Retinal Detachment Surgery and Proliferative

Retinal Detachment
Surgery and Proliferative

Vitreoretinopathy
From Scleral Buckling to Small

Gauge Vitrectomy
Ulrich Spandau
Zoran Tomic
Diego Ruiz-Casas
Editors
123
Retinal Detachment Surgery
and Proliferative Vitreoretinopathy
Ulrich Spandau • Zoran Tomic
Diego Ruiz-Casas
Editors
Retinal Detachment
Surgery and Proliferative
Vitreoretinopathy
From Scleral Buckling
to Small Gauge Vitrectomy
Editors
Ulrich Spandau Zoran Tomic
Department of Ophthalmology Department of Ophthalmology
Uppsala University Hospital Uppsala University Hospital
Uppsala Uppsala
Sweden Sweden
Diego Ruiz-Casas
Retina Department
Hospital Ramón y Cajal
Madrid
Spain
ISBN 978-3-319-78445-8 ISBN 978-3-319-78446-5 (eBook)

https://doi.org/10.1007/978-3-319-78446-5
Library of Congress Control Number: 2018947569
© Springer International Publishing AG, part of Springer Nature 2018

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This book is dedicated to Dr. Živojnović. Relja Živojnović is
one of the fathers of modern vitreoretinal surgery that put
together all its puzzles: vitrectomy (invented by Robert
Machemer), membrane dissection (developed by John D. Scott)
and silicone oil injection (introduced by Paul A. Cibis).
He worked at the Eye Hospital Rotterdam and Middelheim
Hospital Antwerp.
Dr. Živojnović (Photo courtesy DORC)

Preface
The retinal detachment is the most important surgery for a vitreoretinal sur-
geon. Its broad pathological spectrum presents a never ending challenge.
Ophthalmology is a specialized handcraft. But in contrast to a handyman
we do not work with dead objects but with a living organ, which wants to be
treated like a raw egg.
The best situation for an ocular surgeon would be to operate one eye as an
exercise and the second eye for real. Especially in PVR detachment such a
situation would be a dream. The pathology is extremely difficult and we have
a broad choice of surgical options: vitrectomy, episcleral buckling, different
gases, light and heavy silicone oils.
If you want to become a good VR surgeon you need:
1. Practical knowledge of many different surgical techniques (binocular

ophthalmoscopy, scleral buckling, vitrectomy, retinectomy, phacoemulsi-
fication, secondary IOL implantation). A surgeon needs many different
weapons to succeed against retinal pathologies.
2. Experience, because experience results in correct assessment. An impor-
tant part of experience is a tight and complete follow-up of your patients
which results in a valuable feedback about your surgery.
3. Visit other vitreoretinal clinics in order to learn tips and tricks and to be
able to assess the quality of your surgery within the surgical world.
4. Modern equipment and qualified staff. A microscope with a good viewing
system is essential for successful surgery. Vitreoretinal surgery requires
well-educated staff.
5. And finally last but not least and maybe the most important point:
Motivation and passion for ophthalmology and surgery.
Retinal detachment surgery requires theoretical and practical knowledge.

Easy retinal detachments can be learned within 1 year but complicated retinal
detachments require 5 years of training. Avoid being ideological about the
best method to attach the retina. Be pragmatic. The simplest method which
reattaches the retina is the best. And the best method for one eye may not be
the best method for another eye.
What is the difference between theory and praxis? Theory means that you
know everything, but nothing works. Praxis means that everything works, but
you do not know why. So try to acquire as a vitreoretinal surgeon a good
mixture of practical and theoretical knowledge.
vii
viii Preface
In this book all surgical techniques to reattach the retina are demonstrated
in detail. The surgery is described like in a cookbook: First the instruments
and material and then the surgery step-by-step. This surgery is illustrated with
pictures, drawings and many videos.
Additional videos can be viewed on the YouTube channel of Ulrich
Spandau and of Diego Ruiz-Casas.
Uppsala, Sweden Ulrich Spandau

Madrid, Spain Diego Ruiz-Casas
Belgrade, Serbia Zoran Tomic
Acknowledgements
I want to thank my wife, Katrin, for her non-ending patience regarding

her book-writing husband and I want to thank my children, Maximilian,
Moritz and Oskar, for showing me that there is a world outside my beloved
ophthalmology.
Ulrich Spandau
I want to thank to my wife Bojana and our daughter Petra for all the love
they gave me and the inspiration to continue with my work.
Zoran Tomic
ix
Contents
Part I Proliferative Vitreoretinopathy (PVR). Introduction
1 Surgery of Vitreoretinal Disorders:

Past, Present, and Future�� 3
Relja Živojnović
2 Pathogenesis, Histopathology, and Classification �� 11
Salvador Pastor-Idoate, Salvatore Di Lauro, José Carlos
López, and José Carlos Pastor
3 Adjunctive Pharmacological Therapies in the
Management of Proliferative Vitreoretinopathy �� 25
Pasha Anvari and Khalil Ghasemi Falavarjani
4 Facts and Figures About Retinal Detachment Based
on a Retinal Detachment Register from North Sweden�� 35
Eva Olofsson
Part II Before Surgery
5 Assessment of a Retinal Detachment�� 45

Ulrich Spandau and Zoran Tomic
6 Biometry Binocular Occlusion and Anesthesia�� 63
7 Devices and Instruments �� 67
Part III Surgery
8 Surgical Techniques �� 79

9 Pneumatic Retinopexy with BIOM�� 89
10 Combined Phaco/Vitrectomy for Easy Retinal
Detachment�� 93
xi
xii Contents
11 Episcleral Buckling for Detachment Surgery

with BIOM�� 105
12 Combined Buckle/Vitrectomy�� 121
13 Vitrectomy for PVR Detachment Grade C�� 131
14 180° Retinotomy �� 147
15 Silicone Oil Removal�� 153
Part IV Special and Advanced Cases
16 Total and Chronic Retinal Detachment �� 159

17 Recurrent Retinal Detachment �� 163
18 Inferior and Inferior Recurrent Detachments�� 167
19 Anterior PVR �� 181
20 PVR Stage D �� 185
21 Traumatic Retinal Detachment in Children�� 191
22 Traumatic Retinal Detachment Secondary
to Open Globe�� 197
23 Perforations with IOFB �� 203
Part V After Surgery
24 After Surgery and Complications�� 215

25 Surgicals Pearls�� 219
Contents xiii
Part VI Proliferative Vitreoretinopathy (PVR).

An International Approach
26 Vitreoretinal Surgeons Assess Surgical Cases:

A Questionnaire�� 241
D. Ruiz-Casas, Ulrich Spandau, Felix Armadá-Maresca,
F. Cabrera Lopez, Jorge I. Calzada,
J. M. Cubero Parra, Felipe Dhawahir-Scala,
Mostafa Elgohary, F. Espejo Arjona,
F. Faus Guijarro, B. Fernandez Arevalo, G. Fernandez-Sanz,
J. R. García-Martinez, Khalil Ghasemi Falavarjani,
F. Gonzalez-Gonzalez, Victor N. Kazaykin, Philippe Koch,
Shunji Kusaka, F. J. Lara-Medina, Alejandro J. Lavaque,
Charles W. Mango, J. Marticorena Salinero,
Marco Mura, J. Nadal Reus, S. Natarajan,
J. C. Pastor Jimeno, M. I. Relimpio-Lopez, Zoran Tomic,
Marc Veckeneer, and Javier Zarranz-Ventura
27 My Approach to Retinal Detachment:
An Iranian Surgeon’s Perspective�� 257
Khalil Ghasemi Falavarjani
28 My Approach to Retinal Detachment:
A Russian Perspective�� 261
Victor Kazaykin
29 PVR Detachment: My Surgical Approach�� 269
Shunji Kusaka
30 Surgical Management of Proliferative
Vitreoretinopathy: An Indian Perspective �� 275
Sundaram Natarajan
31 My Approach to PVR Detachment:
An American Perspective�� 283
Charles W. Mango
32 Surgical Treatment of PVR Cases�� 289
Marco Mura and Antonella D’Aponte
33 Vitreous Anatomy, Anterior PVR, and Hypotony�� 297
D. Ruiz-Casas
34 Postoperative Complications After Vitreoretinal
Surgery�� 307
Zora Ignjatović
xiv Contents
Part VII Surgical Trends and Case Reports
35 PVR Detachment Questionnaire: Part 1�� 325

D. Ruiz-Casas, Felix Armadá-Maresca,
J. R. Garcia-Martinez, Khalil Ghasemi Falavarjani,
Contents xv
38 Video Cases�� 385

D. Ruiz-Casas, Ulrich Spandau, Felix Armadá-Maresca,
F. Cabrera Lopez, Jorge I. Calzada, J. M. Cubero Parra,
Mostafa Elgohary, F. Espejo Arjona, F. Faus Guijarro,
G. Fernandez-Sanz, J. R. García-Martinez,
F. Gonzalez-Gonzalez, Philippe Koch, F. J. Lara-Medina,
J. Marticorena Salinero, J. Nadal Reus, M. I. Relimpio-López,
Zoran Tomic, Marc Veckeneer, and Javier Zarranz-Ventura
Contributors and Collaborators
Contributors
Pasha Anvari Eye Department, Eye Research Center, Rassoul Akram

Hospital, Iran University of Medical Sciences, Tehran, Iran
F. Espejo Arjona Ophthalmology Department (Vitreo-Retina and Ocular
Oncology), Virgen Macarena University Hospital, Seville, Spain
Felix Armadá-Maresca Ophthalmology Department, University Hospital
La Paz, Madrid, Spain
Jorge I. Calzada Charles Retina Institute, Memphis, TN, USA
D. Ruiz-Casas Retina Department, University Hospital Ramón y Cajal,
Madrid, Spain
Antonella D’Aponte The King Khaled Eye Specialist Hospital, Riyadh,
Kingdom of Saudi Arabia
Mostafa Elgohary Kingston Hospital, Kingston upon Thames, UK
Khalil Ghasemi Falavarjani Eye Department, Iran University of Medical
Sciences, Tehran, Iran
F. Gonzalez-Gonzalez Retina Unit, Hospital Perpetuo Socorro, Complejo
Hospitalario Universitario Badajoz (CHUB), Badajoz, Spain
Ophthalmology Department, Hospital Quiron Salud CLIDEBA, Badajoz,
Spain
F. Faus Guijarro Universitary Hospital Miguel Servet, Zaragoza, Spain
Zora Ignjatović Milos Clinic Eye Hospital, Belgrade, Serbia
J.C. Pastor Jimeno Ophthalmology Department, Hospital Clinico
Universitario of Valladolid, Valladolid, Spain
Carlos III Institute of Health, Valladolid, Spain
Victor Kazaykin IRTC “Eye Microsurgery” Ekaterinburg Center,
Ekaterinburg, Russia
Philippe Koch Paris South University, Orsay, France
xvii
xviii Contributors and Collaborators
Shunji Kusaka Department of Ophthalmology, Kindai University Faculty

of Medicine, Osaka, Japan
Salvatore Di Lauro IOBA (Eye Institute) Retina Group, University
of Valladolid, Valladolid, Spain
Department of Ophthalmology, Hospital Clinico Universitario, Valladolid,
Spain
F. Cabrera Lopez Ophthalmology Department, Complejo Hospitalario
Universitario Insular, Materno-Infantil de Gran Canaria, Palmas de Gran
Canaria, Spain
Ophthalmology Department, Universidad de Las, Palmas de Gran Canaria, Spain
José Carlos López IOBA (Eye Institute) Retina Group, University
Department of Pathology, Hospital Clinico Universitario, Valladolid, Spain
M.I. Relimpio-Lopez Virgen Macarena Hospital/Santa Angela de la Cruz,
VIAMED Hospital, Seville, Spain
aMIRAS Ophthalmology Clinic, Seville, Spain
Charles W. Mango Weill Cornell Medical College, New York Presbyterian
Hospital, New York, NY, USA
Jesus Ramon Garcia Martinez Hospital La Paz Madrid, Madrid, Spain
Oftalvist Madrid, Madrid, Spain
F.J. Lara-Medina Hospital Clínico Universitario Lozano Blesa, Zaragoza,
Spain
Marco Mura The King Khaled Eye Specialist Hospital, Riyadh, Kingdom
of Saudi Arabia
Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
Sundaram Natarajan Aditya Jyot Eye Hospital, Mumbai, Maharashtra,
India
Eva Olofsson Department of Clinical Sciences, Ophthalmolgy, Umeå
University, Umeå, Sweden
J.M. Cubero Parra Vitreo-Retina Unit Hospital la Arruzafa, Córdoba,
Spain
José Carlos Pastor Hospital Clinico Universitario of Valladolid, Carlos III
Institute of Health, Valladolid, Spain
Salvador Pastor-Idoate IOBA (Eye Institute) Retina Group, University
Department of Ophthalmology, Hospital Clinico Universitario, Valladolid,
Spain
J. Nadal Reus Retina Department, Centro de Oftalmología Barraquer,
Barcelona, Spain
Contributors and Collaborators xix
J. Marticorena Salinero Department of Ophthalmology, Complejo

Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
G. Fernandez-Sanz Fundacion Jimenez Diaz University Hospital and
Ruber Juan Bravo Hospital, Madrid, Spain
Ulrich Spandau Department of Ophthalmology, Uppsala University
Hospital, Uppsala, Sweden
Zoran Tomic Department of Ophthalmology, Uppsala University Hospital,
Uppsala, Sweden
Marc Veckeneer ZNA Middelheim Hospital, Antwerp, Belgium
Relja Živojnović Stjepe Sarenca 2, Herceg Novi, Montenegro
Collaborators for Video Cases
B. Fernandez Arevalo Guadalajara Universitary Hospital, Guadalajara,

Spain
F. Espejo Arjona Ophthalmology Department (Vitreo-Retina and Ocular
Oncology), Virgen Macarena University Hospital, Seville, Spain
Felix Armadá-Maresca University Hospital La Paz, Madrid, Spain
Jorge I. Calzada Charles Retina Institute, Memphis, TN, USA
Felipe Dhawahir-Scala Central Manchester University Hospitals NHS
Foundation Trust, Manchester Royal Eye Hospital, Manchester, UK
Mostafa Elgohary Kingston Hospital, Kingston upon Thames, UK
Khalil Ghasemi Falavarjani Eye Department, Iran University of Medical
F. Gonzalez-Gonzalez Retina Unit, Hospital Perpetuo Socorro, Complejo
Hospitalario Universitario Badajoz (CHUB), Badajoz, Spain
Hospital Quiron Salud CLIDEBA, Badajoz, Spain
F. Faus Guijarro Universitary Hospital Miguel Servet, Zaragoza, Spain
Victor Kazaykin IRTC “Eye Microsurgery” Ekaterinburg Center,
Philippe Koch Orsay-Paris South University, Brussels, Belgium
Shunji Kusaka Department of Ophthalmology, Kindai University Sakai
Hospital, Osaka, Japan
Alejandro J. Lavaque Oftalmológica, San Miguel de Tucumán, Argentina
F. Cabrera Lopez Complejo Hospitalario Universitario Insular Materno-
Infantil de Gran Canaria, Canary Islands, Spain
Universidad de Las Palmas de Gran Canaria, Canary Islands, Spain
xx Contributors and Collaborators
M.I. Relimpio-Lopez Virgen Macarena Hospital/Santa Angela de la Cruz,

VIAMED Hospital, Seville, Spain
Charles W. Mango Weill Cornell Medical College, New York Presbyterian
Hospital, New York, NY, USA
J.R. García-Martinez Hospital La Paz Madrid and Oftalvist, Madrid, Spain
Carlos Mateo IMO Instituto de Microcirugía Ocular, Barcelona, Spain
F.J. Lara-Medina Hospital Clínico Universitario Lozano Blesa, Zaragoza,
Spain
Marco Mura The King Khaled Eye Specialist Hospital, Riyadh, Kingdom
of Saudi Arabia
Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
Sundaram Natarajan Aditya Jyot Eye Hospital, Mumbai, Maharashtra,
India
J.M. Cubero Parra Vitreo-Retina Unit Hospital la Arruzafa, Córdoba,
Spain
José Carlos Pastor Hospital Clinico Universitario of Valladolid, Carlos III
Institute of Health, Valladolid, Spain
J. Nadal Reus Centro de Oftalmología Barraquer, Barcelona, Spain
J. Marticorena Salinero Department of Ophthalmology, Complejo
Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
G. Fernandez-Sanz Fundacion Jimenez Diaz University Hospital and Ruber
Juan Bravo Hospital, Madrid, Spain
Ulrich Spandau Department of Ophthalmology, Uppsala University
Zoran Tomic Department of Ophthalmology, Uppsala University Hospital,
Uppsala, Sweden
Marc Veckeneer ZNA Middelheim Hospital, Antwerp, Belgium
Javier Zarranz-Ventura Institut Clínic of Ophthalmology (ICOF), Hospital
Clínic of Barcelona, Barcelona, Spain
List of Videos
Video 8.1 Left old vitreous cutter. Right novel TDC cutter with
6000 cpm and 450 mmHg
Video 8.2 Regular cutter
Video 8.3 Flow regular cutter
Video 8.4 TDC cutter
Video 8.5 Flow TDC cutter
Video 9.1 Pneumatic retinopexy with Biom
Video 10.1 27 G Retinal detachment without PFCL
Video 10.2 Retinal detachment in high myopia with PFCL
Video 10.3 27 G Retinal detachment
Video 10.4 27 G Retinal detachment for high myopia
Video 10.5 27 G Redetachment
Video 10.6 Managing dry macular folds after vitreoretinal surgery
by Dr. Mateo
Video 11.1 Episcleral buckling with BIOM 1
Video 11.2 Episcleral buckling with BIOM 2
Video 11.3 Scleral buckling for PVR C2
Video 11.4 Complication during scleral buckling
Video 12.1 Failed RD
Video 12.2 27 G ppV and segmental buckle for primary RD with
PVR at 9 o’clock
Video 12.3 PPV + buckle
Video 12.4 Too short buckle
Video 12.5 27 G vitrectomy and episcleral buckling (for primary
detachment with hole at 6 o’clock)
Video 12.6 Inferior PVR detachment part 1
Video 12.7 Inferior PVR detachment part 2
Video 13.1 PVR detachment
Video 13.2 Membrane peeling in ARN
Video 13.3 Cerclage
Video 13.4 Cerclage removal
Video 13.5 Extraction of a sponge and cerclage
Video 13.6 Phacoemulsification
Video 13.7 Iris retractors
Video 13.8 Core vitrectomy
Video 13.9 Vitreous base shaving
Video 13.10 Staining with trypan blue
xxi
xxii List of Videos
Video 13.11 PVR peeling short

Video 13.12 PVR peeling detailed
Video 13.13 Peeling techniques for PVR detachment
Video 13.14 Removal of peripheral membranes
Video 13.15 Subretinal peeling
Video 13.16 Removal of subretinal membranes
Video 13.17 PFCL
Video 13.18 Ando iridectomy
Video 13.19 Silicone oil injection
Video 14.1 Retinotomy
Video 14.2 Laser for retinotomy
Video 14.3 180° retinotomy
Video 15.1 27G silicone oil removal
Video 15.2 Densiron 68 removal with 25 G
Video 18.1 180° retinotomy
Video 18.2 Aphakia and retinal detachment
Video 18.3 Inferior PVR detachment_buckle
Video 18.4 Inferior recurrent PVR detachment
Video 18.5 Complicated retinal detachment
Video 19.1 Anterior retinal displacement
Video 19.2 Inferior retinal detachment with anterior retinal
displacement
Video 19.3 Vitrectomy for total retinal detachment secondary to
morning glory syndrome
Video 20.1 PVR stage D
Video 20.2 First surgery for PVR detachment secondary to morning
glory syndrome
Video 20.3 Second surgery for total retinal detachment for morning
glory syndrome
Video 20.4 Final surgery morning glory syndrome
Video 22.1 Surgical management of a corneal and scleral perforation
Video 22.2 Implantation of an Opthec IOL (iris-IOL prosthesis)
Video 22.3 Napkin ring
Video 22.4 Trauma with kick scooter_napkin ring
Video 22.5 Trauma with snowblower
Video 22.6 PVR detachment secondary to trauma
Video 23.1 IOFB case 1—stepwise surgery
Video 23.2 IOFB case 2
Video 23.3 IOFB case 3
Video 23.4 Total retinal detachment and IOFB
Video 23.5 PVR redetachment_IOFB
Video 23.6 IOFB_final part
Video 23.7 Total retinal detachment_short version
Video 24.1 Basal iridectomy
Video 24.2 Iris-IOL capture
Video 24.3 Complication laser necrosis
Video 27.1 Interface vitrectomy_Ghasemi
Video 28.1 Viktor Kazaikin (Russia): Pediatric PVR detachment stage D
List of Videos xxiii
Video 29.1 FEVR Kusaka (Japan)

Video 30.1 PVR1 Natarajan India
Video 30.2 PVR2 Natarajan India
Video 31.1 Combined TRD and RRD Videocourtesy John Kitchens
Retina Associates of Kentucky
Video 31.2 PVR RD (Early) Videocourtesy John Kitchens Retina
Associates of Kentucky
Video 33.1 Anterior PVR and hypotonyQ8
Video 33.2 (Anterior PVR hypotony). Anterior hyaloid detachment
Video 38.1 Armada
Video 38.2 Cabrera
Video 38.3 Calzada
Video 38.4 Cubero
Video 38.5 Elgohary
Video 38.6 Espejo
Video 38.7 Faus
Video 38.8 Fernandez-Sanz
Video 38.9 García-Martinez
Video 38.10 Gonzalez
Video 38.11 Koch1
Video 38.12 Koch2
Video 38.13 Lara
Video 38.14 Marticorena
Video 38.15 Nadal
Video 38.16 Relimpio
Video 38.17 Ruiz-Casas1
Video 38.18 Ruiz-Casas2
Video 38.19 Tomic1
Video 38.20 Tomic2
Video 38.21 Tomic3
Video 38.22 Tomic4
Video 38.23 Tomic5
Video 38.24 Tomic6
Video 38.25 Veckeneer
Video 38.26 Zarranz
Part I
Proliferative Vitreoretinopathy (PVR).
Introduction
Surgery of Vitreoretinal Disorders:
Past, Present, and Future 1
Relja Živojnović
Pre-Gonin era: Retinal detachment has always 1.1 he Beginning of Retinal

T
been a dramatic and terrifying experience for the Surgery: Jules Gonin
patient and for the surgeon a source of frustration
for a long time. Practical knowledge in the nine- In the early twentieth century, after extensive
teenth century was based on pathoanatomical studies of pathological specimens, ophthalmo-
observations, and the therapy consisted of drain- scopic observation of the dynamics of pathologi-
age and bed rest. Invention and introduction of cal process and looking for holes in the retina,
ophthalmoscopy by Helmholtz in 1851, enabling and trying all the hitherto applied surgical meth-
fundus visualization in vivo for the first time, ods in treatment of retinal detachment, Jules
marked the decisive step in understanding and Gonin, Lausanne, Switzerland, came to the
treatment of retinal detachment. Nevertheless, it epochal conclusion that a hole in the retina is the
took 70 long years to totally comprehend the cause of detachment. Using Paquelin’s thermo-
course and dynamics of the pathological process. cautery to perforate the eyeball on the spot of
The main components of this process—traction, defect and incarcerating its edges by withdrawal
fluid, current in the eye, as well as the hole in the of the needle, he achieved retinal reattachment.
retina—were observed separately but were not Using this method he successfully reattached the
causally connected. The importance of particular retina in 40–50% of cases. After long years of
components of the pathological process was disbelief and dismissal, he finally got recognition
either over- or underestimated, while the therapy for his work at the international congress in
itself relied on the surgeon’s assumptions. Cutting Amsterdam in 1929. His enthusiastic followers
of the “vitreous strands” (Deutschmann and were Arruga in Spain, Amsler in Switzerland,
Graefe); intraocular injection of various substi- and Wewe in the Netherlands. However, in spite
tutes with or without drainage of subretinal fluid; of the 40–50% success rate in the previously
extensive diathermy (Lagrange); and shortening inoperable cases, a large number of patients still
of the eyeball (Müller), combined with strict bed could not be treated successfully. The reason was
rest and positioning are some of many futile that the treatment did not comprise the other two
attempts whose rare positive results were at the components of the pathological process, vitreo-
most only temporary. retinal traction and fluid current in the eye.
Shortening of the eyeball to reduce its volume as
introduced by Lindner and later by Wewe, based
R. Živojnović on earlier attempts by Müller, resulted in certain
Stjepe Sarenca 2, Herceg Novi, Montenegro improvement.
© Springer International Publishing AG, part of Springer Nature 2018 3

U. Spandau et al. (eds.), Retinal Detachment Surgery and Proliferative Vitreoretinopathy,
https://doi.org/10.1007/978-3-319-78446-5_1
4 R. Živojnović
Ophthalmoscopy. As it was said before, in Custodis, Dusseldorf, Germany, who used a plas-
1850, Helmholtz introduced ophthalmoscopy, tic “egzoplant” sutured on the sclera. This tech-
which technically consisted of a strong source of nique was soon accepted and increased positive
light near the patient’s head and concave mirror results in surgery to 80%. However, frequent
with a hole in the middle through which the sur- complications of globe perforation due to hard-
geon—by means of reflected light via convex ness of the plastic material, combined with sur-
lens—could see the lightened fundus. In the face diathermy, inspired surgeons in many
1950s that system was developed into a sophisti- countries to look for other solutions. For detach-
cated ophthalmoscope with light and a system of ments with multiple holes in the periphery,
lenses, which was used as both direct and indirect Arruga introduced cerclage equatorial—circum-
ophthalmoscope. Development of visualization ferential buckle—by suturing a nylon thread
was of crucial importance for the development of through the sclera on the equator of the eyeball.
vitreoretinal surgery and had a curious course. In The logic and simple use of this method was
the early 1950s, Schepens, Boston, USA, and the appealing. Perhaps that is why perforation of the
Fison in London, UK, designed the binocular globe during surgery and ischemia of the anterior
indirect ophthalmoscope, which was accepted segment postoperatively were rather frequent
and used in these countries at the time. In complications. The idea itself was perfected by
Germany the Zeiss ophthalmoscope for direct Schepens, Boston, USA, who used softer mate-
and indirect ophthalmoscopy came into use very rial, i.e., silicone. An encircling band with or
early. In the 1960s, it was replaced by the bono- without a radial buckle, combined with dia-
scope, an indirect monocular ophthalmoscope thermy, replaced finally Arruga’s cerclage.
with extra strong light. In France, indirect oph- Complications with plastic material inspired
thalmoscopy was as good as unknown, and direct Pofique and Spira, Lyon, France, to use a biologi-
ophthalmoscope was used in surgery, which cul- cal material—the human sclera. Lamellar scleral
minated in the use of Goldmann’s three-mirror pocket—poche scleral—filled with pieces of the
glass under the microscope. Superiority of the human sclera or sutured upon the sclera, and
binocular indirect ophthalmoscope with the pos- poche apportee, filled with the same material,
sibility of indentation of the periphery was obvi- were frequently used in the 1960s. At the same
ous, so that in the 1980s it was eventually time Kloeti, Zurich, Switzerland, propagated the
generally accepted. For diagnostic purposes, use of fascia lata as cerclage material. Naturally,
besides the ophthalmoscope, Goldmann’s three- biological materials did not cause any complica-
mirror glass and panfundoscope for its panoramic tions, but the effect of indentation was short-lived
picture were used. In the 1990s they were all and in some cases caused redetachment. Looking
replaced by 90D lens. for new materials more or less ended, when
Lincoff, New York, USA, introduced Silastic
sponge and replaced diathermy by cryocoagula-
1.2 Scleral Indentation tion. In the early 1970s, this became the method
of choice in treatment of detachment and has
Introduction of scleral indentation was a capital been sustained as such up to the present time.
contribution in this surgery, as it simultaneously Recently hydrogel as the material for indentation
treated all three components of the pathological has not brought much change.
process: vitreoretinal traction, fluid current, and Retinopexy: The purpose of retinopexy is to
their consequence—the retinal hole. The first create a chorioretinal scar, and it has no impact
attempt at indentation—“buckle”—was reported on vitreoretinal traction. After the use of thermo-
in 1937, when Jess sutured a gauze tampon under cautery in Gonin’s time, surgery moved on to
Tenon’s capsule. Although basically logical, this non-perforative diathermy as introduced by
attempt did not find followers. The father of the Pischel. Diathermocoagulation, technically
“buckle” surgery was undoubtedly Ernst improved by Wewe, was applied for many years.
1 Surgery of Vitreoretinal Disorders: Past, Present, and Future 5
In the 1970s, Lincoff, following Bietti’s (Rome,

Italy) experience, combined the Silastic buckle
with cryocoagulation, which, properly used, did
not damage the sclera. It should be mentioned
that extensive use of diathermy and also of cryo-
coagulation may have very serious consequences
and provoke proliferative process in the eye. At
the beginning of the 1960s, Meyer-Schwickerath,
Essen, Germany, introduced xenon photocoagu-
lation opening a new chapter in retinopexy. Laser
coagulation based on the same principle and
Fig. 1.1 Cibis syringe for injection of silicone oil
introduced by Zweng and Little, USA, was tech-
nically much easier to use and replaced com-
pletely xenon photocoagulation. In this way the arate the detached retina from the changed vitre-
chapter of retinopexy has been completed. ous and fibrotic membranes. At the same time,
he tried to attach the retina by evacuating intra-
ocular fluid. With successful result, he left sili-
1.3 Intraocular Tamponade cone oil in the eye as permanent tamponade. By
this extremely difficult technique, he achieved
Owing to his attempt in 1911 to treat retinal surprisingly good results in some cases that used
detachment by means of intravitreal air injection, to be inoperable. Probably owing to its difficult
Ohm can be regarded as the forerunner of tam- application, this technique had only few follow-
ponade. With much more understanding of the ers in the USA (Okun, Watzke). In the mid-1960s,
pathological process, Rosengren, Gothenburg, attempts to establish this technique in some
Sweden, used the air for tamponade in 1938. In European countries were published—Moreau in
the early 1970s, Norton, Miami, USA, introduced France, Dufour in Switzerland, Liesenhof, Lund
SF6, and in the early 1980s, Lincoff pioneered in Germany. Cibis’ early death and legal prob-
long-lasting gases, which have the advantage of lems concerning the use of silicone oil being an
long-lasting tamponade and disadvantage of industrial product not registered by FDA resulted
expansion under low pressure. in restricted spread of this method. In Europe
Tamponade is fully effective only when com- surgeons did not use binocular ophthalmoscope
bined with indentation. Without indentation, and were not very familiar with dynamics and
propagated as fast and cheap surgery, it only has a consequences of pathological processes in the
temporary effect because of persistence of vitreo- eye, which resulted in poor outcome and discon-
retinal traction. From the early 1970s, the “buckle” tinuation of the use of silicone oil in Europe in
surgery combined with cryocoagulation, drainage the late 1960s.
if necessary, with or without tamponade has Modern times. In the early 1970s, John Scott,
become the method of choice in treatment of reti- Cambridge, UK, impressed by Cibis’ results with
nal detachment, and it is successful in 90–95% of silicone oil, attempted the treatment of complex
detachments with the mobile retina. But it failed cases in which conventional technique was unsuc-
with detachments complicated by multiple equa- cessful. Trying to separate fibrotic membranes and
torial ruptures, with giant tears, and detachments the changed vitreous body from the contracted
caused by proliferative process. retina by means of expansion of the silicone bub-
Introduction of silicone oil. In the 1970s, Paul ble, he also used intraocular instruments. He used
Cibis, Saint Louis, USA, introduced silicone oil the bent pick needle to lift membranes, the blunt
in retinal detachment surgery (Fig. 1.1). Under flute needle for fluid evacuation, and scissors. The
control of binocular ophthalmoscope in reversed surgery was performed under control of binocular
picture, using surface tension of silicone oil and ophthalmoscope in reversed picture. With positive
expansion of the silicone bubble, he tried to sep- outcome the central retina could be reattached and
6 R. Živojnović
the fibrotic tissue and membranes pushed to the implemented was detachment caused by a hole in
periphery. Silicone oil would stay as permanent the macula, which due to its location used to pres-
tamponade preventing recontraction of fibrotic tis- ent a problem. In the past, indentation techniques
sue. With his skill, insight in the course of patho- were applied with modest success, such as the sil-
logical process, as well as by his enormous ver ring of Rosengren, the silver plomb of Gloor
persistence, John Scott achieved remarkable (Zurich, Switzerland), and others. For this kind of
results. Owing to difficulty of the procedure itself detachments, pars plana vitrectomy with removal
and his good results, only a small number of sur- of epiretinal membranes, gas tamponade, and
geons could be compared to him, so that Cambridge positioning was the method of choice then and
was the place of reference for patients from all has remained so ever since. Recently, relocation
over the world. With this method John Scott made of the macula as introduced by Machemer in the
a huge step forward in the treatment of difficult 1990s is one more indication for implementation
cases, but even this method had its limitations. of vitrectomy.
Giant tears with PVR, traumatic detachments with Pars plana vitrectomy has opened new possi-
the incarcerated retina, diabetic tractional detach- bilities for research of proliferative processes
ment, and others could not be treated successfully which now can also be followed in pathological
in this way. Permanent tamponade with silicone specimens of the ocular tissue. In the late 1970s,
oil also caused complications in the long run. Machemer described proliferative process in the
At the end of the 1960s, David Kasner, Miami, eye on the basis of acquired specimens and clini-
USA, tried a new treatment of prolapse of the vit- cal experience and introduced the familiar name
reous body during cataract surgery and trauma of proliferative vitreoretinopathy (PVR), instead of
the eye and called it open sky vitrectomy. Using MVR (massive vitreous retraction).
cellulose sponges and scissors, he removed the Pars plana vitrectomy was rather hesitantly
prolapsed vitreous body. By successful surgery he accepted in Europe by way of pioneers in particu-
proved that the vitreous body was not of vital lar countries: Kloeti in Switzerland, Laqua and
importance to the eye. In 1970 the new technique Heimann in Germany, and Leaver in the UK. In
inspired Robert Machemer, Miami, USA, with the 1970s, Jean Haut, Paris, France, was the first
technical assistance of J.M. Parel, to design an to combine vitrectomy with silicone oil.
instrument which enabled entering the vitreous
space through a relatively small opening and
under the microscope to remove the blurred vitre- 1.4 The New Concept
ous body. The multifunctional instrument called
vitreous infusion suction cutter was a revolution- In the early 1970s, practicing retinal surgery in
ary step in the history of vitreoretinal surgery. Rotterdam, the Netherlands, I was dissatisfied
Short time after that, O’Malley introduced a with my results. Visiting other centers in Europe—
bimanual system with a separate source of light Zurich, Bonn, and Paris—and comparing my
and standardized system of 20-gauge instruments. work with that of the others, I did not notice major
Pars plana vitrectomy opened new possibilities in differences in results. After several visits to John
the vitreous body surgery, but it was not aimed at Scott, I was convinced that his technique and
the treatment of retinal detachment. Even more approach were absolutely superior to anything I
the fear of injuring the retina during surgery was had seen before. In the late 1980s, I implemented
great and comparable to the fear of loss of the vit- his technique in surgery of a considerable number
reous body in earlier cataract surgery. In the USA, of patients and achieved results satisfying for that
the standard procedure for the treatment of retinal time. After a year, together with Diane Mertens, I
detachment for more than 10 years was the Silastic abandoned binocular ophthalmoscopy. I switched
buckle with cryopexy and possible gas tampon- to the surgical microscope with contact lens
ade. Complex cases of detachment with prolifera- (Fig. 1.2). Now I had a free hand and a direct
tive process usually were not operated on. The image as in reality. For me the surgical micro-
only kind of detachment in which vitrectomy was scope is part of vitrectomy as surgical technique.
Fig. 1.3 Scissors and forceps
Fig. 1.2 The surgical microscope is an essential part of

vitrectomy
I also abandoned combined vitrectomy with

silicone oil, using it only as temporary tampon-
ade. As the admitted patients were increasingly
complex, it was soon obvious that this technique
also had its limitations. In complex cases, when
due to proliferative process the retina was con-
tracted, incarcerated, or shortened, removal of all
membranes and scarred tissue was not sufficient
to produce results we aspired to. The only solu-
tion for these cases appeared to be surgical inter- Fig. 1.4 Air-driven silicone oil pump
vention—retinotomy and retinectomy. Initially
only one-eyed patients in a desperate situation
were treated in this manner. Nevertheless, I very
soon managed to operate a considerable number
of the most difficult, previously inoperable cases
with favorable results.
I therefore established a new concept of treat-
Fig. 1.5 Back-flush needle with silicone tip
ment, which consisted of vitrectomy, meticulous
removal of all epi- and subretinal membranes,
retinal surgery, retinotomy, and retinectomy—if Besides numerous small instruments, we devel-
necessary, laser coagulation and temporary tam- oped together the foot-driven silicone pump
ponade with silicone oil. After the first publica- (Fig 1.4), the back-flush needle with silicone tip
tions and frequent presentations at meetings, the (Fig 1.5), 4-port system, 25-gauge vitreous cutter
introduction of retinal surgery in the arsenal of and instruments, replaced Ando’s plastic tacks with
surgical measures was soon accepted and adopted. steel ones for preoperative use, etc. Ger Vijfvinkel
At the very beginning of the development of with his inventiveness contributed considerably to
this demanding technique, I was confronted with the development of vitreoretinal surgery.
absence of adequate instruments for this new This new, more aggressive concept of vitreo-
kind of surgery. Presence of Ger Vijfvinkel, a retinal surgery was not associated with many
technician in our hospital, was crucial for the postoperative complications. After the introduc-
development of new instruments (Fig. 1.3). tion of 6 o’clock iridectomy (Ando, Japan, 1986),
His frequent presence in the operating theater the problem of pupillary block was solved. Other
and observation of surgery resulted in prompt complications could be ascribed to inadequate
design and construction of adequate instruments. surgical technique or to continuation of prolifera-
8 R. Živojnović
tive process which had required frequent reopera- sors. Still, the development of vitreoretinal sur-
tions. This proliferative process was also often gery was many times slowed down for seemingly
provoked by careless surgery. It should be men- incomprehensible reasons. For instance, it took
tioned that the pathological basis of all complex many years before absolutely superior binocular
cases was the biological process and that surgical ophthalmoscopy was generally accepted in
therapy is only adequate and indicated in absence Europe. Further, more than 10 years after the
of a better and more appropriate treatment. epochal invention of pars plana vitrectomy, the
In the last 20 years, no radical changes in complex pathology was not treated in the USA,
therapy have taken place. Introducing PFCL while at the same time, such cases were success-
(heavy liquid), Stanley Chang greatly simplified fully treated in Cambridge. How to explain it?
the surgical process. Double filling silicone with Was it complacency, vanity, conservatism, or
PFCL as used by Peperkamp, Rotterdam, the arrogance? Perhaps some of it all, but the main
Netherlands, in prevention of inferior detach- reason was poor flow of information. For a long
ment gave positive results. Improved visualiza- time retinal surgeons were perceived as curious
tion of membranes by the use of colors—trypan people, almost hobbyists, and were isolated.
blue—as well as triamcinolone acetonide for Results of both successful and unsuccessful oper-
better visualization of vitreous cortex made the ations were considered inadequate. For quite a
surgical process easier and safer. The use of while, the prestigious biannual Gonin club meet-
finer instruments, thinner vitreous cutters, as ing was almost the only place for exchange of
well as sutureless vitrectomy simplified the ideas and experiences. The presentation tech-
course of surgery. Even with all this technical nique was weak and unconvincing. Mutual visits
progress, meticulous removal of complete pro- were not frequent or common, and learning and
liferative tissue before retinal surgery and injec- transfer of knowledge were not formalized, at
tion of silicone oil remain an absolute must for least not in Europe.
success of the operation. This situation dramatically changed in the
A correctly performed “buckle” surgery with early 1980s. With introduction of new surgical
binocular ophthalmoscope and its success rate of methods, new technology, and better results,
90–95%, with the mobile retina, is practically interest in the new surgery was on the rise. At
complication-free. (Choroidal bleeding at drain- numerous meetings the new surgery was pre-
age is the complication most frequently men- sented by new visual means: film, video, and live
tioned, which we practically reduced to zero by surgery, in an attractive, instructive, and impres-
using the blunt lacrimal probe for penetration of sive way. Initially, that advancement was limited
the choroid after incision of the sclera.) This con- to the developed countries, but now it has cov-
ventional surgery is much cheaper than vitrec- ered most countries that can afford it. Vitreoretinal
tomy in terms of both personnel and instruments. surgery is not restricted to a small number of
Pars plana vitrectomy in itself is an invasive places. Instead, the number of centers as well as
method with more possible complications such the number of vitreoretinal surgeons has
as endophthalmitis, cataract, etc. However, now- multiplied.
adays, there are a few people ready to master However, this very optimistic and stimulating
indirect ophthalmoscopy, and I am afraid that in development is followed by another, much less
the future conventional surgery will lose battle positive one. For years the existing management
with 90D lens, wide-angle microscope and in healthcare service has applied the system of
vitrectomy. general cost-effectiveness and control in order to
Finally I would like to add a few comments. reduce expenses. This system, which has savings
Development of the surgery has confirmed an old of both money and time as its main aim, is
truth again: Not a single, even the most important undoubtedly useful in many aspects, but it often
step in development can exist alone but only neglects interests of the patient. In its aspiration
builds on earlier achievements of its predeces- to maximize results in the shortest possible
time—calling the operation a product and the ence building and, consequently, the quality of
patient a client—this system is focused on rou- surgical work. Under the circumstances, transfer
tine surgery. A patient with complex pathology of experience in this atypical surgery to our
demanding long operations is not a welcome younger colleagues also becomes an issue. A
guest. Working in such circumstances, pressur- solution of this unfavorable situation, which
ized by the hospital, insurance company, and a tends to worsen with time, lies in triage of diffi-
lawyer in front of the operating theater, the sur- cult, complex cases and concentration of their
geon is less and less stimulated to treat difficult treatment in corresponding centers. There, expe-
cases with uncertain outcome and prospect of rienced surgeons, working without pressure and
reoperations. Moreover, the challenge and attrac- limitations, would provide appropriate treatment
tiveness of this surgery in the pioneering time are to such patients. Young surgeons would get an
no longer present, and there is no financial incen- opportunity to acquire knowledge and experience
tive. Accordingly, negative selection of difficult in these centers.
cases becomes understandable and increasingly Institutions in charge of health expenses,
frequent. Besides the fact that not operating such which disparagingly criticize modest result of
cases is an ethical offense, it also has other far- this demanding surgery and consequently do not
reaching consequences. Frequent selection and stimulate its development, have to remember that
exclusion of these cases becomes a common an operated patient with the final visual result,
practice. The decreased number of such opera- even only light projection or hand movement,
tions, the pathology being rare anyway, and its demands much less money from the society than
distribution on a great number of centers and sur- a totally blind person.
geons question the possibility of surgical experi-
Pathogenesis, Histopathology,
and Classification 2
Salvador Pastor-Idoate, Salvatore Di Lauro,
José Carlos López, and José Carlos Pastor
2.1 PVR Anyway, initial mechanisms implicated in PVR

are similar to any retinal injury repair process [2].
2.1.1 Overview of the Disease: After separation of the neuroretina, photoreceptors
Pathogenesis started to die mainly by apoptosis (and also by
other cell death mechanisms) very early, but also
Proliferative vitreoretinopathy, or PVR, is a term outer layers of the retina became ischemic, because
adopted in 1983 for describing a complication of their separation from the choriocapillaris.
occurring after some retinal detachments (RD) Ischemia obviously produces the loss of neurons
[1]. PVR develops in 5–10% of RD, and although but also triggers several cell and molecular pro-
it can occur spontaneously, before surgery, it is cesses. This loss of neurons stimulates a reaction of
commonest after it [2]. Pathogenesis, in the origi- retinal glial cells (Müller, astrocytes, and microg-
nal description, was focused on the formation of lia) starting a new event directed to remodeling the
membranes in both surfaces of the retina, but retina and to preserve the retinal structure [4].
more recently, the existence of intraretinal Those changes lead to membrane formation, over
changes have been added as the more severe form and behind the retina, but above all, they induced
of PVR [3]. intraretinal glial changes, which shorten the retina
making it very difficult to reattach even by surgery,
unless a retinectomy was performed [3].
Not all RD develop this severe complication,
although all of them have many common facts:
separation of retina layers, ischemia, breaks
affecting the whole thickness of the retina, and a
S. Pastor-Idoate · S. Di Lauro · J. C. Pastor (*) breakdown of the blood-retinal barriers allowing
IOBA (Eye Institute) Retina Group, University of an intraocular inflammation and also facilitating
Valladolid, Valladolid, Spain
the intraocular migration of cells which release
Department of Ophthalmology, Hospital Clinico more inflammatory products into the vitreous cav-
Universitario, Valladolid, Spain
e-mail: [email protected] ity [2]. Therefore, one of the current challenges is
the appropriate identification of those patients
J. C. López
IOBA (Eye Institute) Retina Group, University of with a high risk of developing this complication.
Valladolid, Valladolid, Spain Initial approaches for detecting those patients
Department of Pathology, Hospital Clinico at high risk of developing PVR were based on the
Universitario, Valladolid, Spain identification of clinical factors [5], but since

https://doi.org/10.1007/978-3-319-78446-5_2
12 S. Pastor-Idoate et al.
2006, we have been working in elucidating the This problem has not yet been solved and
role of the genetic profile of each patient [6–8]. seems an essential point to set the appropriate
We are now convinced that genetics plays an framework for an efficient clinical research,
important role in some crucial steps of this com- since now.
plication. For instance, cytokine production, In fact, in a recent review of the literature [13],
which is a crucial element in retinal scarring, is a we found that only 74% of the revised papers
gene-regulated process [9, 10]. related to treatments, published between 2000 and
PVR still poses some challenges to the retina 2014, used a standardized classification, being in
specialist, because despite the efforts made the 56.3% of cases the updated Retina Society
over the past 40 years, we are still unable to classification of 1991 and in 33.9% the original
prevent or to treat it, and continues to be the one of 1983 [1] (Fig. 2.1). But when the updated
most frequent and severe complication after RD Retina Society classification was used, only
surgery [2, 11]. 10.4% of authors used a full C grade description
For almost two decades, researchers have (Fig. 2.2). It is clear that current classifications
been focused on several steps of the disease: cell have a very limited value in clinical practice, but
migration (giving a crucial role to RPE cells in for clinical research purposes, we are convinced
PVR pathogenesis), epi- and subretinal mem- that a new one is needed.
brane formation, and further contraction of those We have pointed out some of the critical ele-
membranes [11]. These events are essential parts ments, which in our opinion must be part of this
of PVR, but currently we know that there are new classification [2]: type of morphologic changes,
more players in this story and probably more rel- extension of changes, signs of severity and progres-
evant if our target is inhibiting this abnormal siveness, and, for sure, some still unidentified signs.
repairing process and then getting an efficient Regarding the prophylactic measures or medi-
prophylaxis. One, without any doubt, is the glial cal treatments, no one has been widely accepted
reactivity and hypertrophy which is a basic repair for clinical use [2].
element in the retina as well as in any other part PVR is a complex process involving several
of the central nervous system [12]. And there are risk factors and over the last 25 years, and besides
some others. the spectacular evolution of vitreoretinal surgery
The lack of an appropriate classification is techniques, which includes small gauge instru-
also a bottleneck which has prevented an ade- mentation, the emphasis has been placed on hav-
quate comparison of the proposed treatments ing a success in the primary surgery for RD
along decades. repair, ignoring some other important factors.
Retina Society Terminology Committee classification

Grade Clinical signs
A (minimal) Vitreous haze and pigment clumps
B (moderate) Surface retinal wrinkling, rolled edges of the retinal,

Fig. 2.1 Classification retinal stiffness and vessel tortuosity
from the Retina Society
Terminology Committee C (marked) Full thickness fixed retinal folds in:
(1983). Modified from:
C-1 One quadrant
The Retina Society
C-2 Two quadrants
Terminology
Committee, “The C-3 Three quadrants
classification of retinal
D (massive) Fixed retinal folds in four quadrants that result in:
detachment with
D-1 A wide funnel shape;
proliferative
vitreoretinopathy,” D-2 A narrow funnel shape;
Ophthalmology, vol. 90, D-3 Closed funnel without view of the optic disc
no. 2, pp. 121–125, 1983
2 Pathogenesis, Histopathology, and Classification 13
The Retina Society updated classification
Grade and type Clinical signs

A Vitreous haze, pigment clumps, pigment clusters on inferior retina
B Wrinkling of inner retinal surface, retinal stiffness, vessel tortuosity, rolled

and irregular edge of retinal break, decreased mobility of vitreous
CP (posterior) Full-thickness retinal folds or subretinal strands posterior to equator

- Type: (1–12 clock hours involvement)
I. Focal I. Starfolds posterior to vitreous base;
II. Diffuse II. Confluent starfolds posterior to vitreous base; optic disc
may not be visible;
III. Subretinal III. Proliferation under the retina; annular strand near disc
linear strands; motheaten-appearing sheets
CA (anterior) Full-thickness retinal folds or subretinal strands anterior to equator

- Type: (1–12 clock hours involvement), anterior displacement,
condensed vitreous strands
I. Circumferential I. Retina contraction inwards at the posterior edge of the
vitreous base; with central displacement of the retina;
peripheral retina stretched; posterior retina in radial folds;
II. Anterior II. Anterior contraction on the retina at the vitreous base; ciliary
body detachment and epiciliary membrane; iris retraction
Fig. 2.2 The Retina Society updated classification Michels, “An updated classification of retinal detachment
(1991). Modified from: R. Machemer, T. M. Aaberg, with proliferative vitreoretinopathy,” Am J Ophthalmol,
H. M. Freeman, A. R. Irvine, J. S. Lean, and R. M. vol. 112, no. 2, pp. 159–165, 1991
But incidence of PVR remains unchanged, rang- outcomes of vitreoretinal surgery for established
ing from 4% to 34% in prospective studies [2]. PVR. But results have failed in demonstrating
Basic and clinical research has suggested that this possible improvement [15].
adjuvant agents could reduce that incidence. To complete these examples, anti-VEGF (vas-
Pharmacological strategies have included anti- cular endothelial growth factor) has been pro-
inflammatory drugs, antiproliferative agents, anti- posed as an adjuvant to inhibit PVR. But in a very
neoplastic, antigrowth factors, and antioxidants [2]. recent meta-analysis [16], authors concluded that
Clinical strategies would probably require a based on the available evidence, intravitreal injec-
multimodal combinatorial approach, because, as tion of bevacizumab in patients with PVR-related
mentioned, PVR is a complex and multifactorial RD did not decrease retinal re-detachment rate or
disease. Surprisingly few combinations have improve visual function. Authors suggested bet-
been reported in the literature. Last reports reiter- ter-designed studies with larger simple sizes and
ate those approaches. longer follow-up periods to reach valid conclu-
Resveratrol has been widely proposed for sions. Moreover, they highlighted that evaluation
cardioprotection, neuroprotection, chemother- of anti-VEGF therapy on surgical outcomes in
apy, and antiaging therapy. And it seems to eyes with milder subtypes of PVR or no PVR, but
attenuate TGF-β2-induced wound closure and deemed at high risk of PVR, may be worthy of
cell migration in ARPE-19 cells in a scratch future consideration. This is a very interesting
wound test [14]. observation and emphasized the need of a more
Also, dexamethasone-loaded polymer consistent classification useful for compare differ-
(Ozurdex®) has been evaluated for improving the ent treatments [2, 13].
Nevertheless and besides those clear limita- but separation from the choriocapillaris does not
tions, we have currently a more accurate and lead to immediate neuron death, because intrinsic
detailed understanding of its pathogenesis, and protective mechanisms are activated, specifically,
we are more than sure that in the near future, its stress-response genes and signaling pathways
prevention could be possible, after a more exact [20]. When these mechanisms failed, neurons
identification of high-risk patients and, although died, mainly by apoptosis but also by other cell
surgery will be essential for managing it once it death forms [21].
appears, some adjuvant measures will be But ischemia is not the unique process
adopted. involved in RD and in PVR. Inflammation and
proliferation of several cell types as well as the
production of local factors are also important
2.1.2 Histopathology events. Separation of the neuroretina from the
RPE triggers the repairing response mediated by
Because it is difficult to obtain human tissue sam- glial cells orientated to remodeling the retina
ples, especially in early stages of the disease, which is losing neurons [22].
most of our current knowledge derives from Very soon after RD, RPE cells dedifferentiate
experimental models. But we are very critical into fibroblasts, or macrophage-like cells. By
with these models because in our opinion, they this process, driven by factors not fully under-
do not mimic adequately the human disease [2]. stood, contractile cellular or fibrocellular mem-
Our group has proposed the use of organotypic branes are created. These membranes are
cultures of retina as potential tools for analyzing considered a characteristic feature of PVR, but
early changes in neuroretina structure [17–19]. except for the periretinal membrane formation,
In any RD, when neuroretina separates from the glial hyperreactivity is quite similar to the
the RPE, outer layers become ischemic. one elicited by any RD not necessarily compli-
Neuroretina presents a high metabolic demand, cated with a PVR [22] (Fig. 2.3).
a b
Fig. 2.3 Retinal distribution of glial fibrillary acidic pro- chloride). At 9 days of neuroretina culture (b), GFAP was
tein (GFAP) in fresh neuroretina and 9-day culture sam- markedly upregulated at the cytoplasm of glial cells, and
ples. Freshly isolated retina explants (a) showed GFAP GFAP-positive extensions formed a layered-like structure
(red) staining at the end feet of Müller cells and in astro- outside the retinal tissue (arrows). Cell modifications were
cytes. The outer nuclear layer (ONL), inner nuclear layer also observed in the retinal structure. Scale bar, 20 μm
(INL), and ganglion cell layer (GCL) were identified with (Courtesy of Dr. Ivan Fernandez-Bueno, IOBA, University
DAPI dye (blue, 4′,6-diamino-2-phenylindole dihydro- of Valladolid, Spain)
Therefore, a yet unidentified factor must be growth factor (FGF), epidermal growth factor
necessary to direct the above mentioned events (EGF), insulin-like growth factor (IGF), vascular
toward a PVR, which is currently interpreted as endothelial growth factor (VEGF), hepatocyte
an exaggerated healing response [2]. growth factor (HGF), and transforming growth
As pointed out, many of the early changes factor β (TGF-β) [29].
have been obtained from animal models, due to But also glial cells have a crucial role in
the difficulties of getting human material. PVR. As mentioned, PVR could be considered as
Therefore, findings should be extrapolated care- an exaggerated response of the remodeling pro-
fully to the humans. cess of the retina, triggered by the retinal break
In cats, photoreceptors degenerate within 24 h [22]. Müller cells suffer changes visible 24 h
after detachment. Degeneration reaches a peak at after RD [31]. By the third day, Müller cell bod-
3 days and continues as long as the retina remains ies migrate to the outer layers (nuclear and plexi-
detached [23]. Müller cells become activated form) occupying the spaces left by dead
15 min after RD [24]. RD also induces prolifera- photoreceptors, extending their processes into
tion of nonneuronal cells, such as astrocytes, the subretinal space [30]. These cells, along with
endothelial cells, pericytes, and microglia [25]. some others such as RPE cells, microglia, and
Some of these changes are reversible with a macrophages, contributes to form the subretinal
prompt reattachment of the retina [26], but other membranes, which are relatively uncommon in
changes are more consistent affecting photore- PVR, but more often after ocular trauma.
ceptors and glial cells. In some cases, the reactivity of Müller cells
But once again, all these changes are also and microglial cells is not confined in the
present in any RD even if they do not complicate detached areas but has been also observed in
with a PVR. intact attached areas of the retina. This finding
During the 1990s, RPE and glial cells were could be important in explaining the loss of
identified in epiretinal membranes [27], and they vision detected in a significant percentage of
have been considered one of the main actors of patients with macula-on and successful RD sur-
PVR. In experimental models (cats), RPE cells gery [32].
initiate changes 24 h after RD [28]. They dedif- Macrophages are also important players in
ferentiate, lose their polarity, and migrate into the PVR development [27]. Any RD has a break-
subretinal space. But in RD blood-retinal barriers down of the blood-retinal barriers allowing the
are breakdown, allowing the passage of chemo- passage of these cells into the subretinal space
tactic and mitogenic factors into the vitreous cav- and into the vitreous cavity. The presence of a
ity. These factors stimulate the migration and high number of these cells into the vitreous
proliferation of both RPE and glial cells [28]. fluid has been considered a fact associated with
RPE cells migrate into the vitreous cavity a high risk of developing PVR after rhegmatog-
through the retinal breaks, and they participate in enous RD [33]. These cells have been also
the formation of epiretinal membranes [29]. This found inside of the retinal tissue and around
process involves an epithelial-mesenchymal tran- retinal vessels in human PVR samples [3]
sition of the RPE cells which acquire a mesen- (Figs. 2.4 and 2.5).
chymal phenotype including enhanced capacity In summary, three major cells types are impli-
of migration, invasiveness, more resistance to cated in RD and in PVR: RPE, glial cells, and
apoptosis and above all the capacity of producing macrophages, whose major role is remodeling of
extracellular matrix, became RPE cells a fibro- the retinal structure after neurons’ death caused
blast-like cells [29, 30]. by RD. And three major histological changes can
The exact mechanism of RPE proliferation is be observed in PVR-affected retinas: subretinal
not fully understood, but the presence of some membranes, which are rare; epiretinal mem-
growth factors seems necessary. Among them are branes, considered for many years the most
platelet-derived growth factor (PDGF), fibroblast specific finding of PVR; and retinal gliosis and
Fig. 2.4 Human retina

in an eye with
proliferative
vitreoretinopathy (PVR).
Sample obtained by
retinectomy due to retina
shortening.
Immunostained with
CD68 particularly useful
as a marker for the
various cells of the
macrophage lineage,
including monocytes,
histiocytes, and others.
The image shows
CD68-positive cells,
macrophages (red
stained), located around
blood vessels at the top
and bottom center of the
figure (magnification
40×)

in an eye with
proliferative
vitreoretinopathy (PVR).
Sample obtained by
retinectomy due to retina
shortening.
Immunostained with
CD68 (marker of
macrophages/
histiocytes). Two
CD68-positive
macrophages (red
stained) are identified
inside of the retina
(magnification 40×)
shortening which are now recognized as the most This loss of neurons stimulates a remodeling pro-
severe form [2] (Figs. 2.6, 2.7, and 2.8a, b). cess directed to maintain the retinal structure,
Finally, and very briefly, these are our ideas on where Müller cells, astrocytes, and microglia
the pathogenesis of PVR (Fig. 2.9). play an important role.
Initial mechanisms are not different between At the same time and due to the blood-retinal
PVR and any RD. After RD, outer retinal layers barriers’ breakdown, microglia and macro-
become ischemic and photoreceptors start to die. phages migrate into the subretinal space and the

obtained after
retinectomy in a case of
retinal shortening by
PVR after RD. Picture
shows diffuse
architectural
disorganization and loss
of neurons. (H&E)
(magnification 40×)
Fig. 2.7 Human retina sample obtained by retinectomy stained in red and therefore the reactivity of Müller cells
in a case of retinal shortening by PVR. Immunostained and astrocytes, which are replacing the neurons. This
with glial fibrillary acidic protein (GFAP) an intermediate causes a shortening of the retinal tissue preventing its reat-
filament protein that is expressed by numerous cell types tachment to the eyeball. We named this form as “intrareti-
of the central nervous system (CNS) including astrocytes. nal PVR” (magnification 40×)
The image shows widespread positivity of the retina
vitreous cavity where they release inflammatory amplify entering in the PVR process. It is possi-
products. Then, some cells, mainly RPE, enter ble that, according to the clinical experience, this
in a mesenchymal transformation, deriving into critical inflammatory level may be caused by the
fibroblast-like cells able to synthesize extracel- accumulation of clinical and surgical factors,
lular matrix and therefore producing periretinal such as extensive RD, presence of blood into the
membranes. vitreous, excessive retinopexy, and others [5].
Our hypothesis is that when inflammation But in some other cases, the genetic profile of the
reaches a certain level, the remodeling mecha- patient can be a definitive factor in PVR develop-
nisms elicited in any RD are exaggerated and ment [6–8, 34–36].
a b
Fig. 2.8 (a) Human retina in an eye with proliferative pink with H&E. Retinal tissue and neurons have been
vitreoretinopathy (PVR) in its more severe form: intrareti- replaced by fibrous tissue (arrows). Fibroblasts are also
nal PVR. Intraretinal fibrous tissue: light pink areas seen as the spindle-shaped nuclei stained in purple (H&E
(arrows). (H&E magnification 5×). (b) Detail of an area magnification 20×)
with collagen fiber deposits: collagen bundles stain light
Fig. 2.9 Pathogenesis of PVR: our conception. Adapted practical consequences. Prog Retin Eye Res. 2016
from: Pastor JC, Rojas J, Pastor-Idoate S, Di Lauro S, Mar;51:125–55. Reproduced by permission of the Editor
Gonzalez-Buendia L, Delgado-Tirado S. Proliferative vit- and Publisher
reoretinopathy: A new concept of disease pathogenesis and
2.1.3 The Problem Classification was then updated in 1991 [40]

of the Classification according to modifications proposed by the
Silicone Study Group and also by other authors
As mentioned PVR was identified as an indepen- (Fig. 2.2). But this classification appears to be
dent clinical entity in 1983 by the Retina Society difficult to use in clinical practice and may not
Terminology Committee, and a classification was offer any special advantage for decision-making
created [1]. This classification divided PVR into in relation to the treatment of the disease. Thus,
four stages, A, B, C, and D, apparently by increas- this relatively new classification has been rarely
ing its severity, from minimal to massive PVR used in clinical work.
(Fig. 2.1). As mentioned, PVR was considered As mentioned, papers dealing with PVR treat-
only a problem related to cellular proliferation, at ment evaluation published between 2000 and
that time. This classification is simple to use but 2014 were analyzed in 2016 [13]. We localized
does not provide clinically relevant information 138 publications and we found that only in 103 of
in terms of medical or surgical decisions. them, authors used standardized classifications.
Unfortunately, this classification had numerous The most used one was the updated Retina
limitations. It did not consider the location of the Society classification [40] (Fig. 2.2), followed by
vitreoretinal traction and the magnitude of the the first classification of 1983 [1] (Fig. 2.1), and
contraction. In addition, some of the stages pro- only four used the Silicone Study grading system
vide a false idea of severity; for instance, D3 [39]. In addition, four papers used “customized”
caused by a localized epiretinal membrane could classifications, and four publications showed
be more easily treated by surgery than a C1 serious mistakes in the application of the
caused by intraretinal changes. classifications.
Even more, grade A was defined as the pres- It seems clear that this lack of uniformity
ence of vitreous haze and pigment clumps, but reflects the uselessness of the existent classifica-
these findings are not specific of PVR. They are tions and made difficult the comparison between
present, for instance, in many posterior uveitis series and proposed treatments. Current classifi-
and in some long-lasting RD without any addi- cations are purely descriptive and do not provide
tional sign of PVR [37]. neither information on the pathobiology of this
A more specific sign is the presence of rolled complex disease nor information on the stage of
edges of the retinal break, with or without retinal activity of the process, which is crucial for esti-
stiffness and vessel tortuosity, which was consid- mating the risk of re-proliferation after surgery or
ered by the Retina Society as grade B. But these when surgeons decided to remove the long-last-
signs can be present in RD which do not further ing endo-tamponade. Furthermore, current clas-
develop a more extensive PVR, and some surgeons sifications do not provide any prognostic
treated them successfully with scleral techniques, information neither visual results nor anatomical
which usually failed in established PVR [38]. success, after surgery.
In 1989, the Silicone Study Group introduced Results of our review suggested that current
a new classification [39] adding new characteris- classifications have a limited value, and in fact,
tics, such as the location, anterior or posterior, many surgeons do not use any of them referring
and the type of contraction. The most important to PVR grades by generic names such as mini-
contribution of this classification was the inclu- mal, moderate, and severe [41, 42]. Even more,
sion of proliferative phenomenon in the pre- grades A and B present in each classification are
equatorial zone of the retina and vitreous base, often ignored, and most authors refer only to
which is relatively frequent after previous most advanced stages of PVR, basically grade C,
attempts to reattach the retina, named anterior which seem easy to identify from a clinical per-
PVR. Nevertheless, authors stated that they do spective [13].
not attempt to predict the PVR severity which is This lack of an appropriate classification
a crucial point from the clinical point of view. might have prevented advances in the under-
standing the pathogenesis of the disease and then brane is better than an intraretinal change [2, 3,
the search of a more adequate treatment or 11]. As explained in Sect. 2.1.1, glial cells,
prophylaxis. including Müller and astrocytes, not only
For instance, because the Retina Society become reactive but also do replicate inside of
Committee defined PVR as a “proliferative dis- the retina in PVR, and it is thought that this glio-
ease,” many treatments based on the inhibition sis, as well as the loss of neurons, contributes to
of cell proliferation were developed for more retinal shortening [3]. RPE cells are also
than 20 years, none of which appears to have involved in this process, although their numbers
produced a significant clinical advance. appear to be small compared to its relevant role
Therefore, a review of both the classification and in periretinal membranes formation. But in this
the pathogenesis of PVR appear to be appropri- form of PVR, gliosis, with or without epiretinal
ate to aid the development of new treatments [2, and/or subretinal membranes, can cause marked
43, 44]. This use of different and non-normal- retinal distortion and localized retinal thicken-
ized classifications creates severe communica- ing that can lead to the formation of a focal
tion problems between clinicians and comparison mass. However, until now, intraretinal changes
of different studies became problematic or even have been detectable only during surgery when
impossible. Thus, it is clear that over the last the surgeon could not reattach the retina to the
15 years, clinicians have progressively aban- eye wall by pushing it back by air or PFCL. Also,
doned PVR classifications [13]. little attention has been paid to the identification
Considering these facts, we believe that a new of these changes before surgery or in the postop-
classification is needed, paying attention not only erative period. Even in some recent papers,
to the type of morphologic changes and their these retinal changes have not been fully recog-
extension but also to the presence of signs of nized [37], although they are evident for any
severity and progressiveness, including the experienced surgeon, probably because they are
amount of intraocular inflammation and the pro- not easy to identify by routine clinical
inflammatory genetic profile of each patient. examination.
Nevertheless, there is hope that the use of new
imaging technologies could add relevant informa-
2.2 The Problem tion regarding the intraretinal changes [46, 47].
of the Intraretinal Changes Considering these facts, we believe that attention
should be focused on changes in the retinal tissue
One of the most important absences in any of rather than membrane extensions [2].
the existing classification is the ignorance of the
intraretinal PVR. The crucial fact is that besides
the periretinal membranes, in PVR, the neuro- 2.3 OCT Imaging
retina itself might suffer a shortening process
due to cellular changes that is relatively recent One of the crucial points in PVR management
[3] (Figs. 2.6, 2.7, and 2.8). And as mentioned, should be the clear identification of epiretinal,
intraretinal PVR should be considered the most subretinal, and, above all, intraretinal changes.
severe form in which there are major changes Recent advances in optic coherence tomography
affecting retinal architecture and leading to sig- (OCT) and the development of intraoperative
nificant dysfunction [45]. Furthermore, these OCT (iOCT) may be extremely useful in clinical
forms have a huge influence in the surgical com- practice allowing intraoperative assessment of
plexity and in the anatomical and functional retinal status. The iOCT may be useful to iden-
outcomes, especially when the posterior pole is tify intraretinal changes and/or subretinal PVR
involved. Epiretinal or subretinal membranes membranes which cannot be easily peeled as the
can be relatively easily removed by surgery, and epiretinal membranes [2] (Fig. 2.10a, b).
therefore the prognosis of an epiretinal mem- Intraretinal forms are especially difficult to iden-
Fig.2.10 (a and b) Intraoperative OCT (iOCT) applica- nal membranes and cannot be surgically removed. Thus, a
tion in PVR management. In this case with established retinectomy is mandatory to reattach the retina. Image
PVR, iOCT allows intraretinal changes’ identification obtained with the Zeiss Rescan® 700 iOCT (Carl Zeiss
(arrows). These changes are neither epiretinal nor subreti- Meditech, Oberkochen, Germany)
tify preoperatively, but their presence may be References

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Adjunctive Pharmacological
Therapies in the Management 3
of Proliferative Vitreoretinopathy
Pasha Anvari and Khalil Ghasemi Falavarjani
3.1 Introduction cellular components involved in the pathophysiol-

ogy and development of PVR has resulted in the
Proliferative vitreoretinopathy (PVR) is consid- investigation of several new pharmacologic agents
ered the major culprit of failed retinal detachment including new antineoplastic drugs and anti-VEGF
(RD) surgery, complicating 5–10% of RD repairs agents for modifying the healing process at vari-
[1, 2]. PVR is an abnormal healing response, ous stages [12–18].
analogous to exaggerated scar formation [3]. It is A variety of pharmacological agents targeting
characterized by membrane formation and con- specific stages of PVR development have been
traction on both sides of the retinal surfaces or tested to enhance the success rate for PVR treat-
within the vitreous cavity, resulting in traction ment. The emphasis of these therapeutic strate-
over the retina and recurrent RD. gies is on interrupting the inflammatory cascade,
Currently, the mainstay of the treatment of inhibiting the cellular proliferation, interfering
PVR is surgery, however, despite recent advances with growth factor, and preventing the formation
in surgical approaches, the rate of unfavorable and contraction of scars (Fig. 3.1).
outcomes including the risk of re-detachment and The aim of this chapter is to provide a compre-
unsatisfactory visual outcomes is high [4–6]. hensive summary of the experimental and clinical
Therefore, a search for novel treatment modali- findings on current and emerging pharmacological
ties is warranted. approaches in preventing or mitigating PVR.
Previous studies have suggested a possible ben-
eficial role for anti-inflammatory and antineoplas-
tic agents such as corticosteroids, 5-fluorouracil 3.2 Anti-inflammatory Agents
(5-FU), and daunorubicin; the use of these drugs
was not popularized due to the lack of efficacy in 3.2.1 Corticosteroids
larger-scale clinical trials, complications, or safety
concerns [7–11]. Continued advancement in our Corticosteroids are widely used to suppress inflam-
understanding of intricate molecular interplays matory response in various clinical situations. They
between various cytokines, growth factors, and have been administered intravitreally [19, 20], peri-
ocularly [21], or systemically [22] to suppress the
vitreoretinal scarring response. Inhibition of cell
proliferation is presumably the result of anti-
P. Anvari · K. G. Falavarjani (*) inflammatory activity and a subsequent interrup-
Eye Department, Eye Research Center, Rassoul
Akram Hospital, Iran University of Medical Sciences,
tion in the breakdown of the blood-retinal barrier.
Tehran, Iran Despite a reduced postoperative incidence rate of

https://doi.org/10.1007/978-3-319-78446-5_3
26 P. Anvari and K. G. Falavarjani
Fig. 3.1 Proposed Scar formation and

interventions in different Inflammation Proliferation
contraction
phases of wound healing.
Abbreviations: NSAID Corticosteroids Corticosteroids LMWH
nonsteroidal anti-
inflammatory agents, NSAIDS 5-FU Colchicine
5-FU 5-fluorouracil,
VEGF antivascular Daunorubicin MMP inhibitors
endothelial growth factors,
Retinoic acid
MTX methotrexate, LMWH
low-molecular-weight Anti-VEGF
heparin, MMP matrix
metalloproteinases Colchicine
MTX
PVR with corticosteroids in experimental animal reduced the development of the epiretinal mem-
models, human trials were not highly successful in branes [26].
the long term. Not only their beneficial effect is not
conclusively proven but also, intravitreal and peri- 3.2.1.3 Dexamethasone
ocular delivery of corticosteroids is likely to be Dexamethasone and heparin in the infusion
associated with adverse ocular effects including solution has been reported to reduce the prolif-
cataract, and glaucoma. eration but it has been noted that this combined
infusion increases hemorrhage rates [27].
3.2.1.1 Triamcinolone Preoperative injection of subconjunctival dexa-
Triamcinolone is a synthetic non-soluble gluco- methasone (10 mg in 0.5 ml) reduced break-
corticoid. In a randomized study in eyes with RD down of the blood- retinal barrier in scleral
and PVR grade C that underwent vitrectomy with buckle surgery [28].
silicone oil tamponade, a 4 mg intravitreal injec- Dexamethasone is more powerful than triam-
tion of triamcinolone at the final stage of surgery cinolone, but its usage is restricted because it has
was not significantly effective in lowering the a short half-life. In an animal model, while intra-
recurrence of PVR or rates of reoperation [23]. vitreal injection of Ozurdex (a slow-releasing
Another randomized study of intraoperative tri- dexamethasone intravitreal implant; Allergen
amcinolone showed no difference in the need for Inc., Irvine, CA, USA) suppressed the expres-
additional surgery at 1 year of follow-up [24]. sion of inflammatory markers, it did not decrease
the severity of PVR [29]. Meanwhile, a case
3.2.1.2 Prednisolone report described that a 0.7 mg Ozurdex implant
In a study of complications of scleral buckling shows effectiveness in prevention of PVR fol-
with postoperative oral prednisolone (1 mg/kg lowing scleral buckling surgery [30]. In a small
for 10 days), no statistically significant change retrospective study, individuals with recurrent
was found in retinal re-detachment or PVR rates RD and PVR grade C undergoing vitrectomy
[25]. However, a placebo-controlled double-blind and retinectomy with silicone oil tamponade and
randomized trial demonstrated that oral predniso- Ozurdex implantation achieved complete retinal
lone (100 mg tapered to 12.5 mg over 15 days) reattachment and increased visual acuity approx-
was beneficial in early PVR stages, where it imately 1 year later [31].
3 Adjunctive Pharmacological Therapies in the Management of Proliferative Vitreoretinopathy 27
However, a prospective, randomized con- with 5-FU [36, 37]. In rabbits, subconjunctival
trolled clinical trial of Ozurdex in eyes undergo- low-dose 5-FU injections (100 μL of a 5% or
ing vitrectomy for PVR did not find improvement 1.25% solution) showed no toxicity, but higher
in PVR recurrence and retinal reattachment dosages were accompanied by electrophysio-
rates [7, 8]. logical and histological changes [38]. In con-
trast, in rats, the epithelium of ciliary body was
affected by subconjunctival 5-FU (0.2 mL of 5,
3.2.2 Nonsteroidal Anti- 10, and 30 mg) [39].
inflammatory Agents A randomized clinical trial reported that
10 mg intravitreal 5-FU injection after vitrec-
To avoid the side effects of corticosteroids, an alter- tomy for PVR is well-tolerated with minor
native approach is employing the anti-inflammatory toxicity, but reattachment rates are not
action of nonsteroidal anti- inflammatory agents improved [40].
(NSAID).
3.3.1.1 Low-Molecular-Weight Heparin
3.2.2.1 Naproxen and 5-Fluorouracil Low-molecular-weight heparin (LMWH)
In rabbits, a combination therapy of intravitreal reduces post-vitrectomy fibrin formation [41].
naproxen and 5-fluorouracil impedes PVR pro- Fibrin is a structural protein that confers a scaf-
gression [32]. Nevertheless, no clinical study has fold for cell migration and proliferation. In addi-
evaluated or supported the efficacy of NSAIDS in tion, LMWH inhibits RPE proliferation and
PVR. binds to fibrogenic growth factors [41].
Experimental animal models show that LMWH
can reduce PVR [41]. Systemin heparin increases
3.3 Antiproliferative intraoperative bleeding but reduces post-vitrec-
and Antineoplastic Agents tomy fibrin formation [42]. Similarly, intraocu-
lar LMWH infusion inhibits formation of fibrin
3.3.1 5-Fluoropyrimidines in rabbits [43, 44]. Notably, the eye-cup electro-
retinogram does not change with LMWH perfu-
5-Fluorouracil (5-FU) is a potent, low- sion [45].
molecular- weight, water-soluble chemothera-
peutic agent that directly affects mitotic activity. 3.3.1.2 Fluorouracil and Low-
This pyrimidine analogue, irreversibly binds to Molecular-Weight Heparin
thymidylate synthase and introduces errors in Both LMWH and 5-FU attack PVR development
RNA translation that ultimately inhibit cellular but at different stages. The former works during
proliferation. It is extensively used for the treat- early phases (cell attachment and migration), and
ment of epithelial tumors. In ophthalmology, the latter acts on late phases (cell proliferation).
5-FU is often used in trabeculectomy surgery to Two studies have investigated the effect of a
modulate the wound healing response to reduce combination of LMWH (5 IU/mL) and 5-FU
postoperative scarring in blebs [33]. (200 μg/mL). One study focused on the patients
In animal models, 5-FU usage has been suc- with underlying pre-existing conditions that
cessful in lowering PVR rates [34, 35]. Retinal place them at higher risk of PVR [46]. It high-
pigment epithelium (RPE) cells and Tenon’s lighted the advantages of this treatment in these
capsule fibroblasts experience prolonged individuals where the incidence of postopera-
growth inhibition from a transient interaction tive PVR was significantly lower in the group
treated with 5-FU and LMWH (12.6%) com- A few small-scale noncontrolled studies
pared with the controls (26.4%). The other study evaluated intravitreal MTX in prevention of re-
included a broader range of patients, and this detachment in proliferative diabetic retinopathy
therapy not only did not reduce the re-detach- and retinal detachment associated with PVR
ment rate, but also, it was associated with dete- [51–53]. In a small case series, eyes at high risk
riorated visual acuity in macula-sparing RD of PVR development undergoing PPV for
individuals [9, 10]. RD repair, intravitreal MTX infusion
(40 mg/500 mL saline), lowered PVR incidence
rates [54]. Despite this encouraging finding, this
3.3.2 Daunorubicin study suffered from a small sample size, absence
of a control group, and possible biased selection
Daunorubicin is a topoisomerase, anthracycline of patients. In a comparative study, our group
antibiotic that inhibits RNA and DNA synthesis, evaluated intrasilicone injection of MTX at the
which in turn blocks cellular proliferation. end of vitrectomy for PVR and found no signifi-
Intravitreal application of liposome-encapsu- cant difference in the rate of re-detachment due
lated daunorubicin in an animal model showed to PVR between the two groups despite an
that this sustained release drug delivery system improvement in success rate in case group [55].
can prevent PVR and is less toxic than unen-
closed daunorubicin [47]. Furthermore, a small- 3.3.4 Colchicine
size clinical study suggested that intravitreal
daunorubicin infusion (1 μg/mL) is effective Colchicine depolymerizes microtubules and
against PVR after 1 year [48]. inhibits mitosis [56]. Experiments show that very
A randomized controlled trial found no signifi- low concentrations of colchicine can inhibit cel-
cant reduction in reattachment rates when dauno- lular proliferation and migration in PVR [56].
rubicin perfusion (7.5 μg/mL for 10 min) was However, no significant benefit has been observed
used during vitrectomy surgery. However, reop- with oral administration of 1.2 mg/day [57].
eration rates were significantly decreased [49]. Moreover, in eyes undergoing scleral buckling,
Another randomized study in individuals oral administration (2 mg/day for 50 days) did
with PVR grade D or worse who had intravitreal not prevent PVR-related RD [58].
daunorubicin (5 mg) injection after retinal sur-
gery showed no significant difference in attach-
ment rate at 3 months. Media/vitreous clarity 3.3.5 Retinoids
was improved in the treatment group [11].
Evidence for daunorubicin efficacy comes from Retinoids are vitamin A derivatives that interact
small and sparse clinical trials. Moreover, the use of with nuclear receptors to regulate the expression
daunorubicin alone showed incosistent results that of genes and inhibit cell proliferation. Retinoic
prevented clinical applications [50]. Therefore, this acid induces growth factor arrest of RPE cells. In
drug has not been incorporated in clinical routines. animal models, 13-cis-retinoic acid was effective
in preventing PVR [59–61].
In a retrospective study, postoperative oral
3.3.3 Methotrexate (MTX) administration of 13-cis-retinoic acid (80 mg/
day) for 4 weeks reduced PVR and improved
Methotrexate (MTX) is an antimetabolite agent the postsurgical retinal attachment rates [62]. In
derived from folic acid, and it interferes with cel- a nonblinded controlled randomized interven-
lular proliferation by inhibiting pyrimidine and tional case series, postoperative oral dosage of
purine syntheses. 20 mg/day over 8 weeks in individuals with RD
and PVR resulted in higher retinal reattachment appear to be fibroblasts are the result of transition
rates and lower macular pucker formation rates of RPE cells into mesenchymal state [74]. The
[63]. A nonrandomized study showed that drug has not been used in human studies.
isotretinoin is not effective in people with
established PVR; however, in eyes at high risk
for PVR, treatment with isotretinoin was asso- 3.4 Emerging Agents
ciated with an improved anatomic success rate
[64, 65]. 3.4.1 Matrix Metalloproteinases
Inhibitors
3.3.6 Anti-vascular Endothelial Matrix metalloproteinases (MMPs) are zinc-

