Retinal Detachment |
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10.1Detachment Surgery
A rhegmatogenous retinal detachment (RRD) with multiple breaks is a surgery for experienced surgeons, as there is a significant complication profile. The beginner should start with a localized detachment (one to two quadrant detachment and a single break), as this is usually easier to manage.
Pits & Pearls
Lincoff rules: The key for the understanding of a rhegmatogenous detachment are the four Lincoff rules. They indicate where the primary break is located with a very high probability (Kreissig 2000).
DVD
Video 14 Retinal detachment
How do you deal with what type of detachment?
The general recommendations are that in phakic patients, one should perform a buckling surgery if possible. In pseudophakic patients, a PPV is recommended (Heimann et al. 2007). In pseudophakia with multiple breaks, we always perform a PPV; this is often named ‘primary vitrectomy for retinal detachment’.
There is a tendency towards combining all PPV for RRD in all phakic patients of 50 years or above with phako & IOL. This greatly facilitates the trimming of the vitreous base that is necessary in primary vitrectomy. The three major steps of RRD surgery are:
1.Removal of the lens
2.The use of a chandelier light
3.Shaving of the vitreous base under PFCL
U. Spandau, H. Heimann, Practical Handbook for Small-Gauge Vitrectomy, |
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DOI 10.1007/ 978-3-642-23294-7_10, © Springer-Verlag Berlin Heidelberg 2012 |
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10 Retinal Detachment |
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Diagram 10.1 Flow chart |
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Retinal detachment |
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for retinal detachment |
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Phakic |
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Pseudophakic |
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>50 yrs |
<50yrs |
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Phaco |
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No phaco |
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ppV |
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Injection of PFCL and laser |
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PFCL / silicone oil |
PFCL / air exchange |
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exchange |
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Injection of gas or silicone oil
Remove trocars
Instruments
1.4-port trocar
2.120D lens
3.Endodiathermy
4.Endolaser
5.Fluid needle
6.Scleral depressor
Dye
Triamcinolone to stain the vitreous
Tamponade
Intraoperative: PFCL
Postoperative: 20% SF6, 15% C2F6, 14% C3F6, 1000 or 5000 cSt silicone oil
Individual steps
1.4-port system (see also Diagram 10.1)
2.Phacoemulsification with/without IOL
10.1 Detachment Surgery |
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3.Core vitrectomy and posterior vitreous detachment
4.Marking of breaks with endodiathermy
5.Injection of PFCL up to the posterior edge of the break and drainage of subretinal fluid
6.Vitrectomy of the break flap and the peripheral vitreous
7.PFCL injection up to ora serrata or drainage of anterior subretinal fluid
8.Laser photocoagulation around breaks
9.Trimming of the vitreous base (shaving)
10.Implantation of the IOL
For the beginner (or if necessary), we recommend as next step:
Silicone oil tamponade with PFCL/silicone oil exchange: Continue at 11.
For the advanced surgeon, we recommend as next step: Gas tamponade with PFCL/air exchange: Continue at 12.
11.PFCL/silicone oil exchange Continue at 14.
12. PFCL/air exchange and drainage of anterior subretinal fluid
13.Gas tamponade
14.Removal of trocars
1. 4-port system
The position of the trocars does not need to be changed according to the location of the detachment.
Visualize the location of the infusion cannula in order to avoid a choroidal detachment.
2. Phacoemulsification
The IOL can be implanted in this step or later when all the breaks are treated (step 10). The advantage of early IOL implantation is that one works with a stable anterior segment, and the IOL implantation is usually easier at this stage compared to the end of the surgery. The disadvantage is that the edge of the IOL may interfere with the view of the retinal periphery and the vitreous base.
Pits & Pearls
Corneal suture: In case of an unstable anterior chamber, place a single 10-0 nylon suture at the end of the phaco & IOL. This avoids accidental opening of the corneal wound during indentation, which may lead to flattening of the anterior chamber and even dislocation of the IOL. The suture can be removed once the vitrectomy has been completed.
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10 Retinal Detachment |
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Pits & Pearls No. 49
Capsular tension ring: A good idea is the insertion of a capsular tension ring after aspiration of the cortex. The capsular tension ring stretches the capsular bag so that the posterior capsule does not sag or dip. This reduces the risk of injury to the lens capsule during vitrectomy. If you are using a capsular tension ring, make sure that it is in the right place, as removing a capsular tension ring from the vitreous base is not an easy task.
Pits & Pearls
Corneal lubrication: A major problem during vitrectomy, especially in combined surgeries with duration of over 1 h, is corneal epithelial oedema. With generous application of methylcellulose (Celoftal, Alcon), the cornea remains clear for many hours.
3. Core vitrectomy and posterior vitreous detachment
Perform a core vitrectomy and identify the posterior vitreous face to verify that a PVD is present. If the vitreous is still attached, perform induction of a PVD. Then continue with vitrectomy, and search for retinal breaks. Carefully remove the vitreous close to the retina in the area of detached, fluttering retina (Fig. 10.1).
Fig. 10.1 A highly bullous superior detachment. First a phacoemulsification was performed, and no IOL implanted. A chandelier light illuminates this eye. Now a vitrectomy is being performed