Retinal detachment 2016

RETINAL
DETACHMENT
SB , PR , PPV
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DR DINESH MITTAL DR SONALEE MITTAL
DRISHTI EYE HOSP VIJAYNAGAR INDORE

RETINAL
DETACHMENT
SURGERY
FLOWCHART

RETINAL DETACHMENT
• retinal detachment is used to describe
a separation of the neurosensory retina
from retinal pigment epithelium (RPE).
• A retinal detachment re-establishes the
potential space that exists between the
original layers of the embryonic optic
cup.

TYPES OF RETINAL DETACHMENT RD
• Three categories of RD are
rhegmatogenous, exudative, and
tractional.
• Rhegmatogenous RD are sometimes
referred to as primary detachments,
while both exudative and tractional
detachments are called secondary or
nonrhegmatogenous detachments .

RHEGMATOGENOUS RD
•Rhegmatogenous detachments are the most
common form of retinal detachment. They
are caused by a break in the retina through
which fluid passes from vitreous cavity into
subretinal space.
• The responsible break(s) can be identified
preoperatively in more than 90%of cases, but
occasionally presence of a minute, unseen
break must be assumed.

EXUDATIVE RD
•Exudative detachments, also called serous
detachments, are due to an associated
problem that produces subretinal fluid
without a retinal break. This underlying
problem usually involves the choroid as a
tumor or an inflammatory disorder.

TRACTIONAL RD
•Tractional detachments occur when
pathologic vitreoretinal adhesions or
membranes mechanically pull the retina
away from the pigment epithelium without a
retinal break. The most common causes
include PDR , ROP , proliferative sickle
retinopathy, and penetrating trauma.
•Retinal breaks may subsequently develop,
resulting in a combined tractional and
rhegmatogenous detachment.

MECHANISM OF RHEGMATOGENOUS
RETINAL DETACHMENT
• requirements for a rhegmatogenous RD
include a retinal break and low-viscosity
vitreous passing through break into the
subretinal space. The usual sequence
causing retinal detachment is vitreous
liquefaction followed by a PVD that causes
traction at site of significant vitreoretinal
adhesion with a subsequent retinal tear.
Fluids from vitreous cavity then pass
through tear into subretinal space .

Characteristics Rhegmatogenous RD
• (1) the existence of liquefied vitreous gel
• (2) tractional forces that can precipitate a
retinal break
•(3) the presence of a retinal break that will
allow the passage of liquefied vitreous into
the subretinal space .
•All three factors need to be present to cause
a rhegmatogenous retinal detachment.

LIQUEFIED VITREOUS , TRACTION
AND TEAR REQD FOR RD
•For example, if a tear or hole is present in
the absence of tractional forces and liquid
vitreous, it is unlikely that retina will detach.
Examination of postmortem eyes indicates
that approximately 5 to 10% of eyes have
full-thickness retinal defects without any
apparent detachment. Subclinical retinal
detachments are defined as having less than
1 to 2 disc diameters of subretinal fluid and
usually do not progress.

TYPES OF BREAKS
•Retinal breaks may be subdivided into
tears, holes, and dialyses . Tears are
produced by traction on the retina,
whereas holes are due to a gradual
thinning of the retina . Tears usually
occur suddenly, with the retina frequently
appearing completely normal before the
acute event. Atrophic holes appear to
develop slowly, whereas traumatic
dialyses probably occur acutely.

TYPES OF BREAKS
•Most breaks causing retinal
detachment are associated with
vitreoretinal traction in the vicinity of
the break(s). Dialyses usually feature
traction on the retina immediately
posterior to the break, and if traction is
confined to the retina anterior to the
dialysis, a giant tear is more likely to
evolve.

Horseshoe
tear with
flap
adherent
to
posterior
cortical
vitreous

Horseshoe tears HST
• Also referred to as flap or U-shaped tears, HST occur
in most cases at the irregular posterior margin of the
vitreous base during posterior vitreous detachment.
• The flap thus remains adherent to the posterior
vitreous surface following the creation of a tear .
Preexisting vitreoretinal adhesion and traction applied
to this point via the vitreous are required for creation
for HST. Because of the associated vitreous traction,
flap tears frequently lead to detachment. Horseshoe
tears are most common in middle age and appear most
often near the equator of the eye

Operculated tear with free
operculum adherent to detached
cortical vitreous

Retinal Break Location vs. Age

Distribution of Retinal Breaks

Lattice
degeneration
associated
with multiple
round
atrophic
holes

PROLIFERATIVE VITREORETINOPATHY
•The most ominous and clinically significant
finding in retinal detachment is presence of
proliferative vitreoretinopathy (PVR), the
process that is responsible for the vast
majority of surgical failures of retinal
reattachment surgery. The consequence of
cell migration and elaboration of collagen is
the formation of membranes involving the
inner and outer surfaces of the retina, as
well as the vitreous.

PVR
•In time, and under the influence of
mediators of inflammation, the
membranes contract, distorting the
retina into folds . Localized contracture
in the periphery is referred to as a star
fold , and a similar process in the
posterior pole is referred to as a
macular pucker .

•RD is usually associated with decreased
IOP secondary to increased resorption of
fluid from subretinal space. Uveitis may also
decrease production of aqueous humor to
the point of hypotony and eventual phthisis.
•Rubeosis iridis may also develop in long-
standing detachment, resulting in NVG .
When a long-standing detachment is
repaired, glaucoma may replace relative
hypotony due to damage to trabecular
meshwork.

PREOPERATIVE EVALUATION AND
DIAGNOSTIC APPROACH
• The diagnosis of rhegmatogenous RD is
suggested by symptoms of floaters, photopsia,
peripheral vision loss, and decreased vision. In
patients with clear media, the diagnosis is
confirmed by I / O with scleral depression. Slit-
lamp biomicroscopy with a three-mirror contact
lens may also be helpful in identification of
retinal pathology. The location and type of retinal
breaks, as well as the size and duration of retinal
detachment, are factors that help determine the
timing and type of SB procedure performed.

PREOPERATIVE ASSESSMENT
• Having taken a careful history (and noted relevant
systemic health problems and past ophthalmic history),
anterior and posterior segments of the eye are carefully
examined using slit lamp biomicroscopy and I / O
• A particular note is made of the following:
• Macular involvement
• The presence of vitreous detachment
• Signiﬁcant ocular co-pathology, which may affect
management ( glaucomatous optic neuropathy, aphakia
with vitreous in anterior chamber, a history of strabismus
surgery)
• The number and position of the retinal breaks.

PREOPERATIVE EVALUATION AND
DIAGNOSTIC APPROACH
•In patients with opaque media, the retinal
status may not be visualized. Diagnostic
USG is critical in establishing RD .
•Optical coherence tomography (OCT) is
useful in documenting subretinal fluid,
especially in the macula, and the extent of
any accompanying intraretinal edema or
epiretinal proliferation .

