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Primary Retinal Detachment

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110<br />

6 Minimal Segmental Buckling With Sponges and Balloons<br />

Limits of Minimal Segmental Buckling Without Drainage<br />

There are limits to minimal segmental buckling; however, more<br />

than 90% of rhegmatogenous detachments can be treated by extraocular<br />

minimal buckling alone – the remaining 10% can be divided<br />

into three major categories.<br />

First Category of Difficult <strong>Detachment</strong>s<br />

In this type of detachments, the limits of the minimal procedure<br />

are exceeded if the tears are posterior (in about 1%),multiple at different<br />

latitude (in 2–3%), or with a circumferential extent greater<br />

than 70° (in 1–2%). A tamponade with an expanding gas bubble<br />

without drainage represents the next level of a minimal surgery for<br />

these conditions, but it requires an intraocular injection. Consequently,<br />

in this first category, a gas tamponade will suffice.A vitrectomy<br />

will be needed for the rare situation of a giant tear of less than<br />

or equal to 150° with an overhanging flap or, as in some hands, if<br />

the tear is greater than 90°.<br />

Second Category of Difficult <strong>Detachment</strong>s<br />

These are detachments with local vitreous traction that caused the<br />

redetachment of a horseshoe tear that had been buckled or detachments<br />

with proliferative vitreoretinopathy in more than two quadrants.<br />

In these detachments, a primary vitrectomy may be indicated.<br />

However, it is not indicated per se if the starfolds are more than<br />

1 clock hour from the tear to be buckled. In these difficult detachments,<br />

buckling first is advisable (Fig. 6.8) [33–35]. However, if one<br />

decides upon a vitrectomy, it has to be combined with a meticulous<br />

removal of proliferative preretinal membranes and the anterior vitreous.<br />

Why? Because the additional gas tamponade, combined with<br />

the vitrectomy, can provoke anterior vitreoretinal proliferation.

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