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Outcomes 89 will be visible under air. The scleral buckle is then adjusted to the desired height, and perfluorocarbon liquid is added until the level reaches the level of the retinal tears. Endophotocoagulation is placed around the retinal breaks through perfluorocarbon liquid. In some cases, the anterior portion of the retinal break may still be detached, and the laser treatment around the anterior locations can be completed after fluid-air exchange. Fluid-air exchange is done by placing an extrusion needle in the saline compartment near the retinal breaks as the air bubble enters the eye. The anterior retina is flattened by the air bubble, and then the perfluorocarbon liquid is passively aspirated. At the end of the exchange, the retinal tears are flattened under air with minimal or no visible subretinal fluid remaining.There should be visible photocoagulation treatment surrounding the retinal breaks. Usually two to three rows of treatment are sufficient. The eye is then flushed with a mixture of sulfur hexafluoride (25%) and air, or perfluoroethane (15%) and air, depending on the location of the retinal breaks. When retinal breaks are present inferiorly, a longer-lasting gas is used. Air alone can also be used for easier cases. Outcomes The increasing use of vitrectomy for the primary management of retinal detachment was studied at one hospital that compared the characteristics of the surgical procedures used in 1979–1980 with their cases 20 years later (in 1999) [6]. Of 124 eyes managed in 1979–1980, only one had vitrectomy as the primary mode of treatment. In 1999, 79 of 126 (63%) were managed with vitrectomy. The severity of cases did also differ, however, with more complex cases, such as pseudophakic retinal detachments, giant retinal tears, and proliferative vitreoretinopathy cases managed in 1999. The rates of retinal reattachment after vitrectomy vary from 64% to 100% after a single operation [7–11]. When all the cases are combined, the retina was reattached in 87.7% (421 of 480 eyes) of
90 5 Vitrectomy for the Primary Management of Retinal Detachment eyes after one operation and 96.7% after multiple operations. The surgical techniques did vary and might explain some of the differences in anatomic outcomes. In some series, concomitant scleral buckling was done [10], but in others, a scleral buckle was not used in any of the eyes [9]. Also, vitrectomy was done only in pseudophakic eyes, compared with other series that were operated without regard to the lens status. The most common causes of failure of the primary operation were missed retinal breaks or the development of PVR. In a series of 25 failed cases analyzed for the cause of failure, missed retinal breaks were responsible for 64.3% of failures [12]. These cases were managed with vitrectomy revision with or without scleral buckling. The visual acuity outcomes are not stated in many of these reports, and it is not possible to determine if the outcomes are more favorable than in eyes treated with scleral buckling alone. Some retrospective reviews and randomized clinical studies comparing the anatomic outcomes between vitrectomy and scleral buckling as the primary operation have been reported [13–15]. In general, they report similar anatomic and visual outcomes and probably have too small a number of eyes to have sufficient power to detect a difference. A large prospective randomized study with matched retinal detachments would be required to find if there is a difference in visual acuity outcomes. Such a study would probably require hundreds of patients, since the anatomic reattachment rates are high both with scleral buckling and with vitrectomy and is currently in progress in Germany (SPR Study) [16]. There are several advantages to the use of vitrectomy in the primary management of retinal detachment. Intraocular visualization is much improved, reducing the possibility of missing retinal breaks. In one prospective study of 51 eyes undergoing vitrectomy, 7 (13.7%) eyes were found to have previously undetected retinal breaks, and additional holes were found in 21 (41%) eyes [17]. The traction on the tear is removed with vitrectomy with any vitreous debris or hemorrhage. Thus, the patient rarely sees “floaters” postoperatively. The retina is almost completely flattened at the time of surgery with the help of perfluorocarbon liquids, and there is
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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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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 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
Page 94 and 95: Indications 85 Fig. 5.2. The vitreo
Page 96 and 97: Surgical Technique 87 vitrectomy an
Page 100 and 101: Outcomes 91 almost no persistent su
Page 102 and 103: References 93 7. Heimann H, Bornfel
Page 104 and 105: 96 6 Minimal Segmental Buckling Wit
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Page 108 and 109: 100 the operating table with the re
Page 110 and 111: 102 6 Minimal Segmental Buckling Wi
Page 114 and 115: 106 a b 6 Minimal Segmental Bucklin
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Page 130 and 131: 122 c d 6 Minimal Segmental Bucklin
Page 132 and 133: 124 c Fig. 6.14c 6 Minimal Segmenta
Page 134 and 135: Table 6.1. Preoperative characteris
Page 136 and 137: Table 6.3. Final attachment after m
Page 138 and 139: 130 Choroidals In 4 of the 1,462 de
Page 140 and 141: Table 6.4. Visual acuity at 2 years
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140 Probably, the future question n
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142 6 Minimal Segmental Buckling Wi
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144 6 Minimal Segmental Buckling Wi
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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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