Features of Direct vs. Binocular
Indirect Ophthalmoscopy

Optical principles of direct
method of ophthalmoscopy

Optics INDIRECT OPHTHALMOSCOPY

INDIRECT OPHTHALMOSCOPE
•Due to high illumination, binocular
viewing, and high-quality optics, a good
indirect ophthalmoscope and aspheric
lens provide good resolution in spite of
low magnification. Substantial
advantages gained include a very wide
field of view, stereoscopy, large depth
of focus, and dynamic examination
capability.

•During the early stages of learning
indirect ophthalmoscopy, it is essential
to accept that one has to work with a
smaller image size; after a time, one
ceases to be troubled by it. After
enough experience with indirect
ophthalmoscopy, one is rarely aided in
an evaluation of detail by increased
magnification

•Magnification is increased by
moving the examiner’s head closer
to the patient’s eye (rather than
examining at nearly arm’s length as
is usual).
•Using a lower power condensing
lens, such as a 14 diopter lens, also
provides more magnification .

•When examining for RD , perhaps even
more important than the field of view is the
viewable field. Direct ophthalmoscopy
permits the study of 60% to 70% of the
total fundus area in a well-dilated,
emmetropic eye . Thus, peripheral
examination is very difficult, and as
explained above, even when the periphery
can be seen with the direct
ophthalmoscope, the image is very blurry.

•so practically , direct ophthalmoscope is
rarely used to examine beyond the posterior
pole. Since 30% of the retina lies anterior to
the equator, failure to study this region will
result in overlooking serious pathology in
many, if not most cases.
•Diseases such as senile retinoschisis,
peripheral uveitis, and most retinal tears
and detachments defy evaluation by any
other technique.

Illumination
•Image brightness of a DIRECT is low due to
limited power output. DIRECT ophthalmoscope
operated by batteries provide about one-half
watt of illumination.
•Instruments operated through transformers
deliver several times this amount, but never
more than several watts.
• I / O can deliver up to 18 watts of output.
Better illumination results in improved
resolution and improved performance in
presence of media opacities

ROLE OF DIRECT OPHTHALMOSCOPY
•Most retina surgeons dilate pupil and
examine posterior pole of retina with slit
lamp biomicroscopy using a 78 or 90 diopter
lens or a contact lens, and they use I / O to
examine the periphery. If this equipment and
the expertise to use it are available, direct
ophthalmoscope offers no added benefit for
the dilated patient. In the undilated eye, the
direct ophthalmoscope can be useful in
providing a limited view of the posterior pole

Choice of condensing lenses
•The most commonly used condensing lens
is a 50-mm +20 diopter lens. The higher the
power of the condensing lens, the less
magnified the image will be and the wider
the field of view. Lower-power lenses have
to be held farther from patient’s eye. A 20D
lens gives a good compromise between
field size and magnification, and permits a
convenient working distance from the
patient’s eye.

Choice of condensing lenses
•Lenses of 28-D or 30D power provide a
substantial advantage when examining
patients with poorly dilating pupils or
patients with extremely complicated retinal
topography . lowest power that is practical
to use in binocular indirect ophthalmoscopy
is about 14D. These lenses offer the
advantage of higher magnification, but 78 or
90 diopter lenses are usually used with a slit
lamp when higher magnification is desired

Indirect
lenses:
78, 28,
and 20
diopters

Correct position of head for
beginning examination of fundus

Position is unsatisfactory for
general examination of fundus

Use of patient’s own hand as
target has several advantages

Lens is grasped
between ball of
thumb and tip
of index finger.
Wrist extended,
& third finger
extended as pivot

Manner in
which lens is
moved closer
to or away
from eye is
shown

Alignment of eyepiece, condensing
lens, pupil, and scleral depression on
visual axis

technique
of holding
lens is
shown

Two techniques for manipulating
thimble scleral depressor

Normal
fundus
with
principal
structures
labeled

Fundus
photograph
of subtle
demarcation
line

DETECTION OF RETINAL BREAKS
•The entire retina should be carefully
examined for retinal breaks by binocular
indirect ophthalmoscopy, supplemented
by scleral indentation for periphery .
While breaks may be found in any area,
the distribution of the subretinal fluid is
a clue to the most likely location of a
primary retinal break

Finding the retinal break
•Missed retinal breaks are an important cause
of surgical failure so the preoperative
examination should be very thorough.
• Even when a break has been found, it is
essential to complete examination of the
retina, as most retinal detachments have
more than one break.
• Their location is carefully documented on a
chart that can be referred to subsequently
during surgery .

•These drawings should show the location of
retinal breaks in relation to easily visible
retinal landmarks such as small
hemorrhages, vascular bifurcations, and
areas of pigmentation.
•This carefully documented preoperative
assessment has many advantages. If in
doubt, an area of retina can be re-examined
alternately with I/O and slit lamp to establish
whether a break is truly present.
• Drawings made can be referred to if retinal
view becomes obscured during surgery.

Color
Code for
Retinal
Drawings

LINCOFF’S RULES
• Lincoff has shown how the location of retinal
breaks determines the distribution of
subretinal fluid .
• Review of the retinal drawings will therefore
determine whether break location is
consistent with the subretinal fluid
distribution.
• When the distribution of fluid does not seem
to obey Lincoff’s rules reexamine the retina
to ensure that no breaks have been missed

An inferior
detachment
slightly higher
on the temporal
side pointing
to a break on
that side

A subtotal retinal
detachment – the
break is usually
close to
the upper border
of the ﬂuid on the
side it is highest.

Fluid crosses
midline
superiorly implying
a superior break
near 12 o’clock .
ﬂuid has tracked
down further nasal
implying the break
is slightly to
the nasal side

The presence of
bullae implies a
superior break. A
shallow sinus of
ﬂuid leads to a
small superonasal
break

LOCATION OF BREAK
•If one superior quadrant is detached, the
break is apt to be near the upper edge of
detachment. When the superior half of
the retina is detached, break is most
likely near the 12-o’clock meridian.
• An inferior quadrantic detachment
usually has break near the upper edge
of the detachment or in the meridian
bisecting the area of detachment.

• If the inferior half is symmetrically detached,
the break could be anywhere with in the
detachment, but when the fluid is higher on
one side of an inferior detachment than break
is usually on the higher side.
• In a total retinal detachment, break is often
between 10- and 2-o’clock meridians. If there
are inferior bullae, examiner should assume
that a retinal break is above horizontal
meridian. In the presence of a demarcation
line, the break is often found in the meridian
that bisects the demarcated area.

• When the detachment has progressed
rapidly, the break is usually superior, fairly
large, and probably located nearer the
equator than the ora. If the history suggests
slow progression of the detachment, a small,
inferior, or extremely peripheral break should
be sought.
•The quadrant of first detectable field loss is a
valuable indication of location of break .
Special attention should be paid to all areas
of abnormality : lattice degeneration,
meridional folds, pigmentation, opercula, and
hemorrhage .

