bubble by a smooth

uniform

movement,

leaving

the

tip of the needle

in the

already

partially

injected

gas

bubble to

reduce

the

likelihood

of "fish

eggs."

Depending

on the desired

longevity

of the gas bub-

ble as well

as

the

maximal

degree

of expansion,

either SF6

(two and one-half

times

expansion),

or

PFP

(four

times expansion)

may

be used. As

a gen-

eral

rule,

postoperative injection

of

air

is not

rec-

ommended

because of

the

volume

limits imposed.

Immediately

following

injection

of

gas,

the

IOP

may be elevated

in excess

of 50 mm Hg and

associ-

ated with

pulsation

(and

in

some

cases

closure)

of

the central

retinal

artery.

I generally

perform

paracenteses

immediately

following

gas injections

to normalize

the

pressure

to approximately

30 mm

Hg or less, using

full

per-

fusion

of

the optic

nerve

as

a clinical

endpoint.

Paracentesis

can be dangerous

in aphakic

and pseudo-

phakic eyes

if the posterior

capsule

is not

intact.

Following gas

injection,

the

fundus

should

be

inspected

to ascertain

that

the optic

nerve

is

well

perfused

and

that

no gas bubbles

have

migrated

into

the subrerinal

space. The

likelihood

of this compli-

cation can

be

reduced

by

avoiding

gas injection

in

eyes with

very

large open

tears, and positioning

the

head prior

to injection

in

such a way that the large

tears

are in a dependent

position

relative

to

the

site

of the gas injection.

Previous

studies

in

humans

and

experimental

animals indicate

that

the

injection

of

a

0.3-D.4 cc

volume of

expansile

intraocular

gas

is

well toler-

ated, with

normalization

of the lOP

within

40 min-

utes

after

injection

and

no

appreciable

rise during

the period

of maximal

expansion.

In patients

with

preexisting

glaucoma

or the

recent

placement

of an

encircling

buckle,

lOP

may

rise

unpredictably

and

additional

caution

is thus

warranted.

Complications

and Postoperative

Management

129

Blumenkranz

MS.

Management

of

complicated

retinal

detachment. In: Tso

M, ed. Retinal Diseases.

Philadel-

phia: JB Lippincott;

1985.

Blumenkranz

MS. Gardner

T,

Blankenship

G. Fluid gas

exchange

after vitrectorny.

I. Indications, technique and

results. Arch OphthalmoI1986;104:291.

Charles

S. Vitreous

Microsurgery.

8th Ed.

Baltimore:

Williams

& Wilkins;

1987:207-214.

Chignell

A. Retinal

Detachment

Surgery.

Ber lin/Heidel-

berg/New

York: Springer-Verlag;

1980: 139-162.

Fison PN. Chignell

AH. Diplopia

after

retinal

detachment

surgery. Br J Ophihalmo!

1987;71 (7):521-525.

Grizzard

WS. Hilton

GF. Hammer

ME. Taren

D. A multi-

variate analysis

of anatomic

success

of

retinal detach-:

rnents treated with scleral

buckling. Graefes Arch Clin

Exp Ophthalmol

1994;232( 1): 1-7.

Hay A, Flynn HW Jr.• Hoffman

JI, Rivera AH. Needle

pene-

tration of

the

globe

during

retrobulbar

and peribulbar

injections. Optuhalmotogy

1991;98(7): 1017-1024.

Kanski J. Retinal Dctachment:

A Colour Manual

of Diagno-

sis and Treatment. Oxford:

Butterworth: 1986: 129-154.

Levkovitch-Verbin

H. Treister

G. Moisse iev J. Pneumatic

retinopexy

as supplemental

therapy for

persistent

reti-

nal detachment

after scleral buckling

operation.

Acra

Ophthalmol Scand 1998:76(3):353-355.

Maeno T. Maeda N. Ikeda T. Tano Y. Tissue plasminogen

acti-

vator treatment

of postvitrectorny

pupillary

fibrin

mem-

brane. Nippon

Ganka

Gakkai

Zasshi

1991 ;95( 11):

1124-1128.

Packer

A, Maggiano

J. Aaberg

T. et

al,

Serous choroidal

detachment after

retinal

detachment

surgery. Arch

Oph-

thalmol 1983; 101: 1221.

Regillo

CD. Benson

WE. Retinal

Dctochment:

Diagnosis

and Monagement,

3rd

Ed. Philadelphia:

Lippincott-

Raven; 1998.

Schepens

C. Retinal

Detachment and

Allied

Diseases.

Vol.

I. Philadelphia:

WB Saunders;

1983: 1024-1086.

Tabandeh

H. Flaxel

C. Sullivan

PM. Leaver

PK. Flynn

HW

Jr. Schiffman

J. Scleral

rupture

during

retinal detach-

ment surgery: risk

factors.

management options.

and

outcomes. Ophrhalmology

May 2000: 107(5):848-852.

van Meurs JC, Humalda

D. Mertens

DA, Peperkamp

E. Reti-

nal folds

through

the

macula.

Doc

Ophrhalmol

199J ;78(3-4):335-340.

Wade E. Flynn

HW Jr. Olsen

KR. Blumenkranz

MS. Nichol-

son D. Subretina]

hemorrhage

management

by

pars

plana vitrectorny

and internal

drainage.

Arch

Ophtha}:

mol 1990;108:973-978.

