RETINAL DETACHMENT

Dr Laltanpuia ChhangtePG 3GMC, HaldwaniRETINAL DETACHMENT

1Retinal detachment (RD) is a separation of the neurosensory retina from the retinal pigment epithelium with the accumulation of fluid in the potential space between them.

TYPES OF RDRHEGMATOGENOUS - associated with break(s).TRACTIONAL - associated with traction, without breaksEXUDATIVE - due to fluid exudation which may resolve spontaneously

Differential d/d Retinocele, Retinal cyst, REtinoschisis3RD HISTORYBeer 1817 first to detect RD clinically. Von Helmholtz 1851 invented the ophthalmoscope. Coccius 1853 first to find retinal breaks (r.b.). De Wecker 1870 first suggested that r.b. were the causes of RD. RD History: cont.Leber 1882 found r.b. in 70% of RD, vit. deg. And collapse traction r.b. RD. Changed to pre-retinal memb. r.b. (in PVR). Jules Gonin 1919 Father of RD surgery. Performed the first RD operation to close r.b. Ignipuncture of Thermocautery. RD EPIDEMIOLOGYIncidence 1: 10,000 / year, eventually BE in 10% In aphakics: 1 3%. In the second eye (-): 5%. In the second eye (+): 10%. 99% of untreated symptomatic RE blindness. 5 15% of population with retinal break(s) 7% of these develop new break(s). Normal anatomical landmarks

Normal variants of ora serrata

Anatomy of vitreous base

3-4 mm wide zone straddling ora serrataStrong adhesion of cortical vitreousAnterior limit of posterior vitreous detachmentAPPLIED PHYSIOLOGYAcid mucopolysaccharide (GAG) b/w RPE and the sensory retina acts as a biological glue.RPE cell sheaths mechanically hold the sensory retinaRPE pump and hydrostatic pressure the SRF is pumped out by the RPE ATP-ase dependent pump, which lowers the hydrostatic pressure and the vitreous pressure flattens the retina.Vitreous tamponade cortical vitreous impedes movement of liquid through breaks.Retina stays attached because:-Mechanics of RD formationVitreous liquefactionPartial/complete posterior vitreous detachment, VR tractionRetinal breaks tearholedialysisEye movements (Edies current)

PVDDue to loss of hyaluronic acid collapse of vit. collagen with liquifaction. Rare before 30 yrs. Increases with age (63% in > 70 yrs.) 15% of acute PVD have a retinal tear. Increases significantly after cataract extraction: pathologic vs physiologic PVD.

RDPVD

13-19% of PVD have vit. Hem. PVD + hem. 70% with tears. PVD + no hem. 2-4% with tears.

Acute PVD:-Examine periphery. + vit. Hem. - rest, patching examine. U/S. RRD Risk factorsMyopiaAphakiaTraumaLattice degenerationSnail track degenerationZonular retinal traction tuftsDegenerative retinoschisisRetinal pits and rarefactionRetinal pigment epithelial clumpsGlaucomaProliferative retinopathies- Diabetes- BRVO- Sickle cell, ROPInfections RD in fellow eye or F/H of RD

ERD Risk factors

Damage to RPE by subretinal disease ; Passage of fluid derived from choroid into subretinal space Convex, smooth elevation + May be very mobile and deep with shifting fluidSubretinal pigment (leopard spots) after flattening

18TRD Risk factors

Tractional RD is caused by progressive contraction of fibrovascular membranes over large areas of vitreoretinal adhesion. In contrast to acute PVD in eyes with rhegmatogenous RD, PVD in diabetic eyes is gradual and frequently incomplete. It is thought to be caused by leakage of plasma constituents into the vitreous gel from a fibrovascular network adherent to the posterior vitreous surface. Owing to the strong adhesions of the cortical vitreous to areas of fibrovascular proliferation, PVD is usually incomplete. In the very rare event of a subsequent complete PVD, the new blood vessels are avulsed and RD does not develop.