Proliferative vitreoretinopathy
(PVR) grade A, pigment clumps.

Rolled
posterior
edge of
retinal
break

Subretinal fibrosis. (A) Diffuse sheet
with strands. (B) Multiple strands

RD SURGERY Practice
•RD is an uncommon disease, affecting
approximately 1 in 10,000 people in general
population per year. incidence of retinal
breaks is 5% to 7% of the population.
•Obviously, many retinal breaks have minimal
risk for possible development of a RD . This
includes asymptomatic, small, round
atrophic holes near the ora serrata.
•However, equatorial HST with relevant
symptoms progress to RD in most cases.

TREAT OR WAIT
•Probably all surgeons would agree that a
large HST near the equator in the superior
temporal quadrant, with new-onset
symptoms of flashes and floaters and
associated vitreous hemorrhage, should be
treated prophylactically to avoid RD .
• In contrast, most would not advise
treatment of a small, round atrophic hole
near the inferior ora serrata in an
asymptomatic patient with no history of
prior detachment.

Risk Factors for Rhegmatogenous RD

Laser burns surrounding a retinal
tear and focal retinal detachment

Summary of Treatment of Retinal
Breaks

SURGICAL ANATOMY
•The thickness of the sclera varies. It is
thickest around the optic nerve (1.2 mm) and
thinnest under the recti behind their
insertions so attempts to pass scleral
sutures under the muscles are particularly
hazardous. Where scleral mattress sutures
are more typically passed, at the equator, it
is approximately 1 mm thick.
• Passage of sutures is facilitated by the lamellar
arrangement of collagen ﬁbers, which allows
spatulated (or “side cutting”) needles to follow a
plane between lamellae.

Retinopexy
•The indent from the explant closes retinal
breaks but retinopexy is required to produce
an enduring bond between the retina &
retinal pigment epithelium that will persist
even if the indent disappears.
•Retinopexy was initially achieved using
diathermy in association with lamellar
scleral dissection and scleral implants.
• Cryotherapy has supplanted diathermy
because it can be performed without scleral
dissection .
• Intraoperative cryopexy remains a quick
and simple technique.

Scleral Buckling Surgery
•Though primary VIT has become increasingly
utilized, an essential surgical procedure for
the repair of rhegmatogenous RD is SB . The
goal of SB is to close retinal breaks by
indenting eye wall, preventing the passage of
liquefied vitreous into the subretinal space.
This flexible approach incorporates the
benefits and advantages of different
techniques and materials, maximizing the
rate of anatomical and visual success while
minimizing potential complications .

HISTORICAL REVIEW
•Recognition of vitreoretinal traction and
retinal breaks in the pathogenesis of
retinal detachment by Gonin in 1919
ushered in the era of repair, in which
drainage of subretinal fluid and
treatment of retinal breaks were
employed. Custodis, thirty years later,
introduced the concept of scleral
buckling.

HISTORICAL REVIEW
• The introduction of binocular I / O and
scleral depression by Schepens in 1951
revolutionized the localization of peripheral
retinal pathology. Advancements were made
when Schepens combined scleral dissection,
diathermy, and intrascleral implantation of
silicone buckles for scleral buckling.
• Lincoff refined Custodis’ procedure by using
silicone sponge explants and cryotherapy.

Scleral Buckling three basic steps in closing
retinal breaks & reattaching the retina
• 1 Conducting thorough preoperative and intraoperative
examinations with the goal of locating all retinal breaks
and assessing any vitreous traction on the retina.
2. Creating a controlled injury to the retinal pigment
epithelium and retina to produce a chorioretinal adhesion
surrounding all retinal breaks so that intravitreal fluid can
no longer reach the subretinal space.
3. Employing an appropriate technique, such as scleral
buckling and/or intravitreal gas, to approximate the retinal
breaks to underlying treated retinal pigment epithelium.

Scleral Buckling SB
•The fundamental goal of scleral
buckling is the functional closure of
all retinal breaks, so that normal
physiological forces can maintain a
permanent state of attachment.
Drainage of subretinal fluid and
scleral buckling will usually close the
responsible break(s) immediately

several beneficial effects of SB
• 1 reduction of vitreoretinal traction by
displacing the eye wall and retina centrally
•2. displacement of subretinal Fluid away from
the location of the retinal break and scleral
buckle
•3. postoperative increase in the height of the
scleral buckle
•4. approximation of retinal break and
adjacent vitreous gel .

several beneficial effects of SB
•5. increase in resistance to fluid flow
through the retinal break, with
consequent increase in the relative
reattachment forces;
•6. alteration in the concave shape of the
eyeball, resulting in a change in the
effect of intraocular currents that
encourage liquid vitreous to enter the
subretinal space.

PRINCIPLES OF SB
•The most important skill required in surgery
for RD is the ability to detect all retinal
breaks and additional areas of vitreoretinal
pathology. SB is performed to produce
functional closure of retinal breaks . Various
kinds and shapes of silicone are used,
including segments of silicone sponge as
well as solid silicone shaped into bands for
encircling the eye and into additional forms
to augment the width and height of the
buckle in selected areas .

PRINCIPLES OF SB
•Following localization and treatment of
retinal breaks and areas of vitreoretinal
degeneration, the silicone buckling element
is sutured to the scleral surface. Drainage of
subretinal fluid is performed in majority of
cases. Intravitreal gas injection is sometimes
employed in conjunction with scleral
buckling. Problems encountered at any point
of the procedure may require modifications
in technique.

Cryotherapy
• Cryotherapy (cryopexy) produces an effective
pigment epithelial–retinal adhesion without
scleral complications that characterize
diathermy. This provides cryotherapy with
significant advantages:
• (1) retinal pathologic conditions can be treated
without the need for scleral dissection; and
• (2) retinal breaks can be treated regardless of
their location in relation to vortex veins or long
posterior ciliary vessels or nerves.

Cryotherapy
•The histologic response after cryo depends
on whether the RPE alone or RPE and the
overlying detached retina together are
frozen.The ability to treat detached retina is
another significant advantage over both
diathermy and photocoagulation. If only the
RPE is frozen without freezing overlying
retina, the RPE –retinal adhesion that forms
once the retina is reattached shows pigment
epithelial hyperplasia and loss of retinal
outer segments .

Cryotherapy
•Therefore the normal microvillous
interdigitations seen between retina and
RPE are missing. If both the RPE and
overlying retina are frozen, the adhesion
that results after reattachment
demonstrates cellular connections between
the retina and RPE consisting of
desmosome formation between retinal glia
and RPE or direct contact between retinal
glia and Bruch’s membrane.

