Primary Retinal Detachment

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Technique 61 solution; however,these need to be started 24–48 h prior to the procedure with frequent use to substantially affect the ocular flora, limiting their usefulness as a true prophylactic method in this setting. A wire-lid speculum is used to open the lids, avert the lashes from the field, and protect the lid margin from cryopexy damage. If the patient is to undergo a one-step procedure, then cryopexy is performed prior to gas injection, as small breaks may be difficult to visualize following gas injection. Cryopexy is the preferred method in cases where media opacities limit the view, when the break(s) are located in the far periphery, or when there is underlying pigment epithelial atrophy. Laser, via a two-step method, is preferred with bullous superior detachments with large retinal breaks, when breaks occur over a previously placed buckle element, and with posteriorly located tears. Some surgeons feel that there is a lower incidence of PVR with laser retinopexy compared with cryopexy. Laser can be difficult to perform through or around the gas bubble and will not provide adequate adhesion if there is still a small amount of fluid present near the tear site. Small breaks may be difficult to find with the laser once the retina is reattached. Laser might form a chorioretinal adhesion faster than cryopexy, which decreases the critical duration of required post-operation positioning. Multiple rows of confluent laser are placed around each tear with careful attention to carry the treatment anterior to the ora serrata. It should be noted that the two methods are not mutually exclusive, and many instances are best managed by a combination of both modalities. Preparation of the chosen gas is performed by withdrawing gas from a cylinder via a valve system through a Millipore filter into a 1-ml or 3-ml syringe. The valve, tubing, filter, and syringe are flushed with gas once, and the process is repeated to eliminate room air from the system. High pressures may damage Millipore filters, so care must be taken to maintain lower pressures during gas filtration. The filter is replaced with a 30-gauge needle, and excess gas is pushed out of the syringe until the desired amount for injection remains behind.
62 4 Pneumatic Retinopexy for Primary Retinal Detachment Paracentesis of the anterior chamber is a controversial step in the procedure. Some surgeons routinely soften all eyes prior to injection, while some perform the step only rarely. Others perform paracentesis after the gas injection as required by the IOP. Paracentesis is less important with one-step procedures where the scleral depression associated with cryopexy softens the globe and in cases where smaller volumes of expansile gas are utilized. Paracentesis is most often required in two-step (laser) cases and when injecting large gas volumes. The step is performed by entering the anterior chamber with a 30-gauge needle affixed to a 1-ml syringe without the plunger.Aqueous humor is allowed to passively egress until the anterior chamber shallows. A sterile cotton tip applicator is rolled onto the needle track as the needle is withdrawn to avoid additional fluid egress. Care is given to avoid needle tip-lens touch. Paracentesis is contraindicated in aphakic and pseudophakic patients with vitreous prolapse into the anterior chamber. Gas injection is the most important component step of PR, and many postoperative complications can be avoided with proper technique. The surgeon utilizes the indirect ophthalmoscope for lighting, visualization of needle tip, and later to assess gas location and patency of the central retinal artery. The patient is placed in a recumbent position with the head tilted 45° away from the operative eye. This places the temporal pars plana as the highest point on the globe. The injection is given 4 mm posterior to the limbus, usually in the temporal quadrant, unless the retina is bullously detached in the area. The needle tip is advanced into the mid-vitreous cavity, under direct visualization with the indirect ophthalmoscope to penetrate the anterior hyaloid face. Then the needle is withdrawn until just the tip is visible, 2–3 mm through the pars plana epithelium. Gas is injected in a brisk but controlled manner. Following gas injection, the head is carefully rotated to a neutral position in order to move gas away from the injection site and avoid egress of gas out the needle track. A sterile cotton tip applicator is rolled over the track as the needle is removed to minimize
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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
Page 20 and 21: 10 1 The History of Retinal Detachm
Page 26 and 27: 16 ion [147]. Perfluorocarbon liqui
Page 36 and 37: 26 2 Prophylaxis in Fellow Eye of P
Page 42 and 43: 32 found that eyes with pre-existin
Page 46 and 47: 36 3 Encircling Operation with Drai
Page 64 and 65: Chapter 4 Pneumatic Retinopexy for
Page 66 and 67: Technique 57 Case Selection Proper
Page 68 and 69: Technique 59 Table 4.1. Gas charact
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
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112 6 Minimal Segmental Buckling Wi
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114 a 6 Minimal Segmental Buckling
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116 a b 6 Minimal Segmental Bucklin
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122 c d 6 Minimal Segmental Bucklin
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124 c Fig. 6.14c 6 Minimal Segmenta
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Table 6.1. Preoperative characteris
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Table 6.3. Final attachment after m
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130 Choroidals In 4 of the 1,462 de
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Table 6.4. Visual acuity at 2 years
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140 Probably, the future question n
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146 7 Pharmacological Approaches to
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152 heparin was published in eyes u
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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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