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1. Myopia and RDMyopia constitute 10% of the general population and over 40% of RD occur in myopic eyes.High myopia >6D 60 year myope risk of RD is 2.5% whereas normal risk is 0.06%In myopia : - Lattice degeneration is commoner - Snail tract degeneration is commoner;Diffuse CRA may cause small holes- Macular hole predisposition- Higher incidence of PVD and vitreous dengeration;- Higher risk with vitreous loss during sx;- Posterior capsulotomy has a higher risk for RD

212. Lattice and other peripheral deg.Present in 8% of the population. In SA 9.1% As a cause of RD in 20-30%. In RDs with L.D.:- 30-45% Atrophic holes. 55-70% A tear at edge of L.D.

Predisposing peripheral degenerations

Innocuous peripheral retinal degenerations

Microcystoid degenerationPavingstone degenerationHoneycomb (reticular) degenerationPeripheral drusen

(A) Microcystoid seen on scleral indentation; (B) pavingstone; (C) honeycomb (reticular); (D) drusen

243. CATARACT SurgeryIncreases PVD: Does it convert physiological PVD to a pathological one?1.3% RD in aphakes. ICCE > ECCE. Risk of RD increased with:- - P.C. otomy: 1.3%. - Vit. loss. 50% of RDs in 1st year. 4. GlaucomaIn general population 1% COAG. In RD patients 4-7% COAG. > in pigment dispersion synd. ? myopia. Miotics & RD. 5. Hereditary factorsThe most common hereditary conditions associated with RD are axial myopia and lattice degeneration.

6. TRAUMA7. Intraocular inflammationsCLINICAL EVALUATION SIGNS AND SYMPTOMSSudden increase in FloatersPhotopsiaVISUAL FIELD DEFECTMetamorphopsia and sudden DOVSudden VASudden increase in floaters due to acute PVD, cobwebs (PVD) , opaque ring (weiss ring)Photopsia subjective light flashes due to mechanical stimualtion of the retina due to vr traction. Their position may have limited localizing value also. They may persist even after reattachmentVisual field defect : when it extends posterior to the equator casiing a dark curtain or shadow to appear in the field. This has important localizing value for the source of the break. It may change with the time of day wherein the subretinal fluid may pass out into the vitreous flattening the retina at night with a reduced field defect, which in the morning progressively increases through the day.Metamorphopsia and sudden reduction in visual acuity indicates macular detachment. Since the inferior detachments progress slowly, the reductin in acuity upon macuylar extension is slow and affects vision lesser compared to superior ones.Sudden decrease in acuity may signify macular detachment or a large superior bullous RD overhaning in front of the macu7la in absence of any macular involvement

30SYSTEMIC HISTORYDrugs use; Glaucoma ; Past strabismus surgery ; Post cataract surgeryASSOCIATED CONDITIONSCVS, RS, anticoagulants intake, DMFAMILY HISTORYRD myopia, lattice degeneration, familial VR degenerationsGenetic diseases marfan, homocystinuria, sticklers syndromeDrugs use miotics like pilocarpine may predispose to RDPreexisting eye diseaseGlaucoma drainage surgery is required to prevent IOP risePast strabismus surgery positioning of explants difficultPost cataract surgery limbal wound strength is compromised

31EXAMINATIONVA VFAMSLER gridRefractive errorExt. Ocular examination Pupils SCLERA Anterior segmentIOPLensPost segment : blood, pigment (shafers sign) in the vitreousCareful Binocular IO with scleral indentation

VA preoperative vision is an important determinant of post operative visionVF corresponds to the area of detachment posterior to the equatorAMSLER GRID to quantitate the distance b/w the detachment edge and macula centerRE to detect myopia if presentExternal examination ; infection , strabismus 6. pupils marcus gunn pupil (RAPD) , scLERA ECTASIA , thinnig, Anterior segement mild iritis is common; 9. IOP lower by 3-5mm HG compared to the normal eye 10. Lens subluxation, aphakia, vitreous face status

32Examination techniquesIndirect ophthalmoscopyScleral indentationFundus drawingSlit lamp biomicroscopyUltrasonography B scan33

The technique of scleral indentation was originally suggested by Trantas in 1900, who while examining with the direct ophthalmoscope pressed the globe with his fingernail. The thimble depressor of Schepens permits easy and accurate depression.

