Primary Retinal Detachment

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146 7 Pharmacological Approaches to Improve Surgical Outcomes scleral buckling as a first operation, and although the immediate postoperative morbidity may be lower,the final rate of proliferative vitreoretinopathy (PVR) may be higher than scleral buckling alone [3–5]. Similarly, when scleral buckling alone is considered for eyes with early or late forms of proliferative vitreoretinopathy, success rates are considerably lower, and the case for use of an adjuvant agent, either to facilitate intraoperative flattening, such as perfluorocarbon, or one of several different anti-proliferative agents seems better justified [7–9]. Recently, a British group has developed a predictive formula to calculate the risk of PVR following primary retinal reattachment, which may aid in the selection of patients who might benefit most from the use of adjuvant pharmacological methods [10]. Improvement in Visual Acuity Improvements in visual acuity following reattachment surgery may be achievable using several different methods. The first would be a reduction in the rate of complications associated with macular dysfunction. These include both macular edema and macular pucker. Both are well-described complications of retinal reattachment surgery as well as other vitreoretinal conditions and may be amenable to pharmacological intervention. Recent reports suggest that intravitreal steroids, principally triamcinolone acetonide, and also dexamethasone in a bioerodable polymer may reduce macular edema associated with several conditions, including diabetic retinopathy, uveitis, and retinal vein occlusion [11, 12]. The use of steroids by other routes of administration, including oral and parenteral, may also be of benefit in preventing macular complications, such as pucker [13]. It may also be possible to improve visual acuity through the enhancement of photoreceptor regeneration in eyes with macula-off retinal detachments. Processes governing photoreceptor renewal and normal alignment of the outer segments following retinal
The Cell Biology of PVR 147 reattachment are still poorly understood, and the potential use of pharmacological agents and, specifically, cytokines may be a promising avenue to restoring visual function above and beyond that which might be expected simply by reattachment of the macula, particularly in eyes with more longstanding retinal detachments. To date, there are no well-defined or well-controlled clinical trials that would suggest such an agent is available or on the near horizon, but it is anticipated that in the future this approach may be feasible. Reduction in Other Non-Macular Complications Limiting Either Anatomic <strong>Retinal</strong> Reattachment or Normal Physiological Function Well-known complications of retinal reattachment surgery include alterations in the intraocular pressure, both glaucoma and hypotony, postoperative inflammation, cataract, motility disorders, and PVR. Pharmacological therapy, both intraoperatively as well as postoperatively, may play a role in the reduction of several of these complications, either singly or in combination. The remainder of this chapter is devoted to a discussion of the principal cause of retinal reattachment failure after primary surgery, PVR, and the methods by which pharmacological therapy might favorably influence this condition. The Cell Biology of PVR PVR is the most common cause of failure following attempted retinal reattachment repair in primary cases, as well as complex forms of retinal detachment. The precise initiating events remain poorly understood, but it is known that the disease is characterized by cell-mediated tractional forces exerted on both preretinal and subretinal membranes, as well as more diffusely to the vitreous gel
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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
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Technique 59 Table 4.1. Gas charact
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Technique 61 solution; however,thes
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Technique 63 gas reflux. Following
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Complications: Prevention and Manag
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New Possibilities 67 ing on type an
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Results 69 Table 4.7 (continued) Au
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Discussion 71 surgical failures. Fa
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Discussion 73 Disadvantages of PR A
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References 75 situations, then to p
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References 77 24. Tornambe PE, Hilt
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References 79 51. Pournaras CJ, Don
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Chapter 5 Vitrectomy for the Primar
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Indications 83 Table 5.1. Indicatio
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Indications 85 Fig. 5.2. The vitreo
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Surgical Technique 87 vitrectomy an
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Outcomes 89 will be visible under a
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Outcomes 91 almost no persistent su
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References 93 7. Heimann H, Bornfel
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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
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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
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Page 136 and 137: Table 6.3. Final attachment after m
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Page 140 and 141: Table 6.4. Visual acuity at 2 years
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Page 168 and 169: Chapter 8 Systematic Review of Effi
Page 170 and 171: Materials and Methods 163 Table 8.2
Page 172 and 173: Discussion 165 30% 25% 20% 15% 10%
Page 174 and 175: Discussion 167 Fig. 8.2. The small
Page 176 and 177: Conclusion 169 vitrectomy and searc
Page 178 and 179: References 171 8. Brazitikos PD, D
Page 180 and 181: References 173 34. Gunduz K, Gunalp
Page 182 and 183: References 175 63. Schepens CL (195
Page 184 and 185: 178 9 Repair of Primary Retinal Det
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Page 192 and 193: 186 a b 9 Repair of Primary Retinal
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Page 198 and 199: Chapter 10 Retinal Detachment Repai
Page 200 and 201: Retinal Detachment Repair: Outlook
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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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