algorithm, and it provides only rough guidelines. Again, the concepts presented in this book must be thoroughly understood in order to make an appropriate selection of a surgical procedure. This algorithm reflects only the opinion of the authors and does not establish the standard of care for a given case.

Some limited detachments may need only delimiting laser or cryopexy treatment. This is usually done with a laser indirect ophthalmoscope, but cryopexy can be used as well. There is no consensus regarding which small detachments only need delimiting treatment rather than surgery for the detachment to resolve. Generally, new retinal tears are delimited even if a small area of subretinal fluid surrounds them. Also, a shallow, asymptomatic, or chronic retinal detachment that doesn’t extend posterior to the equator and has a limited circumferential extent would be demarcated rather than repaired. Sometimes such detachments prove to be not progressive.

Assuming that definitive repair is required, the algorithm then goes through a list of contraindications to PR. Typically, if there are no contraindications to PR, this may be the procedure of choice since it is the least morbid procedure and may yield the best visual outcome. However, the surgeon or the patient may choose another approach.

If PR is contraindicated or is not selected, the algorithm goes through findings that may suggest vitrectomy as the procedure of choice. Lacking those, scleral buckling is often the selection. However, preferences vary greatly, and the choice depends on the surgeon and the patient.

CONCLUSION

The fundamental goal of all forms of surgery for retinal detachment is the identification and closure of all responsible retinal breaks; if this can be accomplished without complications, the development of new retinal breaks, and/or the development of PVR, the procedure will be successful. Currently, reattachment surgery is performed using one of the three techniques, or combinations thereof, described in this chapter.

There is relative agreement among surgeons in regard to the use of vitrectomy with or without scleral buckling for complicated retinal detachments. Vitrectomy is also increasing in popularity for noncomplicated pseudophakic retinal detachments, particularly using microincisional techniques. PR may have advantages in the relatively simple cases for which it is an option, although there is wide variation in how broadly that category is defined. Scleral buckling can be useful in a wide spectrum of cases, but the degree to which it is used depends very much on the surgeon’s preference.

There are many factors discussed in this book that may influence the selection of one procedure over another, but we still differ widely in our preferences. Hopefully these issues will be clarified by the development of more meaningful evidence bases in the future.

248 II: Practice

SELECTED REFERENCES

Aylward GW: Optimal procedures for retinal detachments. In: Ryan, SJ, Wilkinson CP, eds: Retina (Volume 3, 4th Edition). Philadelphia: Elsevier Mosby; 2006:2094–2105.

Barrie T, Kreissig I, Holz ER, Mieler WF: Debate: Repair of a primary rhegmatogenous retinal detachment. Br J Ophthalmol 2003;78:782–790.

Heimann H, Ulrich Bartz-Scmidt K, Bornfeld N et al.: Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment. A prospective randomized multicenter clinical study. Ophthalmology 2007;114:2142–2154.

McLeod D: Is it time to call time on the scleral buckle? Br J Ophthalmol 2004;88:1357–59.

Schepens CL, Hartnett ME, Hirose T: Schepens’ Retinal Detachment and Allied Diseases. 2nd Edition. Boston: Butterworth-Heinemann, 2000. pp. 347–353.

Sharma S: Meta-analysis of clinical trials comparing scleral buckling surgery to pneumatic retinopexy. Evidence-Based Eye Care 2002;3:125–128.

Wilkinson CP, Rice TA: Michels Retinal Detachment. St Louis: CV Mosby Co; 1997; pp. 595–640.