Growth Factors containing enzymes involved in degrading and
remodeling of extracellular matrix proteins.
Vascular endothelial growth factor (VEGF) is Disturbed functions of MMPs and MMP inhibi-
a glycoprotein mitogen for angiogenesis that tors are implicated in PVR pathogenesis. Both
escalates vascular permeability. Higher con- MMP-9 and MMP-2 are present in PVR vitreous
centrations of VEGF are detected in subreti- samples [75]. Therefore, it would be reasonable
nal and vitreous fluids of eyes with to explore the role of MMP inhibitors.
PVR-related RD than in eyes with uncompli- Prinomastat is a lipophilic, pseudopeptide
cated RD [66–70]. hydroxamate MMP inhibitor. Intravitreal prino-
mastat injections in rabbits showed inhibitory
3.3.6.1 Bevacizumab effects that reduced incidence of PVR develop-
Bevacizumab (Avastin, Genentech, Inc., South ment [76, 77]. Nonetheless, no clinical trial was
San Francisco, CA, USA) is a monoclonal anti- designed to further investigate this effect.
body that binds to VEGF. Injection of bevaci-
zumab (1.25 mg) in individuals with PVR grade C
at the end of vitrectomy surgery did not signifi- 3.4.2 N-Acetylcysteine
cantly reduce the RD rate [71]. Similar reports did
not find a reduction in RD rates or an improvement N-acetylcysteine is an antioxidant agent that pre-
in visual outcomes for bevacizumab in PVR- vented the development of RD in an experimental
related RD surgeries [15, 16, 72]. model of PVR in rabbits by hindering the activa-
tion of a platelet-derived growth factor [78].
3.3.6.2 Ranibizumab
Ranibizumab (Lucentis, Genentech, South San
Francisco, CA, USA) is an antibody fragment 3.4.3 Epithelial-Mesenchymal
derived from bevacizumab that has higher affin- Transition Pathway
ity for VEGF-A than bevacizumab. In experi-
mental animal models and in vitro models of Formation of the fibrotic membrane in the
PVR, ranibizumab neutralizes platelet-derived detached retina is the hallmark of PVR. The
growth factors (PDGFs) and decreases vitreous fibrotic membrane is composed of RPE cells that
bioactivity [17, 18]. Therefore, it has been con- undergo a transition from epithelial to mesenchy-
cluded that ranibizumab prevents rabbits from mal phenotype and ultimately differentiate into
development of PVR. One criticism is that in myofibroblastic cells. Proliferation, migration,
these aforementioned studies PVR in rabbits was and matrix modification of these myofibroblasts
induced by conjunctival injection of fibroblasts participates a key role in the epiretinal membrane
cells [73]. However, in humans, the cells that contraction [79–83].
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Facts and Figures About Retinal
Detachment Based on a Retinal 4
Detachment Register from
North Sweden
Eva Olofsson
The city of Umeå is located in northern Sweden, • The age distribution showed a median age of
and the University Hospital of Umeå has the only 62 years, and the youngest patients were
vitreoretinal center in this part of Sweden 11 years old and the oldest 95 years of age.
(Fig. 4.1). All eye clinics in northern Sweden • The sex distribution revealed a strong prepon-
refer their primary retinal detachments and rede- derance for men (62%) compared to women
tachments to the University Hospital of Umeå, (38%).
which means that all patients with retinal diseases • Cause of retinal detachment (Fig. 4.2): In the
within this huge geographic area are operated at time period from October 2010 to 2015, the
only one place. eye clinic performed 1645 retinal detachment
The vitreoretinal center at the University surgeries. Of these 1645 surgeries, 68% were
Hospital of Umeå has a register for retinal detach- primary (fresh) detachments, 15% were
ments. All retinal detachments operated here are recurrent (failed) detachments, 7% had a sec-
entered in this register. Since this is the only vit- ond failed surgery, 5% had a detachment fol-
reoretinal center in the north of Sweden, almost lowing vitrectomy for other vitreoretinal
all patients with a recurrent retinal detachment conditions than detachment, and 5% of the
are reoperated here. There is thus only a small detachments were due to other unspecified
risk of loosing patients to other viteoretinal cen- reasons.
ters for follow-up or second surgery. This gives a • Pathology of retinal detachments (Fig. 4.3):
complete registration of our patients and a reli- Of the 1084 patients with a primary rheg-
able register. matogenous retinal detachment, 89% were
The time period from October 2010 to 2015 was easy retinal detachments, and 11% were com-
evaluated, and the following findings were made: plicated retinal detachments. In this latter
group 4% had a giant tear, 5% had a PVR
• The annual amount of primary rhegmatoge- grade C or D, and 2% had different causes.
nous retinal detachment surgeries increased • Regarding the surgical technique (Fig. 4.4), a
from 180 in 2011 to 230 surgeries in 2015. major change in surgical technique occurred
from 2011 to 2015. In 2011, 61% of surgeries
performed for primary rhegamotgenous
detachment were vitrectomies 36% episcleral
E. Olofsson
buckling and 3% were vitrectomies combined
Department of Clinical Sciences, Ophthalmolgy, with scleral buckles. In the following years,
Umeå University, Umeå, Sweden more and more vitrectomies with 25G were
e-mail: [email protected]

https://doi.org/10.1007/978-3-319-78446-5_4
36 E. Olofsson
Fig. 4.1 The marked area is Northern Sweden, and all retinal patients are referred to the University of Umeå. Northern
Sweden has 892,000 inhabitants. Photo courtesy Lantmäteriet, Sverige
5%
performed, and in 2015 90% of surgeries were
7%
vitrectomies, 9% were episcleral buckling and
1% combined vitrectomy and buckle. Looking
at the year 2015, episcleral buckling was only
performed on phakic patients, whereas vitrec-
15% tomy was performed on both phakic and pseu-
dophakic patients. The average age for
episcleral buckling was 57 years and for pseu-
5% 68% dophakic vitrectomy 63 years.
• The rate of a recurrent detachment (Fig. 4.5)
depends very much on the cause. During a
follow-up of at least 6 months, the redetach-
ment rate after surgery of primary (fresh)
Primary rhegmatogenous retinal detachment retinal detachments was 12%. The detach-
ment rate, however, is very different between
Retinal detachment following vitrectomy
easy and complicated retinal detachments.
Redetachemnt The redetachment rate for easy retinal
More than one redetachment
detachments was 10% and for complicated
detachments 30%. Regarding complicated
Other causes retinal detachments, the failure rate was
Fig. 4.2 Cause for retinal detachments 21% for giant tear and 38% for PVR grade
C and D.
4 Facts and Figures About Retinal Detachment Based on a Retinal Detachment Register 37
0
Giant tear PVR grade C and D Other cause
Fig. 4.3 Pathology of complicated retinal detachments
200
180
160
140
120
100
80
60
40
20
0
2011 2012 2013 2014 2015
Vitrectomy Episcleral buckling
Fig. 4.4 Surgical techniques for retinal detachment
• The change of surgical technique from epi- 4.1 Review of International

scleral buckling to vitrectomy improved Retinal Detachment Studies
the success rate of primary attachment
from 85% to 90%. Retinal redetachment following primary retinal
detachment surgery depends on many factors and
38 E. Olofsson
Failure rate of retinal detachments

40
35
30
25
20
15
10
0
All retinal Easy retinal Complicated Giant tear PVR grade C and
detachments detachments retinal D
detachments
Fig. 4.5 Recurrent detachments of 2014–2015. The failure rate for retinal detachment depends very much on the
pathology
varies according to multiple studies. These stud- diverse studies is though difficult due to different
ies are diverse, ranging from large multicenter settings. For instance, lens status (phakic/pseudo-
retrospective studies including 7678 cases and phakic), choice of endotamponade, location of
176 surgeons [1] to small single-surgeon reports breaks, postoperative positioning, and follow-up
[2]. The scleral buckling versus primary vitrec- time vary which must be considered when dis-
tomy in rhegmatogenous retinal detachment cussing reattachment rates. In the SPR study, the
study (the SPR study) [3] is a randomized, multi- reattachment rate was 63.8% in phakic eyes and
center, prospective study, including 681 eyes, 72% in pseudophakes [3]. This study was later
which has had a large impact on retinal detach- included in two meta-analyses of uncomplicated
ment surgery since it was published in 2007. In retinal detachments that calculated reattachment
this study it was shown that phakic patients had a rates after vitrectomy in phakic of 68% and 77%,
better visual outcome after scleral buckling sur- respectively, as compared to 75% and 78%,
gery than after vitrectomy, probably due to cata- respectively, in pseudophakic eyes [4, 5]. It has
ract progression in vitrectomized eyes. However, been speculated that residual vitreous in phakic
in pseudophakic eyes the primary anatomical eyes may increase the risk of redetachment [6].
success rate was higher after vitrectomy than It is well known by surgeons that the lens prevents
after buckling surgery. These findings in addition a thorough removal of the anterior vitreous, and
to modern surgical technique have guided many today many surgeons c onsider combined phaco-
surgeons toward vitrectomy as the preferred pro- emulsification and IOL implantation when per-
cedure today. forming vitrectomy in phakic eyes.
4.2 Retinal Reattachment 4.3 Gases
Retinal reattachment following primary vitrec- In uncomplicated retinal detachments, the gases
tomy for uncomplicated retinal detachment varies used as endotamponades are air, sulfur hexafluo-
between 98% [2] and 64% [3]. Comparing these ride (SF6), hexafluoroethane (C2F6), and perfluo-
ropropane (C3F8). Air gives the shortest tamponade of the breaks is more comfortable and may thus
and persists for only about 1 week. SF6 is also a increase compliance rendering a better outcome.
short-acting gas that, at the most commonly used The role of positioning for complications and
concentrations of gas-air mixture, persists in the anatomical success is though controversial and
vitreous cavity for 1–3 weeks, whereas C2F6 lasts has not been found to reduce the risk of retinal
for 4–6 weeks and the even longer-acting C3F8 for redetachment [17, 18] although some studies
1–2 months [7, 8]. The efficacy of the different have shown high reattachment rates of 90–94.5%
gases for retinal break closure allowing time for after adjustable positioning justifying this
the retinopexy to cause a firm chorioretinal adhe- method [14, 15, 17, 19, 20].
sion, thus preventing redetachment, is controver-
sial, but a longer-acting gas may be beneficial in
detachments involving the lower quadrants [9]. 4.5 Scleral Buckling
The number of quadrants involved is a known risk
factor for failure [10–12] as well as inferior breaks Due to the difficulties with vitrectomy and gas,
that are difficult to seal with gas long enough for especially if the breaks are located inferiorly, the
the chorioretinal adhesion to establish [13]. use of a segmental or encircling scleral buckle to
Longer-acting gases which also prolong visual support the vitreous base and relieve vitreous
recovery and delay air travel may actually not tension is an alternative and well-established
give a higher success than shorter-acting gases in method for retinal detachment repair. A scleral
detachments with inferior breaks [12, 14, 15]. The buckle as the primary procedure in retinal
success rate of C3F8 and silicone oil as tamponade detachment surgery gave an attachment rate of
for detachment surgery is the same [6]. The type 63.6% in phakic eyes and 53.4% in pseudopha-
of intraocular gas and its concentration used in kic eyes in the SPR study [3]. The two later
vitreoretinal surgery for retinal detachments is meta-analyses that both included the SPR study
largely dependent on local traditions at different calculated slightly higher reattachment rates of
clinics. 68–76% in phakic eyes as compared to 67–68.8%
in pseudophakes following scleral buckle sur-
gery [4, 5]. Neither meta-analysis could confirm
4.4 Postoperative Positioning the result of the SPR study that vitrectomy was
superior to scleral buckle in pseudophakic pri-
Postoperative positioning is often recommended mary retinal detachment surgery. However many
to get the gas bubble in the right place to provide studies comparing scleral buckling to vitrectomy
surface tension across retinal breaks, preventing show conflicting results, and the superiority of
fluid from entering the subretinal space [16]. one to the other in uncomplicated retinal detach-
However, positioning varies depending on the ment surgery has yet to be established [21–23].
preference of the surgeon and the compliance of In recent years though the trend has changed
the patient. During the first postoperative period, from scleral buckle surgery to vitrectomy as the
many prefer prone positioning which is thought preferred approach by many surgeons, reflecting
to reduce the risk of complications. Gas may improved surgical instrumentation such as small
increase the intraocular pressure and cause cata- gauge vitrectomy systems and wide-angle view-
ract and posterior synechiae of the iris. The ing technique [24, 25]. In addition, surgeons
prone position may reduce the risk of these com- today, influenced by previous studies, probably
plications by compressing the gas backwards select surgical method depending on the situa-
which also may prevent from retinal folds and tion. For instance, scleral buckling is more pre-
macular pucker development due to the displace- ferred in younger phakic patients, especially in
ment of remaining subretinal fluid and pigment the absence of a posterior vitreous detachment
epithelial cells from the posterior pole. However, [25, 26]. In regard to these trends and advances,
an adjustable position depending on the location it is not surprising that many later studies have
40 E. Olofsson
reported generally higher primary reattachment 3. Heimann H, et al. Scleral buckling versus primary
rates compared to the SPR study that was con- vitrectomy in rhegmatogenous retinal detachment:
a prospective randomized multicenter clinical study.
ducted a decade ago. For scleral buckle surgery, Ophthalmology. 2007;114(12):2142–2154.e2144.
a thorough patient selection gives attachment 4. Soni C, et al. Surgical management of rheg-
rates of 85–91% [1, 24–26]. Improved anatomi- matogenous retinal detachment: a meta-analysis
cal results are also reported following vitrec- of randomized controlled trials. Ophthalmology.
2013;120(7):1440–7.
tomy, and recent studies show that 81–95% of 5. Sun Q, et al. Primary vitrectomy versus scleral buck-
the retinas are attached after primary vitrectomy ling for the treatment of rhegmatogenous retinal
[1, 6, 11, 19, 22–25, 27, 28]. detachment: a meta-analysis of randomized controlled
Many surgeons add a scleral buckle at the time clinical trials. Curr Eye Res. 2012;37(6):492–9.
6. Caiado RR, et al. Effect of lens status in the sur-
of vitrectomy in primary retinal detachments gical success of 23-gauge primary vitrectomy
repair, especially when there is an inferior detach- for the management of rhegmatogenous reti-
ment where gas may not be sufficient for retinal nal detachment: the Pan American Collaborative
break closure. However, multiple studies have Retina Study (PACORES) group results. Retina.
2015;35(2):326–33.
not been able to show an advantage of combined 7. Jacobs PM, et al. Behaviour of intraocular gases. Eye
vitrectomy and buckle surgery over vitrectomy (Lond). 1988;2(Pt 6):660–3.
alone, as a primary procedure [1, 2, 11, 27–29]. 8. Kontos A, et al. Duration of intraocular gases fol-
lowing vitreoretinal surgery. Graefes Arch Clin Exp
Ophthalmol. 2017;255(2):231–6.
9. Tan HS, et al. Air versus gas tamponade in retinal detach-
4.6 Summary ment surgery. Br J Ophthalmol. 2013;97(1):80–2.
10. Mitry D, et al. Surgical outcome and risk stratification
In the period from October 2010 to 2015, the for primary retinal detachment repair: results from the
Scottish Retinal Detachment study. Br J Ophthalmol.
University Hospital of Umeå operated 1645 reti- 2012;96(5):730–4.
nal detachments. Almost Ninety percent of the 11. Wickham L, et al. Surgical failure following pri-
retinal detachments were uncomplicated, and mary retinal detachment surgery by vitrectomy: risk
11% were complicated where of 4% had a giant factors and functional outcomes. Br J Ophthalmol.
2011;95(9):1234–8.
tear and 5% PVR grade C or D. PVR grade C and 12. Zhou C, et al. Air versus gas tamponade in rheg-
D. In the beginning of the study, a third of all matogenous retinal detachment with inferior breaks
detachments were operated with episcleral buck- after 23-gauge pars plana vitrectomy: a prospective,
ling and at the end only 9%. This change resulted randomized comparative interventional study. Retina.
2015;35(5):886–91.
in an increased primary attachment rate. The fail- 13. Goto T, et al. A comparison of the anatomic successes
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30% for complicated detachments. This is not Ophthalmol. 2013;91(6):552–6.
14. Martinez-Castillo V, et al. Pars plana vitrectomy alone
inferior to published studies which have a failure for the management of inferior breaks in pseudopha-
rate of 25% for vitrectomy for phakic patients kic retinal detachment without facedown position.
and 20% for vitrectomy for pseudophakic Ophthalmology. 2005a;112(7):1222–6.
patients [3]. 15. Martinez-Castillo V, et al. Management of inferior
breaks in pseudophakic rhegmatogenous retinal
detachment with pars plana vitrectomy and air. Arch
Ophthalmol. 2005b;123(8):1078–81.
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Part II
Before Surgery
Assessment of a Retinal
Detachment 5
A good and correct assessment of the detached 2. The superotemporal/superonasal detachment

retina is essential for surgical success. The retina (Fig. 5.2c, d).
behaves logical. And you need to understand this 3. The inferior shallow detachment (Fig. 5.2e).
logic in order to become a successful vitreoreti- 4. The inferior highly bullous detachment
nal surgeon. (Fig. 5.2f).
The second finding of Lincoff and Gieser is

5.1 hat Is the Anatomical
W that every detachment shape (1–4) has a rupture at
Course of a Retinal a specific location. This rupture (primary hole) is
Detachment? responsible for the specific shape of detachment.
More ruptures are possible, but in most cases,
Lincoff and Gieser [1] found the following devel- there is only one second hole which is within one
opment of a retinal detachment (Fig. 5.1). quadrant from the primary hole. The location of
the primary hole is as follows (Figs. 5.3 and 5.4):
5.2 he Next Most Important

T 1. Superotemporal/superonasal detachment: The
Theoretical Knowledge primary hole lies within 1½ clock hours of the
for Retinal Detachment Are highest border.
the Lincoff Rules 2. Superior/total detachment: The primary
hole is located within a triangle where the
Lincoff rules: Lincoff and Gieser examined 1000 apex is located at 12:00 and the sides at
patients with retinal detachments and extracted 4 10:30 and 1:30.
different shapes of retinal detachments [1]: 3. The inferior shallow detachment has a hole on
the side with the higher detached edge. The
1. The superior detachment is identical to a total hole is located in an area between the upper
detachment. A superior detachment develops/ edge of the retinal detachment and 6:30.
goes over to a total detachment (Fig. 5.2a, b). 4. The inferior highly bullous detachment is the
most astounding one. The small hole is not, as
one may expect, located in the inferior pole
U. Spandau (*) · Z. Tomic but at 11:00 or 1:00. A peripheral bridge con-
Department of Ophthalmology, Uppsala University nects the hole with the inferior detachment.

https://doi.org/10.1007/978-3-319-78446-5_5
46 U. Spandau and Z. Tomic
a b
c d
Fig. 5.1 Development of a retinal detachment. A horse towards the inferior pole (c). Finally the detachment
shoe tear at 10:30. The detachment spreads first to the ora moves upwards until it reaches the height of the break on
serrata (a). Then the subretinal fluid moves towards the the other side (d). It will not move further, a total retinal
optic disc (b). Then the retinal detachment continues detachment is not possible with a hole at 10:30
Frequency of Lincoff 1–4 detachments [1]: The shallow inferior and bullous inferior
The frequency of the superior detachments is detachment (types 3 and 4) are considered com-
80%. The frequency of the inferior detachments plicated detachments. The shallow inferior
is 20%. detachment is easy to operate if the break is
Classification of Lincoff 1–4 detachments: located between 3 and 5 clock hours and compli-
The superior, superotemporal/superonasal cated if the break is located at 5–7 clock hours.
detachment (type 1 and 2) are considered easy The type 4 detachment is complicated if you
detachments. An exception is superior detach- make the wrong assessment. If you search for a
ments with giant tears or myopic eyes with mul- hole at the inferior pole, then you will miss the
tiple tears. hole at the superior pole and fail.
5 Assessment of a Retinal Detachment 47
a b
Superior detachment
c d
e f
Inferior detachment
Fig. 5.2 Lincoff and Gieser found two types of superior temporal (d) detachment. Regarding the inferior detach-
detachments and two types of inferior detachments. The ments, a shallow detachment (e) and a highly bullous
superior (a) or total detachment (b) is identical. The detachment (f) can be identified
superonasal (c) detachment is equivalent to the supero-
5.3 t the University of Uppsala,

A 5.4 t the University of Uppsala,
A
We Employ the Following We Assess Retinal
Surgical Methods Detachments
in the Following Way
1. Pneumatic retinopexy
2. Combined (25G, 27G) phaco + vitrectomy 5.4.1 Easy Detachments
3. Episcleral buckling (segmental buckle with
chandelier light and microscope) 5.4.1.1 Focal Detachments
4. Encircling band + PPV + bimanual peel- A retinal break with detached edges is a focal
ing + silicone oil detachment. A focal detachment requires a treat-
5. Combined segmental buckle + vitrectomy ment with gas or episcleral buckle to attach the
6. Retinotomy break onto the retinal pigment epithelium and
a a
Hole between upper

border and 6:30
1,5 clockhours from b Tiny hole

the upper edge at 1o’clock
Fig. 5.4 (a) Inferior shallow detachment. The hole is

located in an area between the upper edge of the retinal
Fig. 5.3 (a) Superior or total detachment. The primary detachment and 6:30. (b) Inferior highly bullous detach-
break is located within a triangle where the apex is located ment. A small hole is located at 11:00 or 1:00
at 12:00 and the sides at 10:30 and 1:30. (b)
Superotemporal/superonasal detachment. The primary
break lies within 1½ clock hours of the highest border
then a laser photocoagulation or cryopexy of the

retinal edges. A focal detachment cannot be
treated with laser alone. Figure 5.5 shows an
example where one focal detachment was treated
with laser photocoagulation and one focal detach-
ment with a buckle. The focal detachment treated
with a buckle is safe, while the focal detachment
treated with laser photocoagulation is not safe. Fig. 5.5 An eye with two focal detachments at 10 and 4
We treat only focal detachments from 10 o’clock o’clock. The focal detachment at 10 o’clock was treated
successfully with a radial buckle. The focal detachment at
to 2 o’clock and an attached superior arcade 5 o’clock was only treated with a laser barrier. There is a
(Fig. 5.6a, b). We treat the focal detachment with risk that the subretinal fluid breaks through the laser bar-
gas and cryopexy. rier and enlarges to a retinal detachment
5.4.1.2 Superotemporal, Superonasal All patients older than 50 years of age, with natu-
and Superior Detachments ral lens or pseudophakia, are operated at our clinic
The huge majority of retinal detachments in a first- with combined phaco/vitrectomy. Why combined?
world setting are an easy detachment. The detach- The success rate of retinal attachment is higher in
ment is usually 2–5 days old, and the patients are pseudophakic eyes than in phakic eyes. We oper-
pseudophakic or phakic. Aphakia is very seldom. ate 90% of all primary detachments with vitrec-
a b
Fig. 5.6 (a, b) A focal detachment at 12 o’clock (a) and at 3 o’clock (b). Both cases are suitable for pneumatic
retinopexy
Olofsson from Umeå in Sweden reports a recur-

rent detachment rate of 30% for complicated
detachments (see Chap. 4). Typical complicated
retinal detachments are giant tears, PVR grade C
and D, inferior detachments and chronic detach-
ments. For some complicated detachments, the
scleral buckling technique is superior; for other
complicated retinal detachments, vitrectomy is
the technique of choice. The first surgery deter-
mines about the fate of the eye.
5.4.2.1 Buckle vs. Vitrectomy

Today the huge majority of retinal detachments
are operated with vitrectomy. The technique of
episcleral buckle disappears more and more. One
reason is that young retinal surgeons do not learn
Fig. 5.7 An easy detachment. A superotemporal detach- to visualize the retina with the binocular indirect
ment. The typical surgical technique is a combined phaco/ ophthalmoscope. In this book we will demon-
vitrectomy strate a technique for episcleral buckling surgery
where a binocular indirect ophthalmoscope is not
tomy. The type of these detachments is needed. We perform episcleral buckling only
superotemporal/superonasal and superior detach- with a microscope and BIOM. Episcleral buck-
ment (Lincoff types 1 and 2) (Fig. 5.7). For these ling is mainly reserved for young patients or
detachments we use always a gas tamponade. complicated cases. For episcleral buckling we
use only segmental sponges and place them radial
or circumferential.
5.4.2 Complicated Detachments When operating complicated retinal detach-
ments, both techniques, episcleral buckling and
When approaching a complicated detachment, vitrectomy, must be mastered and employed to
the surgery becomes challenging and the out- achieve surgical success. The complicated retinal
come sometimes frustrating. Remember: Eva detachments are as follows:
5.4.2.2 Inferior Retinal Detachment and C2F6 gas tamponade. The patient should be
Retinal detachments in patients <40 years, we positioned for 3 days on the cheek opposite to
operate with episcleral buckling. The posterior the break.
vitreous is attached, and the optical media are An inferior RD with a break between 5:00
clear. Typical examples are young myopes. and 7:00 is tricky (Fig. 5.9b). If you perform a
Myopic eyes with an inferior RD are a good indi- vitrectomy with gas (C2F6 or C3F8), then there
cation for episcleral buckling surgery. Encircling will be an insufficient tamponade at 6 o’clock.
bands and segmental buckles are used for this Why? A 100% gas tamponade is not possible;
pathology. An encircling band causes a myopic even a 90% gas tamponade is difficult to achieve.
shift of approximately 3D, and a segmental If you want to perform vitrectomy with gas,
buckle causes astigmatism. In both cases the then the patient must position on the back with-
buckle can be removed after 4 weeks so that the out a pillow for 3 days. If the patient cannot or
globe can regain its original shape. We employ does not want to position like this for 3 days,
always segmental buckles in these cases. For then the following alternatives are possible: seal
example, in a 27-year-old male patient with the break at 6 o’clock with an episcleral buckle
−3.5sph = 0.4 and an inferior detachment with 6 or alternatively an encircling band with a
holes at 6–7 o’clock, cryopexy and segmental grooved strip at 6 o’clock. This surgery can be
buckle from 5:30 to 7:30 (under inferior rectus performed as episcleral buckling alone or com-
muscle) (Fig. 5.8a, b) was done. bined buckle/vitrectomy and a gas tamponade.
The following two examples show the same If the break is located on the buckle, then a posi-
shape of inferior detachment but different retinal tioning is not necessary. Another simple alterna-
holes (Fig. 5.9a,b). And the different hole loca- tive is the use of Densiron 68 as tamponade. The
tion decides over a different surgical technique. latter is, in our experience, the easiest surgical
With an inferior RD with a break at 4 o’clock technique for inferior detachments. Find more
(Fig. 5.9a), we would operate with vitrectomy details about inferior detachment in Chap. 18.
a b
Fig. 5.8 (a, b) Myopic retinal detachment (a) is an ideal candidate for scleral buckling (b)
a b
Fig. 5.9 (a, b) A shallow inferior detachment (Lincoff case (b). Even a tamponade with C3F8 or silicone oil
type 3) (a, b). In one case the retinal break is located at 4 would not seal this break effectively. The best surgical
o’clock (a) and in the other case the retinal break is technique for a hole at 6:00 is a circumferential silicone
located at 5:30. In the first case a vitrectomy with C2F6 gas sponge from 5:00 to 7:00. If you want to perform vitrec-
tamponade is a good surgical option but not for the second tomy then a tamponade with Densiron 68 is required
a b
Fig. 5.10 (a, b) A superotemporal detachment with a buckling and vitrectomy, and the second case can only be
retinal break anterior to the equator (a) and posterior to operated by vitrectomy. The break is too posterior to be
the equator (b). The first case can be operated by scleral covered by a silicone sponge (b)
The decision of buckle vs. vitrectomy depends equator (Fig. 5.10b), then it cannot be reached by
also on the location of the retinal break. If the a sponge, and you must choose a vitrectomy
break is located anterior to the equator, then it can instead. So in this case of an easy (superotempo-
be reached by a silicone sponge (Fig. 5.10a). But ral) detachment, you can use vitrectomy in both
if the retinal break is located posterior to the cases but episcleral buckling only in the first case.
a b
Fig. 5.11 (a–c) An inferior highly bullous detachment 1–2 days (b). A vitrectomy is rather difficult because the
(Lincoff type 4). The tiny hole is located at 11 o’clock (a). trapped fluid has to be aspirated from the tiny hole at 11
A radial buckle at 11:00 will attach the retina within o’clock (c)
The highly bullous inferior detachment 5.4.2.3 Ora Dialysis

(Lincoff rule 4) (Fig. 5.11a–c) is anatomically The ora dialysis is on the border of an easy and
very interesting because a tiny hole at 1:00 or difficult detachment. The success rate of reat-
11:00 causes a huge inferior detachment. In tachment for ora dialysis is 99% with episcleral
this case the rule “Treat the hole and not the buckling. If you choose to operate an ora dialysis
detachment” becomes very true. If you place a with vitrectomy, you need to achieve the same
radial buckle on the tiny hole at 1:00 or 11:00 reattachment rate. For example, in a 42-year-old
then the detachment will disappear within one male patient with ora dialysis at 6–7 o’clock and
day (Fig. 5.11a, b). If you choose to perform a chronic inferior detachment due to trauma, scleral
vitrectomy, then you have the technical prob- buckling with a segmental buckle from 5 to 8
lem to drain the highly bullous inferior detach- o’clock (under inferior rectus muscle) was per-
ment from a tiny superior hole (Fig. 5.11c). formed (Fig. 5.12a). After 2 months, the
a b
Fig. 5.12 (a–c) A chronic ora dialysis after a trauma with was present but reduced (b). After 6 months the residual
a plastic ball 1 year ago (a). A cryopexy with episcleral fluid was absorbed (c)
buckling was performed, and after 2 months residual fluid
subretinal fluid was reduced (Fig. 5.12b), and the lens and then vitrectomize an inflamed eye
after 6 months the subretinal fluid had completely resulting in increased PVR and recurrent detach-
disappeared (Fig. 5.12c). ment risk. If you choose episcleral buckling,
things get much easier. The clear optical media in
5.4.2.4 Traumatic Detachment children facilitates working with a binocular
A traumatic detachment in a child’s eye is a com- indirect ophthalmoscope or microscope, and the
plicated retinal detachment. But a reattachment is attached vitreous makes reattachment easy. For
much easier to achieve with episcleral buckling example, in a 6-year-old boy with traumatic infe-
than with vitrectomy. A vitrectomy is technically rior detachment and a rupture from 5 to 7 o’clock,
very difficult because you may need to remove cryopexy and segmental buckle from 4 to 8
a b
Fig. 5.13 (a, b) A traumatic retinal detachment in a to tamponade a large break at 6 o’clock; easy for scleral
6-year-old boy (a); a very difficult case for vitrectomy and buckling because only a focal detachment is present. A
a rather easy case for scleral buckling; difficult for vitrec- circumferential buckle reattached the retina (b)
tomy because you remove an attached vitreous and have
exchange. A PFCL against silicone oil exchange

is not necessary. The risk of a slippage is higher
if you do not use PFCL. As tamponade we use
gas tamponade or 1000 csts silicone oil.
5.4.2.6 R etinal Breaks in Two

Quadrants
Even a middle-aged patient with myopic detach-
ment is a good indication for an episcleral buckle.
For example, in a 47-year-old male patient with
−8.5sph = 0.6 and a temporal detachment with 4
holes on the same height (Fig. 5.15a), cryopexy
and segmental buckle from 7 to 11 o’clock (under
temporal rectus muscle) (Fig. 5.15b) were
performed.
Fig. 5.14 A giant retinal tear has a length of 90° and
more. A good candidate for vitrectomy 5.4.2.7 Chronic Detachment
The chronic focal detachment is definitely a com-
o’clock (under inferior rectus muscle) (Fig. 5.13a, plicated detachment. But in case of a clear hole
b) were performed. situation and the employment of episcleral buck-
ling, this complicated detachment becomes easy.
5.4.2.5 Giant Tear Vitrectomy would be much more difficult. Why?
For giant tears, vitrectomy is the technique of The pigment epithelium in the detached area is
choice (Fig. 5.14). We instill PFCL to attach the weak, and the subretinal proliferations enhance
retina and the hole edges, continue with laser the detachment. In case of vitrectomy, you need
treatment and then perform a PFCL against air to remove the subretinal proliferations and then
a b
Fig. 5.15 (a, b) A myopic detachment with four retinal breaks in two quadrants. The posterior vitreous is attached.
Scleral buckling with a circumferential buckle reattaches the retina
a b
Fig. 5.16 (a, b) A chronic and asymptomatic retinal achieve because the RPE in this area is weak. A scleral
detachment in a young patient. The vitreous is attached. A buckling is easier, and the permanent indentation of the
vitrectomy is difficult, and attachment is difficult to silicone sponge gives the RPE more time to recuperate
instill a gas tamponade to press the retina against cryopexy and scleral buckling of a radial sponge
the pigment epithelium. A buckle creates an was performed (Fig. 5.16b).
excellent impression between the weak pigment The surgery of a chronic and total detachment
epithelium and the retina and seals the hole. For is unthankful because the surgery is very diffi-
example, in a 34-year-old female patient with cult; often several surgeries are necessary to
superotemporal quadrant detachment, subretinal achieve a final attachment. The visual outcome
proliferations and a hole at 10:30 (Fig. 5.16a), remains poor. Therefore, even if you succeed
reattaching the retina, the most patients will not For example, in a 45-year-old male patient
praise you for your surgical excellency. We do with a 6-month-old retinal detachment (Fig. 5.18),
not operate chronic retinal detachments older operated 5 years ago without complications with
than 1 year (Fig. 5.17). Surgically ZT would episcleral buckling for a retinal detachment and
choose an encircling band with vitrectomy and now total retinal detachment (Fig. 5.18a), a com-
silicone oil tamponade. In some cases an inferior bined vitrectomy and placement of an inferior
redetachment occurs. In this case the silicone oil segmental buckle was performed (Fig. 5.18b).
will be removed and exchanged against Densiron After silicone oil removal, the retina remained
68. Surgically US would perform a combined attached.
buckle/vitrectomy. If an inferior PVR detach-
ment is present, then US would place a circum- 5.4.2.8 PVR Stage C
ferential 90° sponge on the inferior equator to The PVR stage C is a surgically demanding RD
reattach the inferior retina. with a high redetachment risk (Fig. 5.19a). It is
possible to use episcleral buckling technique for
stage C, but we prefer vitrectomy in most cases.
Chronic and total detachment We usually do not use an encircling band/tyre in
(<1 year old) these cases. In most cases, we use a silicone oil
tamponade. In case of a redetachment (Fig. 5.19b),
Author: Zoran Tomic Author: Ulrich Spandau
US would place a segmental buckle on the inferior
pole and use a silicone oil tamponade. An alterna-
tive is to place a radial buckle on the causative hole
Inferior segmental at 3 o’clock without a tamponade. ZT would
Encircling band
buckle and silicone remove the membranes in order to mobilize the
and silicone oil
oil
retina and if necessary perform a retinotomy. Our
Fig. 5.17 Treatment algorithm for a chronic and total treatment algorithm for PVR detachment stage C
detachment, PVR stage C and a recurrent detachment is depicted in Fig. 5.20.
Old
buckle
1000 csts
silicone oil
a b
Fig. 5.18 (a, b) A chronic and total retinal detachment with placement of an inferior circumferential buckle was
with PVR stage C. Five years earlier the eye was operated performed (b), and after removal of the silicone oil, the
with success with scleral buckling (a). Now a vitrectomy retina remained attached
a b
Fig. 5.19 (a) First surgery: PVR stage C with starfolds and a horse shoe tear at 1 o’clock. Operated with vitrectomy.
(b) Second surgery: Recurrent retinal detachment with a new retinal break at 3 o’clock
Fig. 5.20 Our treatment

First surgery Primary PVR detachment
algorithm for a primary
PVR stage C detachment
and a recurrent
detachment Peeling + laser +
LIGHT silicone oil
Second surgery Recurrent inferior

detachment
Laser + HEAVY silicone oil Laser +

inferior circumferential buckle
5.4.2.9 R ecurrent Retinal Detachment cryopexy was performed, then the retinal break
(Failed RD) responsible for the recurrent detachment is now
According to the retinal detachment register from difficult to find. Here a Schlieren test and the
Umeå, the failure rate for an easy retinal detach- knowledge of Lincoff rules help to find the posi-
ment is 10%. The failure rate for a complicated tion of the retinal break. Our treatment algorithm
retinal detachment is 30%. The highest risk for for a recurrent detachment is depicted in Fig. 5.21.
recurrent detachment has eyes with a VA < 2/60, a
detachment involving more than three quadrants 5.4.2.10 Total Recurrent
and a previous retinal detachment [2]. The main Redetachment
problem for recurrent detachments is to find the A total or superior recurrent detachment has a
retinal break. The Lincoff rules apply also here, hole between 10:30 and 1:30 (Fig. 5.22). The
but the presence of cryopexy or laser scars influ- presence of laser scars makes the search for a
ences the flow of subretinal fluid. In addition, if in retinal break difficult, and in addition the break
the first surgery a 360° laser cerclage or extensive may be caused by a laser necrosis, i.e. at the edge
Fig. 5.21 Our treatment Recurrent detachment

algorithm for a recurrent
detachment. There are
four surgical options; we
use in most cases the
last three options
Retinotomy
with silicone oil Silicone oil
Encircling band (tyre) Segmental circumferential buckle

with C3F8 with gas or silicone oil
a b
Fig. 5.22 A total recurrent retinal detachment (a). The ser the superior part of the laser cerclage or place a buckle
eye was operated previously with vitrectomy and laser in the suspected area (b). If this surgery fails, then a per-
cerclage. The retinal hole must be located in a triangle at manent silicone oil tamponade is advisable
12 o’clock, possibly a laser necrosis. You can either rela-
of a laser scar. You can either place 2–3 extra the inferior pole resulting in a PVR reaction. An
rows around the suspected laser necrosis or place inferior recurrent redetachment occurs often
a silicone sponge on the suspected area. With the after silicone oil removal [3].
buckle you have an additional chance to seal the Our procedure in a recurrent detachment
hole without the use of silicone oil. In our experi- with no intraretinal PVR is as follows:
ence the surgical success rate of this case is low. Vitrectomy + bimanual membrane removal until
the retina is mobile and Densiron 68 tamponade.
5.4.2.11 Inferior Recurrent In case of a recurrent detachment with
Redetachment foreshortened retina secondary to intraretinal

The inferior recurrent redetachment is very PVR, two surgical procedures can be employed:
common. The reason for this is that a 100% tam- (1) A 180 retinotomy and (2) an inferior circum-
ponade is not possible leaving a puddle of aque- ferential 5 mm buckle on height of the equator.
ous at the inferior pole resulting in the The strong retinal impression of the buckle
accumulation of inflammatory and glial cells at avoids a retinotomy.
a b
15% C2F6
Fig. 5.23 A recurrent inferior retinal detachment (a, c). This occurred after silicone oil removal. A scleral buckle was
placed circumferential from 5:00 to 7:00, and the retina remained attached (b)
The inferior and circumferential 5 mm buckle 68 is impossible. An inferior buckle solves two
can be used for two pathologies: problems at once. It closes the (not visible) hole
and the strong indentation of the 5 mm silicone
(a) An inferior retinal detachment with no intra- sponge, reattaches the retina onto the pigment
retinal PVR. A retinal hole is not visible hole epithelium and prevents a retinotomy.
due to chorioretinal scars (Fig. 5.23). The
buckle is placed (blind) on the entire detached 5.4.2.12 Retinotomy Versus Inferior
retina. Alternatively, a Densiron 68 tampon- Circumferential (Ora Parallel)
ade is possible. Segmental Buckle
(b) An inferior retinal detachment with severe What is the aim of a retinotomy or episcleral
intraretinal PVR. The hole is again not visible buckle? The aim is to reattach the foreshortened
due to cryopexy or laser scars (Fig. 5.24). The inferior retina onto the retinal pigment epithelium.
inferior retina is so much foreshortened that a A 360° encircling band creates a sufficient inden-
reattachment with an encircling and or Densiron tation for a detached retina with little intraretinal
a b
1000 cSt
silicone oil
Densiron 68
x
x x x xx
x x x
xx
xx xx
x x x x x x
Fig. 5.24 An inferior detachment under silicone oil (a). or an inferior circumferential buckle. After an inferior
The inferior retina is foreshortened secondary to intrareti- buckle from 4 to 8 o’clock and injection of Densiron 68,
nal PVR. The only surgical options are a 180° retinotomy the inferior retina reattached (b)

Recurrent retinal detachment with inferior foreshortened retina
algorithm for recurrent
retinal detachment with
foreshortened inferior
retina Author: Zoran Tomic Author: Ulrich Spandau
Retinotomy Circumferential buckle
Failure
Permanent silicone oil tamponade Failure
PVR but an insufficient retinal indentation for a buckle fails, you still have the surgical option of
detached retina with severe intraretinal PVR. A the retinotomy. If you perform straight away a
90° circumferential buckle, however, creates a retinotomy, then you choose a way of no return. If
sufficient retinal indentation for a severely fore- the retina anterior to the buckle is fibrotic and stiff
shortened retina. Why? Because the 90° buckle is (due to several vitreoretinal surgeries), then a
focal and receives no counterpressure from the buckle will not achieve a reattachment. In this
superior pole. In addition a sponge is 5 mm wide case an excision of the fibrotic retina is required
and a band only 2 mm. The main advantage of a (retinectomy). Our treatment algorithm is depicted
buckle is that you do not remove retina. If the in Fig. 5.25.
Table 5.1 Choice of surgical technique depending on the

pathology
Scleral
Pathology Vitrectomy buckling
Easy detachments Vitrectomy
Giant tear Vitrectomy
Retinal detachment Vitrectomy
secondary to globe
rupture
PVR stage B–C2 Vitrectomy Scleral
buckling
PVR stage C3 Vitrectomy
PVR stage D Vitrectomy
Ora dialysis Scleral
buckling
Retinal detachment Scleral
<40 years buckling
Inferior detachment Scleral
with hole at 6 o’clock buckling
Fig. 5.26 A PVR stage D detachment with open funnel
Myopic detachment Scleral
and 360° anterior PVR secondary to a morning glory
buckling
syndrome
Chronic focal Scleral
detachment buckling
Technically the inferior buckle is placed dur-
ing a vitrectomy. Typical example (Figs. 5.23 and
about vitrectomy and scleral buckling. The
5.24): Inferior detachment after silicone oil
correct choice of technique is important
removal. Three-port trocar setup and a limbal
because the first surgery decides about the fate
peritomy are performed, and three holding
of the eye. The following table summarizes the
sutures are inserted. A scleral buckling during
choice of techniques at the University of
vitrectomy is much easier than a scleral buckling
Uppsala (Table 5.1). This may of course differ
without vitrectomy. The technique is described in
from other vitreoretinal clinics.
detail in Chap. 12.
5.4.2.13 PVR Stage D

A PVR stage D is in most cases an old detach-
References
ment. The surgery is very difficult and the prog- 1. Lincoff H, Gieser R. Finding the retinal holte. Arch
nosis is very bad. We do not operate detachments Ophthalmol. 1971;85(5):565–9.
older than 1 year. A PVR stage D is a clear indi- 2. Törnquist R, Bodin L, Törnquist P. Retinal detach-
cation for vitrectomy with 360° encircling band ment. A study of a population-based patient material
in Sweden 1971–1981. IV. Prediction of surgical out-
OR 180–360° retinotomy (Fig. 5.26). come. Acta Ophthalmol. 1988;66(6):637–42.
3. Vitrectomy with silicone oil or sulfur hexafluoride gas
in eyes with severe proliferative vitreoretinopathy:
Conclusion
results of a randomized clinical trial. Silicone Study
If you want to operate the complete spectrum Report 1. Arch Ophthalmol. 1992;110(6):770–9.
of retinal detachments, then you must learn
Biometry Binocular Occlusion
and Anesthesia 6
Extras: Powerpoint file 6.1. (K1 and K2) of the left eye for the right eye.
In the case of astigmatism, this may result in a
high error of IOL measurement.
6.1 Biometry But, this simple method does not function in
the case of anisometropia. It is therefore essential
Biometry is challenging in the eyes with a retinal to check the glasses and to ask the patient if one
detachment because the macula is detached, and eye was more near or far sighted than the other. If
the axial length (AL) measurement is wrong. this is the case, then the following thumb rule will
Start with an IOL Master of the healthy eye. Then help us: 1 mm ≈ 2.5–3D. This means that 1 mm
measure the corneal power (K1 and K2) of the of AL correlates to 2.5–3D of corrected visual
“detached” eye. An axial length measurement of acuity. For example, the left eye has a retinal
the detached eye is not possible. Use the axial detachment, and the IOL Master measures an AL
length measurement of the healthy eye for the of 23 mm in the right eye and 21 mm in the left
“detached” eye. eye. The glasses have a refraction of −3D (right
An example is depicted in Fig. 6.1. The right eye) and −6D (left eye). The AL of the right eye
eye has a retinal detachment and the left eye is must be shorter than the AL of the left eye. The
normal. You can see that the axial length (AL) AL of 21 mm of the left eye is therefore wrong,
of the right eye is too short because the laser but using the AL of the right eye (23 mm) would
light measures from the cornea to the detached also be wrong. Now we use the thumb rule:
retina. If you would choose an IOL with these 6D−3D = 3D. 3D correlates to 1 mm. The AL of
measurements, then you would require a 49D the left eye is therefore approximately 24 mm.
IOL (which does not exist). The solution is to One more recommendation in case of a white
use the axial length of the left eye as AL of the nucleus. The IOL Master can often not measure
right eye. The result is depicted in Fig. 6.2. the AL in the case of a hard nucleus. In these
Important: Do not use the corneal measurements cases an A-scan is recommended. If it is not
possible to measure the axial length with the
Electronic Supplementary Material The online version A-scan, then change the settings in the A-scan
of this chapter (https://doi.org/10.1007/978-3-319-78446- from “normal” to “aphakic.” In the “aphakic”
5_6) contains supplementary material, which is available setting, the A-scan measures “over” the nucleus;
to authorized users.
he pretends that there is no nucleus, and in this
U. Spandau (*) · Z. Tomic case you will always get a reliable AL measure-
Department of Ophthalmology, Uppsala University
ment. If you succeeded with an AL measurement,

https://doi.org/10.1007/978-3-319-78446-5_6
Fig. 6.1 The biometry of a right eye (OD) with retinal detachment. The left eye (OS) is healthy. Observe the different
axial lengths (AL)
then add 0.3 mm to the AL. The reason for this 6.1.1 Conclusion
is that the A-scan machine measures too short in
the aphakia setting. For example, the eye has a In the case of retinal detachment, perform a nor-
white cataract, and you excluded a retinal mal biometry of the healthy eye, and measure the
detachment with the B-scan. Take your A-scan, corneal power (K1 and K2) of the “detached”
change the settings to “aphakia,” and now you eye. An axial length measurement of the detached
measure easily an AL of 22.5 mm. The final AL eye is not possible. Then use the axial length of
is 22.5 + 0.3 = 22.8 mm. the healthy eye for the detached eye. Finished.
6 Biometry Binocular Occlusion and Anesthesia 65
Fig. 6.2 The corrected biometry. The AL of the left eye is used as AL for the right eye
6.2 riday 4 o’Clock Detachment

F pneumatic retinopexy has a PVR rate of 6–7%.
and Binocular Occlusion Are there better options?
In the old times of buckling surgery, a tech-
In California pneumatic retinopexy is very popu- nique was used which is practically unknown
lar and so popular that a Friday afternoon detach- today to young surgeons: binocular occlusion.
ment is called a Friday retinopexy. Why? Both eyes are occluded with an eye patch; the
Because pneumatic retinopexy is a fast proce- patient shall rest and only take off the eye patches
dure and stabilizes the eye until Monday. But for toilet and eating. The result of binocular
Fig. 6.3 A retrobulbar cannula from Atkinson. The blunt tip prevents a scleral perforation
occlusion is that macula endangering retinal painful procedures such as episcleral buckling,
detachments will not progress, and the macula we add 3 ml into the superior orbital and 1–2 ml
will not detach until Monday. In the case of acute through the caruncle. If the patient complains
vitreous hemorrhage, 50% of it will settle over- during surgery about pain, we add only Carbocain
night and 89% will settle enough by 4 days to and inject 2–3 ml into the caruncle. The anes-
make the retina visible and available for laser or thetic effect comes after approximately 1 min
cryopexy to close a tear [1]. (Fig. 6.3).
6.2.1 Conclusion
6.3.1 Tipps and Tricks
In the case of a retinal detachment endangering
the macula and arriving at your clinic at Friday 4 Scleral Perforation. If you use a 25G or 23G
o’clock, prescribe binocular occlusion; the mac- cannula, you may perforate the globe during ret-
ula will not be detached on Monday morning. robulbar anesthesia. Use a blunt 25G retrobul-
bar cannula from Atkinson instead. The blunt tip
prevents a scleral perforation.
6.3 Anesthesia
In most cases a peribulbar anesthesia is sufficient. Reference

We use 50% Carbocain 20 mg/ml and 50%
Marcain 5 mg/ml. We inject approximately 1. Lincoff H, Stopa M, Kreissig I. Ambulatory binocular
5–6 ml into the inferotemporal orbital region. In occlusion. Retina. 2004;24:246–53.
Devices and Instruments
7
7.1 Chandelier Light Fibre
Chandelier light fibre (Figs. 7.1, 7.2, 7.3

and 7.4)
A chandelier light provides a panoramic light
source and illuminates the entire fundus. A chan-
delier light is either fixated directly in the sclera
(Fig. 7.1) or in a trocar (Fig. 7.2). This enables
bimanual surgery and allows the surgeon to use a
second active instrument in addition to the vitre-
ous cutter. An alternative is the 27G, an Eckardt
TwinLight Chandelier with scleral fixation
(DORC 3269.MBD27) (Fig. 7.3). Fig. 7.1 Four-port vitrectomy with chandelier light. The
For optimal illumination of a chandelier light, chandelier light is fixated into the sclera (Awh, Synergetics,
USA)
an external light source (photon, xenon) or a
modern vitrectomy machine (Stellaris PC,
Constellation, Eva) is required. Old vitrectomy
machines such as Accurus (Alcon) or Millennium
(B&L) do not give sufficient light for a chande-
lier light fibre. In our OR we use the chandelier
light from synergetics (Fig. 7.1) and the external
photon illumination (Fig. 7.4).
Fig. 7.2 This chandelier light is placed into a trocar

U. Spandau (*) · Z. Tomic which is technically easier (DORC, NL)

https://doi.org/10.1007/978-3-319-78446-5_7
Fig. 7.3 An Eckardt Twin Light Chandelier (DORC, NL)
Fig. 7.5 Membrane pic
and separate both tissues from each other. A reti-

nal massage is possible if there are retinal folds.
A bleeding vessel can be occluded with a knob
spatula and waiting time of 1 min. Alternatively
the vitreous cutter can be used. A wonderful
instrument which we recommend warmly
(EyeTechnology, UK: VR-2095).
7.3 Instruments for Removal

Fig. 7.4 An excellent external illumination for light of Membranes
fibres and especially for chandelier lights (Photon,
Synergetics)
Eckardt endgripping forceps (Fig. 7.8a, e)
The 27G endgripping forceps from DORC is a
7.2 Epiretinal Peeling mix of ILM forceps and endgripping forceps. It
functions well for ILM and membranes. We use
7.2.1 Instruments for Delamination the 27G forceps for 27G and 25G surgery (DORC,
of Membranes 27G disposable microforceps. 1286.WD04).
Power endgripping forceps (Fig. 7.8b, e)
Membrane pic (Fig. 7.5) The power endgripping forceps is useful for
Indication: To elevate a membrane, which is firmly attached membranes such as in PVR reti-
firmly attached to the retina (DORC 1292.EO4). nal detachment (DORC, 27G disposable micro-
Retinal scraper (27G retrobulbar cannula forceps. 1286.WPD04 or DORC, 23G disposable
Atkinson, Fig. 7.6a, b) microforceps. 1286.WP06).
This blunt cannula is suitable for opening of Serrated forceps (Fig. 7.8c, e)
the posterior hyaloid or delamination of flat The serrated jaw forceps is an alternative to
membranes (A, B). The membrane can be lifted the power endgripping forceps and useful for
up with the blunt cannula and then be removed removal of firmly attached membranes
with the microforceps (Beaver Visitec, 27G retro- (23G:DORC. 1286.CO6).
bulbar cannula Atkinson). Curved microscissors (Fig. 7.8d, e)
Knob spatula (Fig. 7.7) The microscissors are a useful instrument for
The 23G and 25G knob spatula has a thick cutting of membranes (DORC, 27G disposable
knob at its tip. Indication for use is the manipula- microscissors. Available in 23G (DORC 1286.
tion of membranes, a retinal massage and hae- M06), 25G (DORC 1286.MD05) and 27G (2286.
mostasis. For delamination place the knob PD04)).
spatula between the membrane and the retina Intravitreal forceps (Fig. 7.9)
7 Devices and Instruments 69
Fig. 7.6 (a, b) The 25G and 27G retrobulbar cannula is suitable for delamination of epiretinal membranes
7.4 Instruments for Subretinal

Peeling
Subretinal spatula (Fig. 7.11)

The subretinal spatula is only available in
20G. The trocars must be removed before use.
The subretinal spatula pierces the retina (retinot-
omy) and then delaminates the membrane from
the retina (Geuder, 20G subretinal spatula, 37545
Fig. 7.7 Knob spatula and 37546. DORC, 20G subretinal spatula
1295-1 0995).
Subretinal forceps (Fig. 7.12)
This new microforceps has sharp edges and a The subretinal forceps is only available in
strong grip and is therefore ideal for removal of 20G. The subretinal forceps pieces the retina (ret-
PVR membranes. A removal of ILM and epireti- inotomy) and then delaminates the membrane
nal membrane is also possible (DORC, 27G dis- from the retina (Geuder, 20G subretinal forceps,
posable microforceps. Available in 27G (1286. 36236. DORC, 20G subretinal forceps 1286 01
WR004)). 1095).
Straight microscissors (Fig. 7.10) Serrated forceps (Fig. 7.13)
The straight microscissors are a useful instru- The serrated jaw forceps is necessary for
ment for cutting of membranes (Available in 23G bimanual removal of the subretinal membranes
and 25G. Geuder. G-36578 or DORC, 1286.JO6). (DORC. 1286.CO6 (23G)).
a b c
d e
Fig. 7.8 (a–e) Intravitreal forceps and scissors
Fig. 7.9 Intravitreal

forceps
Fig. 7.10 Straight microscissors
Fig. 7.11 Subretinal spatula

Fig. 7.12 Subretinal forceps
Fig. 7.15 Vertical scissors
Fig. 7.13 Serrated forceps
Fig. 7.14 Endodiathermy probe
7.5 Instruments for Retinotomy

Fig. 7.16 Knob spatula
Endodiathermy probe (Fig. 7.14)

An endodiathermy probe is required to cauter-
ize the edges of the retinotomy (Alcon, DORC).
Vertical scissors (Fig. 7.15)
The vertical scissors are required for perform-
ing a circumferential retinotomy. Vertical scissors
are available in 23G (1286.E06) and 25G (1286.
ED05) (DORC). Better alternatives are the 25G
and 27G cutters which can also be used for a
retinotomy.
7.5.1 Flattening of Retinotomy

Edges Fig. 7.17 Charles flute needle with silicone tip
Knob spatula (Fig. 7.16) Charles flute needle with silicone tip (Fig. 7.17)
Available in 23G and 25G (EyeTechnology, Available in 23G, 25G and 27G (DORC
UK: VR-2095) 2281_AD04)
7.5.2 Dyes sponge. Indication: Ora dialysis, all breaks

<=3 mm in width for a radial buckle. This
Triamcinolone sponge requires a 7 mm marking (Fig. 7.20).
Kenalog (Squibb) indication: For staining of 2. A large silicone sponge (5.28 mm × 7.5 mm).
the vitreous and membranes. We use it only for Less common used silicone sponge.
vitreous staining. We recommend to dilute the Indication: Big breaks, i.e. <=5 mm in width
triamcinolone 1:3 with BSS. It must be injected for a radial buckle. This sponge requires a
repeatedly because triamcinolone crystals only 9.5 mm marking (Fig. 7.21).
stain the outer part of the vitreous cortex.
Combined dye (trypan blue and brilliant
blue G) 7.5.4 Sutures for Episcleral Buckling
It contains two dyes (trypan blue and brilliant
blue G) (Membrane Dual®, DORC). Indication: Mersilene 5-0 (Fig. 7.22)
For staining of epiretinal membranes and ILM. Indication: Suturing of an encircling band
(tyre) (Ethicon)
Supramid 4-0 (Fig. 7.23)
7.5.3 Episcleral Buckling Indication: Suturing of an episcleral sponge
(Serag-WIessner, Germany)
Encircling bands (tyre) (Fig. 7.18) Vicryl 6-0 (Fig. 7.24)
The encircling band (Fig. 7.18) is placed Indication: Suture of conjunctiva (Ethicon)
under all four rectus muscles. The sleeve
(Fig. 7.19) which connects both ends is located at
the inferotemporal quadrant. 7.5.5 Tamponades
Segmental Sponges
The buckle can cover the rupture in a radial or Air: Use a bacterial filter when drawing up the
circumferential position. gas inside a syringe.
Sf6: 20%
1. A normal-sized (3.77 × 5 mm) silicone C2F6: 15%
sponge. Our most common used silicone C3F8: 14%
Circling bands
s 2969 (40 Style) s 2987 (240 Style) s 2950 (2950 Style)
2.5
2 2.5
0.75 125 0.6 125 0.75 125
To be used with 1,2,4. To be used with 1,3,4. To be used with 1,3,4.
Fig. 7.18 Encircling bands

Silicone sleeves
Round
S 3018 (70 Style) S 3019 (270 Style) S 3071 (72 Style)
2.1 1.65 2.4

1 0.76 1.5
30 30
30
2 3 6
Oval
S 3083 (3083 Style) S 3084 (3084 Style)
2.5 3.75
1.6 1.8
5 5
1 5
Fig. 7.19 Silicone sleeves
5
80
3.77
S 1985-5
Width: 5.0 mm
Reduces extraocular bulge
Good buckle height
Smooth edges and surfaces
No sculpting needed
No exposed open cells contacing sclera
Consistent shape and size
Saves time
Fig. 7.22 Sutures for suturing of sponge
Fig. 7.20 Segmental sponges
80
5.28
S 1985-7
Width: 7.0 mm
Reduces extraocular bulge
Good buckle height
Smooth edges and surfaces
No sculpting needed
No exposed open cells contacing sclera
Consistent shape and size
Saves time Fig. 7.23 Sutures for suturing of sponge
Fig. 7.21 Segmental sponges
Fig. 7.24 Suture for conjunctiva Fig. 7.26 Zeiss microscope with Resight viewing
system
Fig. 7.25 Vitreoretinal OR with red neon light Fig. 7.27 We use a vacuum pillow which provides a cus-
tomized positioning and fixation of the patient’s head
7.5.6 Surgical Setup
For positioning of the head, we use a pillow
In our OR we use neon lights which we painted which stiffens around the patient’s head with the
with red colour in order to minimize bright white use of a vacuum pump (Germa AB, Sweden)
light on the OR field and in the microscope ocu- (Figs. 7.27 and 7.28).
lars. At the same time, it allows sufficient illumi- The typical surgical setup in our OR is a four-
nation for the staff (Fig. 7.25). We use a Zeiss port vitrectomy with chandelier light at the
Lumera microscope with Resight Biom viewing inferonasal position. An extra light fibre is fix-
system (Fig. 7.26). The 120D, 90D and 60D ated with a carbo band at the patient’s forehead
loupes can be changed as required during surgery. (Fig. 7.29). A very practical instrument is the
Fig. 7.30 (a, b) We work with 25G and 27G vitrectomy

(a). The trocar forceps (DORC) is useful for manipulation
of trocars (b)
Fig. 7.28 A vaccum pump removes the air from the pil-
low until is hard. The complete procedure takes a few sec-
onds (Germa, Sweden GE22393300000 55 × 30 cm)
Fig. 7.31 The standard instruments for a vitrectomy
trocar forceps from DORC (Fig. 7.30a) to

manipulate trocars during surgery (Fig. 7.30b).
The standard instruments for a vitrectomy are
depicted in Fig. 7.31.
Fig. 7.29 Typical surgical setup with chandelier light

fibre and handheld light fibre
Part III
Surgery
Surgical Techniques
8
Extras: Videos 8.1, 8.2, 8.3, 8.4, and 8.5. 15% C2F6 and 1000 cSt silicone oil. We use
very seldom C3F8.
3. Combined vitrectomy and episcleral buck-
8.1 t the University of Uppsala,
A ling: Here we combine a 25G or 27G vitrec-
We Employ the Following tomy with a segmental buckle.
Surgical Techniques 4. A retinotomy for recurrent detachments with
the foreshortened retina. The main indication
Easy detachment: is an inferior foreshortened retina.
5. We use Densiron 68 for inferior (recurrent)
1. Pneumatic retinopexy. detachments.
2. 25G and 27G combined phaco/vitrectomy
with chandelier light. As tamponade we use Two remarks: (1) In easy detachments we use
20% SF6 for breaks at the superior pole and only one technique and only one tamponade. (2)
15% C2F6 for breaks at the inferior pole. In complicated detachments we use several tech-
niques and several tamponades. This phenome-
Complicated detachment: non reflects the variety of surgical approach for
complicated detachments.
1. Episcleral buckling—We use a novel tech-
nique. Instead of working with a binocular
ophthalmoscope, we use only a microscope 8.1.1 Pneumatic Retinopexy
with viewing system and illuminate the retina (Fig. 8.1)
with a chandelier light.
2. 25G and 27G combined phaco/vitrectomy We perform pneumatic retinopexy only in supe-
with chandelier light. As tamponade we use rior retinal detachments with attached superior
temporal arcade and a hole between 10 o’clock
and 2 o’clock (Fig. 8.1). Retinal breaks at 3 and
Electronic Supplementary Material The online version 9 o’clock can also be treated with pneumatic
of this chapter (https://doi.org/10.1007/978-3-319-78446-
retinopexy but require 3-day positioning. As
5_8) contains supplementary material, which is available
to authorized users. technique we work without binocular ophthal-
moscope. We insert instead a chandelier light
U. Spandau (*) · Z. Tomic
Department of Ophthalmology, University of Uppsala and perform the cryopexy and gas injection with
Hospital, Uppsala, Sweden the microscope and viewing systems.

https://doi.org/10.1007/978-3-319-78446-5_8
8.1.2 Episcleral Buckling bullous inferior detachment with a small hole at

(Figs. 8.2 and 8.3) 11 o’clock (Fig. 8.2). You perform cryopexy and
suture a sponge on the hole at 11 o’clock. No
Episcleral buckling is an excellent method to drainage. On the very next day, the subretinal
operate retinal detachment (RD) because you can fluid has completely disappeared (Fig. 8.3) dem-
repair almost all RDs with episcleral buckling onstrating two phenomenons: Firstly, the RPE is
using a very little amount of material. Secondly, a very powerful cell layer in removing subretinal
doing episcleral buckling you understand the fluid. Secondly, a retinal detachment is not a
pathophysiology of RDs. An example is a highly static but a very dynamic process. The whole
time old subretinal fluid is removed, and at the
same time, new subretinal fluid flows inside the
hole. If you want to learn detachment surgery,
start with episcleral buckling.
We apply the minimal buckling technique
from Lincoff/Kreissig: cryopexy, segmental
buckle, and no drainage. We work without bin-
ocular ophthalmoscope and operate only with
microscope and viewing system (Fig. 8.3). We
suture also the silicone sponge under the micro-
scope. We use only segmental silicone sponges
and never use encircling bands (tyres). The indi-
cation for episcleral buckling is children, young
myopics, ora dialysis and old chronic
detachments.
Remark: Episcleral buckling is not only via-
Fig. 8.1 Our setup for pneumatic retinopexy. If the reti-
nal break is located superior, we insert the chandelier light ble for phakic patients and eyes with attached
inferior. The retina is viewed with a BIOM system posterior hyaloid. Episcleral buckling can be
a
b
Fig. 8.2 (a) A highly bullous retinal detachment with a tiny hole at 1 o’clock. (b) A radial sponge at 1 o’clock reat-
taches the retina after 1 day
8 Surgical Techniques 81
Fig. 8.3 A chandelier light illuminates the retina. Note

the holding sutures. The retina is examined with a viewing Fig. 8.4 A normal setup for a vitrectomy with 25G or
system, and the sponge is sutured under view of the 27G: four-port vitrectomy with chandelier light
microscope
used in all eyes: pseudophakic eyes, eyes with

PVD, and vitrectomized eyes. Episcleral buck-
ling can also be employed in PVR detachment
stages B and C.
8.1.3 Vitrectomy (Fig. 8.4)
We perform always a four-port vitrectomy

(Fig. 8.4): one infusion trocar, two instrument
trocars, and one chandelier light. We operate
only with 25G or 27G. 27G has smaller scle-
rotomies than 25G and is therefore better for
highly myopic eyes. In the case of a presbyopic Fig. 8.5 Note the 27G trocar (Alcon). A circumferential
lens, we perform a combined phaco/vitrectomy. 90° buckle is sutured onto the sclera
A lens-sparing vitrectomy is employed in
patients younger than 50 years. In the case of 68. We rarely use 5000 cSt, for example, for per-
PVR, we remove the membranes bimanually. manent silicone oil tamponades.
We rarely use the technique encircling band/
tyre with C3F8 tamponade. Our rationale for this
is according to the silicone oil study, C3F8 is equal 8.1.4 Combined Vitrectomy
to silicone oil and SF6 worse than silicone oil [1]. and Episcleral Buckling
According to our experience, an encircling band (Fig. 8.5)
(tyre) with gas is equal to silicone oil, and a tyre
with silicone oil is better than a tyre with gas. For The main indication for this technique is a PVR
this reason we use a routine silicone oil without stage C detachment, a recurrent detachment, and
encircling band. a foreshortened retina. A 25G or 27G vitrectomy
As gas tamponades, we use only SF6 and C2F6. is combined with a segmental buckle. In most
We never use C3F8 because it causes ocular irrita- cases, a 90° circumferential buckle is placed on
tion and inflammation. As silicone oil tampon- the inferior equator. As tamponade we use gas or
ades, we use 1000 csts silicone oil and Densiron silicone oil tamponade.
Fig. 8.6 An inferior 180° retinotomy in case of inferior

detachment with intraretinal PVR
8.1.5 Retinotomy (Fig. 8.6)
The main indication is an inferior foreshortened

retina. In most cases, we perform a 180° retinot-
omy from 3 o’clock over 6 o’clock to 9 o’clock.
As tamponade we use 1000 csts silicone oil or a Fig. 8.7 Densiron 68 from Fluoron (Geuder) is a silicone
Densiron 68 tamponade. oil which tamponades the inferior pole
In this book we will demonstrate a technique

8.1.6 Densiron 68 (Fig. 8.7) for episcleral buckling surgery for which a
indirect ophthalmoscope is not needed. In our
The main indication is a primary inferior detach- clinic we operate 90% of all primary detach-
ment (Lincoff type 3) and an inferior recurrent ments with vitrectomy. Episcleral buckling is
detachment. Densiron 68 is as easy to use as mainly reserved for young patients or compli-
1000 or 1300 csts silicone oil. We inject Densiron cated cases. We use almost exclusively a seg-
68 always in an air-filled eye, and you achieve an mental buckle (radial or circumferential) and an
excellent tamponade of the inferior pole. We encircling band (tyre) we use seldom, maybe six
remove the oil after 6–12 weeks. The side effects times per year. But, if you operate retinal detach-
are the same as for 1000 csts silicone oil. ments, you must be capable to operate with epi-
scleral buckling. The healing rate of an ora
dialysis with episcleral buckling is 100%; it is
8.2 Buckle or Vitrectomy difficult to find an explanation, if you perform a
vitrectomy instead.
Episcleral buckle is in our experience a very The scleral buckling technique is superior to
powerful surgical tool which can treat success- vitrectomy regarding reattachment rate and PVR
fully easy and complicated retinal detachments. (Table 8.1) [2]:
It can even be used for retinal detachment grades Today the huge majority of retinal detach-
B and C. The visualization of the hole and the ments are operated with vitrectomy. The tech-
marking of the hole on the sclera are, however, nique of episcleral buckling disappears more and
technically difficult. more. This notion is confirmed by the retinal
Table 8.1 Scleral buckling has a higher attachment rate 8.3 Retinal Detachment
and causes less PVR
and Small-Gauge Vitrectomy
Scleral buckling (%) Vitrectomy (%)
Reattachment 93 87 We started to operate vitrectomies with 20G scle-
rate
rotomies. 20G sclerotomies have a diameter of
PVR rate 1 5
0.9 mm (see Table 8.3). In 2006 we switched to
23G trocar vitrectomy. We used trocars with
Table 8.2 Advantages and disadvantages of episcleral valves from DORC. We were very satisfied and
buckling and vitrectomy
could not imagine at all to switch to 25G. Then
Advantages Disadvantages
we started to operate membranes with 25G and
Episcleral Exact sealing of Technically
segmental hole possible difficult
had some problems with the softer peeling for-
buckling ceps. We returned to 23G but tried again 25G for
Excellent Ametropia myopic eyes. This was a clear improvement
impression of because less postoperative hypotony occurred.
hole And successively we switched completely to
Fast visual Difficult
rehabilitation visualization with
25G.
binocular Then 27G came up and again we thought that
ophthalmoscope we would never use 27G. 27G has a diameter of
Little PVR 0.41 mm. But a few ROP cases forced us to use
Easy 27G. And then we used 27G for myopic eyes, and
visualization of
retina with
27G proved to be superior for myopic eyes com-
microscope and pared to 25G. Regarding peeling surgery, we
chandelier light could not see an advantage. But in retinal detach-
Vitrectomy Easy Long visual ment surgery, 27G was again superior to 25G
visualization rehabilitation with because in 27G there is no leakage from the scle-
with microscope long-lasting gases
rotomies. At the end of surgery, the globe has a
Technically not Sealing of hole less
difficult effective with gas normal tonus, without sutures and without rein-
than with buckle jecting gas. In addition, the lack of leakage results
No ametropia Higher PVR risk in a prolonged gas tamponade.
than episcleral Today we operate all our cases with 27G. 27G
buckling
is in our experience the best gauge for the experi-
Excellent method
for easy enced vitreoretinal surgeon. The soft instruments,
detachments however, are a disadvantage which must be
solved in the future.
detachment database from the University of

Umeå, Sweden (see Chap. 4). The database Table 8.3 Outer diameter of a needle in gauge and mm
shows that in 2010 one third of the retinal detach-
Gauge External diameter in mm
ments were operated with episcleral buckling and
17 1.4
in 2015 only 10%. One reason is that young reti- 19 1.07
nal surgeons do not learn to visualize the retina 20 0.9
with the indirect ophthalmoscope and that the 23 0.64
visualization of the retina with the microscope is 25 0.51
much easier. 27 0.41
The advantages and disadvantages of both 29 0.34
techniques are listed in Table 8.2. 30 0.30
Fig. 8.8 The inner and

outer size of the 23G,
25G, and 27G trocar
(Alcon) Inner diameter: 23G
Outer diameter: 22G
Inner diameter: 25G

Outer diameter: 23G
Inner diameter: 27G

Outer diameter: 25G
8.3.1 Does Size Matter? Table 8.4 Advantages and disadvantages of 27G
Advantages of 27G
We are convinced that size does matter. Size # A 27G trocar induces a 25G sclerotomy. A 23G
was the major motivator to switch from ECCE trocar induces a 22G sclerotomy. A 22G sclerotomy is
more prone to leakage of fluid and gas than a 25G
to phacoemulsification. The small incisions of sclerotomy.
phacoemulsification are better in almost all # No sutures, no suture granuloma
aspects than the gaping wound of ECCE: faster # No postoperative irritation and foreign body
postoperative recovery, improved visual sensation
results, less astigmatism, and a watertight • Fast healing
# Less leakage
globe. • Less postoperative hypotony
The same principle applies for vitrectomy. 27G • Improved gas tamponade
trocars create sclerotomies with a size of 25G. # Small instruments
23G trocars, however, create a sclerotomy with a • Atraumatic surgery
size of 22G (Fig. 8.8). After removing 27G trocars, Disadvantages of 27G
the globe has a normal tonus (without a gas fill- # Soft instruments
ing). To achieve the same effect for 23G, you need
a gas filling. And even with a gas filling, the eye But 27G is the only sutureless vitrectomy, not
has often a low tonus directly after surgery. In 27G 25G, not 23G. 27G is the only gauge where
the small sclerotomies induce an improved post- sutures are not required. In contrast, 25G and
operative gas filling and less leakage which is even more 23G sclerotomies require often
important for retinal detachment surgery. sutures. If you operate a myopic patient for
Smaller trocars result in smaller instruments. retinal detachment, then you need no sutures
It is obvious that the small 27G instruments for 27G. And sutures result quite often in con-
induce less intraoperative trauma and result in a junctival granulomas, which are very irritating
faster postoperative recovery. for the patient.
When talking about small-gauge vitrec- The principle “the smaller the Gauge, the bet-
tomy, we mention often sutureless vitrectomy. ter” is evident (see Table 8.4).
8.3.2 he Dilemma of the Law

T also for aspiration and infusion rates. These obvi-
of Hagen–Poiseuille ous disadvantages of 27G became obsolete after
a novel type of vitreous cutter was introduced.
But physics are against small-gauge vitrectomy and The companies DORC (the Netherlands) and
27G. The Hagen–Poiseuille equation states that the Geuder (Germany) developed this novel double-
flow is proportional to the fourth power of the inter- cut citreous cutter.
nal diameter of a lumen (see Table 8.5). The flow in
23G is 3.65 times slower than in 20G. The flow in
27G is 12.5 times slower than in 23G. 8.3.4 History of Double-Cut
If the performance of a 23G cutter is 100%, Vitrector
then a 25G cutter has approximately 30% less
performance and a 27G cutter approximately The initial idea for the novel vitreous cutter
30% less performance (Table 8.6). came from Hayafuji and colleagues from Japan
This physical obstacle has been overcome in 1992 (see Table 8.7). After a journey of trial
with powerful vitrectomy machines and novel and errors, the final vitrector was developed in
vitreous cutters with double-cutting frequency 2013 from DORC. This new vitreous cutter has
and permanent flow. The novel double-cut vitrec- two open cutting ports and a second cutting
tor has made 27G to a fierce competitor of 23G. blade. It is named twin duty cycle (TDC) cutter
(Fig. 8.9). This new invention comprises two
new features: (1) a permanent flow and (2) two
8.3.3 27G and Double-Cut Vitreous cutting blades.
Cutter
A 27G vitrectomy was developed in 2010 from 8.3.5 he New TDC Cutter Is Much
T
Oshima and colleagues in Japan. The old 27G Faster than the Regular Cutter
cutter had lower fluid dynamics and less cutting
efficiency than a 25G cutter. The same applied The two cutting blades have the result that the
cutter cuts two times during one movement,
Table 8.5 Hagen–Poiseuille equation (flow ≈ diameter4) effectively doubling the cutting speed. The vitre-
and its relevance for vitrectomy ous cutter has a cutting rate of 8000 cuts/min. But
Internal diameter the actual cutting rate with two cutting blades is
Gauge in mm 8000 × 2 = 16,000 cuts/min, which reaches new
23 0.39 3.65 × less flow than 20G dimensions. The second novelty is a continuous
25 0.29 2.8 × less flow than 23G and even flow due to the two open cutting ports.
27 0.20 12.5 × less flow than 23G This novel technology reduces vitreous traction,
Table 8.6 Performance comparison of a regular and TDC cutter in relation to the gauge. Measured is the aspiration
time of artificial vitreous (Courtesy of DORC)
Performance comparison
23G 25G 27G
100% 70% 30%
–30% –30%
Table 8.7 Historical development of TDC cutter (Photo decreases the surgical time, and increases the
courtesy of DORC) safety of surgery (see Table 8.8).
Year Description Image
First M. Hayafuji
idea Y. Hanamura
(1992) S. Niimura 8.3.6 7G, 25G, and 23G and PVR
2
Detachment
Can 27G only be used for easy detachments and

DORC Vitreous shaver not for complicated detachments? Nowadays, all
(1996) with 3 required intravitreal instruments such as scissors,
adjustable (slit)
aspiration ports forceps, and delamination instruments are avail-
Luiz New dual port able in 27G. Regarding silicone oil removal or
Lima cutter system silicone oil injection, we insert a 25G trocar for
(2010) this step. So, there is no hinder to employ 27G for
difficult PVR detachments.
Rizzo Extra aspiration # 27G is very useful for the following
(2011) port in internal
capillary pathologies:
DORC Twin duty cycle
(2013) vitrectome 1. Myopic eyes: No sutures necessary, excellent
tamponade
First blade (old) Second blade (new)
Second opening (new)
First opening
(old)
Fig. 8.9 The novel

TDC cutter with two
blades (Photo courtesy
of DORC)
Table 8.8 Performance comparison of TDC cutter vs. regular cutter (Courtesy of DORC)
TDC cutter Regular cutter Comparison
23G TDC 23G regular 164% faster

2.
Easy retinal detachment: Tight globe, less Conclusion
leakage resulting in better tamponade 27G is superior to 25G and 23G for easy reti-
nal detachments because the small sclerotomies
=>These are eyes which tend to have a postop- minimize leakage and result in a prolonged gas
erative hypotony and make them therefore excel- tamponade. In addition, the small 27G instru-
lent candidates for 27G. ments are less traumatic resulting in less surgi-
# 27G is less useful for the following cal trauma and faster postoperative recovery.
pathologies: The disadvantage of 27G is the softness of the
instruments making the removal of the periph-
1. Difficult retinal detachments with PVR and eral vitreous more difficult. 25G and 23G are a
silicone oil tamponade: The soft instruments better choice for difficult retinal detachments
make the removal of peripheral membranes because the stiff instruments function well in
difficult, and the injection and removal of sili- the periphery and the injection and removal of
cone oil with 27G are time-consuming. silicone oil are fast. Therefore, 25G may be a
2. Silicone oil removal: Less postoperative good compromise having stiff instruments and
hypotony compared with 23G but long surgi- small sclerotomies. 23G is in our perspective
cal time. no longer required.
# 25G is very useful for the following

pathologies:
References
1. Difficult retinal detachments with PVR and 1. Vitrectomy with silicone oil or sulfur hexafluoride
silicone oil tamponade: The 25G instruments gas in eyes with severe proliferative vitreoretinopa-
are stiff enough to remove peripheral thy: results of a randomized clinical trial. Silicone
membranes. Study Report 1. Arch Ophthalmol. 1992;110(6):
770–9.
2. Silicone oil removal: Less postoperative 2. Kreissig I. A practical guide to minimal surgery for
hypotony compared with 23G and fast surgi- retinal detachment. Germany: Thieme; 2000. ISBN
cal time. 9783131606914
Pneumatic Retinopexy with BIOM
9
Extras: Video 9.1.
9.1 Introduction
In a focal detachment with a retinal break between

10 and 2 o’clock and an attached superior arcade, we
would operate with a pneumatic retinopexy
(Fig. 9.1). There are two possible techniques: (1)
binocular ophthalmoscopy with helmet or (2) the
microscope with BIOM and insertion of a chandelier
light. We describe the second method.
9.1.1 he Surgery Step-by-Step:

T
Figs. 9.2, 9.3, 9.4, 9.5, and 9.6
1. Insertion of a chandelier light (Figs. 9.2 Fig. 9.1 A focal retinal detachment from 11 to 1 o’clock
and two retinal breaks at 12 o’clock
and 9.3)
2. Flick in the BIOM (Fig. 9.4)
3. Cryopexy of the break (Fig. 9.5)
Insert the chandelier light on the opposite side

of the break. If the break is localized at 12
o’clock, then insert the chandelier light at 6
o’clock. Flick in the BIOM, localize the break,
and freeze the break edges with cryopexy.
Electronic Supplementary Material The online version

Hospital, Uppsala, Sweden Fig. 9.2 Insertion of chandelier light

https://doi.org/10.1007/978-3-319-78446-5_9
Fig. 9.5 Cryopexy of the retinal break

Fig. 9.3 Insertion of chandelier light (Synergetics, USA)
Fig. 9.4 Flick in the BIOM Fig. 9.6 Injection of 0.5 ml 100% SF6
4. Removal of the chandelier light 9.1.2 Complications (Fig. 9.7a, b)

5. Paracentesis
6. Injection of air or gas (Fig. 9.6) Sometimes an inferior detachment occurs. In
most cases, a retinal break cannot be found, and
Remove the chandelier light. A suture (Vicryl the cause is therefore most likely a tractive
8–0) of the sclerotomy may be necessary. Perform detachment. In this case we would perform a
a paracentesis and drain aqueous from the ante- 25 G or even better 27 G vitrectomy + laser + C2F6
rior chamber. Then inject 0.5 ml 100% SF6 into tamponade. This complication occurs mainly in
the vitreous cavity. young patients with attached posterior vitreous.
9.1.1.1 Tips and Tricks

Air as tamponade: Air is an excellent alternative 9.1.3 AQ: What Is the Reason
F
to SF6. The duration of an air tamponade is maxi- for an Inferior Detachment?
mal 1 week. A shorter tamponade duration
reduces the risk for complications such as a trac- It only occurs in eyes with attached posterior vit-
tive detachment. Use air for a hole between 11 reous. The gas bubble pushes the superior vitre-
and 1 o’clock. ous against the retina and pulls the inferior
9 Pneumatic Retinopexy with BIOM 91
a b
Fig. 9.7 (a, b) A typical complication. The gas bubble compresses the vitreous body at the superior pole and pulls at
the vitreous body at the inferior pole (a). The inferior traction may cause an inferior detachment (b)
posterior vitreous resulting in an inferior detach- Can I perform pneumatic retinopexy with
ment (Fig. 9.7). laser instead of cryo?
Remember: Pneumatic displacement in old Yes, you can. Perform a paracentesis and drain
patients secondary to submacular hemorrhage anterior chamber fluid. Then inject 0.5 ml 100%
never results in a retinal detachment because the SF6 into the vitreous cavity. One day later, when
posterior vitreous is detached. the retinal break is attached, you can perform
How high is your success rate? lasercoagulation.
Ninety percentage, but remember, we use a
very restricted indication with breaks only from
10 to 2 o’clock.
Combined Phaco/Vitrectomy
for Easy Retinal Detachment 10
Extras: Videos 10.1, 10.2, 10.3, 10.4, 10.5, indented with the scleral depressor: Nobody
and 10.6. indents as well as your second hand.
10.1 Introduction 10.1.1 PFCL or No PFCL?
A rhegmatogenous retinal detachment (RRD) Some vitreoretinal clinics use PFCL as a routine;
with multiple breaks is a surgery for experienced others hate it. PFCL is an excellent tool for vit-
surgeons, as there is a significant complication reoretinal surgery and we recommend using it, if
profile. The beginner should start with a localized necessary. We use PFCL in large, macula-off
detachment (1–2-quadrant detachment and a sin- detachments, and we work without PFCL in
gle break), as this is usually easier to manage. focal, macula-on detachments. In giant tears we
Regarding surgery we recommend two things, always use PFCL due to the risk of slippage.
which simplify vitrectomy very much: phaco-
emulsification and usage of a chandelier light.
We recommend performing a phacoemulsifica- 10.1.2 25 G or 27 G?
tion in all patients older than 50 years because the
anterior vitreous and the vitreous base can be 27 G is superior to 25 G in myopic eyes. 27 G
removed completely (Fig. 10.1). Secondly, we sclerotomies require no suture. Myopic eyes tend
recommend the usage of a chandelier light to leak and 27 G sclerotomies have only minimal
because it facilitates every step of the vitrectomy. leakage. Minimal leakage results also in improved
Visualization and removal of the vitreous base is gas tamponade. In deep eyes it is difficult to reach
easier with chandelier light. The retinal breaks the vitreous base with the 27 G vitreous cutter;
are located in the periphery and need to be here a 25 G vitreous cutter is recommended.
10.2 The Surgery Step by Step

Electronic Supplementary Material The online version Instruments
to authorized users. 1. 25/27 G three-port trocar system
2. Chandelier light
Department of Ophthalmology, Uppsala University 3. 120D lens
Hospital, Uppsala, Sweden 4. Endodiathermy

https://doi.org/10.1007/978-3-319-78446-5_10

algorithm for retinal Primary retinal detachment
detachment surgery
Phakic Pseudophakic
> 50 yrs < 50 yrs
Phaco No Phaco
PPV
Small Large
detachment detachment
Fluid x air Injection of

exchange PFCL and laser
Laser Fluid x air

treatment exchange
Tamponade
5. Endolaser 3. Core vitrectomy and posterior vitreous

6. Backflush instrument detachment
7. Scleral depressor 4. Marking of breaks with endodiathermy
5. Injection of PFCL up to the posterior edge of
Dye the break and drainage of subretinal fluid
Possibly: Triamcinolone to stain the vitreous 6. Vitrectomy of the break flap and the periph-
Tamponade eral vitreous
Intraoperative: PFCL 7. PFCL injection up to ora serrata
Postoperative: 20% SF6, 15% C2F6 8. Laser photocoagulation around breaks
9. Trimming of the vitreous base (shaving)
10. Fluid/air exchange
10.3 Individual Steps 11. Drainage of subretinal fluid
12. Complete lasercoagulation
1. 25 G/27 G three-port system with chandelier 13. Gas tamponade
light 14. Removal of trocars
2. Phacoemulsification with IOL 15. Postoperative posture
10 Combined Phaco/Vitrectomy for Easy Retinal Detachment 95
5 G/27 G Three-port System with Chandelier

2 Corneal suture: In case of an unstable anterior
Light (Fig. 10.2) chamber, place a single 10-0 nylon suture at the
Insert the trocars at the usual locations 3.5 mm end of the phaco and IOL. This avoids accidental
behind the limbus. Visualize the location of the opening of the corneal wound during indentation,
infusion cannula in order to avoid a choroidal which may lead to flattening of the anterior
detachment. Then insert the chandelier chamber and even dislocation of the IOL. The
light inferonasally 3.5 mm behind the limbus. suture can be removed once the vitrectomy has
been completed.
Phacoemulsification
The IOL can be implanted in this step or later Tips and Tricks
when all the breaks are treated (step 10). The Corneal lubrication: A major problem during vit-
advantage of early IOL implantation is that one rectomy, especially in combined surgeries with
works with a stable anterior segment and the IOL duration of over 1 h, is corneal epithelial edema.
implantation is usually easier at this stage com- With generous application of methylcellulose
pared to the end of the surgery. The disadvantage (Celoftal, Alcon), the cornea remains clear for
is that the edge of the IOL may interfere with the the complete surgery.
view of the retinal periphery and the vitreous
base. ore Vitrectomy and Posterior Vitreous
C
Detachment
Tips and Tricks Perform a core vitrectomy, and identify the pos-
Phaco or no phaco: If a cataract is present, then terior vitreous face to verify that a PVD is pres-
remove it during the same surgery. Why? The ent. If the vitreous is still attached, perform
vitrectomy and the gas tamponade will increase induction of a PVD. Then continue with vitrec-
the lens opacification resulting in a bad view to tomy, and search for retinal breaks. Carefully
the retina. The risk that you miss a recurrent remove the vitreous close to the retina in the area
detachment is high especially if it is inferior. of detached, fluttering retina.
Tips and Tricks Tips and Tricks

