54.3 Treatment Principles |
461 |
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Q&A
Q What if the patient with an RD arrives Friday afternoon?
AWith rare exceptions (see below), surgery can safely be postponed until Monday morning, when all is available to give it the best chance of success. The patient has to understand the risks if he is unwilling to remain in bed until the operation (counseling, see Chap. 5).
¥Patching both eyes is highly inconvenient for the patient, but it eliminates eye/ head movement and thus greatly reduces the height of the detachment Ð less crucial if PPV is performed, but very helpful in bullous RDs if the surgeon plans to do SB.
¥If the macula is on, the patient should be positioned so that the ßuid does not get in the macula.
¥The rods recover rather well,27 even if the RD is long standing.
¥The cones do not recover that well, but even if the macula is off for a few days, the chance of recovering reading vision is still 70%.
¥The most urgent situation is an RD that is just about to reach into the fovea.
54.3.2 The Goals of Surgery
The surgeonÕs goals with surgery, irrespective of its type, are the following:
¥Address the traction.28
¥Bring the neuroretina in apposition with the RPE.
¥Prevent ßuid re-entry into the subretinal space through the break.29
The surgeon can choose between 3 different treatment options.30 Of these SB and pneumatic retinopexy are mostly exterior31 procedures; PPV is solely internal. Table 54.5 presents a comparison between SB and PPV, which are occasionally used in combination.
27That is, the visual Þeld.
28As mentioned above, it is extremely rare for VR traction not to be the underlying cause of the RD. Consequently, this must be the primary target of the surgery (whichever of the 3 options is chosen), with the break being a close second.
29Akin to closing and locking the door and thus preventing access to a room.
30There is a fourth option, a temporary buckle (balloon), but it is out of favor today.
31Except that a gas tamponade is always used in pneumatic retinopexy and often in SB. In the latter, drainage also makes it an intraocular procedure.
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54 Retinal Detachment |
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Table 54.5 Comparison of SB versus PPV for RD* |
|
|
Variable |
SB |
PPV |
Surgery rational? |
No: an internal problem is |
Yes: an internal problem is |
|
addressed by an external |
addressed by an internal |
|
procedure. The eyewall is |
procedure. The detached |
|
pushed toward the |
retina is pushed toward its |
|
detached retina, causing a |
normal resting place, |
|
permanent deformation in |
maintaining the original |
|
the contour of the eyewall |
contour of the eyewall |
Main purpose of surgery |
Weakening of the traction |
Elimination of the traction force |
|
force to the point that the |
|
|
traction becomes |
|
|
ineffective |
|
Able to address |
No, or with signiÞcant |
Yes |
nonrhegmatogenous RD? |
morbidity (posterior break |
|
|
or staphyloma-spanning |
|
|
RD in high myopes) |
|
Can be employed if severe |
No |
Yes |
PVR or subretinal |
|
|
component is present? |
|
|
What if the sclera is thin? |
Thin sclera must not be |
The thin area should not be |
|
sutured; if the ectatic sclera |
selected as a sclerotomy site |
|
cannot be avoided, SB is |
|
|
either contraindicated or a |
|
|
scleral patch needs to be |
|
|
placed Þrst |
|
Need for detailed |
Yes |
No |
preoperative examination |
|
|
(to identify the VR |
|
|
traction and the location of |
|
|
the retinal break/s) |
|
|
Surgery doable if signiÞcant |
No |
Yes |
VH present? |
|
|
DifÞculty of intraoperatively |
Somewhat to very difÞcult |
Easy |
identifying VR traction |
|
|
Multiple breaks in multiple |
Causes decision-dilemma and |
Does not change the surgical |
quadrants |
technical difÞculties |
planning or the essence of |
|
|
surgery |
DifÞculty of intraoperatively |
May be impossible in |
Virtually always possible |
identifying retinal break |
pseudophakic eyes with |
|
|
capsular opacity, especially |
|
|
if the break is small |
|
Separation of hyaloid from |
Not needed |
A major goal of surgery but |
the retina |
|
impossible in some cases |
Draining of subretinal ßuid |
External Ð if performed at all |
Internal Ð almost always |
|
|
through the original break |
|
|
(continued) |
54.3 Treatment Principles |
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463 |
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Table 54.5 (continued) |
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Variable |
SB |
PPV |
Complete draining of |
May be difÞcult or impossible |
Almost always possible (see the |
subretinal ßuid |
to do and risks subretinal |
text for technical details) |
|
bleeding |
|
Possibility of treating |
No |
Yes |
concurrent problems such |
|
|
as macular hole, EMP |
|
|
Cryopexy |
Even though a risk factor for |
No (laser instead; see the text |
|
PVR development, it may |
for more details) |
|
be necessary if the drainage |
|
|
was incomplete or indirect |
|
|
ophthalmoscopic laser is |
|
|
unavailable (see Chap. 29) |
|
Intravitreal gas (air) |
Risks causing secondary |
Straightforward |
tamponade |
retinal break/s |
|
Leftover ßuid under fovea |
Rather common |
No |
PVR risk |
Low (if cryopexy is not |
Low, but may be higher than |
|
applied or is done |
with SB |
|
properly) |
|
PVR prophylaxis |
Not possible |
Silicone oil use, |
|
|
chorioretinectomy, and the |
|
|
avoidance of cryopexy may |
|
|
help |
Possibility of preventing |
No |
Yes (see below) |
future EMP formation |
|
|
Side effect |
Permanent deformation of the |
Cataract in phakic eyes (will |
|
eyewall (myopia, |
eventually occur even if the |
|
astigmatism) |
patient is young) |
Intraoperative complications |
Long list (see textbooks for |
Long list (see textbooks for |
|
details) |
details) |
Postoperative complicationsa |
Long list (see textbooks for |
Long list (see textbooks for |
|
details) |
details) |
DifÞculty to do optimal |
High (ÒitÕs an artÓ) |
High (it is just as much an art as |
surgery |
|
SB is, not a Òblue-collar |
|
|
jobÓ) |
PatientsÕ preference |
No |
Yes (eye more ÒcomfortableÓ |
|
|
both during surgery and |
|
|
postoperatively) |
*Although this has been a strong trend in recent years, I have no intention here to suggest that surgeons should abandon SB and switch to PPV. Every surgeon must make his own decision based on his own preferences, rationale, and comfort zone, as well as the speciÞcs of the case. This table is provided to help with the decision-making process, not as an argument in favor of one option over another. aEMP, as one example, can occur in up to half of eyes undergoing SB and in up to a third of eyes undergoing PPV. The latter offers prevention of this complication if the ILM is removed during the original RD surgery (see Sect. 50.2.3).
