Q&A

Q Should PFCL be routinely used in retinal detachment surgery?

AIt is the individual surgeonÕ decision. PFCL does make maneuvers such as the draining of the subretinal ßuid easier, unless the break is very central and especially if it is still under traction (see Sect. 35.3.1.1). Conversely, PFCL is expensive, and there is a risk that it will not be fully removed. I use PFCL only as an exception, when the break is very peripheral.

¥One of the beneÞts of performing PPV for RD is that it is extremely rare71 to have subretinal ßuid persist under the fovea (see Fig. 54.11).

Fig. 54.11 Persisting subfoveal fluid after successful retinal reattachment with SB

54.5.2.4 Laser Retinopexy

Laser serves two purposes in my practice:

¥First, 2Ð3 rows of conßuent laser spots around the break to seal its edge.72

¥Second, laser cerclage (see Sect. 30.3.3) to create a barrier between the equator and the ora serrata to counter the effects of any residual/developing VR traction.

Pearl

Cryopexy is as (if not more) effective in creating a chorioretinal adhesion as laser. However, even if not overdone (and some surgeons do just that Òto achieve maximum scar strengthÓ and thus release RPE cells into the vitreous) and done correctly to surround the break without freezing the naked RPE, cryopexy causes massive inßammation. This is a known risk factor for PVR. Laser is always preferred to cryopexy (see Chap. 29 for more details).

71It is much more common with SB.

72In case a small amount of vitreous has been left behind; this may contract subsequently, lifting the retinal edge. The shearing caused by the eye/head movements can then redetach the retina.

54.5.2.5 Intraocular Tamponade

In most cases a short-term ÒtamponadeÓ (see below, Sect. 54.5.2.6) is sufÞcient: by the time the bubble allows a signiÞcant amount of ßuid to accumulate in the vitreous cavity, the lesion will have been sealed by the laser treatment. If longer-term tamponade is necessary, I prefer silicone oil to a long-acting gas such as C3F8 (see Sect. 35.4 and Table 35.1).

Q&A

Q When to use silicone oil, rather than gas tamponade, in RD surgery?

ASilicone oil requires a second operation for removal, but it offers several beneÞts. The retina is visible from day 1; the retina remains attached until the laser spots reach maximum strength; if additional laser is needed, it can be easily added at any time; if the Þll is 100%, the risk of PVR is reduced; if PVR occurs, the retina cannot rapidly collapse into a closed funnel.

The lens is likely to opacify sooner rather than later if in contact with silicone oil. To maintain retinal visualization throughout the entire period while the silicone oil is in the eye, it makes sense to remove the lens prior to oil implantation.

Q&A

Q What is the rationale to use heavy silicone oil?

ATo spare the inferior retina, by switching the location of PVR development superiorly. Unfortunately, it is much more difÞcult to operate on the superior than on the inferior retina.

The timing of silicone oil removal is more controversial. Unless some circumstance73 forces me, I do not remove the silicone oil earlier than 4 months: I have seen PVR to develop after the silicone oil was removed at 3 months. Others feel comfortable removing the oil earlier.

54.5.2.6 Postoperative Positioning

¥If the vitreous removal has truly been complete, there is no real need for positioning in a gas-Þlled eye.74 Should the surgeon, however, be less conÞdent that he left no tractional force behind, a few days of positioning may be beneÞcial.75

73High IOP due to overÞll (almost never happens), subsequent intraocular hemorrhage (very rare), early emulsiÞcation (quite common). If the emulsiÞcation occurs before the plan calls for oil removal, oil exchange is indicated.

74The goal of gas use is less for tamponading the break; rather, it occupies space in the vitreous cavity, depriving the slowly accumulating intravitreal ßuid of its ability to cause shearing on the edge of the retinal break (see Sect. 14.1).

75Just remember that positioning is very inconvenient and uncomfortable to the patient.