Primary Retinal Detachment

Surgical Technique 87
vitrectomy and scleral buckling. Giant tears with an inverted posterior
retinal flap are best repositioned with perfluorocarbon
liquids after core vitrectomy. Giant tears that do not have a rolled
posterior flap might be managed with scleral buckling alone.While
PVR usually develops as a complication of prior retinal surgery,
it is occasionally seen primarily. Such situations might result
from a delay in diagnosis, or in eyes with vitreous hemorrhage or
choroidal detachment. Vitrectomy is necessary if the epiretinal
traction prevents the retinal breaks from flattening on the scleral
buckle.
Surgical Technique
Advances in surgical instrumentation and technique have made
vitrectomy a safer and more effective procedure in an eye with a
detached, mobile, elevated retina. Critical components of the surgical
instrumentation should include a high-speed vitreous cutter
(2,500 cuts/min), a panoramic viewing system, and perfluorocarbon
liquids. High-speed vitreous cutters allow shaving of the
vitreous near mobile retina. The vitreous traction can be relieved
around the tear, and it is possible to shave vitreous around areas of
lattice degeneration, even with a mobile retinal detachment. The
intraoperative use of perfluorocarbon liquids flattens the retinal
detachment and reduces the potential for iatrogenic retinal breaks,
as the vitreous instruments pass in and out of the sclerotomy sites.
Also, the perfluorocarbon liquids reduce the mobility of the retina,
as the cortical vitreous is shaved near the vitreous base (Figs. 5.1,
5.2). Panoramic viewing allows better visualization of the periphery
and helps to localize the retinal tears or breaks. This is
particularly useful in pseudophakic eyes with a small optical aperture,
or in eyes with microcornea.
The surgical algorithm starts with a decision about the necessity
for a concomitant scleral buckle. In aphakic or pseudophakic
eyes, where the retinal breaks are small and located in the vitreous