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In this way the inverted position of the chart in relation to the patient's eye corresponds to the image of the fundus obtained by the observer. Retinal arterioles are not usually drawn unless they serve as a specific guide to an important lesion.Thin retina is indicated by red hatching outlined in blue, lattice degeneration is shown as blue hatching outlined in blue, retinal pigment is black, retinal exudates yellow, and vitreous opacities greenCharting of RD : extent and topography of the RD; identify all breaks; evaluate macula and optic nerve; areas of vitreoretinal traction.

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To obtain a more peripheral view of the retina the lens is tilted to the opposite side asking the patient to move the eyes to the same side. For example, to obtain a more peripheral view of 12 oclock (with mirrors at 6 oclock) tilt the lens down and ask the patient to look up).59, 67, 73 degree angle of inclination38DETERMINE FRESH & OLD RD

Corrugated appearance is due to retinal oedema; Retinal thinning should not be confused with retinoschisis; Intraretinal cysts if present more than 1 year; High water marks if present more than 3 months39

U-tear in detached retinasuperior bullous retinal detachmentshallow temporal retinal detachmenFresh retinal detachment. (A) U-tear in detached retina; (B) superior bullous retinal detachment; (C) shallow temporal retinal detachment; (D) B-scan shows a totally detached retina with linear echogenic structures inserting onto the optic nerve head to form an open funnel40

Long-standing retinal detachment. (A) Secondary retinal cyst; (B) B-scan shows a retinal cyst; (C) high water mark in an eye with an inferior retinal detachment

41Proliferative vitreoretinopathy

Retina society grading of proliferative vitreoretinopathyA vitreous haze , pigment clumpsB- wrinkling of the inner retinal surface, rolled edge of retinal break , retinal stiffness , vessel tortousityC1,2,3 full thickness retinal folds in 1,2,3 quadrantsD fixed retinal folds in 4 quadrants1,2,3 wide funnel shape, narrow funnel shape (op n visible) , closed funnel (op n not visible) on ultrasonography. Triangular sign42Assessment of BreaksFinding the 1 breakTractionType of breakAge of breakSize of breakNumber of breaksLocation of breakSymptomsSize of detachmentVitreous statusAphakiaFamily history of detachmentOther disease states

Lincoffs RULE44

Saleh Al Amro, MD, FRCS, FCOPHTH

Criteria For Seriousness Of Breaks

Differences between RRD, TRD and ERDRhegmatogenousTractionalExudativeSymptom Floaters and flashesAbsentAbsentVF defectDevelops fastDevelops slowly may remain statis for monthsDevelops fastLateralityU/L other eye may be involved laterU/L other eye may be involved laterInvolves both eyes simultaneouslyPVDUsually follows PVD which is completeNot associated with PVD, which is incompleteNot associated with PVD BreakAlways presentAbsentAbsentRPE PUMPIntactNot affectedOccurs d/t RPE failureConfigurationConvex, bullous, corrugated foldsConcaveConvex but surface is smooth, no folds Mobility of retinaMobile in fresh case, restricted in old caseRestrictedMobileExtentExtends to oraSeldom extendsExtends to oraPVR Present in due course of timeAbsentAbsentSRF SHIFTNo shittShallous and no shitShift with postureTreatmentSurgicalSurgicalNo surgery, treat underlying causeDifferences between RRD and CDRRDCDSymptomsFlashes and floaters positiveAbsentVisual field defectDevelops fastAbsent unless it is very extensive i.e., kissing choroidalsAC and IOPNormal AC, IOP is lowShallow AC, IOP is very lowBreakPresentAbsentConfigurationGreyish white, corrugated, retinal fold, mostly mobileConvex, dome shaped brownish, smooth and not mobileExtentFrom disc to oraMostly anterior to equator, it usually extends beyond oraTreatmentSurgicalMostly there is spontaneous resolutionRETINAL DETACHMENT TREATMENTPRINCIPLES OF SURGERYEmergency. Localization of break(s). Creation of C-R adhestion around the break(s). Closure of break(s). Relief of V-R traction. Dr. D'Amico's49Creation of C-R adhesion It can be achieved by CryotherapyDiathermyPhotocoagulation1. CRYOTHERAPYAdvantagesDisadvatagesFull thickness buckle can be applied to full thickness sclera, which is not damaged1. Difficult to see reaction in deep SRF2. No thermal damage to vitreous or sclera easy reoperations2. Excessive cryo release of RPE cells into the vitreous cavity. This has been linked to PVR. 3. Can be applied transconjunctivally or directly to sclera

