Primary Retinal Detachment

90
5 Vitrectomy for the Primary Management of Retinal Detachment
eyes after one operation and 96.7% after multiple operations. The
surgical techniques did vary and might explain some of the differences
in anatomic outcomes. In some series, concomitant scleral
buckling was done [10], but in others, a scleral buckle was not used
in any of the eyes [9]. Also, vitrectomy was done only in pseudophakic
eyes, compared with other series that were operated without
regard to the lens status. The most common causes of failure of the
primary operation were missed retinal breaks or the development
of PVR. In a series of 25 failed cases analyzed for the cause of failure,
missed retinal breaks were responsible for 64.3% of failures [12].
These cases were managed with vitrectomy revision with or without
scleral buckling. The visual acuity outcomes are not stated in
many of these reports, and it is not possible to determine if the
outcomes are more favorable than in eyes treated with scleral
buckling alone. Some retrospective reviews and randomized clinical
studies comparing the anatomic outcomes between vitrectomy
and scleral buckling as the primary operation have been reported
[13–15]. In general, they report similar anatomic and visual outcomes
and probably have too small a number of eyes to have sufficient
power to detect a difference. A large prospective randomized
study with matched retinal detachments would be required to find
if there is a difference in visual acuity outcomes. Such a study would
probably require hundreds of patients, since the anatomic reattachment
rates are high both with scleral buckling and with vitrectomy
and is currently in progress in Germany (SPR Study) [16].
There are several advantages to the use of vitrectomy in the
primary management of retinal detachment. Intraocular visualization
is much improved, reducing the possibility of missing retinal
breaks. In one prospective study of 51 eyes undergoing vitrectomy,
7 (13.7%) eyes were found to have previously undetected retinal
breaks, and additional holes were found in 21 (41%) eyes [17]. The
traction on the tear is removed with vitrectomy with any vitreous
debris or hemorrhage. Thus, the patient rarely sees “floaters” postoperatively.
The retina is almost completely flattened at the time
of surgery with the help of perfluorocarbon liquids, and there is