41 principles retinal detachment surgery
TRANSCRIPT
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PRINCIPLES OF RETINALDETACHMENT SURGERY1. Scleral buckling
2. Pneumatic retinopexy
• Configuration of buckles• Preliminary steps• Localization of breaks• Cryotherapy• Insertion of local explant• Encircling procedure• Drainage of subretinal fluid• Causes of early failure
3. Vitrectomy• Giant tears• Proliferative vitreoretinopathy (PVR)• Diabetic tractional RD
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Configuration of scleral buckles
RadialSegmental circumferential
Encircling augmented by radial sponge
Encircling augmented by solid silicone tyre
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Preliminary steps
Peritomy Insertion of squint hook under rectus muscle
Insertion of bridle suture Inspection of sclera for thinning or anomalous vortex veins
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Localization of breaks
• Insert 5/0 Dacron scleral suture at site of apex of break• Grasp cut suture with curved mosquito forceps close to knot
• While viewing with indirect ophthalmoscope check position of indentation in relation to break
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While viewing with indirect ophthalmoscopeindent sclera gently with tip of cryoprobe
Freeze break until sensory retina justturns white
Cryotherapy
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Insertion of local explant
Distance separating sutures measured and marked
Ends trimmedSutures tightened over explant
Insertion of mattress-type suture
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Encircling procedure
Strap fed under four recti Ends secured with Watzke sleeve
Strap slid posteriorly and secured in each quadrant
Strap tightened to produce requiredamount of internal indentation
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Drainage of subretinal fluidIndications
Haemorrhage
• Difficulty in localizing break• Immobile retina• Longstanding RD• Inferior RD
Retinal incarceration
Complications
Technique
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Causes of early failure
May be associatedwith communicating radial retinal fold
Insert additional radial buckle
Buckle failure
‘ Fishmouthing ’ of retinal tear
Buckle inadequate size or height Buckle incorrectly
positioned
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Technique
(a) Cryotherapy
Pneumatic retinopexy
Indications
RD with superior breaks
(b) Gas injection
(c) Postoperative positioning
(d) Flat retina
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Vitrectomy for giant tears
Unrolling of flap with light pipe and probe
Completion of unrolling Injection of silicone oil or heavy liquid
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Vitrectomy for PVR
• Dissection of star folds and peeling of membranes• Injection of expanding gas or silicone oil
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Vitrectomy for diabetic tractional RD
Release of circumferential traction
Release of antero-posterior traction Endophotocoagulation