Thus direct freezing over the breaks has been discouraged recently4. No damage to large vessels, vortex veins or ciliary vessels lesser risk of ant. Seg ischaemia5. Can be safely over staphylomatous areas taking care to allow complete thawing before removing the probe6. By forcing fluid during indentation, it may allow for buckcle placement without drainage7. Applicable to wet sclera as may occur following premature release of SRF8. Lower incidence of macular puckerPrefered over diathermyLeads to destruction of choriocapillaries, RPE and outer retinal layers with the formation of a chorioretinal scar.

512. DIATHERMY

Causes focal coagulation of sclera, choroid and RPE causing chorioretinal scar. Applied over dry area . Scleral applications are done 1.5 2 mm apart and for 3-4 seconds.523. PhotocoagulationLaser delivery systems coupled with indirect ophthalmoscopeGreat precision in intensity and locationCauses less breakdown of blood ocular barrier.The thermal effect is confined to retina and RPE sparing choroid and scleraInduces adhesive reaction within 24 hoursHowever an attached retina is prerequisite and hence SRF needs to be drained before laser retinopexy.Select a spot size of 200 m and set the duration to 0.1 or 0.2 secondsSurround the lesion with two rows of confluent burns of moderate intensity

RD TREATMENT CONTD/Scleral buckle. Orbital balloon. Pneumatic retinopexy. Primary vitrectomy + GFX, Long-term tamponade. LA/GA Surgical techniques:-

By Earnst custodis1. ENCIRCLAGE BUCKLES360 deg buckling effect that relieves the vitreoretinal tracitonSupport the suspected but non visualized pathology b/w the ora and equatorAchieve buckling effect with band onlyOccupy volume replacing the drained fluidSupport a contracted retina in early PVRFALSE ORA created prevents further hole formation and detachment; this in practice needs for deep indent and is not recommendedUndetected holes are sealed when no breaks were found

2. RADIAL BUCKLESUsed in Wide horse shoe tears b/c they cause lesser fish mouthing of the posterior edgeVery posterior breaks easier to place sutures as well as reach posteriorly

3. CIRCUMFERENTIAL BUCKLESUsed inDialysisMultiple tearsUncertain about breaks SRF not located, failed RD, aphakiaGRTThin scleraStatis vitreoretinal traction

Factors promoting attachmentPhysiologic adhesion of retina and RPEThermal chorioretinal adhesionsScleral buckling promotes retinochoroidal approximationTraction on retinal surface reduced/eliminatedBuckles may favourably influence fluid flux

Factors favouring detachmentVitreous tractionFluid movements and retinal breaksEpiretinal membranes

Promoting attachment of retina to the eyewallSRF drainageIntravitreal bubble of gas or airReducing vitreretinal traction

By Hilton and GrizzardBuoyancy and surface tension.A 0.3ml bubble can cover 90 degrees of arc of retinal surface. A final bubble size of 1-1.5ml is prefered.The injection is done 4mm posterior to the limbus in a phakic patient69Gases PurityExpansionLongetivityNon expansile conc.Air - 05- 7 days0%SF699.92x10- 14 days18%C3F899.74x30-35 days14%Xe99.99501 -Physical characteristics of gases

Contraindications to pneumatic retinopexya. Breaks larger than one clock hour or multiple breaks over more than one clock hourb. Breaks in inferior four clock hoursc. Proliferative vitreoretinopathy grade C or Dd. Physical disability or mental incompetence preventing maintainance of head positioning4. Severe uncontroled glaucoma/recent Catract surgery5. Cloudy media preventing adequate assessment of the retinaComplications of pneumatic retinopexyIntraoperative complicationsPostoperative complicationsElevated iopNew retinal breaksVitreous haemorrhageInfective endophthalmitisVitreous incarcerationCataractSubconjunctival gasIntravitreal proliferationExtension of detachmentLow anatomic success rateMultiple gas bubblesSubretinal gasEnlargement of tears

