06.02.2013 Views

Primary Retinal Detachment

Primary Retinal Detachment

Primary Retinal Detachment

SHOW MORE
SHOW LESS

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

Conclusion 49<br />

encircling continue to be popular and are used by a majority of<br />

surgeons. Careful preoperative examination including a detailed<br />

fundus drawing was advocated by Schepens and should still be<br />

done,irrespective of the surgical method.Examination is time consuming<br />

in the age of managed care and even the best effort cannot<br />

always identify all breaks. For the buckling procedure to be successful,<br />

all breaks have to be identified and closed, encircled or not.<br />

Encircling and drainage were successful in 78–96% and have<br />

become synonymous with scleral buckling [15, 37]. Since the 1950s,<br />

at least two generations of surgeons have been well trained in<br />

this procedure. It is “dependable” and incorporates the barrier<br />

concept [2]. Intraoperative localization as to latitude is critical,<br />

but meridional localization may be less precise compared with<br />

minimal radial buckling. The vitreous base is ring-like; supporting<br />

it treats the hidden break and the anticipated traction. Broad buckles<br />

support anterior PVR and circumferential retinotomies [42].<br />

This “ring” concept is behind prophylactic buckling and laser<br />

circling for 360 degrees, as they are meant to barrage and reduce<br />

the incidence of secondary breaks in alternate techniques [14, 16].<br />

Most encircling is reversible: a band can be cut in a timely fashion<br />

without re-detachment or permanent damage from ischemia.<br />

Can the surgeon sleep better after the retina has been drained<br />

flat? It depends: a non-drainage procedure increases the chance<br />

of primary failure, but the eye will survive the attempt almost<br />

intact. By draining, the retina may be attached on the table, yet<br />

morbidity (blood under the macula etc.) may forever preclude<br />

visual recovery. Who could sleep well after the latter? From a<br />

pathologist’s viewpoint, drainage will always be a penetrating injury<br />

to a vascular tissue in an inflammatory and hypotonous<br />

setting. The data reporting intraocular hemorrhage attest to this<br />

simple fact that cannot be changed by even the most sophisticated<br />

technique. The fear of anatomic failure (first operation success or<br />

lack thereof ) apparent to both physician and patient has helped<br />

the propagation of techniques that flatten the retina under the<br />

surgeon’s eye, like external drainage or internal drainage during

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!