• Current cryotherapy instrumentation
employs expansion of high-pressure nitrous
oxide at the tip of a probe generating
temperatures as low as −89°C. Temperature
effect is confined to the tip of the probe by
an insulating sleeve. A probe 2.0 to 2.5 mm in
diameter usually is used for retinal work.
Treatment of retinal breaks & pathologic
conditions requires accurate placement of
the cryoprobe tip. The surgeon must be
certain that the indentation visualized with
the I / O is the tip of the probe and not the
shaft .

• The goal is to surround all retinal breaks with 1
to 2 mm of contiguous treatment. Treatment
should include freezing of overlying retina,
because this results in a stronger adhesion than
does treatment of RPE alone. To avoid damage
of refreezing, treatment should not significantly
overlap. The treatment end point is retinal
whitening without ice crystal formation. Slight
whitening of retina because of retinal edema is
noted several minutes after freezing, which helps
to assess adequacy of treatment. If retinal
treatment is impossible because of bullous
retinal elevation, treatment of RPE alone may be
performed, or treatment can be deferred until
after drainage of SRF .

•For flap retinal tears, treatment is
performed contiguously around the tear
and then extended anteriorly to the ora
serrata. Care is taken not to freeze bare
RPE in the bed of the retinal break
where there is no overlying retinal
tissue. Small retinal breaks and atrophic
retinal holes can be treated with single
freezes centered on the retinal break

•Cryopexy remains the
choice of most retinal
surgeons for the
intraoperative treatment of
retinal breaks during
scleral buckling

Cryotherapy is applied by the surgeon
under direct visualization with I / O .

Encircling silicone bands are
traditionally Fixed with a single
mattress suture

•Example 1: A detachment with a single
elevated equatorial tractional tear .
This may be closed successfully using
a single radial sponge without drainage
of subretinal ﬂuid. If a silicone tire is
used in the same situation the indent
may not be high enough to close retinal
breaks without subretinal ﬂuid drainage
and/or gas injection.

•Example 2: A detachment due to a
series of round retinal holes . The holes
are anterior to equator at various
distances from the ora. They may be
treated with a circumferential explant.
A very high indent is not required
because there is no traction on the
breaks and the ﬂuid is very shallow. As
the distance from the ora varies the
broader indentation from a tire can
close all the breaks.

•Example 3: A pseudophakic eye with a total
RD . Good visualization of the peripheral
retina is impeded by peripheral capsule
opaciﬁcation and limited pupil dilatation . No
tears are seen. An internal approach using
PPV has many advantages here. If this is not
possible, an encircling tire may be used. The
buckle may be secured just behind rectus
muscle insertions to support the anterior
retina where breaks are likely to be located.
The tire supports whole area of subretinal ﬂuid .
The placement of an encircling silicone band in the
groove of the tire maintains the height of the indent
so that undetected retinal breaks remain closed.

Example 4: Three tractional tears are
present . can be treated with separate
radial sponges or with a single buckle.

• Example 5: Three tractional tears are again
present but they are too close together to be
easily closed with individual radial sponges .
A circumferential buckle is an easier option.
A high circumferential sponge may be used
but it can be difficult to close all breaks
because of variable distances from limbus.
high circumferential sponges are likely to
result in fishmouthing .
• circumferential tire combined with
subretinal fluid drainage and/or gas injection
may be used.

Retinal dialysis. Provided indent is high enough (a
3-mm circumferential sponge usually works well),
and subretinal ﬂuid drainage is usually unnecessary

Fishmouth Retinal Tears
•There are three basic techniques in the
management of fishmouth retinal tears.
The easiest is to decrease the height of
the circumferential buckle. This usually is
effective only if buckle height is
excessive. Placement of a radial element
beneath the circumferential element
effectively closes most fishmouth tears .

Fishmouth Retinal Tears
• The radial element increases surface area of pigment
epithelium and choroid beneath break, thereby decreasing
disparity between retinal surface area & surface area of
bed of buckle. Injection of an intravitreal gas bubble,
combined with positioning, also effectively closes
fishmouth tears. The gas is injected through pars plana
under direct visualization with the I/O . During the
injection, care must be taken to avoid formation of multiple
small bubbles, which may then pass through the tear into
the subretinal space. This can be prevented by injecting
into most superior aspect of vitreous cavity. With accurate
positioning, a bubble of 0.3 ml is adequate to close retinal
breaks of up to one clock hour.

•Isolation of the four rectus muscles usually
allows adequate access to all areas of the
sclera necessary to perform scleral
buckling.
•The suture is passed through the sclera at
one half to three fourths depth over a
distance of 3 to 5 mm, usually in a
horizontal mattress fashion. A combination
of adequate depth and length is necessary
for maximum suture strength. Once the
proper scleral depth has been obtained, the
suture should be passed at that level .

• . Uneven passage of the needle induces
buckling of the sclera, which may lead to
perforation. After the needle has been
passed through the sclera and the tip
brought out, the needle is released from the
needle holder and the tip is grasped. It is
important to complete passage of the needle
along the arc of the needle, avoiding
posterior pressure or dragging on the hub of
the needle, which may perforate through the
remaining underlying sclera .

WIDTH OF SUTURES
• Usually sutures are placed a minimum of
2 mm farther apart than width of scleral
contact for a given element ( 9 mm apart
for a 7 mm element). To ensure that the
most posterior edge of the retinal break is
supported, the surgeon places posterior
suture a minimum of 2 to 3 mm posterior
to scleral localization mark.

MANAGEMENT OF SUBRETINAL FLUID
• rationale for drainage of SRF is twofold: to
diminish intraocular volume so as to allow
elevation of buckle without difficulties with
elevated IOP and to allow the retina to settle on
the elevated buckle by removing fluid from the
subretinal space. drainage of SRF places the
retinal breaks in juxtaposition to the buckle,
thereby facilitating closure of the breaks.
Although many retinal detachments can be
effectively managed without drainage as
described later, we prefer to drain retinal
detachments with one or more of the following
characteristics:

MANAGEMENT OF SRF
•1. Bullous detachments. Drainage is usually
necessary in these cases so that retinal
break can be placed in juxtaposition to
buckle. This is particularly valid if confluent
retinopexy around tear cannot be obtained
because of the bullous elevation.
•2. Inferior breaks. Inferior breaks tend to
settle less readily on the buckle than do
superior breaks, perhaps because of gravity.
Also, inferior breaks are less effectively
managed postoperatively with air injections.

MANAGEMENT OF SRF
• 3. Proliferative vitreoretinopathy. PVR may
prevent the retina from settling, resulting in
open retinal breaks. We drain all cases of
grade B or greater that undergo scleral
buckling.
• 4. Highly myopic detachments and aphakic or
pseudo-phakic detachments. The syneresis
of the vitreous that occurs in myopia or
following lens extraction may be a factor in
the failure of these retinas to settle on the
buckle without drainage.