By Robert Machemer

OTHER MODALITIESLincoff balloon (Orbital/Episcleral)Absorbable scleral buckles fascia lata or GelatinSuprachoroidal hyaluronic acidSubretinal fluid drainage and intraocular gas injectionPrimary vitrectomy without bucklingNd:Yag laser vitreolysisCombination of techniques1. LINCOFF BALLOON (orbital /episcleral)Used to create a temporary scleral bucklingA deflated balloon with catheter is inserted into the tenon space via a conjunctival incision, which is then inflated by fluid to cause scleral indentationCryotherapy before or photocoagulation after insertion to create C-R adhesionMonitor IOP and CRA perfusionComplication Shift in positionSuccess rate 64 96%

2. Absorbable scleral bucklesFascia lata - it has excellent strength and mild elasticity with easy manipulation and no immunogenic reactivityIt eventually gets bonded to the episcleraIt has low rate of extrusion and reinforces thin scleraIt can also be layered or coiled to achieve great thickness and widthOther materials used preserved sclera, plantaris tendon, Achilles tendon, Cartilage, tarsus, perichondrial tissue, dura matter, embryonic bone and human skin

2. Absorbable scleral buckles cont/Gelatin : available as thin dehydrated sheets, which are then hydrated and cut to required sizesMay produce severe allergic reactionsUsually used with scleral dissection and embedded in the scleral bedCan be used in non drainage surgery since its buckle height increases on absorbing fluidSlowly absorbed in 2-24 months and then its effect disappearsCan be used beneath the silicone buckle Other absorbable materials : collagen, catgut and fibrin (not commercially available)

3. Suprachoroidal hyaluronic acidBy injecting materials like hyaluronic acid into the suprachoroidal space, the choroid and the RPE are pushed against the retina and apposed.4. SRF drainage and intraocular gas injectionScleral buckling is not doneDrainage is f/b subsequent intraocular gas injectionCombines the advantages of pneumatic retinopexy with that of conventional RD surgeryCANDIDATE small or medium sized breaks in the superior quadrants without significant vitreoretinal traction

5. Primary vitrectomy without bucklingUsually reserved for complicated detachments wherein it decreases the risk and difficulties associated with scleral bucklingHelps to relieve the traction and assists in introducing a sizeable amount of intravitreal gas

6. Nd: Yag laser vitreolysisNd:Yag is used to cut the flap of hourshoe shaped retinal tearsTraction is understood to be relieved when the flap becomes a free operculum and is pulled centrally into the vitreous

7. Combination of techniquesThe most commonly used methods are scleral buckling and intraocular gas tamponadeOther alternatives : combining pneumatic retinopexy with orbital balloon or aspiration of liquid vitreous or absorble scleral buckling materialsPROPHYLAXIS OF RDCANDIDATES

Symptomatic holes2. Aphakic holes3. Fellow eye with detachment and breaks4. Asymptomatic holes in dialysis, GRT5. Snail tract degeneration with holes6. Lattice degeneration in fellow eyes, aphakia and myopiaFellow eye of atraumatic GRT

Complication of RD surgery

Complication of RD surgery contd/

Adie syndrome, sometimes known asHolmesAdie syndromeorAdie's tonic pupil, is aneurological disordercharacterized by atonicallydilatedpupil that reacts slowly to light but shows a more definite response to accommodation (i.e., light-near dissociation). It is caused by damage to thepostganglionic fibersof theparasympathetic innervationof the eye, usually by aviralorbacterialinfection which causesinflammation, and affects thepupilof the eye and theautonomic nervous system.89COMPLICATIONS OF RD SX contd/

Pupillary block glaucoma late glaucoma cataract in an eye with (inverted pseudo-hypopyonband keratopathy

