Primary Retinal Detachment

Complications: Prevention and Management 65
though perhaps not employed by all). If this maneuver fails, the
patient should be positioned face down for 6–12 h in order to
prevent subretinal migration. During this time period, fish eggs
inevitably unite to form the desired, effective single large bubble.
Migration of bubbles, especially with expansile gas, into the subretinal
space is a substantial complication. This event can be avoided
by visualizing the needle within the vitreous cavity prior to
injection, achieving a single bubble rather than fish eggs, and
by avoiding case selection involving large tears with severe traction.
Once gas enters the subretinal space, it may be managed by
maneuvering the patient’s head and eye in such a way that it rolls
the bubble back through the tear into the vitreous cavity. This is
often aided by simultaneous scleral depression. These maneuvers
are often unsuccessful, and vitrectomy surgery is necessary for
removal. During vitrectomy, the bubble will displace the detached
retina anteriorly toward the lens – making infusion line placement,
sclerotomy incisions, and instrument entry into the eye problematic.
A small retinotomy performed with the vitreous cutter probe
located at the most anterior, superior pole of the subretinal bubble
usually works well for evacuation.
Postoperative
The most common postoperative complication of PR is new and/or
missed retinal breaks (Table 4.6) [3, 9, 11–18]. Most of these are discovered
during the first postoperative month, with between 61%
and 86% being identified during this time period [19, 20]. Of new
and/or missed breaks, 76% occur in the superior two-thirds of the
retina. They almost invariably occur anterior to the equator and
are more common in pseudophakic or aphakic eyes [20]. Missed
breaks can be avoided by performing a very thorough preoperative
retinal examination. The authors have found that a 78D or 90D
exam of the peripheral retina is invaluable for discovering small
breaks preoperatively. Additionally, cases with media opacities,