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All of the techniques require entry into the subretinal space, which is a potential space located between the retina and the retinal pigment epithelium (<jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content>). Knowledge about obstacles and critical steps in relation to subretinal procedures is therefore needed. This thesis explores the functional and histological consequences of separation of the retina from the <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content>, extensive <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> damage, a large cut in the retina (retinotomy) and <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> phagocytosis in a porcine model.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Experiments were performed in 106 female domestic pigs of Danish landrace distributed over five studies. Under general anesthesia, different procedures for expansion of the subretinal space were conducted. Outcomes were visual function measured electrophysiologically with multifocal electroretinogram (mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content>) and retinal morphology examined histologically. <jats:italic>Study I:<\/jats:italic> The effect of anesthesia on mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> was examined by repeated recordings for 3\u00a0hr in isoflurane or propofol anesthesia. Outcome was mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> amplitude. <jats:italic>Study <jats:styled-content style=\"fixed-case\">II<\/jats:styled-content>:<\/jats:italic> Consequences of a large separation of the photoreceptors from the <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> were examined by injecting a perfluorocarbon\u2010liquid (decalin) into the subretinal space. Two weeks after, in a second surgery, decalin was withdrawn. Outcomes were mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> and histology 4\u00a0weeks after decalin injection. <jats:italic>Study III:<\/jats:italic> Extensive <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> damage was examined by expanding the subretinal space with saline and removing large sheets of <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content>\u2010cells through a retinotomy. Outcomes were mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> and histology 2, 4 and 6\u00a0weeks after the procedure. <jats:italic>Study IV:<\/jats:italic> Consequences of a large retinotomy were examined by similar procedures as in Study III, but in study <jats:styled-content style=\"fixed-case\">IV<\/jats:styled-content> only a few <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> cells were removed. Outcomes were mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> and histology 2 and 6\u00a0weeks after surgery. <jats:italic>Study V:<\/jats:italic> Clearance of the subretinal space was examined by injecting fluorescent latex beads of various sizes into the subretinal space. Outcome was histologic location of the beads at different time intervals after the procedure.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p><jats:italic>Study I:<\/jats:italic> Mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> amplitudes decreased linearly as a function of time in propofol or isoflurane anesthesia. Duration of mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> recording could be decreased without compromising quality, and thereby could time in anesthesia be reduced. <jats:italic>Study II:<\/jats:italic> Mf<jats:styled-content style=\"fixed-case\">ERG<\/jats:styled-content> and histology remained normal after reattachment of a large and 2\u2010week long separation of the photoreceptors and <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content>. Repeated entry into the subretinal space was well tolerated. Fluid injection into the subretinal space constitutes a risk of <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content>\u2010damage. <jats:italic>Study III:<\/jats:italic> Removal of large sheets of retinal pigment epithelial cells triggered a widespread rhegmatogenous\u2010like retinal detachment resulting in visual loss. <jats:italic>Study IV:<\/jats:italic> A large retinotomy with limited damage of the <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> was well tolerated, and visual function was preserved. <jats:italic>Study V:<\/jats:italic> Subretinal latex beads up to 4\u00a0<jats:italic>\u03bc<\/jats:italic>m were phagocytosed by the <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> and passed into the sub\u2010<jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> space. Beads up to 2\u00a0<jats:italic>\u03bc<\/jats:italic>m travelled further through the Bruch's membrane and were found in the choroid, sclera and inside blood vessels.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>A large expansion of the subretinal space, repeated entry, a large retinotomy and limited <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> damage is well tolerated and retinal function is preserved. Subretinal injection of fluid can damage the <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> and extensive <jats:styled-content style=\"fixed-case\">RPE<\/jats:styled-content> damage can induce a rhegmatogenous\u2010like retinal detachment with loss of visual function. Foreign substances exit the subretinal space and can reach the systemic circulation.<\/jats:p><\/jats:sec>","DOI":"10.1111\/aos.14249","type":"journal-article","created":{"date-parts":[[2019,11,11]],"date-time":"2019-11-11T08:16:56Z","timestamp":1573460216000},"page":"1-23","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["Subretinal surgery: functional and histological consequences of entry into the subretinal space"],"prefix":"10.1111","volume":"97","author":[{"given":"Nina Buus","family":"S\u00f8rensen","sequence":"first","affiliation":[{"name":"Department of Ophthalmology Copenhagen University Hospital Rigshospitalet K\u00f8benhavn Denmark"},{"name":"Department of Neurology Zealand University Hospital K\u00f8ge 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