Pupillary block glaucoma caused by oil in the anterior chamber; (B) late glaucoma due to trabecular blockage by emulsified oil; (C) cataract in an eye with emulsified oil (inverted pseudo-hypopyon); (D) band keratopathy

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LATE REDETACHMENT

9490-95% - Approx. success. Overall 40-50% 20/50 or > 25% 20/60 20/100 25% 20/200 or .If macula off 1-8 wk 50% 20/70 pr >. If macula on 90% Preop. VA pucker, CME, recurrent RD. RD prognosis & VA: cont.Excellent prognosis (nearly 100%):Detachments due to dialysis or to small or round holes. Detachments with demarcation lines. Detachments with minimal subretinal fluid. RD Prognosis: Slightly poorer prognosis (95%):Aphakic detachments. Total detachments. Detachments with associated de-tachment of the nonpigmented epithelium of the pars plana. Detachments caused by flap tears. RD Prognosis: cont.RD Prognosis: cont.Poor prognosis (50 to 70%):Detachments with associated choroidal detachment Detachments with breaks larger than 180. Detachments with PVR. Detachments in patients with sticklers syndrome. Detachments caused by acute retinal necrosis. Clinical TrialsClinical TrialsGas Injection: PR

Tornambe published experiences in 302 eyes, in which he found a single injection attachment rate of 68% and a final attachment rate after reoperations of 95%, with a minimum follow-up of 6 months.He found that the extent of retinal detachment, the number of breaks and the lens status affects the rate of attachment.In a subgroup where less than 25% of the retina is detached with a single small hole and clear media and no PVR, the reattachment rate was 98% when he used 360 retinopexySR 81 88 % ( described by)Custodis in germany, Lincoff et all and Schepens et al in USA); PPV alone many case series (64 100%)101Gas Injection: PR contd/

Recently, Ellakwa evaluated long-term data after PR in a prospective interventional case series of 40 patients and found a stable reattachment of the retina in 60% after a single injectionThe final anatomical success rate after additional procedures was reported as 96.1%, additional breaks were found in 11.7% and PVR occurred in 5.2% according to a review by Chanet al.

Gas Injection: PR contd/

In a recently published retrospective chart analysis of 213 patients receiving PR, Daviset al. found a single injection success rate of 64% with a follow-up of at least 6 months. TThey found that vitreous hemorrhage and large detachments (>4.5 clock hours) are indicators for a high risk of failure.[Single injection success rates are different between phakic and nonphakic eyes. In phakic eyes, success rates are reported to be between 71 and 84% and in nonphakic eyes the success rates are between 41 and 67%. Complications of PR were new retinal breaks (733%), cystoid macular edema (08%), subretinal gas (04%), PVR (313%), cataract formation (120%) and epiretinal membranes (211%)Primary Pars Plana Vitrectomy

In a retrospective comparative case series Kinoriet al. found a reattachment rate of 81.3% in patients treated with vitrectomy alone, whereas the reattachment rate after one surgery was 87.1% in patients where vitrectomy was combined with an encircling band. The difference was not statistically significant. There was also no difference in final visual acuity between the two groups.In that study all patients were included if they had either ppV or ppV and SB. Patients after trauma, with PVR C or worse, giant retinal tears, children under 16 years, patients with previous vitreoretinal procedures and patients with proliferative retinal diseases were excludedPrimary Pars Plana Vitrectomy contd/

In another retrospective study by Mehta and coworkers, a significant difference in reattachment rates occurred in phakic patients; 83% in the vitrectomy alone group versus 97% in the vitrectomy and encircling band group. In pseudophakic patients no difference was foundIn another study by Weichelet al., reattachment rates in pseudophakic retinal detachments were 92.6% in the vitrectomy alone group and 94% in the ppV and SB group, which was not significant. Also, the rate of complications was statistically not different in both groups in this retrospective comparative study.Primary Pars Plana Vitrectomy contd/Wickhamet al.found no difference in the reattachment rates between vitrectomy with or without a buckle in detachments caused by inferior breaks.[Primary Pars Plana Vitrectomy contd/

