Ординатура / Офтальмология / Учебные материалы / Primary Retinal Detachment Options for Repair Kreissig Springer

earlier animal experiments on the strength of the cryosurgical adhesion and the time it takes to develop a sufficiently strong adhesion. Thus, 10 years after the experimental data on the strength of the cryosurgical retinal adhesion were obtained, it was confirmed by the temporary balloon buckle,placed under the break surrounded by cryosurgical lesions and removed after a week. The balloon operation is performed under topical or subconjunctival anesthesia.

No sutures have to be placed to fixate the balloon buckle, and the small conjunctival wound of 1–2 mm needed to insert the balloon catheter will close by itself after withdrawal of the balloon. After that, sustained attachment will depend exclusively on the strength of the retinal adhesion,induced by transconjunctival cryopexy prior to insertion of the balloon, or by laser, applied postoperatively, after attachment of the break on the balloon buckle.

The balloon operation represents the ultimate refinement of closing a leaking break ab externo and without leaving a buckle at the wall of the eye. The break is sealed off by surrounding retinal adhesions. It represents a procedure with a minimum of surgical trauma. The balloon operation follows the postulate of Gonin – to find the break and to limit the treatment to the area of the leaking break – and the principle of Custodis – not to drain subretinal fluid. With the balloon, the last complications of segmental buckling, infection or extrusion, and diplopia are eliminated.

Some detachments, which were treated with the temporary balloon buckle, will be depicted:

1.A detachment with a break under a rectus muscle is an optimal indication (Fig. 6.10), since after withdrawal of the balloon, diplopia disappears.

2.A total pseudophakic detachment with an apparent circular anterior traction line (which is, in fact, the vitreous base), capsular remnants,and no certain break (Fig. 6.11). The treatment consists here as well of a temporary balloon buckle in the suspected area to test for the presence of a break; after attachment, the so-called traction line tends to disappear.

a

Fig. 6.10. Detachment with break under rectus muscle. a Top: The detachment has a break at 9:00 in the area of the rectus muscle. Bottom: With the parabulbar balloon placed in the area of the rectus muscle to tamponade

the horseshoe tear at 9:00, the ocular rotations are limited

b

Fig. 6.10. b Top: After 1 week the balloon was withdrawn; after that only pigmented cryopexy lesions surrounding the horseshoe tear at 9:00 were visible. Bottom: Within hours after withdrawal of

the balloon, the diplopia had disappeared, because the eye muscles function normally again

c

Fig. 6.11c

Fig. 6.11. A total pseudophakic detachment with capsular remnants. a In the detachment in the anterior so-called traction line at 11:30 a little tit was discovered. To find this area of suspicion at the operating table, in the radian of the tit a laser mark was placed in the pars plana prior to surgery. b After balloon operation (1 day): The balloon was inserted beneath the tit at 11:30. The localizing cryopexy lesion is visible on the balloon buckle. The retina is attached. Since a break was not found for certain, it has,however,to be located in the area of the balloon buckle. Therefore,the entire buckle had to be secured with interrupted laser lesions. The lattice degeneration with a pseudohole was not treated, not even at a later time. c After balloon operation at day 9: The balloon was withdrawn, and the entire area of suspicion, formerly placed on the buckle, is covered with pigmented thermal lesions. The retina remained attached during the entire follow-up of 7 years

1186 Minimal Segmental Buckling With Sponges and Balloons

3.An old detachment with a pigment demarcation line and an intraretinal cyst (Fig. 6.12); here too, a balloon buckle sufficed.

4.The balloon can also be used as a diagnostic tool to test for presence of only one break in two separate detachments (Fig. 6.13).

5.Or, the balloon can be used even in a detachment up for reoperation with PVR stage C2 (Fig. 6.14).

Why Is the Balloon Operation so Difficult to Accept?

The premises for success are: (1) a maximum of preoperative diagnostics, so as not to overlook a break; (2) a precise localization of the break at the table without prior drainage; (3) marking the detached break on mobile conjunctiva (in contrast to the segmental sponge operation, in which the break can be marked precisely on the sclera); and (4) localization of a highly elevated break on a yet slightly indenting parabulbar balloon in presence of a bullous detachment with a pronounced and misleading parallax.

Advantages of the Balloon Operation

Advantages of the balloon operation are as follows:

1.The surgery is short, ranging between 10 min and 20 min

2.The anesthesia is topical or subconjunctival

3.The recovery of vision is fast and optimal

4.The last complications of segmental buckling are eliminated, i.e., there is no buckle infection, because the balloon is removed, and no diplopia. Diplopia, if present, disappears after the balloon is withdrawn.

a

b

Fig. 6.12. Old inferior detachment. a The detachment has several pigment demarcation lines, an intraretinal cyst, and a round hole at 5:30. b After balloon operation at day 9: After balloon insertion (1 day) the retina had attached. After pigmentation of the cryopexy lesions around the break, the balloon was withdrawn after a week. There are still visible the pigment demarcation lines and the intraretinal cyst

Fig. 6.13. Two separate detachments with only one questionable break. a There is a superior detachment with two lattice degenerations and “erosions”. A most likely break is located at 11:00 with obvious vitreous traction at the lateral edge of lattice degeneration. The convex pigment demarcation line beneath the superior detachment posterior to the lattice degeneration indicates that a full thickness break might be present at 11:00. In the inferior detachment, there is a questionable tear at 8:00 at the lateral edge of lattice degeneration. When lying the patient flat, no communication between the two separate detachments was detected. b After insertion of a diagnostic balloon (1 day) beneath the suspected break at 11:00: The break and the entire lattice is surrounded with cryopexy lesions. The superior retina had attached and the inferior detachment diminished in size, indicating that its fluid is originating from the superior break now being tamponaded. c After balloon operation (10 days): The balloon was withdrawn after 8 days when the cryopexy lesions were pigmented. The lattice degeneration at 12:00 was surrounded with laser lesions. There is still residual fluid around the inferior lattice degenerations. d After balloon operation (4 weeks): The residual fluid had disappeared. No further treatment was added