PVD in RRD: In about 15% of patients with
RRD, the vitreous is still attached at the posterior
pole. One group at risk is myopic patients below
the age of 50 years with multiple small round
breaks. The vitreous may be very adherent to the
retina in such cases, and trying to induce a PVD
can lead to multiple iatrogenic breaks. These
cases usually do very well with scleral buckling
surgery. If in doubt, check the status of vitreous
attachment/detachment with preoperative ultra-
sound before deciding to perform a vitrectomy.
Tips and Tricks

Triamcinolone and RRD: Many cases of RRD are
Fig. 10.2 Our regular setup for retinal detachment.
caused by strong vitreoretinal adhesion. It may
Three-port vitrectomy and one chandelier light at the not be possible to separate the vitreous and retina
inferonasal position simply by engaging the vitreous with the vitreous
cutter and pulling it off the retina—you may retinal break at the entry site of the Schlieren in
enlarge pre-existing breaks or induce iatrogenic cases of “unseen breaks.”
breaks in some cases. If you find very strong vit-
reoretinal adhesions, it is advisable to “stop pull-
I njection of PFCL to Posterior Edge of Break
ing” and start “shaving” the vitreous of the retina.
and Drainage of Subretinal Fluid
This is facilitated by staining the adherent vitre-
The PFCL has three tasks in detachment
ous with triamcinolone. When staining the vitre-
surgery:
ous with triamcinolone, use minimal amounts
and direct the injection to the area of interest. We
1. Stabilization of the mobile retina
dilute triamcinolone 1:3 with BSS. Injecting too
2. Removal of the subretinal fluid
much triamcinolone may interfere with your
3. Elevation of the peripheral vitreous
view, and it can be cumbersome to remove this
later on in the procedure.
The PFCL pushes the subretinal fluid from the
central pole toward the periphery and presses it
ark the Breaks with Endodiathermy (Figs. 10.3
M through the retinal break into the vitreous cavity.
and 10.4) First, the PFCL is injected up to the posterior
The key concept of all retinal detachment surger- edge of the most central break, while we observe
ies is to identify and treat all retinal breaks. how the subretinal fluid is forced through the
Perform a thorough internal search for breaks break into the vitreous cavity. You can accelerate
following Lincoff’s rules that point to the most this step by aspirating subretinal fluid actively
likely areas of retinal breaks. If you fail to iden- with the Charles flute needle (Figs. 10.5 and
tify and treat a retinal break in detached retina, 10.6). The PFCL also has the effect that the
failure and retinal redetachment following vitrec- mobile retina is attached, and a vitrectomy in the
tomy are guaranteed. Mark the edges of the break vicinity of the detached retina is less dangerous.
with endodiathermy. A break, which is not
marked, is hard to identify when it is attached to
Tips and Tricks
the underlying retinal pigment epithelium.
PFCL is quite expensive. In more complicated
cases, it may be necessary to perform multiple
Tips and Tricks manipulations under PFCL, occasionally remov-
Unseen breaks and Schlieren phenomenon: Inject ing and then again adding PFCL at a later stage.
PFCL slowly and watch for the “Schlieren phe- If PFCL needs to be removed, you can easily
nomenon.” In particular in long-standing RRD,
the subretinal fluid appears like a muddy stream
when entering the vitreous cavity. This “Schlieren
phenomenon” may point to the location of the
Fig. 10.4 After diathermy of the retinal edges, the retinal

Fig. 10.3 The retinal break is hard to visualize break is easy to visualize
aspirate it back into the injection syringe for rein- you can drain the residual subretinal fluid with a
jection at a later stage of the procedure. complete PFCL fill. However, if the break is
located between the equator and ora serrata, then
a complete drainage of subretinal fluid is not pos-
itrectomy of the Tear Flap and the Peripheral
V
sible. The subretinal fluid is trapped between the
Vitreous
break and the ora serrata (Figs. 10.7 and 10.8). In
After ensuring the presence and completion of a
the first case, you can proceed with laser photo-
PVD, the next step is to perform a trimming of
coagulation. In the latter case, a complete laser-
the vitreous base. Start within the area of the
coagulation is not possible because the retinal
break(s), and also remove the flap, as the vitreous
break is partially detached. You can perform a
traction on the flap caused the detachment. The
partial laser photocoagulation and complete the
scleral depressor in the second hand is a great
laser after the fluid/air exchange in step 10.
help when indenting the retina.
Tips and Tricks

PFCL Injection up to Ora Serrata
Iatrogenic break: If the retinal break and the bul-
Depending on the anterior/posterior location of
lous detachment are far apart from each other, it
the break, there is more or less subretinal fluid
anterior to the break (trapped fluid) (Figs. 10.7
and 10.8). If a break is located at the ora serrata,
Trapped fluid
break
PFC
Fig. 10.7 PFCL flattens the retina and anterior trapped

fluid is present
Fig. 10.5 Injection of PFCL and at the same time aspira-
tion of subretinal fluid from the retinal break
Backflush
instrument
Trapped
fluid
PFC
Fig. 10.6 Aspiration of subretinal fluid from retinal

break Fig. 10.8 Much trapped fluid is visible
is difficult to drain the subretinal fluid from the tion site for the formation of new retinal breaks.
break. In the first case, one can try to massage the They may also cause contraction of the choroid or
subretinal fluid with a scleral depressor to the even choroidal hemorrhages. A typical beginner’s
break. Or perform an iatrogenic break in the area mistake is to perform too much laser or cryother-
of trapped fluid. Mark the inferior retina close to apy as an extra safety measure that then may turn
the ora serrata with endodiathermy. Then cut a out to have exactly the opposite effect.
hole with the vitreous cutter (setting, approx. 300
cuts/min) by suctioning the retina and then cut-
Tips and Tricks
ting it cautiously. Drain the subretinal fluid from
Laser cerclage: A circumferential 360° laser is
this break. Another alternative is the aspiration of
not recommended. It is essential to identify and
the subretinal fluid with a 41 G cannula.
treat all retinal breaks. A circumferential laser
has the big disadvantage that in case of a rede-
Laser therapy of Breaks (Fig. 10.9) tachment, the breaks are difficult to find within
Apply three rows of laser burns around the the patches of chorioretinal atrophy.
breaks. The settings depend on the laser device.
It is possible that subretinal fluid has accumu-
Tips and Tricks
lated anterior to the break (so-called trapped
Laser necrosis: Another complication of laser is a
fluid) which makes it difficult to apply a laser
retinal necrosis. Too high laser intensity may cause
onto the anterior part of the break. Try to indent
a necrosis of the retina and small, difficult-to-find
the break with the scleral depressor so that the
holes. These tears occur often at the outer edge of
subretinal fluid is pushed away. Apply white laser
the laser treatment. The same applies for cryopexy.
burns. A good alternative is to freeze the break
with a cryoprobe. If you do not succeed due to
excess trapped fluid, then complete the laser rimming of Vitreous Base (Shaving) (Figs. 10.10
T
treatment in a later step. and 10.11)
If it has not been performed before, a thorough
vitrectomy of the vitreous base has to be per-
Tips and Tricks
formed at this stage using the scleral depressor.
Laser: Be careful with your laser energy. Only a
This procedure is also called “shaving.” PFCL
mild whitening of the RPE is necessary. 200 ms
lifts the vitreous up and enables a secure and thor-
duration is sufficient; 300 ms is too much, and you
ough trimming of the vitreous base. In those
may create a laser necrosis. Burns which are too
areas, where PFCL does not rest on the retina,
strong will weaken the retina and are a predilec-
there is vitreous which has to be removed. Indent
the sclera and move the vitreous cutter along the
meniscus of the PFCL. Hereby you can maneuver
the vitreous cutter very close to the retina because
the heavy liquid presses against the retina.
Tips and Tricks

Trimming of vitreous base: There are various ways
to trim the vitreous base: (a) bimanual technique
using a scleral indentor, (b) removal under coaxial
light (only with microscope illumination) by using
a cotton wool swab or a scleral depressor to indent
the sclera, or (c) using the light fiber as an external
scleral depressor (this gives you a focused beam of
Fig. 10.9 Laser treat the complete hole after removal of light transsclerally to illuminate the vitreous base).
subretinal fluid
air is bad. Therefore, it is essential to understand the

characteristics of PFCL and air. PFCL and air
“work” as antagonists. Air exerts a pressure in the
eye from peripheral (anterior) to central (posterior)
but PFCL vice versa from posterior to anterior.
PFCL presses most of the subretinal fluid from
the central pole to the periphery through the retinal
break into the vitreous cavity, but a part of it flows
beyond the break up to the ora serrata, where it
cannot be aspirated (“trapped fluid”) (Figs. 10.7
and 10.8). This “trapped fluid” can, however, be
removed with air: The air attaches the retina,
beginning in the periphery and ending at the cen-
Fig. 10.10 Observe the “empty space” between the ret-
tral pole, and thereby pushes the “trapped fluid” in
ina and PFCL. The empty space is vitreous
the direction of the break (Figs. 10.12 and 10.13).
Tips and Tricks

Air test for detachment: When the retina is com-
pletely attached under air, you have drained the
subretinal fluid completely. Air presses the entire
subretinal fluid from the periphery to the optic
disc, where it is easy to spot. This is only partly
true for PFCL because PFCL pushes the subreti-
nal fluid from the posterior pole to the periphery,
where the “trapped fluid” is hard to detect.
Remark: PFCL attaches the retina by its specific
gravity (specific gravity of PFCL = 1.75,
Densiron 68 = 1.06). Air, in contrast, attaches the
Fig. 10.11 Remove the peripheral vitreous and the PFCL
will attach onto the retina retina due to its high surface tension pressure.
Fluid Against Air Exchange Drainage of Subretinal Fluid

If the shaving is finished, a PFCL × air exchange is How do we proceed in practice? Before you
performed. Before we perform this procedure, we switch to air, hold the flute tip in the middle of
have a look at Diagram 10.1, to get a better sense of the break. If necessary, take the scleral depres-
the situation in the vitreous cavity. Before the sor to help. If several breaks are present, start
PFCL × air exchange, the vitreous cavity is filled with the most peripherally located break, and
with PFCL, and on top of it is a layer of water. then move to the next more central break
During the PFCL × air exchange, there is an ante- (Fig. 10.14). Now, the scrub nurse switches the
rior phase of air, a middle phase of water, and a pos- three-way tap from water to air. In the begin-
terior phase of PFCL. After the PFCL × air ning, disturbing air bubbles arise and the view
exchange, only air is in the eye, which is then deteriorates. Remain calm and turn the front
replaced by gas. Postoperatively, water will accu- lens with the BIOM-focus wheel up. The visi-
mulate again under the gas phase. Consequently, the bility will gradually improve.
gas does not effectively tamponade the lower pole. In the beginning the break is covered with
The PFCL × air exchange is certainly the most PFCL. After a short time, the PFCL is suctioned
difficult and most important maneuver in the whole to the posterior edge of the break. Now the air
detachment surgery, mainly because visibility under presses the subretinal fluid in the direction of the
Diagram 10.1 Diagram Postoperatively

Intraoperatively
of the location of fluids
during the PFCL × air PFCL xair exchange
exchange
Before During After
BSS Air Gas Gas
BSS
PFCL PFCL Aqueous
at the same time the water phase between air and

PFCL (Figs. 10.12, 10.13, and 10.15).
Only when the “trapped fluid” and the water
Subretinal fluid phase in the vitreous cavity are completely aspi-
Air rated, can you continue to aspirate PFCL beyond
Backflush
instrument the posterior edge of the break. This is very
important because the subretinal fluid, which you
BSS
do not aspirate, will continue to flow beyond the
PFC break in the direction of the optic disc.
If the “trapped fluid” is completely removed,
you switch with the flute needle alternately
between the PFCL bubble in order to reduce it
and the break in order to aspirate fluid here.
Fig. 10.12 Sandwich tamponade with air and Try to aspirate without indenting the break.
PFCL. Aspirate first BSS and then PFCL until the PFCL But sometimes you can only reach the break
meniscus reaches the posterior edge of the hole with the flute needle if you indent it with the
scleral depressor. But you should not indent
the break itself but the retina on either side of
the break. By indenting the break, you close it
and prevent the aspiration of subretinal fluid.
Backflush
instrument This procedure is usually not easy and requires
Air patience.
The remaining PFCL is aspirated by holding
the flute tip directly in front of the optic disc.
Make sure that the PFCL is completely removed
PFC and that neither the retina nor the optic disc is
affected.
If after complete removal of PFCL, residual
subretinal fluid remains in the central pole, then
you may either inject PFCL again up to the break
Fig. 10.13 If the PFCL has reached the inferior edge of
and aspirate the fluid or—if it is only a small
the retinal break, then aspirate the subretinal fluid. Then
you can continue to remove the residual PFCL amount—leave it. The subretinal fluid will be
absorbed on the first postoperative day.
break. The subretinal fluid is trapped between
anterior-located air and posterior-located PFCL, Tips and Tricks
the so-called sandwich tamponade. Now you Active aspiration: In 25 G/27 G the aspiration of
aspirate the subretinal fluid through the break and subretinal fluid is easier and more effective with
cone tip, the risk of retinal or optic disc touch is

much lower. (2) If you are not sure whether you
aspirated the entire PFCL, instill a little water
into the air-filled vitreous cavity (with a brief
water × air exchange), and then completely
remove the residual PFCL/water puddle.
1
2 Complete Lasercoagulation (Fig. 10.16)
If necessary complete now the laser therapy
3 around the retinal break in the air-filled eye.
Tamponade (Diagram 10.2)

Concerning the use of tamponade, there are sig-
nificant differences between vitreoretinal units
at national and international level. The trend
nowadays is to use SF6 in a primary detachment
and longer-acting gases and silicone oils for
Fig. 10.14 If several holes are present, start to remove re-detachments.
subretinal fluid from hole 1 and continue with hole 2 and
then 3 We differentiate between detached breaks and
attached breaks. The choice of tamponade
depends only on the detached breaks (see
Diagram 10.2). If all detached breaks are located
above the 3–9 o’clock meridian, we use SF6. If
Backflush
one detached hole is located below the 3–9 o’clock
instrument
Air meridian, we use C2F6. If the detached break is
located at 6 o’clock, we would use Densiron 68
Trapped
fluid or perform episcleral buckling. An alternative is
of course C3F8.
PFC
Tips and Tricks

27 G and air tamponade: 27 G sclerotomies leak
very little. In case of a superior detachment with
a break between 11 and 1 o’ clock, we use often
Fig. 10.15 Only if the complete trapped fluid is removed
you can continue with removal of PFCL. Otherwise the only air as tamponade. There is an excellent tam-
trapped fluid will flow towards the posterior pole and ponade present for 7–10 days, and laser treatment
detach the macula is effective after 3–4 days.
Why does it matter? Especially professionally
active patients will appreciate to regain their visual
active (than passive) aspiration. If you do not want
acuity after 1 week. In comparison, C3F8 makes an
to use PFCL, e.g. because only a focal retinal
eye blind and the patient earthbound for 2 months.
detachment is present, then you should a bsolutely
Gas tamponade: air against gas exchange. If
aspirate subretinal fluid with active aspiration.
the retina and the breaks are fully attached, you
can flick the BIOM out, and insufflate the diluted
Tips and Tricks gas. The gas container is connected to the
Removal of PFCL: There are two pearls for PFCL three-way tap, the scrub nurse injects the gas, and
removal: (1) When using a flute needle with sili- the surgeon decompresses the globe with use of a
flute instrument. The globe should remain attached under air, then it is also attached under
normotensive. gas. The same statement is not true for silicone
oil. Why? Because the surface tension of silicone
oil/water with 50 mN/N is less than that of air/
Tips and Tricks
water. So when the retina is attached under air, it
Gas vs silicone oil: If the retina is attached under
might not be attached under silicone oil.
air in detachment surgery, then it will also be
attached under gas but that’s not necessarily the
case for silicone oil. Why? The surface tension Removal of the Trocar Cannulas
pressure of the gas/water interface is the greatest Finally, the trocars are removed. Remove first the
and therefore is the most effective in closing reti- instrument trocars and at the end the infusion tro-
nal breaks (70 mN/N). So when the retina is car. In case of a gas tamponade, add some gas
until the globe is normotensive. No suture is
needed neither for gas nor for silicone oil.
10.4 Postoperative Posture

(Diagram 10.2)
For day 1 we recommend to keep a supine position

(flat on the back) for the first hours after the surgery.
Why? In some cases, you will not succeed in remov-
ing all subretinal fluid. If a substantial amount of
subretinal fluid persists and cannot be removed,
leave a puddle of preretinal fluid, and instruct the
patient to keep a supine position for the first hours
Fig. 10.16 Complete laser photocoagulation if
necessary after the surgery. In case of a prone position (face
Sitting up 12 Sitting up
SF6
9 3
C2F6 C2F6
C3F8
Diagram Left cheek to pillow Right cheek to pillow

7 5
10.2 Tamponade and
posture for retinal
detachment depending Supine
on the location of the
break
down) directly after surgery, a macular fold may submacular fluid and face-down positioning.
occur (see Diagram 10.2). Why? The surface tension pressure of silicone
From day 2 to day 7, we recommend “sitting oil is lower than that of gas.
up” if all breaks are above the horizontal merid- Regarding 3: If an eye with submacular
ian. If inferior breaks are present, the posture fluid and gas tamponade is positioned supine
should support the breaks, for example, “left (on the back), then no macular fold will
cheek to pillow” in a break in the nasal inferior develop. Why? The gas presses against the
quadrant of the left eye. If breaks in the superior IOL and not against the macula.
and inferior periphery are present, a supine posi- What is the solution? (a) Leave so much
tion “flat on the back” or “alternating sides, BSS that the apex of the submacular fluid is
left and then right cheek to pillow,” are recom- covered with BSS (Fig. 10.17). Then position
mended. Posture should be carried out for a the patient the first postoperative hours on the
week, day, and night, for a minimum of 50 min back and then for the night on the opposite
on the hour. side of the retinal break. (b) Alternatively, use
PFCL to remove the subretinal fluid.
10.5 Complications
10.6 FAQ
1. Posterior capsular defect
This is a stupid complication during How do you deal with what type of detachment?
detachment surgery because the tamponade The general recommendations are that in pha-
will press the IOL forwards and gas or sili- kic patients, one should perform a buckling sur-
cone oil will flow into the anterior chamber. In gery if possible. In pseudophakic patients, a PPV
case of a gas tamponade, we would inject air is recommended [1]. In pseudophakia with mul-
into the anterior chamber to counterpress, and tiple breaks, we always perform a PPV; this is
in case of a silicone oil tamponade, we would often named “primary vitrectomy for retinal
perform an iridectomy and fill the anterior detachment.”
chamber with Healon GV. There is a strong tendency toward a combined
2. Slippage phaco/vitrectomy for RRD in all phakic patients
In cases of giant tears, the retina in the area of 50 years or above. Phacoemulsification greatly
of the break may slip/glide postoperatively facilitates the trimming of the vitreous base that
toward the posterior pole (slippage). This is is necessary in retinal detachment.
associated with the risk of developing retinal Must I change the position of the trocars
folds postoperatively which, in the worst of according to the location of the detachment?
cases, may involve the macula. This phenom- No. The trocars are always located at the
enon is caused by inadequate drainage of sub- same positions. You can however make small
retinal fluid during fluid-air exchange. To deviations according to the location of the break,
avoid slippage, perform a direct PFCL × sili- i.e. to reach the break more easily. For example,
cone oil exchange. if the retinal break is located at 12 o’clock, then
3. Macular folds place the trocars more toward 3 and 9 o’clock.
Cause: Three factors are necessary to cause This way you can reach the 12 o’clock break
macular folds: (a) submacular fluid, (b) gas easier.
tamponade, and (c) face-down positioning. What do you do if a macular hole is present?
Regarding 1: Macular hole patients have Always check for the presence of a macular
gas tamponade and face-down positioning and hole. This is present in 0.5% of all retinal detach-
never have a macular fold. Why? The reason ments, and if you don’t consider it, chances are
is that they do not have submacular fluid. that you will miss it. Check either during the pre-
Regarding 2: Patients with silicone oil tam- operative examination or during the surgery. This
ponade have no macular folds even in case of is important for prognostication and your surgery,
fovea may be mistaken for a macular hole by the

inexperienced examiner.
GAS
Should I perform an ILM-peeling under
PFCL?
BSS
If the retina at the posterior pole is attached,
then perform an ILM-peeling in a water-filled
Submacular fluid
eye. If it is detached, then perform an ILM-
peeling under a PFCL bubble. Stain the ILM
Fig. 10.17 In case of residual subretinal fluid, leave a
before you inject PFCL.
puddle of BSS so that the retina is covered with BSS
as you may be able to perform an ILM-peeling Reference

during the vitrectomy in order to increase the
1. Heimann H, Bartz-Schmidt KU, et al. Scleral buckling
chances of a postoperative hole closure. To cor- versus primary vitrectomy in rhegmatogenous retinal
rectly identify a macular hole in cases of macula- detachment: a prospective randomized multicenter
off RRD is difficult as the thinned retina at the clinical study. Ophthalmology. 2007;114(12):2142–54.
Episcleral Buckling
for Detachment Surgery 11
with BIOM
Extras: Videos 11.1, 11.2, 11.3, and 11.4. place an encircling band on a bicycle tire? No. Why
do we place an encircling band around an eye?
11.1 Introduction
11.1.1 Minimal Buckling Versus
The principle of buckle surgery can be explained Maximal Buckling Technique
very easily when comparing it with a puncture in a
bicycle tire. The tire is the sclera and the tube is the Nowadays two different episcleral buckling tech-
retina. The first step in repairing a puncture is the niques are employed (Fig. 11.1): (1) maximal
search for a hole underwater. Unfortunately the buckling surgery with encircling band/tire and a
same test is not available for the eye. Here we use grooved strip which covers the hole and (2) mini-
an indirect ophthalmoscope and Lincoff rules. mal buckling surgery with a segmental silicone
When the puncture in the tube is found, we mark it sponge which seals only the hole.
and according to the size of the puncture, we place
a patch on it. In the eye we mark the hole on the
sclera and according to the size of the hole, we 11.2 ur Surgical Technique at
O
suture a sponge on it. Then we pump the tire up the University of Uppsala
with air. If the tube remains filled, we solved the for Episcleral Buckling
problem. If the tube gets soft again, then either the
old hole is not well patched or a second hole is Minimal buckling surgery: The episcleral buck-
present. This situation correlates completely to the ling technique we apply is the minimal buckling
eye. If the retina is attached the next day, then the technique according to Kreissig/Lincoff [1].
problem is solved. If the retina remains detached, In short, (1) cryopexy of the tear and (2) appli-
then either the first hole is not located on the buckle cation of a segmental buckle. Finish. No drainage
or a second break is present. Remark: Would you necessary. No encircling band necessary.
The complete surgery is performed with a
microscope. We use the microscope with BIOM
instead of a helmet with binocular ophthalmos-
5_11) contains supplementary material, which is available copy. For endoillumination a chandelier light is
to authorized users. inserted.
Why? Today vitreoretinal surgeons are more
Department of Ophthalmology, Uppsala University used to the microscope. It is easier for a
Hospital, Uppsala, Sweden vitreoretinal surgeon to inspect the retina with a

https://doi.org/10.1007/978-3-319-78446-5_11
a b
Fig. 11.1 Minimal buckling surgery with a radial sponge (a). Maximal buckling surgery with an encircling band and
a grooved strip (b)
Table 11.1 Choice of silicone sponge depending on the then the sponge must be at least 3 mm in size.
size of the break We have only 5 and 7 mm sponges and choose
Break, mm Sponge Suture, mm therefore in this case a 5 mm sponge. If the
1 5 mm radial 7 break is 4–5 mm, we choose a 7 mm sponge. If
2 5 mm radial 7 the break is larger than 5 mm, we place the 5 or
3 5 mm radial 7 7 mm circumferential buckle (see Table 11.1).
4 7 mm radial 9
5 7 mm radial 9
6 Circumferential 7 (in case of 5 mm
sponge)
11.2.1 Instruments
microscope than with binocular ophthalmos- Here you will find all the details of our episcleral
copy. In addition, suturing of the silicone buckling instrument set, which we use at the
sponge is easier under a microscope than with a University Hospital of Uppsala (Fig. 11.2). The
helmet. This is especially the case for long instruments vary, of course, from hospital to hos-
myopic eyes. pital. The instruments in bold are absolutely
Radial or circumferential buckle? necessary.
Radial scleral buckle is indicated for U-shaped Blepharostat
tears or fishmouth tears and posterior breaks. 1× Williams open adult
Circumferential (ora parallel) scleral buckle is Cannulas
indicated for multiple breaks, anterior breaks, 1× rough curved
and wide breaks. Encircling buckles = encircling Forceps
band = cerclage = tire are indicated for breaks 2× anatomical forceps
covering more than two quadrants of retinal area, 2× forceps claw 1 × 2
lattice degeneration located on more than two 1× forceps Bonn
quadrant of retinal area, undetectable breaks, and Scissors
proliferative vitreous retinopathy. 1 scissors eyes straight sharp
Choice of buckle (Table 11.1) 1 scissors eyes bent sharp
The choice of buckle is dependent on the size 1 scissors Westcott Geuder 19750 (Fig. 11.3)
of the retinal break. If the break is 1 mm in size, 1 scissors straight Vannas Geuder 19760
11 Episcleral Buckling for Detachment Surgery with BIOM 107
Fig. 11.2 Episcleral

buckling instrument set
Fig. 11.4 Orbital spatula Sautter

Fig. 11.3 Westcott scissors
Clamping scissors
2 clamping scissors bent Halstedt
2 clamping scissors Hartman straight
1 clamping scissors Crile straight 14 cm
Needle holders
1 needle holder Barraquer without lock
1 needle holder Snowden-Pencer with lock
Orbital spatula
1 orbital spatula Helvestone
Fig. 11.5 Caliper Castroviejo
1 orbital spatula Sautter Geuder 15740
(Fig. 11.4)
Knot holder 11.2.2 Material
2 knot holder Rapp
Other 1. Silicone sponge (Fig. 11.7)
1 caliper Castroviejo straight 1–20 mm (a) 5 × 3.77 mm partial thickness sponge
Geuder 19135 (Fig. 11.5) (Labtician, Canada). Our most common
1 ruler used silicone sponge. Indication: Ora
4 clamps Diefenbach 2 dialysis, all normal size breaks. This
1 depressor scleral with or without marker sponge requires a 7 mm marking.
1 strabismus hook Bonn 1 mm hole, Geuder (b) 7.0 × 5.28 mm partial thickness sponge
15821 (Fig. 11.6) (Labtician, Canada). Less common used
Fig. 11.6 Strabismus

hook Bonn
5 7
80
3.77 5.28 80
S 1985-5 S 1985-7
Width: 5.0 mm Width: 7.0 mm
Fig. 11.7 Silicone sponge
silicone sponge. Indication: Big breaks. 11. Inspect the retina.

This sponge requires a 9.0 mm marking. 12. If sponge covers the break, fasten the
2. Surgical skin marker with ultrafine tip (many sponge permanently. If sponge does not
companies, e.g., 1456XL SR-100, Viscot cover the break, then replace the sponge.
Medical LLC, USA) 13. Remove the chandelier light and suture
3. Supramid suture 4-0 (REF SP151399, Serag the sclerotomy with a Vicryl 8-0 suture.
Wiessner, Germany). Alternative: Polyester 14. Remove the traction sutures and close the
5-0 (Alcon) conjunctiva with Vicryl 6-0.
4. Silk suture 3-0 (Ethicon)
The surgery step by step (Figs. 11.8, 11.9,
11.10, 11.11, 11.12, 11.13, 11.14, 11.15, 11.16,
11.2.3 The Surgery 11.17, 11.18, 11.19, 11.20, 11.21, 11.22,11.23,
11.24, and 11.25):
1. 180° limbal peritomy.
2. Two or three traction sutures. 1. 180° limbal peritomy.
3. Insertion of a chandelier light. 2. Two or three traction sutures.
4. Search for the retinal break with scleral
depressor. The limbal peritomy and the three traction
5. Cryopexy of the break. sutures are placed according to the location of the
6. Scleral marking of the break. break. If the break is located at 12 o’clock, then
7. Marking of sutures. the lateral rectus, medial rectus, and superior rec-
8. Apply the sutures. tus require traction sutures, and the limbal perit-
9. Paracentesis, release aqueous from ante- omy is located from 9 o’clock over 12–3 o’clock.
rior chamber. If the break is located at 1:30, then a limbal
10. Fasten the sponge. peritomy from 12:00 to 3:00 is performed, and
Fig. 11.11 Freeze the retinal break with the cryopexy

Fig. 11.8 Place a strabismus hook with hole under the handpiece
complete muscle and insert a silk suture
Fig. 11.9 Insert a chandelier light at 6 o’clock opposite Fig. 11.12 Locate the retinal break with a cotton swab or
to a break at 12 o’clock scleral depressor
Fig. 11.10 It is easy to examine the retina with the Fig. 11.13 Then mark the sclera or limbus at the position
microscope and a viewing system of the cotton swab
a b
7mm
Radial buckle
Rupture
Fig. 11.14 (a, b) A radial sponge. The rupture is in the middle of the sponge (a, b)
Muscle insertion
a
First suture First suture
Second suture Second suture
Muscle insertion
b
First suture
Fig. 11.15 (a) Radial

buckle: Place one suture
above the rupture and
the second suture below
the rupture. (b) Radial
buckle. Tighten the Second suture
suture on the sponge as
depicted
b
Limbus
a Muscle insertion
Upper half
2 mm
Lower half 7 mm rupture
5 mm
Fig. 11.16 (a, b) For circumferential buckle. The ruptures are located on the upper half of the sponge (a). Then place
the sponge under the inferior rectus muscle and tighten the sutures (b)
Muscle insertion
a
First suture Second suture
Retinal hole
Muscle insertion
b
Fig. 11.17 (a, b)

Circumferential buckle:
Retinalhole
Place the first suture as
depicted and then the
second suture (a). Then Circumferential buckle
place the sponge under
the suture, and tighten
the knot with 2-1-1
throws (Supramid
suture) (b)
Marking of rupture
9mm for big sponge
Fig. 11.18 Set the caliper to 9 mm for a big sponge and Fig. 11.21 Place the second scleral bite at the second
to 7 mm for a normal sponge marking
Fig. 11.19 Then mark the sclera with the caliper Fig. 11.22 The first suture is done
Suture for limbus

parallel sponge
Rupture
Fig. 11.20 Place the first scleral bite for limbus parallel Fig. 11.23 Place the sponge under the straight muscle
(= circumferential) buckle and then under a suture
4. Search for the break with scleral depressor

(Fig. 11.10).
Flick in the BIOM and search for the break.

This maneuver is a bit more difficult compared to
vitrectomy because the globe is more difficult to
rotate. The search for a retinal hole goes like this:
For example, in a retinal detachment from 6:00 to
10:00, place the scleral depressor at 10:00, and
move it slowly in a straight line from the ora ser-
rata toward the posterior pole. Look for a hole or
a hole flap. Then continue placing the depressor
at 9:30, move it in a straight line toward the pos-
Fig. 11.24 Close the suture with 2–1–1 throws terior pole and so on. It is like mowing a lawn.
5. Cryopexy of the break (Fig. 11.11).

6. Scleral marking of the break (Figs. 11.12
and 11.13).
Freeze now the break (Fig. 11.11), keep the

cryopexy handpiece in place, flick out the BIOM,
rotate the globe, and the assistant inserts an orbital
spatula between the tenon/conjunctiva and sclera
to identify the freezing spot. Dry the freezing spot
with a cotton swab and mark it with the surgical
marker pen (Figs. 11.12 and 11.13). The sclera
must be absolutely dry that you can mark it.
Fig. 11.25 Fasten the suture on both sides 7. Marking of sutures (Figs. 11.14, 11.15,
11.16, and 11.17).
two holding sutures are placed under the superior
and lateral rectus muscle. Decide now whether you want to apply a
Perform a limbal peritomy and place a strabis- radial sponge or a limbus parallel (circumferen-
mus hook with hole behind a straight muscle. tial) sponge (Figs. 11.14, 11.15, 11.16, and
Confirm that you grabbed the whole muscle 11.17). If the break is located under a muscle, an
because you may place a sponge beneath the ora parallel (= circumferential) approach is advis-
muscle. Insert the silk suture into the hole and able because it is difficult to suture under the
retract the hook with the suture (Fig. 11.8). Tie a muscle. Paint the tips of the caliper with the sur-
knot into the suture. Repeat this procedure with gical skin marker pen. Mark the sclera with the
the two other straight muscles. caliper (Geuder). How wide? Two millimeters
more than the width of the sponge. If the sponge
3. Insertion of a chandelier light (Fig. 11.9). is 5 mm wide, then mark 7 mm (Table 11.1).
Where to mark? In case of a radial sponge,
Continue with insertion of the chandelier hold the caliper so that the hole is in the middle
light. The best location is opposite to the break. If (Fig. 11.14a, b). Make two markings approxi-
the break is located superiorly, then insert the mately 2 mm anterior to the break and 2 mm pos-
chandelier light inferiorly. terior to the break (Fig. 11.15a, b).
In case of an ora parallel (circumferential) second suture. Important: Do not pull the traction
sponge and a retinal break at 6:30, place two sutures while tying the sponge in order to achieve
markings at 5:30 and two markings at 7:00 a good indentation (Fig. 11.26).
(Figs. 11.16a, b and 11.17a, b). Place the silicone
sponge under the inferior rectus muscle. The 11. Inspect the retina.
muscle force will help to indent the sponge.
Flick in the BIOM and inspect the retina. If
8. Apply the sutures (Figs. 11.18, 11.19, 11.20, the sponge does not cover the break, then reposi-
11.21, and 11.22). tion the sponge. The repositioning surgery goes
usually faster than the first surgery.
You need one suture with one needle for two
markings. Cut the suture in two halves so that 12. Remove the chandelier light.
you have two sutures with one needle each. How 13. Remove the traction sutures and close the
to suture? The suture is the most dangerous conjunctiva with Vicryl 6–0.
maneuver in the complete surgery because you
can perforate the sclera. Move the needle less Remove the chandelier light and suture the
deep but a long way through the sclera. The nee- sclerotomy with a Vicryl 8–0 suture. Continue
dle must be visible through the sclera. Repeat this with cutting the traction sutures and remove
maneuver at the second marking (Figs. 11.19 and them. Replace the conjunctiva and close it with
11.20). Vicryl 6–0 or 8–0.

Retinal tear under a muscle. Alternatively to an 11.2.4 Brief Case Reports
ora parallel (= circumferential) sponge, you can
apply a radial sponge. If you want to apply a 1. 90° circumferential buckle (Figs. 11.27 and
radial sponge under the muscle, then remove the 11.28)
muscle, suture the sponge, and suture the muscle
back to place. Or suture the sponge onto the mus- Young myopic eyes with an inferior RD are a
cle. If the patient experiences diplopia after sur- good indication for episcleral buckling surgery
gery, you can remove the sponge after (Fig. 11.27a, b). A 90° circumferential buckle
approximately 3–4 weeks. under one rectus muscle is required (Fig. 11.28).
We employ always segmental buckles in these
9. Perform a paracentesis, and release aque- cases.
ous from anterior chamber. Example: 27-year-old male patient with
−3.5 sph = 0.4 and an inferior detachment with
You need a soft globe to achieve a proper six holes at 6–7 o’clock. Cryopexy and segmen-
indentation of the sponge. Perform a paracentesis tal buckle from 5 to 8 o’clock (under inferior rec-
and release aqueous from the anterior chamber. tus muscle).
10. Fasten the sponge (Figs. 11.23, 11.24, and 2. 180° circumferential buckle (Figs. 11.29 and
11.25). 11.30)
Place the silicone sponge under the sutures Even a middle-aged patient with myopic
(Fig. 11.23), make two throws, tighten the suture detachment is a good indication for an episcleral
a little bit, then release tension on the traction buckle (Fig. 11.29a, b). Example: 47-year-old
sutures and then tighten the suture again male patient with −8.5 sph = 0.6 and a temporal
(Figs. 11.24 and 11.25). The knot has 2–1–1 detachment with five holes on the same height.
throws. Perform the same maneuver with the Cryopexy and segmental buckle from 7 to 11
a b
Fig. 11.26 (a) A superotemporal detachment with a rup- o’clock is wrongly placed, and the break at 6:15 is still
ture at 2 o’clock and at a second rupture at 6:15. Both detached. The buckle is 5 mm wide so you have to replace
breaks are treated with one buckle for each break. (b) A the buckle 2.5 mm to the right side. (c) The sponge is
residual detachment. The silicone sponge is placed on the replaced 2.5 mm, and 1 day later the retina is reattached,
break and the break is dry. But the silicone sponge at 6 and the rupture is located now on the buckle
a b
Fig. 11.27 (a) A young myopic patient with several retinal breaks at 6–7 o’clock. (b) A circumferential buckle is
placed from 5:30 to 7:00, and the retina is reattached 1 day later
o’clock (under superior and temporal rectus mus- 4. Traumatic detachment: 90° circumferential
cle) (Fig. 11.30). buckle (Figs. 11.33 and 11.34)
3. Ora dialysis: 90° circumferential buckle A traumatic detachment in a child’s eye is a

(Figs. 11.31 and 11.32) complicated retinal detachment (Fig. 11.33). But
a reattachment is much easier to achieve with epi-
The ora dialysis is on the border of an easy scleral buckle than with vitrectomy. A vitrectomy
and difficult detachment (Fig. 11.31). The suc- is technically very difficult because you first need
cess rate of reattachment for ora dialysis is 99% to perform most likely a phaco + IOL and then
with episcleral buckling. If you choose to operate vitrectomize an inflamed eye resulting in increased
an ora dialysis with vitrectomy, you need to PVR and recurrent detachment risk. If you choose
achieve the same reattachment rate. Example: episcleral buckling, things get much easier. The
42-year-old male patient with ora dialysis at 6–7 vitreous in children is clear and attached. The
o’clock and chronic inferior detachment due to dense pediatric vitreous serves as a scaffold.
trauma. Buckle. Cryopexy and segmental buckle These attributes facilitate working with a panoph-
from 5 to 8 o’clock (under inferior rectus muscle) thalmoscope and the reattachment with a buckle.
(Fig. 11.32). Example: 6-year-old boy with traumatic inferior
detachment and a rupture from 5 to 7 o’clock.
Cryopexy and segmental buckle from 4 to 8
o’clock (under inferior rectus muscle) (Fig. 11.34).
5. Chronic detachment: Radial buckle
The chronic focal detachment is definitely a

complicated detachment. But in case of a clear
hole situation and the employment of episcleral
buckling, this complicated detachment becomes
Fig. 11.28 A 90° buckle is placed under one rectus
muscle easy. Vitrectomy would be much more difficult.
a b
Fig. 11.29 (a) A middle-aged myopic patient with a superotemporal detachment and four retinal breaks. (b) A 180°
circumferential buckle is placed under two muscles, and the retina is redetached after 1 day
Why? The pigment epithelium in the detached excellent impression between the weak pigment
area is weak and the subretinal proliferations epithelium and the retina and can seal the hole. In
enhance the detachment. A buckle creates an case of vitrectomy you need to remove the
peripheral-located subretinal proliferations and
then a gas tamponade to press the retina against
the pigment epithelium. Example: 34-year-old
female patient with a chronic superotemporal
quadrant detachment, subretinal proliferations,
and a hole at 10:30. Cryopexy and segmental
buckle (Fig. 11.35, 11.36, and 11.37).

Radial buckle: Place the buckle exactly on the
scleral marking.
Fig. 11.30 A 180° circumferential buckle is placed

under two muscles. An extra suture is required between
the temporal and superior rectus Fig. 11.31 An ora dialysis from 6:00 to 7:15
Limbus
8 o’clock 5:30 o’clock
Silicone sponge
Ora dialysis
Fig. 11.32 A
circumferential buckle
was placed from 5:30 to
8:00. Note that the
sponge is placed under
the rectus muscle which Muscle
increases indentation
Circumferential buckle: Place the buckle a bit of more than 180° of if under three rectus muscles
more posterior than the marking. an encircling band should be preferred.
One hole: Radial buckle.
Many holes at the same height: Circumferential 11.2.4.2 Tips and Tricks
buckle. Encircling bands are employed in all eyes and the
Hole under the muscle: Circumferential same appliofes for segmental buckles. Segmental
buckle under the muscle. sponges can be employed in all eyes: phakic
Circumferential buckle: The usual length is eyes, pseudophakic eyes, eyes with PVD, eyes
approximately 90°. The maximal length is 180° and without PVD, and vitrectomized eyes.
maximally under two rectus muscles. For a length
11.2.5 Complications
Scleral perforation
A scleral perforation can be seen by leakage
of intraocular fluid. Redraw the needle, freeze the
leakage site with cryopexy and repeat the suture
at a different location.
Repositioning of a buckle (Fig. 11.26a–c)
It is no problem and in fact technically quite
easy to reposition a wrongly placed buckle
(Fig. 11.26a). In some cases the perioperative
visualization of the hole on the buckle is not easy.
One day later at the slit lamp, the visualization is,
however, in the most cases better. If the hole is
located aside the buckle and not on the buckle,
then try to estimate how many millimeter the hole
is aside (Fig. 11.26b). Keep in mind that the
Fig. 11.33 A traumatic detachment from 5:00 to 7:00 buckle is 5 mm wide. If, for example, the hole is
and a focal detachment located at 5:30 and the buckle at 6:00
Limbus
7:00 o’clock 5:00 o’clock

Silicone sponge
Break
Inferior rectus
Fig. 11.34 A circumferential buckle is placed under the inferior rectus from 4:30 to 7:30
a b
Fig. 11.35 An approximately 4-year-old chronic detachment with subretinal proliferations and a retinal break at 11.
VA = 0.7 (a). A radial buckle seals the break and the retina attached after 1 day. Observe the subretinal strands (b)
Fig. 11.37 Attached retina after cryopexy and scleral

buckling. Note the subretinal strands
What about episcleral buckling in a vitrec-

Fig. 11.36 An undetected retinal detachment from 2011 tomized eye?
to 2014 This is no problem. It is actually easier because
the impression of the sponge is more pronounced
(Fig. 11.26b), then remove the old sponge, place due to the absent vitreous body. In case of a focal
new sutures 2.5 mm next to the old sutures, and recurrent detachment, we often place a segmental
refasten the same sponge (Fig. 11.26c). buckle. Often the retinal break is difficult to find
and often it is a laser necrosis which causes a tiny
break. Place a sponge on this laser treated break
11.2.6 FAQ and the retina will be attached the next day.
Can I place a silicone sponge during Is it difficult to reposition a silicone sponge?

vitrectomy? It is no problem and in fact technically easy to
Yes. If you want to buckle, for example, a break reposition a wrongly placed buckle, as well during
at 6 o’clock, then place a limbus parallel (circum- the first surgery as during a second surgery. For
ferential) silicone sponge under the inferior rectus. more see chapter “Buckle with Chandelier.”
The indentation of my buckle (silicone

sponge) is insufficient.
There are three tips to improve indentation of
a silicone sponge:
1. Reduce the IOP: Perform a paracentesis at the
limbus and release aqueous.
2. When tying the knots on the silicone sponge,
the scrub nurse must release tension on the
holding sutures.
3. In case of a 5 mm silicone sponge: Instead of
placing the sutures at width of 7 mm, place
them at a width of 9 mm. The effect is an
improved indentation.
When to choose a silicone sponge or an Fig. 11.38 The tip of the sponge is sutured to the sclera
encircling band?
Up to 90° of the circumference of the globe a insertion. Then you can suture the tip of the
silicone sponge is recommended; over 90° an sponge to the sclera (Fig. 11.38).
encircling band is recommended. In case of sin- 3) Removal of sponge: A sponge causes discom-
gle holes, a radial silicone sponge is the method fort in the first weeks; then the discomfort usu-
of choice. ally disappears. A sponge can be removed
after 1 month. I remove sponges after 3 months
FAQ: if they cause discomfort or are exposed.
1) Single hole behind the equator: A hole behind
the equator is difficult to reach with a buckle.
Try to reach it with a radial buckle. If this is
not possible, then choose vitrectomy. Reference
2) Sponge exposure: The ora serrata is located at
1. Kreissig I. Minimal surgery for retinal detachments.
the height of the muscle insertion. The sponge
Stuttgart: Thieme; 2000. isbn:3131110619.
can therefore be cut, if it exceeds the muscle
Combined Buckle/Vitrectomy
12
Extras: Videos 12.1, 12.2, 12.3, 12.4, 12.5, In case of an inferior retinal detachment with a
12.6, and 12.7. foreshortened retina, the surgical aim is to attach
the retina onto the retinal pigment epithelium. This
can be achieved with a retinotomy or with an epi-
12.1 Introduction scleral buckling. A retinotomy is surgically difficult
and the complication spectrum is large. In addition,
The author Ulrich Spandau started with this tech- a permanent silicone oil tamponade is necessary in
nique due to a surgical failure in a 74 y/o male the majority of cases. In contrast, the complication
patient with a chronic and total retinal detach- spectrum of a buckle is small and if you fail you
ment. A rupture was present at 7 o’clock. During can still continue with retinotomy.
PFCL × air exchange, air was pressed subretinally Why do I use a segmental buckle and not an
through the rupture. The inferior retina was obvi- encircling band? The main reason is that a segmen-
ously foreshortened. I placed therefore a circum- tal buckle makes a much stronger impression of the
ferential encircling band on the equator. But again retina than a tyre/cerclage. Why is this so? The
air was present in the subretinal space. In this situ- (360°) encircling band creates a symmetrical/even
ation, a PFCL × silicone oil exchange is no alter- 360° impression of the retina. A segmental circum-
native in this situation because the silicone oil ferential buckle, however, creates an asymmetrical
would track subretinally. The only option is a reti- impression of the retina because it receives no
notomy. Therefore, I performed a 180° retinot- counter pressure (Figs. 12.1 and 12.2).
omy but at the end a macular fold persisted.
This failure made me employ a technique
which is easier in my hands: vitrectomy plus seg- 12.1.1 Tips and Tricks
mental buckle. So looking back I would have
placed a radial or circumferential segmental Effect of buckle: sealing of hole
buckle on the hole by 7 o’clock. Effect of encircling band (tyre): relief of vitre-
ous base
Electronic Supplementary Material The online version Effect of circumferential buckle: attachment of
of this chapter (https://doi.org/10.1007/978-3-319-78446- pigment epithelium and foreshortened retina
to authorized users. The second disadvantage of episcleral buckling
is the difficult visualization with the head ophthal-
Department of Ophthalmology, Uppsala University moscope. This disadvantage is obsolete because
Hospital, Uppsala, Sweden scleral buckling is performed with the microscope

https://doi.org/10.1007/978-3-319-78446-5_12
Table 12.1 Advantages and disadvantages of episcleral

buckling with segmental buckle, encircling buckle, and
vitrectomy
Episcleral Exact sealing Technically difficult
segmental of hole
buckling possible
Excellent Ametropia
impression of
hole
Easy Difficult visualization
visualization with
with chandelier panophthalmoscope
light and
microscope
Little PVR
Vitrectomy not
necessary
Encircling Positioning of Technically not
Fig. 12.1 An encircling buckle creates a weak scleral band hole only difficult
impression and does not attach a foreshortened retina possible on
height of
equator
In the most
cases used in
combination
with
vitrectomy
Moderate Induces myopic shift
impression of approximately -3D
Little PVR
Vitrectomy Easy Technically not
visualization difficult
with
microscope
Increased PVR
Sealing of hole
less effective
with gas than
with buckle
Fig. 12.2 A segmental buckle is wider and creates a
stronger indentation of the sclera which is in the most
cases sufficient to attach a foreshortened retina
I extended this technique for inferior recur-
rent detachments with PVR changes. Today this
and a viewing system. The marking of the hole is technique is my favorite technique for compli-
simple with help of the scleral depressor and the cated retinal detachments and recurrent
suturing of the sponge is done under microscope detachments.
view. The advantages and disadvantages of the Indications for combined buckle/vitrectomy
different techniques are listed in Table 12.1. are:
This technique combines the advantages of
vitrectomy and episcleral buckling. The episcleral 1. Failed RD surgery
buckling during vitrectomy is much easier than 2. Inferior recurrent detachment
episcleral buckling with chandelier light alone. 3. Inferior detachment with foreshortened retina
Why? The marking of the hole is much easier. 4. PVR stage C
12 Combined Buckle/Vitrectomy 123
12.2 Surgery
12.2.1 Instruments
1. 25 or 27 G four-port vitrectomy with infusion

nipple and chandelier light
2. Retinal detachment tray
Fig. 12.3 The silicone sponge 5 × 3.77 from Labtician,
3. Silicone sponge: 5 × 3.77 mm partial thick-
Canada
ness sponge (Labtician, Canada) (Fig. 12.3)
12.2.2 Surgery Step by Step
1. Inferior limbal peritomy (in case of an

inferior detachment).
2. Three holding sutures.
3. Insertion of trocars.
4. Phaco + IOL.
5. Staining of vitreous with triamcinolone.
6. Vitreous base shaving.
7. Staining of membranes with trypan blue.
8. Membrane peeling.
9. Instill PFCL.
10. Remove the inferior ports.
Fig. 12.4 Place three holding sutures at the temporal,
11. Mark the location of the hole.
inferior, and medial rectus
12. Mark the sutures.
13. Place the sutures.
14. Fasten the buckle. 4. Phaco + IOL.
15. Replace the inferior ports. 5. Staining of vitreous with triamcinolone.
16. Laser treatment. 6. Vitreous base shaving.
17. PFCL against air exchange and tamponade.
18. Close the conjunctiva. If the natural lens is still present, then start
with a phacoemulsification and IOL implanta-
tion. Continue with a thorough peripheral vit-
12.2.3 Every Step in Detail rectomy. Why? In order to avoid anterior PVR,
the anterior vitreous must be removed com-
1. Inferior limbal peritomy (in case of an infe- pletely. In addition, in case of a previous sili-
rior detachment). cone oil tamponade, the vitreous is pressed
2. Three holding sutures. against the ciliary body causing fibrotic mem-
3. Insertion of trocars. branes resulting in hypotony. Stain the vitreous
base with triamcinolone (1:3), and perform a
Open the inferior conjunctiva along the limbus meticulous shaving of the vitreous base with
from 3 to 9 o’clock with Westcott scissors, dis- scleral impression holding the scleral depressor
sect the Tenon capsule from the sclera with a stra- in one hand and the vitreous cutter in the other
bismus scissors, and place three holding silk hand. The vitreous staining must be repeated
sutures at the lateral, inferior, and medial rectus several times because triamcinolone stains only
(Fig. 12.4). Insert then the trocars and a chande- the outer part of the vitreous cortex. If neces-
lier light. sary, instill PFCL to stabilize the retina.
7. Staining of membranes with trypan blue.

8. Peeling if necessary.
If you see membranes, then stain them with

trypan blue. If the membranes are located periph-
erally, then stain them under air. Then remove all
epiretinal membranes. Before you instill PFCL in
the next step, check that all membranes are
removed and that the retina is mobile. If tractions
persist, PFCL will flow through the break into the
subretinal space and accumulate at the posterior
pole.
9. Instill PFCL.
10. Remove the inferior ports.
Fig. 12.6 Then mark the sclera at the position of the cot-
Instill PFCL to stabilize the retina up to the ton swab or scleral depressor. Repeat then the maneuver at
8:00
height of the hole. Then remove the inferior ports
(infusion port and chandelier light at the infero-
nasal quadrant). The PFCL will hold the globe
stable and the low globe pressure will allow for
Scleral depressor
an excellent buckle impression.
11. Mark the location of the hole (Figs. 12.5

and 12.6).
12. Mark the sutures (Figs. 12.7 and 12.8).
13. Place the sutures (Figs. 12.9 and 12.10).
14. Fasten the buckle (Figs. 12.11, 12.12,
12.13, and 12.14).
Fig. 12.7 In case of two retinal breaks, indent the retina

on the left side of the left rupture with the scleral depres-
Fig. 12.5 Locate the retinal break with a cotton swab or sor, and then mark the sclera. Then repeat the maneuver
scleral depressor with the right break
Fig. 12.8 The drawing

shows the position of the
marking at the limbus
and of the two markings
of the sutures on the
m
7m
sclera
m
2m
7m
1-
1-2
m
mm
Cornea
Muscle insertion
= marking
Fig. 12.11 Radial sponge
Fig. 12.9 Move the needle 3–4 mm through the sclera
Fig. 12.10 And then the second bite at the posterior

marking Fig. 12.12 Circumferential sponge. Place the sponge
first under the inferior rectus
Fig. 12.13 Circumferential sponge. Suture at 8:00 Fig. 12.14 Circumferential sponge. And then a suture at
4:00
Decide first if you want to place a radial or cir- too soft, then reinsert the infusion line until the
cumferential buckle (Figs. 12.11 and 12.12). In tonus is normal. The placing of sutures at the
most cases, I use a circumferential buckle. First inferior pole is difficult due to the lack of space.
you must mark both ends of the buckle. Use a In many cases you cannot place the sutures as
light fiber and flick in the BIOM. Decide now posterior as planned. This does not matter. Try to
where you want to locate the buckle. If there is a place as posterior as possible and this will be
hole at 9:00 and PVR at 10:00, then I would place sufficient.
a buckle from 8:00 to 11:00. Indent the sclera at Finally the silicone sponge is sutured. The
8:00 with the sclera depressor, and remove the placement of a radial sponge is depicted in
light fiber, but leave the sclera depressor. Flick out Fig. 12.11. In most cases, a circumferential
the BIOM system, and mark the limbus at the buckle is used. The circumferential buckle is
8:00 location (Figs. 12.5 and 12.6). Repeat the located under the inferior rectus (Figs. 12.12,
maneuver at 11:00. Remark: I do not mark the 12.13, and 12.14). Place first the buckle under the
holes on the sclera. complete muscle using a surgical forceps. Place
In the next step, you mark the sutures. The mark- the silicone sponge under one suture and tie it
ing of the sutures depends on the width of the with 2-1-1 throws. Repeat the maneuver on the
buckle. Commonly 1 mm is added to each side. We other side. The impression of the globe seems
use almost always the same 5 mm buckle (Labtician, excessive in this moment. But I never had to redo
Canada). The marking with the caliper is therefore the suturing, and at the end of surgery, the impres-
7 mm. The first suture marking at 4:00 is 1–2 mm sion is always perfect.
posterior to the muscle insertion (Fig. 12.8). The
second suture marking is 7 mm posterior to the first 15. Replace the inferior ports.
suture marking at 4:00. Repeat the same maneuver 16. Laser treatment.
at 8:00. Remark: The circumferential buckle is 17. PFCL against air exchange and
approximately on height of the equator. If you place tamponade.
a radial buckle, then mark the sclera 7 mm wide 18. Close the conjunctiva.
with the hole in the middle (Figs. 12.7 and 12.8).
The next step is the placing of sutures. The Reinsert the infusion trocar and infusion line.
globe is soft during suturing because the infusion Then reinsert also the chandelier light. Inspect
is removed. The advantage is that you achieve an the location of the buckle (Figs. 12.15 and 12.16).
excellent buckle impression; the disadvantage is Remove then the subretinal fluid with PFCL or
that the suturing may be difficult. If the globe is air. For a PFCL against air exchange, we use a
Fig. 12.17 Cut the 5 × 3.77 sponge in two halves and

place one half as radial sponge under the circumferential
Fig. 12.15 View the circumferential buckle and the rup- buckle
ture at 10 o’clock
12.3 Brief Case Reports
12.3.1 Case Report 1
A 72-year-old male patient with a superotempo-

ral retinal detachment stage B3 and a retinal
break at 6 o’clock was operated with vitrectomy
and scleral buckling of a radial buckle at 6 o’clock
(Fig. 12.17). Two weeks later a superior rede-
tachment was detected. A superior circumferen-
tial buckle from 10:00 to 2:00 was placed. Then
2 weeks later, an inferior detachment at 5 o’clock
occurred. A vitrectomy with Densiron 68 tam-
ponade was performed. Two months later the sili-
cone oil was removed and the follow-up 2 months
later showed an attached retina (Fig. 12.18).
12.3.2 Case Report 2

Fig. 12.16 Laser photocoagulation of two ruptures on
the buckle A 45-year-old male patient with a 6-month-old
retinal detachment was operated 5 years ago
vacuum cleaner with active aspiration. Then con- without complications with episcleral buckling
tinue with laser treatment. We place two laser for a retinal detachment. He was resubmitted
rows around the hole edge and two parallel rows with a total retinal detachment (Fig. 12.19). A
on the circumferential buckle.Which tamponade? combined vitrectomy and placement of an infe-
If the hole is located on the buckle, we choose a rior segmental buckle were performed
gas tamponade. If an inferior hole with additional (Fig. 12.20). Two weeks later an inferior rede-
star folds is present in the inferior periphery, we tachment with a small hole anterior to the sili-
use Densiron 68 as tamponade. Close finally the cone sponge was detected. The silicone oil was
conjunctiva with Vicryl 6–0. removed, the hole was laser treated, and Densiron
1000 csts
silicone oil
Fig. 12.18 In the first vitrectomy, a buckle was placed at

6 o’clock. At the recurrent detachment, a segmental cir-
cumferential buckle was placed from 10:00 to 2:00
Fig. 12.20 After two surgeries and an inferior segmental
buckle, the retina was reattached
Old
buckle
retinal break was present at 10 o’clock. A com-
bined vitrectomy with epiretinal membrane dis-
section and placement of a circumferential buckle
at 9 o’clock was performed.
Two months later an inferior redetachment
was observed (Fig. 12.21). The 1000 cst silicone
oil was extracted, the peripheral membranes were
peeled, and finally Densiron 68 was injected.
12.4 FAQ
Question 1: The globe is very soft during the

buckling procedure. What can I do?
Answer 1: Bulbar hypotony: Especially in vit-
Fig. 12.19 A total and chronic retinal detachment was
present. The eye was operated a few years before with rectomized eyes, the globe may be hypotensive
scleral buckling with scleral folds. Inject BSS with a 30 G needle
via pars plana until the globe is normotensive, or
68 was injected. Two months later the silicone oil inject BSS with a Charles flute cannula through a
was removed and the retina remained attached. trocar into the vitreous cavity.
The visual acuity 1 month post-op was 0.1–0.2. Question 2: If the circumferential buckle does
not cover the break completely because the break
is located posterior to the buckle?
12.3.3 Case Report 3 Answer 2: Two possibilities: (1) Use Densiron
68 tamponade and (2) cut the same silicone
A 67-year-old female patient with a superotem- sponge in two halves and place one half under the
poral retinal detachment. Intraretinal PVR and circumferential buckle. The break is now covered
subretinal cysts were present at 9 o’clock and a (Fig. 12.17).
Fig. 12.21 Two-month postoperative status after vitrec- ula, good buckle impression temporal, and a focal PVR
tomy, peeling of epiretinal membranes and segmental redetachment from 6 to 7 o’clock
buckle. Now, subretinal PFCL bubble superior to the mac-
Vitrectomy for PVR Detachment
Grade C 13
Extras: Videos 13.1, 13.2, 13.3, 13.4, 13.5, Regarding the timing of surgery, an early
13.6, 13.7, 13.8, 13.9, 13.10, 13.11, 13.12, surgical treatment is favourable because it pre-
13.13, 13.14, 13.15, 13.16, 13.17, 13.18, and serves the loss of photoreceptors and improves
13.19. a favourable visual outcome. A delayed surgi-
cal treatment (after 6 weeks) is unfavourable
for the visual function but surgery is easier; the
13.1 Introduction and Definition
The name proliferative vitreoretinopathy (PVR) was

provided in 1989 by the Silicone Oil Study group
[1]. The name is derived from proliferation of the
retinal pigment epithelial and glial cells and vitreo-
retinopathy to include the tissues which are affected,
namely, the vitreous and the retina (Fig. 13.1).
The current management is the surgical
relief of vitreal, preretinal and subretinal trac-
tions. The final aim is the re-establishment of
retinal attachment and visual function.
The principles of management are (1) clo-
sure of all retinal breaks, (2) relief of traction and
(3) long-term retinal stabilisation. The following
Table 13.1 shows the principles and surgical pro- Fig. 13.1 PVR detachment stage C3
cedures for PVR detachment.
Table 13.1 Principles and surgical procedures for PVR
detachment
Principle Surgical procedure
Electronic Supplementary Material The online version Closure of all retinal • Identification
of this chapter (https://doi.org/10.1007/978-3-319-78446- breaks • Closure
5_13) contains supplementary material, which is available Relief of traction • Membrane dissection
to authorized users. • Retinotomy/retinectomy
U. Spandau (*) · Z. Tomic Long-term retinal • Laser photocoagulation
Department of Ophthalmology, Uppsala University stabilisation • Scleral buckle
Hospital, Uppsala, Sweden • Intraocular tamponade

https://doi.org/10.1007/978-3-319-78446-5_13
p roliferative membranes become “mature” and anterior dissection. An encircling band is used
are therefore surgically easier to remove. less and less nowadays. In our clinic we use it
Indication: Feasible pathologies for this sur- maybe four times per year. We place an encir-
gery are the first surgery of PVR detachments cling band in PVR stage C3.
grade C2, C3 and D.
13.2.1.1 The Surgery
Instruments
13.2 Every Surgical Step in Detail Mersilene 5-0
Silk 3-0
13.2.1 Encircling band (tyre). Encircling band (S2987, Labtician, Canada)
13.2.2 Phacoemulsification and IOL (Fig. 13.2) and sleeve (S3083, Labtician, Canada)
implantation. (Fig. 13.3)
13.2.3 Pars plana vitrectomy. Strabismus hook (of Gass)
13.2.4 Vitreous staining with triamcinolone. Orbita spatula
13.2.5 Vitreous base shaving. The Surgery of an Encircling Band Step by
13.2.6 Staining of membranes with trypan Step
blue.
13.2.7 Removal of epiretinal membranes. (a) Limbal peritomy 360 degrees.
13.2.8 Instillation of perfluorocarbon liq- (b) Dissect Tenon from the sclera.
uids (PFCL). (c) Place four holding sutures (Silk 3-0) on the
13.2.9 Removal of subretinal membranes. straight muscles.
13.2.10 Laser photocoagulation. (d) Place the encircling band under all four
13.2.11 Prepare the anterior chamber before straight muscles.
tamponade. (e) Check that the band is not twisted.
13.2.12 Tamponade. (f) Insert both ends of the band into the sleeve
at the inferotemporal quadrant.
(g) Mark the sclera with caliper at axial
13.2.1 Encircling Band (Cerclage, Tyre) length/2 mm behind the limbus.
(h) Place a stitch (Mersilene 5–0) for encir-
Introduction: An encircling band relieves trac- cling band.
tion at the vitreous base. It facilitates also the clo- (i) Tie the suture and continue with the next
sure of peripheral retinal breaks. And finally an three quadrants.
encircling band supports the vitreous base during (j) Tighten the band.
Circling Bands
2.5
2 2.5
125 0.6 125 0.75 125
0.75
To be used with 1,2,4. To be used with 1,3,4. To be used with 1,3,4.
Fig. 13.2 Circling bands

13 Vitrectomy for PVR Detachment Grade C 133
Silicone Sleeves
Round
2.1 1.65 2.4

1 0.76 1.5
30
30 30
2 3 6
Oval
S 3083 (3083 Style) S 3084 (3084 Style)
2.5 3.75
1.6 1.8
5 5
1
5
Fig. 13.3 Silicone sleeves
The Surgery in Detail
(a) Limbal peritomy 360 degrees.

(b) Dissect Tenon from sclera.
(c) Place four holding sutures (silk 3-0) on the
straight muscles.
Open the conjunctiva 360 degrees at the
limbus with a Westcott scissors and anatomic
forceps. Then dissect the Tenon’s capsule
from the sclera using a strabismus forceps.
Dissect to the equator. Then place a strabis-
mus hook with hole under a rectus muscle
and insert a silk 3-0 suture. Pull back the
hook with suture and place a knot on the Fig. 13.4 With a strabismus hook with hole, the encir-
suture. Repeat this step with all four rectus cling band can be placed under all rectus muscles
muscles.
(d) Place the encircling band under all four (Fig. 13.4), and so on until you are back to
straight muscles. the inferotemporal position with both ends.
(e) Check that the band is not twisted. Then check all four quadrants that the band
Start at the inferotemporal position. Pull is not twisted.
the holding sutures of the inferior and tem- (f) Insert both ends of the band into the sleeve
poral rectus, insert the orbita spatula, and at the inferotemporal quadrant.
insert the silicone band behind the temporal Now comes the most difficult step for this
rectus. Double check that the encircling surgery: Place the sleeve on the special
band is located behind the complete muscle. forceps (Labtician, Canada), and insert first
Then pull the sutures of the temporal and one end (this is easy) and then the second end
superior rectus, insert the orbita spatula, and (this is very tricky). If you succeeded, then
place the band behind the superior rectus tighten the band a little bit.
(g) Mark the sclera with caliper at axial serves otherwise as a scaffold between the poste-
length/2 mm behind the limbus. rior and anterior chamber. For example in case of
(h) Place a stitch (Mersilene 5-0) for encir- a silicone oil tamponade, the oil may prolapse
cling band. into the anterior chamber and cause anterior
(i) Tie the suture and continue with the next chamber complications.
three quadrants.
We continue now at the superotemporal ips and Tricks: Management
T
quadrant. Pull the sutures and insert the orbita of Miotic Pupil
spatula. Then mark the sclera at AXL/2, i.e. A miotic pupil may be a major obstacle for PVR
the eye has an AXL = 23 mm, and then mark surgery because the pathology is often located in the
the sclera at 11.5 mm. The marking is located periphery. In many cases an intracameral injection
in the middle of the band. Fixate then the of adrenaline (1:10) is sufficient. Adrenaline may
band with a forceps anterior to the marking, also be given during surgery. If posterior synechiae
and place the first stitch (Mersilene 5-0) are present, then a synechiolysis is recommended.
1.5 mm posterior to the marking. Then fixate This can be achieved through iris stretching. Insert
the band posterior to the first stitch, and place two Sinskey hooks through the paracenteses and
a second stitch with the same suture 1.5 mm stretch the pupil (Fig. 13.5). Alternatively, iris
anterior to the marking. Then tie the suture retractors with four-point fixation or a Malyugin
and continue with the next three quadrants. ring can be implanted (Figs. 13.6 and 13.7).
The final suture is located at the sleeve.
(j) Tighten the Band.
Now tighten the band. The globe should be 13.2.3 Pars Plana Vitrectomy
a little bit hypotensive, approximately 8 mmHg,
to achieve a good impression. You can either A main step in pars plana vitrectomy is the
tighten the band until the band lies tense on the removal of the core vitreous resulting in relief of
sclera or tighten the band maximally 8mm. transvitreal traction.
We use a standard three-port PPV with 25 G
ips and Tricks
T trocars. We use 25 G and not 23 G because
A too tight encircling band may cause anterior smaller trocars require smaller instruments,
segment necrosis and globe pain. If you cut the and this results in less traumatic surgery and
band, the pain disappears immediately. In less leakage from the trocars. In case of
addition, an encircling band reduces the ocular pseudophakia, the sclerotomies are placed
blood flow and ocular pulse. Cutting of the encir- 3.5 mm behind the limbus and in case of a nat-
cling band restores the ocular circulation [2].
13.2.2 Phacoemulsification and IOL

Implantation
For vitrectomy of PVR detachment, we recom-

mend regardless of the age a phacoemulsification
with IOL implantation in the bag. The lens
removal allows the visualisation of the vitreous
base and assessment of anterior PVR, and it
allows more importantly the surgical access to
the vitreous base. We avoid a (pars plana) lensec-
tomy because the lens capsule is absent which Fig. 13.5 Iris stretching with Sinskey hooks
scleral depression. We use the Resight-Biom

system from Zeiss together with a Zeiss
Lumera microscope.
13.2.4 Vitreous Staining

with Triamcinolone
A staining of the peripheral vitreous with triam-

cinolone improves visualization very much.
Dilute triamcinolone 1:3 and inject it from both
side ports towards the periphery.
Fig. 13.6 Iris retractors
13.2.5 Vitreous Base Shaving
A posterior vitreous detachment (PVD) is usually

present in idiopathic PVR. In contrast, a PVD is not
present in diabetic and traumatic PVR. Induce the
PVD as far anteriorly to the vitreous base as possible.
The vitreous in PVR is inflamed and therefore a thor-
ough removal is important. We recommend the stain-
ing of the vitreous with triamcinolone to assess if a
PVD is present and to allow a meticulous shaving of
the vitreous base. “Shaving” means that the vitreous
cortex is removed to the surface of the peripheral
retina. The settings of the vitreous cutter are a high
clip rate (5ooo–7500 cuts/min) and a low aspiration
rate (200 mmHg). Crucial for a successful shaving is
Fig. 13.7 Malyugin ring
a wide-angle viewing system and scleral depression.
Ideally the scleral depression is performed bimanu-
ural lens 4.0 mm. Insert the infusion line in a
ally under illumination of a chandelier light.
quadrant without anterior traction. Otherwise
the infusion will be located subretinally. In
complicated vitrectomies, we insert always a
13.2.6 Membrane Dissection
chandelier light (four-port PPV) which allows
for bimanual dissection of membranes, biman-
In general, the removal of preretinal membranes
ual injection of PFCL and injection of silicone
results in relief of preretinal traction. All epireti-
oil under view to retina.
nal membranes must be removed. Even in case of
A vital point for successful and complica-
retinotomy, remove all membranes up to the
tion free vitrectomy is a good visualisation.
retinotomy edges. If you leave the epiretinal

Wide-angle viewing systems have a viewing
membranes, then they will continue to proliferate
field of 60–130°. They allow for anterior dis-
and cause a tractive detachment. In contrast,
section and limit the need of scleral depres-
remove subretinal proliferation only if the
sion. The visualisation in an air-filled eye is
posterior retina is not flattened under PFCL. Begin
improved. The s tereopsis is however reduced.
with removal of the membranes located at the
The conventional contact lens system has a
posterior pole and continue with membrane dis-
viewing field of only 20–30° and requires
section in the peripheral retina (Fig. 13.8).
Fig. 13.11 The dye is dropped on the membrane
Fig. 13.8 In PVR detachment, membrane, dissection

starts in the central posterior pole and continues in the
periphery
Fig. 13.9 A Charles flute needle
Fig. 13.12 The vitreous cavity is filled with air. This

method increases the concentration of the dye and enables
the staining of peripheral membranes
dye is longer and more concentrated before the

Fig. 13.10 A 3 cc syringe filled with trypan blue is easier dye falls down to the posterior pole. Perform a
to use than an original syringe
fluid × air exchange and drop a few drops of the
dye directly on the membranes (Figs. 13.11 and
Technique of membrane staining: We refill 13.12). Wait 30 s, aspirate first the dye from the
the dye into a regular 3 cc syringe because the posterior pole, and then continue with an
dye can be ejected in more controlled manner air × fluid exchange. With this method a higher
(Figs. 13.9 and 13.10). In PVR detachments the concentration of the dye is achieved and there-
membranes are located centrally and peripher- fore a better staining of the membranes.
ally. It is easy to stain central membranes in a Technique of membrane removal: The peel-
BSS-filled eye because the dye falls down to the ing of PVR membranes is technically very diffi-
posterior pole. This manoeuver is, however, dif- cult. It requires patience, good visualisation and
ficult for peripherally located membranes. good instruments. Centrally located membranes
We stain, therefore, in an air-filled eye. In an can be removed with one hand, but peripherally
air-filled eye, the contact between membrane and located membranes require bimanual peeling.
Our setup is a four-port PPV with three trocars

and one chandelier light.
13.2.7 Removal of Epiretinal

Membranes
A successful membrane removal depends to a

large amount on the instrument, even if you are
an experienced vitreoretinal surgeon. You need
good delamination instruments and good forceps.
Test therefore many different peeling forceps to
find the one which suits you best.
For delamination of the membrane, we use a 25 Fig. 13.13 Removal of peripheral membranes with end-
or 27 G blunt retrobulbar cannula (Atkinson, gripping forceps and straight scissors
Beaver Visitec). Alternatively, you can use a mem-
brane pic (DORC). For dissection of membranes, sclerotomy site. Furthermore, it facilitates drain-
three different forceps from DORC are available. age of subretinal fluid through anterior retinal
In our experience the 27 G endgripping forceps breaks. Important: All breaks must be freed of
(DORC) is suitable for every tissue from ILM to traction before they come in contact with the
thick membranes. Membranes with strong adhe- PFCL. Otherwise there is a risk that the PFCL
sions require stronger forceps such as the serrated tracks subretinally.
jaws forceps or a strong endgripping forceps. Subretinal proliferations are present in
Vitreoretinal tractions can be cut with straight 25 G nearly half of the cases of PVR but rarely pre-
microscissors (Fig. 13.13) (DORC, NL and Eye vent retinal reattachment. Must all proliferations
Tech, UK) and curved 27 G microscissors (DORC). be removed? No, only the significant ones. A
The most difficult surgical manoeuver for significant subretinal membrane is one that will
removal of PVR membranes is the delamination preclude flattening of the retina unless it is
of the membranes from the retina. This manoeu- removed. Their significance becomes obvious
ver is even more difficult in the eyes after a sili- when PFCL is instilled. Remove a subretinal
cone oil tamponade. After a silicone oil proliferation only if the posterior retina is not
tamponade, the membranes are even more adher- flattened under PFCL. A special case of a sub-
ent to the retina. Delaminate the membrane with retinal proliferation is a “napkin ring.” A napkin
an Atkinson cannula and create an opening ring is a tight annular band near the optic disc.
between the membrane and the retina. Then lift Its removal requires a 360 degrees retinotomy.
the membrane here with a forceps, and move at See chapter “Traumatic PVR.”
the same time the delamination cannula or alter-
natively a 25 G knob spatula (Eye Tech, UK) 13.2.8 Removal of Subretinal
backward and forward through the opening. Proliferations
The peripheral membranes are very difficult to
remove because the retina is detached and Before removing subretinal membranes, perform
because the membranes are difficult to reach with a complete posterior and anterior epiretinal
the instruments. Instil PFCL to stabilise the pos- dissection.
terior retina and facilitate membrane removal. In Instruments:
addition, perfluorocarbon liquids (PFCLs) draw
the vitreous base more posteriorly. This effect 1) 20 G subretinal spatula DORC 1295-1 0995
facilitates anterior dissection and reduces the 2) 20 G subretinal forceps DORC 1286 01 1095
chances of retina or vitreous incarceration in a 3) 20 or 23 G serrated jaws forceps
The surgery step by step: help of both forceps. If you do not work biman-
ual, then you will create a giant tear.
1. Identify the subretinal membranes which have 7. If the subretinal membrane breaks in small
to be removed and those which can be left: parts although it is not completely removed,
Instil PFCL and identify those subretinal then do not continue because the residual sub-
membranes which lift the retina. retinal membrane creates no tension.
2. Create two 20 G sclerotomies. Remove either 8. Manoeuvers 5–7 have to be performed from
both instrument trocars and enlarge the scle- the nasal and temporal side for the same
rotomy with a V-lance (Alcon) or create two membrane.
new sclerotomies (Fig. 13.14).
3. Insert a chandelier light.
4. Plan a retinotomy in the middle of the subreti- 13.2.9 Instillation of PFCL
nal membrane.
5. Insert the subretinal spatula, pierce the retina, As next step we perform an attachment test
and dissect the subretinal membrane from the (Fig. 13.17). For an attachment test, you can use
retina (Fig. 13.15). PFCL or air. PFCL attaches the retina with its
6. Now work bimanual with serrated jaws forceps gravity. Air attaches the retina with its surface ten-
and subretinal forceps: Place the subretinal for- sion pressure. If the retina is attached under PFCL,
ceps through the retinotomy, grasp the subreti- then perform a PFCL against air exchange, and
nal membrane with the subretinal forceps, and check if the retina is also attached under air. If this
pull it through the retinotomy (Fig. 13.16). is the case, then the retina will also be attached
Then pull out the subretinal membrane with under a gas tamponade. But, the retina is not nec-
essarily attached under a silicone oil tamponade
because the surface tension pressure of silicone oil
is lower than the surface tension pressure of air.
Injection of PFCL: We inject PFCL bimanu-
ally; one hand holds the PFCL syringe, and the
other hand holds the Charles flute needle. Hold
the tip of the PFCL cannula in the middle of the
vitreous cavity and inject a little bit. If air bubbles
escape, then aspirate them at once with the flute
needle. Then start to inject the PFCL at the poste-
rior pole and keep the tip of the cannula always in
the PFCL bubble in order to prevent small bub-
Fig. 13.14 Create first two 20 G sclerotomies at 10 and 2
o’clock because the subretinal instruments are 20 G
Fig. 13.16 Then grasp the membrane with the subretinal

Fig. 13.15 Then pierce the retina with the subretinal forceps, and remove it together with a serrated jaws
spatula and loosen the subretinal membranes forceps
PFCL
BSS
Charles flute
needle
Air
BSS
PFC Fig. 13.19 Keep the Charles flute needle constantly in

the PFCL bubble to prevent emulsification. Move the
injection needle slowly forwards to the lens
BSS PFCL
Charles
Fig. 13.17 Opposite mechanisms of action of PFCL and flute needle
air in a BSS-filled eye. Air fills the globe from anterior to
posterior. PFC fills the globe from posterior to anterior
BSS PFCL
Charles flute
needle
Fig. 13.20 Do not inject the PFCL towards the macula or
a retinal break
13.2.10 Laser Photocoagulation
The aim of laser photocoagulation is a long-term

stabilisation of the reattached retina. Laser photo-
coagulation causes less RPE cell dispersion than
Fig. 13.18 Work bimanual. Aspirate first air bubbles
from the PFCL needle and then start with a small PFCL
cryotherapy and consequently less PVR. In addi-
bubble tion, laser photocoagulation induces no disrup-
tion of the blood-aqueous barrier.
bles (Fig. 13.18). These small bubbles will fusion 13.2.10.1 Technique of Laser
after some time with the large bubble. Be cau- Photocoagulation
tious where the PFCL cannula is aiming to. Aim Laser photocoagulation can be performed in the
never towards the macula or a retinal break PFCL-filled eye or in the air-filled eye. Apply the
(Fig. 13.19). The PFCL bubble becomes bigger laser effects confluently surrounding all retinal
and bigger; pull the PFCL cannula slowly breaks. Our laser power for retinal breaks with an
backwards, but the tip remains constantly inside argon laser (Iridex, CA) is as follows: power, 100–
the bubble (Fig. 13.20). 300 mW; duration, 200 ms; and interval, 300 ms.
360 deg laser-

cerclage
Silicone oil
No tamponade =>
High detachment risk
Fig. 13.21 In case of a 360 deg laser cerclage, there is a

risk of a laser necrosis at the inferior pole due to a lack of Fig. 13.22 Ando iridectomy with vitreous cutter
tamponade
chamber to the anterior chamber. Not in all cases
Tips and Tricks: an iridectomy must be performed. In a normal
Laser cerclage ≠ encircling band (Fig. 13.21). pseudophakia situation, an iridectomy is not
Both an encircling band and a laser cerclage cre- necessary. An iridectomy is however necessary in
ate a barrier for tears located anterior to the bar- aphakia, in 360 degrees posterior synechia and in
rier. In addition, an encircling band creates an partial zonular lysis. In the aphakic eye, the infe-
indentation of the retina which results in a relax- rior peripheral iridectomy prevents a pupil block
ation of the shortened retina. A laser cerclage, by the anterior surface of silicone oil. Face-down
however, does not create an indentation and can positioning for the first 24 h is necessary to
therefore not help in relaxing a shortened retina. ensure the reformation of the anterior chamber.
This is important for PVR detachments with In addition you can inject methylcellulose into
intraretinal PVR and a shortened retina. the anterior chamber to prevent an immediate
postoperative flow from silicone oil into the ante-
ips and Tricks
T rior chamber. The methylcellulose causes no IOP
Cryopexy versus laser photocoagulation: Cryopexy increase in case of a silicone oil tamponade.
creates PVR; this is especially the case if the poste-
rior hyaloid is detached. In vitrectomy for retinal
detachment surgery, laser photocoagulation is rec- 13.2.12 Tamponade
ommended because it induces less PVR.
13.2.12.1 PFCL Removal
and Tamponade
13.2.11 Prepare the Anterior For gas tamponades, a PFCL × air exchange is
Chamber Before routine. For silicone oil tamponades, two surgical
Tamponade techniques exist: (1) a PFCL against silicone oil
exchange and (2) a PFCL against air and then an
Before finalising surgery with the intraocular air against silicone oil exchange. We use a PFCL
tamponade, the anterior segment has to be pre- against silicone oil exchange in traumatic retinal
pared (Figs. 13.22 and 13.23). In case of 1000 or detachments. Otherwise we use always a PFCL
5000 cst silicone oil, an inferior Ando iridectomy against air exchange.
is performed to enable a flow of aqueous from the Slippage is a complication which occurs in
inferiorly located aqueous phase in the posterior giant tears or retinotomies. If subretinal fluid is
chamber to the anterior chamber. In case of a present at the posterior pole and the eye is filled
Densiron 68 tamponade, a superior iridectomy is with gas and the patient is located face down, then
performed to enable the flow of aqueous from the a slippage at the posterior pole with macular folds
superior located aqueous phase in the posterior may occur. To avoid the slippage, use PFCL,
a b
Iridectomy Aqueous
1000 cSt silicone oil
Densiron 68
Iridectomy Aqueous
Fig. 13.23 An inferior (a) or superior (b) iridectomy depending on the silicone oil
a b
BSS
PFC
Backflush Backflush
instrument instrument
Silicone oil
BSS Silicone oil
PFC PFC
Fig. 13.24 PFCL against silicone oil exchange: In a first removal of BSS (b), hold the flute needle into the PFCL
step (a) silicone oil is injected and fills the eye from ante- phase and remove it
rior to posterior. Aspirate first the BSS phase. After
perform a thorough aspiration of fluid at the giant 13.2.12.2 Intraocular Tamponade

tear edges, and avoid face-down positioning Gas or silicone oil: According to the silicone oil
directly after surgery. In silicone oil, slippage with study, C3F8 is superior (higher reattachment rate
macular folds does not occur. The reason for this and better visual outcome) to SF6 in complicated
is that the surface tension pressure of silicone oil detachments. The silicone oil study does not
is too low to press away the fluid at the posterior compare C3F8 with silicone oil. The advantages
pole; the fluid is resorbed by the pigment epithe- and disadvantages of C3F8 are listed in Table 13.2
lium, and the retina slowly reattaches. and of silicone oil in Table 13.3. For compli-
PFCL against silicone oil exchange cated retinal detachments, we prefer silicone oil.
(Fig. 13.24). For this step a chandelier light is not The main reason is that the recurrent detachment
required. If you exchange PFCL against silicone risk in complicated RDs is higher than in easy
oil, one hand aspirates the PFCL, and the other detachments. And a recurrent detachment under
hand holds the light fibre while the silicone oil is silicone oil is better than a recurrent detach-
injected with the infusion line. ment under gas. Why? A recurrent detachment
Table 13.2 The pros and cons of C3F8 Infusion

line
Advantages of C3F8 Disadvantages of C3F8
Disappears Only temporary tamponade s
spontaneously Ga
High surface tension Specific head positioning (not
pressure for children, disabled)
Air travel must be postponed
(risk of expansion)
Backflush
Vision is restricted (not for
instrument
monocular patients)
Cataractogenic
Air
Table 13.3 The pros and cons of silicone oil
Advantages of silicone oil Disadvantages Fig. 13.25 The setup for a gas injection. The gas is
“Non-temporary” longer Need for a second injected through the infusion line and the flute needle
tamponade operation evacuates the air
Does not require positioning Scaffold for
reproliferation (?)
Earlier visualisation (option Cataractogenic
for monocular patients)
Air travel is possible Low surface tension
pressure
Air
Lower risk of hypotony
Backflush
instrument
under gas develops fast into a PVR detachment. flute needle
A recurrent detachment under silicone oil devel- Air Air

ops slowly. Under gas an immediate surgery is
required. Under silicone oil you can postpone and
Gas
plan surgery.
Gas tamponade: Gas has two great advan-
tages over silicone oil. The surface tension pres-
sure of gas is much higher than for silicone oil
which enables a more effective sealing of retinal Fig. 13.26 The heavy gas fills the vitreous cavity from
posterior to anterior and the flute needle aspirates the light
holes. Secondly, the gas is a temporary tampon- air
ade. Long-term damages of gas are therefore not
existent compared to silicone oil.
Injection of gas: SF6, C2F6 and C3F8 are due to 13.2.12.3 Silicone Oil Tamponade
the fluorine atoms heavier than air. The gases Silicone oil is an excellent temporary tamponade
sink therefore to the ground, whereas the lighter but a very bad permanent tamponade. It causes
air stays above. Hold the Charles flute needle high IOP and emulsifies and the final result is an
behind the lens to aspirate the air, and the gases optic atrophy. Silicone oil should be avoided in
can fill the vitreous cavity from posterior to ante- fresh and primary detachments. Silicone oil is
rior (Figs. 13.25 and 13.26). indicated in recurrent detachments, in compli-
cated PVR detachments and in diabetic tractive
Tips and Tricks: detachments. But even in these cases, try to
Shake the 50 cc gas syringe before injection because remove the silicone oil after 3 months.
the gas sinks to the bottom of the syringe resulting Silicone oil injection under view to retina:
in a wrong concentration of the gas in the eye. Figs. 13.27, 13.28, and 13.29
Silicone oil injection without view to retina: Surgical Tip:

Figs. 13.30, 13.31, and 13.32 Silicone oil overfill (Fig. 13.33): Cut the
1000 or 5000 csts silicone oil: 5000 csts infusion line with a scissors so that the
induces less IOP increase and less emulsification. excessive silicone oil can escape. An IOP of
If you plan a long silicone oil tamponade (longer approximately 10 mmHg is fine or wait so
than 6 months), then use 5000 csts silicone oil. If long until no more oil escapes from the
you plan a short duration (shorter than 6 months), infusion line.
then use 1000 csts silicone oil. The duration of
the silicone oil is listed in Table 13.4.
Fig. 13.27 Silicone oil

injection under view to
retina. Note that a
chandelier light is
required
Air
il
Air infusion eo
on
S ilic
Chandelier Backflush
instrument
light fibre
Air
Backflush instrument Silicone oil

Fig. 13.29 You work bimanual in order to inject the sili-
Fig. 13.28 Setup for oil injection with view to retina cone oil under view to retina
Fig. 13.30 Silicone oil

injection without view to
retina. Note that no
chandelier light is
present
Table 13.4 The duration of a silicone oil tamponade at

n
s io the University of Uppsala
n fu
ri Duration of Normal Young Trauma case
Ai
silicone oils case patient (with low IOP)
1000/1300 csts 1.5–3 1–3 6 months to
silicone oil months months ∞
5000 csts 3 months 1–3 6 months to
silicone oil to ∞ months ∞
Densiron 68 1.5–3 1–3 6 months to
Si months months ∞
lic
on
e
oil
Backflush instrument
Fig. 13.31 Setup for silicone oil injection without view

to the retina
Air
il
n eo
lico
Si
Backflush
instrument
Air
No view
Fig. 13.33 Cut the infusion line after silicone oil injec-
tion so that excessive oil can flow out
Fig. 13.32 If you have no chandelier light, then you have

no view to the retina
Conclusion attachment cannot be achieved with one sur-

In a retrospective study at the University of gery. Instead 2–3 surgeries are necessary to
Uppsala (unpublished results), 50 eyes (49 achieve reattachment.
patients) were operated in the period of 1998–
2002 (5 years). The PVR grade was ≥C-2. The
anatomical results were an attached retina in References
96% and a detached retina in 4%. The mean
number of surgeries was 2.6 (1–6). The func- 1. Vitrectomy with silicone oil or sulfur hexafluoride gas
tional results were an increased visual acuity in eyes with severe proliferative vitreoretinopathy:
(>2 Snellen lines) of 82%, an unchanged of results of a randomized clinical trial. Silicone Study
Report 1. Arch Ophthalmol. 1992;110(6):770–9.
16% and worse visual acuity of 2%. 2. Kreissig I. A practical guide to minimal surgery for
Remark: In case of a complicated retinal retinal detachment. Stuttgart: Thieme; 2000. ISBN:
detachment, we inform our patients that retinal 9783131606914
180° Retinotomy
14
Extras: Videos 14.1, 14.2, and 14.3. Recurrent detachment
14.1 Introduction and Definition Removal of membranes
If despite meticulous transvitreal, epiretinal, and

Immobile foreshortened retina Mobile retina
subretinal dissection the retina remains foreshort-
ened preventing an attachment of the retina with
the retinal pigment epithelium, the surgeon Retinotomy
should perform a retinotomy or retinectomy in
order to relax the retina. Retinotomy involves
incising the retina, whereas retinectomy involves Silicone oil tamponade
excising the retina. The peripheral retina is cut
parallel to the ora serrata (180, 270 or 360°), and Diagram 14.1 The treatment algorithm regarding
retinotomy
the retinotomy edges are treated with laser photo-
coagulation in order to reattach the retina. See
Diagram 14.1. PVR detachment is performed in the area with
Retinotomy could be performed in a radial persistent contraction of the retina usually affect-
fashion, but most commonly it is done circum- ing the two lower quadrants, due to the physical
ferentially, parallel to the ora serrata. The major- property of the 1000 cSt silicone oil that is regu-
ity of PVR cases can be managed without larly used for the first surgery. This silicone oil is
retinotomy/retinectomy. We almost never use it lighter than water and therefore is leaving some
in the first surgery, except for the penetrating space filled with aqueous inferiorly, thus
injuries with PVR and incarceration of the retina tamponeding better the upper two quadrants
in the penetrating wound. The circumferential where recurrent detachment almost never occurs.
retinotomy in repeated surgery for idiopathic
14.2 Timing
5_14) contains supplementary material, which is available A retinotomy (Fig. 14.1) should only be per-
to authorized users. formed in the second (or later) surgery. You
should avoid retinotomy in the first surgery.
Department of Ophthalmology, Uppsala University Typically, it goes like this: PVR detachment and
Hospital, Uppsala, Sweden first surgery with silicone oil tamponade, then

https://doi.org/10.1007/978-3-319-78446-5_14
laser, and finally injection of silicone oil. This eye

will develop a PVR redetachment, and the prolif-
erating membranes did not develop after retinot-
omy but were present from the beginning. If you
do a retinotomy, you must also remove all mem-
branes; otherwise you will fail. In my hands (US),
retinotomy does not work well. I prefer to place a
90° circumferential buckle on the inferior equator,
and as final technique I use retinotomy. In the
hands of ZT, who masters the technique of macu-
lar translocation, retinotomy works well, and the
postoperative results are good.
14.5 Conclusion
Fig. 14.1 A typical 180° retinotomy
The retinotomy and retinectomy are surgical pro-
inferior redetachment and second surgery with cedures to attach foreshortened retina secondary
retinotomy and again silicone oil tamponade, and to intraretinal PVR. The procedure and the effect
then 3 months later silicone oil removal. are traumatic for the eye and result in a huge
Remark: Even if you perform a retinotomy, complication spectrum in which hypotony domi-
you need to remove all membranes up to the reti- nates. A retinotomy is therefore the final step in
notomy edges. If you do not peel the membranes, our surgical repertoire to reattach the retina. An
then the retina will contract under silicone oil, alternative is a 90° circumferential buckle giving
and the retinotomy edges will roll in. the opportunity to perform a retinotomy at a later
stage. If you perform a retinotomy in the first sur-
gery, then you may regret your decision later on.
14.3 Complications You cannot bring back the retina which has been
cut. In addition, if you did not remove the vitre-
The complication spectrum is big. Hypotony is a ous base completely and all epiretinal mem-
frequent side effect of retinotomy. The retina branes, then a reproliferation will occur at the
serves as a barrier between aqueous and choroid. retinotomy edges. This will lead to a new, more
A retinotomy and retinectomy remove this bar- central located retinotomy and this can trigger a
rier partially and the IOP sinks. The consequences vicious circle until you reach the temporal arcade.
are hypotony and decompensated cornea which In addition, if you perform a retinotomy, you
makes a removal of the silicone oil impossible. increase the risk of a permanent silicone oil tam-
The redetachment rate after oil removal is ponade. The larger the retinotomy the bigger the
reported to be 17–25%. In the silicone oil study, a risk for permanent tamponade.
redetachment rate of 20% after silicone oil
removal has been observed. Around 40–50% of
eyes with retinotomy are required to have a per- 14.6 The Surgical Technique
manent silicone oil tamponade [1–10].
14.6.1 T
he Relaxing Retinotomy
Consists of Three Main
14.4 Remark Surgical Steps
The technique of retinotomy is technically very 1. Ora parallel diathermy

difficult. Retinotomy does not mean circumferen- 2. Retinotomy
tial cut in the retina with the vitreous cutter, then 3. Removal of anterior retina (retinectomy)
14 180° Retinotomy 149
The most common problem with the retinotomy retina. The area to be incised should be marked
is underestimation of the necessary size of the tis- with a row of endodiathermy, and incision
sue to be removed so that contraction persists. The should be tapered into the normal retina at both
most common size of retinotomy is 180° tapered to ends of the contracted retina. If endodiathermy
the two lower quadrants and extending from 3 over is not possible, i.e., the retina does not become
6–9 o’clock. A 360° retinotomy is seldom and may white during endodiathermy, then vitreous is
be required in penetrating injuries with incarcera- left. Remove the residual vitreous with the vitre-
tion of the retina and PVR stage D. It is usually ous cutter and continue with diathermy
followed by some distortion of the retina after reat- (Figs. 14.2 and 14.3). If you find a membrane at
tachment and requires relocation of the retina using the edge, remove it at once; otherwise it will
the flute needle with silicone tip in order to reestab- continue to proliferate and cause a recurrent
lish its normal anatomical position. detachment.
14.6.2 Instruments
1. 25 or 27 G vitreous cutter
or vertical scissors
2. 23 or 25 G knob spatula (Eye Tech, UK)
or flute needle with silicone tip
3. Perfluorocarbon liquid (PFCL)

4. 1000 cSt or 5000 cSt silicone oil
14.6.3 The Surgery Step by Step
1. Row of diathermy as anteriorly as possi-

ble within the contracted retina
2. Retinotomy
3. Retinectomy (removal of remaining ante- Fig. 14.2 A row of diathermy as anteriorly as possible
rior retina)
4. Hemostasis of the retinotomy edge
5. Injection of PFCL
6. Flattening of retinotomy edges
7. Attachment test
8. Laser treatment
9. PFCL × air exchange
10. Air x silicone oil exchange
14.6.4 Every Step in Detail
1. Row of diathermy as anteriorly as possi-

ble within the contracted retina (Figs. 14.2
and 14.3)
Retinotomy should be performed as anteri-

orly as possible in order to preserve the healthy Fig. 14.3 Diathermy before retinotomy
(Fig. 14.5). Meticulous haemostasis of the reti-

notomy edge is essential, as any bleeding may
lead to recurrent PVR.
5. Injection of PFCL
6. Flattening of the retinotomy edges
The retina is then reattached using perfluoro-

carbon liquid (PFCL). Instill PFCL up to the reti-
nal edge. Folds or areas of retinal distortion are
adjusted with a retinal manipulator (knob spat-
ula) or a flute needle with silicone tip. In case of
residual membranes, dissect the membrane with
a membrane pic or CRVO knife. The PFCL is not
removed for this maneuver; it creates counterten-
Fig. 14.4 A retinotomy anterior to the row of sion. Grasp the membrane with a forceps and
endodiathermy remove it. You may need to work bimanual with
the forceps in one hand and the dissection instru-
ment in the other hand. If you lift the retina care-
fully, then the PFCL will not spill over the edges
and flow subretinally.
7. Attachment test
8. Laser treatment (Fig. 14.6)
Before continuing with laser photocoagula-

tion, check whether the retinotomy edges are
completely attached under PFCL. If not then fix
the problem: remove the membrane or enlarge
the retinotomy. If the attachment test is positive,
continue with laser treatment (Fig. 14.6).
Fig. 14.5 A retinectomy of the anterior retina
2. Retinotomy (Fig. 14.4)

3. Retinectomy (removal of the remaining
anterior retina) (Fig. 14.5)
4. Hemostasis of the retinotomy edge
The retinotomy is performed with the vitreous

cutter at a low cut rate of 100–150 cuts/min or
vertical scissors (Fig. 14.4). A 27 G vitreous cut-
ter is due to its size very suitable for a retinotomy.
The remaining anterior retina is then removed
with the vitreous cutter at higher cut rate of 5000– Fig. 14.6 Laser photocoagulation of the retinotomy
7500 cuts/min and is called anterior retinectomy edges
14 180° Retinotomy 151
For laser photocoagulation of retinal edges, we x silicone oil exchange. We prefer the first method
recommend a higher laser power than usual. A because the retinotomy edges detach and enroll
higher laser power induces an immediate congeal- with the second method.
ing of outer retinal proteins by heat resulting in a Start with a PFCL × air exchange until the air
more immediate adhesion. Our recommended reaches the retinal edges. It is important to aspirate
laser power for retinotomy edges with an argon thoroughly the fluid at the edges of the retinotomy
laser device (Iridex, CA) is: Power: 100-300 mW, to avoid slippage. Then continue to remove the
Duration: 300 ms, Interval: 300 ms. This is espe- residual PFCL. The whole procedure is finished
cially the case for laser treatment of retinotomy with an injection of 1000 cSt silicone oil into the
edges. For retinal holes and for a laser cerclage, a air-filled cavity. We never use a gas temponade in
reduced laser power is recommended. an eye with retinotomy because in case of recur-
rent detachment, there will be a fast progression to
14.6.4.1 Tips and Tricks PVR. Heavy silicone oil such as Densiron 68 can
Laser photocoagulation for retinotomy: more be used but is not necessary. If the retina is relieved,
laser power than usual, 300 ms duration instead then 1000 cSt oil is sufficient.
of 200 ms!!
9. PFCL × air exchange (Fig. 14.7) 14.6.5 FAQs

10. Air x silicone oil exchange
1) How to avoid slippage? In case of a large reti-
For this step two methods are possible notomy (>180°), slippage is possible.
(Fig. 14.7): (a) first a PFCL × air exchange and Important is a strong laser treatment which
then a silicone oil injection and (b) a direct PFCL creates immediate retinal adhesion and a
a b
Silicone oil
Air Air
BSS
PFCL
Silicone oil
Fig. 14.7 Silicone oil injection in an air-filled eye (a) and instead of (b). Why? In (a) the retinotomy edges are
in PFCL-filled eye (b). In an air-filled eye, the silicone oil attached under air and remain attached when the silicone
fills the eye from posterior to anterior (a); in a PFCL-filled oil is filled in. In (b) the retinotomy edges are attached
eye, the silicone oil fills the eye from anterior to posterior under PFCL but detach as soon as the silicone oil comes
(b). In case of a retinotomy, it is advisable to use (a)
meticulous aspiration of fluid at the retinot- edges do not lift, if you laser photocoagulate
omy edges. them, even if you use a high laser power. They
2) Too short retinotomy: If the retinotomy is too will, however, lift when membranes are pres-
short (if contracted retina remains), then the ent. To prevent uplifting, all membranes must
retina is under tension, and silicone oil will be removed. If the membranes cannot be
flow subretinally. If this happens remove the removed because they are very attached and
silicone oil, enlarge the retinotomy, and rein- fibrotic, then perform a few radial cuts with
ject silicone oil. the scissors at the retinotomy edge. This will
3) Attachment test: If the retinotomy edges are result in an attachment of the retinotomy
not attached under PFCL or air, then do not edges.
continue with a silicone oil tamponade.
Silicone oil has a lower surface tension pres-
sure than air. It is therefore likely that the ret- References
ina detaches under silicone oil. Enlarge the
retinotomy instead. 1. Vitrectomy with silicone oil or sulfur hexafluoride gas
4) Is the retinotomy large enough? In case of an results of a randomized clinical trial. Silicone Study
inferior recurrent detachment with foreshortened Report 1. Arch Ophthalmol. 1992;110(6):770–9.
retina, we recommend to do a 180° retinotomy 2. Han DP, Lewis MT, Kuhn EM, et al. Relaxing reti-
from the beginning: from 3 over 6–9 o’clock. notomies and retinectomies: surgical results and
predictors of visual outcome. Arch Ophthalmol.
5) PFCL x silicone oil tamponade or PFCL x air 1990;108:694–7.
x silicone oil tamponade? 3. Federman JL, Eagle RC Jr. Extensive peripheral reti-
For silicone oil tamponades, two surgical nectomy combined with posterior 360° retinotomy for
techniques exist (Fig. 14.7): (a) a PFCL against retinal reattachment in advanced proliferative vitreo-
retinopathy cases. Ophthalmology. 1990;97:1305–20.
silicone oil exchange and (b) a PFCL against 4. Zivojnovic R. Silicone oil in vitreoretinal surgery.
air and then an air against silicone oil exchange. Dordrecht: Martinus Nijhoff/Dr W Junk; 1987.
We use a PFCL against silicone air exchange p. 141–52.
in giant tears and traumatic retinal detach- 5. Blumenkrantz MS, Azen SP, Aaberg T, et al. Relaxing
retinotomy with silicone oil or long-acting gas in eyes
ments. Otherwise we use always a PFCL with severe proliferative vitreoretinopathy. Silicone
against air exchange. Why? (a) Visualization Study Report 5. The Silicone Oil Study Group. Am J
of PFCL phase and silicone oil phase is diffi- Ophthalmol. 1993;116:557–64.
cult. (b) PFCL and air are very potent in 6. Bovey EH, De Ancos E, Gonvers M. Retinotomies of
180 degrees or more. Retina. 1995;15:394–8.
attaching the retina. PFCL attaches the retina 7. Quiram PA, Gonzales CR, Hu W, et al. Outcomes
with its gravity and air with its high surface of vitrectomy with inferior retinectomy in patients
tension pressure. Silicone oil, however, has a with recurrent rhegmatogenous retinal detachments
low surface tension pressure. If you exchange and proliferative vitreoretinopathy. Ophthalmology.
2006;113:2041–7.
from PFCL to silicone oil, then you remove a 8. Grigoropoulos VG, Benson S, Bunce C, Charteris
fluid with good attachment quality to a fluid DG. Functional outcome and prognostic factors in
with low attachment quality. If you do a PFCL 304 eyes managed by retinectomy. Graefes Arch Clin
against silicone oil exchange in an eye with Exp Ophthalmol. 2007;245:641–9.
9. Shalaby KA. relaxing retinotomies and retinecto-
180° retinotomy, then the retinal edges lift up. mies in the management of retinal detachment with
This will not happen if you exchange from severe proliferative vitreoretinopathy (PVR). Clin
silicone oil to air. In an air-filled eye, the sili- Ophthalmol. 2010;4:1107–14.
cone oil falls on the posterior pole and fills the 10. Adelman RA, Parnes AJ, Sipperley JO, Ducournau
D. Strategy for the management of complex retinal
eye up from posterior to anterior. detachments: the European Vitreo-Retinal Society
6) Lifted retinotomy edges during/after laser retinal detachment study report 2. Ophthalmology.
photocoagulation: Usually the retinotomy 2013;120:1809–13.
Silicone Oil Removal
15
Extras: Videos 15.1 and 15.2. 15.1.3 Heavy Silicone Oil
The heavy silicone oil (Oxane HD, B&L) and

15.1 Introduction Densiron 68 (Fluoron) are a bit tricky to remove,
because the silicone oil sticks to the retina and
15.1.1 1000 cSt Silicone Oil the final oil bubble may fall onto the posterior
pole. We remove Densiron 68 6–12 weeks after
We use in almost all cases 1000 or 1300 cSt sili- injection.
cone oil. The duration is 2–6 months. The emul-
sification is acceptable and an IOP increase can
be treated with glaucoma drops. 15.1.4 Removal of Silicone Oil
Preserves the late complications such as emulsifi-

15.1.2 5000 cSt Silicone Oil cation and secondary glaucoma and restores the
binocular vision in operated patient. The silicone
5000 cSt silicone oil causes less ocular hyperten- oil can be removed when the retina is completely
sion and less emulsification than 1000 cSt sili- attached, chorioretinal scars are formed, and the
cone oil. It is therefore suitable for a permanent eye is not hypotensive. We remove the silicone
tamponade. We use 5000 cSt silicone oil for per- oil 1.5–6 months after injection. We remove sili-
manent tamponade such as ocular hypotension, cone oils as fast as possible in young patients
trauma cases, and recurrent PVR detachments. (4–6 weeks). We are more tolerant with silicone
oil in patients over 80 years and trauma eyes.
15.1.5 Surgical Management
25 G and even more 27 G are excellent choices for

Electronic Supplementary Material The online version silicone oil removal because the risk of postopera-
5_15) contains supplementary material, which is available tive hypotony is significantly reduced. 1000 and
to authorized users. 5000 cSt silicone oil can be easily removed with
27 G. Remove a valve from an infusion trocar and
Department of Ophthalmology, Uppsala University attach the silicone oil infusion line (VFE, DORC)
Hospital, Uppsala, Sweden (Fig. 15.1). 1000 cSt oil can be removed within

https://doi.org/10.1007/978-3-319-78446-5_15
Fig. 15.1 Silicone oil removal with a silicone tube (VFE,

DORC)
Fig. 15.3 Densiron 68 removal with a long 23 G metal

cannula (DORC), good for myopic eyes
15.2 ight Silicone Oil (1000,

L
1300, and 5000 cSt) Removal
Silicone oil removal with a modern vitrectomy

machine is simple and fast. Insert three trocars.
Attach the high infusion (VFE, DORC) to the
trocar and actively aspirate the silicone oil
(Fig. 15.1). If you want a faster removal, then
Fig. 15.2 Silicone oil or Densiron 68 removal with a use the 25 G trocar from Alcon (Fig. 15.2). When
25 G metal cannula (Alcon)
extracting the silicone oil, make sure that the tip
of the aspiration cannula is always located in the
10 min and 5000 cSt oil within 20 min. A faster silicone oil bubble and not in the BSS phase.
alternative is the 25 G metal cannula (Alcon) for
silicone oil injection and removal (Fig. 15.2).
Heavy silicone oil (Oxane HD, Densiron 68) 15.3 eavy Silicone Oil (Densiron
H
can be removed with the 25 G metal cannula 68®) Removal
(Alcon, Fig. 15.2) or a novel 23 G metal cannula
(10 mm, DORC) (Fig. 15.3). The latter is espe- Heavy silicone oil removal cannot be performed
cially recommended for myopic eyes. with 27 G. Heavy silicone oil removal can be per-
formed with 23 and 25 G. We prefer 25 G because
15.1.5.1 Tips and Tricks the eye has less hypotony after surgery due to the
The removal time is of course much faster with small sclerotomies. In any case perform a
25 G and especially 23 G. With 23 G the removal fluid × air exchange at the end.
time for 1000 cSt oil is 1–2 min and for 5000 cSt
oil 5–7 min. The disadvantage of 25 G and espe-
cially 23 G is the postoperative hypotony. In case 15.3.1 A
ctive Removal of Heavy
of 23 and 25 G, you need an air tamponade, and Silicone Oil (e.g., Densiron 68®)
in myopic eyes, you even need to suture the scle-
rotomies. The air tamponade and sutures are not There are two extraction cannulas available:
necessary for 27 G. It is therefore recommended
to use a hybrid system: 27 G trocars for infusion 1. Short 25 G metal cannula (Fig. 15.2, Alcon):
and light fiber and a 23 or 25 G trocar for oil This cannula can be used with all modern vit-
removal. rectomy machines (EVA, Constellation or
15 Silicone Oil Removal 155
40–50 mmHg until the BSS comes. Then reduce

back to 25 mmHg.

When removing Densiron 68® with a short can-
nula, it is important not to lose contact with the
bubble before it starts “floating up” toward the
cannula. If you lose contact with the bubble and
it is too small to be reached with the short can-
nula, you need to proceed with a backflush can-
nula (which takes a long time).
Fig. 15.4 Removal of Densiron 68 with a 10 mm long 15.4 Complications

23 G metal cannula from DORC
1. Postoperative hypotony with choroidals
Stellaris). The removal is simple and fast. occurs often after silicone oil removal. In
Remove the silicone oil bubble as one would order to avoid, take the following
with conventional silicone oil, always staying precautions:
in touch with the bubble with active suction 23 G: Close the sclerotomies with a suture
(Fig. 15.4). The residual bubble will stay con- and use an air tamponade.
nected to the short cannula through the 25 G: Use an air tamponade, a closure of
“siphoning” effect, will move upward toward sclerotomies is not necessary. Exception:
the cannula, and can easily be removed this myopia.
way. Be aware that the cannula has constant 27 G: No sutures necessary even in myo-
contact to the Densiron 68 bubble. If you lose pia; in normal eyes an air tamponade is not
contact, then the residual bubble will fall on required. In myopic eyes an air tamponade is
the posterior pole. In this case, fasten a 25 G recommended.
Charles flute cannula onto the silicone oil 2. A dreaded complication is a retinal and even
syringe and aspirate the residual bubble. Small sometimes choroidal damage from the infu-
remnant bubbles at the posterior pole can then sion fluid. This happens in the beginning of
be collected with the backflush instrument. an air × BSS exchange: The vitreous cavity is
The removal time is approximately 5 min. filled with air and you switch back to BSS. If
2. 23 G metal 10 mm cannula (Figs 15.3 and you now aspirate actively with a Charles flute
15.4, DORC): A good alternative is a longer needle within the air phase, you will create an
23 G metal cannula from DORC. Especially under-pressure, and the infusion fluid will
for long myopic eyes where you easily loose stream with great force into the eye damaging
contact with the oil bubble, this cannula is the retina and choroid. In order to avoid this,
recommended. aspirate only passively. You can control the
pressure on your own by closing the side
15.3.1.1 Tips and Tricks opening of the Charles flute needle with your
Clogged infusion line in the beginning of the index finger.
procedure: The reason of the clogged infusion
line is silicone oil within the infusion because
you compress the globe with the silicone oil 15.5 FAQ
cannula. Countermeasures are as follows: (1)
Do not press with the syringe onto the globe. Is it possible to remove heavy silicone oil with
You press otherwise the silicone oil into 25G?
the infusion line. (2) Increase the IOP to Yes, this is no problem.
Part IV
Special and Advanced Cases
Total and Chronic Retinal
Detachment 16
The chronic and total retinal detachment has a high The surgical spectrum in general varies from
recurrent detachment risk and is surgically demand- 360° retinotomy with radial cuts and silicone
ing, and a reattachment without a permanent sili- oil tamponade to encircling band and C3F8 gas
cone oil tamponade is difficult to achieve. We tamponade. Our approach is as follows: We
operate only eyes with a duration of retinal detach- inform the patient that in most cases, 2–3 sur-
ment up to 1 year. What information can you give a geries are necessary to achieve retinal reattach-
patient with a macula-off detachment (Figs. 16.1 ment. The author ZT would treat a total and
and 16.2) regarding visual acuity outcome? chronic retinal detachment with encircling
Prognostic factors for a macula-off retinal band, vitrectomy, peeling, and 1000 csts sili-
detachment are [1] the following: cone oil. The author US would treat a total and
chronic retinal detachment with vitrectomy and
• Extent and height of macular detachment a segmental buckle. The segmental buckle
• Duration of macular detachment would be placed as a radial buckle on an infe-
• Age of the patient rior retinal hole or in case of inferior PVR as a
• Myopia circumferential buckle.
–– The visual acuity of a retinal detachment In some cases an inferior recurrent detach-
that has persisted less than 1 week is sig- ment occurs. In a second surgery, we would
nificantly better than after 1–2 weeks. A repeat peeling and use a Densiron 68 tamponade.
retinal detachment with a duration of 2 If the inferior retina remains foreshortened, we
weeks is not significantly better than one use two different techniques: ZT who is an
with a duration of 1 year. expert in macular translocation prefers an infe-
–– The postoperative recovery takes up to 1 rior 180° retinotomy, and US prefers an inferior
year. Patients with an age under 60 years circumferential (ora parallel) buckle. The advan-
show an improved postoperative recovery tage of a segmental buckle to an encircling band
than patients with an age over 60 years. is that the impression is much stronger.
–– In myopia recovery of visual acuity is
poorest in patients with a myopia of −6D
and more. 16.1 Example 1 (Fig. 16.3)
A 45-year-old male patient with a 6-month-old

U. Spandau (*) · Z. Tomic retinal detachment. Operated with vitrectomy,
Department of Ophthalmology, inferior buckle, and silicone oil. Silicone oil
Uppsala University Hospital, Uppsala, Sweden

https://doi.org/10.1007/978-3-319-78446-5_16
Fig. 16.1 An OCT of a

detached macula
secondary to retinal
detachment
Fig. 16.2 The same eye

as in Fig. 16.1. An OCT
of an attached macula
after successful
vitrectomy
a b
Old
buckle
1000 csts
silicone oil
Fig. 16.3 (a) A total and chronic retinal detachment with inferior PVR. The retina was operated a few years ago with
scleral buckling. (b) An attached retina after a vitrectomy with inferior circumferential buckle
16 Total and Chronic Retinal Detachment 161
removal after 3 months and VA of 0.1–0.2. For band, vitrectomy, and C3F8; and (3) segmental
detailed case report and video, see Chap. 12. buckle from 5:00 to 6:30, vitrectomy, and tam-
ponade. We chose the third option.
16.2 Example 2 (Figs. 16.4

and 16.5) 16.3 Example 3 (Fig. 16.6)
A 72-year-old male patient with a chronic and A 35-year-old female patient, 17 weeks preg-
total retinal detachment. The primary hole is nant,, presents with an old inferior detachment:
located at 12 o’clock and three holes are located She saw flashes. An old pigmented inferior
at 6 o’clock. There are several surgical options: detachment is detected with two holes at 5:30. A
(1) Scleral buckling with a circumferential cryopexy with a radial buckle is performed. A
buckle from 11:30 to 12:30 and a second circum- follow-up 9 years later shows an attached
ferential buckle from 5:00 to 6:30; (2) encircling retina.
a b
Fig. 16.4 A chronic and total detachment. One pri- formed. A segmental buckle was placed on the three
mary hole at 12 o’clock, which is alone responsible for holes at 6 o’clock and silicone oil as tamponade. Two
the total detachment, and three holes at 6 o’clock (a). months after silicone oil removal, the retina remained
A combined buckle/vitrectomy procedure was per- attached (b)
Fig. 16.5 The same

patient as in Fig. 16.2.
Status before silicone oil
removal. At 2 months
follow-up, the retina
remained attached
Fig. 16.6 A 33-year-old

female patient with a
chronic inferior
detachment. A radial
buckle was placed on
two holes at 5:30. This
picture is taken 9 years
later
Reference
1. Kreissig I. A practical guide to minimal surgery for
retinal detachment. Stuttgart: Thieme; 2000. ISBN:
9783131606914
Recurrent Retinal Detachment
17
17.1 Introduction the hole, then a stronger sealing is necessary. An

episcleral buckle is a more effective sealing
The main question when examining the retina of method. Alternatively, place two to three rows of
a recurrent detachment is: Where is the hole? If a laser around the old laser scars and finalize sur-
new hole is present, we would operate the eye as gery with a tamponade.
a primary detachment. But in many cases, a reti- If you cannot find the hole, then I would again
nal break cannot be found. In this case a minihole place a segmental buckle according to the Lincoff
must be searched for. This minihole is often a rules or alternatively instill a permanent silicone
laser necrosis and located at the edge of a laser oil tamponade.
scars. In order to localize the hole, you must
remember the Lincoff rules and use the following
trick: Inject PFCL posterior to the suspected hole 17.2 Surgical Technique
and look for Schlieren. Schlieren is subretinal for Recurrent Detachment
fluid which enters the vitreous cavity through the Under Silicone
hole. Search for the hole using a light fiber and
scleral depressor. There are two surgical options: (1) Leave the
If you found the hole, then perform a laser silicone oil and remove the epiretinal mem-
photocoagulation. If you are insecure about the branes under silicone oil. This so-called inter-
hole location, then place a buckle according to face vitrectomy is only advisable for experienced
the Lincoff rules. surgeons (see chapter of Dr Ghasemi from Iran).
But if an already laser-treated hole reopened, I (2) Remove the silicone oil and inspect the ret-
would place a segmental buckle on this hole. ina under BSS. The advantage of this procedure
Why? Well, why did this hole reopen although is that the complete retina can be assessed under
the hole edges were laser photocoagulated? BSS, and you may detect membrane and holes
Traction on the edges? Pigment epithelium atro- which were covered under the silicone oil.
phy? So, something is wrong with the hole and
the regular tamponade with gas did not do the
job. If obviously a gas tamponade could not seal 17.3 Conclusion
In case of a recurrent detachment under silicone

U. Spandau (*) · Z. Tomic oil, we recommend first the complete removal of
Department of Ophthalmology, silicone oil. Then stain the retina for membranes,

https://doi.org/10.1007/978-3-319-78446-5_17
continue with the consequent removal of mem- with laser and silicone oil tamponade. The author
branes, and finalize with a silicone oil tamponade. Ulrich Spandau prefers a combined vitrectomy
with laser and episcleral buckling.
17.4 Surgical Management

of a Recurrent Detachment 17.4.2 Examples
17.4.1 Two Surgical Procedures Total recurrent detachment (Figs. 17.1 and 17.2).
When a recurrent retinal detachment occurs, the

authors prefer two different surgical approaches:
The author Zoran Tomic prefers a vitrectomy
a b
Old
buckle
1000 csts
silicone oil
Fig. 17.1 Initially a chronic PVR C2 detachment. o’clock (a). The silicone oil was removed, the break
Operated with combined buckle/vitrectomy and laser treated, and a Densiron 68 tamponade used. After
1000 cSt silicone oil. Two weeks later an inferior 2 months the silicone oil was removed and the retina
detachment occurred with a small retinal break at 6 remained attached (b)
17 Recurrent Retinal Detachment 165
a b
Fig. 17.2 Initially a total detachment with PVR B2 and a inferior redetachment occured. A circumferential segmen-
retinal break at 12 o’clock (a). A vitrectomy with silicone tal buckle was placed from 5:30 to 6:30. The retina reat-
oil was performed. One week after silicone oil removal an tached (b)
Inferior and Inferior Recurrent
Detachments 18
Extras: Videos 18.1, 18.2, 18.3, 18.4, and 18.5.
18.1 Inferior Detachment Silicone oil
An inferior retinal detachment has a frequency of

20% and is more difficult to treat than a superior
detachment (Fig. 18.1). Why? Because gas and
silicone oil tamponade insufficiently the inferior
pole. An exception is the heavy silicone oil
Densiron 68 which tamponades the inferior pole.
If you do not have Densiron 68 in your surgical
cupboard, then you require episcleral buckling
with encircling band and/or segmental buckle in
your surgical armamentarium.
Fig. 18.1 An inferior recurrent detachment with starfolds
The surgical options depend on the location of under silicone oil
the hole. See Diagram 18.1.
Vitrectomy with C2F6 or C3F8 can be used for a 6 o’clock hole. Here a Densiron 68 tamponade
holes from 3 to 5 o’clock but both for holes from is required or an episcleral buckling.
5 to 7 o’clock. For holes from 5 to 7 o’clock, an
episcleral buckling or a Densiron 68 tamponade
is advisable. The most difficult hole location is 18.2 Inferior Recurrent
6 o’clock. A C3F8 tamponade does not tamponade Detachment
18.2.1 Pathology
The inferior recurrent detachment occurs more

often than a superior recurrent detachment. The
of this chapter (https://doi.org/10.1007/978-3-319-78446- reason for this is that all proliferative cells accu-
5_18) contains supplementary material, which is available mulate due to gravity at the inferior pole and
to authorized users. cause a PVR reaction resulting in a PVR detach-
ment. After removal of epiretinal and subretinal
Department of Ophthalmology, PVR, intraretinal PVR persists and causes a fore-
Uppsala University Hospital, Uppsala, Sweden shortened retina.

https://doi.org/10.1007/978-3-319-78446-5_18
Diagram 18.1 Surgical Inferior detachment

options for an inferior
detachment
Vitrectomy with Vitrectomy with Vitrectomy with

Segmental buckle
Encircling band and gas C2F6 or C3F8 Densiron 68
I-III I-II I-III I-III
I: 3-4 o’ clock
II: 4-5 o’ clock
III: 5-7 o’ clock
ment may be an undetected hole (rhegmatogenous

retinal detachment) or a tractive detachment.
The possible surgical techniques are shown in
Table 18.1. The most popular surgical technique
is an encircling band with C3F8; other possibili-
ties are a retinotomy and an inferior circumferen-
tial buckle. The easiest technique is, however, a
tamponade with a heavy silicone oil (Densiron
68) which tamponades the inferior pole.
The correct choice of these techniques
depends on the extent of intraretinal PVR, i.e.
how much the inferior retina is foreshortened.
If an inferior mildly foreshortened retina is
present, then the following surgical techniques
can be used:
Fig. 18.2 A recurrent inferior detachment is present.
Only a mild intraretinal PVR is present 1. An encircling band with C3F8 tamponade
2. A tamponade with Densiron 68
18.2.1.1 Recurrent Inferior 3. Retinotomy (possible, but not recommended)
Detachments
Recurrent inferior detachments (Fig. 18.2) occur If an inferior severely foreshortened retina is
often and especially after silicone oil removal. present, then the following surgical techniques
According to the silicone oil study, a recurrent are possible:
retinal detachment occurs in 20% of cases after
silicone oil removal [1] and in other studies with 1. Retinotomy
17–25% [2–7]. Reasons for a recurrent detach- 2. Inferior circumferential buckle
18 Inferior and Inferior Recurrent Detachments 169
Table 18.1 Surgical

Inferior redetachment
options for inferior
recurrent detachment
180º retinotomy with Densiron 68

Encircling band silicone oil
Inferior circumferential buckle
with C3F8
with silicone oil
18.2.1.2 he Surgical Management

T
of a Mildly Foreshortened
Inferior Retina
Cerclage and C3F8 (Figs. 18.2 and 18.3)

The advantage of a gas compared to silicone oil
is the higher surface tension pressure. In addi-
C3F8
tion, C3F8 maintains a good gas filling of the
vitreous cavity for 2 months. The disadvantage
of gas is a bad tamponade of the inferior pole.
This d isadvantage of a gas tamponade for infe-
rior detachments can be encountered with an
encircling band (Figs. 18.2 and 18.3).
Densiron 68 (Figs. 18.4 and 18.5)

Fig. 18.3 The indenting effect of an encircling band and
Densiron 68 is a wonderful tamponade for infe- the high surface tension pressure of C3F8 may reattach a
rior detachments. The surgery is simple and fast. mild foreshortened retina. But if the inferior retina is
Postoperatively the inferior retina in the most severely foreshortened, the inferior retina will redetach
cases is attached. In our experience Densiron 68
can reattach a mildly foreshortened retina but
cannot reattach a severely foreshortened retina. and requires immediate surgery. In contrast, a
redetachment under Densiron 68 progresses
Encircling Band with C3F8 Versus Densiron 68 slowly and does not require immediate
We never use the technique encircling band surgery.
with C3F8 tamponade. Our rationale for this is
according to the silicone oil study, C3F8 is equal 18.2.1.3 he Surgical Management
T
to silicone oil and Sf6 worse than silicone oil of a Severely Foreshortened
[1]. According to our experience, an encircling Inferior Retina
band (tyre) with gas is equal to silicone oil, and
a tyre with silicone oil is better than a tyre with Inferior Circumferential Segmental Buckle
gas. For this reason we never use the encircling (Figs. 18.6 and 18.7)
band plus gas technique but only silicone oil. In this technique a segmental circumferential
The best silicone oil for inferior recurrent buckle is placed on the inferiorly detached retina
detachments is Densiron 68. In addition, we approximately from 4 to 8 o’clock. In case of a
prefer Densiron 68 over an encircling band with foreshortened retina, an inferior buckle on height
C3F8 because a redetachment under C3F8 pro- of the equator reattaches the retina. If the retina is
gresses fast to an advanced PVR detachment severely foreshortened, we add a Densiron 68
Fig. 18.4 A recurrent inferior detachment with mild Fig. 18.6 A recurrent inferior detachment with severe
intraretinal PVR intraretinal PVR
Gas or
Densiron 68
Densiron 68
Fig. 18.5 A tamponade with Densiron 68 reattaches an Fig. 18.7 The inferior segmental buckle indents the
inferior retina with mild intraretinal PVR in the most sclera much more than an encircling band. If you add a
cases tamponade with Densiron 68, then you have a second help
to attach the inferior retina
tamponade. If the inferior retina is less foreshort-
ened, a C3F8 or 1300 cSt silicone oil tamponade and a high amount of eyes requires a permanent
may be sufficient. A complete removal of prereti- silicone oil tamponade.
nal membranes is not necessary.
Retinotomy (Figs. 18.8, 18.9, 18.10 18.2.2 Treatment Algorithm

and 18.11) for Inferior PVR Detachment
The most popular surgical procedure for an at the University of Uppsala
inferior foreshortened retina is an inferior 180°
retinotomy. This technique is surgically diffi- The easiest surgical option is a tamponade of the
cult because all preretinal membranes must be inferior pole, and available on the market are
removed meticulously. Otherwise the retina Densiron 68 (Fluoron, Germany) and Oxane HD
will redetach (Fig. 18.11). The complication (Bausch & Lomb). If this technique fails or if the
spectrum of this technique is therefore high, inferior retina is severely foreshortened, then two
Silicone oil
Fig. 18.8 A recurrent inferior detachment with severe PVR Fig. 18.11 If the preretinal membranes are not removed,
the inferior retina will redetach. After removal of silicone
oil, the detachment risk is 20%
surgical options are available: retinotomy or seg-

mental buckle on the inferior equator. See
Silicone oil
Diagram 18.2.
18.2.3 Retinotomy Versus Inferior

Segmental Buckle
A retinotomy requires a complete membrane

removal. An inferior circumferential buckle
does not require a complete membrane
removal. In the hands of ZT, a retinotomy is
Fig. 18.9 If the preretinal membranes are removed, the the best option. He masters this technique in
inferior retina will reattach perfection from the macular translocation sur-
gery. In the hands of US, segmental buckles
are the best option. US uses a segmental cir-
cumferential buckle which is placed on the
inferior pole and covers the hole as well as the
PVR in vicinity. US prefers the excellent
impression of the segmental buckle over the
moderate impression of the encircling band.
The circumferential inferior buckle is not only
employed for the sealing of holes but also to
reattach an inferior retina with PVR starfolds.
In case of a failure, US would perform a
retinotomy. The big disadvantage of retinot-
omy is its large late complication spectrum:
~20% hypotony, ~20% decompensated cor-
nea, ~40% permanent silicone oil tamponade
Fig. 18.10 A recurrent inferior detachment with severe and ~20% retinal detachment after silicone oil
intraretinal PVR
Diagram 18.2 Our

treatment algorithm for Inferior detachment
inferior recurrent
detachment with
foreshortened retina Densiron 68
Inferior redetachment with foreshortened retina
Author: Zoran Tomic Author: Ulrich Spandau
Inferior segmental
180º retinotomy
Failure
Permanent silicone oil

Failure
tamponade
removal [2–7]. The advantages and disadvan- Densiron 68 can be injected with a
tages of the different techniques are listed in PFCL × Densiron 68 exchange, but we prefer the
Table 18.2. In the following chapter, our three air × Densiron 68 exchange. Even if residual sub-
favourite techniques are demonstrated. macular fluid is present, you can inject Densiron
68. The subretinal fluid will be pressed away
Tips and Tricks immediately and there is no risk for macular
Timing of surgical procedure: You can use folds. We remove Densiron 68 after 6–12 weeks.
Densiron 68 for first and second surgery; you can But even in eyes with a Densiron 68 tamponade
perform an inferior buckle at the (first and) sec- of 1 year duration, we have not observed any
ond surgery; avoid retinotomy in the first surgery; complications.
perform a retinotomy only in a second surgery;
an exception is a PVR stage D.
18.3.2 Indication
18.2.4 Conclusion If the retina is not foreshortened and no PVR is

present, we use always Densiron 68. If the retina
In case of an inferior detachment with mild intra- is severely foreshortened or PVR is present, US
retinal PVR, we prefer a Densiron 68 tamponade. uses the buckle/vitrectomy technique and ZT the
In case of an inferior detachment with severe retinotomy technique.
intraretinal PVR, US prefers an inferior 90°
buckle, and ZT prefers a 180° retinotomy.
18.3.3 The Surgical Technique
18.3 Densiron 68 18.3.3.1 Material and Instruments

Densiron 68 (Fluoron, Germany) (Fig. 18.12)
18.3.1 Introduction Maybe: PFCL
Four-port vitrectomy with chandelier light
This surgery is very easy and fast. The surgical
time is ~30 min. The most important ingredient 18.3.3.2 The Surgery Step by Step
is Densiron 68 (Fig. 18.12). Densiron 68 is 1. Four-port vitrectomy.
heavier than water. It tamponades the inferior 2. Identify the retinal hole.
pole and does not tamponade the superior pole. 3. Fluid × air exchange OR instillation of PFCL.
Table 18.2 180° retinotomy vs. segmental buckling

(inferior and circumferential (=ora parallel) from 4 to 8
o’clock)
Encircling band Moderate Not sufficient
(cerclage) impression, impression for
good for mild severe
foreshortened foreshortened
retina retina
Technically Causes ametropia
easy
Relaxes the
vitreous base
in PVR
Circumferential Excellent
90° buckling impression,
sufficient for
severe
foreshortened
retina
Technically Causes ametropia
easy, complete
membrane
removal is not
required
Retinotomy Good method Technically
for severe difficult, complete
Fig. 18.12 Densiron 68 (Fluoron, Germany)
foreshortened removal of
retina preretinal
membranes
required held light fibre. Mark the break with
No ametropia Retinal slippage endodiathermy. If necessary perform a vitre-
Proliferations at
ous base shaving.
the retinotomy
edges 3. Fluid × air exchange OR instillation of
Many late PFCL.
complications: 4. Laser treatment.
hypotony (25%), If possible perform a fluid against air
decompensated
cornea (25%),
exchange and aspirate the subretinal fluid. A
permanent silicone shallow detachment of the macula is no prob-
oil tamponade lem because the Densiron 68 will press it
(40%), recurrent immediately away. If too much subretinal fluid
retinal detachment
after silicone oil
is present, then instil PFCL anterior to the
removal (20%) [2–7] edge of the retinal hole. Continue with laser
photocoagulation. Treat only the hole; a laser
cerclage is not necessary. Remark: A laser cer-
4. Laser treatment. clage may cause a recurrent detachment
5. Injection of Densiron 68 into an air-filled eye. through laser necrosis and makes it impossible
to find the break within the laser scars.
18.3.3.3 Every Step in Detail 5. Injection of Densiron 68 into an air-filled
1. Four-port vitrectomy. eye (Fig. 18.13).
2. Identify the retinal hole. If the eye is filled with PFCL, then con-
Insert three trocars and a chandelier light. tinue with a PFCL against air exchange.
Remark: The chandelier light is required if Residual subfoveal fluid is no problem. Then
you plan a silicone oil tamponade with view to inject the Densiron 68 under view to fundus
retina. Then search for the hole with a hand- into the eye. One hand injects Densiron 68 and
Air infusion
Chandelier
light fiber
Backflush instrument Silicone oil
Fig. 18.13 Surgical setup for injection of silicone oil. A

chandelier light is required
Fig. 18.14 A 180° retinotomy at the inferior pole
the other hand holds the Charles flute needle.

Remark: If you want to inject silicone oil with
view to fundus, then you need a chandelier retina onto the underlying retinal pigment epi-
light. If you do not have a chandelier light thelium. US usually places a 90° segmental
available, then inject silicone oil without view circumferential buckle onto the inferior equa-
to fundus. tor. Why a 90° segmental buckle and not a
360° encircling buckle? A segmental buckle
creates a stronger impression than a 360°
18.4 Retinotomy encircling band because the segmental buckle
has no counter pressure (Figs. 18.15 and
If despite meticulous removal of epiretinal 18.16).
membranes the inferior retina remains fore- In the hands of US, this is the safest and eas-
shortened preventing an attachment of the retina iest procedure for inferior recurrent detach-
with the retinal pigment epithelium, then you ment. If the inferior retina is foreshortened and
have two surgical options (see Diagram 18.2): if you do not have Densiron 68 available, then
(1) 180° retinotomy and (2) an inferior segmen- this is a wonderful surgical option with excel-
tal buckle. lent postoperative results. The surgery is
We usually perform a retinotomy from 3 already presented in a previous chapter. In this
o’clock over 6 o’clock to 9 o’clock (Fig. 18.14). chapter we will only demonstrate the placement
As tamponade we would use 1000 cSt silicone oil of an inferior segmental circumferential buckle.
or Densiron 68. The surgical technique is demon- Usually the buckle is placed under the inferior
strated in the chapter “180° Retinotomy”. muscle and sutured at 4 and 8 o’clock. But this
might vary according to the location of the
pathology.
18.5 Combined Buckle/
Vitrectomy
18.5.1 Instruments and Material
If despite thorough removal of epiretinal mem-
branes the inferior retina remains immobile, Silicone sponge 5 × 3.77 (Labtician, Canada)
i.e. the retina does not reattach under PFCL or (Fig. 18.17)
air, then a retinotomy or an episcleral buckling Sponge suture: Mersilene 5-0 (Alcon) or
procedure is required in order to reattach the Supramid 4-0 (Serag-Wiessner, Germany)
1. Inferior peritomy.
3. Three-port vitrectomy.
4. Identification of holes or PVR.
5. Marking of left and right end of the buckle at
the limbus or sclera.
6. Marking of sutures.
7. Placing of two sutures.
8. Place the silicone sponge first under the infe-
rior rectus.
9. Fasten the suture on the right side of the infe-
rior rectus.
10. Fasten the suture on the left side of the infe-
Fig. 18.15 An encircling band creates a minor indenta-
rior rectus.
tion of the sclera than a segmental buckle. The inferior 11. Fluid × air exchange.
retina may not attach 12. Laser treatment.
13. Tamponade.
18.5.3 Every Step in Detail
1. Inferior peritomy.
3. Three-port vitrectomy.
BSS Start with an inferior peritomy and dissect
the tenon capsule from the sclera. Place three
holding sutures at the medial, inferior and
temporal rectus. Then insert three trocars.
The setup is a three-port vitrectomy. If
peripheral vitreous is present, then perform a
meticulous removal of the residual vitreous.
Staining with triamcinolone helps to visual-
Fig. 18.16 A segmental buckle creates a stronger inden- ize the vitreous.
tation of the sclera because the sponge is wider and no 4. Identification of holes or PVR.
counterpressure is present. The inferior retina attaches in 5. Marking of left and right end of the buckle
the most cases
at the limbus (Figs. 18.18 and 18.19).
Fig. 18.17 Our

favourite silicone sponge
for inferior retinal
detachments for
combined buckle/
vitrectomy
m
7m m
2m
7m
1-
1-
m
2m
Cornea
m
Muscle insertion
= marking
Fig. 18.20 After marking of the limbus, the sutures must

be marked. One marking 1–2 mm behind the muscle inser-
tion and the second marking 7 mm behind the first marking
Fig. 18.18 Mark the cornea at both ends of the planned

sponge. Note the scleral depressor at 4 o’clock
Examine the inferior pathology with a
handheld light fibre in one hand and the
Mark limbus on Mark limbus on scleral depressor in the other hand. First you
the left side of the right side of
the hole the hole localize the left end of the pathology with the
scleral depressor or cotton wool swab,
remove the light fibre, flick out the BIOM
and then mark the limbus on height of the
depressor. Then the same manoeuver for the
right hand of the buckle. Now you have two
limbal or scleral markings.
The buckle is placed circumferential (ora
parallel) on height of the equator. If you
suture as posterior as possible, then you
have the correct height. I use always the
standard buckle from Labtician, Canada
(5 × 3.77). The caliper is set at 7 mm.
Posterior to the first limbal marking, place
the first suture marking 1–2 mm behind the
muscle insertion (Fig. 18.20). The second
Fig. 18.19 Marking of the ends of a circumferential
suture marking is located 7 mm posterior to
buckle on the left side of the left retinal break and then on the first suture marking and now the same
the right side of the right break manoeuver with the second limbal marking.
Mark the sclera 1–2 mm behind the muscle
insertion and 7 mm more posterior. Remark:
6. Marking of sutures (Fig. 18.20). Dry the sclera with a cotton swab before
The first important step is the localization of marking.
the PVR pathology and the retinal breaks. If 7. Placing of two sutures (Fig. 18.21).
holes are present, then cauterize the hole 8. Place the silicone sponge first under the
edges. If no holes are present, then place the inferior rectus.
buckle under the PVR pathology, i.e. 9. Fasten the suture on the right side of the
starfolds. inferior rectus.
Limbus Place the sponge first under the infe-

Inferior rectus rior rectus using two surgical forceps
1-2mm (Fig. 18.21). Then place one end of the
sponge under one suture. Before fasten-
ing the suture, check the tension of the
7mm
globe. If the tension is over 10 mmHg,
then release some BSS with a flute nee-
dle. If the tension is lower than 6 mmHg,
then continue to fasten the sponge. The
globe impresses very much during this
Fig. 18.21 Place the silicone sponge under the rectus manoeuver. Don’t worry. Later when the
muscle and sutures, and then tie the sutures globe is normotensive, it will look per-
fect. Then the same manoeuver on the
other side.
10. Fasten the suture on the left side of the 11. Fluid × air exchange.
inferior rectus. 12. Laser treatment.
Remove now the infusion line. You need 13. Tamponade.
two sutures (Supramid or Mersilene) with Reinsert the infusion line. Continue with a
one needle each. The assistant pulls two fluid × air exchange. The next step is a laser
holding sutures and holds the orbital spat- photocoagulation. If the inferior retina has
ula. Work now under microscope view. much PVR changes and much subretinal
Place the first suture on the anterior scleral fluid, we recommend Densiron 68. If the
marking. Move the needle a long bite retina is dry, then use gas or 1000 cSt sili-
through the sclera: ~3–4 mm. The poste- cone oil as tamponade.
rior suture is difficult due to the lack of
space. The suture is easier if you indent
the sclera with an anatomic forceps. Then 18.5.4 Examples (Figs. 18.22
repeat the manoeuver on the other side. and 18.23)
a b
1000 csts
silicone oil
Densiron 68
Fig. 18.22 A focal recurrent detachment under sili- Densiron 68 was injected (b). Two months later the
cone oil (a). The silicone oil was removed, and a cir- silicone oil was removed and the retina remained
cumferential buckle was placed from 4:00 to 7:00, and attached
a b
1000 csts
silicone oil
Densiron 68
Fig. 18.23 An inferior retinal detachment under silicone oil tached (b). The initial retinal status before the first vitrectomy.
(a). After scleral buckling of an inferior circumferential 5 mm Note the ischemic retina (c). After the second surgery with
silicone sponge and injection of Densiron 68, the retina reat- inferior buckle and Densiron 68, the retina is reattached (d)
References 4. Zivojnovic R. Silicone oil in vitreoretinal surgery.

Dordrecht: Martinus Nijhoff/Dr W Junk; 1987.
p. 141–52.
1. Vitrectomy with silicone oil or sulfur hexafluoride gas
5. Blumenkrantz MS, Azen SP, Aaberg T, et al. Relaxing
retinotomy with silicone oil or long-acting gas in eyes
results of a randomized clinical trial. Silicone Study
with severe proliferative vitreoretinopathy. Silicone
Report 1. Arch Ophthalmol. 1992;110(6):770–9.
Study Report 5. The Silicone Oil Study Group. Am J
2. Han DP, Lewis MT, Kuhn EM, et al. Relaxing reti-
Ophthalmol. 1993;116:557–64.
notomies and retinectomies: Surgical results and
6. Bovey EH, De Ancos E, Gonvers M. Retinotomies of
predictors of visual outcome. Arch Ophthalmol.
180 degrees or more. Retina. 1995;15:394–8.
1990;108:694–7.
7. Quiram PA, Gonzales CR, Hu W, et al. Outcomes
3. Federman JL, Eagle RC Jr. Extensive peripheral
of vitrectomy with inferior retinectomy in patients
retinectomy combined with posterior 360° reti-
with recurrent rhegmatogenous retinal detachments
notomy for retinal reattachment in advanced pro-
and proliferative vitreoretinopathy. Ophthalmology.
liferative vitreoretinopathy cases. Ophthalmology.
2006;113:2041–7.
1990;97:1305–20.
Anterior PVR
19
Extras: Videos 19.1, 19.2, 19.3. A foreshortening and shrinkage of the vitre-
ous base results in radial folds of the retina (like
a hand fan; circumferential contraction).
Finally, a transvitreal proliferation results in a
19.1 Introduction perpendicular traction and a funnel-shaped
detachment.
Anterior PVR is the most common cause of failure The surgical aim is the removal of these trac-
to reattach the retina after vitrectomy for PVR. tional forces.
Anterior PVR does usually not occur in primary
detachment. It occurs typically in recurrent
detachments after vitrectomy. Anterior PVR is 19.2 urgical Treatment of Focal
S
PVR occurring at the height of the peripheral ret- Anterior PVR (1–2 Quadrants):
ina and the vitreous base. Three major tractional (Figs. 19.1, 19.2, and 19.3)
forces are present in anterior PVR. The first one is
an anteroposterior tractional force, the second is a Stabilize first the anterior retina using perfluoro-
circumferential tractional force, and the third carbon liquids (PFCLs). In addition, PFCL pulls
minor force is a perpendicular tractional force. down the vitreous base.
A migration of proliferative cells into the vitre-
ous base pulls the peripheral retina anteriorly 1. The anterior trough is incised and opened cir-
(anteroposterior traction) resulting in an anterior cumferentially with scissors or a 25 G/27 G
displacement of the vitreous base (anterior cutter. The opened but still compressed vitre-
trough) and anterior displacement of the retina ous base is then removed with the vitreous
(anterior retinal displacement). cutter.
2. If radial retinal folds are present, then stain the
circumferential membranes with trypan blue
Electronic Supplementary Material The online version (air technique), and remove them with a
of this chapter (https://doi.org/10.1007/978-3-319-78446- delamination instrument and a forceps.
5_19) contains supplementary material, which is available 3. If all tractions are removed and the retina reat-
to authorized users. taches under PFCL, then continue with laser
photocoagulation and silicone oil tamponade.
Department of Ophthalmology, Uppsala University If the retina does not reattach under PFCL, then
Hospital, Uppsala, Sweden a segmental buckle or a retinotomy is required.

https://doi.org/10.1007/978-3-319-78446-5_19
Fig. 19.3 After mobilizing the displaced retina, a cir-

cumferential buckle was placed from 5:00 to 7:00. The
retinal break at 5:30 was caused through membrane
Fig. 19.1 An example of focal anterior PVR. A chronic peeling
and total detachment with an anterior PVR at 6–7 o’clock.
The anterior PVR consisted of a trough formation and
anterior retinal displacement
19.3 urgical Treatment of Anterior
S
PVR (3–4 Quadrants):
(Figs. 19.4 and 19.5)
The two surgical options are an encircling band

or a retinotomy. The problem is that a complete
membrane removal at the height of the trough is
not always possible. An encircling band may
therefore lead to a recurrence. In case of retinot-
omy, the trough and anterior retina can be com-
pletely removed, and the recurrence risk is much
lower.
If the anterior PVR extends to 3–4 quad-
rants, then we would choose a 270–360° reti-
notomy (Fig. 19.4). The length depends on the
Fig. 19.2 The compressed vitreous base (trough) and
then the retinal band were opened with the vitreous cutter extent of the anterior PVR. Sometimes it is not
resulting in a mobilization of the retina easy to perform an anterior retinectomy due to
19 Anterior PVR 183
Fig. 19.5 Reattached retina after a vitrectomy with 360°

retinotomy
Fig. 19.4 An example of 360° anterior PVR. A total and
chronic retinal detachment secondary to morning glory
syndrome. A 360° anterior PVR is present
an anterior trough which is often present and eye may get hypotonic which may result in a
may even cover the ciliary body. If you do not phthisis, a functional and anatomic loss of the
succeed in removing it completely, then the eye.
PVR Stage D
20
Extras: Videos 20.1, 20.2, 20.3, and 20.4. PVR stage D detachment cannot be treated
with scleral buckling due to the extensive circum-
PVR stage D with closed funnel without view to ferential traction. A PVR stage D detachment is a
optic disc (Fig. 20.1) is surgically the most clear indication for vitrectomy. A PVR stage D
demanding and most difficult pathology within vitrectomy includes in the most cases a 180–360°
PVR detachments. The retina is stiffened with retinotomy. Alternatively you can use an encir-
full-thickness retinal folds. A circumferential cling band. In our experience an encircling band
traction leads to a purse string funnel detach- does not create a sufficient impression to attach
ment. The surgical aim is to remove these trac- the stiffened retina.
tional forces and mobilize the retina. Prognosis: The visual prognosis is low, and
we therefore operate only PVR stage D detach-
ments with <1 year of duration.
20.1 360° Retinotomy Surgery
20.1.1 Instruments
1. Peeling instruments
2. Retinotomy instruments
3. PFCL
4. 5000 cSt silicone oil
Fig. 20.1 A funnel detachment without view to optic

disc. Start with a core vitrectomy
1. Four-port vitrectomy with chandelier
5_20) contains supplementary material, which is available light
to authorized users. 2. Vitrectomy with complete removal of vit-
reous base
Department of Ophthalmology, Uppsala University 3. Removal of epiretinal membranes from
Hospital, Uppsala, Sweden posterior pole to ora serrata

https://doi.org/10.1007/978-3-319-78446-5_20
4. Ora parallel (circumferential) 3. Removal of epiretinal membranes from pos-

endodiathermy terior pole to ora serrata (Figs. 20.3 and 20.4)
5. 270–360° retinotomy This step is VERY time-consuming. A com-
6. Meticulous cautery of retinal edge plete posterior and anterior dissection of
bleeding epiretinal membranes is required in order to
7. Retinectomy of anterior retina mobilize the foreshortened retina. Stain the
8. Removal of subretinal membranes membranes with trypan blue or triamcino-
9. Instillation of PFCL lone. Start with membrane dissection at the
10. Flattening of retinal edges posterior pole (Fig. 20.3), and continue
11. Attachment test and rotation test towards the ora serrata. Work bimanual with
12. Laser treatment an endgripping forceps, a delamination
13. PFCL against silicone oil exchange instrument (knob spatula, Atkinson cannula,
20.1.3 The Surgery in Detail
1. Four-port vitrectomy with chandelier

light
2. Vitrectomy with complete removal of vit-
reous base
A three-port vitrectomy with chandelier light
is recommended. Start with a core vitrec-
tomy, and continue with a peripheral vitrec-
tomy (Figs. 20.1 and 20.2).
Fig. 20.3 Start with removal of central membranes
Fig. 20.2 In PVR detachment, start with a central peel- Fig. 20.4 Continue with removal of peripheral
ing and continue with a peripheral peeling membranes
20 PVR Stage D 187
pic) and a curved or straight scissors ring is present. A napkin ring is a fibrotic
(Fig. 20.4). ring around the subretinal retina at the optic
4. Ora parallel (circumferential) disc (see Chapter 22 Traumatic RD).
endodiathermy 9. Instillation of PFCL
5. Retinotomy (Fig. 20.5) 10. Flattening of retinal edges
6. Meticulous cautery of retinal edge 11. Attachment test and rotation test
bleeding 12. Laser treatment (Fig. 20.7)
After removal of all epiretinal membranes, Inject now PFCL until the retinal edges
continue with diathermy. Cauterize the are completely attached. If a retinal edge
peripheral retina with an ora parallel, cir- is rolled up, then flatten it; if a fold in the
cumferential row of diathermy spots. If the retina is visible, then massage it; and if this
retina cannot be cauterized, then vitreous is
present. Remove the vitreous and then cau-
terize the retina again. The same applies for
residual membranes. The next step is a reti-
notomy. Use a vertical forceps or even better
a 25 G and even better a 27 G vitreous cutter
(Fig. 20.5). A meticulous cautery of haemor-
rhages at the retinal edge is necessary in
order to prevent recurrent PVR.
7. Retinectomy of anterior retina (Fig. 20.6)
Remove the residual anterior retina with the
vitreous cutter (Fig. 20.6).
8. Removal of subretinal membranes
Check if subretinal membranes are present
and remove them. Check also if a napkin
Fig. 20.6 Removal of anterior retina (retinotomy)
Fig. 20.7 Laser photocoagulation of retinal edges with

Fig. 20.5 Retinotomy with 25 G cutter increased laser power: 300 ms duration
does not help, then look for membranes and

remove them. This manoeuver can be care-
fully done under PFCL. If the retinal edges
are 360° nicely attached, then observe if
the macula is at the correct position. If not,
rotate the retina with one or two vacuum
cleaners. Continue with laser photocoagula-
tion (Fig. 20.7). We need a high laser power
for retinal edges to prevent a postoperative
slippage. Choose laser settings of 300 ms
duration.
13. PFCL against air and then against sili-
cone oil exchange
Finalize surgery with a PFCL against air
Fig. 20.8 A total recurrent detachment after vitrectomy
exchange. When the PFCL reached the reti- for PVR stage D detachment
nal edges, aspirate meticulously subretinal
fluid at the retinal edges. Then remove the
complete PFCL phase. Inject then 1300 or
5000 cSt silicone oil into the vitreous cavity.
20.1.4 Tips and Tricks
Lifted Retinotomy Edges During/After Laser

Photocoagulation
Usually the retinotomy edges do not lift, if
you laser photocoagulate them, even if you use a
high laser power. They will, however, lift when
membranes are present. To prevent uplifting,
all membranes must be removed. If the mem-
branes cannot be removed because they are very
attached and fibrotic, then perform a few radial Fig. 20.9 Radial retinotomies
cuts with the scissors at the retinotomy edge.
This will result in an attachment of the retinot-
omy edges.
20.1.5 FAQ
Question: Is a radial retinotomy possible?

Answer: Yes, a radial retinotomy is possible.
Example: A 25-year-old female patient presented
with a traumatic PVR stage D detachment. In the
first surgery, a combined phaco/vitrectomy with
360° retinotomy was performed. After 4 weeks of
follow-up, she presented with a total redetach-
ment (Fig. 20.8). In the second surgery, several
Fig. 20.10 Postoperative fundus after radial retinoto-
radial retinotomies were performed to reattach mies. This eye was operated two more times due to
the retina (Figs. 20.9 and 20.10). The retina rede- detachment and reproliferations of the retinal edges
20 PVR Stage D 189
tached two times again at the edges of the reti- disc syndrome was present (Fig. 20.12). A sur-
notomies. The patient, a 25-year-old female, gery in general anaesthesia with a surgical time
experienced no visual improvement (after five of 3 h was performed. 1000 cSt silicone oil was
surgical procedures). used as tamponade. In a final surgery, 1000 cSt
silicone oil was removed, perioperatively a rede-
tachment at the posterior hole was observed, and
20.1.6 Case Report (Figs. 20.11, 20.12 therefore 5000 cSt silicone oil was reinjected as
and 20.13 permanent tamponade (Fig. 20.13).
A PVR stage D detachment with anterior PVR is

the surgically most demanding case of all com-
plicated retinal detachments. An encircling band
does not solve the problem because the anterior
retinal displacement persists. In most cases, the
only surgical option is a 180–360° retinotomy,
removal of all epiretinal and subretinal mem-
branes and then a 1000 cSt silicone oil
tamponade.
A 17-year-old girl presented with total retinal
detachment (Fig. 20.11) and PVR D. A com-
bined vitrectomy with removal of epiretinal
membranes and silicone oil tamponade was per-
formed. A total PVR redetachment stage D under
silicone oil occurred. In addition, a 360° anterior
PVR with trough formation and anterior retinal
displacement secondary to morning glory optic
Fig. 20.12 Recurrent retinal detachment with PVR stage
D and 360° anterior PVR
Fig. 20.11 Initial status. Central and peripheral mem-

branes. A retinal break is present at the edge of the optic Fig. 20.13 Attached retina after 360° retinotomy and
disc laser photocoagulation around the optic disc
Traumatic Retinal Detachment
in Children 21
The surgery of a traumatic RD in children with The surgery step by step:

vitrectomy is very difficult, the risk of a PVR
redetachment is high, the likelihood of several 1. Limbal peritomy.
surgeries is also high, and the outcome is poor. 2. Three holding sutures.
In contrast, the surgery of a traumatic RD with 3. Cryopexy of the retinal break.
episcleral buckling is easier and the outcome in 4. Marking of the break.
almost all cases excellent. Why? A common 5. Choice of silicone sponge in regard to retinal
retinal finding after trauma is an ora dialysis. break size.
Ora dialysis has a 100% attachment rate with 6. Suturing of a silicone sponge.
scleral buckling. The other common pediatric 7. Inspection of retina.
detachments are giant tears with more or less 8. In case of detached retinal edges, inject 0.5 ml
focal detachments. The vitreous may be air.
detached at the area of the giant tear, and
removing this attached vitreous with vitrec- Material: Silicone sponge:
tomy creates only problems and complications.
The vitreous in a child is dense and attached. It 1. 5 × 3.77 mm partial thickness sponge (Labtician,
serves as a scaffold for the retina. For buckling Canada). Our most common used silicone
surgery the vitreous is not removed. Place a sponge. Indication: Ora dialysis, all normal size
buckle on the sclera and seal the retinal break; breaks. This sponge requires a 7 mm marking.
that’s all. 2. 7.0 × 5.28 mm partial thickness sponge
The surgical technique: (Labtician, Canada). Less common used sili-
For children we use the conventional surgical cone sponge. Indication: Big breaks. This
technique with binocular indirect ophthalmo- sponge requires a 9.0 mm marking.
scope because the view to retina in children is
excellent. The cornea, the lens, and the vitreous The surgery step by step:
are clear. For the suturing of the silicone sponge,
we use the microscope. 1. Limbal peritomy.
This part is done with the microscope: Start with
a limbal peritomy, and dissect the thick tenon
Department of Ophthalmology, from the sclera. Then place three holding sutures
Uppsala University Hospital, Uppsala, Sweden on the rectus muscles closest to the break.

https://doi.org/10.1007/978-3-319-78446-5_21
3. Cryopexy of the retinal break. 7. Inspection of retina,

4. Marking of the break. 8. In case of detached retinal edges, inject
5. Choice of silicone sponge in regard to reti- 0.5 ml air.
nal break size. This part is done with the indirect ophthalmo-
This part is done with the indirect ophthal- scope: Observe if the sponge covers the break,
moscope: Place a cryopexy on the retinal and observe if the retinal edges are very ele-
break until you see a white bleaching of the vated. If the latter is the case, then inject 0.5 ml
retina. Leave the cryopexy tip on the sclera, air into the eye. Remark: Air is inside the eye
insert an orbital spatula behind the cryopexy for 3–5 days and this is sufficient to tamponade
tip, and rotate the globe toward you. Dry the the break. SF6 is not necessary because it stays
sclera around the cryo tip, remove the cryo too long in the eye, causes ocular irritation and
tip, and mark the sclera. In children the sclera PVR, and may result in a tractive detachment.
is often bluish after cryopexy. Continue with
cryopexy and marking for the complete reti-
nal break. At the end, the retinal break is
marked on the sclera and you can choose a 21.1 Case Series Report
silicone sponge. If you are insecure, then
measure how wide the break is with help of a 21.1.1 Case 1: (Figs. 21.1 and 21.2)
caliper. If the break is 3 mm wide, then a
5-mm-wide sponge is sufficient. If the break An 18-year-old male patient was hit in his left eye
is 5 mm wide, then a 7-mm-wide sponge is of a hockey stick. Due to visual acuity decrease, he
required. visited an optician the following week. The optician
Tips and Tricks

a
A cryopexy is also diagnostic for finding of a
retinal break: When the retina becomes white
from cryopexy, then you see the dark break inside
the white retina.
6. Suturing of a silicone sponge.

This part is done with the microscope:
Suture the sponge onto the sclera so that the
sponge covers the complete break. Mark
first the location of the sutures with the cali-
per. Tip: Mark the tips of the caliper with the b
pen so that the sclera is marked by the
caliper.
Then place two sutures. Before placing
the sponge, we need a hypotensive globe.
Take a syringe with 30 G cannula and remove
aqueous from the anterior chamber. If you
use a paracentesis knife, then you must
suture the paracentesis because this is a
child’s eye.
Fig. 21.1 (a) A 18-year-old male patient with a 4-week-
Then place the sponge, and tie the knot old traumatic retinal detachment secondary to an ora dial-
with 2-1-1 throws in case of Supramid suture ysis with rolled edges. (b) Four-day postoperative view to
and 3-1-1 in case of Mersilene. fundus. Operated with scleral buckle and air injection
21 Traumatic Retinal Detachment in Children 193
Fig. 21.2 A
7.5-mm-wide silicone
sponge was used for this
case (Labtician, Canada)
stated a visual acuity decrease to 0.2 uncorrected edges persist and the choroid is visible
and submitted him to the local eye clinic. Three (Fig. 21.1b).
weeks later he was examined at the local eye The 1-month follow-up showed a completely
clinic, and a PVR detachment with a large ora attached retina; VA was 0.2 with −3.0 D and IOP
dialysis was detected. The macula was shallowly of 16 mmHg. The retina is completely attached.
detached and the retinal edges at the ora dialysis The enrolled edges persist.
were rolled in. The visual acuity was +3.0 sph = 0.1
and the IOP was 0 mmHg. He was consequently
submitted to us for surgery (Fig. 21.1a). 21.1.2 Case 2: (Figs. 21.3, 21.4,
I decided to perform an episcleral buckling. I and 21.5)
always perform an episcleral buckling on young
eyes because the optical media is excellent and A 5-year-old boy was injured with a stick. At
the vitreous body is attached and intact and serves examination an inferior detachment with a large
as an excellent scaffold when performing epi- rupture from 5 to 7 o’clock was detected. A cryo-
scleral buckling. In my opinion a vitrectomy in pexy of the retinal edges was performed, and a sili-
these cases is extremely difficult and has a large cone sponge was placed from 7:30 to 9:15. The
complication spectrum. In contrast, an episcleral upper edge of the silicone sponge is 1–2 mm below
buckling in traumatic detachment is fairly easy, the muscle insertion. The retina was reattached
and even if the surgery fails, you can convert to within 2 days. If you choose a vitrectomy, the sur-
vitrectomy. gery becomes difficult. Why? (1) The natural lens
I operated with binocular indirect ophthalmo- of a child. If you remove it, then the eye will
scope, cryopexy, and a 9 × 5.77 sponge from become severe amblyopic. (2) The removal of the
Labtician, Canada (Fig. 21.2). The intraoperative dense pediatric vitreous which serves as a scaffold
retinal inspection showed a minihole at 11:45, a may result in an inferior PVR detachment.
large ora dialysis from 12 to 3 o’clock, and PVR
from 3 to 6 o’clock. I placed the buckle under the
superior and lateral rectus and placed a suture at 21.1.3 Case 3: (Figs. 21.6, 21.7, 21.8,
11:30, 1:30, and 3:30. The suture at 1:30 is neces- and 21.9)
sary to achieve a sufficient impression. I injected
0.5 ml air to attach the enrolled retinal edge. I An 11-year-old boy was hit in the left eye by a
also injected triamcinolone subconjunctivally to football. An ophthalmological examination
reduce PVR risk and to increase the IOP. revealed an ora dialysis. A silicone sponge was
The 3-day follow-up showed a completely placed under the inferior rectus muscle. The
attached retina, 0.2 VA without correction, a 20% upper edge of the sponge was in height with the
air bubble, and an IOP of 18 mmHg. The enrolled muscle insertion. No drainage necessary.
a b
Fig. 21.3 (a, b) A 4-year-old boy with traumatic retinal tion spectrum. Try first a scleral buckle and in the most
detachment (a). A giant tear from 7:30 to 9:15. A vitrec- cases you will succeed with one surgery. The retina was
tomy in this case is very difficult and has a large complica- attached after 2 days (b)
Limbus
10:00 o’ clock 7:00 o’ clock 7

Silicone sponge
5.28 80
Break
S 1985-7
Fig. 21.5 This silicone sponge was used (Labtician,

Canada)
Inferior rectus
Fig. 21.4 The silicone sponge was placed under the infe-
rior rectus muscle
21 Traumatic Retinal Detachment in Children 195
Limbus
8 o’ clock 5:30 o’ clock

Silicone sponge
Ora dialysis
Muscle
Fig. 21.8 The silicone sponge was placed under the infe-
rior rectus muscle. The muscle indents the sponge
7
Fig. 21.6 An 8-year-old boy with ora dialysis secondary
to a football 5.28 80
S 1985-7
Fig. 21.9 This silicone sponge was used (Labtician,

Canada)
Fig. 21.7 The retina is attached after 2 days

Traumatic Retinal Detachment
Secondary to Open Globe 22
Extras: Videos 22.1, 22.2, 22.3, 22.4, 22.5, and endophthalmitis is high, and the prognosis is
22.6. poor. If the IOFB is of metal, then the prognosis
is better. An endophthalmitis is seldom.
In case of a perforation affecting the cornea, the
22.1 General Introduction prognosis is good because the endophthalmitis risk
is low and the posterior segment is not affected. In
Trauma presents with a huge variety. Not one trau- case of a scleral injury, the prognosis is poor
matic case can be compared with the other. This because the retina may be incarcerated and a sub-
makes trauma surgery exciting and demanding but choroidal, subretinal or intravitreal haemorrhage
makes also recommendations for surgical proce- may be present. Many eyes get lost in a hypotony.
dure rather difficult. Generally, a globe injury is
divided into an open globe injury and a closed
globe injury. Here we will only talk about open 22.2 Indication to Vitrectomy
globe injuries. For open globe injury, two major
traumas are possible: (1) an ocular injury with The indication for surgery is a retinal detachment.
intraocular foreign body (IOFB) and (2) globe Not every eye with open globe has a retinal detach-
injuries affecting the sclera (scleral injury) or the ment. If the scleral defect is located at the height of
cornea (corneal injury). Remark: A corneal injury the limbus, then the retina is not involved. If you
is often called a perforation, and a scleral rupture are insecure, then measure the distance between
is also named a globe rupture. (See Fig. 22.1). the limbus and scleral rupture with the caliper.
The IOFB causes in most cases only a small If the distance is shorter than 4 mm (pars plana),
defect in the cornea or sclera which is good for then a retinal engagement is unlikely. It is helpful to
the prognosis of the globe. But if the IOFB is of perform a preoperative ultrasound. In addition,
organic material such as wood, then the risk for control if light perception in all directions exists.
Why not perform a prophylactic vitrectomy?
An eye which suffered a trauma is very inflamed.
Electronic Supplementary Material The online version A vitrectomy in an inflamed tissue (vitreous and
of this chapter (https://doi.org/10.1007/978-3-319-78446- retina) increases the risk of a retinal detach-
5_22) contains supplementary material, which is available ment. Example: A vitreous haemorrhage after
open globe injury. A wound at the limbus from
U. Spandau (*) · Z. Tomic 12 to 3 o’clock is sutured successfully. Two
Department of Ophthalmology, Uppsala University days later you perform an ultrasound and

https://doi.org/10.1007/978-3-319-78446-5_22
Fig. 22.1 Open globe Open globe injury

injury and different
prognosis
Intraocular foreign body Corneal injury Scleral injury
Good prognosis
Metal foreign body Wooden foreign body Bad prognosis

algorithm for open globe Open globe rupture
injuries (posterior to pars plana)
Acute
Closure of rupture
2 weeks later
Vitrectomy
suspect a retinal detachment. You perform a vit- But the prognosis is often poor. The main rea-
rectomy and find an attached retina. One week son for failure in the long run is hypotony and cor-
later the eye has with big likelihood a PVR neal decompensation. But the spectrum of trauma
retinal detachment. is very large which makes it very difficult to gen-
eralize. We inform the patient that the prognosis is
very poor but that in the majority of cases the out-
22.3 Timing of Surgery come is better than without surgery. In our experi-
ence patients with open globe rupture are
In an initial surgery, we close the globe, and postoperatively much more satisfied than patients
2 weeks later we perform vitrectomy. (See our with chronic and total retinal detachment.
treatment algorithm in Fig. 22.2.) Other authors
recommend to operate after 5–7 days [1]. Even
eyes with minimal or no light perception can 22.4 Anatomical Characteristics
be operated because visual acuity often
increases after surgery. Perform an ultrasound: Anatomical characteristics of the posterior seg-
Is a subchoroidal haemorrhage (SCH) present? ment in open globe injuries are an attached pos-
Is a vitreous haemorrhage present? Is a retinal terior hyaloid, an incarcerated retina and a
detachment present? This information will napkin ring (subretinal annular ring around the
help you to find your way during vitrectomy. optic disc) (Figs. 22.3, 22.4 and 22.5).
22 Traumatic Retinal Detachment Secondary to Open Globe 199
22.6 Characteristics of Surgery
The surgery is difficult due to poor visualization

secondary to a cloudy media and blood. Due to
Incarcerated retina the extensive intravitreal, subretinal and subcho-
roidal haemorrhage, it is very difficult to see the
difference between the blood, vitreous, retina and
choroid. The retina may be incarcerated in the
wound and has to be relieved from the wound
through a retinotomy. A PVD is usually not
present.
A napkin ring may form subretinally at the
optic disc. It has the shape of a ring and constricts
Fig. 22.3 The retina is incarcerated in the scleral wound the retina (Fig. 22.5). The annular membrane
on the right side, and a large break is present on the left side occurs after a chronic detachment. In order to
remove the napkin ring, a 360° circumferential
retinotomy is required. The surgery should be
performed in general anaesthesia, and the surgi-
Incarcerated retina
cal time is 2–4 h.
22.7 he Surgical Management

T
of an Open Globe
with Scleral Injury
22.7.1 Material and Instruments
1. 23 G or 25 G trauma trocars (Alcon)

Fig. 22.4 A large retinal break on the left side and a reti- 2. Chandelier light
nal incarceration on the right side 3. Maybe: Artisan IOL
4. PFCL
5. Silicone oil
22.5 Planning of Surgery
The main indication for surgery is a retinal detach- 22.7.2 The Surgery Step by Step
ment. Silicone oil is the most common tampon-
ade. The situation of the anterior chamber, 1. Insertion of anterior chamber maintainer
therefore, is very important for surgery. Assess 2. Removal of hyphema
whether a cataract surgery has been performed or 3. Inspection of posterior segment
not. In many cases aphakia due to a luxated lens/ 4. Core vitrectomy
IOL and sometimes even aniridia are present. 5. Insertion of trauma trocars
Aniridia and aphakia, however, are a big hinder 6. Peripheral vitrectomy and PVD
for silicone oil tamponade. In case of aphakia, an 7. Endodiathermy of traumatic retinal edges
Artisan IOL can prevent a silicone oil prolapse. In 8. Retinotomy of incarcerated retina
case of aphakia and aniridia, an iris-IOL prosthe- 9. Removal of subretinal membranes
sis (Ophtec, NL) or a suture net is a good option. 10. Removal of napkin ring
Fig. 22.5 A subretinal

fibrotic ring around the
retina located at the
optic disc = napkin ring
= napkin ring
11. Instillation of PFCL not a problem because a large retinotomy is

12. Attachment test and rotation test required in the end.
13. Laser treatment 5. Insertion of trauma trocars
14. Preparation of anterior chamber before 6. Peripheral vitrectomy with PVD
silicone oil tamponade 7. Endodiathermy of traumatic retinal edges
15. PFCL against air and exchange Assess the periphery for a suitable area to
16. 1000 cSt silicone oil tamponade insert the trocars. Try to insert at least two
instrument trocars so that you can work eas-
ier in the posterior segment. As trocars we
22.7.3 Every Step in Detail use 23 G or 25 G trauma trocars from Alcon.
Then continue with a vitrectomy. In many
1. Insertion of anterior chamber maintainer cases a PVD is absent. Induce a PVD and
2. Removal of hyphema then instil PFCL to flatten the central retina.
A hyphema is present in many trauma cases. Perform a thorough peripheral vitrectomy as
Remove the hyphema with irrigation and possible. If you leave the peripheral vitreous
aspiration. If the cornea is cloudy, perform a and use silicone oil as tamponade, then the
corneal abrasion. If the view does not silicone oil will press the peripheral vitreous
improve, then a haemorrhagic cornea is against the ciliary body causing ciliary body
likely. The only solution is now a corneal insufficiency and hypotony. Perform a metic-
transplantation. Examine the iris and the lens ulous diathermy of bleeding retinotomy
status. If the iris is haemorrhagic, do not edges in order to prevent recurrent PVR.
insist to remove the blood, but cut only a 8. Retinotomy of incarcerated retina
central pupil with the vitreous cutter. (Figs. 22.6 and 22.7)
3. Inspection of posterior segment 9. Removal of subretinal membranes
4. Core vitrectomy 10. Removal of napkin ring (Fig. 22.8)
Insert the light fibre through a side incision, 11. Instillation of PFCL
and examine the retina, i.e. try to examine If the retina is incarcerated into the scleral
the retina. If you do not see anything, then wound, then perform a retinotomy at the
work carefully because the retina may be scleral wound in order to mobilize the incar-
totally detached. Start to cut centrally on cerated retina (Figs. 22.6 and 22.7). Continue
height of the pars plana. Try to identify the with removal of subretinal membranes.
retina, choroid and haemorrhagic vitreous Finally remove the fibrous ring around the
from each other. If you cannot identify any optic disc. Then reattach the retina through
structures in the centre behind pars plane, instillation of PFCL over the retinotomy
then continue to work in the periphery. Even edges. Check if the retina is completely
if you cut the retina in the periphery, this is attached at the optic disc. If not then you did
22 Traumatic Retinal Detachment Secondary to Open Globe 201
Fig. 22.6 The retina is incarcerated on the right side into

the scleral wound
Fig. 22.8 Note the napkin ring which is located subreti-
nally around the optic disc
Fig. 22.7 After retinotomy: note the residual retina in the

scleral wound on the right side Fig. 22.9 In case of aphakia, insert an IOL, in this case
an Artisan IOL with retropupilar fixation. It will prevent a
silicone oil prolapse
not remove the complete napkin ring
(Fig. 22.8). This procedure is difficult
because the retina is mobile. Check also the 300 ms is required. Remark: The usual laser
retinal edges. Are they attached or enrolled? duration for retinal breaks is 200 ms.
Flatten the distorted retina with a Charles 14. Preparation of anterior chamber before
flute needle with silicone tip or a knob spat- silicone oil tamponade (Figs. 22.9, 22.10
ula. If a membrane causes a radial retinal dis- and 22.11)
tortion, then remove the membrane. 15. PFCL against air and exchange
12. Attachment test and rotation test 16. 1000 cSt silicone oil tamponade (Fig. 22.12)
13. Laser treatment Before continuing with a tamponade, the
Check now if the macula is correctly located anterior chamber must be prepared for the
or if a rotation is present. If you observe a tamponade. Is an aphakia present? If aphakia
rotation, then rotate the retina with the vac- is present and you plan to use silicone oil,
uum cleaner or a knob spatula. Continue then an iridectomy is required to prevent a
with three rows of laser along the retinotomy pupillary block. If possible insert an Artisan
edges. For retinal edges a laser duration of iris-claw IOL with a retropupillary implanta-
Fig. 22.10 An IOL-iris prosthesis from Ophtec,

Netherlands. The diameter is 9 mm. A large incision is Fig. 22.12 The final view to the retina. Visual acuity is
therefore required. The colour of the prosthesis turns out 0.1, the globe is normotensive and the patient is satisfied.
brighter when inserted in the eye. We use only the brown The minority of these cases have such a good outcome
iris. The prize is ~400 Euros
tion (Fig. 22.9). If aniridia is present, then

3. implant an iris-IOL prosthesis (Ophtec, NL)
2. 6. (Fig. 22.10). An alternative is a suture net
(Fig. 22.11). If you plan a silicone oil tam-
ponade, then fill the anterior chamber with
8. 7. methylcellulose to prevent an intraoperative
prolapse of silicone oil into the anterior
chamber. The next step is a PFCL against
9. 10. silicone oil exchange. If you prefer first a
PFCL against air exchange, then perform a
meticulous fluid aspiration at the retinotomy
12. edges. Close the case with a 1300 csts or
11.
5000 csts silicone oil tamponade (Fig. 22.12).
13.=knot. 1. 5.
4. Reference
Fig. 22.11 A drawing of the suture. Start with 1 and end 1. Kuhn F. The timing of reconstruction in severe mechan-
with 12; number 13 is the knot. One continuous suture ical trauma. Ophthalmic Res. 2014;51(2):67–72.
Perforations with IOFB
23
Extras: Videos 23.1, 23.2, 23.3, 23.4, 23.5, 23.6, with IOFB, a posterior vitreous detachment (PVD)
and 23.7. is required. The most patients with IOFB, however,
are young and have a well-attached posterior vitre-
ous. But if you wait 4 weeks, then the metallic IOFB
23.1 enetrating Eye Injury by
P will induce a posterior vitreous detachment. So the
Metal Intraocular Foreign surgical delay results in less PVR and a PVD. We
Bodies (IOFB); Delayed wait maximal 4 weeks. In addition, an air tampon-
and Stepwise Surgery ade is sufficient. This procedure applies to metallic
IOFB only. Organic IOFB should be operated
Penetrating eye injuries should be treated by experi- immediately, as the endophthalmitis risk is high.
enced surgeons. These cases are associated with a We do not prefer the immediate surgery because
high complication rate, and a guarded prognosis and (1) the experienced retinal team is often not present
the initial surgical intervention are of vital impor- when the trauma case arrives at the clinic, (2) a
tance. There has been a long debate about the timing PVD is not present, and (3) if retinal wounds are
and the extent of the initial surgical intervention. present and if the foreign body sticks in the retina,
then immediate extraction will cause bleeding from
the exit wound and result in PVR from the wound
23.2 Delayed
edges. (4) A silicone oil tamponade is required.
Vitrectomy ↔ Immediate
Four weeks of waiting will quieten the retinal
Vitrectomy
wound, and the foreign body can be extracted
without bleeding or PVR from the wound edges.
We prefer a delayed vitrectomy. A traumatized eye
This notion is confirmed by OCT examinations
is very inflamed. Inflammation increases the risk for
showing the reduction of retinal wound swelling
PVR. Delaying surgery results in reducing the risk
within 1 month (Figs. 23.1 and 23.2).
for PVR. When performing a vitrectomy in an eye

23.3 ur Treatment Algorithm at
O
of this chapter (https://doi.org/10.1007/978-3-319-78446- the University of Uppsala Is
5_23) contains supplementary material, which is available as Follows (Fig. 23.3)
The first step is the primary closure of the wound
Department of Ophthalmology, (cornea or sclera). We do not remove a traumatic
Uppsala University Hospital, Uppsala, Sweden cataract in the same session. If there is suspicion

https://doi.org/10.1007/978-3-319-78446-5_23
a b
1 day post injury 1 day post injury
5 days post injury
Fig. 23.1 OCT examinations of a retinal wound after trauma with a metal IOFB. The OCT after 1 day shows moderate
wound swelling (a, b). After 5 days the wound swelling is much more pronounced (c)
a b
12 days post injury 12 days post injury
21 days post injury
Fig. 23.2 After 12 days the retinal swelling is markedly reduced (a, b) and almost disappeared after 21 days (c)
23 Perforations with IOFB 205
Vitrectomy worsens therefore the result of the

Perforation with metal foreign body
phacoemulsification if both are performed at
the same time points. If phacoemulsification
and vitrectomy are performed at the same time,
Acute then the extensive vitrectomy with gas tampon-
Closure of corneal ade will tamper with the IOL. The gas may lux-
wound
ate the IOL into the anterior chamber; the
vitrectomy may cause posterior synechiae and
so on.
2 weeks after trauma
PVD
Phaco and IOL
23.4 Tips and Tricks
Avoid operating an inflamed or vascularly active

4 weeks after trauma eye. If the retina is attached, wait and treat the
Vitrectomy + extraction of inflammation and vascularization; use steroids
foreign body
and anti-VEGF. If the retina is detached, you
have to operate.
Fig. 23.3 Our treatment algorithm for stepwise IOFB
surgery. After 4 weeks a PVD is present, the eye is quiet,
and the PVR risk is low when extracting the IOFB. If the
retina is detached, we operate at once 23.5 I OFB Extraction: Delayed
and Stepwise Surgery
of a non-sterile penetration, we inject intravit- 23.5.1 The Surgery

real antibiotics. We treat the patient then for
10 days with intravenous antibiotics (1.5 g 23.5.1.1 Instruments
Zinacef® three times daily). In most cases, there 1. 25 G or 27 G trocars with chandelier
is view to fundus. In case of vitreous hemorrhage, illumination
an ultrasound examination is necessary. If the 2. Endomagnet (Synergetics, USA)
retina is attached, we continue to wait; if the 3. Diamond dust-coated foreign body forceps
retina is detached, we operate immediately. But (Fig. 23.4)
retinal detachments during the natural course of 4. Laser probe
IOFB are seldom.
After ~2 weeks we perform a cataract surgery 23.5.1.2 Tamponade
and implant an IOL. In many cases the lens cap- Intraoperative: Maybe PFCL
sule is partially injured. We try to implant the Postoperatively: Air
IOL into the bag or into a stable sulcus position.
A scleral-fixated IOL is rarely necessary. Then
~2 weeks after phacoemulsification, we perform 23.5.2 Individual steps
vitrectomy with foreign body extraction.
Vitrectomy is easy because a PVD is present and 1. 25 G or 27 G three-port system with chan-
the retinal wound has healed. The risk of bleed- delier light.
ing from the retinal/choroidal wound is much 2. Vitrectomy, PVD.
less, and the risk of PVR from the wound edges is 3. Exposure of IOFB.
highly reduced. 4. Prepare the exit sclerotomy.
We prefer to perform phacoemulsification 5. Extraction of IOFB through sclerotomy.
and vitrectomy at different time points because 6. Apply laser at the impact site.
the posterior capsule is often damaged. 7. Air tamponade.
Fig. 23.4 A IOFB forceps with a diamond-dusted grip. 20 G foreign body forceps. The sclerotomy must be
The foreign body is extracted through a 20 G sclerot- enlarged according to the size of the IOFB
omy (without trocar). Available are 17 G, 19 G, and
23.5.3 T
he Surgery Step by Step
(Figs. 23.5, 23.6, 23.7, 23.8, 23.9,
and 23.10)
1. Three-port system with chandelier light.