Another debate is the use of transconjunctival techniques using 23, 25 or even 27 gauge instruments for vitrectomy.In a retrospective chart review, Muraet al.found a single success rate of 92.4% after 25-gauge vitrectomyThese very good data were confirmed by Bourlaet al. with single surgery success rates of 97.4% in a retrospective case series with a follow-up of 3 months.Similar data were reported by Milleret al. (92.9%)and Mendrinoset al. (92%).However, only 74% were reported by Lai and coworkers.[For 23 gauge vitrectomy, good single surgery success rates were also reported. In Tsanget al.'s prospective case series, this rate was 91.7%Primary Pars Plana Vitrectomy contd/

In a retrospective comparison between 25- and 20-gauge vitrectomy, von Frickenet al.reported single surgery success rates of 90.6% for 25-gauge vitrectomy and 91.8% for the 20-gauge group.Colyer and coworkers compared success rates of transconjunctival 25-gauge vitrectomy with the standard 20-gauge approach. They found a single operation success rate after 25-gauge transconjunctival vitrectomy in 83.3% and in 89.6% after 20-gauge vitrectomy in pseudophakic eyes with inferior breaks, indicating no differenceSB versus Primary Vitrectomy

Schaalet al. noted reattachment rates of 86% for SB, 90% for ppV alone, 94% for the combination of SB and ppV and 63% for PR after 1 year.For pseudophakic retinal detachments Le Rouicet al. found similar reattachment rates for SB as well as for ppV (84% SB vs 82.5% ppV)confirmed by Mikiet al. who found reattachment rates of 92% in both groups

(Top) Illumination pipe; (bottom) cutter

110SB versus Primary Vitrectomy contd/In SPR TRIAL,In phakic eyes, primary reattachment was achieved in 63.6% with SB and in 63.8 % with vitrectomy. Final anatomical success was also the same. However, final visual acuity was worse in the vitrectomy group because of cataract progression. In pseudophakic eyes, primary reattachment was achieved in 53.4% of eyes after SB but in 72.0% of eyes after vitrectomy. This difference was statistically significant.The final anatomic success again was the same; however, in the SB group more patients needed further intervention

Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment (SPR Study): viewing system for PPV (PICTURE)111SB versus Primary Vitrectomy contd/Azadet al. did not find a statistically significant difference between SB and ppV with respect to retinal reattachment rates (80.6% for SB vs 80% for vitrectomy). Cataract progression in the vitrectomy group was the major risk factor for worse visual outcome, confirming the SPR findings

INFUSION CANNULA, LIGHT PIPE AND CUTTER112PR versus SB

The Retinal Detachment Study was a prospective clinical trial where SB was compared with PR in a multicenter setting. A total of 198 patients were followed over 6 months. Patients were recruited with retinal breaks not greater than 1 o'clock diameter and located in the superior two-third of the fundus. Significant PVR was excluded. The single operation reattachment rate was 82% for SB and 74% for PR. Final success rates were 98 and 99%, respectively. The occurrence of PVR was not significantly different between the groups but the morbidity was less in the PR group and the visual acuity was better in the PR group. Therefore, PR was recommended for those types of retinal detachments meeting the admission criteriaPR versus SB contd/

Mulvihillet al. conducted a small prospective clinical trial comparing ten patients with PR and ten patients with SB. They reported a final success rate of 90% in the PR group and 100% in the SB group after one or more proceduresPR versus SB contd/

In the comparative case series of Hanet al., single procedure success rates were reported for PR as 62% and for SB as 84%. In this series, 50 eyes in each group were followed for a minimum postoperative period of 6 months.However, the final reattachment rate was 98% in both groups. For phakic eyes the visual outcome was comparable in both groups115

RECOMMENDATIONS FOR VR SXSimple detachment (phakic eye, one break less than 1 o'clock size, shallow detachment, no PVR, no visible traction, and good visibility): SB or PR (if the resources for SB are not given);Complex detachment (pseudophakic eye or bad visibility, PVR, large breaks, multiple breaks, irregular breaks, central breaks or other complicating factors): primary vitrectomy or primary vitrectomy plus SB

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