Pediatric Vitreoretinal Surgery

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Article initiated by:

M. Margarita Parra, MD

All contributors:

Juan D. Arias, M. Margarita Parra, MD, Sudha Nallasamy, MD, S. Grace Prakalapakorn, MD, MPH, Neelakshi Bhagat, MD, FACS, Vamsi Gullapalli, MBBS, PhD

Assigned editor:

Grace M. Wang, MD PhD, Vamsi Gullapalli, MBBS, PhD

Review:

Assigned status Up to Date

 by Vamsi Gullapalli, MBBS, PhD on July 2, 2024.

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Vitreoretinal surgery in pediatric patients

Informed consent

Informed consent is a fundamental document in any surgical procedure, both in adults and children. It is required that parents or responsible caregivers of the child understand the procedures that will be performed, as well as the therapeutic implications, prognosis and possible derived complications.

Informed consent should be the first step in building a solid relationship with the patient and the parents, providing at the sime an adequate surgical approach.

Fundamentals in pediatric vitreoretinal surgery

Surgical anatomy

Location of entry

This table describes the entry sites of sclerotomies according to age. Lemley, C.A., & H.a.n, D. (2007). An age-based method for planning sclerotomy placement during pediatric vitrectomy: a 12-year experience. Transactions of the American Ophthalmological Society, 105, 86-89; discussion 89-91.

The location of the sclerotomies depends mainly on the age of the patient and the intention of a lens-sparing vitrectomy. Pars plana does not form until 6 to 9 months after delivery, and a distance of 4 mm from limbus to sclerotomies should not usually be performed before 4 years of age.

When the intention is lens-sparing, in children with retinopathy of prematurity ROP, a distance of 0.5 mm posterior to the limbus is required.

Usually 1 mm of distance from the limbus is considered for each year of the patient's life up to four years .

Transillumination of the globe wall can be used to identify the extension of ciliary body and the entry site.

Types of surgical approach in pediatric patients. A. Translimbal approach. Note the presence of trocar over the anterior iris surface. B. The trocar is entering behind the iris. In both cases an anterior chamber infusión was placed. Liu X, Zheng T, Zhou X, Lu Y, Zhou P, Fan F, Luo Y. Comparison between Limbal and Pars Plana Approaches Using Microincision Vitrectomy for Removal of Congenital Cataracts with Primary Intraocular Lens Implantation. J Ophthalmol. 2016;2016:8951053.

However, in not all cases, a pars plicata /pars plana approach is required. In some cases, a translimbal approach must be performed , through the root of the iris, in order to avoid entering to the subretinal or suprachoroidal space. It is reserved for patients in whom a lensectomy must be performed and in whom there may be peripheral anomalies, such as anterior proliferative vitreoretinopathy PVR , stage 5 of ROP, anterior traction or persistent fetal vasculature PFV . Therefore, a pars plicata/pars plana approach is considered if the instruments can enter without causing iatrogenic results.

When there is anterior retinal traction, an approach through the pars plana can be dangerous and cause retinal tears. For this reason, a limbal approach is preferred in which the lesectomy will also be performed. Ranchod TM, Capone A Jr. Tips and tricks in pediatric vitreoretinal surgery. Int Ophthalmol Clin. 2011 Winter;51(1):173-83.

Lemley, C.A., & H.a.n, D. (2007). An age-based method for planning sclerotomy placement during pediatric vitrectomy: a 12-year experience. Transactions of the American Ophthalmological Society, 105, 86-89; discussion 89-91 .'

When a scleral approach is performed, it must be taken into account that children's sclera is very thin, so insertion must be perpendicular to the sclera, parallel to the visual axis.

On the contrary, an oblique insertion could cause inadvertent damage to the lens. It is recommended to suture the entry site.

Lens

Children have small axial lengths. The proportion of lens ratio compared to entire globe volume is higher compared to adults, being a consideration that must be taken into account in pediatric surgery. On the other hand, the pediatric response to surgical trauma is different. Children usually develop cataracts easily with the lens touch, in addition severe inflammatory reactions to surgery could be present.

Vitreoretinal interface

The posterior hyaloid is firmly attached to the retinal surface in children. Furthermore, the interaction of the vitreoretinal interface is different in patients with ROP and other hereditary vitreoretinopathies. In many of these cases, vitreoeschisis is present, which makes its complete removal difficult.

Likewise, attempting complete removal and inducing posterior vitreous detachment can lead to iatrogenic retinal tears, which are an important factor in surgical failure, especially in ROP. Complete removal of the vitreous is not recommended in patients with ROP.

Surgical approaches

Vitrectomy

Surgical approaches using 2 or 3 ports have been implemented in vitreoretinal surgery. Ensuring an infusion line is essential. In many cases the use of a 23G needle may be required. In the presence of PVR, care should be taken to segmentation of the epiretinal membranes, seeking to avoid traction. In patients with ROP, it is extremely important to avoid iatrogenic retinotomies or tears due to the high risk of failure and PVR. Likewise, the induction of posterior vitreous detachment shouldn't be a goal in pediatric vitreoretinal surgery. Rather, it seeks to release the traction of the epiretinal membranes.

Scleral buckling in a pediatric patient. Kychenthal B. A., Dorta S. P. (2017) Management of Stage 4 ROP. In: Kychenthal B. A., Dorta S. P. (eds) Retinopathy of Prematurity. Springer, Cham. https://doi.org/10.1007/978-3-319-52190-9_9

Scleral buckling

Making the decision to use a scleral loop can be a bit complex, especially in young children in whom the eyeball is growing and visual development is in process. The scleral loop can be a procedure used alone or in combination with vitreoretinal surgery, especially in retinal detachment with PVR. A 2.5mm circular silicone band is commonly used.

Drainage of subretinal fluid can be ensured by transillumination to avoid access to the vortex veins. Some complications may be related to the use of a scleral buckle. These include central retinal artery occlusion, scleral growth limitation, risk of amblyopia. In cases where eye growth occurs, division of the band is performed 3 to 6 months later.