Primary Retinal Detachment

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154 search for compounds with heparin-like qualities on growth factors, but without the potential hemorrhagic issues. It is known that fractionation of longer chains of heparin into smaller molecular weight fragments causes loss of some of the anticoagulant activity while preserving the ECM effects.As a result, low-molecular-weight fractions of heparin with a molecular weight of 5000 or less retain their ability to catalyze the inhibition of Factor Xa, but lose their ability to directly inhibit thrombin [49]. When low-molecularweight heparin was introduced into the infusate during vitrectomy in an animal model, fibrin formation was markedly reduced without any coincident increase in intraocular hemorrhage [50]. Use of 5 IU/ml of low-molecular-weight heparin in the infusate during creation of an experimental model of proliferative vitreoretinopathy reduced the rate of traction detachment from 77% to 28% at 3 months [51]. These encouraging results led to the inclusion of lowmolecular-weight heparin in the infusate, along with 5-FU, which was studied in the prevention of PVR in humans [15, 42, 50, 51]. In another important PVR trial, when conventional heparin (1 IU/ml) was combined with a steroid dexamethasone (5 mg/ml) in the infusate, there was a slight increase in the retinal reattachment rate compared with controls from 65% to 80% in addition to a reduction in the rate of reproliferation from 26.5% to 16%.A mild increase in the rate of hyphema and vitreous hemorrhage was seen, although it was not judged to be clinically significant [33]. Summary 7 Pharmacological Approaches to Improve Surgical Outcomes Pharmacological methods remain a promising potential adjunct to the successful treatment of retinal detachment. In addition to conventional strategies, including adequate pupillary dilatation, control of inflammation by anti-inflammatory agents, and intraocular pressure by ocular hypotensive agents, drugs may play a further role by inhibiting other late complications. These include proliferation and macular edema. Steroids, fluoropyrimidines, and he-
References 155 parin-like compounds, particularly low-molecular-weight heparin, all appear to be potentially useful agents either singly, or in combination. The ability to combine agents together with differing mechanisms of action, either as a single intravitreal injection, or, more recently, as a component of the infusate or with extended delivery devices, opens up new therapeutic avenues. Issues related to bioavailability, particularly in eyes with long-acting tamponades, either gas or silicone oil, are particularly challenging but intriguing. The use of modern bioerodable polymers and other fixed extended delivery devices may further enhance the utilization of such agents. In the future, additional capabilities, including the use of intravitreal steroids for control of macular edema and cytokines for the improvement of photoreceptor recovery, may further improve visual acuity results beyond those that might be expected when anatomic reattachment reaches a high plateau. Further understanding of the cellular biology of retinal reattachment and macular function will undoubtedly lead to concomitant improvements in therapeutic advances. References 1. Lincoff H, Kreissig I (1972) The treatment of retinal detachment without drainage of subretinal fluid. Trans Am Acad of Ophthalmol Otolaryngol 76:1221–1232 2. Han DP, Mohsin NC, Guse CE, Harz A, Tarkanian CN (1999) Comparison of pneumatic retinopexy and scleral buckling in the management of primary rhegmatogenous retinal detachment. Southern Wisconsin Pneumatic Retinopexy Study Group. Am J Ophthalmol 127: 741–743 3. Campo RV, Sipperley JO, Sneed SR, Park DW et al (1999) Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments. Ophthalmology 106:1811–1815 4. Brazitikos PD, Androudi S, D’Amico DJ, Papadopoulis N et al (2003) Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks. Retina 23:615–621
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Ingrid Kreissig (Ed.) Primary Retin
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Professor Dr. med. Ingrid Kreissig
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Contents 1 The History of Retinal D
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List of Contributors Gary W. Abrams
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List of Contributors XI Hermann D.
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2 Helmholz in 1850 made an accurate
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4 (vitreous, gelatin) into the ante
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6 with scleral resection that set t
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8 ditis [72-74].Temperatures up to
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10 1 The History of Retinal Detachm
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16 ion [147]. Perfluorocarbon liqui
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26 2 Prophylaxis in Fellow Eye of P
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32 found that eyes with pre-existin
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36 3 Encircling Operation with Drai
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Chapter 4 Pneumatic Retinopexy for
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Technique 57 Case Selection Proper
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Technique 59 Table 4.1. Gas charact
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Technique 61 solution; however,thes
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Technique 63 gas reflux. Following
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Complications: Prevention and Manag
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New Possibilities 67 ing on type an
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Results 69 Table 4.7 (continued) Au
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Discussion 71 surgical failures. Fa
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Discussion 73 Disadvantages of PR A
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References 75 situations, then to p
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References 77 24. Tornambe PE, Hilt
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References 79 51. Pournaras CJ, Don
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Chapter 5 Vitrectomy for the Primar
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Indications 83 Table 5.1. Indicatio
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Indications 85 Fig. 5.2. The vitreo
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Surgical Technique 87 vitrectomy an
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Outcomes 89 will be visible under a
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Outcomes 91 almost no persistent su
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References 93 7. Heimann H, Bornfel
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96 6 Minimal Segmental Buckling Wit
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98 6 Minimal Segmental Buckling Wit
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100 the operating table with the re
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102 6 Minimal Segmental Buckling Wi
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Page 170 and 171: Materials and Methods 163 Table 8.2
Page 172 and 173: Discussion 165 30% 25% 20% 15% 10%
Page 174 and 175: Discussion 167 Fig. 8.2. The small
Page 176 and 177: Conclusion 169 vitrectomy and searc
Page 178 and 179: References 171 8. Brazitikos PD, D
Page 180 and 181: References 173 34. Gunduz K, Gunalp
Page 182 and 183: References 175 63. Schepens CL (195
Page 184 and 185: 178 9 Repair of Primary Retinal Det
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Page 192 and 193: 186 a b 9 Repair of Primary Retinal
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Page 200 and 201: Retinal Detachment Repair: Outlook
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References 207 It is impossible to
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210 C Campbell 7 case selection 57,
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212 M Machemer 13 macular - complic
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214 retinal - detachment - - bilate
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