MANAGEMENT OF SRF
• 5. Chronic detachments. SRF in chronic RD
becomes viscous . High osmolarity of fluid
may slow resorption by pigment epithelium.
• 6. Poor RPE function. Detachments in
patients with ARMD and high myopia are
characterized by prolonged resorption of SRF
, because of decreased ability of the RPE to
remove fluid from the subretinal space.
• 7. Eyes intolerant of sustained IOP rises,
such as those with known glaucoma.

selection of external drainage site
Obviously the location of SRF is a primary concern.
We prefer to select our drainage site after
placement of scleral sutures and loose placement of
the buckle. This ensures that the location or amount
of the SRF has not changed during the placement of
sutures. It is not necessary to drain where the fluid
is greatest but where there is adequate fluid to
safely enter the subretinal space. When possible
drain just above or below the horizontal meridian,
either temporally or nasally . This location avoids
the major choroidal vessels and vortex veins. vortex
veins can be identified and thereby avoided.

SRF DRAINAGE
• The horizontal meridian allows easy access
to sclera, although in patients with large
noses or tight orbits the nasal approach
sometimes can be difficult. If SRF in the
horizontal meridian is inadequate, drainage
must be performed elsewhere. Usually either
side of vertical rectus muscles avoids major
choroidal vessels. We try to avoid drainage
through areas that have received cryotherapy
because of the choroidal hyperemia and
congestion that cryotherapy induces.

SRF DRAINAGE
•Drainage can be performed via either a
radial sclerotomy or external needle
drainage . External needle drainage is
technically more challenging. It is
performed either with the scleral buckle
left loose as originally described by
Charles or with it tightened to an
appropriate height and the sutures
permanently tied.

Encirclement
•Segmental buckles provide local support
which often fades. This may lead to reopening
of breaks if insufﬁcient retinopexy has been
applied.
• Encirclement produces permanent support
of the vitreous base retina.

Encirclement
•Encirclement has a role in certain situations:
• Early PVR
• detachment in which breaks are difﬁcult to
detect eg aphakic and pseudophakic RD .
• Multiple breaks in three or more quadrants.
•Encirclement is produced with a combination
of a local silicone tire (conﬁned to the areas
of visible breaks) with a 2-mm band, which
lies in the gutter of the tire and encircles the
globe before being attached to itself.

Encirclement
•The 2-mm band is often too narrow to
support breaks and its primary purpose is
to maintain the height of the indent from
the tire.

The steps are:
•1. A 360° peritomy with slinging of all
four rectus muscles.
•2. Break localization, retinopexy and pre-
placement of the mattress sutures of the
tire.
•Generally two sutures are required per
quadrant.

The steps are:
•3. Threading the tire and band together under
the recti and mattress sutures. Ensure that
both limbs of all the mattress sutures are
above the buckle as it is not uncommon to
leave one under the encirclement by mistake.
Some thought needs to be given to where the
ends of the band will be secured at this
stage. It is also important to ensure that the
band does not become twisted.

The steps are:
• 4. Subretinal ﬂuid drainage is required in
the majority of cases. The exact stage at
which it is performed is variable but it
may be done now to create space for the
indent.
• 5. Tighten the mattress sutures over the
tire to create a local indent.

•6. Place a small holding stitch over the band
in each quadrant where there is no tire to
stop it bow stringing forward when
tightened. These are placed at the equator
(approximately 12 mm behind the limbus).
•7. Fasten the ends of the band to each other.
A Watzke sleeve is a small silastic tube
designed to secure the ends and allow
adjustment of the tension in the band. The
steps for engaging the ends of the band in
the sleeve with a specially designed cross
acting (“Watzke”) forceps are illustrated .

•8. The ends of the band are pulled to create
the encircling indent. A 6-mm shortening will
produce approximately a 1-mm indent,
irrespective of the size of the globe. The end
point of this tightening is best judged
ophthalmoscopically; a shallow indent should
be just visible.
•9. The optic nerve perfusion should be
checked and, if necessary steps taken to
normalize it such as paracentesis, SRF
drainage , or adjusting the buckle.

PNEUMATIC RETINOPEXY
•Sulfur hexaﬂuoride (SF6) and
perﬂuoropropane (C3F8) are the
gases most frequently used with
PR. Success also has been
reported with sterile room air.

• The value of the intraocular bubble is based on
three features: buoyancy, surface tension, and
isolation of retinal tears from intraocular currents.
• Buoyancy applies upward pressure on the
detached retina. The surface tension of the bubble
closes the retinal break and prevents the bubble
from passing into the subretinal space. With the
break closed, the retinal pigment epithelial pump
removes the subretinal ﬂuid.

• Because of their low solubility in water, SF6
and C3F8 tend to diffuse from the eye very
slowly. However, the nitrogen and oxygen that
are in solution in surrounding tissues of the eye
are much more soluble and pass relatively
quickly into the gas bubble, following the law of
partial pressures. The net result is the initial
expansion of a bubble of pure SF6 or C3F8
within the vitreous, followed by gradual
resorption.

CASE SELECTION AVOIDED IN
•1. Breaks larger than 1 clock-hour or
multiple breaks extending over more than 1
clock-hour of the retina.
•2. Breaks in the inferior 4 clock-hours retina.
•3. Presence of PVR grade C or D .
•4. disability precluding maintenance of the
required positioning.
•5. Severe or uncontrolled glaucoma.
•6. Cloudy media precluding full assessment
of the retina.

PR presents a advantage IN
• 1. Macular breaks and other posterior retinal breaks.
Posterior retinal breaks are difﬁcult to treat with SB,
so PR is the procedure of choice in many of these
cases, especially in phakic eyes. It also has been
reported as an effective option in the treatment of
optic pits with macular detachment.
• 2. Redetachment or persistent detachment after SB .
When SRF accumulates or persists because of a
superior break after SB, PR may be much easier to
perform than buckle revision. This is especially
effective if the break is located on or anterior to the
buckle.

•3. Isolated tears under the superior
rectus. Placing a segmental buckle
under a vertically acting muscle runs the
risk of iatrogenic diplopia; this is
eliminated with PR.
•4. Filtering blebs. If a functioning
ﬁltering bleb is present, or if a ﬁltering
procedure may be necessary in future,
PR should be considered.

•5. Impending macular detachment. Because
PR can be performed promptly in the office
without delays required to prepare a patient
for the operating room, & because the gas
bubble can be used proactively to move the
fluid away from the macula .
•6. Bullous detachment. When RD is highly
bullous, retinal tears can be difficult to
localize and treat with SB, a problem which is
avoided by two-session PR.

One-session / two-session procedure
•PR can be done in one session, with
cryopexy applied to the retinal breaks just
before gas injection, or as a two-session
procedure, with initial gas injection followed
by laser 1 or 2 days later, when the retina is
reattached. One-session procedures always
involve cryopexy, since laser cannot be
applied to detached retina. Two-session
procedures are usually, but not always, done
with the laser.

