Discussion 73 Disadvantag

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Discussion 73 Disadvantages of PR Anatomical success is one key issue regarding the outcome of surgical techniques for the repair of RRD. The cumulative initial success rate for the surveyed papers was 75.5% (Table 4.7) [3, 9–18, 26–29], with a final overall success of 97.4%. This is lower than reported rates for PPV (85%) [31] and SB (88% – 1,440/1,630) [62–67]. The case selection for PR typically involves simple anatomy, so matching for similar cases done with PR or SB might uncover a larger disparity in success rates. A prospective, randomized multicenter trial comparing PR with SB found a lower primary success rate with PR (73%) versus SB (82%), but a similar final success rate of 99% versus 98%, respectively [13]. A retrospective comparative series by McAllister [61] found a higher success rate for SB (96%) compared with PR (71%). However, when aphakic and pseudophakic eyes with open posterior capsule were excluded, the success rate for PR improved to 81%. A similar study by Han [17] found a higher anatomic success rate for SB (84% versus 62%), but an equal final success rate of 98%. The data does support the fact that for RRD, SB and primary PPV offer superior initial success rates, yet equivalent final anatomic success rates. Pneumatic retinopexy has a lower initial success rate for two major reasons: (1) re-opening of the original break; and (2) new and/or missed retinal breaks. Both SB and primary PPV permanently relieve vitreoretinal traction, and, therefore, break re-opening is a relatively rare phenomenon. With PR, there is no relief of traction, so that the laser- or cryopexy-induced chorio-retinal adhesion must be strong enough to overcome this tractional force on the retina. New and/or missed retinal breaks are more commonly encountered with PR than with PPV or SB. One contributing factor for missed breaks may be the extent of retinal examination performed with each technique.All patients undergo extensive retinal examination prior to any of the three surgical procedures, but SB and primary PPV provide additional examination opportunities. During SB, an exam under anesthesia with open conjunctival
74 scleral depression is routinely performed, thereby allowing discovery of previously missed breaks. PPV, especially when performed under wide-field viewing, allows extensive, high-magnification, peripheral examination under anesthesia. In addition, PPV will remove media opacities, such as an opacified posterior capsule, vitreous hemorrhage, or vitreous debris, resulting in a superior view of the retinal periphery. New retinal breaks do occur following PR. It is postulated that a gas bubble within the vitreous cavity creates additional vitreoretinal traction, particularly when the bubble is positioned between the retina and posterior hyaloid face. These breaks may occur in any quadrant, but 76% are located in the superior two-thirds of the retina, and 52% are located within 3 clock hours of the original causative break. The majority (59%) of new breaks occur during the first postoperative month [13]. Prophylactic 360° peripheral barricade laser has been advocated to reduce the risk of new and/ or missed retinal breaks. Tornambe [14] found a single operation success rate of 55% when focal retinopexy was employed compared with 85% for patients following 360° retinopexy. Presumably, this difference was due to a lower number of failures due to new and/or missed breaks in the 360° retinopexy group. Conclusion 4 Pneumatic Retinopexy for Primary Retinal Detachment Pneumatic retinopexy certainly has a place alongside SB and primary PPV in the constellation of surgical techniques for the repair of RRD. It is evident that PR has a lower single procedure primary anatomic success rate than the other techniques in most clinical situations. During informed consent discussions with patients, when describing the risks and benefits of the various treatment options, PR shines forth. Patients frequently choose PR, in spite of its lower primary success rate, because of the perceived benefit of less pain, less time away from work and favored activities, less surgical risk, and lower costs. It is reasonable to try PR first in favorable
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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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Page 32 and 33: 22 1 The History of Retinal Detachm
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Page 42 and 43: 32 found that eyes with pre-existin
Page 46 and 47: 36 3 Encircling Operation with Drai
Page 64 and 65: Chapter 4 Pneumatic Retinopexy for
Page 66 and 67: Technique 57 Case Selection Proper
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 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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Page 108 and 109: 100 the operating table with the re
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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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134 6 Minimal Segmental Buckling Wi
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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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