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10 Retinal Detachment |
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Pits & Pearls No. 56
Slippage
1. In cases of giant tears, the retina in the area of the break may slip/glide postoperatively towards the posterior pole (slippage). This is associated with the risk of developing retinal folds postoperatively which, in the worst of cases, may involve the macula. This phenomenon is caused by inadequate drainage of subretinal fluid during fluid-air exchange. To avoid slippage, perform a direct fluid-silicone oil exchange.
2. In some cases, you will not succeed in removing all subretinal fluid despite several attempts. In this case, you can follow two different methods: (a) If only a small amount of subretinal fluid is present, instruct the patient and nursing staff to ensure a face down position for about 4–6 h immediately after the surgery. By this time, the subretinal fluid should be reabsorbed without causing a retinal fold. (b) If a substantial amount of subretinal fluid persists and cannot be removed, leave a puddle of preretinal fluid behind (i.e. do not complete a full fluid-air exchange, it is not necessary to tamponade all breaks) and instruct the patient to keep a supine position (flat on the back) for the first hours after the surgery.
Diagram 10.4 Tamponade and posture for retinal detachment depending on the location of the break
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Sitting up |
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SF6 |
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C2F6 |
C2F6 |
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C3F8 |
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Silicone oil |
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Left cheek to |
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Right cheek to |
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pillow |
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pillow |
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Flat on the back |
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13. Tamponade (Diagram 10.4)
Concerning the use of tamponade, there are significant differences between vitreoretinal units at national and international level. Some units use SF6 at any location of the break, some use C3F8 and others always use silicone oil.
The trend nowadays is to use SF6 in a primary detachment and longer acting gases and silicone oils for re-detachments.
10.1 Detachment Surgery |
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Fig. 10.15 Completion of laser therapy in an air-filled eye. Now the break is easy to laser because the edges are attached after a successful sandwich technique
As tamponade, we use mostly 20% SF6, because a tamponade duration of 2–4 weeks is sufficient to attach the retina. In difficult detachments (multiple breaks above and below), we recommend a longer tamponade such as 14% C2F6, 12% C3F8 or silicone oil. If multiple inferior breaks are present at 6 o’clock, we use Densiron 68® to tamponade the inferior pole or perform an episcleral buckling and inject C2F6. This is our approach, which can off course differ from other retinal units.
Gas tamponade: air to gas exchange
If necessary, complete the laser therapy in the air-filled eye now (Fig. 10.15). If the retina and the breaks are fully attached, you can flick the BIOM out and insufflate the diluted gas. The gas container is connected to the three-way tap, the scrub nurse injects the gas and the surgeon decompresses the globe with use of a fluid needle. The globe should remain normotensive.
Silicone oil tamponade: exchange of air with silicone oil
In a 4-port vitrectomy, the following method is easiest: Set an IV line onto the silicone oil-filled syringe and insert the IV line into an instrument trocar (see Fig. 4.10a, b). Reduce the air inflow to 10–20 mmHg. When the last air bubble vanishes behind the IOL, switch the air infusion off. For details see Sect. 4.2.
14. Removal of the trocar cannulas
Finally, the trocars are removed. No suture is needed if a gas tamponade is installed. If silicone oil is used, suturing is recommended.
Postoperative posture (Diagram 10.4)
For day 1, we recommend a face down posture in order to have a good tamponade of the posterior pole.