Primary Retinal Detachment

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110 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.
Complications 111 Third Category of Difficult Detachments These are represented by pseudophakic detachments; the problem lies in the opacities of the optic media after an anterior segment surgery, which precludes finding the break and the application of minimal external buckling. However, the limits of external minimal buckling in this third category are in a gray zone. Actually,the indication for a vitrectomy in these eyes, combined with a preceding anterior segment surgery, does not depend only on the size of the tear or the presence of vitreoretinal proliferation, but also on the expertise of the surgeon in diagnostics in the presence of optical interferences. Biomicroscopy with the use of the new indirect wide-field contact lenses combined with simultaneous depression of the retinal periphery and application of the 4 Rules for finding the primary break [19, 20] might enable a limited prospective buckling and reduce the need for an invasive surgery. Complications There are no intraocular complications after minimal segmental buckling without drainage, except for a rare choroidal in a highly myopic eye (about 0.3%). The remaining complications are extraocular and reversible: in less than 0.5%,a buckle infection or extrusion may occur, and, in about 1%, diplopia may occur. However, diplopia after segmental buckles can be reduced to a minimum by avoiding trauma to the perimysium of the muscles during surgery, i.e., by avoiding grasping muscles with sharp instruments or uncontrolled pulling on the traction sutures. In addition, starting on the first day postoperatively, the patient should practice binocular motility exercises in all directions several times a day; this should be done independent of the state of the retina. This will avert the development of muscular adherences to the sclera or neighboring tissues and postoperative diplopia.
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Ingrid Kreissig (Ed.) Primary Retin
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Professor Dr. med. Ingrid Kreissig
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Contents 1 The History of Retinal D
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List of Contributors Gary W. Abrams
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List of Contributors XI Hermann D.
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2 Helmholz in 1850 made an accurate
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4 (vitreous, gelatin) into the ante
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6 with scleral resection that set t
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8 ditis [72-74].Temperatures up to
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10 1 The History of Retinal Detachm
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16 ion [147]. Perfluorocarbon liqui
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26 2 Prophylaxis in Fellow Eye of P
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32 found that eyes with pre-existin
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36 3 Encircling Operation with Drai
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Chapter 4 Pneumatic Retinopexy for
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Technique 57 Case Selection Proper
Page 68 and 69: Technique 59 Table 4.1. Gas charact
Page 70 and 71: Technique 61 solution; however,thes
Page 72 and 73: Technique 63 gas reflux. Following
Page 74 and 75: Complications: Prevention and Manag
Page 76 and 77: New Possibilities 67 ing on type an
Page 78 and 79: Results 69 Table 4.7 (continued) Au
Page 80 and 81: Discussion 71 surgical failures. Fa
Page 82 and 83: Discussion 73 Disadvantages of PR A
Page 84 and 85: References 75 situations, then to p
Page 86 and 87: References 77 24. Tornambe PE, Hilt
Page 88 and 89: References 79 51. Pournaras CJ, Don
Page 90 and 91: Chapter 5 Vitrectomy for the Primar
Page 92 and 93: Indications 83 Table 5.1. Indicatio
Page 94 and 95: Indications 85 Fig. 5.2. The vitreo
Page 96 and 97: Surgical Technique 87 vitrectomy an
Page 98 and 99: Outcomes 89 will be visible under a
Page 100 and 101: Outcomes 91 almost no persistent su
Page 102 and 103: References 93 7. Heimann H, Bornfel
Page 104 and 105: 96 6 Minimal Segmental Buckling Wit
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Page 108 and 109: 100 the operating table with the re
Page 110 and 111: 102 6 Minimal Segmental Buckling Wi
Page 114 and 115: 106 a b 6 Minimal Segmental Bucklin
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Page 130 and 131: 122 c d 6 Minimal Segmental Bucklin
Page 132 and 133: 124 c Fig. 6.14c 6 Minimal Segmenta
Page 134 and 135: Table 6.1. Preoperative characteris
Page 136 and 137: Table 6.3. Final attachment after m
Page 138 and 139: 130 Choroidals In 4 of the 1,462 de
Page 140 and 141: Table 6.4. Visual acuity at 2 years
Page 148 and 149: 140 Probably, the future question n
Page 154 and 155: 146 7 Pharmacological Approaches to
Page 160 and 161: 152 heparin was published in eyes u
Page 162 and 163: 154 search for compounds with hepar
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Chapter 8 Systematic Review of Effi
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Materials and Methods 163 Table 8.2
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Discussion 165 30% 25% 20% 15% 10%
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Discussion 167 Fig. 8.2. The small
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Conclusion 169 vitrectomy and searc
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References 171 8. Brazitikos PD, D
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References 173 34. Gunduz K, Gunalp
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References 175 63. Schepens CL (195
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178 9 Repair of Primary Retinal Det
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180 a b Fig. 9.3a,b. Legend see pag
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186 a b 9 Repair of Primary Retinal
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188 might eliminate traction on the
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Chapter 10 Retinal Detachment Repai
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Retinal Detachment Repair: Outlook
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References 207 It is impossible to
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210 C Campbell 7 case selection 57,
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212 M Machemer 13 macular - complic
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214 retinal - detachment - - bilate
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