We use the three-port trocar system with chan-
delier light.
2. Vitrectomy, PVD.
The advantage of a delayed surgery is that a
PVD is almost always present. It is very
important to induce a posterior vitreous
detachment; otherwise there is an increased
risk of PVR.
Fig. 23.5 After 4 weeks there is still a retinal hemorrhage
3. Exposure of IOFB (Figs. 23.5 and 23.6).
at the perforation site
One has to resist the urge to remove the IOFB
as soon as you can see it. An extensive vitrec-
tomy should be performed first and in particu-
lar around the IOFB. Only remove the IOFB
when no more vitreous is attached or sur-
rounding it and around the sclerotomy through
which it will be removed.
4. Prepare the exit sclerotomy.
Before grasping and extracting the IOFB,
decide where the exit sclerotomy is placed.
Open here the conjunctiva and perform a
limbus-parallel sclerotomy. The sclerotomy is
as wide as the IOFB.
5. Extraction of IOFB through sclerotomy
(Fig. 23.7). Fig. 23.6 Note that the IOFB is inside a retinal pocket
The foreign body can be extracted with the for-
ceps (serrated or diamond dusted) or the endo-
magnet. Before extraction of the foreign body, IOFB, and extract it through the sclerotomy. In
it is advisable to inject a PFCL bubble to pro- many cases a bimanual extraction is necessary.
tect the macula. Then enlarge the sclerotomy One forceps (e.g., 27 G endgripping forceps,
sufficiently parallel to the limbus. Insert the DORC) is inserted through a trocar and extracts
forceps through this sclerotomy, grasp the the IOFB from the retina. The IOFB forceps is
Fig. 23.7 The IOFB which was inside the eye for Fig. 23.10 An air tamponade is sufficient
4 weeks: no PVR and no endophthalmitis
inserted through the large sclerotomy, takes

over the IOFB from the endgripping forceps,
and extracts it through the sclerotomy.
Congratulations! The worst part is done. Take
a deep breath, and continue with closing the exit
sclerotomy with Vicryl 8-0 cross sutures.
6. Apply laser at the impact site (Figs. 23.8 and
23.9).
Then you have to photocoagulate the retina
around the impact site. If the retina is detached
in the area of laser treatment, you must first
inject PFCL in order to flatten the retina.
7. Air tamponade (Fig. 23.10).
We use in most cases an air tamponade.
Fig. 23.8 The perforation site after removal of the IOFB
23.6 I OFB Extraction: Immediate

Surgery
In the following the surgical procedure is pre-

sented if you choose to perform an immediate
surgery (see Fig. 23.11). An immediate surgery is
more difficult because a combined vitrectomy
and a chorioretinectomy have to be performed.
23.6.1 The Surgery
23.6.1.1 Instruments
1. 25 G or 27 G trocars with chandelier
Fig. 23.9 Three rows of laser photocoagulation. After illumination
4 weeks the retinal edges cause no PVR 2. Endomagnet
Perforation with metal foreign body 23.6.3 T

he Surgery Step by Step
(Figs. 23.12 and 23.13)
1. Three-port system with chandelier light.

Acute We use the three-port trocar system and insert
a chandelier light.
# Closure of corneal wound 2. Vitrectomy.
# Phaco and IOL 3. Induction of PVD.
# Vitrectomy and PVD It is very important to induce a posterior vitre-
# Extraction of foreign body ous detachment; otherwise there is an
increased risk of PVR. As it can be difficult to
# 1mm Retinectomy and diathermy of choroid
determine a posterior vitreous detachment in
# Laser treatment
young eyes, it is advisable to use dyes such as
# Silicone oil tamponade triamcinolone or trypan blue.
4. Exposure of IOFB.
Fig. 23.11 Our treatment algorithm in case of immediate One has to resist the urge to remove the IOFB
surgery. The main difference is that a 1 mm retinectomy as soon as you can see it. An extensive vitrec-
around the wound edges followed by diathermy of the
tomy should be performed first and in particu-
choroid has to be performed (Ferenc Kuhn technique). In
addition, a PVD has to be induced and a silicone oil tam- lar around the IOFB. Only remove the IOFB
ponade is required when no more vitreous is attached or sur-
rounding it and no vitreous is in the way at the
sclerotomy through which the IOFB will be
3. Diamond dust-coated foreign body forceps removed. If the IOFB is stuck in the choroid
4. Diathermy and sclera, you may apply laser around it in
5. Laser probe order to lower the intraocular hemorrhage that
will occur when you pull the IOFB out of the
23.6.1.2 Tamponade sclera.
Intraoperative: Maybe PFCL 5. Extraction of IOFB through sclerotomy or
Postoperatively: 1000 or 5000 cSt silicone oil cornea.
Before extraction of the IOFB, decide whether
to extract the IOFB through the sclera or a
23.6.2 Individual Steps corneal main incision. The latter is possible if
a posterior capsular defect is present. Extract
1. 27 G three-port system with chandelier then the IOFB through the main incision. In
light. this case the IOL is implanted after extraction
2. Vitrectomy. of the IOFB.
3. Induction of PVD. 6. 1 mm retinectomy around the impact site
4. Exposure of IOFB. and diathermy of the exposed choroid
5. Extraction of IOFB through sclerotomy or (Figs. 23.12 and 23.13).
cornea. After successful extraction of the IOFB, a
6. 1 mm retinectomy around the impact site 1 mm retinectomy is performed around the
and diathermy of the exposed choroid. impact site. You should also cauterize the
7. Apply laser at the impact site. underlying choroid. This is thought to reduce
8. Silicone oil tamponade. the rate of postoperative PVR. First, cauterize
Wound site 8. Silicone oil tamponade.

with 1mm
diathermy edge
If you perform a vitrectomy immediately after
surgery, we recommend a 1000 or 5000 cSt
silicone oil as tamponade. This is due to the
high postoperative risk of developing PVR
from the wound edges.
23.6.4 Complications
The possible complications of immediate vit-

rectomy are:
# Peroperative choroidal bleeding from exit
Fig. 23.12 In immediate surgery, a 1 mm diathermy
around the wound edges is recommended (Ferenc Kuhn wound
technique) # Postoperative PVR from wound edges.
# Postoperative anterior segment inflamma-
tion with posterior synechiae and dislocation of
IOL
23.6.5 FAQ
Perforation 1mm
What about the risk of retinal detachment?
site
In our experience the retina is often injured
but detaches very seldom. If the retina is attached,
there is no reason for an immediate surgery. And
the retina is attached in most cases. If the retina is
detached, immediate surgery is necessary. Assess
the retina once a week with slit lamp or
Fig. 23.13 The retina and choroidea is cauterized 1 mm ultrasound.
around the perforation site Is the risk of endophthalmitis not increased
if you wait 4 weeks for vitrectomy?
the retina 1 mm distant from the edge of the The highest risk of endophthalmitis is within
impact, and then cut the retina with the the first week after injury. We had four cases of
25 G/27 G vitreous cutter at a low cutting rate endophthalmitis in 10 years: two foreign bodies
(about 200 cuts/min). Finally, the underlying were wood and two were metal. In all four cases,
choroid is cauterized with diathermy or laser. an endophthalmitis was present at the initial
7. Apply laser at the impact site. examination.
After successful retinectomy and cauteriza- What about the timing of surgery
tion of the choroid, you must photocoagulate (Fig. 23.14)?
the retina around the impact site. If the retina The penetrating wound has to be sutured acute.
is detached in the area of laser treatment, When to extract the foreign body? Two schools: At
inject first PFCL in order to flatten the once. Our treatment algorithm is as long as the
retina. retina is attached, we wait. And the retina is usu-
Surgical window
PVR risk
Inflammation risk
0 3 4 weeks
Fig. 23.14 The timing of vitrectomy for penetrating injuries with IOFB is important. Do not operate too early and do
not wait too long. A surgical window between 3 and 4 weeks is an optimal time point for IOFB extraction
ally attached after a penetration with a foreign Retinal detachment: One patient with endo-
body. Usually we extract the foreign body after phthalmitis developed a retinal detachment after
1 month. Advantages: The eye is quiet, the poste- vitrectomy. The eyes of the two patients with
rior hyaloid is usually detached, and the impact wooden foreign body were enucleated. All other
site is usually very quiet resulting in a lower risk of 18 patients had no retinal detachment.
PVR from the wound edges. An air tamponade is PVR: The PVR arises from the perforation
sufficient. What happens if you wait longer than site. The retinal swelling at the perforation site
4 weeks for surgery? The IOFB causes a sterile disappears within 4 weeks, and then you can
inflammation which increases the risk for a PVR operate with minimal PVR risk. In addition, after
detachment. 4 weeks a PVD is present, which is an advantage
A retrospective study from the University in case of young patients.
of Uppsala, Sweden, in the time period from Surgical technique: The first patient was oper-
2008 to 2016 showed: ated immediately according to Ferenc Kuhn’s
Number of penetrating injuries with IOFB: 21 technique with retinochoroidectomy. Three
Type of IOFB: 2 wooden IOFB and 19 metal weeks later the eye developed a PVR reaction at
IOFB the perforation site. All other patients were oper-
Localization: Central and peripheral ated after 4 weeks with delayed vitrectomy. There
Our treatment algorithm is as follows: were no postoperative complications such as
acute, suturing of the corneal and scleral injury, PVR. Only one patient developed a postoperative
then 1 week IV antibiotics, and then weekly retinal detachment which could be reattached
follow-ups. There is view to the retina under with a second vitrectomy.
the complete follow-up: after 2 weeks,
phaco + IOL; after 4 weeks ppV + removal of
foreign body. 23.6.6 Tips and Tricks
Endophthalmitis: Two patients with wooden
IOFB and two patients with metal IOFB. The 23.6.6.1 Anterior Chamber
patients with wooden IOFB came directly after Hemorrhage
injury to the hospital, and an endophthalmitis A fresh ACH is not easy to remove, because the
was present. In case of metal IOFB, the endo- fibrin is difficult to aspirate. Inject rtPA at the
phthalmitis was present after 3 days. All other beginning, wait a few minutes, and then the blood
patients had no endophthalmitis. can be removed easier.
23.6.7 Tips and Tricks tional radial buckle were performed. The silicone oil
was removed 2 months later, and the final follow-up,
23.6.7.1 Timing of Surgery (Fig. 23.14) 4 months later, showed a completely attached retina
An endophthalmitis risk is high in the first week. with a visual function of 0.3 ().
The patient should receive oral and local antibiot- Remark: The father reported that 2 months
ics. Then perform a weekly follow-up. If the ret- earlier he and his son worked in the garage and
ina detaches, then operate at once. If the retina something hit his son’s eye, but after 1 day he
remains attached, which is the regular course of complained of no pain.
this pathology, then plan surgery after 3–4 weeks.
Now the PVR risk from the perforation site is
minimal. It is not recommended to wait longer
because the metal IOFB causes a focal sterile
inflammation with engagement of the retina.
23.6.8 Case Report
A 5-year-old boy presented in OPD with visual acu-

ity decrease, and a total retinal detachment was diag-
nosed. A combined phaco/vitrectomy with inferior
segmental buckle was performed. A metallic intra-
ocular foreign body was detected and extracted
(Fig. 23.15). Two weeks later a recurrent detachment Fig. 23.15 Note the IOFB at the inferior pole. The other
was observed. A membrane peeling and an addi- round markings indicate a retinal tear caused by the IOFB
Part V
After Surgery
After Surgery and Complications
24
Extras: Videos 24.1, 24.2, and 24.3. subtenon betametasone (whole ampule). In case
of an IOP between 21 and 30 mmHg, we prescribe
antiglaucomatous drops and acetazolamide ×2–4
24.1 Positioning (Diagram 24.1 if the IOP > 30 mmHg. Young patients with sili-
and Fig. 24.1) cone oil tamponade have often increased IOP and
require acetazolamide for a longer duration.
In case of gas and silicone oil tamponade, we
position the patients for 1 week. In case of
1000 cSt and 5000 cSt silicone oil, we position 24.3 Follow-Up
in the same way as with a gas tamponade. In
case of Densiron 68, the patient is advised to Retinal detachment with vitrectomy: 1 day
sleep on the back (supine) and free positioning postop, 1 week postop for IOP measurement and
under the day. 2 weeks postop.
Retinal detachment with episcleral buckling:
1 day postop; if the retina is attached once more,
24.2 Eye Drops 2 weeks postop.
Caution for silicone oil removals: They have a
For all retinal detachment cases, we prescribe rather high detachment risk, and a PVR detach-
atropine 1% ×1 and cortisone drops ×5 for ment quickly develops. We see these patients
2 weeks. In case of postoperative uveitis, we inject 1 day postop, 1 week postop and 2 weeks postop.


Department of Ophthalmology,

https://doi.org/10.1007/978-3-319-78446-5_24
Diagram 24.1
Tamponade and posture
for retinal detachment
depending on the Sitting up 12 Sitting up
location of the break
SF6
Silicone oil
9 3
C2F6 C2F6
Silicone oil Silicone oil
Buckling
Densiron 68
C3F8
Left cheek to pillow 7 5 Right cheek to pillow
Flat on the back
24.4.1 Peroperative Complications

Supine
Choroidal Subepithelial location of infusion

detachment trocar
Prevention • In case of ocular normotony,
check the location of the infusion
Prone trocar during surgery
Treatment • Remove the infusion, replace it in
an instrument trocar, and wait
until the choroidal detachment
disappears
• In case of ocular hypotony, use
Fig. 24.1 Supine (on the back) and prone (face down) 6 mm trauma trocars from Alcon
position. Photocourtesy wikipedia Iatrogenic Dissection of adherent membranes
tears
Prevention Bimanual peeling
PFCL under If the breaks that come in contact
retina with PFCL are still under traction
24.4 Complications Prevention Remove traction before injecting
PFCL
Treatment 1. Active suction with a 41-G
In the following peroperative and postoperative cannula
complications are listed: 2. Inject BSS in the macular area,
and displace PFCL inferiorly
24 After Surgery and Complications 217
24.4.2 Early Postoperative Prevention/ Combined phaco/vitrectomy

Complications treatment
Macular Folds Postoperative submacular fluid
with gas tamponade and face down
Fibrin 1. After synechiolysis; use of iris position
formation retractors Prevention (a) Avoid submacular fluid
2. After combined phaco-/ (b) Posterior drainage retinotomy
vitrectomy surgery (c) Avoid immediate face down
Treatment 1. Steroid drops position after surgery
2. tPA into the anterior chamber, Treatment (a) Induction of retinal
3–6 μg detachment through subretinal
Increased IOP 1. Retained viscoelastica after BSS injection.
combined surgery (b) Reattachment with PFCL
2. Failure in preparing a proper (c) Massage of macular folds
gas concentration Managing dry macular folds after vitreoretinal
3. Overfilling of silicone oil surgery Dr Mateo
Treatment 1. Release of viscoelastica through Subretinal If the breaks or retinotomy are still
existing side ports silicone oil under traction
2. Removal of some silicone oil Prevention Before injecting oil assess retinal
3. Antiglaucomatous drugs traction by fluid × air exchange or
Haemorrhages • From the retinotomy edge attachment under PFCL
• From ciliary processes behind Treatment 1. Remove silicone oil, and
the inf. iridectomy release traction by enlarging
Prevention Meticulous haemostasis of the retinotomies or removal of
retinotomy edge and inspection of membranes
the inferior iridectomy 2. Inject oil again after traction is
Treatment Removal of preretinal/intraocular relaxed
blood Inferior Cyclitic PVR membranes at the
Air travel Air and gas expand at a travel recurrent inferior pole cause an inferior
(Fig. 24.2) height of 10 km and a cabin detachment recurrent detachment
pressure correlating to a height of Prevention 1. Remove PVR membranes
2 km 2. Avoid PVR through atraumatic
Prevention Assess amount of gas before air surgery
travel. If 4 optic disc diameters fit 3. Encircling band
between optic disc and air bubble, Treatment • Densiron 68
then air travel is safe • Retinotomy
• Inferior circumferential buckle
Iris rubeosis Partially detached retina
Prevention Prevent partially detached retina
Treatment • Injection of anti-VEGF
24.4.3 Late Postoperative • Removal of detached retina
Complications Hypotony • Silicone oil presses vitreous
under silicone against ciliary body resulting in
oil fibrotic membranes and ciliary
Recurrent PVR The most common cause for body insufficiency
ultimate failure of the PVR • Pars planitis
surgery • Large retinotomies
Prevention • Meticulous dissection of all Prevention • Meticulous vitreous base
membranes shaving
• Anti-inflammatory medication Treatment • Removal of fibrotic membranes
Cataract • Prolonged exposure to gas or from ciliary body
silicone oil • Anti-inflammatory drugs
• Mechanical injury of the lens Iris bombé in Posterior synechiae
capsule silicone-filled
• Lens capsule damage by eye
infusion fluid
Prevention Pupil dilating drops after surgery
Treatment Basal iridectomy and removal of Prevention Avoid overfill

posterior synechiae Treatment Silicone oil removal
Iris-IOL • Gas tamponade presses the IOL Aqueous shunt device (e.g. Ahmed
capture forward; the IOL is located valve)
(Fig. 24.3) before the iris. Then anterior Laser necrosis Occurs most commonly in the
synechiae form between iris and (Video) inferior pole and causes a retinal
anterior capsule. A pupillary (Figs. 24.4 and detachment
block occurs 24.5)
Prevention • Not too large rhexis Prevention Reduce laser power (until minimal
Treatment • Removal of anterior synechiae white bleaching) and a laser
and reposition of IOL behind iris duration = 200 ms
Ocular • Secondary glaucoma even in Treatment PFCL + laser posterior to the
hypertension underfill necrosis + Densiron 68
under silicone • Overfill of silicone oil (alternatively inferior buckle)
oil
Encircling band
360º laser
cerclage
Buckled retina=>
low detachment risk
Fig. 24.4 360° laser cerclage is safe if an encircling band

is present and the laser cerclage is performed on the
impression of the encircling band. A retinal detachment
Fig. 24.2 Measure the distance from optic disc to the due to laser necrosis is unlikely (see video)
apex of the gas bubble. If the distance is > four times optic
disc diameter, then air travel is safe
360º laser-
cerclage
Silicone oil
No tamponade =>
High detachment risk
Fig. 24.5 360° laser cerclage is not safe if an encircling

band is absent. A retinal detachment due to laser necrosis
Fig. 24.3 Iris-IOL capture after vitrectomy with gas tam- is likely at the inferior pole
ponade (see video)
Surgicals Pearls
25
25.1 Anterior Chamber eyes a complete trimming of the vitreous at the

superior pole.
25.1.1 Surgical Pearls No. 1
urgical Pearls No. 3
S
25.1.1.1 Insertion of a Synergetic BSS damages the phakic lens: In pseudophakic
Chandelier Light eyes BSS is used as irrigation fluid, but in phakic
1. The insertion of the chandelier light is easier eyes BSS Plus® (Alcon) is required to avoid a
using hands rather than with the trocar for- lens damage. BSS Plus® contains also glutathi-
ceps. But the surgeon must exert a relatively one, glucose and sodium bicarbonate.
strong pressure to insert the tip of the chande-
lier through the sclera. If this does not suc- urgical Pearls No. 4
S
ceed, the surgeon can expand the sclerotomy Corneal lubrication: A major problem during vit-
with a 23G cannula. The insertion is now eas- rectomy, especially in combined surgeries with a
ier, but the chandelier sits a little loose in the duration of over 1 h, is corneal epithelial oedema.
sclerotomy. With the application of methylcellulose (Celoftal®,
2. Conjunctival chemosis or haemorrhage may Alcon or Ocucoat®, Bausch + Lomb) on the cor-
make it difficult to identify the sclerotomy. In nea, the cornea can remain clear for many hours. A
such cases use a pressure plate (DORC, no debridement of the epithelium is rarely necessary,
2117), or open the conjunctiva focally with but if needed use a broad blade (crescent knife).
scissors and forceps in order to visualize the
sclerotomy. urgical Pearls No. 5
S
Posterior capsular defect during anterior vitrec-
S tomy: This is no catastrophe, and if the defect is
When working with 27G, insert the superotem- circular you don’t need to do anything. Otherwise
poral trocar towards the superior pole. This cut a round capsular rhexis with the vitreous cut-
upward position of the trocar reduces the bend- ter (e.g. 500 cuts/min). The rhexis will not go out
ing of the instruments and allows in the most and the IOL remains stable in the bag.


https://doi.org/10.1007/978-3-319-78446-5_25

S If the haptic is freed from the lens capsule, it
Small pupil: If the pupil constricts during sur- is easy to grasp with a forceps. Remark: The
gery, inject 0.01% adrenaline into the anterior fourth method is always successful.
chamber. The pupil should enlarge within sec-
onds. If the small pupil is caused by posterior urgical Pearls No. 9
S
synechiae, use stretching instruments such as a Enclavation of iris-claw IOL: Instead of encla-
push-pull instrument (Sinskey hook), or insert vating the IOL from both paracentesis, you can
iris hooks to enlarge the pupil. enclavate the IOL from one paracentesis. The tip
of the enclavation spatula is long enough to reach
S both iris claws.
Posterior dislocated IOL: An IOL in the bag lux-
ated onto the posterior pole is not easy to grasp. It urgical Pearls No. 10
S
is usually enclosed inside the lens capsule. The Do not enclavate too much iris tissue during iris-
lens capsule, however, is difficult to grasp. Lift claw implantation. It may cause ocular irritation.
the IOL up together with the light fibre and a for- In order to avoid this side effect, use the thin
ceps, and then grasp the IOL from the side. As Sekundo enclavation spatula from Geuder.
forceps we prefer a 27G endgripping forceps
(DORC) with sharp edges. urgical Pearls No. 11
S
Fibrin or clotted blood in the anterior chamber
S can be extracted easily with Eckardt forceps via a
Difficult IOL extraction from posterior pole: Try paracentesis.
the following manoeuvres:
1. Grab the haptic or rhexis edge with an intra- urgical Pearls No. 12
S
vitreal forceps. Do not open the pars plana infusion without
2. Insert a chandelier light, and work bimanual visualizing it first. If you are unable to see the
with one intravitreal forceps and one 27G internal opening of the infusion port, start the vit-
membrane pic (DORC) to elevate the IOL. rectomy using an infusion via an anterior cham-
3. Inject a small bubble of PFCL to elevate the ber maintainer. This is especially the case for
IOL and to protect the macula. Grab the ocular hypotony with choroidal detachment.
IOL.
4. Inject a small bubble of PFCL to elevate the urgical Pearls No. 13
S
IOL. Then remove the lens capsule around Corneal suture: In case of an unstable anterior
the haptic with the vitreous cutter (Fig. 25.1). chamber, place a single 10-0 nylon suture at the
end of the phaco and IOL. This avoids accidental
opening of the corneal wound during indentation,
which may lead to flattening of the anterior
chamber and even dislocation of the IOL. The
suture can be removed 1 week postoperative.

S
Capsular tension ring: A good idea is the inser-
tion of a capsular tension ring after aspiration of
the cortex. The capsular tension ring stretches the
capsular bag so that the posterior capsule does
not sag or dip. This reduces the risk of injury to
the lens capsule during vitrectomy. If you are
using a capsular tension ring, make sure that it is
in the right place, as removing a capsular tension
Fig 25.1 A posterior luxated in-the-bag IOL. In case of a
big Soemmering ring, it may be difficult to grasp the IOL ring from the vitreous base is not an easy task.
25 Surgicals Pearls 221

S
6 o’clock iridectomy for light silicone oils: If
aphakia or zonular lysis is present, create an
Ando iridectomy (6 o’clock) to prevent an
increase in intraocular pressure. An Ando iridec-
tomy prevents a secondary angle closure, because
the aqueous can flow through the iridectomy at 6
o’clock into the anterior chamber and presses the
oil bubble back into the vitreous cavity. Work
bimanually: Draw the pupillary edge at 6 o’clock
with an intravitreal forceps. Place the vitreous
cutter (low cut rate, about 200 cuts/min) with the
opening forward behind the iris at 6 o’clock, Fig. 25.2 A silicone oil bubble in the anterior chamber
aspirate the iris, and then cut a hole.

S
12 o’clock iridectomy for heavy silicone oils:
Densiron 68® (Geuder) is a heavy silicone oil and
tamponades the inferior retina. If an iridectomy is
needed, it must be performed at 12 o’clock.
Perform the iridectomy optimally in a perfluoro-
carbon liquid (PFCL) or water-filled eye, i.e.
before silicone oil injection.

S
Methylcellulose in anterior chamber: If a large
zonular lysis is present, inject methyl cellulose into
the anterior chamber; it can be left there postopera-
Fig. 25.3 Remove the silicone oil bubble with I/A. Inject
tively. It holds the anterior chamber silicone oil free. at the end methylcellulose into the anterior chamber
There will be only a slight postoperative rise of IOP.

S urgical Pearls No. 19
S
Silicone oil in the anterior chamber: Remove the One-piece IOL vs three-piece IOL: Do not
silicone oil bubble with I/A handpieces implant a one-piece IOL into the sulcus
(Figs. 25.2 and 25.3). The removal is simple, if because the haptics cause a focal depigmenta-
the vitreous cavity is filled with BSS. Usually the tion of the iris resulting in a secondary pigment
vitreous cavity is filled with silicone oil, and the glaucoma. This does not happen with a three-
risk is that after removal of the silicone oil bub- piece IOL. The reason for this is that a one-
ble, a new bubble comes into the anterior cham- piece IOL has big haptics with sharp edges,
ber. The reason for this is an overfill of silicone whereas a three-piece IOL has small round
oil in the vitreous cavity and a zonular defect. If a haptics.
new bubble comes into the anterior chamber,
then remove first the silicone oil bubble with urgical Pearls No. 20
S
I/A. Then remove the aspiration handpiece, but Posterior synechiae: How do you remove poste-
leave the irrigation in the anterior chamber. Then rior synechiae? (1) Simultaneous injection of
inject with the second hand methylcellulose into viscoelastics and delamination with the visco-
the anterior chamber, and slowly retrace the irri- elastics cannula. (2) If the adhesions are too
gation handpiece. The methylcellulose causes no strong, you can cut them with (curved) vitreous
ocular hypertension. scissors.

S
Cyclocryopexy: 3–5 cryopexy effects on the infe- Air bubbles behind IOL: Beware of a posterior
rior half of the ciliary body with approximately capsulotomy and a fluid-air exchange in pseudo-
30 s duration. Be careful with the dosage of cryo- phakic patients. During a fluid-air exchange, the
pexy because too much may result in an irrevers- water condenses at the posterior surface of the
ible hypotony. It is advisable to perform one IOL in the area of the capsulotomy, thereby
cryopexy treatment with three effects, wait greatly impairing the view of the posterior pole.
4 weeks for the effect, and then repeat the cryo- It can either be removed with a flute instrument
pexy if necessary. or injection of viscoelastics onto the posterior
surface of the IOL (Figs. 25.4 and 25.5).
S
An anterior chamber maintainer can be used for urgical Pearls No. 28
S
a vitrectomy instead of a pars plana infusion, if I think that the implantation of a foldable iris
there is sufficient flow between anterior and pos- prosthesis and a combo iris-IOL prosthesis with
terior chamber, e.g. aphakia. It cannot be used in an IOL injector is the method of choice because
a phakic eye because there is no sufficient flow
from the anterior to the posterior chamber.

S
Seidel test after closure of a corneal wound. In
order to test if the globe is watertight, perform a
Seidel test. Perform a paracentesis and inject
BSS into the anterior chamber. If the globe is nor-
motensive, you can close the case. If the globe is
hypotensive, search for the leakage and close it.

S
Anterior chamber haemorrhage. A fresh ACH is
not easy to remove, because the fibrin is difficult
to aspirate. Inject rtPA at the beginning, wait Fig. 25.4 Condensed air behind the IOL
2–3 min, and then the blood can be removed
easier.

S
Scleral perforation: Measure the distance of the
traumatic scleral defect from the limbus with a
caliper. If the distance is longer than 4.0 mm,
then a retinal defect is likely. Add in this case a
retinal cryopexy.

S
If the same scleral defect is located >4 mm
behind the limbus, then perform a (blind) retinal
cryopexy around the wound edges, and, if you
want to be absolutely safe, suture a silicone Fig. 25.5 Remove the air bubbles with an instrument, or
sponge above the scleral defect. inject methylcellulose on the backside of the IOL
it is easy and because the main incision is only urgical Pearls No. 32
S
2.4 mm wide. Trypan blue: Staining may become difficult if
you use the syringe of the company. If too
Surgical Pearls No. 29 much force is applied during injection, a sud-
The ultimate surgery would be to fasten the IOL- den jet of dye can be injected into the eye
iris prosthesis with the Scharioth method which will obscure the view and is cumber-
(Fig. 25.6). some to remove. We recommend therefore to
change the syringes. We use a regular 3 cc
syringe instead, which is predictable in its
25.2 Posterior Chamber behaviour (Fig. 25.7).
Surgical Pearls No. 30 urgical Pearls No. 33

S
BIOM and air: When filling air into the vitreous Location of fluids in the vitreous cavity PFCL
cavity, the image is out of focus due to the differ- against silicone oil exchange. See Table 25.1.
ent refractive index. If you move the BIOM-lens
a little bit up, the image becomes focussed again. Surgical Pearls No. 34
PVD: If you plan to stain with trypan blue, then
S use it also for PVD instead of triamcinolone. It
PFCL injection: Try to inject one bubble only. makes surgery so much easier. But if you plan to
Start very slowly, and then keep the tip of your stain the vitreous, you need to restain for the
cannula always in touch with the bubble. This membrane.
avoids splitting the stream into multiple bubbles,
which can then displace into the subretinal space. urgical Pearls No. 35
S
Membrane and dye: Stain the membrane repeat-
omplications of PFCL Injection
C edly, as there are often several membranes pres-
Subretinal PFCL: (1) Do not inject PFCL in
direction of a retinal break; the PFCL may flow
subretinal. (2) Use trocars with valves to avoid/
reduce PFCL bubbles.
Fig. 25.7 A 3 cc syringe with trypan blue
Table 25.1 Location of fluids in the vitreous cavity dur-

ing PFCL × silicone oil exchange
Intraoperatively Postoperatively
Fig. 25.6 The combo iris-IOL prosthesis is inserted with Silicone oil Silicone oil Vitreous cavity
an IOL injector. The iris prosthesis is from Human Optics, BSS
Germany, and the IOL from Alcon Perfluorocarbon Aqueous
ent. You can only exclude a residual membrane,

if staining was negative. And the better the mem-
brane is made visible, the easier it can be peeled.

S
In cases of ERM, you can try a “two-in-one”
peeling of ERM and ILM by starting your peeling
more peripheral than usual (e.g. at the major ves-
sel arcades). If you manage to grasp the ILM,
continue your peeling towards the centre. The
ERM should sit on top of the ILM and both layers
can be removed with one peeling.
Fig. 25.8 Inject Brilliant Blue G onto the posterior pole
S in an air-filled vitreous cavity
Staining in Air-Filled Eye
This method ac‑hieves a much higher concentra-
tion of the dye; you need less dye, and staining is
faster. Perform a fluid x air exchange and leave a
small puddle of water on the central pole. Use a
3 cc syringe with a backflush needle for injection.
Inject 2–3 drops of Brilliant Blue G into the pud-
dle, wait 15 s (Fig. 25.8), position the flute tip in
the puddle, and remove the dye (Fig. 25.9). Then
perform an air × fluid exchange. The advantage
here is the dye acts only in the water puddle, and
the surgeon can remove it more quickly than if the
dye is distributed throughout the vitreous cavity.

S Fig. 25.9 Then aspirate the dye and switch to air × fluid
ILM peeling and dot haemorrhages: Small dot exchange
haemorrhages occur only during ILM peeling
and do not appear with ERM peeling (Fig. 25.10).

S
Peeling with chandelier light: Insert a chandelier
light. Assist the dominant hand under peeling,
and you will be surprised how calm your hand is
and without tremor. If you have a hand without
tremor, take a Charles flute needle in the non-
dominant hand, and aspirate the pieces of mem-
brane or ILM. If you use a vacuum cleaner, you
can even lift up the edges of the membrane, and
then remove them with the forceps.
Fig. 25.10 Dot haemorrhages occur only during ILM
S peeling
Backflush instrument: When working with 27G,
you should perform an active fluid aspiration. coming close to the retina. It is not possible to
Use the backflush instrument with active suction aspirate the water completely with the vitrector
or alternatively the vitrector. Be cautious when due to the position of the opening.

S cially the induction of a posterior vitreous
Treat the retinal tears and not the detachment. This detachment become considerably easier.
sounds simple but often an overtreatment is per- 2. To stain the posterior vitreous face with triam-
formed. If you mend a hole in a bicycle tyre, then cinolone, perform a core vitrectomy and a
you only mend the hole and not the complete tyre. peripheral vitrectomy in front of your ports.
The same principle applies to a hole in the retina. Induce the cannula into the mid-vitreous (be
Treat only the hole edges and not the complete careful not to inject peripherally, or you will
retina. inject into the vitreous base and exert traction).
Inject a small amount of triamcinolone that will
S drop down onto the posterior pole. This will
Retinal tear under a muscle. Alternatively to a very nicely stain the bursa praemacularis of the
limbal sponge, you can apply a radial sponge. If vitreous. Do not inject too much triamcinolone
you want to apply a radial sponge under the mus- for vitreous staining. It will only obscure your
cle, then remove the muscle, suture the sponge view and will be cumbersome to remove later
and suture the muscle back to place. Or suture the on during the surgery. Few drops are sufficient
sponge onto the muscle. If the patient experi- for staining the posterior vitreous.
ences diplopia after surgery, you can remove the 3. Once the bursa praemacularis is stained with tri-
sponge after approximately 2–4 weeks. amcinolone, try to engage the posterior vitreous
face at the optic disc. Try to cut a small break in
S the posterior vitreous face nasal to the disc, and
Bulbar hypotony: Especially in vitrectomized then “pick up” the posterior vitreous phase with
eyes, the globe may be hypotensive with scleral the cutter and suction only. Pull anterior towards
folds. Inject BSS with a 30G needle via pars the lens. Try to keep an eye on the advancing
plana until the globe is normotensive. posterior vitreous face in the mid-periphery.
This looks like a tidal wave. It is where breaks
S will develop during induction of a PVD.
PVD
1. The correct assessment of the relationship Surgical Pearls No. 46 (Figs. 25.11, 25.12
between the posterior vitreous face and the and 25.13)
retina/optic disc is one of the key steps to Difficult PVD: If you are not able to induce a
master pars plana vitrectomy. Always check PVD, try the following:
if a PVD is present or not. Even in cases
when you expect a PVD to be present (e.g. 1. Increase the vacuum to 600 mmHg and try
retinal detachments), you will sometimes be again.
surprised by an attached vitreous face. 2. Stain the vitreous with trypan blue or triam-
2. The freshly detached posterior vitreous face cinolone and try again.
has a “beaten metal” appearance. You know 3. Insert a 60D lens and mobilize the posterior
that you have induced a PVD if you see this hyaloid membrane with an Eckardt forceps. If
appear on the posterior surface of the vitreous. you have created a hole, try to aspirate this
When a PVD is induced, suddenly, a lot more part with a vitreous cutter and provoke a PVD.
vitreous, which must be removed, will appear 4. Create a hole in the posterior hyaloid with a
in the vitreous cavity. 27G Atkinson cannula (Beaver-Visitec). Then
mobilize the hole edges with a forceps
Surgical Pearls No. 45 (Figs. 25.11, 25.12 and 25.13).
PVD and Dye
1. We recommend beginners to stain the vitre- urgical Pearls No. 47
S
ous at the beginning of vitrectomy for the first PVD in RRD: In about 15% of patients with
10–20 vitrectomies. The vitreous is much RRD, the vitreous is still attached at the posterior
easier to recognize, and vitrectomy and espe- pole. One group at risk is myopic patients below
the age of 50 years with multiple small round

breaks. The vitreous may be very adherent to the
retina in such cases, and trying to induce a PVD
can lead to multiple iatrogenic breaks. These
Attached
cases usually do very well with scleral buckling
posterior hyaloid surgery. If in doubt, check the status of vitreous
attachment/detachment with preoperative ultra-
sound before deciding to perform a vitrectomy.

S
Triamcinolone and RRD: Many cases of RRD
are caused by strong vitreoretinal adhesion. It
may not be possible to separate vitreous and ret-
ina simply by engaging the vitreous with the vit-
Fig. 25.11 Attached posterior hyaloid
reous cutter and pulling it off the retina—you
may enlarge pre-existing breaks or induce iatro-
genic breaks in some cases. If you find very
strong vitreoretinal adhesions, it is advisable to
“stop pulling” and start “shaving” the vitreous of
the retina. This is facilitated by staining the
adherent vitreous with triamcinolone. When
Opening in
posterior hyaloid staining the vitreous with triamcinolone, use
minimal amounts, and direct the injection to the
area of interest. Injecting too much triamcino-
lone may interfere with your view, and it can be
cumbersome to remove this later on in the
Atkinson cannula procedure.

S
Fig. 25.12 Create an opening in the posterior hyaloid Unseen breaks and Schlieren phenomenon: Inject
with a sharp instrument PFCL slowly and watch for the “Schlieren phe-
nomenon”. In particular in long-standing RRD,
the subretinal fluid appears like a muddy stream
when entering the vitreous cavity. This “Schlieren
phenomenon” may point to the location of the
retinal break at the entry site of the Schlieren in
cases of “unseen breaks”.
ILM forceps urgical Pearls No. 50

S
PFCL is quite expensive. In more complicated
cases, it may be necessary to perform multiple
manipulations under PFCL, occasionally
removing and then again adding PFCL at a later
Opening of stage. If PFCL needs to be removed, one can
posterior hyaloid
easily aspirate it back into the injection syringe
for reinjection at a later stage of the
Fig. 25.13 Then grasp an edge of posterior hyaloid and
create a PVD
procedure.

S that no detachment occurs. If the break is large,
Iatrogenic break: If the break and the bullous however, we recommend lasering the break with
detachment are far apart from each other, it is dif- one row of laser burns. Even if you create a
ficult to drain the subretinal fluid from the break. peripheral break, this is not a problem as long as
In the first case, one can try to massage the sub- you also recognize the break. Surround the tear
retinal fluid with a scleral depressor to the break, with three rows of laser burns and perform a gas
or perform an iatrogenic break in the area of tamponade.
trapped fluid. Mark the inferior retina close to the
ora serrata with endodiathermy. Then cut a hole Surgical Pearls No. 56
with the vitreous cutter (setting: approx. 300 cuts/ Laser Therapy
min) by suctioning the retina and then cutting it 1. A laser treatment can be carried out in a water
cautiously. Drain the subretinal fluid from this (BSS)-filled, silicone oil-filled and PFCL-
break. filled eye. In an air-filled eye, it is difficult to
laser due to a poor visibility.
Surgical Pearls No. 52 2. It is easiest to laser breaks under heavy liquid,
Laser: Be careful with your laser energy. Only a as you have a good apposition of retina and
mild whitening of the RPE is necessary. Burns retinal pigment epithelium. One of the disad-
which are too strong will weaken the retina and vantages of this technique is that the margins
are a predilection site for the formation of new of the break are more difficult to see. Mark the
retinal breaks. They may also cause contraction location of breaks with endodiathermy or
of the choroid or even choroidal haemorrhages. A laser spots before covering it with heavy liq-
typical beginner’s mistake is to perform too much uid. This way it is easy to identify them under
laser or cryotherapy as an extra safety measure heavy liquid.
that then may turn out to have exactly the oppo- 3. Beware of the “continuous” function of the
site effect. laser. You can easily overtreat. This may result
in mini-explosions, choroidal haemorrhage
Surgical Pearls No. 53 and retinal breaks or predispose to postopera-
Laser cerclage: A circumferential 360° laser is tive tears. Pigmentation increases towards the
not recommended. It is essential to identify and periphery. Less energy is needed for periph-
treat all retinal breaks. A circumferential laser eral laser spots.
has the big disadvantage that in case of a rede- 4. The further you move the laser probe away
tachment the breaks are difficult to find within from the retina, the larger the resulting spot
the patches of chorioretinal atrophy. size on the retina (and the more energy you
need to create a burn). This can be quite useful
Surgical Pearls No. 54 if you want to treat larger areas as the result-
Laser necrosis: Another complication of laser is a ing burns have softer edges and do not cut the
retinal necrosis. Too high laser intensity may retina like a knife.
cause a necrosis of the retina and small, difficult- 5. Use 360° prophylactic laser with caution. It
to-find holes. These tears occur often at the outer may not be necessary, may result in anterior
edge of the laser treatment. The same applies for segment ischemia and will make it very diffi-
cryopexy. cult to identify small breaks in cases of post-
operative retinal detachments. Treat only the
Surgical Pearls No. 55 visible tears instead.
Iatrogenic break: When a small break is located
within the vascular arcades, a laser treatment is Surgical Pearls No. 57
not necessary as the pigment epithelium in the Trimming of vitreous base: There are various
central area has sufficient pumping function so ways to trim the vitreous base: (1) bimanual tech-
nique using a scleral indentor, (2) removal under centre of the globe. Work from both sides. (2)
coaxial light (only with microscope illumination) With help of a vitreous cutter, suck the anterior
by using a cotton wool swab or a scleral depres- hyaloid/vitreous (only aspiration), and pull the vit-
sor to indent the sclera or (3) using the light fibre reous cutter towards the centre of the globe. Cut
as an external scleral depressor (this gives you a the vitreous there. Work from both sides.
focussed beam of light transsclerally to illumi-
nate the vitreous base). urgical Pearls No. 63
S
How should epiretinal blood be removed? (1)
S Aspirate epiretinal blood by sweeping with a
Active aspiration: In 236 the aspiration of sub- silicone-tip flute needle over the retina. (2) By
retinal fluid is fast with passive aspiration. In 25G pressing several times on the side opening/tubing
and 27G, the aspiration of subretinal fluid is eas- of the backflush instrument, water is ejected from
ier and faster with active (than passive) the tip of the flute needle and blows the epiretinal
aspiration. blood upward. The blood can then be easily aspi-
rated at the same time with the vitreous cutter. (3)
S Clotted blood can be grasped with an ILM for-
Removal of PFCL: Two pearls for PFCL removal: ceps and be removed with the vitreous cutter.
(1) When using a silicone-tip flute needle, the
risk of retinal or optic disc touch is much lower. urgical Pearls No. 64
S
(2) If you are not sure whether you aspirated the Recurrent vitreous haemorrhage: After a vitrec-
entire PFCL, instil a little water into the air-filled tomy for a vitreous haemorrhage, bleeding may
vitreous cavity (with a brief water-air exchange), reoccur after surgery. If the recurrence is associ-
and then completely remove the residual PFCL- ated with a hyphema, then check if the patient
water puddle. takes anticoagulants, i.e. aspirin. The patient
should stop taking blood-thinning medication for
S approximately 1 month. In most cases the
B-scan: In cases with vitreous haemorrhage, hyphema resolves. If the hyphema resolved spon-
always perform a detailed preoperative ultra- taneously, then continue waiting until the haem-
sound examination. Try to determine the state of orrhage in the vitreous cavity has resorbed.
the posterior vitreous face (attached, partially
attached or detached) and the retina. urgical Pearls No. 65
S
Clogged infusion line in the beginning of silicone
S oil removal: The reason of the clogged infusion
Blocked infusion: The haemorrhagic vitreous line is silicone oil within the infusion. (1) Do not
blocks sometimes the infusion. Check the infu- press with the syringe onto the globe. You press
sion trocar before vitrectomy, and if in doubt then otherwise the silicone oil into the infusion line.
cut the haemorrhagic vitreous around and inside (2) Increase the IOP to 40–50 mmHg until the
the infusion trocar. BSS comes. Then reduce again to 25 mmHg.

S
Removal of anterior hyaloid: In case of a haemor- Peeling and choroidal haemorrhage: Do not pull
rhage directly behind the lens, it may be necessary a diabetic membrane forward to the lens—you
to remove the anterior hyaloid. This is an easy pro- may cause a choroidal haemorrhage. Pull the
cedure in pseudophakic patients but a lens-threat- membrane parallel to the retina.
ening procedure in phakic patients. We perform
two techniques: Work at the edge of the lens (i.e. urgical Pearls No. 67
S
behind the zonules) in order to avoid a lens touch. Intraoperative haemorrhage and adrenaline: If
(1) With help of a serrated jaws forceps, grab the there is constant bleeding from several vessels
anterior hyaloid/vitreous, and pull it towards the under surgery, then add adrenaline to the BSS
bottle. Adrenaline will constrict the vessels and cause a postoperative sterile uveitis. Conclusion:
reduce the bleeding. Do not be satisfied after removal of the large
nucleus but after complete removal of all small
S fragments.
Postoperative vitreous haemorrhages are the
number one problem following vitrectomy for urgical Pearls No. 73
S
proliferative diabetic retinopathy. In order to lower Removal of PVR membranes: After silicone oil
the rate of this complication, be meticulous with tamponade, peripherally located membranes in
haemostasis. Watch out for small oozing bleeding particular are very difficult to mobilize from the
sites after PRP has been performed. Even small retina. A retinal scraper such as a 25G/27G
collections of blood point at continuous bleeding Atkinson blunt cannula can be very helpful. With
sites that should be treated before closing up. its help you can elevate the membrane of the retina.
Then you can grasp the membrane with a forceps
S and cut the adhesions with a scissors (Fig. 25.14).
Lens sparing vitrectomy: In young diabetic
patients, we experienced good results with a lens urgical Pearls No. 74
S
sparing vitrectomy and then a SF6 gas or 1000 cSt The conventional Eckardt ILM forceps is often
silicone oil tamponade. Even after 10–20 years, not sufficient for removal of PVR membranes.
the lens hardly opacifies. Try more powerful forceps such as a serrated jaw
forceps or an Eckardt power forceps.
S
The most patients who underwent a complicated urgical Pearls No. 75
S
cataract surgery do not complain about the com- Doughnut shape of anterior retina: One of the
plication but about the painful procedure. Why? major risks of a retinectomy is cutting into the
The cataract surgery was started with drop anaes- choroid. This will cause a significant haemor-
thesia, and when the complication occurred, the rhage and may be difficult to control. It usually
surgery was continued with the same anaesthesia. happens if the retina is too close to the choroid in
Our recommendation: If you experience a com- the area of the retinectomy. To detach it from the
plication, decide if you continue or delay the sur- choroid, fill the eye with PFCL. The subretinal
gery. If you decide to continue, then add a fluid will be pushed anteriorly in a doughnut
subtenon or retrobulbar anaesthesia before con- shape and will detach the anterior retina. It is now
tinuing surgery. You will have a happy patient. easier to perform a retinectomy, and the anterior
edge of the retina is easily identified.
S
Dropped nucleus: The difficulty of this step is
that the nucleus is located on the posterior pole so
that a damage of the retina is easily induced.
Three advices: (1) Inject a PFCL bubble to (a)
protect the macula and (b) elevate the nucleus.
(2) Work bimanually so that one hand can fixate
the nucleus and the other hand can remove it. (3)
If the posterior vitreous is attached, then the vit-
reous cortex is like a cushion for the nucleus
making its removal difficult. In this case induce a
PVD to free the access to the nucleus.

S
Fig. 25.14 Bimanual removal of peripheral membranes
The trimming of the vitreous base is an important and posterior hyaloid with forceps and scissors (straight
step because a residual nuclear fragment will or curved)

S 4 mm. The reason is that the subchoroidal blood
Laser cerclage ≠ encircling band. Both, an encir- is clotted and cannot be extracted through 3 mm
cling band and a laser cerclage, create a barrier large sclerotomies.
for subretinal fluid originating from tears located
anterior to the cerclage. An encircling band cre- urgical Pearls No. 80
S
ates an indentation of the retina which results in a Subepithelial location of trocars: Especially in eyes
relaxation of the shortened retina. In addition, a with choroidal haemorrhage, an initially correctly
laser cerclage along the indentation of the encir- placed trocar cannula may move subepithelially
cling band is safe against laser necrosis during a later stage of the operation. Double-check
(Fig. 25.15). the trocars several times during surgery.

S
Avoid if possible an inferior laser cerclage Chandelier light for choroidal detachment: It is
(Fig. 25.16) Why? There is always more trac- advisable to use a trocar-based chandelier light.
tion on the inferior pole because the gas or sili- Insert a 6 mm trauma trocar and then the light
cone oil presses against the superior pole. In fibre (e.g. DORC).
case of an inferior laser cerclage, the laser
weakens the retina and may cause a detachment urgical Pearls No. 82
S
along the laser cerclage. Exception: Heavy sili- A hypotony is present if the IOP <6 mmHg. If a
cone oil as tamponade or an encircling band silicone oil-filled eye has an IOP <6 mmHg, you
(Fig. 25.15). cannot remove the silicone oil because the eye
would fall into a hypotony and finally into a
S phthisis bulbi.
Choroidal detachment: Use 6 mm trauma trocars
from Alcon (23G). The risk for a subepithelial urgical Pearls No. 83
S
location is low. PFCL injection: Work bimanual with Charles
flute needle and fluid cannula. Hold the tip of the
S PFCL needle always first centrally in the PFCL
Difficult removal of suprachoroidal blood: If bubble, and then move it forward as the bubble
only little blood can be extracted although a gets larger.
highly bullous choroidal detachment persists,
then you should enlarge the sclerotomies to Surgical Pearls No. 84
Encircling band
360 deg laser-
360 deg laser
cerclage
cerclage
Silicone oil
Bukled retina=> No tamponade =>

low detachment risk High detachment risk
Fig. 25.15 A laser cerclage on the indentation of an Fig. 25.16 A 360° laser cerclage may cause a laser
encircling band is safe for laser necrosis necrosis at the inferior pole
Residual PFCL? Perform a short fluid × air urgical Pearls No. 90

S
exchange (2–3 s), and remove the BSS together Cyclitic membranes: If the vitreous base is not
with the PFCL. removed during vitrectomy and silicone oil used
as a tamponade, then the silicone oil will press
S the vitreous base against the ciliary body result-
Residual PFCL? Aspirate it with a 41G needle. ing in cyclitic membranes and hypotony. It is
Subretinal fluid? Aspirate it with a 41G needle almost impossible to remove these membranes. It
(Fig. 25.17). A laser treatment of the hole is not is therefore essential to prevent them. This can be
necessary. done by trimming thoroughly the vitreous base
during the first surgery.
S
Peeling in diabetic eyes: Peel from periphery to urgical Pearls No. 91
S
posterior pole. Avoid operating an inflamed or vascularly active
Peeling in PVR eyes: Peel from posterior pole to eye. If the retina is attached, wait and treat the
periphery. inflammation and vascularisation; use steroids
and anti-VEGF. If the retina is detached, you
S have to operate.
Subretinal located trocar? Check distance to
limbus! If it is correct, then an anterior retinal urgical Pearls No. 92
S
displacement is likely. Remove the retina Open-globe injury: In case of a scleral defect poste-
around the trocar, cauterize the edges, and then rior to the pars plana, measure the distance between
laser treat. limbus and scleral defect with the caliper. If the dis-
tance <4 mm, then a retinal incarceration in the
urgical Pearls No. 89 (Fig. 25.18)
S wound is unlikely. If the distance >4 mm, then a reti-
Marking of retinal breaks: If you do not have an nal incarceration is likely. Schedule a vitrectomy
endodiathermy, then mark the ora serrata poste- 2 weeks after the primary closure; see Diagram 25.1.
rior to the rupture with a laser burn.

S 25.3 Tamponade
A rhegmatogenous retinal detachment with pig-
ment line: A pigment line is an excellent marker urgical Pearls No. 93
S
for the presence of a retinal break (Fig. 25.19). Gas tamponade: Hold the flute needle behind the
lens or close to the trocar. Do not hold the flute
Fig. 25.17 Aspiration of subretinal fluid with 41G needle

needle in the middle of the vitreous body. The In 27G we use often only an air tamponade in
injected gas is heavier than air and flows to the superior detachments.
bottom of the globe. You can only extract the air
if you hold the flute needle in the front part of the urgical Pearls No. 95
S
eye (behind the IOL). Physics of a gas tamponade (exchange of air
against gas): See Fig. 25.20 and Table 25.2.
S
Air tamponade with 27G: The main advantage of urgical Pearls No. 96
S
27G is the tight sclerotomy. A 27G sclerotomy Shake the 50 cc gas syringe before injection
has less leakage than a 23G sclerotomy, and the because the gas sinks to the bottom of the syringe
gas filling is therefore much better and longer. resulting in a wrong concentration of the gas in
This feature is important for detachment surgery. the eye.

S
Air travel with gas: An airplane travels at a
height of 10 km; the cabin is regarding the air
pressure at a height of 2 km. An air travel with
a gas-filled eye is safe if the distance between
the optic disc and the lower apex of the air bub-
ble is more than 4 disc diameter (see
Fig. 25.21).
urgical Pearls No. 98 (Figs. 25.22 and 25.23)

S
Infusion line and silicone oil: An infusion line
with metal cannula (e.g. Alcon) falls off when
injecting silicone oil. Use instead a DORC
Laser effect to mark infusion line which has a plastic cannula with a
the retinal break
special shape. This infusion will remain stable
in the infusion trocar when injecting silicone
Fig. 25.18 If diathermy is not possible, you can mark the
retinal break with a laser spot above the ora serrata oil.
a b
Fig. 25.19 An inferior retinal detachment with unclear hole situation (a). Note the pigment line at 8:30–9:30 (a). A
pigment line points to a retinal break (b)
Surgical Pearls No. 99 Most vitreoretinal clinics use 20% SF6 as tam-
ponade for macular hole. However, some clinics
prefer 15% C2F6, 14% C3F8 or even 1000 csts sili-
cone oil. Silicone oil is also a good choice for
Open globe rupture patients who are unable to position themselves in
(posterior to pars plana) the prone position.

S
Air as tamponade in 27G: In case of a superior
ACUTE detachment with a break between 11 o’clock and
Closure of rupture
1 o’clock, we use often only air as tamponade.
27G sclerotomies leak very little. There is an
2 weeks later
excellent tamponade present for 7–10 days, and
laser treatment is effective after 3–4 days.
Why does it matter? Especially professionally
Vitrectomy active patients will appreciate to regain their
visual acuity after 1 week. In comparison, C3F8
Diagram 25.1 Our treatment algorithm for open-globe makes an eye blind and the patient earthbound
injuries for 2 months.

S
Air test for detachment: When the retina is
completely attached under air, you have
He
drained the subretinal fluid completely. Air
presses the entire subretinal fluid from the
periphery to the optic disc, where it is easy to
Air spot. This is only partly true for PFCL because
PFCL pushes the subretinal fluid from the pos-
C2F6 terior pole to the periphery, where the “trapped
fluid” is hard to detect. Remark: PFCL attaches
the retina by its specific gravity. (Specific grav-
SF6
ity of PFCL = 1.75, Densiron 68 = 1.06). Air,
in contrast, attaches the retina due to its high
C3F8
surface tension pressure.

S
Fig. 25.20 Relative location of gases within the eye Gas vs silicone oil: If the retina is attached
according to their molecular weight (g/mol). He = Helium under air in detachment surgery, then it will also
(SG = 2.016); Air (SG = 29); C2F6 (SG = 138); SF6 be attached under gas, but that’s not necessarily
(SG = 146); C3F8 (SG = 188)
Table 25.2 Our normogram for tamponades in regard to the specific pathology. We use rarely 5000 csts silicone oil
and C3F8
Easy retinal detachment with
Easy retinal detachment residual submacular fluid PVR detachment
Postoperative SF6 SF6 1000 csts silicone oil; in case of
tamponade inferior detachment: Densiron 68
Duration of 2–4 weeks 2–4 weeks Silicone oil and Densiron 68:
tamponade 6–12 weeks
Postoperative 5 days on the opposite 3 h supine position and then 7 days depending on position of
posture cheek of the retinal hole face down position retinal rupture
DORC
infusion line
Fig. 25.23 Use instead a DORC infusion line which has

Fig. 25.21 An ora dialysis operated with cryopexy and a plastic cannula. It remains stable under silicone oil
scleral buckling and air injection. This patient can air injection
travel because a distance of four optic disc diameters
between optic disc and gas bubble is present
Air
Alcon
infusion line
BSS
PFC
Fig. 25.22 An infusion line with metal cannula (e.g.

Alcon) falls off when injecting silicone oil
the case for silicone oil. Why? The surface ten- Fig. 25.24 Opposite mechanisms of action of PFCL and
sion pressure of the gas/water interface is the air in a BSS-filled eye. Air fills the globe from anterior to
greatest and therefore is the most effective in posterior. PFC fills the globe from posterior to anterior
closing retinal breaks (70 mN/N). So when the
retina is attached under air, then it is also urgical Pearls No. 103
S
attached under gas. The same statement is not Location of liquids during an air/silicone oil
true for silicone oil. Why? Because the surface exchange
tension of silicone oil/water with 50 mN/N is
less than that of air/water. So when the retina is
Intraoperatively Postoperatively
attached under air, it might not be attached
Air Silicone oil Vitreous cavity
under silicone oil. Silicone oil Water

S ing of your backflush instrument before with-
PFCL against silicone oil exchange: Do not con- drawing it from the eye; otherwise the heavy
fuse this method with air against silicone oil liquid bubble will drop back onto the posterior
exchange (Fig. 25.25). If you disconnect the infu- pole.
sion line with air and connect it to the silicone oil
syringe, then the eye will collapse. An air-filled eye urgical Pearls No. 107
S
needs constant air infusion in order not to collapse. PFCL against silicone oil exchange with 20G:
This is not the case in a PFCL-filled eye. The eye is This manoeuver takes much more time with
stable even if you disconnect the infusion line. 20G without trocars because you work in an
open system which leads to a much lower
Surgical Pearls No. 105 (Fig. 25.26) counter pressure. In contrary, a trocar system
Physics of a silicone oil tamponade: with valve creates a much higher counter
pressure.
S
PFCL against Silicone Oil Exchange urgical Pearls No. 108
S
1. If unsure whether there still is some heavy liq- When removing Densiron 68® with a short can-
uid left behind, pause and wait. The heavy liq- nula, it is important not to lose contact with the
uid will collect, and the interface will be bubble before it starts “floating up” towards the
clearly visible after approximately 20 s. cannula. In order to guarantee uninterrupted suc-
2. Removing the final puddle of heavy liquid is tion, check the residual volume that is left to be
not an easy step. The danger is to aspirate the aspirated in your suction line just before you are
retina into the flute needle at the posterior pole about to “pick up” the residual bubble. If only a
or to damage the optic disc. Either try to remove few ml are left in your syringe, remove the oil
the final bubble “in one go” or let it collect over from the syringe by switching to injection mode
the optic disc. Then increase the pressure with outside the eye, and then go back in to remove
the silicone oil injection, and touch the bubble the residual bubble with uninterrupted suction. If
with the opening of the backflush instrument. you lose contact with the bubble and it is too
For small remnant bubbles, indent the eye with small to be reached with the short cannula, you
your ring finger. This will give you a much bet- need to proceed with a backflush cannula (which
ter pressure control than the injection of sili- takes a long time). A special Densiron 68 removal
cone oil with the foot pedal. Aspirate the heavy cannula (23G) is available from the company
liquid bubble, and immediately cover the open- DORC.
a b
Air Air
e oil
on
lic
Backflush Backflush Si
instrument instrument
flute needle
Air
Air Air
Gas
Fig. 25.25 The left eye (a) shows the injection of gas, atoms make the gas heavier than air (a). And silicone oil
and the right eye (b) shows the injection of silicone oil. flows onto the posterior pole because it is heavier than
The gas sinks on the posterior pole because the fluor air (b)

S
View to retina during gas or silicone oil tampon- Caution: During air × fluid exchange, the
ade. An instillation of gas is done without view to instreaming fluid may damage the retina: Use
retina. An injection of silicone oil is usually done Charles flute needle with passive aspiration; DO
under view to retina. If you want to have a view to NOT use active aspiration.
the retina during the injection, then a chandelier
light is required. If you exchange air against sili- urgical Pearls No. 111 (Fig. 25.28)
S
cone oil, you inject the silicone oil with one hand, Scleral perforation: If you use a 25G or 23G can-
and remove the air with the other hand. In order to nula, you may perforate the globe during retro-
view the fundus, you need a chandelier light. bulbar anaesthesia. Use a blunt 25G retrobulbar
cannula from Atkinson instead. The blunt tip pre-
vents a scleral perforation.

S
What is the mechanism for trocar-induced retinal
Air
tear? This occurs during trocar insertion. The
reason is anterior PVR with anterior displace-
Light silicone oil ment of the retina, a very difficult pathological
and surgical situation.
BSS
Practical management:
# Avoid placing a trocar in an area with ante-
rior displacement.
Heavy silicone oil # If it happens, check first that the distance
from the limbus is correct.
# If you find an area in the eye without retinal
PFC
displacement, then replace the trocar there.
# Then cauterize the retinal tear around the
trocar and treat it as a retinal break.
Fig. 25.26 Relative location of fluids within the eye
according to their specific gravity. Air, SG = 0.001; light
# Often you need to do a focal retinotomy at
silicone oil, SG = 0.97; water, SG = 1; heavy silicone oil, this area.
SG = 1.06; PFC, SG = 1.75
a b
Air
Air
Chandelier light
Backflush Backflush
instrument instrument Air
flute needle flute needle
Air
Air Air
Silicone oil
Gas
Fig. 25.27 Gas tamponade without view to the retina (a). Silicone oil tamponade with view to the retina (b). A chan-
delier light is required
Fig. 25.28 A retrobulbar cannula from Atkinson. The blunt tip prevents a scleral perforation

S
Choroidal detachment secondary to ocular
hypotony: If the IoP <6 mmHg then choroidals
develop. A permanent silicone oil tamponade is
required.
Part VI
Proliferative Vitreoretinopathy (PVR).
An International Approach
Vitreoretinal Surgeons Assess
Surgical Cases: A Questionnaire 26
D. Ruiz-Casas, Ulrich Spandau,
Felix Armadá-Maresca, F. Cabrera Lopez,
Jorge I. Calzada, J. M. Cubero Parra,
Felipe Dhawahir-Scala, Mostafa Elgohary,
F. Espejo Arjona, F. Faus Guijarro,
B. Fernandez Arevalo, G. Fernandez-Sanz,
J. R. García-Martinez, Khalil Ghasemi Falavarjani,
F. Gonzalez-Gonzalez, Victor N. Kazaykin,
Philippe Koch, Shunji Kusaka, F. J. Lara-Medina,
Alejandro J. Lavaque, Charles W. Mango,
J. Marticorena Salinero, Marco Mura,
J. Nadal Reus, S. Natarajan, J. C. Pastor Jimeno,
M. I. Relimpio-Lopez, Zoran Tomic,
D. Ruiz-Casas (*)
Retina Department, University Hospital Ramón y J. I. Calzada
Cajal, Madrid, Spain Charles Retina Institute, Memphis, TN, USA
U. Spandau · Z. Tomic J. M. C. Parra
Department of Ophthalmology, Uppsala University Vitreo-Retina Unit Hospital la Arruzafa, Córdoba,
Hospital, Uppsala, Sweden Spain
F. Armadá-Maresca F. Dhawahir-Scala
Ophthalmology Department, University Hospital La Manchester Royal Eye Hospital, Central Manchester
Paz, Madrid, Spain University Hospitals NHS Foundation Trust,
Manchester, UK
F. C. Lopez
Ophthalmology Department, Complejo Hospitalario M. Elgohary
Universitario Insular Materno-Infantil de Gran Kingston Hospital, Kingston upon Thames, UK
Canaria, Las Palmas de Gran Canaria, Spain
F. E. Arjona
Ophthalmology Department, Universidad de Las Ophthalmology Department (Vitreo-Retina and
Palmas de Gran Canaria, Las Palmas de Gran Ocular Oncology), Virgen Macarena University
Canaria, Spain Hospital, Seville, Spain

https://doi.org/10.1007/978-3-319-78446-5_26
242 D. Ruiz-Casas et al.
F. F. Guijarro J. M. Salinero
Universitary Hospital Miguel Servet, Zaragoza, Spain Department Ophthalmology, Complejo Hospitalario
Universitario de A Coruña (CHUAC), A Coruña, Spain
B. F. Arevalo
Ophthalmology Department, Guadalajara M. Mura
Universitary Hospital, Guadalajara, Spain Retina Division, The King Khaled Eye Specialist
Hospital, Riyadh, Kingdom of Saudi Arabia
G. F. Sanz
Fundacion Jimenez Diaz University Hospital and Wilmer Eye Institute, Johns Hopkins University,
Ruber Juan Bravo Hospital, Madrid, Spain Baltimore, MD, USA
J. R. G. Martinez J. N. Reus
Hospital La Paz Madrid, Madrid, Spain Retina Department, Centro de Oftalmología
Barraquer, Barcelona, Spain
Oftalvist Madrid, Madrid, Spain
S. Natarajan
K. G. Falavarjani
AIOS-All India OPHTHALMOLOGICAL Society,
Eye Department, Iran University of Medical
Delhi, India
Indian Journal of Ophthalmology, Mumbai,
F. G. Gonzalez
Maharashtra, India
Retina unit, Hospital Perpetuo Socorro, Complejo
Hospitalario Universitario Badajoz (CHUB), AEGC-ASIAN EYE GENETICS CONSORTIUM,
Badajoz, Spain an NIH- NEI INITIATIVE, Delhi, India
Ophthalmology Department, Hospital Quiron Salud Aditya Jyot Eye Hospital, Managing Trustee,
CLIDEBA, Badajoz, Spain Aditya Jyot Foundation for Twinkling Little Eyes,
Mumbai, India
V. N. Kazaykin
“Eye Microsurgery” Ekaterinburg Center, J. C. P. Jimeno
Ekaterinburg, Russia Ophthalmology Department, Hospital Clinico
P. Koch
Orsay-Paris South University, Brussels, Belgium Carlos III Institute of Health, Valladolid, Spain
S. Kusaka M. I. R. Lopez
Department of Ophthalmology, Kindai University Virgen Macarena Hospital/Santa Angela de la Cruz,
Sakai Hospital, Osaka, Japan VIAMED Hospital, Seville, Spain
F. J. L. Medina M. Veckeneer
Hospital Clínico Universitario Lozano Blesa, ZNA Middelheim Hospital, Antwerp, Belgium
Zaragoza, Spain
J. Zarranz-Ventura
A. J. Lavaque Institute Clínic of Ophthalmology (ICOF), Hospital
Oftalmológica, San Miguel de Tucumán, Argentina Clínic of Barcelona, Barcelona, Spain
C. W. Mango
Weill Cornell Medical College, New York
Presbyterian Hospital, New York, NY, USA
This PVR summary was performed after ana- tricks shared by many of them despite they are
lysing 30 PVR questionnaires from expert vit- referred to only one. I want to appreciate their
reoretinal surgeons. There are many tips and kind collaboration with this chapter.
26 Vitreoretinal Surgeons Assess Surgical Cases: A Questionnaire 243
26.1 RD Surgical Approaches 26.1.1.1 hat Is Your Surgical

W
Approach in This Case?
26.1.1 F
ocal Superior Detachment, Many surgeons pointed out that horseshoe-
Natural Lens, Attached Post shaped tears are rare when the posterior hyaloid
Hyaloid, 56-Year-Old Patient is attached, but they can develop with a partially
detached hyaloid. The most common approach in
retinal detachment (RD) case A is buckling
(49.8%), followed by pneumatic retinopexy
(26.7%) and pars plana vitrectomy (PPV) with or
without phacoemulsification (23.3%).
Encircling Band+Circumferential
Buckle+SRF drainage+SF6
Encircling Band+Gas
Temporary Balloon Buckle
Circumferential Buckle+Gas
Radial Buckle
PhacoVitrectomy+Gas
Encircling Band
Vitrectomy+Gas
Circumferential Buckle
Pneumatic Retinopexy
0 10 20 30
Percent
26.1.1.2 Would You Choose matic retinopexy (20%) and buckling

a Different Approach (19.9%). Only 3.3% of surgeons perform
in a Pseudophakic Case? combined surgery (vitrectomy and encircling
In pseudophakic cases, most surgeons per- band).
form vitrectomy (56.7%) followed by pneu-
Buckle+SRF drainage+Gas
Encircling Band+Gas
Vitrectomy+Band+Gas
Encircling Band
Vitrectomy+Gas
0 10 20 30 40 50 60
Percent
vitrectomy with or without phacoemulsification

26.1.1.3 Would You Choose (36.6%); only 26.5% still perform buckling.
a Different Approach If
the Posterior Hyaloid Is
Detached?
If the posterior hyaloid is detached, most sur-
geons perform pneumatic retinopexy (36.7%) or
Encircling Band+Gas
Temporary Ballon Buckle
Encircling Band
Radial Buckle
PhacoVitrectomy+Gas
Vitrectomy+Gas
0 10 20 30 40
Percent
26.1.2 O
ra Dialysis, Natural Lens, 26.1.2.1 hat Is Your Surgical
W
Attached Post Hyaloid, Approach in This Case?
34-Year-Old Male Patient In this case, the surgical approach is homoge-
neous, with 93.3% of surgeons performing buck-
ling surgery and few performing vitrectomy or
combined vitrectomy and buckling (3.3% for
both).
Vitrectomy+Encircling Band+Gas
Vitrectomy+Gas
Circumferential Buckle+
SRF Drainage
Buckle
Encircling Band
0 10 20 30 40 50
Percent
26.1.2.2 Would You Choose buckling continued to be the most common

a Different Approach approach (56.3%) followed by vitrectomy
in a Pseudophakic Case? (26.7%) and combined vitrectomy and buckling
In a pseudophakic case, the number of surgeons surgery (16.7%).
performing buckling surgery decreased, but
Buckle
SRF Drainage
Vitrectomy+Heavy Oil
Encircling Band
Vitrectomy+Gas
0 10 20 30 40
Percent
26.1.2.3 Would You Choose gery also decreased, but buckling continued to be
a Different Approach if the most common approach (69.9%) followed by
the Posterior Hyaloid Is vitrectomy (20%) and combined vitrectomy and
Detached? buckling surgery (10%).
In a case of posterior vitreous detachment (PVD),
the number of surgeons performing buckling sur-
Buckle
SRF Drainage
Vitrectomy+Gas
Encircling Band
0 10 20 30 40
Percent
26.1.3 C
hronic Detachment, Natural 26.1.3.1 hat Would Be Your Surgical
W
Lens, Attached Post Hyaloid, Approach in This Case?
26-Year-Old Female Patient The surgical approach in this case is homoge-
neous, with buckling surgery the most common
(86.6%). Few surgeons perform pneumatic reti-
nopexy or combined vitrectomy and buckling
surgery (6.7% for each).
Circumferential Buckle+SRF
Drainage
Encircling Band+Gas
Buckle
Radial Buckle+Gas
Encircling Band
Radial Buckle
0 10 20 30 40
Percent
26.1.3.2 Would You Choose ling the most common approaches (43.3% each)
a Different Approach followed by combined vitrectomy and buckling
in a Pseudophakic Case? (10%) and few pneumatic retinopexies (3.3%).
In a pseudophakic patient, a change in the surgi-
cal trend was seen, with vitrectomy and buck-
Buckle
Radial Buckle+Gas
Encircling Band
Radial Buckle
Vitrectomy+Gas
0 10 20 30 40 50
Percent
26.1.3.3 Would You Choose (69.9%) followed by vitrectomy (20%) and com-
a Different Approach If bined vitrectomy and buckling (10%).
Detached?
If the posterior hyaloid is detached, buckling
continues to be the preferred surgical approach
SRF Drainage
Encircling Band+Gas
Buckle
Encircling Band
Vitrectomy+Gas
Radial Buckle
0 5 10 15 20 25
Percent
26.1.4 Paediatric Trauma, 5-Year-Old 26.1.4.1 hat Would Be Your Surgical