Injection of gas
• With the ocular surface still sterile and the
patient supine, the head and the eye are
turned a total of approximately 45° to one
side to place the pars plana injection site
uppermost. The gas usually is injected
temporally unless pars plana epithelium is
detached or large retinal breaks are present
in that area, in which case another site is
selected. The injection is made 3–4 mm
posterior to the limbus with a 12 mm , 30-
gauge needle.

Injection of gas
•The needle is directed toward center of
vitreous & inserted to a depth of 7 or 8 mm to
ensure penetration of pars plana epithelium
and anterior hyaloid face. It is then partially
withdrawn so that approximately 9 mm of
needle shaft is seen outside eye, leaving
only 3 mm of the needle tip inside globe. With
injection site uppermost & needle vertical,
the gas is injected moderately briskly. This
technique creates one single bubble at the
needle tip rather than multiple small bubbles,
often referred to as “ﬁsheggs” .

Multiple small intravitreal gas bubbles
(“Fish eggs”) with subretinal gas

SUMMARY OF PROCEDURE
•The following constitutes sequence of PR :
•1. Anesthetic: topical/subconj or retrobulbar
•2. Cryopexy: if one-session procedure, in lieu
of laser
•3. Sterilization of ocular surface: povidone–
iodine solution
•4. Paracentesis: limbal, or via pars plana if
capsule is open
•5. Intravitreal gas injection: 0.4–0.6 mL of SF6

SUMMARY OF PROCEDURE
• 6. Second paracentesis and/or ocular
compression: as needed to open artery
• 7. Special procedures: e.g., steamroller if
needed (cryopexy should not be performed
before steamroller)
• 8. Antibiotic and patch: draw arrow
• 9. Laser: next day or when retina is
reattached (in lieu of cryopexy as two-
session procedure) with 360° laser if
desired.

OURS MODIFICATION
•Most frequently, WE do a one-session
procedure using cryopexy instead of laser.
our procedure differs from the technique
used by majority of retina surgeons in
following three ways:
•1. We perform paracentesis prior to, rather
than following, gas injection.
•2. We usually inject SF6 instead of C3F8.
•3. We inject a larger gas bubble, 0.5–0.6 mL
in most cases.

Primary Vitrectomy in
Rhegmatogenous RD

PPV
• Compared to SB, PPV offers several
advantages. The view of the retinal periphery
is enhanced, identiﬁcation of retinal breaks is
rendered easier, achievement of complete
intraoperative retinal attachment is possible,
the risks of hemorrhage or retinal
incarceration inherent to external drainage
procedure applied during SB is eliminated,
and the technique is less likely to cause a
refractive change.

PPV
• In addition, recent introduction of small-
gauge vitrectomy has shifted paradigm of
standard vitreous surgery to microincision
vitrectomy surgery that is less invasive,
affords fast recovery, & is sutureless ( MIVS).
As a result of these advances, VR surgeons
now have more procedural choices when
treating RRD patients. Further, recently
trained VR surgeons may be more familiar
with application of PPV (compared to SB) .

PATIENT SELECTION FOR PPV
•SB and/or PR serve as the ﬁrst treatment
option(s) in patients with localized
detachment in one quadrant together with
single neighboring breaks. Young age and
anteriorly located small holes in phakic
patients encourage the use of SB. The
success rates of ﬁnal reattachment are 90–
95%.

PATIENT SELECTION FOR PPV
• PPV is indicated for PTs with wide and
bullous RD, older patients with a liqueﬁed
vitreous. Presence of RD with marked
traction with different anterior posterior
depth of breaks, presence of breaks in
multiple quadrants, or the absence of an
apparent retinal break in a pseudophakic
patient, are all good candidates for the use of
PPV. RD of preoperative PVR grade C, GRT ,
and macular hole RD, are all commonly
treated using PPV.

Developments In Vitrectomy
•Recent developments in PPV including small-
gauge systems, wide-angle viewing systems,
and endoilluminators, as well as adjuvants,
including triamcinolone acetonide
suspension, PFCL , and SF6,C3F8 led the
choice of surgical technique for the treatment
of RRD with medium-complexity shift more
and more towards PPV.
• During the last 5 years, several surgeons
have reported that primary vitrectomy is
method of choice in 40–80% of RRD PTs .

PRINCIPLES OF VITRECTOMY
•The principles of vitrectomy to treat
RRD are release of tractional forces that
precipitated the retinal break, and the
closure and reattachment of breaks to
the underlying RPE . The surgical
procedure requires: (1) removal of the
vitreous gel and preretinal tractional
membrane; (2) intraoperative ﬂattening of
the detached retina; (3) application of
retinopexy; and (4) placement of a
tamponade in vitreous cavity.

•Abnormal vitreoretinal traction (either
perpendicular or tangential) increases
vitreous mobility caused by PVD, and
atypical posterior extension of the anterior
vitreous base predisposes to formation of
retinal tears. Therefore, removal of the
vitreous gel and any abnormal preretinal
structure releases the tractional force
causing retinal breaks and detachment.

•After release of abnormal VR traction, the
detached retina must be reattached. To
stabilize and ﬂatten detached retina, a heavy
liquid is initially applied; this is subsequently
replaced by sterile air. If the retina is mobile
and becomes ﬂattened in air, a nonexpansive
gas–air mixture is used to achieve a postop
gas tamponade. Although silicone oil is not
routinely used in instances of uncomplicated
RRD, use of silicone oil should be considered
if eyes have multiple inferior breaks .

•Retinopexy has been used to create retinal–
RPE adherence. Both forms of retinopexy
(cryopexy, and laser ) cause tissue
destruction and cellular proliferation and
should be used as little as possible.
Continuous laser retinopexy is preferable to
cryopexy . However, if peripheral breaks in
phakic eyes are to be treated, cryopexy is
preferred, because endolaser probe can
touch crystalline lens. The risk of postop PVR
may be minimized if retinal pigment epithelial
cells dispersed after cryopexy are thoroughly
aspirated via a heavy liquid–air exchange.

