined circumferential retinectomy and radial
retinotomy.9 Numerous studies have explored the out-
comes of circumferential retinotomy for the treatment of
complex RD; however, little is known about the anatomic
and functional outcomes of combined 360 degree circum-
ferential retinectomy and radial retinotomy in the treat-
ment of cases with more severe PVR and intraretinal
fibrosis. Despite the worse pathology observed in the
trauma group at baseline, satisfactory anatomic outcomes
were achieved in both groups. Anatomic success in the
RRD and trauma groups at the end of follow-up were 19
of 24 eyes (79%) and 12 of 16 eyes (75%), respectively.
The difference was not statistically significant. No statisti-
cally significant difference in the final VA was detected.
The median postoperative VA at the final examination
was estimated as 20/2000 in both groups. Additionally,
the functional VA (> _20/200) rate achieved in the RRD
and trauma groups at the end of follow-up was similar: 6
eyes (25%) and 4 eyes (25%), respectively.
We compared our results with those of the only rele-
vant published study we found, by Lim and associates,9
who reported a higher anatomic success rate of 93.3%
and median postoperative VA of counting fingers at 2
feet after 6 months follow-up. However, meaningful com-
parison between these 2 studies is difficult. The study by
Lim and associates included patients with RRD; the
circumferential retinotomies were >180 degrees, and all
were performed without previous scleral buckling proce-
dures. There was no clear information on the timing of sil-
icone oil removal and the number of eyes with silicone oil
at the end of follow-up. In our study, 4 eyes (4/24; 17%) in
the RRD group and 5 eyes (5/16; 31%) in the trauma
group had an encircling scleral buckle placed during the
same surgical procedure, prior to radial retinotomy, and
all procedures involved peripheral 360 degree retinot-
omy. The scleral buckling procedure performed in some
patients and the 360 degree circumferential retinotomy
performed in all patients were not efficient in relaxing
the shortened and rigid retina. Attachment of the retina
was achieved by performing radial retinotomy as a last
option.
The mean silicone oil tamponade duration for all eyes
was 4.9 months, and the oil was retained in only 2 eyes
(5%) at the end of the follow-up. The longer period of
follow-up, the lower rate of probable tamponade at final ex-
amination, and the inclusion of patients with more severe
VOL. 163 MANAGEMENT OF RETINAL DETACHMENT WITH RADIAL RETINOTOMY
baseline pathology are the ultimate reasons for the lower
final anatomic success rate in our study patients.
Most published studies of RD associated with severe
PVR subsequently treated by 360 degree retinotomy are
not easily compared because of differences in etiology,
severity of PVR, additional surgical procedures such as
scleral buckling, timing of silicone oil removal, and pres-
ence of silicone oil at the last follow-up examination.
Our findings are in line with the results of Garnier and
associates,14 who reported retinal reattachment in 14 eyes
(70%), mean visual acuity of 40/200, and visual acuity of
20/200 or better in 2 eyes (10%), in a study that included
20 cases undergoing 360 degree retinotomy for RRD with
severe PVR, followed up for 38 months. Additionally, 9
(45%) of the cases had had a segmental scleral buckle in
a previous surgery.
Our findings are comparable with the results of Kolo-
meyer and associates,15 who reported retinal reattachment
in 35 eyes (85%) in a study that included 41 cases undergo-
ing 360 degree retinectomy for RD secondary to a variety of
disorders after a mean follow-up of 29 months. Four eyes
(15%) had had an encircling scleral buckle placed at a pre-
vious operation and 3 eyes (12%) had an encircling scleral
buckle placed at the time of 360 degree retinectomy.
Banaee and associates5 reported retinal reattachment in
14 eyes (70%) in a study including 20 eyes undergoing 360
degree retinectomy for RD secondary to a variety of disor-
ders after mean follow-up of 24.2 months. Eight eyes (40%)
had final BVCA of 5/200 or more and 3 eyes (15%) had 20/
200 or more. Seven eyes (33%) had had scleral buckling at
a previous operation. Faude and associates16 reported
retinal reattachment in 25 eyes (83%) in a study of 30
eyes undergoing 360 degree retinectomy for RD secondary
to a variety of disorders after a mean follow-up of
10 months.
In our study population, silicone oil was retained in 2
eyes at last follow-up examination (in 1 eye of each group).
In the study by Faude and associates16 silicone oil was not
removed. Banaee and associates5 and Garnier and associ-
ates14 reported silicone oil at final examination in 17 eyes
(80%) and 15 eyes (75%), respectively. Information on
intraocular silicone oil at the end the follow-up in the study
by Kolomeyer and associates15 is lacking. Consequently,
our study population included patients with worse baseline
disease, lower rates of intraocular silicone oil at final exam-
ination, and a longer period of follow-up. The anatomic
and functional success rates are comparable to the studies
evaluating RDs associated with severe PVR subsequently
treated by 360 degree retinotomy.