W
Boy, Partial Detached Approach in This Case?
Posterior Hyaloid In this case, the most common surgical approach
is buckling surgery (82.6%) followed by com-
bined vitrectomy and buckling (10.3%) and vit-
rectomy (6.9%).
SRF Drainage
Vitrectomy+Silicone Oil
Encircling Band
0 10 20 30 40 50 60
Percent
26.1.4.2 Would You Choose PVD does not seem to modify the surgical
a Different Approach If approach.
Completely Detached?
SRF Drainage
Buckle
Encircling Band
0 10 20 30 40 50
Percent
26.1.5 Y
oung Myopic, Natural Lens, 26.1.5.1 hat Is Your Surgical
W
25 Years Old Approach in This Case?
The surgical approach in this case is homoge-
neous, with most surgeons performing buckling
surgery (83.3%) followed by combined vitrec-
tomy and buckling (10%) and a few performing
vitrectomy (6.7%).
SRF Drainage
Vitrectomy+Circumferential
Buckle+Gas
Encircling Band+SRF drainage
Vitrectomy+Gas
Buckle
Encircling Band
Radial Buckle
0 10 20 30 40
Percent
26.1.5.2 Would You Choose (69.9%), but both vitrectomy and vitrectomy
a Different Approach If combined with buckling increased in frequency
the Posterior Hyaloid Is (16.7% and 13.3%, respectively).
Completely Detached?
In the presence of a PVD, the most common sur-
gical approach remains to be buckling surgery
SRF Drainage
Encircling Band+SRF drainage
Buckle+Gas
Encircling Band
Buckle
Radial Buckle
Vitrectomy+Gas
0 10 20 30
Percent
26.1.6 A
n Inferior High Bullous 26.1.6.1 hat Is Your Surgical
W
Detachment with a Tiny Hole Approach in this Case?
at 11 O’Clock. Natural Lens. In this case, the patient’s age is not mentioned as
Partially Attached Posterior many surgeons pointed out and that seemed to
Hyaloid change the surgical approach. If the patient was
older than 40 to 50 years, the most common sur-
gical approach is buckling surgery (39.9%) fol-
lowed closely by vitrectomy (with or without
phacoemulsification) (36.7%). Pneumatic retino-
pexy and combined vitrectomy and buckling sur-
gery were performed much less frequently
(13.3% and 10%, respectively). However if the
patient was younger than 40 to 50 years, the fre-
quency of buckling surgery increased to 57.4%,
and vitrectomy was performed by only 19.2%.
Encircling Band+Gas+SRF drainage
Buckle
Buckle+Gas
Pneumatic Retinopexy+Transcleral SRF
Drainage
Radial Buckle+Gas
PhacoVitrectomy+Gas
Encircling Band
Radial Buckle
Vitrectomy+Gas
0 10 20 30
Percent
26.1.6.2 Would You Choose vitrectomy and buckling (13.3%), buckling

a Different Approach (9.9%) and pneumatic retinopexy (6.7%).
in a Pseudophakic Case?
For pseudophakic patients, most surgeons per-
form vitrectomy (70%) followed by combined
Buckle+Gas
Vitrectomy+Transscleral SRF
Drainage +Gas
Radial Buckle+Gas
Radial Buckle
Vitrectomy+Gas
0 20 40 60
Percent
26.1.6.3 Would You Choose sification) (44.8%), followed by buckling surgery

a Different Approach if (27.3%), pneumatic retinopexy (17.2%) and
the Posterior Hyaloid Is combined vitrectomy and buckling (10.3%). If
Detached? patient was younger than 40 to 50 years, vitrec-
If the posterior hyaloid is detached, a different tomy was performed by 27.3% and buckling per-
surgical trend was seen, with most surgeons performed by 44.8%.
forming vitrectomy (with or without phacoemul-
Encircling Band+SRF Drainage+Gas
Buckle+Gas
Pneumatic Retinopexy+Transscleral
SRF Drainage
Radial Buckle+Gas
Encircling Band
PhacoVitrectomy+Gas
Radial Buckle
Vitrectomy+Gas
0 10 20 30 40
Percent
26.1.7 F
ailed RD with PVR, 67 Years 26.1.7.1 hat Is Your Current
W
Old, First Surgery: Phaco/ Approach?
Vitrectomy with Gas In this surgical scenario, all surgeons performed
vitrectomy to remove the vitreous remnants, and
they peeled epiretinal membranes (ERMs) and
performed retinectomies if needed. Combined
vitrectomy and buckling was the approach pre-
ferred by 53.3% followed closely by vitrectomy
alone by 46.6%. Regarding tamponade, most sur-
geons use perfluoropropane (C3F8) (43.3%) or
silicone oil (40%), and a few surgeons use heavy
oil (9.9%) and sulphur hexafluoride (6.7%).
Vitrectomy+Inferior Circumferential
Buckle+Heavy Oil
Vitrectomy+Encircling Band+Heavy Oil
Vitrectomy+Heavy Oil
Vitrectomy+Inferior Segmental
Buckle+C3F8
Vitrectomy+SF6
Vitrectomy+C3F8
Vitrectomy+Encircling Band+
Silicone Oil
Vitrectomy+Encircling Band+C3F8
0 10 20 30
Percent
My Approach to Retinal
Detachment: An Iranian Surgeon’s 27
Perspective
Khalil Ghasemi Falavarjani
Extras: Video 27.1. 27.2 imple (No-PVR C) Retinal

S
Detachment
27.1 Introduction 27.2.1 Phakic Eyes
The treatment of rhegmatogenous retinal For young phakic patients with clear lens, I prefer
detachment (RRD) has been significantly evolved to do scleral buckling (SB), either radial or cir-
in recent years. Several advances in instruments cumferential. This is especially important for
and techniques resulted in improvement of the those with retinal dialysis that are excellent cases
anatomic and visual outcomes. Despite these for circumferential SB. Also, I am in favor of
advances, a significant number of eyes suffer doing SB surgery for eyes with inferior breaks. In
from re-detachment and other complications young phakic eyes with PVR CA1, I tend to do
which affect the visual outcomes. SB surgery, if possible. Also, selected young pha-
In this chapter, I briefly explain my tech- kic eyes with RRD associated with subretinal
nique for the repair of RRD with special focus bands are good candidates for SB surgery before
on cases with proliferative vitreoretinopathy proceeding to vitrectomy.
(PVR). The PVR classification in this chap- For eyes with large breaks (more than 2 clock
ter is based on the updated Retina Society hours), posterior breaks (more than 7 mm from
Classification (1991). It should be noted that muscle insertion), multiple breaks on different
the technique should be individualized based levels, significant media opacity (vitreous hemor-
on the condition of the eye, availability of the rhage, cataract), very bullous RRD, macular hole,
instrument, and general patient’s condition and and epimacular membrane, I prefer to do pars
expectations. plana vitrectomy (PPV).
In eyes with small breaks at the 2 superior
clock hours or at 3 or 9 o’clock, I may proceed
Electronic Supplementary Material The online version with pneumatic retinopexy (PR) after detailed
discussion with the patient for the need for addi-
to authorized users. tional surgeries.
For small subclinical RRD, my preference is
K. G. Falavarjani
three rows of barricade laser photocoagulation.
Eye Department and Eye Research Center, Rassoul
Akram Hospital, Iran University of Medical Sciences, Surgical technique: I, generally, do not use
Tehran, Iran surgical microscope for scleral buckling in

https://doi.org/10.1007/978-3-319-78446-5_27
258 K. G. Falavarjani
routine cases. After localized or 360° peritomy the availability of the 23 gauge instruments and
(for segmental or encircling circumferential the costs associated with smaller gauge instru-
buckle, respectively), the rectus muscles are iso- ments. The sclera is penetrated with a beveled
lated using 4-0 silk sutures. The break is local- angle. I generally use triamcinolone acetonide
ized using indirect ophthalmoscopy and marked to make the vitreous visible except in case with
with either bipolar cautery or marking pen. obvious Weiss ring. I try to induce PVD in all
Cryotherapy is performed over the break for cases without previous vitreous detachment. In
smaller breaks and around the breaks for larger some young eyes, the induction of PVD may be
breaks. For large multiple breaks, typically more difficult using vitrectomy suction alone. In these
than 1 clock hours, that needs extensive cryo- eyes, I may proceed with gentle opening of the
pexy, I prefer to do cryotherapy for the anterior posterior vitreous using an end-gripping forceps.
edge of the break and leave other parts for laser I use PFCL in nearly all cases for retinal reattach-
therapy some weeks after surgery to avoid the ment. It is cheap and ensures proper attachment
risk of future PVR. Generally, I prefer to insert a of retina. I perform three rows of circumferential
segmental buckle (trimming a No. 276 tier, FCI peripheral laser barricade for the breaks, areas
Inc., Paris, France), to support at least 1 clock of retinal thinning, areas of lattice degeneration,
hour beyond the lateral edges of the break. For and areas of vitreoretinal traction. In cases with
those eyes with extensive lattice degeneration/ extensive lattice degenerations, or extensive vit-
round holes, especially highly myopic eyes, and reous traction, the 360 degrees of peripheral laser
those with subretinal bands, my preference is photocoagulation may be needed. My preferred
adding an encircling episcleral band (No. 240, tamponade for simple cases in which the vitre-
FCI Inc., Paris, France) to the segmental buckle. ous can be completely removed is SF6 (20%).
For large tears with more posteroanterior exten- The PFCL is exchanged with air, and the vitre-
sion, a radial sponge (No. 505 or 507, FCI Inc., ous cavity is washed with 20–50 cc of 20% SF6.
Paris, France) is preferred. Seldom, for example, In eyes with high-risk characteristics for future
in those with small breaks at the same level of the PVR, those with incomplete removal of vitreous,
retina without significant traction and with lattice and those who want to go to high altitudes, the
degeneration in other parts of the retina, I insert tamponade of choice is silicone oil (1000 CS). In
only an encircling circumferential episcleral these eyes, I perform focal laser photocoagula-
band. I always try to drain subretinal fluid except tion for the breaks. The PFCL is exchanged with
in cases with very shallow RRD. air, and then silicone oil is injected. In some
cases, such as open posterior capsule or zonu-
lar dehiscence, with the risk of air moving to the
27.2.2 Pseudophakic/Aphakic Eyes anterior chamber, and those with large or giant
retinal breaks, I prefer direct PFCL/silicone oil
Generally, I prefer to do PPV in pseudophakic/ exchange. In 23 gauge cases, I almost always
aphakic eyes with RRD. For eyes with shallow close the sclerotomy using a transconjunctival
RRD with retinal dialysis at the ora, I prefer to do 7-0 or 8-0 vicryl suture. In silicone oil injected
SB surgery. Also, in eyes with small breaks at 2 eyes, I check the IOP before closure of the last
superior clock hours or at 3 or 9 o’clock, I may go sclerotomy using Schiotz tonometer.
for pneumatic retinopexy (PR) after detailed dis-
cussion with the patient for the need for future
PPV. 27.3 RRD Associated with PVR C
For small subclinical RRD, my preference is
three rows of barricade laser photocoagulation. Generally, the treatment of choice for RRD asso-
Surgical technique: I perform PPV surger- ciated with PVR C is PPV. For young phakic eyes
ies using 23 gauge instruments in majority of with RRD associated with PVR CA1 without
cases and 25 gauge in others. This is because of anterior displacement, I prefer to perform SB sur-
27 My Approach to Retinal Detachment: An Iranian Surgeon’s Perspective 259
gery. Although subretinal strands were classified (more than 2 quadrants) retinotomy is unavoid-
as PVR C, we have shown elsewhere that they able, I do not place an episcleral band.
respond well to SB surgery in many cases. The Extensive retinopexy is a risk factor for future
exceptions are cases with napkin ring, significant PVR. Therefore, I never use cryopexy and limit
anterior displacement of the retina, and bullous the laser photocoagulation to three rows barri-
RRDs. cade for the breaks and areas of severe thinning
Surgical technique: I generally use 23 gauge due to membrane peel. I generally perform the
vitrectomy instruments for PPV. Less frequently, I laser retinopexy after PFCL injection and before
use 25/27 gauge especially for those with a small placing the episcleral band. If needed, I complete
focal PVR. If I need to use an episcleral band, I the 360° of laser photocoagulation, later at the
prefer to use 23 gauge instruments. I found EVA, time of silicone removal.
Stellaris PC, and Constellation vitrectomy sys- I am not in favor of removing the crystalline
tems similarly useful for a safe surgery. I feel lens in all phakic eyes because of PVR alone.
comfortable with both noncontact and contact Only those eyes with significant anterior PVR C
viewing systems. In cases with fine membranes, that the membranes cannot be removed without
the contact viewing system is especially helpful. I trauma to the lens are candidates for phacoemul-
start removing the membranes from the posterior sification. In these cases, I tend to insert an intra-
pole (macula and around disc). I use triamcino- ocular lens after phacoemulsification.
lone acetonide for chromovitrectomy in eyes Subretinal bands may not interfere with reti-
without obvious posterior membranes. In eyes nal reattachment. In eyes with subretinal bands,
with posterior PVR C, meticulous removal of after removing epiretinal membranes, if I felt the
membranes ensures removal of posterior hyaloids retina is stiff after PFCL injection, I cut the sub-
adhesions. I use end-gripping forceps to remove retinal band through a small retinotomy preferen-
the membranes. Less frequently, the membrane tially in the superior retina. In severe subretinal
edge is better lifted using a retinal pick. The PFCL proliferations, a small retinotomy may not be
is used for temporary retinal reattachment. In enough, and a large peripheral retinotomy with
cases with severe adherent membranes, the chan- removal of subretinal proliferations is needed.
delier light helps bimanual removal of the mem- For the endotamponade, I generally use sili-
branes. In eyes with clear wrinkling of the macular cone oil 1000 CS and exchange it directly with
surface without an epimacular membrane, I prefer PFCL. If I want to keep the silicone for a long
to remove internal limiting membrane with or period of time or for lifetime, I use silicone oil
without brilliant blue staining. If there was any 5000 CS. I try to avoid heavy (fluorinated) sili-
doubt for remaining PVR membranes, I use try- cone oil tamponade as much as possible. I prefer
pan blue dye to stain membranes. to place an encircling band and inject light sili-
In cases with anterior PVR C, I generally tend cone oil, instead of injecting heavy silicone oil, if
to use an encircling episcleral silicone band (no. possible.
240) and do not use wider tiers. I always perform For recurrent detachment under silicone oil,
vitrectomy and remove the membranes, before I prefer to start with interface vitrectomy with-
deciding to put a circumferential band. Inability out removing silicone oil. Possible advantages
to completely remove the membranes and relieve are lower surgical trauma, significantly reduced
the traction and incomplete vitreous shaving are surgical time and cost, and, probably, better
indications for placing a circumferential band. In assessment of tractional components. In this
focal anterior PVR C, if the membranes are approach, the silicone oil is attached to inflow
adherent, a small retinectomy to remove the sclerotomy (instead of BSS), and surgery is
whole membrane and traction may be the best performed as described above. All surgical
option. However, if extensive retinectomy is maneuvers including forceps membrane peel-
needed for a focal traction, I try first to relieve the ing, delamination and segmentation, retinot-
traction using a circumferential band. If a large omy and retinectomy, internal drainage of
260 K. G. Falavarjani
subretinal fluid, and endolaser photocoagula- PVR; however, the results were inconclusive. I
tion can be performed under silicone oil. only inject subtenone slow-release corticosteroid
Essentially, the membrane dissection technique at the conclusion of the surgery.
is the same; however, higher level of vacuum is
needed for cutter membrane removal, and the
cutter tip should pass the oil bubble to reach the 27.4 Traumatic RRD
oil-retinal interface. When the membrane
removal is completed, silicone is injected to fill The basics of surgery for traumatic RRD are the
the vitreous cavity and remove the residual same as above. For eyes with retinal incarcera-
fluid. If interface vitrectomy was difficult due tion, I release the retina using retinotomy around
to multiple optical components or extensive the site of incarceration with a safety margin to
membranes, or the silicone oil was emulsified, I ensure proper release of the retina. I have a lower
remove the silicone and then remove the mem- threshold to use encircling episcleral band in
branes and reinject the silicone oil. traumatic cases with retinal incarceration espe-
Several intravitreal pharmacotherapeutic cially in pediatric cases and those with incom-
agents have been tried to reduce the rate of future plete peripheral vitreous removal.
My Approach to Retinal
Detachment: A Russian 28
Perspective
Victor Kazaykin
Extras: Video 28.1. (!) release of traction to the retina and with mini-
mal (!) operation trauma. Only subject to these
conditions it is possible to expect with higher
Abbreviations probability a stable retina attachment in the post-
operative period, consistency of chorioretinal
ELC Endolaser coagulation adhesions, and minimization or absence of prolif-
LC Laser coagulation erative vitreoretinopathy (PVR) progression.
RD Retinal detachment Multiple surgical methods are employed for
SRF Subretinal fluid RD surgery. Here it is reasonable to focus on two
of them defined by method of vitreous cavity illu-
mination: (1) with standard illuminator and (2)
with a chandelier. The second variant is prefera-
The technique of vitrectomy for retinal detach- ble when it is necessary to remove membranes
ment (RD) is being constantly modified with the and vitreal strands, tightly adhered to the retina,
advent of new equipment and instrumentation. By and in case of hemorrhage risk.
the time this paper was published, it may be some- Of course, no surgeon is immune from rede-
what changed but will always depend on the sever- tachment; frequently one may suppose its appear-
ity of the disease itself, namely, on the extent of ance during the operation already, for example,
proliferative process on the retina and within the after recent penetrating ocular injury accompa-
retina, edema (!) of the detached retina, length and nied by posttraumatic uveitis. Therefore, stan-
localization of retinal breaks, vitreous body (VB) dard operation protocol may subject to change
fibrosis, presence or absence of choroidal effusion, considering the necessity of future reoperations.
cataract, and other factors. The technique of opera-
tion may vary; anyway, it solves the task of retinal
adaptation to the underlying tissues after complete 28.1 he First Method,
T
with Standard
Electronic Supplementary Material The online version Endoilluminator
5_28) contains supplementary material, which is available First, a 25G cannula (port) is inserted through the
conjunctiva in the inferotemporal sector (approx-
V. Kazaykin imately at 3.30–4.30 o’clock for the left eye and
IRTC Eye Microsurgery Ekaterinburg Center, 7.30–8.30 o’clock for the right eye). Length of

https://doi.org/10.1007/978-3-319-78446-5_28
262 V. Kazaykin
the cannula is 4 mm. Instead of a standard 25G is possible to use 27G port for infusion and 23G
cannula, a 27G infusion cannula with flap valve port for the instrument. Choosing port diameter
may be used which has smaller incision size but for vitrectomy, one should strive for their mini-
approximately the same flow capacity. mization, as wound healing is better with less
In case of pronounced vitreal strands and trac- scleral trauma even comparing 23G and 25G,
tions in pars plana region, sometimes a port with needless to speak about 27G. Nevertheless, mini-
a longer cannula (6 mm) is used to provide guar- mization of port size should not interfere with
anteed perforation of ocular tunicae. Special manipulations in the vitreous cavity which is
attention is required in case of concomitant cho- more important, because the efficacy and dura-
roidal effusion which is almost always accompa- tion of surgery and, finally, subsequent visual
nied by pronounced ocular hypotony. In this case, acuity of the patient depend to a large extent on
after infusion port insertion, the vitreous cavity is the convenience of manipulations.
filled with BSS up to normal intraocular pressure For manipulations in the vitreous cavity and
through an insulin needle on a syringe. As a rule, on the retina, 25G instruments, vitreous cutter,
flat choroidal effusion attaches, and after that endoilluminator, forceps, scissors, and cannulas,
infusion line is connected to the port. In case of are used. 27G instruments are not rigid enough to
high choroidal effusion, vitreous cavity is also work in the periphery which is inconvenient;
first filled with BSS, and if after that the cannula besides, they break quicker which is important
still does not pass to the vitreous cavity, the can- for the budget of operation. With 23G operation
nula is extracted, and suprachoroidal fluid is par- wound is bigger while the convenience of manip-
tially drained through the vacant hole in the ulations in the cavity is practically the same as
sclera. Usually choroid in sclerotomy site with 25G. 23G is preferable for removing very
attaches, or at least the height of choroidal effu- solid hemophthalmia – vitrectomy is performed
sion decreases (which is enough to start surgery). much faster, because vitreous cutter tip is not so
Only after that the infusion cannula is reim- quickly clogged.
planted in the same hole with a stiletto and con- After port installation manipulations in the
nected to the infusion line. vitreous cavity begin. First, anterior vitrectomy is
If there is a complete certainty of correct infu- performed, not immediately behind the lens but at
sion port position, the infusion system is acti- some distance. For cavity illumination, mercury
vated, usually at a pressure of 30 mm mercury, light source (!) is used which provides less photo-
and 23G or 25G valve ports for vitreous cutter toxicity and better visualization. Transparent lens
and endoilluminator are installed, usually at and adjacent transparent vitreous layers are pre-
9.30–10 and 2–2.30 o’clock. In case of transpar- served. The latter slows down lens opacification
ent lens with a large nucleus, the ports are some- in the postoperative period; zonular apparatus of
times placed 4.5–5 mm from the limbus which the lens is preserved. Lens and anterior vitreous
allows increasing of instrument maneuver in the are removed only if they are not transparent and
vitreous cavity near the ora serrata without dam- prevent visualization of the retina.
age to the lens. Sometimes a combination of 25G During vitrectomy, irrigation solution is fed
and 23G ports is used: 25G port for endoillumi- under 25–30 mm mercury pressure through the
nator and 23G port for the instrument. Through operation. Intraocular pressure (IOP) is main-
23G port it is easier to insert bent instruments tained at constant level due to special IOP com-
(e.g., laser probes); silicone oil is injected quicker pensation system integrated into vitreoretinal
(approximately twice quicker), which may be microsurgical system and due to valve ports.
actual in large volume of the vitreous cavity; it is Vitreous cutter frequency varies from 2500 to
possible to remove lens luxated into the vitreous 16,000 cuts per minute with vacuum from 50 to
cavity with fragmatome, etc. 650 mmHg, while working near the retina or pos-
In summary, use of three 25G ports is a stan- terior lens capsule cut frequency is increased
dard for detachment surgery, but in some cases, it simultaneously with reduction of vacuum which
28 My Approach to Retinal Detachment: A Russian Perspective 263
reduces the risk of their suction into the vitreous of vitreous cavity: the larger is the cavity, the
cutter port. Vice versa, while working in the mid- more injections. During every PFCL injection,
dle of vitreous cavity, cut frequency is reduced beginning with the first one, the end of cannula is
together with increased vacuum which acceler- located inside PFCL bubble to avoid emulsifica-
ates vitreous removal. Maximal cut frequency is tion. It is preferable to use perfluorodecalin as it
defined by specifications of the vitreous cutter; is less prone to emulsification. After vitreous cav-
for comfort work near the retina, 5000–10,000 ity filling with PFCL up to 1/2–3/4 of its volume
cuts per minute with 50–150 mmHg vacuum is and vitreous removal up to periphery, endoillu-
sufficient, and in the middle of the vitreous, minator tip is exchanged for extrusion cannula,
2500–3500 cuts per minute with 400–650 mmHg and further PFCL injection may be performed
vacuum. without operation ophthalmoscopy system,
It is mandatory to remove posterior vitreous directly under microscope. Extrusion cannula tip
with posterior hyaloid. Absence of posterior hya- is located above PFCL and cannula for PFCL
loid detachment makes the operation difficult, injection is inside PFCL bubble. During PFCL
especially in high detachments and central retinal injection a corresponding amount of infusion
tears. Usually, the technique of vitreous suction solution flows out passively through the extru-
into vitreous cutter port near the optic disc or sion cannula. This bimanual technique speeds up
along the vessels near the macula with simultane- the surgery. It is necessary to mention that not in
ous vitreous cutter motion along the retina sur- all cases complete PFCL tamponade of the vitre-
face away from the center is used. The vitreous is ous cavity is required, but this will be described
fixed in the vitreous cutter port and comes off the below.
disc edges and the retina. The vitreous should not There are other methods of PFCL injection
be “shaved” up to the retina at once, because in providing intraocular pressure balance, for exam-
this case subsequent separation of the vitreous ple, use of a two-barreled cannula. This method
may be difficult as there will be nothing to suck is more convenient, but two-barreled cannula
into the vitreous port and this technique becomes breaks quicker (which is important for the budget
impossible. Other techniques which may be less of operation). It is also possible to use a cannula
convenient, more prolonged, and possibly trau- with a vent hole which is inserted into a port
matic will be needed. For posterior hyaloid sepa- instead of infusion tube during PFCL injection.
ration, epiretinal membranes may be used – they Another maneuver includes use of an infusion
are grasped with forceps and then separated from tube with a flap valve when infusion tube is tem-
the retina together with the vitreous. If visualiza- porarily removed from the port while the infusion
tion of transparent vitreous is difficult, intraocu- port is left at its place and during PFCL injection
lar dyes such as triamcinolone acetonide, trypan BSS flows out passively through it.
blue, etc. are used. As vitreous cavity is filled with PFCL, epireti-
After posterior hyaloid separation, vitreous nal membranes removal is performed. The mem-
cutter tip is removed, a cannula is passed to the branes are well contrasted by PFCL which makes
disc through the same port, and about 0.3–0.5 cc their removal rather safe and effective. PFCL
of perfluorocarbon liquid (PFCL) is injected. tightly holds the retina in the central zone and
PFCL provides partial immobilization of the ret- limits its mobility in the periphery, thus playing
ina in the macular zone. Then vitrectomy of sepa- the role of a “third hand.” Membranes loosely
rated vitreous layers is performed, vitreous cutter adhered to the retina are removed in water
tip is removed again, and an additional portion of medium. More solid membranes are safer and
PFCL (0.3–0.5 cc) is injected. Such staged simpler removed in “PFCL medium.”
manipulations “vitrectomy-PFCL injection into The number of step-by-step PFCL injections
vacant space” are performed first up to equatorial in each case depends on the character of detached
zone and then up to the ora serrata. A number of retina, PVR grade, retinal break features, and
fractional PFCL injections depend on the volume other factors. In places of most dense adherence
264 V. Kazaykin
of the posterior hyaloid and epiretinal mem- avoided and vascularized membranes during dis-
branes with the retina, bimanual technique with a section with scissors are partially infringed by
chandelier is used. branches which reduces hemorrhagic complica-
tions. Due to these advantages of bimanual tech-
nique, especially in complicated cases and
28.2 The Second Method, pronounced proliferation, operation trauma to
with a Chandelier ocular tissues is reduced, relaxing retinotomy is
often avoided or performed in smaller extent, and
A chandelier is placed as the fourth port, usually operation time is reduced.
at 12 o’clock 4 mm from the limbus. Modern illu- When PFCL achieves anterior part of the vit-
mination systems provide superb visualization of reous cavity, vitreous base is removed; at this
the vitreous cavity using one 25G or even 27G time you should mind the zonulae – maximal vit-
chandelier. It is important to use most advanced reous removal is performed only in case of trac-
illumination systems not to discredit the method. tions to the ciliary body and retina, possibly even
While using a chandelier, standard endoillumina- engaging the pars plana. For facilitating manipu-
tor is seldom needed (plus for the operation bud- lations in this zone and minimizing the risk of
get), with the exception of eyes where more damage to the retina and the lens, vitrectomy is
delicate manipulations near transparent lens are performed with simultaneous scleral depression.
required for better visualization of the posterior If complete mobilization of retina is impossi-
capsule. Like a lamp in the middle of a room, the ble, relaxing retinotomy or retinectomy is per-
chandelier illuminates the entire vitreous cavity, formed with main conditions of sufficiency and
allowing the surgeon to hold another instrument adequacy; namely, excision is performed up to
instead of endoilluminator in the second hand. most “healthy” tissue where edema and mem-
Light direction from the chandelier is easily regu- branes not amenable to separation without dam-
lated by rocking motions of the optic fiber age to the retina are absent. Before retinotomy,
outside. diathermy of the retina is performed along the
Various instrument combinations may be used supposed dissection line, preferably with blunt
with such technique: forceps-forceps, forceps- probe as a greater number of applications may be
scissors, forceps-vitreous cutter, aspiration performed in one entrance into the vitreous cav-
cannula-diathermy, aspiration cannula-endolaser ity compared to sharp one. Retinotomy begins
probe, aspiration cannula-cannula for PFCL with formation of a hole with a vitreous cutter.
injection, etc. The surgeon assists himself during Through this hole vitreous cutter tip is inserted
scleral depression, PFCL consumption decreases into subretinal space with maximal length pos-
(the “third hand” is not so necessary in this case), sible without damage to the surrounding tissues,
coagulation of bleeding vessels is easier (as and then retina dissection is performed by toward
simultaneous aspiration of blood at the place of yourself vitreous cutter motions from the side of
coagulation becomes possible), and PFCL injec- subretinal space. Cut frequency makes 5000 cuts
tion is performed in one step without use of a per minute and more, aspiration 50–150 mmHg;
two-barreled cannula (benefits to the operation these parameters allow to obtain thin dissection
budget). A great advantage of chandelier is pos- line with minimal involvement of “healthy” tis-
sibility of entire operation without assistant. sue. This manipulation is performed in several
Using bimanual technique, the membrane is steps until complete mobilization of the retina. If
grasped with two forceps, separated and frag- retinotomy does not involve 360°, it should
mented by stretching motions along the retina begin and finish at the ora serrata with maximal
surface. Formed flaps are removed from the eye removal of the vitreous in these zones.
cavity with forceps or vitreous cutter. If neces- Important! – if you start retinotomy, it should be
sary, scissors are used; with scissors the manipu- performed until complete mobilization of the
lations are more delicate because tractions are retina; otherwise it will be useless. Absence of
retina displacement and fold formation during remnants are aspirated with extrusion cannula or
PFCL injection is one of the indicators of com- vitreous cutter tip. After retina attachment, addi-
plete mobilization. tional LC is performed in this zone.
Subretinal membranes are removed only if they During PFCL-air exchange, a “fog” on the
prevent adaptation of the retina and decrease visual posterior surface of the lens (or IOL) is usually
functions. Removal is performed through existing seen which, as a rule, does not prevent surgery.
retinal holes or using retinotomy. Approach to the Sometimes the “fog” may be pronounced and
membranes should be sufficient – in necessity reti- may prevent ophthalmoscopy. This problem is
notomy up to 180° and more is performed. easily solved by application of some viscoelastic
After relaxation of all the tractions, vitreous (preferably, sodium hyaluronate based) on the
cavity is filled with PFCL up to the level of scleral posterior surface of the lens (or IOL) with a can-
incisions; at this time subretinal fluid (SRF) flows nula through one of the ports.
out from beneath the retina through retinal After evacuation of subretinal fluid remnants
defects. If retinal breaks are located just at ora and completion of endolaser coagulation, air is
serrata and are extended enough, as a rule, SRF exchanged for gas with long resorption period
flows out through them almost completely. (SF6, C2F6, or C3F8), silicone/fluorosilicone
If the breaks are located not at ora serrata itself oil, or PFCL for postoperative vitreous cavity
(even at a small distance), partial block of SRF tamponade.
always takes place which is solved by air injec- Exchange for gas. A 50-cc syringe is filled
tion into the vitreous cavity (see below). beforehand with 20% SF6, 16% C2F6, or 12%
After filling of the vitreous cavity with PFCL, C3F8 with the use of automatic system integrated
laser coagulation (LC) of the retina is performed. unto vitreoretinal system. Then the syringe is
Laser burns are applied with an interval of one connected to infusion cannula instead of infusion
burn diameter, in two to three rows along the ora tube, and gas is injected from the syringe into the
serrata, around all retinal breaks, retinotomies, vitreous cavity with simultaneous passive aspira-
and vitreoretinal degenerations. Laser cerclage tion through an extrusion cannula using one of
along the ora serrata is performed only in total free ports. In other words, insufflation of the vit-
retinal detachment, because small missed retinal reous cavity with 40–50 cc of gas is performed,
holes may take place. In sectors where retina was which provides given gas concentration at the
not detached, coagulation along ora serrata is not end of surgery. Choice of gas depends on neces-
performed (LC is an additional operation trauma, sary duration of postoperative retina tamponade.
although minimal). Exchange for silicone oil. Oil injection
In patients with high risk of postoperative begins after complete attachment of the retina
redetachment, coagulation is performed in lim- and vitreous cavity filling with air. Exchange
ited volume and in some cases not performed at is performed through one of the ports in the
all, as in case of redetachment, the retina is sclera with a short thin-walled metal cannula on
detached together with applied laser burns. As a a syringe. In air medium oil flows to the pos-
result, an unnecessary loss of RPE cells takes terior pole and gradually fills the vitreous cav-
place, worsening conditions for reattachment. In ity, expelling air. To support normal intraocular
absence of redetachment in such patients, there is pressure, passive air evacuation is performed
a possibility to perform additional laser coagula- through the second port with an extrusion can-
tion through the pupil or simultaneously with oil nula. It is important (!) to control correct can-
removal from the vitreous cavity. nula position in the vitreous cavity, especially
After LC is completed, BSS infusion into vit- at the beginning of oil injection. The whole can-
reous cavity is discontinued and PFCL-air nula must be located in the vitreous cavity, not
exchange is performed. Air expels SRF remnants in ocular tunicae, to avoid oil penetration into
blocked at the ora serrata up to the level of retinal suprachoroidal space. This is a serious compli-
breaks located nearer to the center, where the cation which is difficult to correct.
266 V. Kazaykin
In some cases (seldom) direct PFCL-oil 28.3 Surgical Video

exchange (without air injection) is preferable. In
this case, after LC infusion system is discon- 28.3.1 Remark
nected from infusion cannula, and a tube for sili-
cone oil supply is connected instead. It is better to The narrative of the video is in Russian. In the
use a flip valve cannula, because it is possible to following you can read the narrative in English.
connect an oil supply tube with a larger inner
lumen to it, and then oil supply velocity will be
much higher. Final PFCL injection before the 28.3.2 Preoperative Information
beginning of exchange is performed until com-
plete extrusion of infusion solution which is Patient M., 7 y/o. Operation on the left eye is
important to prevent further BSS remnants that planned. Preoperative status: VA = 0.005, IOP
flow beneath the retina; then PFCL-silicone oil (i-care) = 6 mmHg; total swelling cataract, ante-
exchange is performed. rior chamber 2 mm, ophthalmoscopy is impossi-
It is much easier to perform direct PFCL-oil ble. Ultrasound revealed total retinal detachment
exchange using a chandelier, because in this case it with several retinal cysts and giant retinal tear in
is not necessary to remove infusion system – it is the temporal sector.
simply turned off. After infusion system is turned Anamnesis: present status was revealed
off, PFCL injection is performed until complete 2 months earlier; real duration of the detachment
extrusion of infusion solution from the vitreous unknown. The child was brought late due to fam-
cavity, and immediately (without infusion turning ily reasons.
on!) PFCL is directly exchanged for oil, holding Fellow eye has been operated for retinal
syringe with oil in one hand and extrusion cannula detachment with cataract removal without IOL
for PFCL evacuation in the other. implantation with silicone oil endotamponade
NB! In cases with high redetachment risk, 2 months earlier elsewhere.
namely, with pronounced intraretinal fibrosis and Treatment plan for the left eye: vitrectomy
retinal edema in the inferior sector, after penetrat- with endotamponade, cataract removal with IOL
ing injuries, in pediatric RDs, exudative RDs, implantation. Choice of tamponade depends on
when relaxing retinotomy, is to be performed too retinal status which is to be determined after res-
close to the center, and in case of pronounced toration of optical media transparency.
choriosclerosis, when it is impossible to obtain
reliable chorioretinal adhesions, encircling
scleral buckling is performed in addition to vit- 28.3.3 Operation
rectomy, in some cases from 1 to 11 o’clock.
Operation is finished by ports removal and Operation begins with insertion of three valve
transconjunctival Vicryl 8/0 or Nylon 9/0 (10/0) ports 3 mm from the limbus (taking into consid-
sutures on the sclera. Before suturing, puncture eration planned lens removal). Two 25G and one
sites are rinsed with BSS–PFCL and silicone oil 23G port are used. 23G port is used considering
remnants are removed to exclude their locking big volume of operation and frequent change of
under the conjunctiva postoperatively. Vicryl 8/0 instruments in the vitreous cavity.
suture material is more convenient and provides Then cataract surgery is performed: two para-
better wound sealing but causes surrounding tis- centeses, adrenaline is injected into the anterior
sues irritation postoperatively; that is why it is chamber, 2.2-mm tunnel corneal incision (2.0-
preferable to remove the sutures in 10 days after mm incision may be done but 2.2-mm is more
surgery. Nylon does not irritate tissues, but it is convenient for IOL implantation). Two viscoelas-
more difficult to achieve good wound sealing; tics are consequently injected into the anterior
suturing is more time-consuming as it is neces- chamber: dispersive (Viscoat) beneath corneal
sary to bury the knots into the sclera. endothelium for its protection and then Celoftal
which is injected beneath Viscoat to support the the retina is practically completely covered with
chamber during working with the anterior proliferative tissue; big retinal cysts are visible in
capsule. the nasal sector. Separated tissue is ruptured
Then capsulorhexis is performed. Usually in again with stretching motions and removed with
total cataract I stain the anterior capsule, but in forceps or with vitreous cutter, which may be
this case, I did it without dye. also used in shaving mode at the retinal surface.
Hydrodissection. Phacoaspiration using old The retina is thickened, edematous, and loose;
technique with plastic Simcoe cannula, which is it can be easily injured. I’d like to demonstrate a
very convenient with soft nucleus. complication – an iatrogenic retinal break with
Then anterior chamber is rinsed and epithelial damage of vessels and bleeding. This demon-
cells are removed from the anterior capsule in the strates that the surgeon should not relax and con-
projection of the pupil. trol all the manipulations constantly. The
Cohesive viscoelastic (Provisc) is injected and complication looks serious but can be corrected
a three-piece IOL is implanted. I prefer AcrySof rather easily which will be shown further on. At
MA60AC. After IOL implantation the anterior this step aspiration of blood with simultaneous
chamber is filled with Provisc for further working diathermy of bleeding vessels is performed. Then
in the vitreous cavity. an additional portion of PFCL is injected, and
Infusion cannula is connected to 4 o’clock simultaneously infusion solution is aspirated
port. above PFCL with extrusion cannula. This combi-
Examination of the retina makes it clear that nation is possible due to chandelier use.
bimanual surgery will be needed. That is why a As the retina is expanded, multiple folds are
25G chandelier is inserted at once 3 mm from the found in it; some of them look like elongated
limbus. During port insertion, the anterior cham- cavities pressed by PFCL to underlying tissues.
ber becomes flat. As the eye will have to undergo In fact, they are the result of inner retinal layers
numerous compressions, after anterior chamber displacement in relation to outer layer caused by
refilling with Provisc, the tunnel incision is sealed pronounced retinal edema.
with Nylon 10/0 suture. Then, mobilization of torn off retinal edge is
At last, we start the main surgery. 25G instru- performed with forceps and vitrectome. The
ments are used for all following manipulations. entire edge is folded, significantly thickened,
Working with proliferative tissue begins using and edematous. In the zone where the edge can-
two forceps – one with wide microtextured sur- not be mobilized, it is resected with vitreous
face which has greater gripping force and the cutter up to more or less “healthy” tissue. The
other with toothed branches. The tissue is grasped retina is swollen all over, and there is no place
with both forceps, separated from the retina with without swelling; that is why I say “more or less
stretching motions and ruptured. healthy tissue.” The resected edge is coagulated
Retinal cysts are visible, and the retina is at once.
edematous, thick, and fibrosed. Proliferations For sufficient mobilization of the tear, its
cover its entire inner surface – from the optic disc edges are complemented by relaxing retinotomy
via macula to the torn edge and periphery. at 6 and 12 o’clock. The retina is incised up to
Separated tissue is removed with forceps sufficient length with a vitreous cutter. Points of
through the port or with vitreous cutter. bleeding are coagulated at once.
After partial mobilization of the retina, PFCL Then an additional portion of PFCL is injected.
is injected near the optic disc through a cannula The entire retina attaches without its displace-
on a syringe. PFCL immobilizes center of the ment toward optic disc – that is, without semi-
retina and provides better visualization of prolif- circular folds which confirms good mobilization.
erative tissue in this zone. Posterior hyaloid is After adaptation, tear edge is coagulated at
separated from the disc with two forceps (en bloc full length for prophylaxis of postoperative
with epiretinal membranes). It is seen again that bleeding and fixation to underlying tissues.
268 V. Kazaykin
Then iatrogenic tear is corrected. Using the Then, Densiron 68 silicone oil is injected into
mobility of torn off edge, the retina is partially the vitreous cavity through 10 o’clock port. Oil
displaced toward this zone, and edges of iatro- spreads the medicine on the retinal surface as a
genic tear are approximated with extrusion can- thin film. The retina remains attached to underly-
nula and coagulated along the entire edge. ing tissues.
Then, after infusion line is switched off, vitre- After vitreous cavity filling with oil, it is worth
ous cavity is completely filled with PFCL. Infusion to remember that cataract had been removed at
line is temporarily disconnected from the port the beginning of operation. Acetylcholine is
and emptied from salt solution by air flush; then injected into the anterior chamber to strengthen
infusion line is replaced into the port and PFCL- iris-IOL diaphragm against oil pressure.
air exchange begins: from above, air is supplied; Ports including the chandelier are removed;
from below PFCL is aspirated, first by active scleral incisions are sealed with Vicryl 8/0
aspiration with vitreous cutter (which is quicker), sutures; meanwhile miosis comes.
then – near the retina – passively with an extru- Air remnants are removed from the vitreous
sion cannula (which is safe and atraumatic). cavity with a standard cannula, and Provisc is
Retinal cysts are punctured with diathermy removed from the anterior chamber. In case of oil
and passively drained with extrusion cannula. migration into the anterior chamber, viscoelastic
Then, the same extrusion cannula is used for could be left in its place or Viscoat could be used
passive aspiration of fluid which has accumulated instead; but in this case the problem did not occur.
in the central zone of the fundus during work All the ports are sealed.
with retinal cysts. As you can see, during air tam- Intraocular pressure is tested with forceps.
ponade torn off retinal edge occupies approxi- At the end of operation sutures tightness is
mately the same position in relation to optic disc tested.
as during PFCL tamponade. This is an indication
of sufficient retina mobilization and serves an
important criterion of its stable position in post- 28.3.4 Postoperative Information
operative period.
Then, application of triamcinolone acetonide 1-week follow-up: VA = 0.03; IOP = 14 mmHg;
(preservative-free) on the macular region is attached retina. The family did not show up for
performed. further control.
PVR Detachment: My Surgical
Approach 29
Shunji Kusaka
Extras: Video 29.1. PVR prevention; otherwise, hypotony and

phthisis bulbi arise. However, the complete
removal of these membranes is impossible
29.1 Introduction because the vitreous is firmly attached to the
retina and pars plana in the vitreous base. In
My surgical approach for proliferative vitreo- addition, I believe that encircling is necessary to
retinopathy (PVR) involves the following pro- counteract the concentric force created by the
cedures: (1) encircling, (2) lensectomy, (3) contraction of the vitreous or membranes at the
vitrectomy, (4) retinal membrane removal, (5) vitreous base.
subretinal strand (SRS) removal, (6) peripheral
vitreous shaving, (7) retinotomy (retinectomy),
(8) endophotocoagulation, and (9) long-acting 29.1.1 Encircling
gas or silicone oil injection.
In relatively mild cases, procedures (1), (2), Normally, I do not perform encircling during
(5), and (7) can be excluded considering the vitrectomy for conventional rhegmatogenous
pathology of the eye; however, in severe cases, retinal detachment but perform it often dur-
all procedures are performed. I performed all ing vitrectomy for PVR. After 360° peritomy,
these procedures during cases of severe PVR I create two radial conjunctival incisions.
because I believe that the meticulous removal of Then, I carefully separate the conjunctiva
the vitreous and/or membranes, particularly in and Tenon’s capsule and then place traction
the peripheral retina and vitreous base, is key sutures to the four rectus muscles. It is impor-
for successful retinal reattachment and anterior tant not to damage the muscles during this pro-
cedure. In each quadrant, I use a crescent knife
to create a scleral tunnel slightly anterior to
the equator (Fig. 29.1), where a #240 silicone
Electronic Supplementary Material The online version band is placed. I make it a rule to ligate the
band using a #270 silicone band at the upper
to authorized users. temporal quadrant (Fig. 29.2). By doing so, it
is easy to find the location of the #270 band
S. Kusaka
Department of Ophthalmology, Kindai University
when manipulation, such as the removal or
Faculty of Medicine, Osaka, Japan replacement of the #240 band, is necessary
e-mail: [email protected] during reoperation.

https://doi.org/10.1007/978-3-319-78446-5_29
270 S. Kusaka
Fig. 29.1 A scleral tunnel is made in each quadrant by Fig. 29.3 Complete removal of lens, including lens cap-
crescent knife sule, by pars plana lensectomy
Fig. 29.2 A #240 silicone band is ligated by a #270 sili- Fig. 29.4 Vitrectomy for PVR associated with familial
cone band at the upper temporal quadrant exudative vitreoretinopathy. Infusion port is placed at
superior position because proliferative membrane is pres-
29.1.2 Lensectomy ent in the peripheral temporal area. A 27-gauge twin-light
chandelier is used
In mild PVR, lens can be spared; however, in

severe PVR, lensectomy is necessary to facilitate and stiffer than those of the 25- or 27-gauge sys-
the meticulous removal of the peripheral vitreous tem. These features allow surgeons to perform a
and/or membranes. I usually perform phaco- more efficient peeling and dissection of mem-
emulsification and aspiration with intraocular branes. In addition, the faster removal or injec-
lens (IOL) implantation. In severe PVR or PVR tion of silicone oil is possible using the 23-gauge
with anterior proliferation (anterior PVR), I pre- system. All cannulas should have closure valves
fer pars plana lensectomy with complete removal to prevent collapse of the globe. In anterior PVR
of the lens capsule (Fig. 29.3). This is to dissect cases, preoperative careful observation of the
the vitreous and/or membranes between the lens peripheral retina and anterior vitreous is neces-
capsule and the peripheral retina, pars plana, or sary to avoid damaging the anteriorly pulled ret-
pars plicata. If indicated after retinal reattach- ina by insertion of the cannulas (Fig. 29.4). In
ment, a posterior chamber IOL can be implanted other words, cannulas should be inserted where
either by sulcus transscleral fixation or by intra- the retina is not pulled anteriorly, or they should
scleral fixation. be inserted more anteriorly, e.g., 2 mm from the
limbus. After inserting cannulas, it is important to
confirm that their tips are placed in the vitreous
29.1.3 Vitrectomy cavity.
In most PVR cases, I use a 27-gauge twin-
I prefer the 23-gauge system during PVR surgery light chandelier, which facilitates the bimanual
mainly because forceps and scissors are larger technique. During vitreous cutting, care should
29 PVR Detachment: My Surgical Approach 271
be taken not to aspirate the detached retina. After

core vitrectomy, I remove the vitreous near the
cannulas to prevent ora dialysis in the subsequent
membrane peeling and dissection.
29.1.4 Membrane Peeling

and Dissection
Membrane peeling should be initiated from the

posterior pole, usually above the disc. If the pos-
terior retina is closed (close funnel, Fig. 29.5), I Fig. 29.7 Membrane peeling is being performed at the
open it by viscoelastic materials (Fig. 29.6) and closed funnel
then directly grasp the membrane by forceps
(Fig. 29.7). During this procedure, care should be taken to not grasp any retinal tissue or retinal ves-
sels. Once the membrane on the posterior pole is
removed, I inject perfluorocarbon liquid (PFCL)
to flatten the posterior retina and then remove
membrane to a more anterior direction. I then
remove the internal limiting membrane (ILM) in
the posterior pole to prevent macular pucker for-
mation after surgery. Staining the ILM by bril-
liant blue G makes the removal easier and more
complete. Although I prefer forceps for mem-
brane peeling, they may easily create iatrogenic
retinal breaks. Gentle peeling using pick or
diamond-dusted membrane scraper may be safer
for removing the thin membrane or remaining
posterior vitreous cortex, which can be visualized
by triamcinolone acetonide.
Fig. 29.5 Closed funnel in an eye with familial exudative
vitreoretinopathy
29.1.5 S
ubretinal Strands (SRS)
Removal
This procedure may not be necessary in all cases.

If SRSs do not hinder retinal reattachment, they
do not need to be removed. I usually determine
the necessity of SRS removal under fluid irriga-
tion. However, if I find it difficult to make a deci-
sion, I observe how well the retina is flattened
under PFCL without removing SRSs (Fig. 29.8).
When removing SRSs, I use the bimanual tech-
nique with forceps in each hand. After making an
intentional hole by diathermy, I grasp and pull an
SRS by forceps held in one hand and press down
Fig. 29.6 Viscoelastic material is being injected to open the retina around the hole using the other forceps
the close funnel (Fig. 29.9). This is to prevent the hole from being
272 S. Kusaka
scleral indentation while observing through a

wide-angle viewing system under chandelier illu-
mination. This technique allows access to the
deeper vitreous and/or membranes with mild
scleral indentation. I use the setting of the vitrec-
tomy machine suitable for vitreous shaving, such
as flow mode (EVA®, DORC) or shave mode
(Constellation®, Alcon).
29.1.7 Retinotomy (Retinectomy)
If the retina cannot be flattened even after the

Fig. 29.8 Perfluorocarbon liquid is injected to check
how the retina can be flattened. In this eye, retinal reat-
meticulous removal of epiretinal membranes and
tachment is hindered by subretinal strand SRSs, retinotomy or retinectomy is necessary
to reattach the retina. I usually perform retinec-
tomy around the equator. I perform diathermy on
major vessels to prevent bleeding and then reti-
notomy using vertical scissors. Then, I remove the
“nonfunctional” retina anterior to the retinotomy
site using a vitreous cutter. If the retinectomy
is insufficient, redetachment is likely because
of the remaining traction to the adjacent retina.
Therefore, I perform retinectomy slightly more on
the area that I think is sufficient for reattachment.
29.1.8 Endophotocoagulation
Fig. 29.9 Subretinal strand is being removed using I perform endophotocoagulation at 0.2 s (duration
bimanual technique and interval) with power sufficient to create
homogenous white burns (Fig. 29.10). If PFCL is
enlarged during the procedure. In addition, I use
the other forceps as a “hinge” to change the direc-
tion of pulling; thus, the SRS can be pulled tan-
gentially to the detached retina. If complete
removal is difficult, cutting down the SRS may
be enough for retinal reattachment.
29.1.6 Vitreous Shaving
The peripheral vitreous can be removed under

direct observation with scleral indentation; how-
ever, this technique allows access to the relatively
anterior vitreous. In addition, deep scleral inden-
tation may cause more inflammation postopera-
tively. I prefer performing vitreous shaving with Fig. 29.10 Endophotocoagulation under air irrigation
29 PVR Detachment: My Surgical Approach 273
already in the eye, I prefer performing endophoto-

coagulation under PFCL. It allows more complete
retinal reattachment to the retinal pigment epithe-
lium. Furthermore, it is safer to do so than under
air irrigation, which may cause retinal damage by
drying. On the peripheral retina, endophotocoag-
ulation can be performed using the combination
of a wide-angle viewing system, chandelier illu-
mination (or illumination by a laser probe), and
scleral indentation by a surgeon.
Fig. 29.11 Silicone oil is being injected through VFI
needle. The conjunctiva is sutured except for temporal
area
29.1.9 I njection of a Long-Acting Gas
or Silicone Oil
wound, including those for the 27-gauge twin-
In nonproliferative, rhegmatogenous retinal light chandelier. After closing the nasal scleral
detachment, I use either air or SF6 gas; however, wound, I suture the conjunctiva, except for the
in PVR, I usually use C3F8 gas or silicone oil. area of the two temporal scleral wounds. Silicone
First, I remove the nasal cannula and securely oil is injected via a viscous fluid injector (VFI)
suture the sclerotomy wound using 8-0 vicryl. syringe connected to a VFI needle from the upper
Then, I inject diluted C3F8 gas (up to 14%) temporal cannula (Fig. 29.11). If the vitrectomy
through a three-way stopcock connected with an machine does not allow flow backward from the
infusion tube, with the remaining cannula opened infusion line, I disconnect the infusion tube or
by a back-flash needle. I irrigate at least 25 ml of open the three-way stopcock in the infusion line
gas to make the gas concentration in the eye equal to allow the air inside the globe to escape. I usu-
to that in the syringe. Then, I remove the remain- ally fill up the vitreous cavity with silicone oil. In
ing two cannulas and suture the sclerotomy an aphakic eye, I perform peripheral iridectomy at
wounds. If the intraocular pressure becomes low, the 6 o’clock position to prevent pupillary block.
I adjust its level by injecting the remaining gas in After suturing sclerotomy wounds, I thoroughly
the syringe through a 30-gauge needle. rinse the ocular surface to wash out the remaining
If silicone oil injection is chosen, special care silicone oil; this is followed by conjunctival sutur-
should be taken to prevent silicone oil migration ing and subconjunctival dexamethasone injection.
in the subconjunctival space during and after sur- In severe case, I also give sub-Tenon’s injection of
gery. During this process, I suture every scleral triamcinolone acetonide.
Surgical Management
of Proliferative Vitreoretinopathy: 30
An Indian Perspective
Sundaram Natarajan
Extras: Videos 30.1 and 30.2. immobile retinal folds of detachment and promi-
nent vitreous membranes.
Early recognition of signs of impending PVR
30.1 linical Signs and Diagnosis
C following reattachment of a retina in the 1–3-month
of PVR period postoperatively allows more timely inter-
vention. In many cases of early PVR, timely inter-
Retinal surface and localized fibrocellular mem- vention can avoid the substantial visual loss that
branes, which appear as a white opacification of almost invariably occurs with macula detachment
the retinal surface and small wrinkles or fixed folds in patients with delayed diagnosis and reoperation.
and more extensive PVR, have fixed folds with In our experience, prolonged inflammation
retinal detachment especially which is a common after retinal detachment surgery increases the risk
scenario at Aditya Jyot Eye Hospital, Mumbai. of PVR, especially if associated with postopera-
At our centre cellular dispersion in the vitre- tive uveitis, residual intraocular blood or failure
ous is a rare presentation of PVR; however, early to remove all traction off the retina and failure to
and subtle signs of PVR should always be looked support it with a scleral buckle. The greatest risk
for and noted in the preoperative assessment of period is 4–12 weeks after detachment surgery. A
retinal detachment as it may result in modifica- patient with any of the above predisposing risk
tion of the choice of surgical techniques outlined factors, either preoperatively or as a result of sur-
below during primary repair. gery, should be followed more frequently in the
Diagnosis of established PVR is made by indi- postoperative period to ensure early detection of
rect ophthalmoscopy and slit-lamp biomicros- PVR and recurrence of retinal detachment.
copy with a +78 or +90 diopter lens or corneal Nowadays, with improved surgical techniques
contact lens. In eyes with opaque media, B-scan and techniques using minute gauges, PVR repair
ultrasonography is performed to demonstrate can be carried out with minimal trauma to the
retina.

of this chapter (https://doi.org/10.1007/978-3-319-78446- 30.2 Classification of PVR
Classification of PVR: It can be done by using
S. Natarajan both grade (severity) and contraction type/loca-
Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India tion (focal, diffuse, subretinal, circumferential,

https://doi.org/10.1007/978-3-319-78446-5_30
276 S. Natarajan
anterior loop/anterior or posterior to the equator) The operating rooms at our institute are
to describe the status of the retina. We follow the well equipped with a Zeiss Microscopewith
Retina Society Terminology Committee (four wide-angle observation system from Zeiss
grades: A, B, C and D) and the Silicone Oil Study (Resight) and @Super View from Insight
designations (three grades: A, B and C). Instruments, Inc.
30.2.1 PVR Surgery Basic Principles 30.2.2 P

VR Vitrectomy: When
to Operate?
The primary treatment for PVR is surgery (pars
plana vitrectomy with membrane peeling). In a recently diagnosed PVR case, I operate
The surgical approach for PVR is generally immediately without delay.
the same for primary retinal detachments without In our centre, the patient is worked up for fit-
membranes. However, there is significantly more ness, and the surgery is scheduled for surgery as
retinal traction in PVR, caused by membranes soon as convenient. The next available surgical
and bands rather than vitreous gel only. Various day is preferred or on an emergency surgical
techniques can be used to dissect these mem- operating time.
branes so that retina can be flattened. Scleral buckling in PVR cases is performed
Basic principles of surgical management of using a 2.4 mm encircling silicone band which
PVR are removal of traction and supporting the is passed 360 degrees in partial thickness scleral
retina with a suitable endotamponade. Commonly tunnels and underneath the muscles. I give
used tamponading agents are C3F8, Heavy 0.1 ml of steroid (triamcinolone acetonide) in the
silicone oil (Densiron 68). peripheral retina, at times over the retinal hole. At
A scleral buckle can also be used during the the end of the surgery a sub-tenon steroid injec-
PVR vitrectomy (if not used for initial repair). tion is given before surgical closure.
However, if the plan is to perform an extensive In a phakic PVR case, I never remove the
inferior retinectomy, then a scleral buckle may lens. I use 25G and 27G gauges in vitrectomy.
not be required. To perform vitrectomy, I use both venturi and
The primary surgical goal in PVR surgery is to peristaltic pumps, according to the surgical step.
remove the membranes from the retinal surface and, In PVR cases, if bimanual membrane removal is
if necessary, from beneath the retina. Because these needed, I use four-port vitrectomy with chande-
membranes may be tightly sticking to the underly- lier light.
ing tissue, bimanual surgical technique is useful, In PVR without PVD and in addition to above
with both hands using surgical instruments to tips, fluid air exchange is performed. Retina is
manipulate the retina and other structures. Generally, stretched using air and the cutter. Membranes
silicone oil is used for longer long-term tamponade, are identified and removed using forceps. As
although perfluoropropane (C3F8) gas may also be far as it is safe, I do vitreous separation to the
used for eyes with less extensive disease. maximum extent possible. In case of persist-
ing circumferential traction, and inability to
30.2.1.1 My Surgical Techniques remove the anterior vitreous, on a regular basis,
Followed at Our Institute I perform a retinectomy. I do the complete vit-
Closed-glove technique is followed, and the eyes rectomy (vitreous shaving and pars plana vitre-
are prepared and draped using the usual sterile ous dissection, detaching and removing anterior
techniques. Draping is performed with caution so hyaloid or cutting anterior hyaloid connections
that there is no fogging intraoperatively. to the vitreous base).
30 Surgical Management of Proliferative Vitreoretinopathy: An Indian Perspective 277
30.3 ERM Removal peripheral circumferential retinotomy and sub-

retinal band removal from behind the retina. To
To detect PVR membranes, I use steroids, try- remove subretinal bands without enlarging ret-
pan blue and brilliant blue either individually or inotomy and for subretinal scarring in a placoid
in combination. The staining is preferred after configuration, I do peripheral circumferen-
an air fluid infusion to prevent the staining of tial retinotomy and subretinal plaque removal
the posterior capsule, and the resultant obscured from behind the retina. To remove subretinal
view is prevented. Posterior epiretinal PVR plaques and for napkin ring proliferations, I
membranes are lifted using forceps. Excellent do posterior retinotomy and subretinal mem-
tactile sensation is necessary to peel effectively brane removal through posterior retinotomy.
and safely. One must learn grasp technique to To remove napkin ring membranes, I make a
feel the traction of retina which comes with a posterior retinotomy over napkin ring, segment
lot of experience. I use proportional mode to the membrane, grasp the membrane and then
use fluid to separate membranes, and once little remove it.
delineation is available, I use PFCL to separate. Relaxing Retinectomy (RR)
To avoid tearing the retina in cases of thick Zivojnovic [1] described techniques of man-
membranes and fragile retina, I do careful agement of the retina with silicone oil following
delamination with two instruments (pick and retinotomy or retinectomy.
forceps). Parke and Aberg [2] described the use of
If there is an iatrogenic break, I prefer to a do retinotomies and retinectomies in association
localized retinectomy. In case of very immature with gas tamponade techniques and laser endo-
retinal membranes when I cannot remove them photocoagulation for management of the eyes
easily, I brush them out (Tano scraper or retina with severe proliferative vitreoretinopathy
scratcher or brush). (PVR).
While dealing with anterior PVR membranes at RR is indicated whenever fibrous prolifera-
vitreous base insertion with circumferential traction causes contraction and shortening of the
tion, I do peripheral retinectomy. Preferable instru- retina, and this intractable traction prevents the
ments I use are Alcon Grieshaber, now Vitreq. retina from apposing effortlessly to the retinal
While dealing with anterior PVR with anterior pigment epithelium, like anterior PVR; major
vitreous foreshortening and an anterior retinal subretinal proliferation; high myopia with loss
loop with anteroposterior traction, I do peripheral of retinal elasticity; penetrating trauma, particu-
retinectomy. I start peeling from posterior mem- larly with retinal incarceration; and some cases
branes to anterior membranes. of proliferative vasculopathies like diabetic
In case of a closed funnel, I use PFCL, some- retinopathy.
times viscoelastics, also forceps to open it. If no The decision to perform a relaxing retinotomy
macular membranes were seen, I don’t remove or retinectomy is usually made during surgery,
ILM. I peel membranes under both BSS or under after complete membrane removal. If the retina is
PFCL. cut or excised before complete membrane
removal, further membrane removal will be more
difficult [3].
30.4 Subretinal Membranes The anterior flap of the retinotomy is avascu-
lar and nonfunctional. Excision is recommended:
If the retina does not attach with PFCL, it is I prefer not to rejoin the edges of retina.
necessary to remove subretinal membranes. Proliferation from the anterior flap does not pro-
To remove subretinal bands (strands), I use duce traction on the ciliary body [4].
278 S. Natarajan
Failure to extend the retinotomy into normal manoeuvers, and they should not be performed if
retina or to excise the anterior flap may allow less aggressive measures will suffice.
recurrent proliferation and contraction to rede-
tach the retina. Circumferential RRs are pre-
ferred to radial RRs. Tamponade following RRs 30.5 Retinectomies and Buckling
are based on the Silicone Study that silicone oil
and C3F8 gas were equally effective as tamponade If I cannot reattach the retina despite peeling
for eyes undergoing retinotomy in repeat vitrec- membranes, I plan a peripheral retinectomy. Type
tomies for PVR. There are higher rates of post- of retinectomy depends on traction and intrinsic
operative hypotony in gas-treated eyes compared shortening of retina. If I decide a buckle in a
with silicone-treated eyes. patient of PVR to support the base of the buckle,
I would use 2.4 mm band 360 buckle and put it
anterior to vortex veins.
30.4.1 Follow-Up in Cases If I planned to perform a retinectomy, I don’t
Requiring RR use an encircling buckle. If I perform a retinec-
tomy, I would do it under balanced saline solu-
Eyes not undergoing retinotomy in general tions and PFCL. I try to keep my retinectomy as
attained similar or better final vision than eyes small and peripheral as possible such that I can
that did—probably because RRs are required in completely remove posterior membranes. I use
worse case scenarios. diathermy all around the cutting area before cut-
Complications associated with RRs in partic- ting. I remove the anterior retina or pars plan epi-
ular are postoperative hypotony and recurrent thelium flap only in peripheral retinectomies. To
RD [5]. perform a retinectomy, preferred choices are dia-
Postoperative hypotony is a well-recognized thermy and vitreous cutter.
complication. RR incisions have been theo- In cases of perforating trauma with posterior
rized to expose areas of bare retinal pigment retinal damage or incarceration, future PVR can
epithelium that facilitate the absorption of be prevented by chorioretinectomy 1–2 mm
intraocular fluid, predisposing eyes to hypot- around incarceration site. In cases of penetrating
ony. Removal of the lens or IOL (with bag) trauma or globe rupture with peripheral retina
may be considered for those eyes at greatest incarceration, I free the retina by retinectomy
risk of hypotony. next to the incarceration site.
30.4.2 Re-detachment After RRs 30.6 Tamponades
Although the anatomical success rate after In cases of giant retinal tear (GRT) or large reti-
RRs has been mentioned from 47% to 95%, nectomies, I avoid slippage by using direct
re-detachments are known. The cause: repro- PFCL-silicone oil. I fill PFCL up to brim of the
liferation of epiretinal membranes at the pos- tear, fluid gas exchange to dry thoroughly and
terior edge of the retinotomy incision, leading then silicone oil-PFCL exchange. I use heavy
to retinal rolling. Three to four rows of laser silicone oil in inferior retinectomy. In a PVR
barrage is recommended to strengthen the reti- case, I leave silicone oil tamponade in the eye. I
nal edge. use 1000 cs silicone oil in PVR cases. In case of
RR and retinectomy can improve the curative leaving silicone oil with air fluid exchange after
effect of complicated RD. However, there are PFCL, I prefer to leave the eye with around
potentially serious complications of these 20 mm Hg intraocular pressure after injecting
silicone oil, and I check this by observing optic with PVR, I prefer a 360° laser. However, in a
disc and tactile sensation of the globe. primary retinal detachment with PVR, I perform
I perform an ANDO iridectomy in in aphakic laser around the breaks, holes or lattice.
eyes and at 12 o’clock when using heavy oil. I do
not position the patient after surgery. I remove
silicone oil (including heavy silicone oil) after 30.7.1 Double Sandwich Technique
3 months. But if the patient is one eyed or has
history of several vitreous surgeries, I leave the Vitreoretinal proliferation occurs more frequently
silicone oil permanently into the eye. in the inferior quadrants, as cells gather in the
Use of Densiron outcomes and complications watery space between the retina and the oil bub-
of endo tamponade with Densiron following ble due to the gravity.
complicated retinal detachment repair is thought Removal of PVR can be performed using two
about before proceeding with the surgery. Despite surgical options under silicone oil in situ or after
many advances over the past 30 years, there are removal of silicone oil. Support to retina in our
still significant functional and anatomical chal- centre is provided using silicone oil or Densiron
lenges associated throughout the field of vitreo- (heavy silicone oil). With silicone oil in situ, I
retinal surgery. use two techniques of vitrectomy working under
Many of these lie in treating pathology that is silicone oil or after complete removal of silicone
located at the posterior pole and especially in the oil: PVR removal and subsequent infusion of
lower fundus periphery. These are the two areas silicone oil/Densiron. Disadvantages of this
in which the standard gas or silicone oil endo- technique include intraoperative retinal detach-
tamponades are unable to provide satisfactory ment and more surgical time. Heavy silicone oil
retinal support in the usual upright and supine (HSO) is presumed to have advantages in RRDs
positions. A ‘heavier than water’ intraocular tam- large breaks or PVR in the lower periphery
ponade offers the potential to provide adequate treatment.
support in these particular problem areas and has After reviewing 21 publications, Heimann
therefore been very high on the wish list of vit- et al. concluded that developed heavy silicone oil
reoretinal surgeons. tamponades (Densiron 68 ultrapure polydimeth-
In vitrectomized eyes, different substances ylsiloxane and ultrapure perfluorohexyloctane)
have been used as vitreous substitutes. are safe and effective tools for the use of compli-
Gas and silicone oils have specific gravities cated retinal detachments of the inferior fundus.
lower than water; therefore, they can produce effec- Densiron is a colourless, homogenous liquid
tive tamponade on superior retinal quadrants but composed of a mixture of chemically and physi-
fail to produce an effective tamponade inferiorly. ologically inert and has a viscosity of 1400 mPas.
In fact, the most common complication of sili- In Densiron mainly supporting inferior retina,
cone oil internal tamponade is persistence or recur- there have been cases of superior RD in Densiron-
rence of inferior retinal detachment. As a result, filled eye. In surgical sandwich technique, sili-
using vitreous substitutes heavier than water has cone oil is used to support superior retina, and
always been a matter of intensive research. Densiron is used to support inferior retina.
30.7 Retinopexy 30.7.2 Sandwich Technique
I prefer to use laser most of the time in compli- As routine pars plana vitrectomy, three ports
cated retinal detachments with PVR. I do not use are placed within the pars plana 3 or 3.5 mm
cryotherapy. In a recurrent retinal detachment from the limbus, the infero-temporal port is
280 S. Natarajan
Fig. 30.1 Densiron 68

is injected and does not
mix with existing
silicone oil (Schematic
Epiretinal
diagram by Dr. Chinmay Membranes
Nakhwa)
Oil filled
eye
1000 CS
Densiron
infusion
Membranes
are peeled
under oil
used for Densiron infusion instead of balanced But if there is no PL, we should give up oper-
salt solution (BSS) infusion, and the superior ating on a PVR case.
ports are utilized for other instruments and light
pipe.After assessing the extent of the persistent
or recurrent inferior retinal detachment, PVR 30.7.3 Prevention and Management
tractional membranes (if any), which were pre- of PVR Intraoperatively
venting the retina from being settled, are peeled
off using either forceps or cutter under silicone I follow least tissue-touch technique. I rarely use
oil. As Constellation® platform from Alcon has or I would say I do not use cryotherapy in cases
the facility of simultaneous dual mode viscous of complicated retinal detachments with PVR—
fluid injection and extrusion, it enables the sur- more so due to dispersion of retinal pigment cells
geon to aspirate the persistent subretinal fluid and setting on the retina in turn worsening the
through already present or induced retinotomy, PVR which may cause recurrence of retinal
and injection of Densiron simultaneously, in detachment. I perform a relaxing retinectomy
order to maintain the intraocular pressure after detecting the traction under air instead of a
(Fig. 30.1). 360° regular retinectomy.
Since the Densiron is heavier than the regular Rarely, in patients with an adherent iris, 360
silicone oil and water, it goes under the silicone retinectomy and viscoelastic to open the con-
oil filling the vitreous cavity to settle over the tracted retina are performed. If more than 50%
retina producing tamponade for the inferior part retina does not open, radial retinectomy is per-
of the retina, without being mixed with already formed, and retina is stretched under oil. I aban-
existed silicone oil or losing its unique physical don the case if all the techniques fail, which is
property. hand-counted number of cases.
In cases of re-detachment after PVR surgery, Early surgical intervention results in reason-
my common surgical technique is working under able visual outcomes and anatomical retinal res-
oil, sandwich technique. I peel new membranes toration. Post buckle or post vitrectomy, I prefer
under silicone oil. When dealing with permanent for the membranes to mature which is detected
hypotony, I leave 5000 cs silicone oil by a stable noncontracting PVR on clinical exam-
permanently. ination (Figs. 30.2, 30.3 and 30.4).
Fig. 30.2 A surgical case with preoperative and postoperative status. (Photo courtesy: Dr. Priya Dorairaj, International
Vitreoretinal fellow, Aditya Jyot Eye Hospital)
Fig. 30.3 A surgical case with preoperative and postoperative status. (Photo courtesy: Dr. Priya Dorairaj, International
Vitreoretinal fellow, Aditya Jyot Eye Hospital)
282 S. Natarajan
Fig. 30.4 Left picture shows Prof Machemer, the inventor of vitrectomy. Right picture shows Dr. Relja Zivojnovic, a
pioneer in development of vitrectomy, and Prof Natarajan
Acknowledgements Dr. Priya Durairaj, MBBS, MD: Dr. proliferative vitreoretinopathy. Am J Ophthalmol.
Chinmay Nakhwa, MBBS, MD, FRCS. 1984;97(4):434–43.
Financial Disclosures 3. Nanda SK, Abrams GW. Relaxing retinotomies
The author has nothing financial to disclose. and retinectomies. In: Ryan SJ, editor. Lewis H,
vol. 12. Medical and Surgical Retina: Mosby; 1994.
p. 146–80.
4. Jacobs PM, Cooling RJ, Leaver PK, McLeod
References D. Retinal relieving incisions. Eye (Lond). 1987;1(Pt
4):500–3.
1. Zivojnovic R. Silicone oil in vitreoretinal surgery. 5. Bourke RD, Cooling RJ. Vascular consequences
Dordrecht: Springer; 1987. of retinectomy. Arch Ophthalmol. 1996;114(2):
2. Parke DW 2nd, Aaberg TM. Intraocular argon laser 155–60.
photocoagulation in the management of severe
My Approach to PVR Detachment:
An American Perspective 31
Charles W. Mango
Extras: Videos 31.1 and 31.2. or pseudophakic would not alter my decision
as the patient is older and would likely require
cataract surgery at some point in the near future.
When a new retinal detachment (RD) presents The presence of a posterior vitreous detachment
itself, I prefer to take the patient to the operating (PVD) would play little role in my decision-
room in a timely fashion dependent on macula making since the hyaloid usually detaches easily
involvement. If the macula is threatened but still in an older patient.
attached (superior bullous RD, temporal RD Straight forward new RDs [causative tear in
nearing the macula, etc.), I will attempt to oper- superior portion of fundus between 9 o’clock and
ate within 24 h of the initial exam. If the macula 3 o’clock] in younger patients (<50 years old) are
(including the fovea) has been detached, I will considered for vitrectomy or primary scleral
operate within several days. If the macula is not buckle repair depending on the status of the pos-
threatened (inferior RD), I will operate within terior hyaloid. If the hyaloid is attached, a pri-
several days. In general, the preference is to mary scleral buckle repair is the preference; if the
repair a new RD sooner rather than later. hyaloid is detached (a PVD present), then a pri-
Straightforward new RDs [causative tear in mary vitrectomy is most likely the preference.
superior portion of fundus between 9 o’clock Whether or not the macula is attached or detached
and 3 o’clock] in older patients (>60 years old) will not alter my surgical plan in this scenario.
are operated on via primary vitrectomy repair. New RDs in young patients (<35 years old)
This involves a pars plana vitrectomy, fluid- are almost always approached with a primary
air exchange, endolaser, and air-gas exchange. scleral buckle repair. Often the posterior hya-
Whether or not the macula is attached or loid is firmly attached, multiple areas of lattice
detached will not alter my surgical plan in this are present, and there is a clear crystalline lens.
scenario. Whether or not the patient is phakic In these cases, I prefer a solid silicone element
(my personal choice is a 276 element with a
7 mm width) placed in an encircling fashion and
of this chapter (https://doi.org/10.1007/978-3-319-78446- covering the area of detached retina. I perform
5_31) contains supplementary material, which is available subretinal fluid (SRF) drainage (underneath the
to authorized users. bed of the buckle) in almost all but the shallow-
est of detachments. Whether or not the macula
C. W. Mango
Weill Cornell Medical College, New York is attached or detached will not alter my surgical
Presbyterian Hospital, New York City, NY, USA plan in this scenario.

https://doi.org/10.1007/978-3-319-78446-5_31
284 C. W. Mango
In new RD repairs, there can be compli- If the primary repair was a vitrectomy that
cating issues. Sometimes the causative tear is failed, then the cause is likely a missed tear in a
too small to find. If the tear cannot be located, lower half of the retina (where the gas has
perfluorocarbon liquid (PFLC) (Alcon) is used. resolved). A repeat vitrectomy is performed with
While slowly injecting PFCL over the optic 360 degree laser to cover for any occult tears. I
nerve, SRF (relative thick viscosity and also then choose a longer acting gas (14% C3F8) to
known as “Schlieren”) is looked for peripherally tamponade.
coming out of the previously hidden tear. If a tear If the primary repair was a scleral buckle
cannot be identified, 360° laser is used to cover that failed, then the cause is likely an incorrect
for any hidden causative holes. scleral buckle placement that is not supporting
Another complicating issue is vitreous hemor- the break. A first time vitrectomy is performed
rhage (VH). If the VH is so thick that it is pre- with 360 endolaser along the bed of the buckle.
venting a view posteriorly, I remove the blood I then choose a longer acting gas (14% C3F8)
stained vitreous very slowly (layer by layer) until to tamponade. Of note, the scleral buckle that
I can see retina vessels. Next, I place the vitreous was placed on the initial procedure often makes
cutter in a plane between the hyaloid and the ret- these cases easier than if no buckle had been
ina – usually just nasal to optic nerve (the retina pre-placed.
is attached to optic nerve making this a good
spot). This creates a plane of separation between
the posterior hyaloid and the underlying retina. 31.2 hronic Retinal Detachments
C
Then I gently elevate and cut away the remaining Without Proliferative
vitreous hemorrhage. Vitreoretinopathy
My standard operating room equipment con-
sists of an Alcon Constellation vitrectomy When a chronic RD presents itself, I prefer to
machine with a high- speed vitrector, wide- take the patient to the operating room in a planned
angle light pipe (Alcon), and an extendable fashion with little urgency on timing. Even if the
endolaser probe (Iridex). Forceps choices macula is threatened, most chronic RDs are slow
include (Alcon) Grieshaber DSP single-use moving and are often asymptomatic. A usual
internal limiting membrane forceps and example is a 30-year-old patient with an attached
Grieshaber DSP single-use end-grasping for- hyaloid and a peripheral temporal RD from lat-
ceps. 25 gauge is the preferred gauge for new tice degeneration with holes.
RD cases. 20% SF6 gas (non-expansive concen- Usually in chronic RDs (in young patients), I
tration) is preferred for RDs caused by superior routinely perform a primary scleral buckle with
breaks, and 14% C3F8 gas (non-expansive con- SRF draining. After isolating the muscles, exam-
centration) is my preference for RDs caused by ining sclera, and marking the holes, I apply mini-
inferior breaks. mal cryotherapy to the holes. I then choose a
solid silicone encircling element that I can imbri-
cate around the causative tear or hole. After the
31.1 Recurrent Retinal buckle is in place with loose sutures, the drainage
Detachments Without site is chosen – within the bed of the buckle but
Proliferative away from the hole if possible. I make a 4 mm
Vitreoretinopathy vertical scleral cut down with a blade, and gentle
cautery is applied to the underlying choroid. This
In a recurrent RD that is picked up within a week is done to prevent a choroidal bleed. Next, a
of the primary repair, and before proliferative tapered needle is inserted into the subretinal
vitreoretinopathy (PVR) is noted, an attempt is space and removed often yielding a large and
made to operate within 24 h. This early inter- thick exudation of SRF from the chronic RD.
vention is preferred so as to avoid early PVR It is important for the assistant to maintain
development. tension on the globe with the muscle sutures in
31 My Approach to PVR Detachment: An American Perspective 285
order to prevent hypotony and choroidal bleeding a complete lensectomy, I then remove all lens
during the drainage process. After the SRF has capsule as this can be a scaffold for further PVR
stopped exuding from the drainage site, the growth and often opacifies preventing adequate
scleral buckle is temporally tied down using the postoperative view.
pre-placed sutures. Indirect ophthalmoscopy If the patient is pseudophakic, I leave the lens
should show the tear overlying the bed of the in place as I am still able to access the anterior
buckle. Oftentimes there is some residual SRF retina and the lens provides a barrier to the sili-
present, and it is fine to leave this alone. If there cone oil placed at the end of the case. I do cut out
is a large amount of residual bullous SRF, then the posterior capsule in a pseudophakic patient to
consideration must be made for making a second prevent this area from developing an opacity in
drainage site. However, a second drainage site the postoperative period.
increases your risks of having a complication. Presuming these patients have had a prior vit-
Most chronic RDs respond well to this treat- rectomy for the initial RD repair, it is still wise to
ment. Any residual SRF present may take many assess if there is remaining vitreous present. To
months to eventually resolve. So the trick is to be ensure that a complete vitrectomy has been per-
patient in these cases. Do not bring the patient formed, triamcinolone is injected into the vitre-
back to the operating room unless there is docu- ous cavity. With this visual aid, any residual
mented worsening of SRF. SRF that persists or vitreous is stained and then removed. If a com-
isn’t worsening should eventually dry up. One plete PVD is not present (and the triamcinolone
patient of mine took a year for the residual SRF will show this), a PVD is extended peripherally
to finally resolve. until the vitreous base is reached or until the
adhesion is too strong and further extension
would result in the retina tearing. If a posteriorly
31.3 Proliferative located vitreous base is present, a scleral buckle
Vitreoretinopathy is usually placed (if one is not already present) in
Complicated Retinal order to provide support.
Detachments All epiretinal PVR membranes should be
removed if possible. Either triamcinolone or bril-
A proliferative vitreoretinopathy complicated liant blue stain is used to mark the membranes.
retinal detachment (PVR RD) after a failed pri- Using internal limiting membrane forceps
mary RD repair requires a return to the operating (Alcon) and/or an illuminated membrane pick,
room within 1 week. This is so the PVR does not careful delamination of epiretinal membranes is
worsen significantly and make the upcoming sur- performed. The technique is to start the peel by
gery more complex than it needs to be. 23 gauge grabbing at the edge of the membrane and not the
instrumentation is preferred for PVR RDs as it is center. I peel membranes posterior to anterior if I
stiffer and the fluidics is comparable to 20 gauge. can – there is less stress on the peripheral retina
Except for mild posteriorly located epiretinal in this maneuver. In general, I focus on mem-
membrane PVR RD cases, I start all PVR RD branes located posteriorly first and then move to
cases by removing the crystalline lens. I remove anteriorly located membranes. The posterior ret-
the crystalline lens even if it is clear, since it ina has more tensile strength than the anterior
will allow me to gain access to the anterior por- retina (less likely to tear while peeling mem-
tion of the retina and ciliary body. Furthermore, branes) and is more important for visual restora-
there will be a clear view during postoperative tion. These are often long cases, and the cornea
care (versus a cataract developing and making can decompensate by the end of the case – so
the view suboptimal). After putting in the infu- perform the more important portions of a case
sion cannula and a superonasal trocar, I make a while you still have a clear view.
single 20 gauge sclerotomy superotemporally. If a membrane cannot be removed, I per-
The Alcon phacofragmatome needs a 20 gauge form a localized retinectomy (I cauterize com-
opening to enter the globe. After performing pletely around membrane then remove the
286 C. W. Mango
membrane and underlying retina with the vitre- ity to reattach. Is it flexible enough? I like to visu-
ous cutter). Very immature membranes can be alize the undulations of the retina under BSS – it
left intact or brushed away using a Tano dia- should move freely. I sometimes brush with the
mond dusted scraper (Synergetics) or Finesse light pipe to gauge its pliability. Once satisfied
flex loop (Alcon). with the retina mobility, PFCL is then injected up
If there is foreshortening and/or I am unable to to the level of the ora serrata. I then laser 360° in
remove enough PVR membranes, I will choose additional to surrounding for any causative
to do an inferior 180 degree retinectomy. I prefer breaks. PFCL is then removed with a full air-fluid
to cut as anterior as I can, usually at the posterior exchange. This is done with using a soft-tipped
vitreous base insertion (furthest edge of the cannula and gently going back and forth between
PVD). I perform diathermy in a circumferential the tear/retinectomy edge and over the optic
pattern just posterior to where I will cut the ret- nerve until all PFCL is removed. I then insert a
ina. Then I cut just anterior to the diathermy to stent into a valved cannula and let the air run
prevent bleeding. I remove all anterior retina in through the eye for a minute to let any residual
order to prevent neovascularization in the postop- PFCL evaporate. After confirming the retina is
erative period. attached under air, 1000 centistoke silicone oil is
In significant anterior PVR membranes that placed into the eye using a foot-controlled infu-
involve the ciliary body, I cut the PVR mem- sion pump. The oil level is brought up to the iris
brane overlying and involving the ciliary body plane in an aphakic patient and to just behind the
360°. After removal of the lens and capsule (the IOL in a pseudophakic patient. Lastly, in aphakic
eye is now aphakic), I indent with a cotton tip patients, I make two small inferior peripheral iri-
applicator under direct visualization from the dotomies (side by side) – having two small iri-
microscope. I insert the vitreous cutter just under dotomies ensures that at least one will remain
the anterior PVR membrane and cut along a open and prevent pupillary block IOP rise.
line – I use it like a horizontal scissor to open the
membrane and expose the underlying ciliary
body. Often times I find diathermy is not neces- 31.4 Funnel Proliferative
sary when doing extreme anterior cutting of Vitreoretinopathy
PVR membranes – as long as the ciliary body is Complicated Retinal
not cut. Detachments
Subretinal PVR bands that won’t allow the
retina to reattach under PFCL or air need to be Funnel PVR RDs are approached by removing
removed. Bands that are present, but that don’t the subretinal membranes that are encircling the
interfere with retina reattachment, can be left funnel. The membranes can be approached
alone. When a decision is made to remove a sub- directly since the underside of the retina is
retinal PVR band, I prefer to “punch through” the exposed. There are usually “napkin ring” PVR
retina just adjacent to the band (light cautery membranes in a closed funnel, and these must be
achieves both the punch through and hemosta- segmented in order to proceed. A pearl is to gen-
sis). A MAXGRIP forceps (Alcon) or end- tly loosen up the tight “napkin ring” with a for-
grasping forceps (Alcon) is then used to grab the ceps so that there is enough space to insert the
band and pull through the adjacent hole. Usually cutter between the retinal funnel and the PVR
the band will snap, and one end will go through ring. With the port facing outward toward the
the hole, while the other end retracts due to elas- PVR ring, the ring is segmented (releasing the
ticity. The retracted portion of the band can be constricted retina) and then removed.
left alone as the goal of removing the tent-like After membranes are removed, PFCL is
traction has been accomplished. slowly injected into the opening of the funnel,
Once all membranes are removed and before and the retina should open up and resume its nor-
PFCL is placed, the retina is assessed for its abil- mal configuration. Sometimes gentle rubbing of
31 My Approach to PVR Detachment: An American Perspective 287
the retina with a soft-tipped cannula is necessary in order to prevent further intraocular pressure
to work out some retinal folds and reposition the drop and onset of phthisis.
retina in the correct anatomic position.
Conclusions
New RDs and recurrent RDs require quick
31.5 Postoperative Care Routine action in order to restore vision. Chronic RDs
require patience in the postoperative phase as
The patient needs to realize that the postoperative the fluid resorption can take many months. All
course can be quite a challenge. Whether it is of these scenarios do best if they are fixed cor-
strict head positioning, no flying (if gas is used), rectly with a single successful surgery.
or frequent eye drops to reduce inflammation, Whether choosing a “tried and true” scleral
patient cooperation is important to the overall buckle technique or utilizing the advances
success of the surgery. All patients are positioned possible with small gauge vitrectomy, it is
face down after surgery for several days. At night, important to have multiple options in order to
they can alternate between lying on the side select the best one for our patients.
opposite the causative tear and/or face down. If When a RD fails due to PVR, then the com-
patient has 1000 centistoke silicone oil, I prefer plexity of the case increases. PVR RD surgery
to remove it in the 3–6 month range. requires diligence with membrane removal
In certain instances, I prefer to leave the 1000 and attentiveness with all the structures in the
centistoke silicone oil in the eye instead of eye that are affected by PVR. Finally, the
removing it. These cases include eyes that have patient needs to realize that a successful surgi-
had a 360 retinectomy and have a poor visual cal outcome often requires close cooperation
prognosis. Also if there is hypotony with the sili- between the doctor and patient in the postop-
cone oil in place, I will likely not remove the oil erative setting.
Surgical Treatment of PVR Cases
32
Marco Mura and Antonella D’Aponte
Key Concepts approximately 5–10% of all retinal detachment