Pars Plana Vitrectomy Step by
Step
• Instruments
• 1. 3-port trocar
• 2. 120D or 90D magnifying glass
• 3. Light pipe
• 4. Vitreous cutter
• 5. Scleral depressor
• 6. Fluid needle

Individual steps
• 1. Insertion of trocar cannulas
• 2. Phacoemulsification
• 3. Focussing
• 4. Core vitrectomy
• 5. Induction of posterior vitreous detachment
• 6. Trimming of vitreous base
• 7. Anterior vitrectomy

Individual steps
• 8. Internal search for retinal breaks
• 9. Laser photocoagulation of peripheral breaks
• 10. Cryotherapy of peripheral breaks
• 11. Intraoperative tamponade
• 12. Postoperative tamponade
• 13. Removal of trocar cannulas
• 14. Sclerotomy sutures

SB / PR / PPV
• Complicated detachments are usually managed with PPV ,
whereas localized, relatively simple cases are usually
managed with a “walling-off” (demarcating) procedure
employing laser or cryotherapy, with PR, or with a small
and localized scleral buckling procedure. Between these
two extremes lies a large percentage of cases, probably
50% or more, in which any of the three major options
might be considered; combinations of the three are also
employed by many surgeons in selected situations.
Regardless of technique, if all retinal breaks are
surgically closed, and PVR or other more unusual
complications do not develop, the procedure will be
anatomically successful .

Advantages of SB
• As the standard of care for decades, SB success and
complication rates are relatively well understood. SB is
usually an extraocular procedure (except for the
frequently optional steps of draining SRF and/or injecting
gas), and the risk of endophthalmitis is low, even when
drainage is performed. The cost of equipment and
accessory materials is considerably less than for PPV ,
although much more than for PR. Progressive cataract
formation following surgery is much less likely than with
PPV . Unlike PR and PPV in general, no special postop
positioning is usually required with SB , which may be an
important consideration in individuals with arthritis or
back trouble.

Disadvantages of SB
• Placement of an encircling buckle frequently induces
myopia. Postop muscle imbalance and altered refractive
errors are important complications that are more
commonly seen following SB than after PR or PPV .
Compared to PR, important disadvantages of scleral
buckling include the necessity of performing the
procedure in an operating room, with the attendant costs,
delays, and additional equipment. More patient morbidity
occurs following SB than after PR. Compared to PPV ,
disadvantages include increased difficulty in the
management of very large and/or posterior retinal breaks,
and increased patient morbidity following repairs of
relatively difficult cases. Whereas experience with the
procedure was extensive in the past, a growing number of
VR training programs appear to be providing less
extensive experience with this procedure.

OPTIMAL METHODS FOR
TREATMENT
SB VS PR VS PPV

ROUND HOLE RD
•In eyes with round hole RD , causative breaks
are small round holes, often associated with
lattice degeneration.
•Patients affected are typically young, low
myopes, presenting with blurring of vision
and a visual ﬁeld defect. Some patients are
asymptomatic and picked up on routine
examination .

ROUND HOLE RETINAL
DETACHMENT
• A common misconception is that a
pigment line, or “tide mark” or
“demarcation line” posterior to the area
of detachment will prevent progression.
This is not the case, though such a line
does imply stability of the extent of the
detachment for at least some months.

Conservative management
• Patients with peripheral, or asymptomatic RD
not threatening the macula, can be
considered for conservative management.
When adopting a conservative approach to
these cases, it is important to consider other
factors in addition to the characteristics of
the detachment, including the powers of
observation of the patient and their ability to
attend urgently if they experience symptoms
of progression. Many surgeons recommend
routine examination at regular intervals, for
example every 6 months or annually.

Conservative management
• However, progression is more likely to occur between
follow-up examinations, and if the patient is unable to
detect a change, then there is a risk of the macula
detaching before treatment can be applied. Thus, even if
subsequent treatment is anatomically successful, the
patient may be left with worse vision than if they had
received surgical treatment at presentation. This risk has
to be balanced against risks of complications of surgery,
particularly in this form of detachment, where as we have
seen, the risk of progression is small. A patient who
develops chronic discomfort, diplopia, or visual loss
following surgery for an asymptomatic problem is not
surprisingly dissatisﬁed.

Treatment Laser demarcation
•The extent of RD can be limited by creating a
surrounding adhesion between the retina and
RPE . This is the principle of retinopexy, & is
widely used to treat retinal tears. Principle
can also be applied to wider areas of RD with
a view to limiting progression.
• Such treatment of course does nothing to
resolve an existing detachment, so this choice
“writes off” the detached area of retina. This
is appropriate in patients with asymptomatic
RD , or those with very minimal symptoms.

• The aim of demarcation treatment is to create a
band of effective chorioretinal adhesion, which
completely surrounds area of detachment. This
generally means applying treatment from ora to
ora, just posterior to the ﬂuid . Although cryo could
be used, laser is preferred as it causes less tissue
damage, and less inﬂammatation to the external
eye. There is evidence that adhesion stronger than
normal appears within 24 hours of application of
treatment, but maximum strength is achieved
between 3 and 14 days later. Therefore, laser
demarcation is not suitable for rapidly progressive
detachments.

Scleral buckling
•The primary success rate of SB
in round hole RD is very high,
but there is a risk of ocular
morbidity.

DETACHMENT DUE TO RETINAL DIALYSIS
•There is often a long interval between the
creation of the dialysis,& development of a
symptomatic RD . In the series of traumatic
RD , the time from trauma to RD was up to 40
years, though in 80% of cases, was less than
2 years. The progression of the detachment
can be slow, and this may be related to lack
of vitreous detachment. If the detachment is
not detected until the macula becomes
involved, then the ﬁnal visual acuity can be
compromised.

DETACHMENT DUE TO RETINAL DIALYSIS
•Conservative management :
• The considerations and options for
management of pts with limited detachment
secondary to dialysis are identical to those
for pts with round hole detachments. Cases
with signs of chronicity, such as tidemarks
and retinal cysts, have probably been stable
for some time & with a relatively low risk of
progression.

•Limited detachments secondary to
dialysis respond well to laser
demarcation. This is particularly true for
the majority of detachments from
dialysis which are in the inferotemporal
quadrant. Walling off of the affected
area here results in a permanent ﬁeld
defect superonasally, which is likely to
be less important to the patient, than
inferotemporal ﬁeld loss.

Scleral buckling
• Dialysis respond well to segmental SB
procedures . the primary success rate
varies from 96% to 100 % .

RETINAL DETACHMENT SECONDARY
TO “U” (“HORSESHOE”) TEARS HST
•Conservative management of limited RD is
adopted less commonly than in RRD due to
round holes or dialyses. This is because
patients usually present with symptoms
associated with PVD, & there are rarely signs
of fluid being longstanding. There is therefore
much less confidence that fluid will remain
stationary or progress slowly. Furthermore,
continuing vitreous traction is an additional
factor leading to faster progression.

HST RD Laser demarcation
•Although laser creates an instant
adhesion, this is not of full strength for
up to 14 days. Rapidly progressing ﬂuid
may extend through area of demarcation
before a strong enough adhesion
develops.
•This form of treatment should therefore
be used with caution in patients with
RRD secondary to “U” tears.

PNEUMATIC RETINOPEXY PR
• Given that PR is a relatively quick and
simple procedure, with less morbidity than
SB , it is worth considering as an initial
procedure. This is particularly the case for
patients who have “classic” indications, as
the success rate appears higher in this
group. In a subgroup of patients with phakic
eyes, single breaks, and ﬂuid conﬁned to one
superior quadrant, the primary success rate
was 97%. There is evidence that PR is less
effective in aphakic & pseudophakic eyes.

