Primary Retinal Detachment

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6 Minimal Segmental Buckling With Sponges and Balloons
Limits of Minimal Segmental Buckling Without Drainage
There are limits to minimal segmental buckling; however, more
than 90% of rhegmatogenous detachments can be treated by extraocular
minimal buckling alone – the remaining 10% can be divided
into three major categories.
First Category of Difficult Detachments
In this type of detachments, the limits of the minimal procedure
are exceeded if the tears are posterior (in about 1%),multiple at different
latitude (in 2–3%), or with a circumferential extent greater
than 70° (in 1–2%). A tamponade with an expanding gas bubble
without drainage represents the next level of a minimal surgery for
these conditions, but it requires an intraocular injection. Consequently,
in this first category, a gas tamponade will suffice.A vitrectomy
will be needed for the rare situation of a giant tear of less than
or equal to 150° with an overhanging flap or, as in some hands, if
the tear is greater than 90°.
Second Category of Difficult Detachments
These are detachments with local vitreous traction that caused the
redetachment of a horseshoe tear that had been buckled or detachments
with proliferative vitreoretinopathy in more than two quadrants.
In these detachments, a primary vitrectomy may be indicated.
However, it is not indicated per se if the starfolds are more than
1 clock hour from the tear to be buckled. In these difficult detachments,
buckling first is advisable (Fig. 6.8) [33–35]. However, if one
decides upon a vitrectomy, it has to be combined with a meticulous
removal of proliferative preretinal membranes and the anterior vitreous.
Why? Because the additional gas tamponade, combined with
the vitrectomy, can provoke anterior vitreoretinal proliferation.