1. Proliferative vitreoretinopathy (PVR) is a dis- repairs. Typically, PVR occurs after primary reti-
ease that develops as a complication of rheg- nal detachment repair; however, it can occur in
matogenous retinal detachment. long-standing primary detachment and in trau-
2. The accumulation of fluid in the subretinal matic retinal detachment. PVR can be treated
space and the tractional force of the vitreous with surgery to reattach the detached retina, but
on the retina result in rhegmatogenous retinal the visual outcome of the surgery is unpredictable
detachment. [1–3]. PVR was originally referred as massive vit-
3. The RPE cells lay down fibrotic membranes reous retraction and then as massive periretinal
while they migrate, and these membranes proliferation. The term “proliferative retinopa-
contract and pull at the retina. thy” was coined in 1983 by the Retina Society
4. For a successful management of posterior Terminology Committee. In 1989, the classifica-
PVR is important: localization of all retinal tion was amended by the Silicone Study Group
breaks, release of the traction through mem- before being most recently modified in 1991 to its
brane peeling and dissection. current classification. The name is derived from
5. Retinectomy implies the complete excision of proliferation (by the retinal pigment epithelial and
the entire complex formed by the vitreous base, glial cells) and vitreoretinopathy to include the tis-
anterior membranes, and shortened retina. sues which are affected, namely, the vitreous and
the retina [4]. There is inconsistent and limited
use of the current PVR classifications. The two
32.1 Introduction mostly used classifications are reported in Tables
32.1 and 32.2; in Table 32.3 we report a 1993 mor-
Proliferative vitreoretinopathy (PVR) is a disease phological classification by Robert Machemer
that develops as a complication of rhegmatog- that has important surgical implications.
enous retinal detachment. PVR complicates During rhegmatogenous retinal detachment,
fluid from the vitreous enters through retinal hole.
M. Mura (*) The accumulation of fluid in the subretinal space
Wilmer Eye Institute, Johns Hopkins University,
Baltimore, MD, USA and the tractional force of the vitreous on the ret-
e-mail: [email protected] ina result in rhegmatogenous retinal detachment.
A. D’Aponte During this process the retinal cell layers come in
The King Khaled Eye Specialist Hospital, contact with vitreous cytokines. These cytokines
Riyadh, Kingdom of Saudi Arabia trigger the ability of the retinal pigment epithelium

https://doi.org/10.1007/978-3-319-78446-5_32
290 M. Mura and A. D’Aponte
Table 32.1 The Retina Society Terminology Committee (1983)

A (minimal) Vitreous haze and pigment clumps
B (moderate) Surface retinal wrinkling, rolled edge of retinal, retinal stiffness, and vessel tortuosity
C (marked) Full-thickness fixed retinal folds in:
(1) C1 (1) One quadrant
(2) C2 (2) Two quadrants
(3) C3 (3) Three quadrants
D (massive) Fixed retinal folds in four quadrants that result in:
(1) D1 (1) A wide funnel shape
(2) D2 (2) A narrow funnel shape
(3) D3 (3) Closed funnel without view of optic disc
Table 32.2 The Updated Retina Society Classification (1991)

A Vitreous haze, pigment clumps, and pigment clusters on the inferior retina
B Wrinkling of inner retinal surface, retinal stiffness, vessel tortuosity, rolled and irregular
edge of the retinal break, and decreased mobility of vitreous
CP (posterior) Full-thickness retinal folds or subretinal strands posterior to the equator (1–12-clock
(1) Type: hour involvement)
(a) Focal (1) Starfolds posterior to the vitreous base
(b) Diffuse (2) Confluent starfolds posterior to the vitreous base; optic disc hat may not be visible
(c) Subretinal (3) Proliferation under the retina
Annular strand near disc; linear strands; moth-eaten-appearing sheets
CA (anterior) Full-thickness retinal folds or subretinal strands anterior to the equator (1–12-clock hour
(1) Type: involvement), anterior displacement, and condensed vitreous strands
(a) Circumferential Retina contraction inward at the posterior edge of the vitreous base; with central
(b) Anterior displacement of the retina; the peripheral retina stretched; the posterior retina in radial
folds
(1) Anterior contraction on the retina at the vitreous base; ciliary body detachment and
epiciliary membrane; iris retraction
Table 32.3 Proliferative vitreoretinopathy classification (RPE) to proliferate and migrate. The process
of Machemer (1993) involved resembles fibrotic wound healing by
Proliferative vitreoretinopathy (PVR) classification of the RPE cells. The RPE cells undergo epithelial-
Machemer mesenchymal transition (EMT) and develop the
Full-thickness fold, type: ability to migrate out into the vitreous. During this
(1) Focal
process the RPE cell layer-neural retinal adhesion
Starfold posterior to the equator
(2) Diffuse
and RPE-ECM (extracellular matrix) adhesions
Multiple folds posterior to the equator are lost. The RPE cells lay down fibrotic mem-
(3) Subretinal proliferation branes while they migrate, and these membranes
“Napkin” ring around the disc contract and pull at the retina. All these finally
“Moth-eaten” sheets lead to secondary retinal detachment after primary
(4) Circumferential contraction retinal detachment surgery. A number of studies
Contraction along the posterior edge of the have also shown that arachidonic acid metabolic
vitreous base with central displacement of the
cascade (one of the major inflammatory cascades)
retina
Peripheral retina stretched
is important in the development of PVR. COX-2
Posterior retina in radial folds expression was found in human idiopathic
(5) Anterior displacement epiretinal membranes [5]. Phospholipase A2
Vitreous base pulled anteriorly and cyclooxygenase blocking reduced structural
Peripheral retinal trough abnormalities of the rat retina in concanavalin
Ciliary processes stretched or covered the iris retracted model of PVR [6].
32 Surgical Treatment of PVR Cases 291
The RPE cells migrate out into the vitreous, the globe, and penetrating trauma can cause reti-
proliferate excessively, and lay down ECM on nal detachment. Regmatous retinal detachment
both sides of the detached retina. The ECM laid is more important in the setting of a closed-globe
on the vitreous side of the retina are referred to as blunt trauma or contusion blunt trauma which
epiretinal or preretinal membranes (ERM), and represents about 70–85% of all traumatic retinal
those laid down between the RPE layer and the detachment [13–15]. In the case of blunt trauma
photoreceptors are referred to as subretinal or ret- with rupture and penetrating trauma, TRD sec-
roretinal membranes (SRM). The two membranes ondary to fibrous ingrowth and intraocular pro-
differ in composition; the ERM is composed of liferation is more prominent [16–26].
RPE cells, glial cells, macrophages, and fibro- Complete PVR removal is essential in the
cytes, while the SRM is rich in RPE cells. The treatment of chronic and recurrent rhegmatoge-
subretinal membranes are of two types. One forms nous retinal detachment and in traumatic retinal
as diffuse sheets, which are not contractile and detachment. Epiretinal and subretinal membrane
either lack or contain very little ECM. The pres- removal allow apposition of the contracted retina
ence of this type of membrane does not usually to the retinal pigment epithelium and reestablish-
affect retinal reattachment surgery. The retina can ment of the RPE pump function with consequent
be reattached even with the membrane in place. retinal attachment.
The other type forms a very thick contractile For a successful management of anterior and
membranes which pull at the retina. These are posterior PVR, the following steps need to be
opaque and block the light falling on the retina, so taken into consideration:
the retinal reattachment surgery needs to be per-
formed after manually peeling the membrane off 1. Surgical setup and identification of all retinal
[7, 8]. A number of cytokines such as tumor breaks and membranes
necrosis factor alpha (TNFα), transforming 2. Release of vitreoretinal traction, membrane
growth factor beta 2 (TGFβ2), platelet-derived peeling, and dissection
growth factor (PDGF), and interleukins have been 3. Drainage of subretinal fluid (SRF), sealing of
shown to play a role in PVR progression. retinal breaks, and tamponade
TGFβ2 levels have been shown to be elevated
up to three times the normal during the progres-
sion of PVR. TGFβ2 is the most predominant 32.2 Surgical Setup
isoform in the eye and is secreted as a latent and Identification of Retinal
inactive peptide into the vitreous by epithelial Breaks and Membranes
cells of the ciliary body and the lens epithelium
and is also produced by the RPE cells and the Intraoperative identification of the retinal breaks
Muller cells of the retina. TGFβ2 is known to is made easy using wide field visualization sys-
induce EMT in RPE cells and fibrosis in the eye tems such as BIOM (Oculus, Wetzlar, Germany),
[9]. Expression of PDGF in particular PDGF-AA RESIGHT (Carl Zeiss, Germany), EIBOS (Haag-
is triggered during ocular injury and contributes Streit, Wedel, Germany), and scleral depression.
to PVR pathology [10]. RPE cells express the These devices allow the surgeon to acquire a
receptor for hepatocyte growth factor (HGF). panoramic view on the surgical field up to
HGF stimulates RPE cell migration, and its pres- 120/130 degrees without the help of a surgeon
ence is also strongly detected in retinal mem- assistant; auxiliary chandelier light illumination
branes. Interleukin 6 levels are elevated in the is mandatory in PVR cases to allow bimanual
vitreous humor during PVR [11]. About 15% of dissection and membrane removal in anterior and
all retinal detachments are traumatic; they are posterior PVR.
much more common in the young individuals The gauge choice is dependent on the severity
and more prone to develop rapidly severe PVR of the pathology and the extension and location
[12]. Blunt trauma, with and without rupture of of the PVR. In PVR cases up to grade C, 27 and
25 gauge are our choice; in cases of PVR D or in through the valved trocar cannula, and we facili-
post-traumatic cases, where the membranes are tate the dispersion of the crystals inside the vitre-
more fibrotic, large gauge with broader surface of ous cavity. This is achieved by increasing infusion
action, such as 23 and sometimes 20, are more pressure up to 60 mmHg, aspirating and shaking
often used. We routinely use a four-port approach the eye, or blasting water into the Kenalog with
with a chandelier light located in the inferonasal the backflush cannula. The triamcinolone crys-
quadrant. This location is particularly advanta- tals will stick to the residual vitreous and to the
geous because the chandelier light fiber can eas- vitreous cortex, if present, allowing the surgeon
ily be taped in place on the patient’s nose bridge to detach and remove the vitreous cortex with a
minimizing the risk of displacement. Tano scraper or end-gripping forceps completely.
All our PVR cases are done bimanually. We pre- After doing this maneuver or in case no vitreous
fer to use a combination of end-gripping forceps remnants are identified, we proceed with a sec-
(Eckardt type), curved horizontal scissors, serrated ond staining, injecting Membrane Blue-Dual
forceps, diamond dusted Tano scraper, and illumi- (MBD). We usually take care that the MBD is
nated pick. To help in identifying residual vitreous, injected in the posterior pole and in the peripheral
we standardly use triamcinolone acetonide (Kenalog retina, and we leave the dye in contact with the
40 mg/ml) undiluted. Epiretinal membrane is in our retina for 1 min and 30 s before aspirating.
practice better stained with Membrane Blue-Dual Because of the heavy nature of the staining mol-
(D.O.R.C., Zuidland, The Netherlands). This com- ecules, the dye will sink to the posterior pole; to
bination of 0,15% trypan blue, 0,025% of BBG facilitate the staining of the peripheral mem-
(brilliant blue G), and 4% PEG (polyethylene branes, we first remove the posterior membranes,
glycol) has the advantage of staining both internal and then, when the retina is mobile, we inject
limiting membrane and epiretinal membrane with- PFO up to the edge of the anterior membranes. At
out the need to exchange fluid for air. this stage MBD can be reinjected; the dye now
In PVR cases the use of perfluorocarbon liquid will stay at the top of the PFO bubble allowing
(PFCL) has multiple functions: it helps the sur- the staining of the peripheral anterior membranes
geon to flatten the posterior retina while working (PFO-assisted staining). We usually start peeling
more anteriorly (third-hand effect) and facilitate the membranes using end-gripping (Eckardt
the peeling of posterior membranes in mobile type) forceps because it’s possible to use their
detached retina and/or internal limiting mem- tips as pick instrument.
brane in the detached retina and gives indirect With forceps open we use one of the branches
signs of traction release. Among the PFCLs we to engage the edge of the starfolds from inside
prefer to use PFO (perfluorooctane) because out. The lifting of the edge of the membranes
being lighter than PFD (perfluorodecalin) gives sometimes can be challenging and can be facili-
the surgeon a better feeling of the residual traction tated using a Tano scraper or a pick.
present; also, being PFO volatile, the chance of When the adherence of the membranes to the
retained heavy liquids in the vitreous cavity after retina surface is very strong, the membranes are
surgery is very small because the small droplets very fibrotic, or the retina is very thin (especially
left after PFO-air exchange can freely evaporate. in the proximity of the ora serrata), to avoid iatro-
genic retinal breaks due to the peeling maneuver,
bimanual delamination with a blunt spatula and
32.3 Release of Vitreoretinal forceps or dissection with forceps and scissors
Traction, Membrane Peeling, can be performed. A useful technique in these
and Dissection cases is also the bimanual stretching maneuver
with two forceps. Using a serrated jaws and an
The first step in dealing with PVR cases is to end-gripping forceps, we grasp the edges of the
stain the possible residual vitreous with triam- membrane keeping the forceps next to each other,
cinolone acetonide. We inject triamcinolone and then we move them a part in the opposite
direction. With this maneuver, we can shred the PFO to flatten the entire retina. Laser retinopexy is
epiretinal tissue avoiding traction on the underly- applied in four rows along the entire edge of the
ing retina. retinectomy. The spots are placed in a confluent
We generally tend to remove the epiretinal tis- pattern leading to a total width of the barrage of
sue completely from the retinal surface. When 1500–2000 mm. We consider the starting and the
this is not possible due to intraretinal extension of ending points of retinectomy incision as crucial
the epiretinal tissue or when the traction is still and most vulnerable and therefore often secured
present, we can opt for two solutions: these locations with five rows of laser coagulates.
We did not apply 360° laser as standard procedure
–– Circumferential encircling buckle [27]. At the end, silicone oil is infused after fluid-
–– Retinectomy air exchange or during direct perfluorocarbon liq-
uid-silicone oil exchange. In aphakic cases, a
peripheral iridectomy is made with the vitrectomy
32.4 Circumferential Encircling probe in the inferior quadrants.
Buckle Large retinectomies are often the best approach
to remove large posterior subretinal membrane
We routinely use the circumferential buckle, 240 complexes. Chronic and traumatic RRDs are
band with 70 sleeve, taking care of placing the complicated by subretinal membrane formation.
band posterior to the residual traction. When this These can present as linear or circumferential
is not possible because of the posterior location of bands creating a tenting effect on the retina. In
the pathology or the excessive circumferential more advance cases, these membranes can further
traction with fixed folds or because of excessive contract giving the retinal detachment a posterior
scleral thinning, we opt to perform a retinectomy. closed funnel configuration due to napkin ring
formation. In these cases retinotomy, subretinal
bands, and ring removal are mandatory to achieve
32.5 Retinectomy full retinal reattachment. Linear subretinal bands
and/or limited membrane networks can be better
Retinectomy implies the complete excision of the removed with minimal approach through punch-
entire complex formed by the vitreous base, ante- through retinotomies. Using a serrated-type for-
rior membranes, and shortened retina, sometimes ceps, the subretinal band is pinched and grabbed
involving the pars plana. Much attention is paid to together with a small portion of the overlying reti-
the anatomy surrounding old sclerotomy sites: nal tissue. The band is then pulled anteriorly cre-
often anterior traction is present at these sites, and ating a small retinotomy. The subretinal band can
if so, these areas are included in the retinectomy. then be rotated around the shaft of the forceps for
The circumferential extent of anterior PVR dic- a better grip or grasped with another forceps from
tated the minimal circumferential extent of the reti- the contralateral side to avoid losing the more
nectomy, but often a larger circumferential extent elastic membranes.
of the retinectomy is carried out. We believe that a
retinectomy of at least 6 clock hours, preferably
covering the area between the 3 and the 6 o’clock 32.6 rainage of SRF, Sealing
D
meridian, has the greatest chance of relieving cir- of Retinal Breaks,
cumferential traction. The anteroposterior extent of and Tamponade
the retinectomy is dictated by the individual patho-
logic features. The lower edge of the retinectomy is Subretinal fluid prevents the retina from reattach-
aimed to lie between the equator and the lower vas- ing and must be removed from the subretinal
cular arcade, preferably closer to the equator than space.
to the vascular arcade. After completion of the reti- We tend to drain the SRF from the preexisting
nectomy and coagulation of cut vessels, we use break using the backflush cannula during fluid- air
exchange (FAX). If more breaks are present, we anterior edge of the retinectomy. This can be
choose the more posterior one to avoid shifting of avoided with direct PFO-oil exchange. We con-
SRF posteriorly. We typically set the air infusion to nect the silicone oil syringe directly to the infu-
40 mmHg. We mark the break with endodiathermy sion line, and we set the VFC injection of the
to be able to identify the break under air. We reduce constellation (Alcon, Fort Worth, USA) to 26/30
or switch off the chandelier light to reduce the glare, PSI and the extrusion vacuum to 650 mmHg. We
and we bring the backflush cannula on the top of the let the oil flow into the vitreous cavity through
retinal break, holding it still in position until all the the infusion cannula, until the oil bubble gets in
SRF has been aspirated and the retina is flattened. In contact with the BSS. At this stage we have three
some cases when the breaks are very anterior, sub- different layers: PFO inferiorly, silicone oil
retinal fluid removal through the preexisting break superiorly, and BSS in the middle. At this point,
can be challenging and may result in an uncomplete while we inject the silicone oil, we can passively
SRF removal. In this cases when SRF is very sig- aspirate the BSS from the interface avoiding
nificant, a postoperative retinal fold can occur. retina slippage. Once the retina is flattened, we
To avoid this problem, we usually inject per- need to seal all retinal breaks or the retinectomy
fluoroctane (PFO) under air up to the edge to the edge with laser photocoagulation; we prefer to
primary break to let the fluid egress from the sub- do that either under PFO or air. When we do it
retinal space. To perform this technique, we use under PFO, the whole vitreous cavity needs to be
the chandelier light; from one side we inject PFO, filled with the heavy liquid; the presence of sub-
and from the other side, we passively aspirate the retinal fluid around the breaks or at the retinec-
SRF with the backflush cannula from the break tomy edges will, in fact, not allow laser uptake
(PFO-air exchange). and efficient sealing. When the breaks are poste-
In the retinectomy cases to avoid accumula- rior, we prefer to laser under air to avoid fluid
tion of fluid behind the retina with consequent entrapment in the periphery (donut effect) or
slippage, we use the following strategies: PFO migration in the subretinal space.
Sometimes, in cases with persistent retinal folds
1. Slow fluid-air exchange after PVR membrane peeling and retinectomy,
2. Direct PFO-oil exchange we prefer to inject silicone oil in the vitreous
cavity and defer the laser treatment to a second
surgery, 2–4 weeks after the folds have been
32.7 Slow Fluid-Air Exchange resolved or new PVR has occurred. This delay
allows the retina to regain the original position
With this maneuver, we generally set the air infu- and gives us the chance to reoperate the patient
sion on 40 mmHg, and we take care of aspirating avoiding a more posterior retinectomy (if new
the fluid present between the PFO bubble and the PVR develops).
air bubble until we are sure no more BSS and/or In PVR cases, most of the times, we tampon-
subretinal fluid is present. Contact between PFO ade with silicone oil or long-acting gas (C3F8
and air is in our experience evident when no more 12%). In recurrent cases and when retinectomies
fluid comes out from the backflush cannula placed are performed, our tamponade of choice is sili-
at the edge of the PFO interface and by change in cone oil 1000–5000 cs. Our injection method
reflection at the PFO-air interface (droplet effect). calls for a maximal vitreous cavity filling; we
take particular attention to the complete removal
of any subretinal fluid and to achieve full contact
32.8 Direct PFO-Oil Exchange of the oil bubble to the retinal surface. We always
vent one of the trocar cannulas, and we care to
When the retinectomy is very anterior, complete inject oil until we appreciate the silicone oil
fluid aspiration can be challenging, and BSS can egressing from the vent itself. In this way we
seep behind the retina creating slippage of the minimize the risk of any underfilling.
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Vitreous Anatomy, Anterior PVR,
and Hypotony 33
D. Ruiz-Casas
Extras: Videos 33.1 and 33.2. compartment of the retinal pigment epithelium and
choriocapillaris, or ciliary body damage [1, 2].
However, in cases of RD, if the retina is already
33.1 Introduction attached, hypotony generally is related to ciliary
body detachment due to anterior PVR, referred to
Chronic hypotony, defined as an intraocular pres- as proliferative vitreociliopathy [5]. The contracted
sure (IOP) lower than 5 mmHg for two consecu- anterior hyaloid (AH) pulls the vitreous base (VB)
tive measurements at least 1 month apart, is anteriorly and detaches the ciliary body, leading to
associated with poor visual outcomes, maculopa- aqueous humor hyposecretion and increased out-
thy, papillary edema, corneal opacification, mem- flow [3, 4, 6–10]. It is reported that the IOP
brane proliferation, retinal detachment (RD), and decreases when at least 2 clock hours of ciliary
eventually phthisis bulbi [1, 2]. body detachment are present.
Chronic hypotony after vitrectomy to treat RD is Meticulous removal of the AH during the initial
associated with proliferative vitreoretinopathy surgery might prevent hypotony especially in the
(PVR) and ocular trauma in 18–24% of cases eyes undergoing retinotomy or retinectomy [11].
(7–10% even with attached retina). Hypotony occurs Endoscopic examination has shown that despite the
twice as frequently with the use of C3F8 compared fact that retinectomy increases aqueous outflow, the
to silicone oil tamponade (31% versus 18%) [3, 4]. main cause of hypotony in these cases is anterior
PVR with AH contraction and ciliary body detach-
ment. If the anterior retina was not removed com-
33.2 Hypotony Physiopathology pletely, it was pulled anteriorly and integrated into a
fibrotic tissue covering the ciliary body [4, 6, 12].
Many hypotheses have been forwarded to explain
hypotony, i.e., cyclodialysis, intraocular inflamma-
tion, rerouting of aqueous outflow to the absorption 33.3 Chronic Hypotony
Treatments
of this chapter (https://doi.org/10.1007/978-3-319-78446- Several medical treatments are available to treat
5_33) contains supplementary material, which is available chronic hypotony: ibopamine drops [13], monthly
to authorized users. anterior chamber or pars plana viscoelastic injections
D. Ruiz-Casas [14], intravitreous corticosteroids, or laser trabecular
University Hospital Ramón y Cajal, Madrid, Spain meshwork sclerosis [15], but none is efficacious.

https://doi.org/10.1007/978-3-319-78446-5_33
298 D. Ruiz-Casas
Surgical closure of cyclodialysis clefts is –– The canal of Petit (ChP) is the space between
effective if they are present and no medical or the posterior lens capsule and AH lateral to the
laser treatment is effective [16]. RL and medial to the ACL and posterior zonu-
Most cases of hypotony in RD result from lar adhesions.
anterior PVR, and different surgical techniques
have been used to deal with anterior hyaloid The VB ends anteriorly at the PCL; from this
(AH) scarring: ligament, the AH is no longer intimately adherent
to the epithelium of the pars plana and plicata.
(a) Pars plana vitrectomy to remove lens rem- Thus, it is possible to detach and dissect the AH
nants, intraocular lenses (IOLs), and anterior in this area [21] up to the ACL where there is a
PVR membranes (covering the pars plana strong adhesion between the AH and ACL and
and pars plicata) resulted in resolution of the posterior zonules [21–23] (Fig. 33.1).
hypotony in 33–66% of cases [11, 17, 18].
(b) Endoscopic anterior membrane dissection
that preserved the IOL resulted in resolution 33.5 Anterior Hyaloid Dissection
of the hypotony in 30% of patients [19].
The AH is involved in accommodation by induc-
ing VB traction when the ciliary body contracts.
33.4 Anterior Vitreous Base Therefore, the unremoved AH between the ACL
Anatomy and PCL might be associated with anterior retinal
traction and redetachment [22, 24]. Likewise, AH
The vitreous base (VB), the retinal and pars plana contraction in PVR causes anterior retinal loop
area with intimate vitreoretinal and vitreo-pars and ciliary body detachment with subsequent
plana epithelium adhesion, covers from 3 mm hypotony [25]. Thus, AH removal might improve
posterior to 2 mm anterior to the ora serrata. the success rate and reduce the recurrence rate of
During vitreoretinal surgery, the posterior hyaloid RD with and without PVR [26] (Fig. 33.2).
(PH) is detached until it reaches its insertion point AH detachment from RL is theoretically fea-
at the VB posterior edge, and then it is shaved at sible [27]. The surgical techniques to detach the
this area. Likewise, the anterior hyaloid (AH) is AH from RL are:
inserted at the anterior edge of the VB [20].
The AH is attached to several ocular structures (a) Hydrodissection by injecting fluid from the
through several ligaments: anterior and posterior chambers through the
zonular area [28].
–– The posterior ciliary ligament (PCL) is the (b) Mechanical detachment of the AH: aspirat-
attachment of the AH to the anterior edge of ing the AH at RL, Berger’s space, or canal of
the VB. Petit and then downward pulling in every
–– The anterior ciliary ligament (ACL) is the quadrant [29].
strong attachment of the AH to the ciliary
body and ciliary processes. AH detachment from RL was successful in up
–– Salzmann’s hiatus (SH) is the space between to 50% of cases, but it was still attached to the cili-
the epithelium of the pars plana and pars pli- ary body and posterior zonule due to the strong
cata and AH, limited posteriorly by the PCL adhesion of the AH at the ACL and posterior zon-
and anteriorly by the ACL. ules [21, 22]. Thus, AH detachment did not allow
–– The retrolental ligament (RL) or Wieger’s lig- vitreoretinal surgeons to remove the anterior vit-
ament is the attachment of the AH to the pos- reous traction from the ciliary body to the VB, and
terior and peripheral lens capsule. it might damage the posterior zonular support.
–– Berger’s space (BS) is the space between the Nevertheless, there is an anatomic area
posterior lens capsule and the AH medial to between the ACL and PCL in which the AH is
the RL and connected to Cloquet’s canal. virtually detached from the epithelium of the pars
33 Vitreous Anatomy, Anterior PVR, and Hypotony 299
Fig. 33.1 Vitreous

anatomy
Fig. 33.2 Anterior PVR

with anterior hyaloid
contraction, ciliary body
detachment, and anterior
retinal loop due to the
unremoved anterior
hyaloid
plana and plicata, that is, Salzmann’s hiatus (SH). the posterior hyaloid and VB with deep inden-
In this area, the AH can be dissected by cutting tation (vitreous shaving), and finally dissecting
with the vitrectome and removing any vitreous the AH at SH (complete vitrectomy). AH dis-
scaffold and traction from the ciliary body and section (AHD) is also referred to as hyaloido-
zonular fibers to the VB [23]. zonulocapsulotomy [23].
Vitrectomy is performed first by inducing Complete vitrectomy with AHD can be
a posterior vitreous detachment (PVD), then improved by detaching the AH from the RL and
removing the central vitreous without indenta- then removing the AH up to the posterior zonules
tion (central vitrectomy), followed by shaving of and ACL attachments, but this maneuver does
300 D. Ruiz-Casas
a b
c d
Fig. 33.3 Vitrectomy completeness in phakic patients. (a) PVD induction. (b) Central vitrectomy. (c) Vitreous shaving.
(d) Complete vitrectomy with anterior hyaloid dissection (AHD)
not relax the traction and might impair the sta- Since most phakic patients undergoing
bility of the posterior zonules and lens or IOL vitrectomy will develop significant cataracts in
(Fig. 33.3). subsequent years, it is logical to perform com-
AHD is risky in phakic patients because of the bined phacovitrectomy in presbyopic cases with
anterior location of the SH. However, it is possi- a RD. Phacovitrectomy allows complete vitreous
ble to perform AHD by placing scleral microcan- removal and avoids future cataract surgery. In
nulas 4–4.5 mm from the limbus and closer to 3 combined procedures, the anterior capsule should
and 9 clock hours. Indentation is needed, and it be polished thoroughly to improve intraoperative
may be done from the opposite side by attempt- visualization and avoid capsular phimosis and
ing to keep the vitrectome shaft parallel to the opacification, and then a complete vitrectomy
indented area or by indenting from the same side should be performed by dissecting the AH at
of the vitrectome at the superior, nasal, and tem- SH. After complete vitrectomy with AHD, there
poral quadrants and moving the infusion line are only two disconnected vitreous remnants; one
from the inferotemporal cannula to a superior at the VB and another at the ciliary body. If the
one to dissect the AH at the inferior quadrant AH also is detached from the RL, the ciliary body
from the inferotemporal cannula without cross- remnant is smaller but does not affect the VB
ing the lens. traction (Fig. 33.4).
Fig. 33.4 Complete vitrectomy in pseudophakic eyes. rior ciliary ligaments through Salzmann’s Hiatus (SH).
(a) Anterior hyaloid dissection (AHD), cutting of the (b) Complete vitrectomy with vitreous remnants at the
anterior hyaloid connections between anterior and poste- vitreous base and ciliary body-zonular area
33.6 Anterior PVR relax the anteroposterior traction (from the

optic nerve to ora serrata) due to stiffening of
Development of PVR affects the retina with the retina.
formation of epiretinal and subretinal mem- Likewise, AH contracts in PVR and pulls the
branes, intraretinal shortening, and vitreous ciliary body and VB together. This anteroposte-
contraction. Vitreous contraction at the VB rior traction (from ciliary body to VB) detaches
induces centripetal traction, which can be the ciliary body inducing hypotony and displaces
treated with encircling buckling and/or periph- the peripheral retina anteriorly, creating an ante-
eral relaxing retinectomies. Retinectomies also rior retinal loop with or without retinal detach-
302 D. Ruiz-Casas
Fig. 33.5 (a) Anterior PVR in a pseudophakic eye. The remnants forms scar tissue over the ciliary body. Scarring
AH contraction pulls on the VB and peripheral retina involves the iris, which is pulled posteriorly and becomes
inducing an anterior retinal loop and on the ciliary body mydriatic. The AH contraction pulls on the VB and
inducing ciliary body detachment. (b) Anterior PVR in an peripheral retina inducing an anterior retinal loop and on
aphakic eye. The AH with zonular fibers and lens capsular the ciliary body inducing ciliary body detachment
ment. These complications occur even if an the ciliary body by detaching or dissecting the
encircling buckle is used, since the buckle relaxes AH. Phakic patients with anterior PVR must be
centripetal traction but does not relieve anteropos- managed with a combination of phacovitrectomy
terior traction. If a retinectomy is performed with- or lensectomy to properly manage the anterior vit-
out AHD and complete anterior retina/detached reous pathology.
pars plana epithelium removal, these tissues are AH detachment is easier to perform in PVR
pulled anteriorly creating scar tissue over the pars cases since collagen proliferation stiffens the
plana and pars plicata. In aphakic patients, the AH. The AH can be aspirated using a vitreous
scar tissue also might involve the lens capsular cutter and then pulled downward until it detaches
remnants and iris, pulling them posteriorly from the RL, posterior zonules, and ACL. If the
(Fig. 33.5). AH adhesion is too strong to be aspirated, a reti-
nal pick or forceps can be used to grasp it at the
RL, Berger’s space, or canal of Petit spaces and
33.7 Surgical Technique then pull it downward until it is completely
to Remove Anterior PVR detached. Finally, the AH is shaved up to the
PCL, and silicone oil is left in the eye to help cili-
Apart from dealing with RD and posterior PVR, ary body reattachment and hypotony recovery.
vitreoretinal surgeons should look for anterior Frequently, detaching the AH can be unsuc-
PVR and remove the AH traction on the VB and cessful or risky due to extreme AH adherence to
the posterior zonules and ACL. In that case, ante- zonule in pseudophakic patients, losing the iri-
rior hyaloid dissection (AHD) at SH should be dozonu lar diaphragm and risking silicone oil
performed instead. migration into the anterior chamber. Since the
The AHD is harder in PVR cases because the hypotony recovery success rates range from 20%
vitreous cutter can barely penetrate the scarred to 60%, leaving the AH remnant and IOL with-
AH. An MVR blade is used to incise the AH until out risking zonular damage might be optimal
SH is reached and opened. Vertical scissors also (Fig. 33.6).
can be used to engage the AH, pull it from SH, In aphakic patients with PVR, the AH with
and cut it. The AH gap then is widened to 360° capsular lens remnants and zonular fibers
with the vitreous cutter or scissors (if too rigid). forms scar tissue involving the iris, ciliary
The AH then is shaved anteriorly up to the ACL body, VB, and anterior retina. Aphakic patients
and posteriorly up to the PCL leaving two rem- have no irido-lens diaphragm to keep silicone
nant vitreous rings at the VB and ciliary body/ oil in the vitreous cavity if aqueous secretion
posterior zonular area. does not improve postoperatively. Thus, any
After the AHD, the AH anteroposterior trac- scarred AH tissue from the ciliary body should
tion is relaxed, and the AH remnant at the ciliary be removed completely to eliminate all traction
body/posterior zonular area should not prevent on ciliary body and maximize the recovery of
the ciliary body from attaching, but aqueous the ciliary body.
secretion might decrease. However, stripping The AH is detached from the zonular rem-
this AH remnant with forceps might damage the nants and ACL adhesions using a retinal pick or
a b
c d
Fig. 33.6 Pseudophakic anterior PVR removal. (a) of the scarred AH at SH with an MVR blade. (d) The final
Scarred AH detachment by downward pulling using a result after removing the AH with PVR leaving the VB
pick or forceps. (b) Complete traction removal from the and a scarred AH remnant at the ciliary body and zonular
ciliary body and the VB after removal of AH. (c) Incision area
304 D. Ruiz-Casas
a b
c d
Fig. 33.7 Ando iridotomy. (a) An inferolateral Ando iri- ous moves around the ciliary body and into the anterior
dotomy. (b) When an aphakic patient undergoes an infe- chamber through inferior iridotomy. (d) When an Ando
rior Ando iridotomy, aqueous moves into the anterior iridotomy is not performed in an aphakic patient, the
chamber and keeps the silicone oil in the vitreous cavity. aqueous humor collects in the vitreous cavity, and silicone
(c) Aqueous humor dynamics with Ando iridotomy, aque- oil is pushed into the anterior chamber
serrated forceps pulling the tissue downward in

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Postoperative Complications
After Vitreoretinal Surgery 34
Zora Ignjatović
34.1 Changes of the Cornea
During vitrectomy itself, keratopathy can

develop, especially if the operation is prolonged
or the operated eye is already at an increased risk
of corneal problems (dry eye, diabetes, etc.).
Epithelial edema can progress to such an
extent that the haze requires corneal scraping to
enable the surgeon to finish the intervention.
Smaller or larger corneal erosions (Figs. 34.1
and 34.2) might also occur during the postopera-
tive period. These eyes must be carefully moni-
tored because the effects of topical corticosteroids Fig. 34.1 Epithelial defect
or other risk factors can impair the healing pro-
cess and also cause the ulceration (Fig. 34.3) with
delayed scar formation (Fig. 34.4); finally, infec-
tion may also develop [1]. The patient can experi-
ence symptoms ranging from severe unpleasant
itching to significant pain.
Therapeutically the best option is placing a
therapeutic contact lens if there is no chemosis
of the conjunctiva, which is not uncommon in
the first days after the operation. Alternatively,
the eye can be patched until epithelialization
occurs.
It is recommended to reduce the administra-
tion of topical corticosteroid drops in the first
few days and at the same time monitor and treat Fig. 34.2 Epitheliopathy
Z. Ignjatović
Milos Clinic Eye Hospital, Belgrade, Serbia

https://doi.org/10.1007/978-3-319-78446-5_34
308 Z. Ignjatović
Fig. 34.3 Large erosion of the epithelium
Fig. 34.5 Plug for the lacrimal canal
ously after a few days or weeks, and during that

time, insight into the deeper parts of the eye is
more difficult, so it is sometimes necessary to
perform an ultrasound examination to determine
the condition of the retina. If silicone oil or gas
is placed in the vitreous body, ultrasonography is
irrelevant.
Development of a 2–3 mm hyphema is not
Fig. 34.4 Chronic keratopathy with scarring considered dangerous, but the occurrence of
total hyphema following vitrectomy carries a
possible inflammations (caused by discontinua- discrete risk of corneal hemosiderosis (hema-
tion of the usual therapy). If there is significant tocornea). Since the risk is small unless the
inflammation, sub-Tenon injection of triamcin- intraocular pressure (IOP) is also elevated, only
olone is recommended, avoiding dexametha- monitoring is advised—the blood usually pre-
sone drops. cipitates spontaneously. However, in cases of
Typically, epithelialization occurs in the first total hyphema with an IOP above ~30 mmHg,
couple of days, but if the healing process is pro- the risk of hematocornea is very high, and it is
longed, artificial tears and corneal gels should be necessary to irrigate the anterior chamber no later
added to the treatment, the therapeutic contact than 3–4 days. In the meantime aqueous (blood)
lens reapplied, or a plug placed in the lacrimal can be released daily through a paracentesis and
canal (Fig. 34.5). If the results are still unsatisfac- antiglaucoma therapy applied.
tory, autologous serum (prepared by profession- There is also a risk of silicone oil keratopathy
als using the patient’s own blood) should be occurring if the silicone oil is in contact with the
added in the form of eye drops; a temporary cornea for an extended period of time [2]. There
amniotic membrane may also be placed. In unre- is no exact time limit in terms of the duration of
sponsive cases, photo-therapeutic keratectomy silicone oil-endothelium contact (an absolute risk
(PTK) can be performed. for developing chronic keratopathy), but in most
The stromal edema of the cornea is usually cases, it is reversible in the first 2 months (even if
transitory; it most often withdraws spontane- corneas have been reported to recover after as
34 Postoperative Complications After Vitreoretinal Surgery 309
Fig. 34.6 “Band-shaped” keratopathy Fig. 34.7 Keratopathy due to contact with silicone oil
long as 6 months). In general, the longer the

period of contact between silicone and endothe-
lium, the higher the risk. For an inexperienced
ophthalmologist, it is sometimes not easy to
determine the presence of silicone oil in the ante-
rior chamber if it is completely filled with oil. It
is most easily recognized by a shiny reflection
from the iris surface.
Initially, the cornea remains completely trans-
parent. After several months, however, band
keratopathy develops as the first sign of trouble
(Fig. 34.6). Every effort should be undertaken to
allow removal of the silicone oil from the anterior
Fig. 34.8 Keratopathy due to contact with silicone oil,
chamber, before the endothelium is permanently
following penetrating keratoplasty
damaged. Unfortunately, this is not always pos-
sible (the biggest problem occurs in eyes that do
not produce enough aqueous humor such as fol- segment, which represents a very serious condi-
lowing injuries or multiple surgeries). tion with a poor prognosis.
As soon as the oil has been removed, the cor- Finally, after multiple failed surgeries, various
nea that has long been in contact with silicone oil degenerative changes are possible, most fre-
looks even worse: it becomes hydrated due to quently band keratopathy with calcium deposits,
aqueous penetration into the stroma. If the endo- Salzmann degeneration, or a definitive leukoma.
thelium is not permanently destroyed, this condi-
tion is transient, and the resolution of keratopathy
follows over the next few weeks. In cases of 34.2 Complications Related
chronic keratopathy (Fig. 34.7), penetrating kera- to Surgical Wounds
toplasty (Fig. 34.8) may become necessary. A
small bubble of silicone in the anterior chamber In recent years oblique (tunnel) entries into the
(approximately up to one third of its volume) sclera have become the technique of choice in
does not present a problem. vitreoretinal (transconjunctival) surgery; due to
Very rarely, ischemic keratopathy can develop, the valve effect, there is almost never the need to
caused by a very tight cerclage. It is occasionally place sutures since at the end of the operation, the
combined with ischemia of the entire anterior wound is usually well sealed after a light mas-
310 Z. Ignjatović
sage of the sclera at the incision site. If the sur-

geon finds that the tunnel incision leaks, a suture
could be placed or diathermy used to coagulate
the conjunctiva above the incision site. Sutures
are particularly recommended for eyes after mul-
tiple surgeries where the sclera is very thin and
damaged by many scleral scars and also in eyes
with silicone oil implantation. The use of a suture
is also advised in pediatric patients where the
rigidity of the sclera differs from that of adults
and in cases where the surgeon is keen to avoid
potential postoperative hypotony [3].
Fig. 34.9 Subconjunctival bubble, Dellen
Hypotony is the most common problem asso-
ciated with surgical wounds in the postoperative
period (usually after vitrectomy or removal of the the following day; the silicone oil can be easily
silicone oil). If the eye is slightly hypotonic, it released by incising the conjunctiva with a sharp
should be patched, or viscoelastic can be injected needle (under the slit lamp) and a slight compres-
through a paracentesis at the slit lamp, and the sion with a cotton-tip applicator. If this is not
patient checked again the following day. In most done, over a period of several weeks or months,
patients, the IOP is restored during the following encapsulation of drops of silicone oil below the
24 h. However, in case of extreme hypotony com- conjunctiva can ensue, which makes the oil
plicated with choroidal detachment, a revision is removal more difficult. Rarely, alongside a big
advised, searching for the leakage site and plac- bubble, a Dellen ulceration of the cornea can also
ing a suture there. The leak may be in the cornea be seen (Fig. 34.9).
if intraoperatively a paracentesis has been made. Finally, the ophthalmologist should always
Patients with a leak must be monitored the fol- keep in mind the risk of the development of a reti-
lowing day. The biggest risk in these eyes is an nal tear at the sclerotomy site, caused by the
infection (endophthalmitis). Hypotony also incarceration of the vitreous; untreated, it may
increases the risk of hemorrhage [4]. lead to a retinal detachment. The risk of this com-
The sutures themselves can cause itch- plication is dramatically reduced with the use of
ing, which can be mitigated with the use of the tunnel incisions and trans-scleral cannulas, as
ointments instead (or between) the usual eye opposed to the traditional 20 g surgery.
drops, and the suture in the scleral tunnel inci-
sion can be removed in as short a period as 1
week. (Typically these sutures do not need to be 34.3 Hemorrhage
removed because they degrade over time and fall
out spontaneously.) The intraocular hemorrhage occurring immedi-
Very rarely a granuloma may form around the ately after the surgery most commonly originates
suture; the eye is inflamed and pretty sore so the at the sclerotomy site (Fig. 34.10).
suture should be removed as soon as possible. It usually develops at the time of cannula
Another potential consequence of the suture is removal; sometimes it is already visible on the
astigmatism, linked to the suture’s tightness. operating table, but more often it is detected after
Fortunately, it is almost always transitory and the patch is removed on the first postoperative
spontaneously resolves after several weeks. day. If it is not a large amount of blood, even if it
At the incision site, immediately after the sur- is visible at the end of the surgery, its removal is
gery and sometimes even after a longer interval, a not mandatory; whether to remove it or let it
subconjunctival bubble of gas and silicone oil can spontaneously reabsorb is at the surgeon’s discre-
be observed. The gas will disappear by itself on tion. The appearance of the blood depends on the
Fig. 34.11 Hyphema postoperatively
tored only, and the patient should be informed

that the resolution is expected in the following
2–3 weeks. Even if it is a coagulum over the pos-
terior pole and even if it is behind the silicone oil,
a hemorrhage that is not very large usually spon-
Fig. 34.10 Almost total hyphema on the first post- taneously dissolves in about 3 weeks. Their inter-
vitrectomy day ference with the patient’s vision is greater in
monocular patients since they will be incapaci-
material left behind in the vitreous cavity. In fluid tated during that time; therefore, in such cases,
(BSS, aqueous), the blood is diffuse; in air/gas it the surgeon has to decide whether to intervene
is typically the blood that floats on the surface; in rather than wait for the spontaneous resolution. If
silicone oil, it is usually in front or more rarely reoperation for blood removal is chosen, it is still
behind oil (as a preretinal coagulum). The blood recommended to wait for at least 5–7 days for
from a sclerotomy can sometimes appear in the partial hemolysis because removing the fresh
anterior chamber as well (some surgeons believe coagulum, which is very adherent to the retina,
that this complication can be avoided with dia- carries a risk of causing even more serious com-
thermy at the sclerotomy site at the end of the plications, e.g., tearing the central retina.
surgery). In case of total hemophthalmos or hyphema, it
Postoperative hemorrhage can also occur, usu- is also acceptable to wait for spontaneous reab-
ally during the night, into the fluid in the vitreous sorption for a couple of weeks, as long as regular
cavity or between the gas/silicone oil bubble and echography checkups are performed and the IOP
the retina. This bleeding originates from the reti- is not high (see earlier). A reoperation (“wash
nal blood vessels themselves. The cause of this out” vitrectomy) might still be needed eventually
bleeding is postoperative hypotony or the eleva- if the blood does not start to disappear.
tion of the systemic blood pressure. This blood
becomes visible at the first follow-up just after
the patch is removed (Fig. 34.11). Even if lower, 34.4 Inflammation
the risk is still present in the following days,
especially in patients on anticoagulants. In the last decade, the advancements in technol-
A postoperative hemorrhage is usually an ogy and surgical techniques have made vitreo-
unpleasant surprise, and its treatment depends on retinal surgery much less traumatic to the eye.
multiple factors [5]. Smaller hemorrhages, still The concept of transconjunctival surgery with the
allowing visualization of the retina, are moni- introduction of valvulated cannulas prevents the
312 Z. Ignjatović
sudden IOP drops during the surgery; the reduc-

tion of incision size to 23G, 25G, and 27G helps
avoiding the need for sutures almost entirely; the
efficient vitrectomy machines and improved sur-
gical techniques reduce the length of surgery and
minimize tissue trauma, etc. and have led to
fewer complications postoperatively as well as to
increased convenience to the patients: less irrita-
tion, no pain, or red eye.
The face-down position often leads to the accu-
mulation of precipitates in the lower half of the
cornea (“positional keratopathy”) (Fig. 34.12);
even (small amounts of) fibrin can occur and the
eyelids may become swollen.
However, in eyes undergoing a reoperation for
Fig. 34.13 Fibrin in the anterior chamber
retinal detachment with PVR, PDR, and ROP
retinal detachment or other pediatric retinal
detachments, the surgery can still be a difficult,
complicated, lengthy, and demanding undertak-
ing, with a variety of inflammatory responses in
the postoperative course (Fig. 34.13). Heavy oil
tamponade can also often cause inflammatory
response (Fig. 34.14).
Sometimes the inflammatory response is
already visible on the first postoperative day, but
it may also take a couple of days to fully develop.
Usually this is characterized by serous exudates
or a limited fibrinous reaction, or, very rarely, a
large amount of fibrin resembling a cake or in the
form of a hypopyon can be observed. Fig. 34.14 Fibrin after vitrectomy (heavy oil)
Like after any other surgery, the most impor-

tant thing is to differentiate between a sterile
inflammatory response and an infectious inflam-
matory response (Fig. 34.15).
The rate of endophthalmitis after vitrectomy
varies in the literature reports from 0.03% to
2.17% [4]. After vitrectomy, hypotony is very
conducive to an infection, so these cases deserve
special focus. Pain, swollen eyelids, chemosis
of the conjunctiva, and the presence of hypo-
pyon are suggestive of an infection, especially
in eyes undergoing combined surgery (vitrec-
tomy plus cataract surgery). Sometimes the first
signs of an infection are more easily noticed in
the vitreous cavity, where a fibrin thread or
abscess can be found. It is necessary to take a
Fig. 34.12 Precipitates due to positioning sample for culture from the vitreous cavity and
Fig. 34.15 Endophthalmitis after vitrectomy
Fig. 34.16 Fibrin and blood on the first postoperative

then either intravitreally administer the antibiot- day
ics, or, if the inflammation is more severe,
immediately proceed to re-vitrectomy [6]. The Hourly dexamethasone is prescribed, corti-
surgery is completed with the intravitreal injec- sone ointment before bedtime, mydriatics 2–3
tion of antibiotics (vancomycin plus ceftazi- times a day, and antibiotic drops regularly.
dime). Most commonly, dexamethasone and These patients should be closely monitored, as
triamcinolone are also used, intravitreally or often as a few hours apart on the same day. The
subconjunctivally. There is usually no need for improvement is usually seen in just a day or two.
systemic antibiotics. If all of this is done in a
timely fashion (preferably on the same day that
the diagnosis is made), the prognosis is typi- 34.5 Secondary Glaucoma
cally very good.
If a sterile inflammation is diagnosed, treat- This very serious and relatively frequent compli-
ment with cortisone, subconjunctivally or sys- cation occurring after vitreoretinal surgery is
temically at the dose of 1 mg of prednisolone per sometimes a real enigma in terms of etiology and
1 kg of body weight (avoid systemic administra- treatment, especially for ophthalmologists with
tion in cases of diabetics because of the risk of less experience in the field of posterior segment
elevating the blood sugar), is advised. An antibi- surgery. It is very important to determine the
otic, most commonly vancomycin, can also be exact etiology of the glaucoma and base the treat-
injected subconjunctivally if an infection is not ment on the cause. If the IOP elevation is unrec-
definitely ruled out. ognized and untreated, the eyes may end up blind
Applying TPA (tissue plasminogen activator) despite the anatomical success of the vitreoreti-
in the vitreous space or the anterior chamber to nal surgery.
achieve fibrinolysis results in very quick (in just Glaucoma found in eyes with a silicone oil
half an hour) resolution of the fibrin but can also tamponade, where it is often thought that the sili-
cause profuse bleeding, so it is relatively rare to cone oil is the cause of such glaucoma even
be employed. Also, in case of masked endo- though it is usually not true, is especially
phthalmitis, TPA leads to drastic worsening of intriguing.
the infection. The ophthalmologist should also take into
Sometimes blood, fibrin, or circulating consideration the possibility of an earlier, undi-
erythrocytes imitate serous exudates if minor agnosed glaucoma that was masked, for example,
hemorrhage was present postoperatively by a retinal detachment that had led to hypotony;
(Fig. 34.16). once the retina has been reattached, the IOP can
314 Z. Ignjatović
return to its preoperative, elevated level. The

prevalence of open-angle glaucoma in patients
with rhegmatogenous detachment is 4–5.8%,
compared to 1–3.3% in general population [7].
A study carried out by Anderson and his
coworkers showed that about 15% of patients
have pressure of over 30 mmHg on the first post-
operative day after vitreoretinal surgeries [8].
Statistics and clinical practice show that the
most common type of secondary glaucoma after
vitreoretinal surgery is cortisone glaucoma. It can
develop after several days or up to several weeks
following the operation, e.g., after the postopera- Fig. 34.17 Releasing of aqueous humor from CA
tive treatment with dexamethasone eye drops was
initiated.
It most commonly occurs in myopic patients although some patients respond well to prosta-
after retinal detachment surgery and more often glandin drugs. Carbonic anhydrase inhibitors are
in patients with a history of glaucoma [9]. The administered both systemically and locally, and if
clinical picture is characterized by an initially the IOP value is very high, as soon as glaucoma
moderate IOP spike, but if dexamethasone is not occurs, it is best to release some aqueous through
withdrawn, very high values of IOP can be a paracentesis. This can also be done under a slit
reached after just several days: severe pain and lamp, following a judicious rinse of the conjunc-
pronounced hyperemia, which sometimes pre- tival sac with povidone iodine; an already exist-
cedes the IOP spike by a day or two. It is ing paracentesis can be utilized with a regular
believed that a diffuse swelling of the trabecu- 25 G needle (Fig. 34.17). The tip of the needle is
lum causes the IOP spike so that drainage advanced into the anterior chamber; gentle pres-
through the trabecular meshwork is made very sure on the lower lip of the paracentesis will
difficult or completely impossible. This process release the required amount of aqueous humor. If
is usually reversible, and immediate interven- there is no paracentesis present, one can easily be
tion, i.e., discontinuation of dexamethasone and created with any a 23 or 20 G knife.
introduction of topical antiglaucoma medica- Usually, after just a few days, the IOP begins
tion, results in prompt pressure stabilization. to normalize, and the antiglaucomatous treatment
Continuation of cortisone administration can can be gradually withdrawn and in most cases
result in permanent secondary glaucoma that is stopped completely (note that both eyes should
very difficult to treat. be monitored in the future because of the risk of
If the anti-inflammatory treatment is still open-angle glaucoma [POAG], to which these
needed, in most patients, it is enough to switch to patients are more susceptible).
prednisolone or fluorometholone or NSAID If glaucoma surgery is needed in a vitrecto-
drops, in order for the IOP to normalize. Although mized eye, the most common procedures include
sometimes, especially after repeated surgeries or cyclodestructive ones, although filtration surger-
with a history of cortisone glaucoma episodes, ies are also frequently employed. Shunts, espe-
this is not possible and we can only administer cially the Ahmed valve (Fig. 34.18), are usually
nonsteroidal anti-inflammatory drugs locally. If a safer options than trabeculectomy [10].
patient with cortisone glaucoma has a strong Vitrectomized eyes are more prone to hypotony
inflammatory response, it is much safer to admin- and development of choroidal detachment than
ister cortisone systemically than in the form of nonvitrectomized eyes; if trabeculectomy is per-
eye drops or subconjunctival injections. When it formed, for example, it is advisable to leave a
comes to local antiglaucoma medication, beta- bubble of about 0.5 ml of pure SF6 gas at the end
blockers and alpha agonists are introduced, of the surgery.
Fig. 34.18 Ahmed valve Fig. 34.20 Pupil block
Fig. 34.19 Pupil block glaucoma Fig. 34.21 Iris bombe
Glaucoma caused by a pupillary block

(Figs. 34.19 and 34.20) occurs acutely, the IOP is
very high, the iris is bulging (iris bombe)
(Fig. 34.21), and the eye is painful [11]. In case
of pupillary block glaucoma, two situations can
occur: iris can stick either to anterior capsule or a
tiny membrane. Since the cause of synechiae for-
mation is always some inflammation, we can pre-
sume that there must be some membrane covering
either pupillary edge like a ring only or the entire
posterior surface of the iris. The patient should
immediately undergo Nd:YAG laser iridotomy,
which usually normalizes the IOP immediately
(Fig. 34.22). It is advisable to make a somewhat Fig. 34.22 After a Nd:YAG laser iridotomy
larger opening in the iris than usual and in two to
three places, because these iridotomies have a chosen according to the oil’s molecular weight,
tendency to close fast, especially in eyes with a to allow the necessary aqueous circulation: for
silicone oil tamponade. In case of a silicone tam- regular oil at the 6 o’clock position and for heavy
ponade, the location of the iridotomy should be oil at the 12 o’clock position.
316 Z. Ignjatović
extensively, from 2–3 months to several years

[12]. Emulsification is considered a consequence
of “shaking,” which is mixing the oil with water.
The vitreous cavity can never be completely
filled with silicone so initially the (normal
weight) oil bubble actually floats on the water
surface, and then these two substances start to
mix. If the tamponade is not complete, the menis-
cus of the water is larger so there is more mixing
and the emulsification occurs faster. However,
that is not the only risk factor; sometimes we can-
not explain why in some eyes the oil emulsifica-
tion occurs faster, while in other patients
significant emulsification occurs only after sev-
eral months or years; purity of the oil certainly
plays a role.
The emulsified oil droplets are tiny and move
Fig. 34.23 Ghost cell glaucoma
easily into the anterior chamber where, initially,
they accumulate in the upper half of the cham-
Pupillary block can also occur as a conse- ber angle (where they can be found by goni-
quence of silicone oil protruding into the anterior oscopy); later they can be seen floating in the
chamber and its bubble getting stuck in the pupil- aqueous humor (“magnified Tyndall phenom-
lary area. In such cases the oil should be drained enon”). As time goes by, they increase in number
or possibly pushed back. more and more and take up the upper part of the
If the iridotomy is not performed on time, anterior chamber (so-called inverse hypopyon)
goniosynechiae will develop, and chronic angle- (Fig. 34.24) [12]. The diagnosis is established
closure glaucoma can ensue. If the laser iri- when we find emulsified drops in the aqueous
dotomy is repeatedly closed by newly formed humor and the chamber angle. Such a glau-
fibrin, it is necessary to perform a surgical coma can, at the onset, be treated with topical
iridotomy. antiglaucoma medication for a short time, until
Ghost cell glaucoma (Fig. 34.23) occurs as evacuation or silicone oil exchange is performed.
a consequence of denaturalized erythrocytes Recurrence is possible even after the oil has been
seeping into the anterior chamber from the vit- removed as the remaining drops keep emulsi-
reous cavity. These erythrocytes have lost their fying, breaking apart, and entering the anterior
elasticity and have great difficulty exiting the
eye through the trabecular meshwork, clogging
it up, and causing a spike in the IOP. A yel-
lowish, sanguinolent liquid is typically found
in the anterior chamber. The condition can be
cured with medications and rinsing of the ante-
rior chamber (or the vitreous cavity itself).
Sometimes it is necessary to rinse the chamber
multiple times because the erythrocytes often
stick to the backside of the iris, making their
definite removal difficult [5].
Glaucoma caused by emulsification of the sili-
cone oil occurs after the oil has stayed in the eye
for a certain period of time; this period can vary Fig. 34.24 Emulsified oil, inverse hypopyon
chamber; repeated anterior chamber irrigations 34.6 ore Complications Related

M
may be necessary. to Silicone Oil Tamponade
Glaucoma caused by too large of an oil tam-
ponade—“overfill” glaucoma—is encountered The silicone oil is very conducive to the develop-
very rarely because the surgeon, at the end of the ment of cataract, so much so that even after just a
surgery, must check the IOP. Conversely, few months, it is rare that the crystalline lens is
tamponade-related IOP elevation is not uncom- completely clear. In the presence of cataract,
mon in cases of implanting an inappropriate viewing of the retina is obviously difficult or
mixture of gas. The gas expands and leads to a impossible, and ultrasound examination is of no
sudden spike in IOP [13]. The condition can be use, since the resulting echo of the silicone oil is
treated with medications, but sometimes the gas seen as an elongated globe.
must be released from the vitreous space (the The silicone oil also causes a strong fibrosis
simplest way is by placing a cannula with no of the posterior lens capsule. Therefore, in eyes
valves or by completely replacing the gas.) If the undergoing silicone oil tamponade, either a pri-
sclerotomies are not sutured properly, an expul- mary posterior capsulotomy should be per-
sion of a small amount of oil or gas under the formed during the initial surgery or a Nd:YAG
conjunctiva can easily occur when external pres- laser posterior capsulotomy done at a later date
sure is exerted on the eye. (after silicone oil removal—the disadvantage
Sometimes glaucoma in the vitrectomized eye here is the interference of the capsule with visu-
cannot be placed into any of these categories, so alization until the capsulotomy takes place:
we can consider that it is of unknown etiology. laser application on the posterior capsule is not
These cases should best be treated with antiglau- possible in the presence of oil in the vitreous
coma medication (usually, just in case, we also cavity.
stop using cortisone, as it is the most common Heavy oil is also susceptible to emulsifica-
cause of glaucoma). Close monitoring is recom- tion (Figs. 34.25 and 34.26), similarly to 1000
mended because after a while the true etiology of and 1300 oils, and compared to these oils, it car-
the glaucoma becomes obvious. ries a somewhat higher risk of inflammatory
In case the IOP cannot be controlled medi- response [15].
cally and it persists, surgical treatment is needed. The presence of silicone oil in the anterior
Glaucoma surgery in a vitrectomized eye has its chamber (Fig. 34.27) also risks the development
peculiarities and, not surprisingly, a higher risk of keratopathy (Fig. 34.28).
of early and late postoperative complications
[14]. Filtration surgeries can be associated with
hyperfiltration and choroidal detachment—this
is why, at the conclusion of the trabeculec-
tomy, we often leave an air or pure gas bubble
in the vitreous cavity. In patients with already
scarred conjunctiva, or following cyclodestruc-
tive procedures, a shunt such as the Ahmed
or Molteno valve is the surgeons’ best choice
[10]. Cyclocryo- coagulation is still a useful
option in recalcitrant cases, as are trans-scleral
laser cyclophotocoagulation and repeat vitrec-
tomy with silicone oil removal, combined with
endocyclophotocoagulation (using the standard
endolaser probe). Fig. 34.25 Extreme emulsification
318 Z. Ignjatović
the patient is brought to the operating room where

he/she lays on the table, the oil tends to always
keep coming from the back (because it “finds the
way,” either somewhere between the zonules or
near the larger defects of the posterior capsule in
pseudophakic eyes), and therefore the anterior
chamber usually needs to be filled with visco-
elastic to prevent, at least temporarily, the reap-
pearance of the oil.
In eyes in which the oil tends to prolapse into
the anterior chamber, it is advised not to dilate
the pupil, at least in the first couple of days, as the
iridolenticular barrier may keep the silicone in
Fig. 34.26 Emulsified heavy oil (Oxane HD) the vitreous humor. This warning should be men-
tioned in the discharge summary to the ophthal-
mologist into whose care the patient is released
for follow-ups. In case of total aniridia or lack of
iris in the lower half, the contact between silicone
oil and the cornea is often inevitable in the apha-
kic eyes (Fig. 34.29), especially if the eyes in
question are hypotonic with low production of
aqueous humor. If the oil cannot be removed,
chronic keratopathy occurs, along with band-
shaped deposits; there is also a risk of thinning
and even perforation (Fig. 34.30) over the long
term.
A pupillary block is a rare but possible com-
plication (Fig. 34.31) caused by a bubble of oil
Fig. 34.27 AC filled with oil
that got stuck in the pupillary area while moving
into the anterior chamber. In that case, the oil
should be released or removed immediately,
Fig. 34.28 Keratopathy, silicone
The oil can also be partially released from the

anterior chamber under the slit lamp through a
paracentesis at the 12 o’clock position (with the Fig. 34.29 Large silicone drop in AC, posterior capsule
patient looking down). If that does not work and defect
Fig. 34.30 Mini graft at the perforation site Fig. 34.32 Perfluorocarbon in AC
34.7 Residual Perfluorocarbon
If residual perfluorocarbon is present in small

amounts in the vitreous cavity, it is not a major prob-
lem, but if it is present in the anterior chamber or
under the macula, it must be removed because of the
associated toxicity [16]. It can be recognized postop-
eratively because unlike a bubble of air, gas, or sili-
cone oil, it can always be found at the bottom of the
vitreous cavity or the anterior chamber (Fig. 34.32).
Fig. 34.31 Silicone oil causing pupillary block 34.8 Buckling Procedure
Complications
because the patient has all symptoms of acute
glaucoma. Following an encircling band (“cerclage”), the
Silicone oil is generally translucent, and most serious complication is anterior segment
patients can see through it immediately after the ischemia, caused by a too tight band blocking
surgery, but it also changes the eye’s refractive blood flow in the posterior ciliary arteries. The
power, usually requiring extra ~+3D lens for cor- conditions are characterized by severe keratopa-
rection. If the patient has monocular vision, he/ thy, uveitis, glaucoma, and even loss of the eye, if
she should be given prescription eyeglasses as the cerclage is not loosened (cut).
soon as possible. In patients whose other eye is Cerclage (in case it is set in front of the equa-
emmetropic or myopic, this refractive anomaly tor) can also apply pressure on the vortex veins,
may be unacceptable and should be corrected compromising venous drainage, which may lead
with a contact lens, either on the eye operated or to the enlargement and forward rotation of the
on the other one, depending on the situation. In ciliary body and glaucoma [17].
eyes undergoing combined cataract and vitrec- Glaucoma can also occur via narrowing the
tomy surgery, the IOL calculation is most often angle; the suppression of the iridolenticular dia-
made for the condition after the oil has been phragm, caused by a buckle that is too anterior; or
removed, which means that a temporary aniso- shallow detachment of the ciliary body, which may
metropia is inevitable. also move forward and close the angle (typically
320 Z. Ignjatović
between the second and the seventh postoperative its purpose to achieve retinal reattachment.
days). In these cases, cycloplegics and cortisone Subsequently, even as late as after several years,
should be locally administered, because miotics can buckle protrusion (Fig. 34.35) may occur, com-
cause further movement of the iridolenticular dia- plicated with the conjunctival erosion and an
phragm forward and cause the glaucoma to worsen infection (Fig. 34.36). Such a buckle must be
[18]. As a last resort, the buckle should be removed. removed or, at least, shortened. After irrigating
Deeply embedded radial buckles can deform the subconjunctival space with antibiotics, the
the eyeball and cause a feeling of localized pres- conjunctiva also needs to be sutured once its edge
sure on the eye, as well as pain; it can, with time, has been refreshened.
erode the sclera (Fig. 34.33) and even result in
the buckle being inside the vitreous cavity. If the
buckle is underneath an extraocular muscle, dip-
lopia is a common occurrence. These phenomena
can spontaneously disappear over time.
Excessive cryocoagulation is one of the risk
factors for the development of PVR, and it also
leads to significant pain and swollen eyelids.
A buckle can be displaced immediately after
the surgery (Fig. 34.34), in which case it loses
Fig. 34.35 Buckle protrusion
Fig. 34.33 Buckle protrusion with scleral necrosis
Fig. 34.36 Buckle protrusion with infection
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block glaucoma in phakic and pseudophakic patients
Part VII
Surgical Trends and Case Reports
PVR Detachment Questionnaire:
Part 1 35
F. Faus Guijarro, B. Fernandez Arevalo,
G. Fernandez-Sanz, J. R. Garcia-Martinez,
Khalil Ghasemi Falavarjani, F. Gonzalez-Gonzalez,
Victor N. Kazaykin, Philippe Koch, Shunji Kusaka,
F. J. Lara-Medina, Alejandro J. Lavaque,
J. C. Pastor Jimeno, M. I. Relimpio-Lopez,
Zoran Tomic, Marc Veckeneer,
and Javier Zarranz-Ventura
J. I. Calzada
This PVR summary was performed after analyzing 30 Charles Retina Institute, Memphis, TN, USA
PVR questionnaires from expert vitreoretinal surgeons.
There are many tips and tricks shared by many of them J. M. C. Parra
despite they are referred to only one. I want to appreciate Vitreo-Retina Unit Hospital la Arruzafa,
their kind collaboration with this chapter. Córdoba, Spain
F. Dhawahir-Scala
Manchester Royal Eye Hospital, Central Manchester
D. Ruiz-Casas ()
University Hospitals NHS Foundation Trust,
Retina Department, University Hospital Ramón y
Manchester, UK
Cajal, Madrid, Spain
M. Elgohary
F. Armadá-Maresca
Kingston Hospital, Kingston upon Thames, UK
Ophthalmology Department, University Hospital
La Paz, Madrid, Spain F. E. Arjona
Ophthalmology Department (Vitreo-Retina and
F. C. Lopez
Ocular Oncology), Virgen Macarena University
Ophthalmology Department,
Hospital, Seville, Spain
Complejo Hospitalario Universitario Insular
Materno-Infantil de Gran Canaria, F. F. Guijarro
Las Palmas de Gran Canaria, Spain Universitary Hospital Miguel Servet, Zaragoza, Spain
Ophthalmology Department, Universidad de Las B. F. Arevalo
Palmas de Gran Canaria, Las Palmas de Gran Ophthalmology Department, Guadalajara
Canaria, Spain Universitary Hospital, Guadalajara, Spain

https://doi.org/10.1007/978-3-319-78446-5_35
G. F. Sanz M. Mura
Fundacion Jimenez Diaz University Hospital and Retina Division, The King Khaled Eye Specialist
Ruber Juan Bravo Hospital, Madrid, Spain Hospital, Riyadh, Kingdom of Saudi Arabia
J. R. G. Martinez Wilmer Eye Institute, Johns Hopkins University,
Hospital La Paz Madrid, Madrid, Spain Baltimore, MD, USA
Oftalvist Madrid, Madrid, Spain J. N. Reus
Retina Department, Centro de Oftalmología
K. G. Falavarjani
Sciences, Tehran, Iran S. Natarajan
F. G. Gonzalez
Delhi, India
Hospitalario Universitario Badajoz (CHUB), Indian Journal of Ophthalmology, Mumbai,
Badajoz, Spain Maharashtra, India
Ophthalmology Department, Hospital Quiron Salud AEGC-ASIAN EYE GENETICS CONSORTIUM,
CLIDEBA, Badajoz, Spain an NIH- NEI INITIATIVE, Delhi, India
V. N. Kazaykin Aditya Jyot Eye Hospital, Managing Trustee, Aditya
“Eye Microsurgery” Ekaterinburg Center, Jyot Foundation for Twinkling Little Eyes,
Ekaterinburg, Russia Mumbai, India
P. Koch J. C. P. Jimeno
Orsay-Paris South University, Brussels, Belgium Ophthalmology Department, Hospital Clinico
S. Kusaka
Department of Ophthalmology, Kindai University Carlos III Institute of Health, Valladolid, Spain
Sakai Hospital, Osaka, Japan
M. I. R. Lopez
F. J. L. Medina Virgen Macarena Hospital/Santa Angela de la Cruz,
Hospital Clínico Universitario Lozano Blesa, VIAMED Hospital, Seville, Spain
Zaragoza, Spain
Z. Tomic
A. J. Lavaque Department of Ophthalmology, Uppsala University
Oftalmológica, San Miguel de Tucumán, Argentina Hospital, Uppsala, Sweden
C. W. Mango M. Veckeneer
Weill Cornell Medical College, New York ZNA Middelheim Hospital, Antwerp, Belgium
J. Zarranz-Ventura
J. M. Salinero Institute Clínic of Ophthalmology (ICOF), Hospital
Department Ophthalmology, Complejo Hospitalario Clínic of Barcelona, Barcelona, Spain
35.1 omplex Situations During

C fluid (SRF) anteriorly and force the schlieren effect
RD Surgery: A Questionnaire through the retinal hole to identify it properly.
If a peripheral vitrectomy is performed with
In a fresh RD surgery, what technique would you slit-lamp examination, it seems to be much easier
use to identify a retinal hole or microtear if you to find microtears (P. Koch, M.D.).
could not find it after looking for it? Another trick to find missed microtears is
In this uncommon situation, most surgeons use by using dyes. Brilliant blue or trypan blue can
perfluorocarbon liquid (PFCL) to move subretinal be injected into the subretinal space and then
35 PVR Detachment Questionnaire: Part 1 327
milked to the peripheral retina with indenta- Apart from Lincoff’s rules, if no tears are
tion (F. Dhawahir-Scala, M.D.) or PFCL to identified easily, posterior retinal tears are a pos-
force dye movement into the vitreous cavity and sibility, especially in myopic patients in whom
locate the hole. Brilliant blue usually is injected paravascular microtears can be found (F. Armadá,
into the subretinal space with a 41-gauge nee- M.D.). To highlight posterior microtears, they
dle (M. Elgohary, M.D.) or transclerally with can be stained with dye or fluid-air exchange
a 31-gauge needle (P. Koch, M.D.). A dye also (FAX) performed to look for posterior drainage
can be used to highlight the schlieren effect by points (F. Espejo, M.D.).
staining the vitreous cavity and then pushing the
SRF to the periphery with indentation or PFCL to If you ultimately cannot identify a tear, would
better visualize the clean SRF into the blue bal- you perform 360° laser or laser according to
anced saline solution (BSS) in the vitreous cavity Lincoff’s rules by photocoagulating at the loca-
(J. Zarranz, M.D.). tion where the hole is most likely to be?
Using cryopexy according to Lincoff’s If no tears where found, most surgeons per-
rules in the area of the RD might be helpful form 360° laser (59.3%), laser according to
to induce retinopexy and locate microtears Lincoff’s rules (18.5%), or laser on the previ-
(G. Fernandez, M.D.). ously detached retinal area (14.8%).
360 Laser
Laser according to Lincoff
Laser on Detached
Peripheral Retina
Encircling Band+360 laser
Cryopexy according to
3.70%
3.70% Lincoff
14.81%
59.26%
18.52%
Do you perform any special maneuvers in a In RD cases with a posterior vitreous base
RD case with a really posterior vitreous base insertion, most surgeons do not change their sur-
insertion (360 laser, encircling band)? gical approach (37.9%) or also use an encircling
band (37.9%).
No
Encircling Band
360 Laser
360 Laser and Encircling
Band
3.45% Complete
10.34%
Vitrectomy+Laser Traction
Areas
10.34% 37.93%
37.93%
In a RD case with a thick vitreous hemorrhage Reattaching the retina before performing
and no PVD, what are your pearls to detach and the vitrectomy can be safer by draining
remove the vitreous minimizing retinal damage? subretinal blood transclerally before vitrectomy
This uncommon clinical case usually is observed (M. Veckeneer, M.D.).
in traumatic RD cases and subretinal and intravit- Another way to perform digging is by direct-
real bleeding from neovascular membranes. ing the vitreous cutter toward the theoretical
The most difficult intraoperative procedure is optic nerve position where the retina is fixed in a
induction of a PVD without tearing the retina, very careful way (S. Kusaka, M.D.).
since retinal tissue can be extremely difficult to A good way to perform the digging is by using
differentiate from thick vitreous bleeding. a vitrectome with low suction and keeping the
The most common approach is performing a endolight close to the tip of the cutter to serve as
careful, limited central vitrectomy in the nasal a shield to achieve better visualization and avoid
area of the retina (like digging a well into the retinal damage (J. Garcia, M.D.).
thick vitreous hemorrhage) until the retinal tissue The vitreous can be highlighted with triam-
is observed; then detaching the vitreous from the cinolone to differentiate it from the retina
retina, usually bimanually; and then injecting (F. Cabrera, M.D.).
PFCL to lift the vitreous hemorrhage and hold Another approach is performing vitrectomy
the retina posteriorly to complete the vitrectomy. under PFCL to displace blood and attempt to
Performing vitrectomy in large circles should induce a PVD under PFCL (J. Marticorena,
be avoided, because this sweeping vitreous M.D.). After digging a well in the vitreous cavity,
removal can result in large inadvertent retinecto- PFCL is injected to push the retina peripherally
mies (G. Fernandez, M.D.). However, the infu- and remove the vitreous hemorrhage safely, then
sion line usually is covered with vitreous clots, a PVD can be induced under PFCL or removing
which can hinder its location and induce vitreous the PFCL until the PVD is achieved, and then
haziness with blood. Thus initial cleaning of the inject it again to help posterior hyaloid dissection
vitreous around the infusion line using micro- (J. Zarranz, M.D.).
cannula is recommended (P. Koch, M.D.). A thorough preoperative ultrasound examina-
Removing sufficient central vitreous over the tion can aid in identifying the source of blood and
optic nerve to induce PVD also is important retinal tractions to guide the initial vitrectomy.
(J.M. Cubero, M.D.). The vitrectomy must be performed very carefully
initially under direct visualization in a step-by- so on. A bimanual approach with forceps and cut-
step mode, elevating and then removing a frag- ter until the surgical field is clear might be needed
ment of the vitreous clot, checking the retina, and (V. Kazaykin, M.D.).
35.2 PVR Prevention

PVR prevention
What do you think are the main risk factors to develop
PVR?
What are your tip and tricks to reduce PVR likelihood
in a fresh RD surgery?
How much vitreous do you usually remove in a fresh • Vitrectomy without indentation
RD case? • Vitrectomy with vitreous shaving and indentation
• Complete vitrectomy with vitreous shaving and anterior
vitreous removal (hyaloidozonulotomy)
• Others (explain it)_______
Do you peel ILM in RD cases? • No
• Always
• Only in macula off cases
• Others (explain it)_________
Do you perform 360° laser? • No, just laser the holes
• Always
• Only if there are many peripheral tears
• Others (explain it)__________
Do you leave or remove the lens (without cataract)? • Lens-preserving vitrectomy
• Only in presbyopic patients
• Almost always
• Others (explain it)__________
When would you operate on a PVR case recently
diagnosed? (How long do you wait?)
What are the main risk factors for developing avoiding vitrectomy if the case can be managed
proliferative vitreoretinopathy (PVR)? with buckling surgery and avoiding SRF drain-
Many risk factors have been suggested for age; avoiding lens removal; complete posterior
PVR/RD evolution time, number and size of the hyaloid lifting and shaving; using triamcino-
tear, inflammation, vitreoschisis or unremoved lone to ascertain that no vitreoschisis remains;
posterior hyaloid, incomplete vitreous base shav- avoiding excessive diathermy, laser, or cryo-
ing, bleeding, excessive photocoagulation or cryopexy; using retinectomy as a last resort to reat-
pexy, preoperative PVR, penetrating ocular tach the retina; and completely removing the
trauma, hypotony, choroidal detachment, pediatric SRF.
patients, RD extension, retinal pigment epithelial
(RPE) cells in the vitreous cavity, genetic predis- How much vitreous do you usually remove in a
position, and RPE trauma during SRF drainage. fresh RD case?
However, the most important risk factors are Most surgeons usually perform vitreous shav-
genetics and inflammation (J.C. Pastor, M.D.). ing with indentation (56.7%), complete vitrec-
tomy with anterior vitreous hyaloid dissection
What are your pearls to reduce the likelihood (23.3%), and vitrectomy without indentation
of PVR in a fresh RD surgery? (20%).
Among the most suggested tips to reduce
PVR are complete and atraumatic surgery, i.e.,
Vitrectomy without
indentation
Vitrectomy with vitreous
shaving and indentation
Complete vitrectomy with
vitreous shaving and
anterior vitreous removal
(Hyaloidozonulotomy)
20.00%
23.33%
56.67%
Do you peel the internal limiting membrane remove the ILM if the macula is already
(ILM) in RD cases? detached (16.7%) or if an ERM was observed
Most surgeons do not remove the ILM in (13.3%). The ILM was not removed routinely in
fresh RD cases (70%), but a few surgeons do every RD case.
No
Only in Macula Off RD
cases
In cases with ERM or taut
ILM
13.33%
16.67%
70.00%
Do you perform 360° laser? but surgeons laser only retinal tears (36.7%).
360° laser was performed in most cases in A few surgeons perform 360° laser routinely
the presence of many peripheral tears (46.7%), (10%).
No, Laser only the Tears

Always
Only if there are Many
peripheral Tears
Only laser on peripheral
3.33% Detached retina and Risk
3.33% Lesions
If there are tears 360g +
Traction
36.67%
46.67%
10.00%
Do you leave or remove the lens (without combined phacovitrectomy if the patient is
cataract)? already presbyopic (40%).
In fresh RD cases, most surgeons perform
lens-preserving vitrectomy (53.3%) followed by
3.33%
3.33% Lens Preserving
Vitrectomy
3.33% Only in Presbyopic
patients
Almost always
Only in patients>65
If Silicone Oil is left
as tamponade
53.33%
36.67%
When would you operate on a recently diag- Most surgeons believe that reattaching the
nosed PVR case? How long do you wait? retina and sealing tears are the best ways to stop
All surgeons operate in less than a week and the PVR rather than waiting and allowing the
most (58.6%) in the next available surgical the- PVR to mature (J. Marticorena, M.D.).
ater slot.
Most surgeons do not delay surgery, especially first, removing as many membranes as possible
in rapid progression PVR cases (trauma, hemoph- and reattaching the macula to stabilize the retina
thalmos, or giant tears), but addressing chronic with silicone oil and, second, removing the
detachments with stable PVR might be postponed already mature remnant membranes and any
longer, except chronic cases that have a recent residual traction (retinectomies if needed)
macular detachment (V. Kazaykin, M.D.). (F. Faus, M.D.).
Not delaying surgery usually requires address- In cases with PVR under silicone oil and an
ing immature membranes that are difficult to peel. attached macula, surgery can be postponed until
In these cases a two-step surgery is performed: the membranes mature (J.M. Cubero, M.D.).
No delay
<3 days
<5 days
<1 week
20.69%
58.62%
13.79%
6.90%
Part 2 36
D. Ruiz-Casas ()
F. Armadá-Maresca
Ophthalmology Department, University Hospital F. Dhawahir-Scala
La Paz, Madrid, Spain Manchester Royal Eye Hospital, Central Manchester
F. C. Lopez
Manchester, UK
Complejo Hospitalario Universitario Insular M. Elgohary
Materno-Infantil de Gran Canaria, Kingston Hospital, Kingston upon Thames, UK
Las Palmas de Gran Canaria, Spain
F. E. Arjona
J. I. Calzada F. F. Guijarro
Charles Retina Institute, Memphis, TN, USA Universitary Hospital Miguel Servet, Zaragoza, Spain
J. M. C. Parra B. F. Arevalo
Vitreo-Retina Unit Hospital la Arruzafa, Ophthalmology Department, Guadalajara
Córdoba, Spain Universitary Hospital, Guadalajara, Spain

https://doi.org/10.1007/978-3-319-78446-5_36
G. F. Sanz M. Mura
K. G. Falavarjani
F. G. Gonzalez
Delhi, India
S. Kusaka
M. I. R. Lopez
Zaragoza, Spain
Z. Tomic
J. Zarranz-Ventura
36.1 PVR Vitrectomy

Do you use any medical therapy in PVR cases? If so, which
one?
In a phakic PVR case, do you remove the lens (if not • Always
significant cataract present)? • Never
• In cases with anterior PVR
• Others (explain it)________
If so how do you do it? • Complete lensectomy
• Lensectomy preserving anterior capsule
• Phako + IOL
• Others (explain it)______
Do you use scleral buckling in PVR cases? • Always
• Never
• In cases with anterior PVR
• Others (explain it)_________
Which buckle do you use? • 2.4 mm band 360 buckle

• 4 mm band 360 buckle
• 360 silicone rubber tire
• Localized inferior silicone rubber tire
• Others (explain it_______)
What are your tricks to put it properly in place?
What gauge do you use in vitrectomy for PVR cases? • 20G
• 23G
• 25G
• 27G
What pump would you prefer to perform vitrectomy? • Venturi
• Peristaltic
• Both according to surgical step
• Others (explain it) _________
In what cases would you use four-port vitrectomy (with • Always
chandelier light) in PVR cases? • Never
• If bimanual membrane removal is needed
• Others (explain it)_______
In PVR cases with no PVD and a detached retina, what are
your tips and tricks to detach and remove vitreous?
How far do you detach vitreous in these cases? Where do • Up to the posterior BV despite tears
you stop? (When you think it is too risky?) • Until adhesion is too strong and I can tear the retina
• Only the macular area
• Others (explain it______)
If you couldn’t detach the vitreous anteriorly and after • Trim vitreous base as much as possible and try to
membrane removal there is still circumferential traction, attach the retina
what would be your approach? • Support vitreous base with a scleral buckle
• Perform a retinectomy
• Radial segmentation of circumferential residual
membranes and vitreous
How much vitreous do you remove? • Central vitrectomy (removing central and peripheral
vitreous without indenting
• Vitreous shaving (removing the whole posterior
vitreous base as much as possible with indentation)
• Complete vitrectomy (vitreous shaving and pars
plana vitreous dissection; detaching and removing
anterior hyaloid or cutting anterior hyaloid
connections to the vitreous base)
• Others (explain it_____)
What are your tips and tricks to remove as much vitreous as
possible?
How do you improve vitreous visualization? • Triamcinolone
• Scleral transillumination
• Assistant indentation and direct illumination
Do you use any medical therapy in PVR cases? If roids (oral, sub-Tenon, or intravitreal) (40%). A
so, which one? few studies have reported a reduced incidence of
Most surgeons do not use medical therapy to ERMs in PVR cases treated with oral isotretinoin
reduce PVR (56.67%); other surgeons use ste- (D. Ruiz-Casas, M.D.).
Oral Isotretinoine and