Wilkenson

CPo Rice

TA. Michels

Retinal

Detochment

, 2nd

ed. Philadelphia:

Mosby; 1997.

Adjuvant

therapy. in macular

hole

surgery,

112-113

Anesthesia

agents. ~8-l9

anatomic considerations,

44-48

general

description

of, 43, 53-54

local anesthesia

and, 54

local

complications

of. 51,53

description

of, 43, 48

general anesthesia

and, 54

technique

for,

50-51,

52f

minimal, 5~

monitoring during.

50

needles. 49-50

patient selection

considerations,

43-44,

44t

pharmacologic

considerations,

48-49

premedication

age nts, 50

techniques

Atkinson,

43,

47-48,

48f

local, 50-51,

52f

retrobulbar

injection,

50,

52f

Annulus ofZinn,

45

Aphakia, retinal

detachment

associated with, 25

Atkinson technique,

43,

47-48,

48f

Atrophic retina,

9

Autologous serum,

113

a-wave

(ERG),

19-20

dosing

of, 49t

lidocaine and,

51 t

zor

b-wave (ERG),

19-20,

Carbonic anhydrase

inhibitors,

38

Cataracts, macular

hole surgery

as cause of, l l S

Central retinal

artery occlusion,

21

Central retinal

vein

occlusion.

21

Choriocapillaris.

1, 2f

Chorioretinal pigmentation. 7

Choroid

anatomy

of, 2f

detachment

of

echographic

imaging of.

17

hemorrhagic,

17, 18f

scleral buckling

as cause,

123-124

serous, 17

Circumferential

traction lines,

7

Complications,

of vitreoretinal

surgery

anterior segment ischemia,

l24

cataract, 124

choroidal

detachment,

123-124

classification

of,

119

description

of,

I W

exudative

retinal

detachment, 123

eyelid

swelling,

125

fibrinoid reaction,

124

globe rupture,

120

infections,

125

macular displacement

and fold, 125

muscle imbalance,

125

ocular hypertension,

121-123

postoperative

management

of

fluid-gas

exchange,

126-128

intravitreal

gas

injection,

128-129

132

MANUAL

OF RETINAL

SURGERY

Complications,

of vitreoretinal

surgery

(continued)

retinal folds, 122

retinal

incarceration

in sclerotomy

site,

102-103,120-12\

scleral suture

penetration,

119-120

subretinal hemorrhage,

121

diagnostic

and evaluative

uses

Glaucoma, 96

Hemorrhage

retinal,

9

See Subretinal

subretinal.

hemorrhage

surgical onset

of,

103

Hyaluronidase,

49

Indirect

ophthalmoscopy

fundal examination

using,

6-7

retinal breaks

detected usinz

24

subretinal

fluid drainage,

6~7

technique

for,

6

Informed

consent,

10

Infraorbital nerve,

46f-47f

Infratrochlear

nerve, 47f

Inner limiting

membrane

anatomy

of, 2f

removal during macular

hole

surgery,

110, 111f

Inner nuclear

layer. 2f

Inner plexiform

layer, 2f

Intraocular pressure,

increased

in macular

hole surgery,

114

ocular

hypertension

secondary

to, 121-122

in scleral

buckling, 56

Intraocular

tamponade

gases

description

of, 112, 114

indications, 94

ocular

hypertension

caused

by, 95

perfluoropropane, 94,

127-128

sulfur

hexafluoride,

94, 127

types of, 94

vitrectomy

use, 94-95

for

macular

hole surgery,

105,

112

for retinal

detachments,

103

for scleral

buckling, 68

silicone oil, 112

Intravitreal

gas

injection,

128-129

Lacrimal nerve,

45, 46f-47f

Laser photocoagulation

advantages

of, 28

cryopexy

VS., comparisons

between,

28-29

description

of, 28

disadvantages of,

28

for pneumatic

retinopexy,

35,

37f

posterior retinal break treated using, 90f

technique,3G-31

wavelength

setting, 28

Lattice degeneration

descri ption

of,

7

retinal

detachment

risks,

26

Index

133

Lens

subluxation

of,

6

vitrectomy-induced

damage,

103

Lensectomy, 83-85

Lidocaine

advantages

and disadvantages

of, 51 t

bupivacaine

and, 51t

complications

associated with, 53

description

of,

49t

dosing

of, 49t

Lids. See Eyelids

Local anesthesia

complications of,

51,53

description

of,

43,

48

general

anesthesia

and,

54

technique

for,

5G-51, 52f

Macula

anatomy of,

I

displacement

of,

after

scleral

buckling, 125

Macular hole

classification of,

106t

clinical

findings,

107f

differential diagnosis, 106

surgery for

case selection,

106

cataract

formation

after,

113

complications

associated

with,

114-115,

liSt

goals of,

105,

116

indications, 105-106

instrumentation,

108t

patient positioning

after,

113-114

postoperative

care, 113-114

preoperative evaluation,

106,

108

prognostic factors,

106,

106t

success rates, 107f

summary

overview

of,

115-116

technique

adjuvants, 112-113

air-fluid exchange,

111-112

epiretinal membrane removal, 110

internal

lirniting membrane

removal,

l l O,

IIIf

tamponade,

112, 114

vitrectomy,108-110

techniques

for assessing,

106, 108

traumatic, 106

Marcaine. See Bupivacaine