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12 Subretinal Fluid andRetinal Detachment
inferior RRD, the retinal break is located on the
side of the higher upper uid level, but if the retinal break is at 6 O’clock, the uid levels are equal
on either side.
12.5.8 Development ofProliferative
Vitreoretinopathy inRRD
The development of brous membranes on the
anterior and posterior surfaces of the detached
retina often complicates the RRDs. It is termed
proliferative vitreoretinopathy (PVR). In the
RRD, the RPE cells migrate into the vitreous cavity through the retinal tear, undergo brous metaplasia, and form layers on the anterior and
posterior retinal surfaces. The RPE cells produce
many inammatory cytokines that promote
brous proliferation. Because of the gravitation,
these broblasts most often settle on the inferior
retina and form tractional membranes in the inferior retina more than the superior retina. The retina is dragged into the contracted epicentre of the
scar tissue to create a highly characteristic
appearance of the detached retina termed ‘star
fold’. These contracting membranes are circumferentially oriented in the pre-equatorial retina
and labelled ‘anterior PVR’.
Depending upon the number of quadrants
involved and the resultant conguration of the
RRD, these changes are classied into various
grades. The signicant risk factors for the development of PVR include young age, myopia,
larger and more posterior breaks, giant retinal
tears, choroidal detachment, long duration of
RRD, hypotony, vitreous haemorrhage, inammation, failed surgery and repeated PPV, and
RRDs resulting from penetrating trauma and
retained intraocular foreign bodies [165].
12.5.9 Treatment ofRRD
Gonin laid down the principles of surgery for
RRD more than 100years ago and demonstrated
that retinal tears were primarily responsible for
RRD.Sealing of retinal breaks led to retina reattachment [166]. The primary goal of the surgery
is to locate all the retinal breaks during surgery
and seal them by retinopexy, either using cryopexy, laser photocoagulation, or even diathermy
in the past. Traction on the retinal tear is relaxed
by external support using either a local or a 360°
scleral buckle (SB). Depending upon the surgeon’s preference, external transscleral drainage
of the SRF ensures that the SB supports the retinal breaks during the surgery. Scleral buckling
procedures combined with cryopexy lead to
~90% anatomical success rates in fresh localized
RRDs, which are not complicated by PVR or the
PVR changes are limited up to two quadrants.
More extensive PVR changes, inadequately supported or missed breaks may not allow retina
reattachment. Progression of PVR following surgery may open the retinal break and lead to redetachment. More advanced stages of PVR,
including the open or closed funnel conguration
of RD, large giant tears, posterior tears, and a
macular hole or choroidal coloboma-associated
retinal detachments, require more complex surgical procedures such as PPV with or without an
SB. The principles of PPV include complete
removal of the vitreous gel, separation of the
PHM, dissection and excision of the brous
membranes from both surfaces of the retina, reattaching the retina preoperatively by doing a uid
gas exchange and using laser photocoagulation to
seal the retinal breaks. At the end of the surgery,
the air is exchanged with a mixture of nonexpansile concentrations of long-acting gas SF6
(20–30%) or C3F8 (14%) or silicone oil. With the
current techniques, including small gauge PPV
(23, 25, or 27G), wide-angle viewing systems,
disposable microinstruments, and highly controlled microuidics of the vitrectomy machines,
anatomical success can be achieved in more than
90% of eyes with a single surgery and nearly
98% with repeat surgeries [167]. A recent metaanalysis found single surgery success rates to be
higher with PPV combined with a scleral buckle
than the PPV alone. Ultimately, however, there
was no difference between the success rates or
complications [168]. Of the two techniques used
to reattach the retina, the scleral buckle alone or
PPV alone, the eyes with scleral buckles have a
better visual outcome, and both achieve ~85%
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341
reattachment rates with a single surgery
and~98% following repeat surgeries.
Complications like choroidal detachment,
subretinal haemorrhage, and persistent SRF are
more common with SB, but iatrogenic breaks are
more common with PPV [169].
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