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Primary Retinal Detachment

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Outcomes 91<br />

almost no persistent subretinal fluid involving the macula. Thus, the<br />

recovery of macular function starts immediately postoperatively.<br />

Choroidal detachment is rarely seen in vitrectomized eyes. Endolaser<br />

photocoagulation is more comfortable for the patient and may<br />

cause less surgically-induced inflammation compared with cryotherapy.<br />

If a scleral buckle is used in conjunction with vitrectomy,<br />

it tends to be a smaller buckling element, especially with large<br />

posterior retinal tears. In pseudophakic eyes, there is less change in<br />

postoperative refractive error when no scleral buckle is used.<br />

The complications of vitrectomy may affect the visual and<br />

anatomic outcome. The possibility of iatrogenic retinal breaks as a<br />

result of cutting near mobile retina or from vitreous incarceration<br />

at sclerotomy sites increases the risk of failure. A large gas bubble<br />

may be associated with glaucoma or with iris capture of an<br />

intraocular lens. Unexplained visual field defects may also occur<br />

after vitrectomy. Rarely, a retinal fold that involves the macula is<br />

seen postoperatively. The patient complains of marked distortion.<br />

Endophthalmitis is a rare but devastating complication. In phakic<br />

eyes, the postoperative progression of nuclear cataract may be the<br />

single reason that vitrectomy is not recommended routinely for<br />

every retinal detachment. In a young patient with a clear lens in the<br />

fellow eye, the loss of accommodation resulting from pseudophakia<br />

can be quite disabling. Thus, whenever possible, it is preferable<br />

to use an operation that will not increase the rate of cataract progression.<br />

There are also economic considerations that may play a role in<br />

the choice between vitrectomy and scleral buckling as the primary<br />

treatment for retinal detachment. The cost of supplies for a scleral<br />

buckling procedure is significantly less than that of a vitrectomy.<br />

If cataract surgery is also required later, the cost difference is<br />

multiplied. The rehabilitation time is increased after vitrectomy<br />

compared with scleral buckling. In general, most of my patients<br />

are able to return to work 1 week after scleral buckling. After<br />

vitrectomy, most patients are incapacitated for 2–4 weeks because<br />

of head positioning and inability to drive. There is a prolonged

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