The clinical course and outcomes of acute rhegmatogenous retinal detachment are well studied. However, the outcomes of chronic retinal detachment are not clear enough mainly due to its low incidence. Therefore, choice of the optimal surgical technique for the treatment of chronic retinal detachment remains a topic of debate and lacks consensus. Given age factor, phakic status, and the presence of an undetached posterior vitreous, scleral buckling is commonly regarded as the surgical approach of choice in chronic retinal detachment without PVD [2, 3]. Conversely, primary vitrectomy is typically reserved for cases presenting with posteriorly located retinal breaks, a contracted retina due to intraretinal fibrosis, associated with gigantic intraretinal cyst formation, or following unsuccessful prior scleral buckling surgery.

Vitrectomy procedures in chronic retinal detachment without PVD pose significant challenges due to the difficulties in achieving successful surgical induction of PVD in younger patients, complete removal of the vitreous, and the relaxation of tractions related to subretinal membranes and intraretinal contraction. In the context of addressing these challenges, the utilization of in vivo generated autologous plasmin enzyme as adjuvant during vitrectomy has shown promising results in increasing the success rate of the procedure for various indications, including chronic retinal detachment in young patients [8].

In our study, we used preoperative adjuvant that involved simultaneous intravitreal injection of 50 µg of tissue plasminogen activator (t-PA), along with 0.1 ml autologous whole blood as a source of plasminogen which is main substrate for plasmin generation, three days prior to the surgery. This approach facilitated the separation of the posterior hyaloid from the retina with the help of the generated autologous plasmin enzyme in vitreous cavity, enabling us to perform more comprehensive vitrectomy along with concurrent lens extraction in our cases. The blood in vitreous cavity is generally considered as stimulating factor for proliferative vitreoretinopathy. But, we injected blood 3 days before surgery which is too short time to cause proliferation. Subsequently, we conducted primary circumferential-oral retinotomy in the detached quadrant and, when necessary, retinectomy in the presence of retinal fibrosis. These interventions aimed to address the antero-posterior traction caused by intraretinal contraction and to remove subretinal membranes. In term of outcomes, comparing this approach to the control group, where no prior adjuvants were used and no retinotomy was planned, the new approach consistently achieved a higher rate of initial retinal reattachment.

In the surgical management of retinal detachment complicated with proliferative vitreoretinopathy (PVR), various studies have demonstrated a high rate of reattachment when employing the technique of circumferential retinotomy-retinectomy [9, 10]. The concept of peripheral, clean, straight, and large retinotomies, originally described by Machemer [11], aims to address both intraretinal anteroposterior contraction and subretinal membranes. In our study, following near complete vitrectomy, we performed partial circumferential-oral retinotomy in order to alleviate antero-posterior traction and remove subretinal membranes in the study group. We did not combine vitrectomy with scleral buckling; however, in eyes that underwent vitrectomy following prior failed buckling surgery, the buckles were not removed. Our rationale for utilizing partial circumferential retinotomy was to prevent potential peripheral contraction of the retina, assuming that near complete vitrectomy had been achieved.

The improvement in outcome seen in patients who underwent IVAP assisted vitrectomy and partial circumferential oral retinotomy is primarily due to a more through release of the tractions on the retina which in turn reduces the risk of recurrence of detachment. It has previously been suggested that inadequate removal of the vitreous during vitrectomy could lead to the recurrence of retinal detachment through the proliferation of residual vitreous which could impose further traction on the retina leading to retinal breaks or reopening of the existing ones [12, 13]. In our view, the synergetic action of IVAP assisted vitrectomy and lens extraction ensures a near complete removal of vitreous humor.

It was shown that silicone oil tamponade has higher anatomic success rate and lower hypotony rates when compared to other tamponades in eyes that underwent retinotomy [14, 15]. Therefore, we used silicone oil tamponade in all cases of both groups. In our series, those who underwent IVAP assisted vitrectomy and partial circumferential-oral retinotomy showed a significant reduction in the number of total operations, a significant improvement in vision recovery, and significant increase in single surgery success rates.

Recently, chronic macula-off retinal detachments are delineated into with PVD and without PVD [16]. Those without PVD have significantly lower rates of initial reattachment and high rates of PVR. All the eyes in our study group had preoperatively attached posterior hyaloid which were based on OCT imaging. That is why we used IVAP for facilitating intraoperative separation of posterior hyaloid in all the patients of the study group.

Limitations of our study were its retrospective, nonrandomized manner, relatively small sample size due to low incidence of chronic retinal detachment. Additionally, differences in follow up duration, potential influence on accessibility of the peripheral retina and on visual acuity outcomes of postoperatively phakic eyes in the control group and lack of standardization of some surgical steps between groups were other limitations of our study.

In conclusion, this study provides early evidence that IVAP assisted vitrectomy, partial circumferential-oral retinotomy may improve single surgery success rate in chronic retinal detachment without PVD, but larger prospective, randomized studies with longer follow-up are needed to better evaluate this potential technique for the treatment of chronic retinal detachment without PVD.