Technique 57 Case Selecti

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Technique 57 Case Selection Proper case selection is critical to success with PR. The “ideal” scenario involves an acute, phakic retinal detachment due to a single break or small cluster of breaks located in the superior 8 clock hours of the fundus. Careful preoperative examination is exceedingly important when considering PR. Clear ocular media are essential to allow visualization of all breaks. Sector cataract, vitreous hemorrhage, and pseudophakic lens capsular opacification are relative contraindications. In general, pseudophakic and aphakic detachments are more prone to multiple small breaks than phakic cases. However, if the view to peripheral retina affords a view sufficient to disclose all the breaks, these detachments can be managed with PR. A single break is most easily covered with bubble tamponade. If multiple, the breaks must be close enough together to be covered by a single bubble.Breaks greater than 90–120° apart require large volume injections and, as a result, are relative contraindications. Retinal tears located in the superior 8 clock hours are easier to treat because gas bubbles float in the fluid vitreous. Although retinal tears in attached retina located inferiorly are easily managed with barricade laser, breaks in detached retina in the inferior 4 clock hours present a relative contraindication for PR (see below – New possibilities). There are several other contraindications to PR. Required patient air travel while the bubble is in place is an absolute contraindication. There is no relief of vitreoretinal traction with PR; the adhesion formed must be stronger than the tractional forces generated to achieve long-term success. As a result, patients with severe traction due to proliferative vitreoretinopathy (PVR) are not good candidates. Subretinal fluid is removed by the pigment epithelial pump. This process is much more efficient with the liquid SRF of acute detachments than with the viscid proteinaceous fluid encountered with chronic detachments. Pneumatic retinopexy can be successfully utilized with the latter, but there may be loculated pockets of chronic SRF that persist for months due to delayed
58 resorption. The combination of glaucoma with retinal detachment leads to several considerations with respect to PR. Patients with a functioning bleb or tube shunt device in place may be better managed by PR than scleral buckle (SB). Although an expanding gas bubble has the potential to dramatically raise the intraocular pressure (IOP), bubble expansion typically occurs simultaneously with resorption of SRF. The resolution of SRF provides potential space for bubble expansion without perturbations in the IOP. Only detachments with scant SRF or chronic, thick SRF are more prone to IOP problems and, as a result, are relative contraindications to PR in patients with coexisting glaucoma. Gas Selection 4 Pneumatic Retinopexy for Primary Retinal Detachment Intraocular gas works by temporarily closing retinal breaks via the surface tension properties of the bubble meniscus. Blocking the movement of liquid vitreous into the subretinal space allows the retinal pigment epithelium to actively pump fluid from the subretinal space and flatten the detachment. Once the neurosensory retina is in apposition to the pigment epithelial layer, the adhesive properties of cryopexy or laser retinopexy permanently close the break(s). The most commonly utilized gases are air, sulfur hexafluoride (SF 6), and perfluoropropane (C 3F 8). Choice of gas is based upon volume issues, arc length of contact/bubble size requirements, and bubble duration (Table 4.1) [7]. The tamponade must last until the laser or cryopexy adhesion is strong enough to resist reopening – generally 3–5 days for laser and 5–7 days for cryopexy. Air is non-expansile and quickly disappears from the eye. Sulfur hexafluoride and C 3F 8 are expansile and have longer half-lives. In general, a 1-ml final bubble size tamponades a 120° arc length, which is sufficient for most cases of PR (Table 4.2) [8]. There is, however, considerable variation based on the axial length/ size of the globe, so that larger bubbles are required in myopic individuals to achieve the desired arc length of contact.
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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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Page 18 and 19: 8 ditis [72-74].Temperatures up to
Page 20 and 21: 10 1 The History of Retinal Detachm
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Page 36 and 37: 26 2 Prophylaxis in Fellow Eye of P
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Page 46 and 47: 36 3 Encircling Operation with Drai
Page 64 and 65: Chapter 4 Pneumatic Retinopexy for
Page 68 and 69: Technique 59 Table 4.1. Gas charact
Page 70 and 71: Technique 61 solution; however,thes
Page 72 and 73: Technique 63 gas reflux. Following
Page 74 and 75: Complications: Prevention and Manag
Page 76 and 77: New Possibilities 67 ing on type an
Page 78 and 79: Results 69 Table 4.7 (continued) Au
Page 80 and 81: Discussion 71 surgical failures. Fa
Page 82 and 83: Discussion 73 Disadvantages of PR A
Page 84 and 85: References 75 situations, then to p
Page 86 and 87: References 77 24. Tornambe PE, Hilt
Page 88 and 89: References 79 51. Pournaras CJ, Don
Page 90 and 91: Chapter 5 Vitrectomy for the Primar
Page 92 and 93: Indications 83 Table 5.1. Indicatio
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Page 96 and 97: Surgical Technique 87 vitrectomy an
Page 98 and 99: Outcomes 89 will be visible under a
Page 100 and 101: Outcomes 91 almost no persistent su
Page 102 and 103: References 93 7. Heimann H, Bornfel
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108 a b 6 Minimal Segmental Bucklin
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110 6 Minimal Segmental Buckling Wi
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114 a 6 Minimal Segmental Buckling
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116 a b 6 Minimal Segmental Bucklin
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122 c d 6 Minimal Segmental Bucklin
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124 c Fig. 6.14c 6 Minimal Segmenta
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Table 6.1. Preoperative characteris
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Table 6.3. Final attachment after m
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130 Choroidals In 4 of the 1,462 de
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Table 6.4. Visual acuity at 2 years
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140 Probably, the future question n
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146 7 Pharmacological Approaches to
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152 heparin was published in eyes u
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154 search for compounds with hepar
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Chapter 8 Systematic Review of Effi
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Materials and Methods 163 Table 8.2
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Discussion 165 30% 25% 20% 15% 10%
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Discussion 167 Fig. 8.2. The small
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Conclusion 169 vitrectomy and searc
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References 171 8. Brazitikos PD, D
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References 173 34. Gunduz K, Gunalp
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References 175 63. Schepens CL (195
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178 9 Repair of Primary Retinal Det
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180 a b Fig. 9.3a,b. Legend see pag
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186 a b 9 Repair of Primary Retinal
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188 might eliminate traction on the
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Chapter 10 Retinal Detachment Repai
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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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Primary Retinal Detachment

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