No significant differences in postoperative complica-
tions between the 2 groups were observed. The most com-
mon postoperative complications in both groups were
persistent hypotony and corneal damage (band keratop-
athy, corneal decompensation, and degenerative changes).
In our study population, 6 eyes (25%) in the RRD group
119
and 5 eyes (31%) in the trauma group developed hypotony
during follow-up. Lim and associates9 reported 6.7% hypot-
ony at 6 months after combined circumferential retinec-
tomy and radial retinotomy in the management of
complicated RD. Previous studies have reported 18%–
20% hypotony rates after 360 degree retinotomy in the
treatment of complex RD.14–16 Hypotony may be a
consequence of increased absorption of intraocular fluid
through the area of bare RPE, epiciliary scar tissue
causing dysfunction of the ciliary epithelium, and/or
mechanical detachment of the ciliary body.15 The rates
of persistent hypotony in our study appear to be higher
than in previous reports. We used silicone oil as a tempo-
rary tamponading agent in all of the eyes because of the se-
vere PVR. It has been proposed that silicone oil may reduce
the incidence of hypotony and phthisis.15 However, the
complications of prolonged silicone oil, such as corneal
damage and glaucoma, must be taken into consideration.
The mean tamponade duration for all eyes was 4.9 months,
and only 2 eyes had silicone oil at final examination. The
lower rate of silicone oil at final examination in comparison
with previous reports may be the cause of the higher persis-
tent postoperative hypotony rate. In our study, 7 eyes
(29%) in the RRD group and 6 eyes (38%) in the trauma
group developed corneal decompensation and/or band
keratopathy during follow-up. Previous studies have re-
ported lower rates (6.7%–25%) of corneal damage after
360 degree retinotomy.14–16 Postoperative ERM was
observed in 5 eyes (21%) of the RRD group and 4 eyes
(25%) of the trauma group during follow-up. Lim and asso-
ciates9 reported a lower (13.3%) rate of postoperative PVR
after 6 months. Previous studies have reported 35%–39%
FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: THE FOLLOWING AUTHORS HAVE NO
financial disclosures: Mumin Hocaoglu, Murat Karacorlu, Isil Sayman Muslubas, Hakan Ozdemir, Serra Arf, and Omer Uysal. All authors attest that
they meet the current ICMJE criteria for authorship.
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120 AMERICAN JOURNAL OF OPHTHALMOLOGY
postoperative ERM rates after 360 degree retinotomy.14,15
In this case series, optic nerve atrophy secondary to RRD
or trauma was not observed. Poor functional and
anatomic outcomes were mainly associated with complex
and chronic retinal detachment.
A cost-utility analysis of interventions for severe RD
concluded that PPV procedures are cost effective when
quality of life is considered.17 We found that, regardless
of the etiology, 360 degree retinotomy, anterior flap reti-
nectomy, and radial retinotomy in the management of
advanced PVR are worthwhile. Our patients’ final
anatomic success rates in both groups were satisfactory
(75% and 79%), and 25% of the patients achieved func-
tional VA (> _20/200). In view of the absence of significant
differences between groups in both anatomic and func-
tional outcomes as well as in the incidence of complica-
tions, we believe that combined peripheral 360 degree
retinotomy, retinectomy, and radial retinotomy in the
management of advanced PVR secondary to a variety of
disorders could be an appropriate technique to obtain
retinal reattachment otherwise unachievable.
This study is limited by its retrospective nature and rela-
tively small sample size. Extensive prospective randomized
controlled trials for the treatment of complex RD should
shed more light on the issue.
The anatomic results indicate that vitrectomy with 360
degree retinotomy, anterior flap retinectomy, and radial
retinotomy can be beneficial in the management of com-
plex RDs secondary to various disorders. Despite the
remarkably high incidence of complications such as hypot-
ony and corneal damage, the value of the rate of functional
VA achieved must not be underestimated.
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11. Quiram PA, Gonzales CR, Hu W, et al. Outcomes of vitrec-
tomy with inferior retinectomy in patients with recurrent
MARCH 2016
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VOL. 163 MANAGEMENT OF RETINAL DETACHMENT WITH RADIAL RETINOTOMY
severe proliferative vitreoretinopathy. Graefes Arch Clin Exp
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Zarbin MA. 3608 retinectomy for the treatment of complex
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365–372.
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 Biosketch
Mumin Hocaoglu, MD, FEBO, is a fellow at Istanbul Retina Instıtude, Istanbul, Turkey. He completed his ophthalmology
residency at Ulucanlar Eye Education and Research Hospital, Ankara, Turkey in 2011. His clinical and research expertise is
in the area of retinal, macular and vitreous diseases, retinopathy of prematurity, ophthalmic electrophysiology.

121.e1 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2016