Postoperative Retinal Detachment Treatment & Management
- Author: Lihteh Wu, MD; Chief Editor: Hampton Roy, Sr, MD more...
No role for medical treatment exists in postoperative retinal detachment.
As with all RRDs, the goal is to identify and close all the retinal breaks. Several techniques, as they pertain to the repair of pseudophakic or aphakic RRD, are discussed below. The techniques are discussed in greater detail in Retinal Detachment, Rhegmatogenous.
Many surgeons like to use an encircling band in aphakic or pseudophakic detachments. They reason that the band can relieve vitreous traction that might lead to new break formation.
If a band is used, this should be placed at the posterior border of the vitreous base (usually 2.5-3 mm posterior to the insertion of the recti muscles). If it is placed too posterior (at the level of the equator), it will be useless, since it will not be able to relieve vitreous traction.
On the other hand, others have reported series using segmental elements with similar results.
This may be an ideal procedure for these cases. Axial opacities (eg, lenticular remnants, vitreous hemorrhage) may be removed easily. Vitreoretinal traction may be relieved in an efficient manner without regard to potential damage to the lens by scleral depression. The major complication of vitrectomy with intraocular tamponade is cataract formation, which is a nonissue in these eyes.
Fluid-air exchanges in pseudophakic eyes with an open capsule may pose a problem. Fluid condensation on the surface of the IOL may impair the visibility of the retina, making completion of the fluid-air exchange hazardous and impossible. Thus, if a pseudophakic eye has an intact capsule, do not create a posterior capsulotomy if fluid-air exchange is anticipated unless absolutely necessary. If the IOL is made of polymethyl methacrylate (PMMA) or acrylic, the posterior surface of the IOL may be wiped with a soft-tipped cannula to make the view better. In cases of a silicone IOL, coating the posterior surface with some silicone oil will make the view better.
Careful inspection and attention to detail are necessary since iatrogenic retinal breaks have been reported to occur in up to 16% of cases.
In a prospective randomized study, the single surgery anatomic success rate was found to be higher in the primary vitrectomy group (94%) compared to the primary scleral buckling group (83%). These results have been confirmed by a prospective randomized multicenter clinical trial and a meta-analysis.
Transconjunctival small-gauge vitrectomy has gained popularity in the past few years. 25-gauge transconjunctival vitrectomy was introduced in 2002. Several potential advantages over traditional 20-gauge vitrectomy have been described. These include improved patient comfort, faster wound healing, decreased inflammation, less conjunctival scarring, and a decrease in surgical time in opening and closing. In the beginning, 25-gauge vitrectomy had certain shortcomings. These included excessive flexibility of the instruments, poor illumination, decreased fluidics, and an increase in wound leakage.
The 23-gauge vitrectomy was developed in response to some of these shortcomings. In general, 23-gauge instruments exhibit more rigidity than 225-gauge instruments, which allows performing more peripheral maneuvers. Initially, both 25- and 23-gauge vitrectomy were mostly used in macular cases. However, as surgeons became more familiar and acquainted with both systems more complex cases were being operated on with transconjunctival small-gauge vitrectomy.
After a review of earlier reports, Heimann concluded that transconjunctival 25- and 23-gauge vitrectomy do not show any advantage over scleral buckling techniques in phakic eyes or 20-gauge vitrectomy in pseudophakic eyes. Furthermore, he claimed that transconjunctival 25- and 23-gauge vitrectomy worsen the outcome and increase the postoperative complication rate.
Recent series suggest otherwise. A prospective case series of 22 consecutive eyes from one institution reported that the one operation success rate with 25-gauge transconjunctival vitrectomy for pseudophakic retinal detachments was 95.45% with final reattachment in 100%. Furthermore, 86% of eyes experienced an improvement in visual acuity. Transient hypotony that resolved spontaneously was reported in 9%. Another prospective case series of 15 eyes yielded similar results.
Vitrectomy and scleral buckling
PPV, an encircling band, internal drainage, and intraocular tamponade are effective and efficient methods of repairing primary pseudophakic retinal detachments. Reported complications were minimal. Final anatomical and visual results are comparable to previous reports.[27, 28] Recent studies have shown that the visual and anatomic outcomes were very similar between primary vitrectomy and combined vitrectomy and scleral buckling calling into question the need of the encircling band.[21, 27, 28]
Some series report a lower success rate than phakic eyes. This is not surprising given the difficulty in examining the peripheral retina in these eyes. Reported single surgery anatomic success rates are in the order of 41-81% with final reattachment rates of 93-98%.
Prompt consultation with a vitreoretinal specialist is mandatory.
Depending on whether or not intraocular tamponade with a gas is used, the surgeon will instruct the patient to maintain a certain head position.
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