PR AS ADJUNCT TO SB
•Most surgeons who use
pneumatic retinopexy, apply it as
a primary procedure, and then
employ scleral buckling if it fails.

SCLERAL BUCKLING
•It is important to understand that SB
achieves only closure, and not sealing of
the retinal break, the latter being the
role of retinopexy. The implication of
this is that SB alone has same initial
success rate whether retinopexy is
applied or not, but if indentation fades,
or the SB is removed, the RD will recur.

VITRECTOMY
•As surgeons became comfortable using
vitrectomy techniques to manage cases of
vitreous pathology and complex RD , it
became clear that the advantages of an
internal approach could also be useful for
simpler cases. Kloti was the ﬁrst to report
using vitrectomy for superior bullous
detachments. A subsequent series reported
on vitrectomy and ﬂuid–gas exchange in 29
cases of RRD, in which scleral buckling
would have been the usual approach.

VITRECTOMY
•The reattachment rate following one
operation was 79%, increasing to 93% after
two operations. These results compared
favorably with rates for conventional surgery.
Vitrectomy offers a more successful
approach for simple detachments with
signiﬁcant vitreous opacity, or for those with
posterior breaks which would otherwise
require a large SB . Other agreed indications
include eyes with thin sclera which would
make SB difﬁcult or dangerous.

CONCLUSION
• The treatment of RRD has advanced since Gonin.
Both primary and ﬁnal success rates are now high,
and it is only a small minority of cases whose
retinas remain detached after one or more
operations. There is broad agreement about best
method for some categories of RD , but for majority
of cases, there is both lack of agreement, and lack
of an evidence base to make rational choices of
technique. The goal of treatment should be to
choose a method for any particular case that has
the best chance of anatomical success, but with
the lowest risk of introducing further ocular
morbidity.

Quadrantic
detachment
with one
break.

HST WITH RD
• excellent candidate for PR, in the absence of
contraindications not related to the eye. PR avoids
placement of a SB under a vertically acting muscle. It
also affords the opportunity to promptly protect the
macula from impending detachment, and the
“steamroller” technique should be used in this case.
If the tear causing a quadrantic detachment is
present elsewhere in the upper eight clock-hours of
the periphery, PR is still an excellent choice, although
positioning for tears in the oblique and lateral meridia
will be more difficult than for a 12-o’clock tear. If the
tear is in the inferior four clock-hours, PR is usually
contraindicated.

HST WITH RD
• if the break remains widely open after
buckling, the surgeon may release the
Fluid by untying the sutures to restore
normal IOP and then draining the Fluid.
If significant fish mouthing occurs, a
gas injection may be employed with the
SB if the break is located in superior
two thirds of the fundus.

Total detachment with one break.
•If a single tear is found and there are no
other suspicious areas, and if the fundus can
be thoroughly examined, PR is still an
excellent choice if the tear is in the upper
eight clock-hours . SB technique differs from
case number 1 in that most surgeons prefer
to drain SRF , although many cases have
been managed satisfactorily without
drainage.

Total detachment with one break.
• An encircling (instead of segmental or PR )
should be considered if any of following
conditions is present
• 1 The break is not in the expected position.
• 2. There is question of integrity of peripheral
retina.
•3. There is evidence of PVR .
• 4. The peripheral retina cannot be examined
in all areas.

Detachment with multiple breaks
at same distance from ora
•PR is an option only if all open breaks
are within a several clock-hour arc in the
upper eight clock-hours of the eye.
•Vitrectomy is a reasonable choice in a
pseudophakic eye.
• If SB is chosen, an encircling buckle is
recommended

at different distances from ora
• Vitrectomy is a good choice in this instance,
especially in a pseudophakic eye and when
distances from the ora differ widely.
• PR is only occasionally useful, when limited
breaks are appropriately positioned .
• SB for this case involves a broad, grooved silicone
implant employed to place all the breaks on a
broad buckle. Each break is marked to ensure
they all are adequately supported. The implant is
usually used in association with an encircling
band.

at different distances from ora
•The implant is used in association with
an encircling band. It is sutured to the
surface of the globe, with at least one
(and often with two) broad mattress
sutures per quadrant over its extent, and
the band is routinely anchored to the
sclera in the remaining quadrant(s). SRF
Drainage is drained.

“Aphakic detachment” with
multiple small ora breaks
•In an aphakic/pseudophakic detachment,
retinal breaks are tiny and visualization may
be patchy, so some of the breaks may not be
found. An encircling buckle with or without
vitrectomy is frequently employed. It should
be placed immediately posterior to the ora
breaks. Drainage of SRF is usually required
.PPV without scleral buckling is also a
common choice. A 360-degree peripheral
laser photocoagulation is often applied.

“Aphakic detachment” with
multiple small ora breaks
•If the view is excellent and breaks are
appropriately limited, PR is an option,
but it carries a lower single operation
success rate than buckling and/or
vitrectomy .

Detachment with peripheral
break and macular hole
• Macular holes in this instance are usually
secondary cystic changes and not causally
related to the RRD. These cases are
generally managed with no treatment to the
apparent macular hole. If, however, fluid
reaccumulates around the posterior hole in
the early postoperative course, a second
procedure—usually PR—is required to close
the hole .

Detachment due to macular
break
•Detachments caused by macular
breaks are generally seen in
association with high myopia .
•PPV WITH internal tamponade is the
procedure of choice .

Detachment with retinal dialysis
• A detachment with a retinal dialysis is seen most
often in the inferotemporal periphery in juveniles
or young adults. Patients are typically phakic, and
SB is the procedure of choice. The posterior
margin of dialysis should be treated with
contiguous cryotherapy and by securing a
segmental buckle to the surface of the globe with
several mattress sutures. The buckle should be
placed just behind the posterior edge of the break.
Drainage of SRF is optional .

Detachment with giant break.
• A GRT is generally defined as a break spanning 90 degrees
or more. Especially where a rolled-over flap exceeding 180
degrees is present, vitrectomy with or without a low,
encircling SB is the procedure of choice . The use of PFCL
liquid greatly facilitates this procedure. After removal of all
adherent vitreous and peeling of all membranes, the
infolded retina is flattened against the wall of the eye with
PFCL

Detachment with giant break
• Photocoagulation is applied entirely
surrounding break. Then a gas–fluid
exchange is performed on top of PFCL ,
taking care to remove all water at the edge
of the break. PFCL is carefully replaced with
air while continuing to desiccate the edge of
break and preventing it from slipping
posteriorly. Critical postoperative positioning
is required is required for 5–10 days .

THANK
YOU
DR DINESH
DR SONALEE

Retinal detachment 2016

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