Introduction
Preventing and treating proliferative vitreoretinopathy (PVR) remain a serious challenge for vitreoretinal surgeons. PVR is a devastating complication of retinal detachment that results in recurrent detachment and limits visual recovery. This occurs in 5%–10% of all retinal detachment surgeries, but accounts for 75% of subsequent retinal redetachment surgeries.1
Cellular proliferation produces epiretinal and subretinal membranes and intrinsic foreshortening of the retina—the hallmarks of PVR. These changes decrease retinal elasticity, which leads to the tractional elevation of the retina, creation of new retina breaks and recurrent retinal detachment.1 This cellular proliferation continues for 30–90 days after retinal reattachment. Any effective PVR treatment will need to inhibit this process for at least 60–90 days.
Methotrexate (MTX) may have promise for treating PVR. Elliot and Stryjewski treated a group of 10 eyes with either existing PVR (grade C or higher) or were considered to be at high risk for PVR (had undergone repair of a ruptured globe), with a series of 10 intravitreal MTX (400 µg/0.1 mL) injections over a 3-month period. All of these patients required complicated vitrectomy with silicone oil tamponade to reattach their retinas. The silicone oil was removed at 3 months and 80% of eyes remained reattached with a single surgery over 4–39 months (median 25 months) of follow-up. The final visual acuity ranged from 20/70 to HM (median 20/200). The MTX injections were well tolerated. Only one patient developed mild superficial punctate keratopathy.2
Sedaka and associates added 40 mg of MTX (equivalent to 400 µg/0.1 mL) to the infusion fluid at the time of retinal reattachment in a mixed group of 29 eyes presenting with either recurrent retinal detachment (RD) with PVR or severe inflammation associated with RD. In all, 26 of 29 eyes (90%) remained reattached after the intraoperative MTX infusion.3 Ghasemi Falavarjani et al injected a single dose of MTX (250 µg) into 19 silicone oil filled eyes undergoing repair of a diabetic tractional or combined rhegmatogenous retinal detachment and 19 matched control eyes. The single injection of MTX did not reduce the rate of PVR-induced recurrent RD in this study.4
Here, we report our experience using MTX to treat a series of five consecutive eyes with severe PVR (Cp 6 or worse). All of these eyes required required membrane peeling, relaxing retinectomy and extended perfluorocarbon liquid (PFCL) tamponade. They were treated with a series of low-dose intravitreal injections of MTX (100–200 μg/0.05 mL) every 2 weeks for at least 10 weeks after the surgery. We hypothesised that the MTX injections would suppress the aberrant cellular proliferation of PVR.