Cryopexy

The Steamroller

Technique

The "steamroller"

technique

can

be used

to

force

subretirial

fluid

back

into

the

vitreous

cavity. The

maneuver

is recommended

when

the

gas bubble

might displace

spbretinal

fluid

beneath

an attached

macula or

an attached

inferior

retinal break (Figure

5-4)lor to

prevent

a

macular

fold (with

a superior

detachment

and a large

bubble).

It can also

be per-

formed

to

"debulk"

the overall

size of

the retinal

detachment

resulting

in more

rapid reattachment.

The patient, in a sitting

position,

leans forward

face

down (Figure 5-5A).

Over a lO-minute

period, the

patient's

position

is slowly

changed

from face

down

to a head

position

in

which

the

retinal

break is

uppermost

(Figure 5-58).

If this

maneuver

is antic-

ipated,

cryopexy

should

not be applied

prior

to gas

injection

to

minimize

the chances

of displac

ing

viable RPE cells into the

vitreous

cavity. Although

there may be

a potential

for displacing

viable

RPE

cells

into

the vitreous

cavity,

the Pneumatic

Retinopexy

Clinical

Trial

did not show

an

increased

incidence of

macular

pucker

or

PYR in eyes that

had the steamroller

maneuver performed.

A subconjunctival

antibiotic

may be adminis-

tered near the injection

site, The

eye

is patched

and

an arrow drawn on

the

patch

to indicate

the

correct

postoperative

head

position (i.e.,

the

arrow

should

be aimed

toward

the ceiling).

Alternatively

the

Escalon

Pneuma

Level

can

be

used. This

is an

inexpensive

(about

$5) i-inch,

fluid-filled plastic

disc containing

a

small

air

bubble

with

12 clock

hours printed

on its face

(Figure 5-6),

It is affixed to

the

eye

patch

and

the head positioned

so the

bubble

Figure

5-3. A, Cryopcxy

is applied

to the retinal break.

H, The

needle

is perpendicular to the floor

so that the bubble

forms

around

the needle

tip avoiding

"fish

eggs."

lies over the

desired clock

hour. It greatly

improves

patient compliance

and is particularly

useful

to

aid

positioni ng

for breaks

in

the

difficult

4 and

8

0' clock meridians.

The

patient

and

family

are

shown with

a mirror

the

correct head

posture

to be

maintained

as

long

as possible

for the

first 24-hour

period.

A postoperative

instruction

sheet

is

given

restating

the

procedure,

medication,

instructions,

restrictions,

and

date for

return visit.

The. patient

is

. to use topical

antibiotics

four times daily, and

pred-

nisolone acetate

drops four

times

daily

for 10 days.

For patients

with

glaucoma

or those

who

will

travel

immediately

by

car

to higher

altitudes

(no greater

It has

been recommended

that

the

patient

be posi-

tioned

so

that the bubble

is apposed

to the

retinal

break

for

16 hours

a day

for 3-5 days.

Positioning

duration

depends

upon

the extent

of vitreoretinal

traction.

For example,

a retinal

detachment

sec-

ondary

to a small,

round

break

may

be

treated with

bubble

positioning

until the

break

is flat. If there are

no vitreoretinal

traction

forces,

the

RPE pump will

hold the break apposed

to the RPE

while

the chorio-

retinal

adhesion forms.

However,

in

cases

with

extensive

vitreoretinal traction,

bubble apposition

may be necessary

for longer

periods

of time.

It is not necessary

for

the bubble

to be in contact

with all breaks

simultaneously.

If

multiple breaks

.exist,

the

patient

is positioned

so-that

the bubble

closes

the most

superior breaks

for the first few days.

Then

the

patient

is repositioned

to close

the remain-

ing breaks. The patient can

also be

positioned alter-

nately

during the day so that

all breaks are

in contact

with the bubble

for a few

hours

each

day.

Patients are

examined

on postoperative

day l. If

the retina

is flat,

the patient

returns

in

I week.

If there

Figure 5·5.

Steamroller

maneuver.

The patient

is positioned face down (A), then slowly

rotated

the surface

of the retina

toward the

retinal break

(B), displacing subretinal fluid into the

vitreous

Figure

5-6. The Pneumo Level

adheres

to the eye

patch

and

the

patient

is told

to position

his

or her head

so

that

the

bubble

is placed at a specific

clock hour,

in this

case

2 o'clock.

has been little resorption

of subretina!

fluid

after

24

hours,

either

an open

or

new

break exists

or

the

patient

has not been positioned

properly. A total bul-

lous retinal detachment

usually

flattens completely

within

a few days. Sometimes

thick,

turbid

subretinal

fluid persists inferiorly

and may take several

weeks

to resorb. As long as the macula

is attached,

these

are

managed

conservatively.

In some

cases,

isolated

pockets

of subretinal

fluid

in the

midperiphery

linger

for weeks

or months.

These

eyes

should also

be man-

aged conservatively;

the

fluid

eventually

resorbs.

If the retina

flattens within

a

few days,

the

patient

is rechecked

in 7-14 days.

Use

of

topical

antibiotics and

steroid drops

is maintained

for

1~2

weeks. The patient

is then

seen

on

postoperative

days 30, 60,

120, and

180. The patient

is warned of

the possibility

of developing

a new

retinal break

and told to

notify

the surgeon

immediately

if new

flashes, floaters,

or a curtain

develop.

Patients are

also

instructed to

contact

the

sur-

geon immediately

if pain

or

loss

of

vision occurs,

particularly

within

24-72 hours

after

the intraoc-

ular injection,

since

this may represent

the onset

of endophthalmitis,

which

requires

immediate

treatment.

If the retina

redetaches

while

gas

is still

in

the

eye secondary

to a new

break

in

the

upper

two-

thirds

of the

fundus,

the patient

is repositioned

to

close

the new

break.

If the bubble

has

absorbed

or

is not

large

enough,

pneumatic

retinopexy

is

repeated. If

the

break occurs

inferiorly,

a

scleral

buckling procedure

is performed.

The patient

may

resume

full

activity

2-4 weeks

after

successful

reattachment

but

is

instructed

not

to fly or ascend

to altitudes

greater

than

4,000

feet

until the bubble

completely

resorbs.

If the patient

must undergo

general

anesthesia,

the

anesthesiolo-

gist should

be

warned of

bubble

expansion

and

induce

the anesthesia

appropriately

(no

nitrous

A Different

Philosophy

The most

important parameter

to judge

an ophthal-

.mological

procedure

is vision.

Visual

acuity

describes

how one perceives

the

cye

chart. vision

describes

how one perceives

the environment.

A

20/20 single

operation

surgical

result

might

not

be