Primary Retinal Detachment
Primary Retinal Detachment
Primary Retinal Detachment
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5 Vitrectomy for the <strong>Primary</strong> Management of <strong>Retinal</strong> <strong>Detachment</strong><br />
base, a low encircling scleral buckle is used to reduce vitreous traction<br />
that inherently cannot be removed. A scleral buckle should<br />
also be used to support inferiorly located retinal breaks. In general,<br />
scleral buckling is not needed if the vitreous attachments can be<br />
completely relieved around the retinal break. These are usually<br />
retinal tears that are located posterior to the vitreous base.<br />
A 2.0-mm or 2.5-mm encircling band with low to moderate elevation<br />
can be placed to support the vitreous base region.<br />
After preplacing the scleral buckle, the vitrectomy proceeds<br />
with removal of the central vitreous. If the retinal detachment is<br />
very bullous and close to the posterior surface of the lens, it is possible<br />
to drain subretinal fluid before entering with the vitrectomy<br />
instruments. In my experience, this has never been required. In<br />
cases where the retinal detachment is bullous or the detachment<br />
threatens to involve the macula, it is helpful to use some perfluorocarbon<br />
liquid to flatten the posterior retina.Approximately 1–1.5 ml<br />
of liquid is used, and this can prevent the retinal detachment from<br />
becoming more bullous or a further detachment anteriorly due<br />
to the introduction of the surgical instruments. The vitrectomy<br />
instrument is set using high cutting rates (2,000–2,500 cuts/min)<br />
with relatively low aspiration settings to reduce the chance of<br />
causing iatrogenic retinal breaks during the vitrectomy. At this<br />
point, a wide-field contact lens is used to examine the retina and to<br />
localize the retinal breaks. In most instances, the breaks are readily<br />
appreciated, but occasionally, the retinal breaks will be found after<br />
scleral depression and shaving of the basal vitreous. Occasionally<br />
retinal breaks can also be seen by observing the “schlieren” from<br />
subretinal fluid passing through the retinal break as additional<br />
perfluorocarbon liquid is injected.<br />
It is important to excise much of the peripheral vitreous at the<br />
vitreous base to reduce remaining anterior tractional forces on<br />
the retinal break. It is contraction of residual basal vitreous that<br />
leads to anterior foreshortening of the retina. After careful scleral<br />
depression and peripheral vitreous excision, it may be helpful to<br />
lightly mark the retinal breaks with endodiathermy so that they
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