Steroids
Subtenon Steroids
No
Subtenon and Oral
10.00% Steroids
3.33% Ozurdex
16.67%
13.33%
56.67%
In a phakic patient with PVR, do you remove In fresh PVR cases, a lens-preserving vitrec-
the lens (if no significant cataract is present)? tomy can be performed in association with place-
Most surgeons remove the lens in PVR cases ment of an encircling band. Despite the fact that
with anterior PVR (53.33%) or in every PVR case the presence of the lens makes vitreous removal
(30%). Other surgeons try to preserve the lens more difficult, shallowing the anterior cham-
unless the opacification is significant (16.66%). ber (AC) with temporal fistulization makes the
maneuver safer (M. Veckeneer, M.D.).
Always
Never
In cases with anterior PVR
If Significant lens
Opacification
3.33%
30.00%
53.33%
13.33%
If so, how do you do it? tion (85.19%) compared to a few who perform
Most surgeons perform a normal phacoemul- lensectomy (14.82%).
sification with intraocular lens (IOL) implanta-
Complete lensectomy
Lensectomy preserving
Anterior Capsule
Phacoemulsification+IOL
7.41%
7.41%
85.19%
Do you use scleral buckling in PVR cases? traction is associated with inferior tears).
Most surgeons perform a vitrectomy and Sometimes anterior immature membranes that
buckle procedure in patients with anterior PVR induce retinal folds are difficult to peel, and
(40%); others do it in every patient with signifi- buckling can avoid retinectomy in the acute
cant PVR (40%). Only a few surgeons consider phase (M. Veckeneer, M.D.).
buckling useless (10%). Encircling bands improve the patient progno-
In fresh RD cases, a posterior ERM usually sis by avoiding redetachment, especially in pedi-
can be removed, but the circumferential vitreous atric patients. If immature membranes can be left
is contracted. This contraction is relaxed by or the vitreous base stays low, encircling bands
placing an encircling buckle (combined with a are helpful (M. Mura, M.D.).
segmental inferior tire if the vitreous base con-
Always
Never
In cases with anterior PVR
In cases with Stiff Retina
6.67% In Young Patients with NO
PVD
3.33% In Fresh PVR + Anterior
Retinal Folds (Avoid acute
3.33% retinectomy)
3.33% In cases with PVR>C2
33.33%
40.00%
10.00%
Which buckle do you use? circumferential segmental buckles or combined

The most common buckles are encircling inferior tires associated with encircling bands
bands (92.31%); other surgeons use only inferior (3.85% each).
2.4 mm band 360 buckle

4mm band 360 buckle
Segmental Inferior
Tire/Sponge
3.85% 360g 2.4mm
band+Segmental Inferior
3.85% Tire
7.69%
84.62%
What are your pearls for proper placement? tion (M. Mura, M.D.). The anterior border of the
Almost all surgeons agree that encircling break is one of the most important areas to sup-
bands must be placed behind the pathology, keep- port and is where the posterior vitreous base usu-
ing tears and posterior vitreous base at the crest ally is inserted (M. Veckeneer, M.D.).
or slightly on the anterior slope of the indenta-
The target area usually is at the ocular equator, should be placed 1–2 mm anterior to the vortex
generally 12–14 mm from the limbus. A good veins (A. Lavaque, M.D.).
guideline might be to use the (axial length)/2 to The most precise way to position the band
place the encircling band (Z. Tomic, M.D.). properly is by marking the tears with indirect
It may be better to measure buckle location ophthalmoscopy before vitrectomy so that the
from muscle insertion instead of limbus; the band indents exactly on the tears (J. Marticorena,
proper location is placing the anterior edge of the M.D.). However, if buckling is considered neces-
buckle at 4–5 mm from muscle insertion in adults sary intraoperatively, it might be positioned by
and 2 mm in children (F. Armadá, M.D.). locating the retinal tears and vitreous base to sup-
If large tears extend posteriorly, especially in port during vitrectomy (F. Gonzalez, M.D.).
the inferior quadrants, a segmental circumferen- The depth of the indentation must be sufficient
tial tire (extending 1–2 clock hours beyond the to relax the vitreous base and usually is achieved
location of the tear) can be added to the band to by shortening the buckle by 12 mm, which
support the tears and avoid retinal tenting at the reduces the ocular perimeter by about 2 mm
posterior slope. Thus, combining a 240 band (G. Fernandez, M.D.).
with a 276 buckle allows good indentation that Despite the fact that most surgeons suture
does not decrease over time, relaxes the circum- encircling bands, using scleral tunnels makes
ferential traction, and completely supports the surgery faster, safer, and more comfortable for
inferior vitreous base and retinal tears the patient. In addition, it avoids anterior band
(M. Elgohary, M.D.). migration if the sutures break with time. The sili-
If a segmental circumferential or a 360° tire is cone cuff is left in the inferotemporal quadrant
used, it is placed behind the muscle insertion and (F. Armadá, M.D.).
reaches up to 1–2 mm anterior to the vortex veins,
suturing it with U-stitches to indent the sclera What gauge do you use in vitrectomy for PVR
(I. Relimpio, M.D.). cases?
In myopic patients, the vitreous base gener- Twenty-three gauge is the most common
ally is inserted posteriorly, and encircling bands (62.07%).
23G
25G
27G
6.90%
31.03%
62.07%
What pump do you prefer to perform vitrectomy? Double pump vitrectomy devices make a
Vacuum pumps are used most often (43.3%), major difference in vitreous surgery by allowing
although many surgeons confessed that they had the surgeon to directly control the sphere of influ-
no other options. The possibility to use flow con- ence and avoid ocular collapse using the flow
trol pumps at least in certain surgical steps was mode and performing a faster vitrectomy in the
preferred by more than half of surgeons (53.3%). vacuum mode (D. Ruiz-Casas, M.D.).
Vacuum Control Pump

Flow Conrol Pump
Both according to surgical
3.33% step
It doesn’t matter if good
settings
33.33% 43.33%
20.00%
In what cases would you perform a four-port removal (60%). Other surgeons always use this
vitrectomy with a chandelier light in PVR cases? surgical approach to perform the indentation by
Most surgeons use a four-port vitrectomy themselves and more safely remove membranes.
only in cases that require bimanual membrane
Always
Never
If Bimanual membrane
3.33% removal is Needed
If multiple Epiretinal and
Subretinal PVR
membranes
26.67%
60.00% 10.00%
In PVR cases with no PVD and a detached PFCL can help stabilize the posterior retina
retina, what are your pearls for detaching and and induce PVD safely with two forceps
removing vitreous? (J. Nadal, M.D.).
This is an uncommon RD situation, since vit- Once PVD is achieved, PFCL can be injected
reous attachment avoids RPE cell spilling and between the retina and posterior hyaloid, which
epiretinal PVR; however, subretinal PVR might makes the peripheral vitreous detachment easier.
be found. These cases usually have a chronic If the peripheral vitreous adheres strongly to the
inferior RD in myopic patients. However, if vit- retina, a forceps or Tano scraper can be used to
rectomy is performed, complete vitreous removal peel the posterior hyaloid up to posterior vitreous
is mandatory but difficult to achieve. base (M. Mura, M.D.).
To achieve PVR induction, a central vitrec-
tomy might help to better engage the posterior How far do you detach the vitreous in these
hyaloid (J.M. Cubero, M.D.). cases? Where do you stop? Under what condi-
Inducing PVD might be difficult with a tions is it too risky?
detached retina and might be achieved using the In every RD surgical case, lifting the posterior
cutter extrusion cannula tip at the edge of the hyaloid as anterior as possible is of paramount
optic nerve (J. Marticorena, M.D.). Sometimes importance. However, most surgeons stop poste-
the adhesion is so strong that detaching the posterior hyaloid detachment if the vitreoretinal
rior hyaloid with forceps, pick, or spatula might adherence is too strong and a retinal tear might
be necessary (F. Faus, M.D.). A useful instrument be induced (83.33%). If the posterior hyaloid is
to induce PVD is an aspirating tip that can be not lifted completely up to the posterior vitreous
used to engage the posterior hyaloid and aspirate base insertion, some surgeons tear the retina to
it (M. Veckeneer, M.D.). Bimanual detachment complete lifting of the posterior hyaloid
with a vitreous cutter and forceps might be (16.67%).
needed in some cases (Z. Tomic, M.D.).
Up to the posterior BV
despite tears
Until adhesion is too
strong and I can tear the
retina
16.67%
83.33%
If the vitreous was not detached anteriorly and ing the contracted posterior hyaloid at the vitre-
after membrane removal circumferential traction ous base insertion or removing it bimanually and
remains, what is the approach? finally placing a buckle to support the vitreous
This question was asked to determine the sur- base or remove the anterior retina and vitreous
gical approach if circumferential traction was base by retinectomy.
found during vitrectomy (without buckling). Most surgeons place a buckling instead of per-
Most surgeons perform a step-by-step approach forming a peripheral relaxing retinectomy
by first trimming the vitreous and then segment- (46.43% vs. 35.71%, respectively).
Trim vitreous base as much

as possible and try to attach
the retina
Support vitreous base with
an scieral buckle
7.14% Perform a retinectomy
Radial segmentation of
7.14% 3.57%
circumferential residual
membranes and vitreous
Bimanual excision with
scissors and forceps
35.71%
46.43%
How much vitreous is removed in PVR cases? (53.33%), followed by surgeons who only
Most surgeons try to remove not only the pos- remove the posterior hyaloid and shave the vitre-
terior hyaloid and vitreous base by shaving it but ous base (36.67%).
also the anterior hyaloid at the pars plana
Central Vitrectomy (No

Indentation)
Vitreous Shaving
(Indentation)
6.67% Complete vitrectomy (PP
vitreous dissection with
3.33% Deep Indentation)
Complete Vitrectomy under air
(No Indentation)
36.67%
53.33%
What are your pearls to remove as much vitre- can be performed to remove the posterior hyaloid
ous as possible? more safely than with the cutter (Z. Tomic, M.D.).
Peripheral vitreous shaving is performed safely Finally, the anterior hyaloid can be removed
using PFCL to stabilize the posterior retina, and tri- completely by performing a complete lensectomy
amcinolone is applied to enhance peripheral vitreous and removing the anterior hyaloid with deep
with self-indentation (four-port PPV with chandelier indentation with a cotton tip to decrease globe
light) (U. Spandau, M.D.). Scleral transillumination slippage (C. Mango, M.D.). If an IOL is present or
with a light pipe and PFCL and triamcinolone are phacovitrectomy is performed, the anterior hya-
good methods to highlight the peripheral vitreous loid can be dissected at Salzmann’s hiatus under
and remove it completely, with attention paid to the four-port PPV with BIOM visualization by using
presence of triamcinolone crystals and the double deep indentation and setting the vitreous cutter on
reflex sign of vitreous compressed between the ret- high flow or vacuum and a low cut rate (to remove
ina and PFCL (M. Veckeneer, M.D.). the anterior vitreous, it is necessary to pull the
If a peripheral vitrectomy is performed with a anterior hyaloid centrally since Salzmann’s hiatus
slit lamp and deep indentation, direct visualiza- is compressed with indentation; this kind of vitrec-
tion is optimal. If a flow control cutter is used, the tomy is called trenching) (D. Ruiz-Casas, M.D.).
increase in vacuum is audible when the vitreous Anterior hyaloid dissection in phakic eyes can
is engaged (P. Koch, M.D.). be achieved by placing microcannulas at 5 mm
Tightening the encircling band helps to have a instead of 4 mm (V. Kazaykin, M.D.), AC fistuli-
360° indentation to perform vitreous shaving zation (M. Veckeneer, M.D.), and ipsilateral
(I. Relimpio, M.D.). indentation, by moving the infusion line to reach
Contact wide-field lenses provide a wider field the inferior vitreous (D. Ruiz-Casas, M.D.).
of view, which might reduce the need for indenta-
tion (J. Garcia, M.D.). Vitrectomy under air also How do you improve vitreous visualization?
increases the width of the field, facilitating a safe The most common way to improve vitreous
complete peripheral vitrectomy (J. Nadal, M.D.). visualization is by using triamcinolone (53.57%)
After vitreous shaving, if there is a contracted followed by direct illumination with assistant inden-
posterior hyaloid at the posterior vitreous base tation (32.14%). Other ways, such as transcleral
insertion, a bimanual surgery with forceps and illumination, are used less frequently (7.14%).
scissors holding the posterior retina with PFCL
Triamcinolone
Assitant indentation and
direct illumination
Brilliant Blue
TA+Scleral
Transillumination+PFCL
7.14% 3.57% Slit Lamp Peripheral
Vitrectomy with
Indentation
3.57%
53.57%
32.14%
36.2 Epiretinal Membranes (ERM) Removal

How do you find PVR membranes? • Direct illumination
• Trypan blue staining
• Triamcinolone staining
Others (explain it______)
How do you lift and remove posterior • Using forceps directly
epiretinal PVR membranes? • Using pick and forceps
• Using two forceps
What are your tips and tricks to peel
effectively and safely and what instruments do
you prefer?
What would you do in cases of thick • Careful delamination with two instruments (pick and forceps)
membranes and fragile retina to avoid tearing • Segmentation and leaving them
the retina? • Localized retinectomy
What would you do if you cannot remove the • Leave it
membrane without tearing the retina? • Segmentation
• Localized retinectomy
• Others (explain it________)
What do you do in cases of very immature • Leave them and remove them in a second operation
retinal membranes when you cannot remove • Brush them out (Tano scraper or retina scratcher or brushed
them easily? backflush)
• Retinectomy
How do you deal with anterior PVR • Peripheral retinectomy
membranes at vitreous base insertion with • Remove them with two instruments (pick and forceps, two
circumferential traction? forceps, forceps and scissors)
• Segment them radially
What are your tips and tricks and what
instruments do you prefer?
How do you deal with anterior PVR with • Peripheral retinectomy
anterior vitreous foreshortening and an • Open the loop cutting with cutter or with scissors if closed
anterior retinal loop with anteroposterior • Anterior hyaloid dissection and vitrectomy at pars plana
traction? removing all the vitreous and ciliary body connections
(hyaloidozonulotomy)
• Others (explain it________)
instruments do you prefer?
Where do you start peeling? (from anterior • From anterior membranes to posterior membranes
membranes to posterior membranes or from • From posterior membranes to anterior membranes
posterior membranes to anterior membranes) • I only begin with anterior membranes if there is intense
and why? circumferential traction and the retina is accessible
In case of a closed funnel, how do you • PFCL
open it? • Viscoelastic
• I remove membranes first and then massage the retina before
using PFCL
• Others (explain it_________)
If no macular membranes were seen, would • No
you remove ILM? • Yes
• Only if I’m leaving silicone oil
If so, what are your tips and tricks and favorite
instruments?
Do you peel membranes under BSS or under • BSS
PFCL? • PFCL
How do you find PVR membranes? A way to improve staining is using dyes under air
The most common way to improve membrane so that the air stretches the starfolds, which allows
visualization is by using trypan blue staining better contact of the dye. The air then is removed, and
(63.33%), direct illumination, or triamcinolone PFCL is injected to stretch the stained membranes
(16.67% each). and hold the retina while peeling (F. Faus, M.D.).
Direct Illumination
Tripan Blue Staining
Triamcinolone Staining
Membrane Scraper/Pick
Forceps
3.33%
16.67%
16.67%
63.33%
How do you lift and remove posterior epireti- (56.67%), bimanual delamination with two
nal PVR membranes? instruments (pick and forceps) (30%), or ERM
The most common ways to remove epireti- peeling with two forceps pulling the membrane
nal PVR membranes are directly with forceps in opposite directions (6.67%).
Forceps
Pick and Forceps
Two forceps
23G Pick-Forceps
Tano Scraper
3.33%
3.33%
6.67%
56.67%
30.00%
What are your pearls to peel effectively and as a spatula/pick (Dorc, Vitreq, Alcon)
safely, and what instruments do you prefer? (M. Veckeneer, M.D.).
Most membranes are better removed by If visualization or illumination is insufficient,
peeling them from their edges. Tightly adhering bimanual delamination with serrated forceps and
membrane edges can be lifted with a Tano an Illuminated Membrane Pik (Alcon) makes this
scraper before removing the membrane maneuver easier (C. Mango, M.D.).
(M. Mura, M.D.). ILM forceps tips can be Thick membranes can be removed by
opened to use the tip as a pick and move it ante- directly grasping the center of the starfold or
riorly through the starfold valleys until the the thickest part of the membrane, but the reti-
membrane edges are engaged and the retina nal vessel must not be engaged to avoid bleed-
moves anteriorly; the forceps then are closed ing (S. Kusaka, M.D.).
and membrane is stripped (B. Fernandez, M.D.). Once the membranes are lifted, a good tip to
After staining membranes, a good approach is strip them safely is using two forceps to pull the
using ILM forceps directly to grasp and peel the membrane apart without tearing the retina
membranes under PFCL. In case of very large (F. Armadá, M.D.).
membranes or strong adhesion, using a bimanual Membrane dissection can be assisted with a
technique grasping the membrane with forceps viscoelastic agent (J.M. Cubero, M.D.) or pro-
and delaminating with closed scissors is a good portional fluid reflux (S. Natarajan, M.D.).
approach (V. Kazaykin, M.D.). When membranes Macular membranes should be peeled cen-
are so strongly adherent that they cannot be tripetally at the macula to avoid pulling on the
delaminated anymore or they reach the posterior fovea and a potential macular hole. Peripheral
vitreous base insertion, segmentation or removal membranes usually are peeled centrifugally to
with vertical or horizontal scissors is useful to avoid peripheral retina tearing; however, there
relax traction (J. Marticorena, M.D.). is a potential risk of tearing the fovea, espe-
An excellent instrument to lift membrane cially if PFCL is not used to stabilize the poste-
edges and remove the membranes completely is rior pole. If the fovea is threatened by centrifugal
the 23-gauge pick forceps (Technop) (P. Koch, traction, peeling should be done centripetally,
M.D.). although peripheral tears might develop
Membrane delamination with forceps and (M. Elgohary, M.D.).
closed curved horizontal scissors (Alcon) or ver-
tical scissors (Dorc) facilitates faster surgeries, What would you do in cases of thick mem-
because the instruments can be used to delami- branes and fragile retina to avoid tearing the
nate and cut once delamination is no longer fea- retina?
sible (J. Zarranz, M.D.). Most surgeons follow a step-by-step
An excellent instrument combination is the approach—delamination, segmentation, and
25-gauge end-grasping forceps to grasp the retinectomy—if the previous steps were

retina and vertical scissors, which can be used unsuccessful.
Careful delamination with

two instruments (pick and
forceps)
Segmentation and leaving
them
Localized retinectomy
3.33% Delamination with Scissors
3.33% Delamination with forceps
and 25G needle
10.00%
63.33%
20.00%
What would you do if you cannot remove the It is important to avoid retinectomies and sup-
membrane without tearing the retina? port the retina with buckling in fresh PVR, since
If the membrane was so attached to the retina the process is active and retinectomies might
that it was impossible to remove without tearing stimulate PVR again, resulting in massive prolif-
the retina, most surgeons try to segment the eration and retinal rolling. Posterior starfolds can
membrane to relax traction (53.3%) or perform a be dealt with 5–7 mm sponges and anterior cir-
localized retinectomy (40%). cumferential contraction with encircling bands
In the presence of peripheral membranes, leav- and a circumferential buckle. However, in PVR
ing them in place and relaxing the traction with a reoperations or with established PVR, the mem-
buckling are good choices. If buckling cannot relax branes can be removed with the retina (localized
the retina sufficiently to achieve reattachment, a retinectomies) or complete peripheral relaxing
peripheral relaxing retinectomy that is supported retinectomies (M. Veckeneer, M.D.).
by buckling is needed (V. Kazaykin, M.D.).
Leave it
Segmentation
Localized retinectomy
Try to support them with
a Buckle
3.33%
40.00%
53.33%
What do you treat very immature retinal mem- toward the bevel to make an excellent membrane
branes when you cannot remove them easily? pick to address extremely adherent and immature
Immature membranes usually have little col- membranes (D. Ruiz-Casas, M.D.).
lagen and they break during peeling. Most sur- Sometimes these membranes are impossible
geons try to brush them out (48.15%) or leave to remove. If that is the case and the membranes
them (with silicone oil) and remove them once are peripheral, a relaxing retinectomy can be per-
they are mature during a second operation. formed. If the membranes are posterior, a good
Retinectomies were performed to deal with approach is to try retinal reattachment, leaving
immature membranes in 14.81%. the silicone oil and peeling membranes for a sec-
Despite these membranes being very difficult ond surgery (the macula usually can be attached)
to remove, the maneuver must be attempted. (J. Zarranz, M.D.).
Membranes can be identified after staining If the membranes are small and more than 2
and then grasped and stripped with Spaide Pic clock hours or a disc diameter away from the tear
Forceps (Dorc) (J. Nadal, M.D.). causing detachment, they usually can be left and
If adherence is strong, the membranes can be the retina fully attached; if not, segmentation can
delaminated bimanually using forceps and a be attempted or a localized retinectomy if they
Spade’s knife for RON or an Atkinson 25-gauge are close to the tear causing the detachment
retrobulbar needle (Z. Tomic, M.D.). The (M. Elgohary, M.D.).
Atkinson retrobulbar needle tip can be bent 90°
Leave them and remove

them in a second
operation
Brush them out (Tano
Scraper or Retina Scratcher
or brushed backflush)
14.81%
Retinectomy
37.04%
48.15%
How do you treat anterior PVR membranes at maneuver is sometimes unsuccessful and usually
the vitreous base insertion with circumferential induces iatrogenic tears, which is why 26.67% of
traction? surgeons perform peripheral relaxing retinecto-
Membranes at the vitreous base are usually mies or support them with a buckle (if not already
difficult to remove and need bimanual delamina- in place).
tion (56.67%) or segmentation (10%). This
Peripheral Retinectomy
Remove them with two
instruments (pick and
forceps, two forceps.
Segment them radially
6.67%
Support them with a
10.00%
26.67%
56.67%
What are your pearls and what instruments do If the vitreous base remains contracted and
you prefer? previous maneuvers were unsuccessful in relax-
A step-by-step approach is helpful by first ing the circumferential traction, buckling must be
using the vitrectome to shave the posterior hya- used in fresh PVR and retinectomies in estab-
loid and then using horizontal scissors to dissect lished PVR (M. Veckeneer, M.D.).
the anterior vitreous from the retina like a pick
and then segment it, and, finally, if residual cir- How do you address anterior PVR with ante-
cumferential traction remains, the posterior vitre- rior vitreous foreshortening and an anterior reti-
ous base can be segmented with vertical scissors. nal loop with anteroposterior traction?
The peripheral retina is extremely fragile, and An anterior hyaloid also can be retracted in
gentle maneuvers are needed to avoid excessive PVR, inducing traction on the vitreous base and
pulling (S. Kusaka, M.D.). anterior retina (anterior retinal loop) and ciliary
ERMs that reach the posterior vitreous base body detachment.
can be removed using PFCL to increase tension Most surgeons try to dissect the anterior hya-
at the vitreous base. Two instruments are used, loid at the pars plana to relax the anteroposterior
i.e., two forceps to relax the membranes by pull- retina with a cutter or scissors (62.07%); how-
ing them apart or forceps and scissors for com- ever, because this is time-consuming and some-
plete removal (J.M. Cubero, M.D.). times unsuccessful, others perform direct relaxing
retinectomies (37.93%).
Open the loop cutting
with cutter or with scissors
if closed
Anterior Hyaloid
Dissection and vitrectomy
3.45% at pp
(Hyaloidozonulotomy)
AVB disection with 2
forceps and cutter
37.93%
41.38%
17.24%
What are your pearls and what instruments do good for dissecting the anterior hyaloid
you prefer? (M. Veckeneer, M.D.).
Anterior hyaloid contraction causes anterior An assistant can help with indentation, and a
retinal loop and often ciliary body detachment. bimanual dissection of the anterior hyaloid at the
The traction must be released to reattach the pars plana can be performed using forceps to pull
retina and ciliary body. A hyaloidozonulotomy the anterior hyaloid centripetally and a cutter to
can be performed with deep indentation dissect it (J. Nadal, M.D.). An encircling band
(BIOM + chandelier light) and dissection with can help to indent the peripheral retina and make
a vitreous cutter at Salzmann’s space. Anterior this maneuver easier (G. Fernandez, M.D.).
hyaloid dissection is harder with a cutter than The best way to remove traction on the ciliary
in cases without PVR due to the stiffened hya- body and anterior vitreous base from the anterior
loid; thus, an initial hole can be made at PVR is to remove the lens and capsule, indent
Salzmann’s space with a MVR blade and then and insert a vitreous cutter just under the anterior
enlarged 360° with a cutter or scissors PVR membrane, and cut along using it like a
(D. Ruiz-Casas, M.D.). A 27-gauge vitreous scissor (C. Mango, M.D.).
cutter works as well as the MVR blade and However, complete removal is sometimes
scissors and might make this maneuver easier impossible, and a relaxing retinectomy to remove
(F. Dhawahir-Scala, M.D.). the anterior retina and vitreous is needed
Vertical scissors are ideal for grasping, (S. Kusaka, M.D.). When performing peripheral
detaching, and cutting the anterior hyaloid retinectomies, all posterior membranes must be
(P. Koch, M.D.); they can be used like a pick to removed first to avoid posterior retinal folding
engage Salzmann’s space and detach it by pull- (M. Elgohary, M.D.).
ing downward. The anterior hyaloid then can be Despite retinectomies, the ciliary body
cut 360°. Ovali Delamination Scissors are also might be at risk due to scarring on the anterior
hyaloid and peripheral retina debris. Thus, the the posterior membranes to anterior membranes)
anterior retina, anterior hyaloid, and detached and why?
pars plana epithelium must be removed com- Most surgeons peel from the posterior to ante-
pletely if a retinectomy is performed, regard- rior membranes (55.17%), although a few change
less of whether an encircling band is used their approach if the anterior membranes are
(D. Ruiz-Casas, M.D.). pulled centrally by the vitreous base contraction,
making them most attainable at the beginning of
Where do you start peeling (from the anterior surgery (31.04%). A few begin routinely with
membranes to the posterior membranes or from anterior membranes (13.79%).
From anterior membranes

to posterior membranes
From posterior
6.90% membranes to anterior
membranes
13.79% I only begin with anterior
membranes if there is
intense circumferential
traction and retina is
accessible
I only begin with anterior
membranes if posterior
retina is out of reach due
to massive membranes
24.14%
55.17%
In case of a closed funnel, how do you open it? remove the membranes first and then attach the
Closed funnels result from massive circumfer- retina with PFCL (63.33%); others try to open
ential vitreous base traction and posterior epireti- the funnel with PFCL, a viscoelastic, or both
nal or subretinal membranes. Most surgeons (36.66%).
PFCL
Viscoelastic
I remove membranes first
and then massage the
retina before using PFCL
I remove membranes first
13.33% and then inject PFCL
16.67% PFCL+Viscoelastic
3.33%
6.67%
60.00%
If no macular membranes were seen, would of the surgeons remove the ILM prophylactically
you remove the ILM? (46.67%) and half leave it (50%).
ILM removal can be considered in PVR cases Performing ILM peeling not only in the macular
to avoid sub-silicone oil reproliferations or macu- area but also nasal to the optic nerve reduces PVR
lar PVR that might affect visual prognosis. Half recurrence and funnel RD (I. Relimpio, M.D.).
No
Yes
In ERM or taut ILM cases
3.33%
50.00%
46.67%
If so what are your pearls and favorite hand makes the maneuver easier and safer
instruments? (D. Ruiz-Casas, M.D.).
The ILM can be stained with Brilliant Blue
or Dual Blue under BSS for 1 min. The dye Do you peel membranes under BSS or PFCL?
then is removed and PFCL injected, and the Membrane peeling can be performed under
ILM is removed centripetally using ILM for- PFCL, which holds the retina in place and reduces
ceps (Alcon). The ILM also can be peeled retinal tearing or stretching; however, it also
under BSS, but the retina is stretched too much, pushes the retina peripherally, and visualization
and substantial traction is applied to the optic is not that good. Most surgeons peel both under
nerve retinal fibers. Using PFCL as a third BSS or PFCL according to convenience (40%);
others peel under BSS or PFCL (30% each).
BSS
PFCL
Both
30.00%
40.00%
30.00%
36.3 Subretinal Membranes Removal

In what cases do you think it is • Always
necessary to remove subretinal • If the retina does not attach with PFCL
membranes? • If the retina does not attach with air-fluid exchange
• If pushing with two instruments on the retina at each side of the
membrane, the retina does not attach
• Others (explain it____)
What technique do you use to remove • Punch-through subretinal band grasping and pulling (fulcrum over
subretinal bands (strands)? second instrument, spaghetti technique, two forceps)
• Only segmentation of membranes
• Peripheral circumferential retinotomy and subretinal band removal
from behind the retina
instruments do you prefer to remove
subretinal bands without enlarging
retinotomy?
And for subretinal scarring in a placoid • Punch-through subretinal band grasping and pulling (fulcrum over
configuration? second instrument, spaghetti technique, two forceps)
• Peripheral circumferential retinotomy and subretinal plaque removal
• Posterior retinotomy, subretinal plaque dissection, and removal
through posterior retinotomy
subretinal plaques?
And for napkin ring proliferations? • Peripheral circumferential retinotomy and subretinal membrane
removal or segmentation if strongly attached to the retina or disc
• Posterior retinotomy and subretinal membrane removal through
posterior retinotomy
• Posterior retinotomy and subretinal membrane segmentation
napkin ring membranes?
In which cases is it necessary to remove sub- membrane adhesion to the retina, it is less trau-
retinal membranes? matic to simply cut it. In combination with vast
Subretinal membrane removal is performed if retinal fibrosis anterior to the equator, cerclage
the retina does not reattach under PFCL (55.17%) might be more advantageous. If the membrane
or air (24.14%) or if the retina is so tense that it does not detach the retina (short membrane), it is
does not attach when pushed back with two better to leave it alone, except in the macular
instruments (10.34%). A few surgeons always zone. In case of membrane location in the mac-
remove subretinal membranes (10.34%). ula, the tactics depend on how much the mem-
It is worth removing the subretinal membrane brane affects the visual acuity (which depends on
if it detaches the retina in the posterior fundus time of formation, square of the membrane, and
(central from the equator). If the membrane is other factors determining visual prognosis in
removed easily (without retinal damage), it case of its removal) (V. Kazaykin, M.D.).
should be removed completely. In case of dense
Always
If the retina does not
attach with PFCL
If the retina does not
attach with air-fluid
10.34% 10.34% exchange
If pushing with 2
instruments on the retina
at each side of the
membrane the retina does
not match
24.14%
55.17%
What technique do you use to remove subreti- access retinotomy with diathermy) (75.86%).
nal bands (strands)? Others remove them from behind the retina
The surgical technique performed most with a peripheral retinotomy (10.34%), only
often to remove subretinal strands is grasping segment them (6.9%), or delaminate strands
them with a forceps and pulling them out care- from the overlying retina before pulling them
fully (grasping directly or performing a small out (6.9%).
3.45%
3.45%
Punch-Through
subretinal band grasping
10.34% and pulling (fulcrum over
second intrument,
spaguetti technique, two
forceps)
Only segmentation of
membranes
6.90%
Peripheral circumferential
retinotomy and subretinal
band removal from
behind the retina
20G delamination with
Subretinal Spatula and
Foreceps
Small Retinotomy close to
75.86% the band and membrane
delamination from
overlying retina with Pick
What are your pearls and what instruments do traction using the fulcrum or spaghetti technique
you prefer to remove subretinal bands without until the far end of the membrane is separated.
enlarging retinotomy? If residual anterior membranes remain, these are
The simplest way to remove strands is by removed in the same way or with a retinectomy if
grasping them and pulling them out with ser- needed (M. Elgohari, M.D.).
rated or Maxgrip forceps (M. Mura, M.D.). The A trick to avoid retinotomy enlargement
strands can be grasped directly through the ret- is by using two forceps; one pulls the strands
ina, but an access retinotomy with diathermy can out, and the other is held open over the access
be performed to reduce the risk of bleeding; if retinotomy in a V shape to limit traction on
the band breaks before complete removal, it can the retinotomy. Sometimes it is necessary to
be left in place if the traction is relieved repeat the technique in more than one strand
(J. Calzada, M.D.). segment to remove extensive or adherent bands
Retinotomy enlargement can be reduced by (J.M. Cubero, M.D.).
pulling out the membrane using the Endolight as Strands can be strongly adherent to the overly-
a fulcrum (J. Nadal, M.D.). ing retina and induce excessive traction if
Subretinal strands should be removed by pick- removed directly; to avoid traction, the strands
ing up the thickest part of the band (generally the can be dissected gently with a subretinal spatula
most posterior part near the macular area) with or pick forceps before pulling them out (P. Koch,
forceps through a posterior access retinotomy; the M.D.). This maneuver can be performed with a
strands are removed by applying steady, gentle 20-gauge subretinal pick. The membrane then is
grasped with a 20-gauge subretinal forceps and What are your pearls regarding subretinal
pulled out bimanually with two forceps like a scarring in a placoid configuration?
bucket from a well (Z. Tomic, M.D.). If the subretinal membranes are large, the
A different way to remove subretinal mem- most common approach is to remove them from
branes can be performed using Bernard Wolff’s behind the retina with a peripheral retinotomy
technique by inserting a 25-gauge cannula tran- (65.52%); other surgeons remove them using
sclerally (as if draining SRF) in the subretinal a posterior access retinotomy (34.48%) (half
space and removing it subretinally with forceps delaminate the membrane first from the retina
(M. Veckeneer, M.D.). before pulling it out).
3.45%
13.79% 17.24% Punch-Through

subretinal band grasping
and pulling (fulcrum over
second intrument,
spaguetti technique, two
forceps)
Peripheral circumferential
plaque removal from
behind the retina
Posterior Retinotomy,
subretinal plaque
dissection and removal through posterior
retinotomy
Several Small Retinotomies close
to the band and membrane
65.52% delamination from
What are your pearls and what instruments do to create a small hole, more iatrogenic damage
you prefer to remove subretinal plaques? can be done than if a peripheral retinotomy was
Subretinal plaques can be removed through performed (G. Fernandez, M.D.).
several posterior access retinotomies by dissect- Once the subretinal space is reached, the
ing them carefully from the overlying retina as membranes can be removed with forceps; the
subretinal bands (P. Koch, M.D.). combination of two end-gripping forceps reduces
To grasp thick membranes, end-grasping for- retinal traction (Z. Tomic, M.D.). If the mem-
ceps work better than ILM forceps since they brane adhesion is too strong on the retina or RPE,
meet on a flat platform and not only at the tip the membrane must be delaminated with serrated
(J. Calzada, M.D.). forceps and scissors (M. Mura, M.D.).
The size of the plaque might be underesti- In cases of dense adhesion, trying to remove
mated. If it is doubtful that the plaque can be plaques completely might cause iatrogenic dam-
removed through a posterior access retinotomy, a age, and only segmentation must be considered
peripheral retinotomy is an option. In an attempt (V. Kazaykin, M.D.).
What are your pearls for napkin ring ally are removed from behind the retina with a
proliferations? peripheral retinotomy (79.31%); others remove
Subretinal membranes in a ring configuration them from several posterior access retinotomies
around the optic nerve and posterior retina usu- (17.24%). A few only segment them (3.45%).
3.45%
3.45%
3.45% Peripheral circumferential

membrane removal or
segmentation from
behind the retina
Posterior retinotomy and
subretinal membrane
13.79% removal through posterior
retinotomy
Posterior retinotomy and
subretinal membrane
segmentation
360 Peripheral
Retinotomy and Removal
from Behind the retina
Several Small
75.86% Retinotomies close to the band
and membrane delamination from
What instruments do you prefer to remove When the napkin ring is so close that it creates
napkin ring membranes? a posterior retinal stalk, the membrane is reached
Napkin ring membranes are thick circumferen- through a peripheral retinotomy, it is loosened
tial posterior membranes that detach the posterior sufficiently (with a light pick and forceps) to get
retina and hinder reattachment. These membranes the vitreous cutter in between the ring and the
can be removed through posterior retinotomies retinal stalk, and then the napkin ring is cut with
with forceps (S. Kusaka, M.D.). A combination the cutter port facing outward (C. Mango, M.D.).
of several posterior access retinotomies, mem- Napkin ring membranes are usually very
brane segmentation, and membrane grasping and posterior, around the optic disc, and strongly
removal can release the traction (S. Nataratajan, attached, so damage to the retina or disc is com-
M.D.). However, most surgeons prefer direct sub- mon. Therefore, the surgeon should not hesitate
retinal access from a peripheral retinotomy and to segment the membrane if substantial dam-
dissect these membranes bimanually with forceps age might result by removing it completely
and scissors (F. Cabrera, M.D.). (G. Fernandez, M.D.).
Part 3 37
D. Ruiz-Casas ()
F. Armadá-Maresca
Ophthalmology Department, University Hospital F. Dhawahir-Scala
La Paz, Madrid, Spain Manchester Royal Eye Hospital, Central Manchester
F. C. Lopez
Manchester, UK
Complejo Hospitalario Universitario Insular M. Elgohary
Materno-Infantil de Gran Canaria, Kingston Hospital, Kingston upon Thames, UK
Las Palmas de Gran Canaria, Spain
F. E. Arjona
J. I. Calzada F. F. Guijarro
Charles Retina Institute, Memphis, TN, USA Universitary Hospital Miguel Servet, Zaragoza, Spain
J. M. C. Parra B. F. Arevalo
Vitreo-Retina Unit Hospital la Arruzafa, Ophthalmology Department, Guadalajara
Córdoba, Spain Universitary Hospital, Guadalajara, Spain

https://doi.org/10.1007/978-3-319-78446-5_37
G. F. Sanz M. Mura
K. G. Falavarjani
F. G. Gonzalez
Delhi, India
S. Kusaka
M. I. R. Lopez
Zaragoza, Spain
Z. Tomic
J. Zarranz-Ventura
37.1 Reattaching the Retina

How do you assess the retina is already attachable? • Clinical appearance under BSS
• Fluid-air exchange
• Retinal attachment under PFCL
• Direct PFCL-silicone oil exchange
What are your tips and tricks and what instruments do
you prefer to perform the reattaching test?
If after peeling membranes the retina still looks rigid • Retinal massage with backflush or blunt instrument
as if following the previous form before removing • Retinal stretching with two backflush
membranes, how do you deal with this? • Several fluid-air/air-fluid exchanges
How do you reattach the retina? • PFCL up to the ora serrata

• PFCL behind posterior tear and fluid/PFCL-air
exchange (sandwich)
• Fluid-air exchange through a posterior drainage
retinotomy
• Fluid-air exchange through a peripheral tear (despite
leaving some posterior subretinal fluid)
• Direct PFCL-silicone oil exchange
What are your tips and tricks to avoid slippage
(especially in GRT PVR with large and peripheral
retinal tears or large and peripheral retinectomies)?
What are your tips and tricks to avoid leaving any
subretinal fluid?
How do you assess if the retina is attachable? BSS (30%). FAX is considered the best reattach-
Most surgeons rely on PFCL to asses if the ment test by 23.33% of surgeons, and combined
retina is already attachable (40%); others prefer PFCL and FAX retinal behavior is considered by
to check the clinical retinal appearance under 6.67%.
6.67%
30.00%
Clinical appearance under BSS
Fluid-Air Exchange
40.00% Rentinal attachment under PFCL
PFCL+FAX
23.33%
What are your pearls and what instruments do in contracted retinas. PFCL also has a higher sur-
you prefer to perform the reattaching test? face tension than silicone oil and high density
It is important to know whether the retina is that allows it to reattach stiff retinas in the poste-
attachable or not. FAX can reattach even periph- rior pole. After silicone is left in the eye, it also
eral stiffened retinas due to the gas high surface can leak subretinally. Thus, FAX is a good reat-
tension, especially if the FAX is performed at tachment test in cases with central breaks and
high pressure; however, during the postoperative retinal attachment under PFCL with peripheral
evaluation, silicone oil with a lower surface ten- tears (M. Veckeneer, M.D.).
sion might leak subretinally through retinal holes
During FAX, if retinal shrinkage that can hinder If, after clinical examination under BSS,
reattachment is suspected, air infusion is performed PFCL injection, and checking for remnant epi-/
using relatively low pressure (20–30 mmHg) to subretinal membrane, the retina still looks stiff-
avoid tearing the retina (S. Kusaka, M.D.). ened, a peripheral retinectomy must be performed
Under PFCL, indentation helps to check (J. Zarranz, M.D.).
peripheral retina stiffness (J. Marticorena, M.D.);
non-stiff peripheral retina anterior to the PFCL If after peeling the membranes, the retina still
preserves the dome shape (V. Kazaykin, M.D.). looks as rigid as before membrane removal, how
If laser retinopexy does not cause sufficient do you address this?
whitening under PFCL or air, it is a sign that the In this case, most surgeons massage the retina
retina is contracted (F. Faus, M.D.). (59.26%) or try to stretch it with FAX or PFCL
If the retinal stiffness is in doubt, an encircling (11.1%); others consider this a sign of intraretinal
band can be tightened and FAX performed to PVR and shortening and perform relaxing retinec-
check the attachment under air and buckling tomies (22.22%); and others consider that epiretinal
(I. Relimpio, M.D.). or subretinal membranes are still present (7.4%).
60
50
40
Percent
30 59.26
20
10 22.22
7.407
3.704 3.704 3.704
0
Retinal massage Relaxing Several fluid-air Remove more PFCL to push Check for
with Backflush Retinotomy /air-fluid membranes and and stretch the subretinal
or blunt exchanges Segmental retina down membranes
instrument Buckle
How do you reattach the retina? occurs, attempts to drain residual fluid are not
Although all reattachment techniques are needed); making extra posterior holes to drain
determined based on the individual case, the pre- should be avoided because it causes or stimu-
ferred ways to reattach the retina are the sand- lates PVR. In giant tears or elective anterior reti-
wich technique (53.57%), complete PFCL filling notomy without PVR, a direct PFCL-silicone oil
(17.86%), FAX through a posterior drainage reti- exchange is the best option to prevent slippage
notomy (14.29%), direct PFCL-silicone oil (M. Veckeneer, M.D.).
exchange, or FAX through a peripheral tear leav- In most PVR cases, silicone oil is left as
ing the SRF (7.14% each). tamponade, and due to its surface tension and
In PVR, the retina continues to shrink density, it keeps a spherical configuration. A
postoperatively, so there is no need to avoid
complete silicone oil filling is mandatory, and
some fluid remnants centrally. FAX can be per- SRF should be avoided to get it (D. Ruiz-Casas,
formed followed by oil filling (if no slippage M.D.).
7.14%
PFCL up to the Ora Serrata
7.14% 17.86% PFCL behind posterior tear
and Fluid/PFCL-Air
Exchange (Sandwich)
Fluid-Air Exchange
14.29% through a posterior
drainage retinotomy
Fluid-Air Exchange
through a peripheral tear
(despite leaving some
53.57% posterior subretinal fluid)
Direct PFCL-Silicone Oil
Exchange
What are your pearls to avoid slippage, espe- Slippage can be avoided by leaving four reti-
cially in giant retinal tear PVR with large and nal bridges during exchanges; these then are
peripheral retinal tears or large and peripheral removed once the vitreous cavity is filled with air
retinectomies? or silicone oil (J.M. Cubero, M.D.). However, the
It is important to completely relax the retina to optimal way to avoid slippage is by performing a
avoid slippage. Thus, all tractional membranes direct PFCL-silicone oil exchange. PFCL is
must be removed before trying to reattach the increased to the IOL plane, and a silicone infu-
retina (K.G. Falavarjani, M.D.). Sometimes per- sion line is connected so that the silicone oil is in
forming radial relaxing retinotomies at the edge contact with the PFCL getting adherent to it (due
is necessary to relax the retina completely in case to their low interphase tension). BSS debris is
all the membranes are removed and the retina is pushed anteriorly where they are removed pas-
still slipping (V. Kazaykin, M.D.). sively by backflushing, then the retinal edge is
Laser treatment under PFCL before exchange dried, and, finally, the PFCL bubble is removed
might induce somewhat direct retinopexy that from the optic nerve (J. Marticorena, M.D.).
can reduce slippage (Z. Tomic, M.D.). A modification of the oil splash technique
PFCL/BSS-air exchange can be performed by described by Grazia Pertile is another way to per-
alternating a soft-tip cannula or suction between form PFCL-silicone exchange; in this technique,
the edge of the tear/retinectomy and over the the PFCL is increased to the edge of the tear.
optic nerve. Retinal edge drying must be done FAX then is performed to dry the edge, silicone
gently and thoroughly by going back and forth oil is injected, and the PFCL is removed by back-
sipping from the edge of the tear even when it is flushing. This technique reduces subretinal PFCL
considered dry. Bleeding can result from hard bubbles substantially (S. Natarajan, M.D.).
pressing against bare RPE at the end of the case In cases with inferior breaks, direct PFCL-heavy
and must be avoided (C. Mango, M.D.). silicone oil exchange can be performed. First, the
FAX is performed safely by tilting the eye eye is filled completely with PFCL, which removes
toward the retinal tear and performing a slow and the SRF under the PFCL. The exchange is per-
controlled FAX, remaining at the edge of the formed the same as a direct PFCL-silicone oil
giant retinal tear with suction. If there is some exchange, but the eye is tilted up so that PFCL and
slippage, forceps or a Tano scraper can be used Densiron sink up during exchange, and the flute
to reposition the retina (F. Dhawahir-Scala, needle aspirates the remaining BSS and SRF in the
M.D.). anterior part of the eye but in the inferior vitreous
cavity (by doing this, heavy oil, which is of lower performed by draining through the posterior reti-
density than the PFCL, pushes the SRF away from notomy; after 30 s, the SRF is drained again
the superior retina to the holes in the periphery). because it re-accumulates (G. Fernandez, M.D.).
Once the anterior vitreous cavity is filled with heavy Using PFCL reduces residual SRF. At the
oil (the posterior part is filled with PFCL), there is beginning of FAX, as much SRF as possible is
no longer SRF. Finally, the PFCL is removed with removed; first, the BSS and SRF are removed
the flute needle at the optic nerve, and the eye is above the PCFL and the PFCL then is removed.
filled completely with heavy oil (P. Koch, M.D.). Despite this, intraoperative optical coherence
A common problem performing direct PFCL- tomography images show that the SRF is not
silicone oil exchange is infusion line distension removed completely (S. Kusaka, M.D.).
or disconnection. To avoid this complication, sili- SRF drainage can be improved by adding PFCL
cone oil infusion pressure should be set at 50 psi up to the ora serrata and performing a drainage reti-
(Constellation) or 3 bar (EVA); besides, tying the notomy at the ora serrata or enlarging the peripheral
infusion cannula connection to the tubing may be tears up to the ora serrata (J. García, M.D.).
needed (F. Armadá, M.D.). It is important to completely remove the anterior
A simple but effective way to avoid slippage is to BSS before removing the PFCL behind the retinal
leave the PFCL in place in the vitreous cavity for tear. The removal is complete when the shape of the
2 weeks and then reoperate to remove the PFCL PFCL changes from convex to concave due to the
(medium-term PFCL technique) (J. Calzada, M.D.). absence of a peripheral BSS meniscus. The residual
Buckling surgery associated with vitrectomy SRF then is drained very slowly and steadily
might increase the risk of slippage, especially if through the retinal tear to avoid loculated SRF
the band is tightened excessively. If bands are pockets due to fast SRF pumping (J. Lara, M.D.).
used, they should be tightened after FAX If SRF is trapped in the central retina, PFCL
(Falavarjani K.G., M.D.). can be reinjected reducing air pressure to com-
pletely remove the SRF (Z. Tomic, M.D.).
What are your pearls to avoid leaving SRF? Sometimes it is necessary to perform an air-fluid
The retina can be attached without PFCL exchange again and repeat PFCL injection and
using a posterior drainage retinotomy. FAX is FAX (J. Nadal, M.D.).
37.2 Retinectomies and Bucklings

If you cannot reattach the retina despite peeling • Encircling buckle
membranes, what would you do? • Localized (usually inferior) buckle
• Peripheral retinectomy
• Others (explain it)
If you decide to use a buckle? Which one would • 2.4-mm band 360 buckle
you use? • 4-mm band 360 buckle
• 360 silicone rubber tire
• Localized inferior silicone rubber tire
Would you also use an encircling buckle if you • No
planned to perform a retinectomy? • Yes
• Yes and trying to support the retinectomy edge with the
buckle
If you would perform a retinectomy, how would • Under BSS-PFCL
you do it? • Under air
• Under silicone oil
How large should your retinectomy be? • Extended two clock hours into the normal retina each side
• At least 180° (usually inferior)
• As small as possible
How posterior should your retinectomy be? • As peripheral as posterior vitreous base insertion (or
PVD detachment)
• As peripheral as I could completely remove posterior
membranes
• Posterior relaxing retinotomy without anterior retina
removal
What kind of retinectomy would you perform? • Circumferential
• Radial
• Both
Do you use diathermy before cutting? • No
• Only big vessels
• Yes, all around the cutting area
Do you remove the anterior retina or even pars • Always
plana epithelium flap? • Only in peripheral retinectomies
• Never
What are your tips and tricks and what instruments
would you prefer to perform a retinectomy?
In cases of perforating trauma with posterior retinal • Retinectomy next to the incarceration site
damage or incarceration, how do you prevent future • Retinectomy removing 1–2 mm around incarceration site
PVR? • Chorioretinectomy 1–2 mm around incarceration site
• Just laser around posterior retinal tear
In cases of penetrating trauma or globe rupture • Retinectomy next to the incarceration site
with peripheral retina incarceration, how do you • Retinectomy removing 1–2 mm around incarceration site
free the retina? • Chorioretinectomy 1–2 mm around incarceration site
If you cannot reattach the retina despite peel- most surgeons perform peripheral relaxing reti-
ing membranes, what do you do? nectomies (55.17%), and 44.83% use a buckle,
If the retina cannot be reattached despite peel- most of which are an encircling element; very
ing membranes and no buckling is in the eye, few use a localized inferior buckle.
3.45%
41.38% 55.17% Encircling buckle
Localized (usually inferior) buckle
If using a buckle, which do you choose? (14.29%). A few surgeons use a localized inferior
Most surgeons use a 2.4-mm encircling band segmental buckle (10.71%), and only 3.57% use
(71.43%) or a wider 4-mm encircling band a wider silicone tire encircling element.
3.57%
3.57%
7.14%
2.4 mm band 360 buckle
14.29% 4 mm band 360 buckle
71.43% Localized inferior silicone rubber tire

Slilicone rubber tire 360 buckle
Circumferential Segmental Buckle
5×3.77 mm
Would you also use an encircling buckle if you ers who combine procedures (36.67%). A few
planned to perform a retinectomy? combine procedures if the retinectomies are not
Most surgeons would not use a buckle if reti- extremely large (6.66%).
nectomy was planned (56.67%) compared to oth-
3.33% 3.33%
16.67%
No Yes and trying to support
the retinectomy edge with the buckle
56.67% Yes
Only in small Retinectomies
20.00%
Yes if Retinectomy <270°
What is your procedure to perform a retinectomy?

Most surgeons perform retinectomies under
BSS-PFCL (93.33%) and not under air
(6.67%).
6.67%
Under BSS-PFCL
Under Air
93.33%
How large should the retinectomy be? possible to the adjacent normal retina
Most surgeons perform large retinectomies, (35.71%).
extending them widely into the healthy retina To release tractional forces completely, any
and no smaller than 180° (64.29%); others retinotomy/retinectomy should be extended into
limit the retinectomy extension as much as the normal retina (K.G. Falavarjani, M.D.).
3.57%
3.57%
Extended two clock hours into normal

21.43% retina each side
39.29%
As small as possible
Atleast 180° (usually inferior)
Extended only to normal retina each side
if Encircling Band
Extending it well into healthy tissue
32.14%
How posterior should the retinectomy be? (73.33%), while others set the posterior limit
Most surgeons set the posterior retinectomy slightly anteriorly at the posterior hyaloid detach-
limit where they can completely remove the ment (20%); others do it as posteriorly as needed
membranes and the retina is free of them to reattach the retina (6.66%).
3.33%
3.33%
20.00% As peripheral as I could completely

remove posterior membranes
As peripheral as posterior vitreous
73.33% base insertion (or PVD detachment)
As posterior as possible
As posterior as needed to
attach the retina under PFCL
What kind of retinectomy would you circumferential retinectomies with radial retinot-
perform? omies if there is still circumferential traction
Most surgeons use only circumferential relax- after relaxing anteroposterior traction with cir-
ing retinectomies (62.07%), and others combine cumferential cuts (37.93%).
37.93%
62.07% Circumferential
Both
Do you use diathermy before cutting?

Diathermy is performed mostly all around the
cutting area (63.33%) or only at the big vessels
(33.33%).
3.33%
33.33% Yes, all around the cutting area

63.33% Only in big vessels
No
Do you remove the anterior retina or even the

pars plana epithelial flap?
Most surgeons remove the anterior retina
completely (63.33%); others only do so if the
retinectomy is in the periphery (36.67%).
36.67%
Always
63.33%
Only in peripheral retinectomies
What are your pearls and what are your pre- avulsing it from the diathermy spots (D. Ruiz-
ferred instruments to perform a retinectomy? Casas, M.D.).
Retinectomies should be considered as a last The most common retinectomy used is circum-
resort if the retina cannot be reattached after peel- ferential to relieve any anteroposterior traction; if
ing and buckling (J. Nadal, M.D.). there is still retinal shrinkage due to circumferential
Most surgeons use the vitreous cutter with traction, radial retinotomies also can be performed
low vacuum and high cutting rates to perform (S. Kusaka, M.D.). Radial retinotomies also can be
their retinectomies after diathermy demarcates used in cases of localized circumferential traction
the retinectomy area and reduces bleeding. when membranes cannot be peeled. In these cases,
Additional diathermy might be needed after PVR can be removed with a radial retinectomy and
retinectomy at full length of the incision the retina reattached (P. Koch, M.D.).
(V. Kazaykin, M.D.).
Vitrectomy cutter settings can be adapted using In cases of perforating trauma with posterior
low flow or low vacuum and closed biased and low retinal damage or incarceration, how do you pre-
cut rate of 150 cuts/min to use the vitreous cutter vent future PVR?
as a simulated scissors (Z. Tomic, M.D.). Most surgeons remove 1–2 mm of the retina
Other surgeons prefer doing retinectomies or the retina and choroid from around the incar-
with scissors to obtain a cleaner edge ceration site to reduce PVR (34.48% each); oth-
(J.M. Cubero, M.D.). ers free only the retina (17.24%) or laser only the
It is sometimes difficult to perform a posterior retinal tear (13.79%).
peripheral retinectomy at the 12 o’clock posi- It is mandatory to completely remove the pos-
tion; in those cases, high-power diathermy can terior hyaloid and damaged retina with a local-
help delineate the retinectomy, and the ante- ized retinectomy and apply laser around it. Cryo
rior retina is aspirated and pulled anteriorly must be avoided (F. Gonzalez, M.D.).
13.79%
Retinectomy removing 1-2mm

34.48% around incarceration site
Chorioretinectomy 1-2mm
17.24%
around incarceration site
Retinectomy next to the
incarceration site
Just laser around posterior
retinal tear
34.48%
In cases of penetrating trauma or globe rup- Instead of removing the retina, the following
ture with peripheral retina incarceration, how do can be attempted: freeing the retina from incar-
you free the retina? ceration by lowering the intraocular pressure
Most surgeons only remove 1–2 mm of the (IOP) to 0 mmHg, massaging it with a silicone-
retina around the incarceration site to free it and tipped cannula, and injecting BSS. Once relieved,
avoid PVR (53.57%), while others cut only the the scleral wound should be sutured, although
retina to free it (28.57%). Few surgeons remove most cases ultimately require a retinectomy
both the retina and choroid around the incarcera- (F. Gonzalez, M.D.).
tion site to avoid PVR (17.86%).
17.86%
Retinectomy removing 1-
2mm around incarceration site
53.57% Retinectomy next to the
incarceration site
28.57% Chorioretinectomy 1-2mm

around incarceration site
37.3 Tamponades
In cases of giant retinal tear (GRT) or large • Fluid-air exchange with extremely careful drying
retinectomies, how do you avoid slippage? • Direct PFCL-silicone oil exchange
• Leaving retinal bridges which are cut afterward
What are your tip and tricks to avoid slippage when
you perform your preferred exchange?
In what situations would you use heavy silicone oil? • Never
• Inferior persistent membranes (which don’t prevent
reattachment)
• Inferior retinectomy
What tamponade would you leave in the eye in a • SF6
PVR case? • C3F8
• Silicone oil
Which silicone oil do you use in PVR cases? • 1000 cs
• 2000 cs
• 5000 cs
In case of leaving silicone oil, how do you inject it? • Direct PFCL-silicone oil exchange
• BSS/PFCL-air exchange followed by air-silicone oil
exchange
• Direct BSS-silicone oil exchange
What pressure do you want to leave the eye with
after injecting silicone oil and how do you check it?
In what situations would you perform an Ando
iridotomy?
Do you position the patient after surgery?
If so, how do you do it and how long?
When do you remove silicone oil? • 3 months
• 6 months
• 12 months
And heavy silicone oil? • 1 month
• 2 months
• 3 months
In what situations do you leave silicone oil
permanently into the eye?
In cases of a giant retinal tear or large reti- either direct PFCL-silicone oil exchange or care-
nectomies, how do you avoid slippage? ful FAX (46.67% each); very few use medium-
In the presence of a giant retinal tear or large term tamponade with PFCL (3.33%).
anterior retinectomies, most surgeons perform
3.33%
3.33%
Fluid-Air Exchange with

careful drying
Direct PFCL-Silicone Oil
Exchange
46.67% Leaving retinal bridges which are
cut afterwards
46.67%
Medium Term PFCL
Tamponade (2 weeks)
What are your pearls to avoid slippage when In what situations would you use heavy sili-
you perform your preferred exchange? cone oil?
This question was already addressed. More than half of surgeons would not use
heavy silicone oil (51.72%); others use it in the
presence of persistent inferior membranes
(24.14%) or inferior retinectomies (13.79%).
60
50
40
Percent
30
51.72
20
24.14
10
13.79
3.448 3.448 3.448

0
Never Inferior Inferior Inferior Inferior Complex
Persitent Retinectomy Redetachment Retinectomy Inferior PVR
membranes and Posterior
(which don’t Holes
prevent
reattachment)
What tamponade would you leave in the eye in Silicone Oil

a case of PVR? C3F8
All surgeons use long-lasting tamponades in
PVR; most prefer silicone oil (75.86%) to C3F8
gas (24.14%).
24.14%
75.86%
Which silicone oil do you use in PVR cases? filling must be avoided to limit AC silicone oil
Low-viscosity silicone oil is used by 55.17% migration. An excellent technique to always
of surgeons and high-viscosity oil by 44.83%. achieve complete filling is Kirk Packo’s technique.
First, the AC is left with its normal depth; in pseu-
1000cs
5000cs
dophakic patients BSS can be used. However, in
2000cs aphakic patients a dispersive viscoelastic (Viscoat)
10.34% should be used since BSS tends to induce an exces-
sively flat AC during FAX and air an excessively
deep AC (an Ando iridotomy is mandatory in apha-
kic patients). FAX then is performed to remove all
44.83% SRF, and finally silicone oil is injected up to the iris
plane. Finally, all sclerotomies are sutured except
for a superior one where a microcannula is
44.83%
removed, the sclerotomy presutured, and micro-
cannula placed again. The lid speculum is loosened
slightly and lifted, and a 15–21 mmHg Terry-
Barraquer tonometer is used to check the IOP and
silicone oil injected until the IOP is between 15 and
21 mmHg. Finally, the assistant removes the micro-
cannula, while the surgeon immediately ties the
When leaving silicone oil, how do you inject it? presutured sclerotomy. With this technique, there is
Most surgeons prefer a PFCL/BSS-air exchange always complete silicone oil with a normal AC and
first and then an air-silicone oil exchange if the IOP (D. Ruiz-Casas, M.D.).
risk of slippage is considered acceptable (83.33%). Another way to obtain adequate silicone oil fill-
A few surgeons prefer a direct PFCL-silicone oil ing in aphakic eyes is by removing all fluid from
exchange if silicone oil is used (16.67%). the AC after performing an inferior iridotomy.
BSS/PFCL-Air Exchange
This allows the silicone oil to completely fill the
followed by Air-Silicone AC, while the silicone oil injection is completed.
Oil Exchange
Finally, an air bubble is used to fill the AC, and the
Direct PFCL-Silicone
16.67% Oil Exchange AC and IOP are rechecked with a Schiotz tonom-
eter (K.G. Falavarjani, M.D.).
20
10
7.14% 25
83.33% 15
10.71%
What IOP do you want to achieve after inject-

ing silicone oil and how do you check it?
64.29%
Most surgeons leave the eye with normal pres- 17.86%
sure (15–20 mmHg) (71.43%), others prefer to
leave the eye soft (10 mmHg) (17.86%), and a few
prefer to leave the eye hard (25 mmHg) (10.71%).
However, most rely on their finger or other indirect
signs to check the IOP (92.86%), and very few
measure the IOP intraoperatively (7.14%).
Complete silicone oil filling is mandatory to
reduce inferior PVR and redetachments, but over-
Finger
3.57% Schiotz
In what situations would you perform an Ando
3.57%
3.57%
Terry-Barraquer 15/21 iridotomy?
Forceps
Most surgeons perform Ando iridotomies in
aphakic patients (66.67%), and others perform it
in pseudophakic patients or those with a dam-
aged irido-lens diaphragm (29.63%). Very few
never perform it (3.7%).
An Ando iridotomy is mandatory in aphakic
89.29% patients regardless of whether silicone oil or gas
is used as a tamponade. If not performed, a pupil-
lary block, silicone oil migration into AC, or
complete athalamia can occur. This situation can
be reversed with gas tamponade with the patient
maintaining a face-down position, but it will hap-
pen again and again. Thus, it is better to prevent
it (D. Ruiz-Casas, M.D.).
60
40
Percent
66.67
20
11.11 11.11
3.704 3.704 3.704
0
Aphakia Insufficient Aphakic and Pseudophakic Aphakia or Never
Irido-Lens Pseudophakic if Pseudophakia if
Difragm Silicone insufficent
Tamponade diafragm
Do you position the patient postoperatively? Other surgeons only position patients if retinal
Most surgeons position the patients postoper- tears are located nasally or temporally, since
atively (76.67%). superior ones are tamponaded with oil and the
inferior ones with heavy oil. Patients with periph-
Yes eral tears should be positioned on the other side
No to tamponade the tear properly (P. Koch, M.D.).
If no heavy oil is used, inferior tears can be
tamponaded with the patient in the prone position
23.33% for 24 h and then keeping a supine position
despite cataract (I. Relimpio, M.D.).
If there is a large inferior retinectomy, patients
might need longer positioning at night (lying on
one side or the other) (G. Fernandez, M.D.).
It may be important to change the ocular posi-
76.67%
tion frequently intraoperatively to avoid remain-
ing in the same position for too long to avoid
loculating inflammatory compounds in the same
part of the eye (F. Faus, M.D.).
Others prefer to maintain the patient in a prone
position followed by any position except the
supine position (S. Kusaka, M.D.).
If so, how do you do it and for how long? There is no need to position the patient to tam-
Most surgeons position the patient for fewer ponade, but it might be important to avoid subfo-
than 7 days (63.16%). veal PFCL bubbles. Thus, maintaining the
The most common position postoperatively is face-down position for 24 h is sufficient (D. Ruiz-
the face-down position; the supine position is Casas, M.D.).
avoided (A. Lavaque, M.D.).
30
20
Percent
26.32
10 21.05 21.05
15.79
10.53
5.263
0
24h 3 days 10 days 7 days 5 days 2 days
When do you remove the silicone oil? and no reproliferations are present, the silicone
Most surgeons remove the silicone oil in fewer oil usually is removed in 3 months. If there is sus-
than 3 months (66.67%), and others wait up to picion of reproliferation or an inferior RD not
6 months (33.33%). affecting the macula, the silicone oil is left for 6
The duration of the tamponade depends on the or more months until the PVR is burned out
clinical case. If the retina appears nicely attached (G. Fernandez, M.D.).
3.33%
6.67%
3m
6m
56.67% 1.5-3m
33.33%
2m
And heavy silicone oil?

The heavy oil is removed in fewer than
3 months in 93.75%; only 6.25% of surgeons
wait up to 6 months.
6.25%
12.50%
3m
43.75% 2m
1m
6m
37.50%
In what situations do you leave silicone oil after silicone oil removal, hypotony, persistent
permanently in the eye? peripheral detachment, and when the retina is not
Silicone oil is left permanently in the eye in fully reattached after 1 month.
cases of permanent visual loss, redetachments
37.4 Retinopexy
In what situation do you use cryopexy instead of laser?

In what PVR cases would you perform 360° laser?
How do you do 360° laser? • From posterior vitreous base to the ora serrata
• A few laser bands at posterior vitreous base insertion
• A few bands at the ora serrata
How do you use laser? • Continuous
• Repetition
• Both
In what PVR cases wouldn’t you do laser during • Never
surgery but afterward? • Large retinectomies which can retract
• Almost always to reduce inflammation
In what situation do you use cryopexy instead If cryopexy is used, it must be stopped when
of laser? the retina whitens to avoid retinal atrophy and
Cryopexy is hardly used, but it can be useful scars and perform a better and faster retinopexy
in retinal areas without pigment to obtain RPE (J. Zarranz, M.D.).
damage and over ciliary nerve meridians to avoid
cycloplegia (M. Veckeneer, M.D.).
No good visibility
Laser does not mark well
Large Breaks in the ciliary nerve meridian
Prompt Healing needed at 10 or 2 hours
Supposed tears blocked by non-transparent media
I use external Diodopexy instead
Phakic patients with anterior tears
Blood at Rupture
Non-Reachable Tears with Laser
Anterior Edges of Large Retinectomies
Explant without Vitrectomy
Superior Small Tears
No
0 10 20 30 40
Percent
In what PVR cases would you perform 360° Three hundred sixty-degree laser usually is
laser? performed if there is retinal pathology or tears
that extend for 360°.
Always but performed when silicone oil removal not in active phase
Diffuse Retinal Traction
Microholes or Occult Holes
Many Peripheral Tears and No Buckle
Never
Multiple tears or GRT
Always
If Retinectomy 360 is performed
Peripheral tears in 4 quadrants
0 10 20 30
Percent
How do you use laser?

Most surgeons do a few laser bands at the vit-
reous base insertion (51.72%). Others extend the
laser from the posterior vitreous base insertion to
the ora serrata (37.93%).
3.45%
6.90%
A few laser bands at

posterior vitreous base
insertion
From posterior vitreous base
to ora
51.72% A few bands at ora
37.93% 3 Laser layers (at least) at extreme
periphery or at tractions areas
How do you use laser?

The most common way to apply laser is by
repetition (80%).
10.00%
10.00%
Repetition
Continuous
Both
80.00%
In what PVR cases would you not perform is not flat after extensive peeling and r etinotomy,
laser intraoperatively but afterward? no laser is applied, but PFCL is left in for about
Most surgeons never defer laser (83.33%); 1 week. When the surgeon reoperates, the retina
others might consider it in certain circumstances might be attached and membranes well stained
to reduce inflammation. with trypan blue. The case is ended with injection
When a retinotomy cannot be avoided in fresh of regular silicone oil. This is a very-worst-case
PVR, no laser or only very limited laser is applied backup plan, usually after PVR resulting from
after FAX (not under PFCL as this position is trauma (M. Veckeneer, M.D.).
stretched). In the very worst cases when the retina
3.33%
3.33%
3.33% Never
Almost always to reduce
6.67% inflammation
Large retinectomies which
can retract
In case with localized PVR
in 1-2Q I laser there and
the other Q after a few
months
Previous PVR surgery failed
83.33% due to contraction.
Leaving PVR to burn out
and last it later on
37.5 Failing
What do you think is the most common cause of redetachment • Insufficient traction removal
after RD-PVR surgery? • New membranes
• New tears
In cases of redetachment after PVR surgery, what is your common
surgical technique?
Do you peel new membranes under silicone oil or do you remove
oil first?
When do you think we should give up operating on a PVR case?
How do you deal with permanent hypotony • Leave 5000 cs silicone oil permanently
• Remove anterior capsule and IOL if
present and any ciliary body traction
• Remove any ciliary body traction
(hyaloidozonulotomy),and leave capsule and
IOL to keep silicone oil in the vitreous cavity
What is the most common cause of redetachment

after RD-PVR surgery?
Redetachments are considered to be caused
mainly by unremoved traction (67.86%) or new
membranes with or without new tears (32.14%).
10.71%
21.43% Insufficient Traction Removal

67.86% New Membranes
New Tears due to new Traction
In cases of redetachment after PVR surgery, encircling band if one is not present (17.86%).
what is your common surgical technique? Other surgeons remove the vitreous and mem-
Most surgeons remove residual vitreous and brane completely with a buckle to avoid retinec-
membranes, perform retinectomy, and leave the tomy (10.71%).
silicone oil (50%). Others do the same and add an
Lensectomy+Complete Residual Vitreous and

Membranes Removal, Peripheral Retinectomy, Encircling 3.571
Band and Silicone Oil
Complete Residual Vitreous and Membranes Removal 3.571

Peripheral Retinectomy and C3F8 tamponade
If macula is not threatened leave oil for months and then 3.571
perform retinectomy
Complete Residual Vitreous and Membranes Removal

3.571
Inferior Segmental Buckle
Vitrectomy under oil removing membranes and

7.143
performing retinectomies under oil

Peripheral Retinectomy, Encircling Band and Silicone oil 10.71
tamponade
Complete Residual Vitreous and Membranes Removal and

17.86
360 2.4mm band Oil

50
Peripheral Retinectomy and Silicone oil tamponade
0 10 20 30 40 50
Percent
Do you peel new membranes under silicone

oil or do you remove the oil first?
Most surgeons remove the oil to address mem-
branes under silicone oil (70%).
3.33%
6.67%
Remove Oil
20.00% Under Oil

Both
70.00%
To deal with Epiretinal PVR I
remove oil. To deal with
subretinal PRR I work under oil
When do you think we should forego operating capsule to avoid ciliary body traction; others
on a PVR case? leave the silicone oil in permanently (44.44%).
There are several situations in which surgery If hypotony is present, removing the IOL and
is avoided, i.e., in cases of hypotony, poor visual capsular remnants is the only way to ascertain that
prognosis, intraretinal PVR or ischemic and no ciliary body traction remains (M. Mura, M.D.).
fibrotic retinas, detached posterior pole despite In these situations, gonioscopy must be per-
relaxing retinectomies, and when the retina formed to rule out cyclodialysis clefts. If no cleft
remains unattached after several attempts. If is present and the patient is pseudophakic, the
PVR has an intense retinal tissue effect, as in IOL/zonule can be preserved by keeping the sili-
intraretinal gliosis, the visual prognosis is poor cone oil in the vitreous cavity unless they induce
and retinal reattachment harder (JC Pastor, traction on the ciliary body. If the hypotony does
M.D.). not improve, viscoelastic injections into the AC
can be tried. The new foldable capsular artificial
How do you treat permanent hypotony? vitreous body might be a good option, but there is
Most surgeons try to remove ciliary body trac- no supporting evidence yet (M. Veckeneer,
tion and leave the silicone oil to recover aqueous M.D.).
production (55.55%); 20% remove the IOL and
3.70%
11.11%
Remove any ciliary body traction

(hyaloidozonulotomy) and leave
capsule and IOL
44.44% Leave 5000 cs Silicone oil
permanently
Remove anterior capsule and IOL if
present and any ciliary body traction
40.74% Leave 1000 cs Silicone Oil
permanently
Video Cases
38
D. Ruiz-Casas, Ulrich Spandau,
Felix Armadá-Maresca, F. Cabrera Lopez,
Jorge I. Calzada, J. M. Cubero Parra,
F. Faus Guijarro, G. Fernandez-Sanz,
J. R. García-Martinez, F. Gonzalez-Gonzalez,
Philippe Koch, F. J. Lara-Medina,
J. Marticorena Salinero, J. Nadal Reus,
M. I. Relimpio-López, Zoran Tomic,

D. Ruiz-Casas
Cajal, Madrid, Spain F. Espejo Arjona
Ophthalmology Department (Vitreo-Retina and
U. Spandau (*) · Z. Tomic Ocular Oncology), Virgen Macarena University
Department of Ophthalmology, Uppsala University Hospital, Seville, Spain
F. Faus Guijarro
F. Armadá-Maresca Universitary Hospital Miguel Servet, Zaragoza, Spain
Ophthalmology Department, University Hospital La
Paz, Madrid, Spain G. Fernandez-Sanz
Fundacion Jimenez Diaz University Hospital and
F. Cabrera Lopez Ruber Juan Bravo Hospital, Madrid, Spain
Ophthalmology Department, Complejo Hospitalario
Universitario Insular, Materno-Infantil de Gran J. R. García-Martinez
Canaria, Palmas de Gran Canaria, Spain Hospital La Paz Madrid, Madrid, Spain
Ophthalmology Department, Universidad de Las, Oftalvist Madrid, Madrid, Spain
Palmas de Gran Canaria, Spain F. Gonzalez-Gonzalez
J. I. Calzada Retina Unit, Hospital Perpetuo Socorro, Complejo
Charles Retina Institute, Memphis, TN, USA Hospitalario Universitario Badajoz (CHUB),
Badajoz, Spain
J. M. Cubero Parra
Vitreo-Retina Unit Hospital la Arruzafa, Ophthalmology Department, Hospital Quiron Salud
Córdoba, Spain CLIDEBA, Badajoz, Spain
M. Elgohary P. Koch
Kingston Hospital, Kingston upon Thames, UK Paris South University, Orsay, France

https://doi.org/10.1007/978-3-319-78446-5_38
F. J. Lara-Medina M. I. Relimpio-López
Hospital Clínico Universitario Lozano Blesa, Virgen Macarena Hospital/Santa Angela de la Cruz,
Zaragoza, Spain VIAMED Hospital, Seville, Spain
J. Marticorena Salinero aMIRAS Ophthalmology Clinic, Seville, Spain
Department of Ophthalmology, Complejo
M. Veckeneer
Hospitalario Universitario de A Coruña (CHUAC),
ZNA Middelheim Hospital, Antwerp, Belgium
A Coruña, Spain
J. Zarranz-Ventura
J. Nadal Reus
Institut Clínic of Ophthalmology (ICOF), Hospital
Clínic of Barcelona, Barcelona, Spain
Extras: Videos 38.1, 38.2, 38.3, 38.4, 38.5, 38.6,

38.7, 38.8, 38.9, 38.10, 38.11, 38.12, 38.13,
38.14, 38.15, 38.16, 38.17, 38.18, 38.19, 38.20,
38.21, 38.22, 38.23, 38.24, 38.25, and 38.26.
The video case reports include a written case

description, a fundus drawing, and the video. The
videos can be downloaded from the website
extras.springer.com. Enter the ISBN number of
your book and you can access all videos.
38.1 hronic Retinal Detachment

C
with Anterior and Posterior
PVR and Peripapillar Fig. 38.1 RD with subretinal strands
Subretinal Strands
in a Napkin Ring
Configuration (Video 38.1)
38.1.1 Case Description (Fig. 38.1)
A 72-year-old patient with total retinal detach-

ment (RD), stiff retina, anterior PVR, posterior
epiretinal membranes (ERM), and extensive
peripapillar subretinal strands in a napkin ring
configuration. He had been operated elsewhere
9 months before, but due to RD recurrence, it
was decided not to operate again. Best-corrected
visual acuity (BCVA) was light perception
(LP). He had a transparent cornea and was
pseudophakic with 180° posterior synechia.
Fig. 38.2 Retina attached under silicone oil
38.1.2 Surgery (Fig. 38.2)

Intense retinal rigidity was observed due
A four-port 23G pars plana vitrectomy (PPV) to massive subretinal proliferation. An access
was performed (EVA vitrectomy system with retinotomy was performed on the inferior-
valvulated microcannulae and TDC cutter). nasal retina to remove peripapillar subretinal
38 Video Cases 387
embranes, but complete removal was unsuc-

m
cessful. A second superior-nasal retinotomy was
then performed to achieve complete subretinal
band removal.
Afterward, several ERMs were observed and
removed from the macular area.
Then a 270° relaxing retinectomy (from 5 to
12 h) was performed to deal with retinal stiff-
ness due to intraretinal PVR. The retina was
reattached with heavy liquid (PFCL), and 360°
endophotocoagulation was completed under
heavy liquid.
Finally a direct PFCL-5000cs silicone oil
(SO) exchange (PSX) was performed. First,
PFCL was injected until it flowed back through
the disconnected infusion line, and then SO
was injected through the infusion line at a Fig. 38.3 Preoperative RD with PVR and luxated IOL
3-bar pressure, while PFCL was aspirated by
active extrusion (stopping aspiration when IOP
dropped). (VB) with vitreous cutter and forceps. Then the
IOL was displaced into the anterior chamber
(AC) with two end-grasping forceps and removed
through a limbal incision.
38.1.3 Follow-Up Afterward posterior epiretinal membranes
(ERMs) were removed bimanually using for-
The patient was instructed to remain face down ceps + vitreous cutter or two forceps. A subreti-
for 10 days after surgery. Two months after sur- nal band was also removed through a pre-existing
gery, BCVA was of counting fingers, and the ret- retinal tear at XI with forceps using endoillumi-
ina remained attached. nator as a fulcrum.
Then, heavy liquid (PFCL) was used to reat-
tach the retina draining chronic thick subretinal
38.2 Retinal Detachment fluid (SRF) through peripheral tears at 7 and 11
with PVR CP9, Subretinal hours.
Strands, and Luxated IOL The lower fibrotic posterior hyaloid (PH) at
VB insertion was also removed bimanually with
38.2.1 Case Description (Fig. 38.3) forceps and scissors.
Finally a 360° laser cerclage and PFCL-Air
A 55-year-old pseudophakic patient (cataract exchange (FAX) followed by Air-5000cs sili-
surgery 1 year ago) with previous uveitis history cone oil (ASX) were performed.
was referred due to visual acuity (VA) loss for Silicone oil (SO) was left for 6 months and
6 months. He presented a RD PVR CP9 with cornea got cloudy. Thus SO removal was done
intraocular lens (IOL) and capsular bag luxation using an Eckardt temporary keratoprosthesis
(Video 38.2). (TKP) after removing the cloudy cornea and
releasing anterior synechiae. The retina
remained attached without SO, but PFCL bub-
38.2.2 Surgical Procedure bles in the vitreous cavity were found, which
were removed with a dual bore cannula. A mac-
A four-port 23G pars plana vitrectomy (PPV) ular ERM was peeled with end-gripping forceps.
was performed. First the luxated IOL was There were also a few subretinal PFCL bubbles
released from the lower fibrotic vitreous base that were removed through microretinotomies
(made with a 23G Pick) using active suction one of the superior cannulas. Care is taken to
with a silicone tip cannula. Finally the donor avoid unnecessary loss of SO passively through
corneal graft was sutured. the ports by having an instrument or a plug inside
the port at all times. Even with an open port, the
high viscosity of SO leads to very slow flow of oil
38.2.3 Follow-Up (Fig. 38.4) out of the eye, helping maintain the IOP within
target range.
The retina was completely attached without tam-
ponade, and BCVA was 0.2 after the two surgical
procedures. 38.3.2 Surgery Description
(Figs. 38.5 and 38.6)
38.3 VR Reoperation Under

P The most critical steps of two-port PPV are
Silicone Oil (Video 38.3) epiretinal membrane (ERM) peeling, peripheral
interface vitrectomy, retinectomy, and subreti-
38.3.1 Case Description nal fluid (SRF) aspiration. Most cases, like the
one in our video, begin with forceps membrane
The technique presented in the video is my pre- peeling. I usually prefer to identify and peel
ferred approach for pars plana vitrectomy (PPV) ERMs initially in the posterior pole and con-
reoperation for recurrent retinal detachment (RD) tinue the peeling dissection to the periphery.
when silicone oil (SO) is already inside the vitre- Peeling under SO has advantages and disadvan-
ous cavity. Instead of standard three-port PPV, in tages. If a meniscus of aqueous fluid is present
these cases I do not use an infusion cannula, so under the SO and over the retina, identification
we call it “two-port PPV under oil.” The endoil- of the plane of the peeling may be difficult.
luminator is introduced through one port, and the
active instrument is introduced through the sec-
ond port. Intraocular pressure (IOP) is managed
by intermittently injecting silicone oil (SO) into
Fig. 38.4 Postoperative retinal reattachment and corneal

graft Fig. 38.5 Epiretinal membrane peeling under silicone oil
38 Video Cases 389
retinal space and track posteriorly to a

submacular hemorrhage. Meticulous hemostasis
during dissection is particularly important with
this technique.
Subretinal fluid (SRF) drainage can be per-
formed directly through a retinal break under
the silicone oil (SO). As SRF is drained, SO
may need to be injected into the eye to main-
tain adequate IOP. The steps of peeling, reti-
nectomy, SRF aspiration, and SO injection may
be repeated as needed until the retina is
attached. At this point, laser retinopexy can be
Fig. 38.6 Interface vitrectomy with subretinal fluid performed through the SO with an intraocular
drainage under silicone oil laser probe.
A significant advantage of this general tech-
nique is total duration of surgery when com-
Continued experience with this technique pared to other more involved procedures. The
improves the ability of the surgeon to properly patient’s tolerance for the procedure and the
grasp the ERM as intended. Once a membrane low levels of inflammation postoperatively are
is grasped and peeling is initiated, the reflection also benefits. This technique can be combined
of the SO over the ERM actually facilitates the with phacoemulsification in a phaco-vitrectomy
visualization of the sheet of proliferative vitreo- approach for simultaneous management of a
retinopathy (PVR) membranes. In the video pre- cataract. Pars plana lensectomy in an oil-filled
sented, one can clearly visualize the leading eye with the two-port PPV approach may be
edge of the ERM as it’s been lifted off of the very difficult, though, and in my opinion is best
retina and extended toward the retinal avoided.
periphery.
During PVR reoperation under SO, complete
removal of retinal traction and drainage of SRF 38.4 Retinal Detachment
lead to immediate reattachment of the retina. If with PVR CP6 and Hypotony
all identifiable ERMs are peeled and the retina (Video 38.4)
still remains detached, the usual next step is
peripheral retinectomy. Intraocular cautery 38.4.1 Case Description (Fig. 38.7)
should be used to delineate the area of retinec-
tomy and to decrease bleeding from the site of A 72-year-old woman with recurrent retinal
the retinectomy. Intraocular hemorrhage in two- detachment (RD) under silicone oil (SO) in her
port PPV under SO can be a problem some- right eye. She had been operated of pars plana
times, since the blood doesn’t diffuse through vitrectomy (PPV) because of RD and macular
the SO in the vitreous, leading to a localized hole three times.
clot. This local hemorrhage can either impede The right eye was pseudophakic, and it was
visualization of the retina that requires dissec- diagnosed of atrophic age-related macular degen-
tion or retinectomy or can extend into the sub- eration (AMD) 6 months ago.
two forceps to avoid retinal tearing. The scarred

PH remnants at VB were dissected bluntly with
two forceps in order to relieve circumferential
traction.
Then, heavy liquid (PFCL) was used to
reattach the retina but inferior retinal stiffness
prevented it. Thus, an inferior retinectomy was
performed to relax anterior-posterior traction.
Diathermy was applied to the cutting area,
and the vitreous cutter was used to remove the
stiff anterior retina and anterior vitreous rem-
nants to avoid any traction at ciliary body and
hypotony.
Fig. 38.7 Preoperative RD A subretinal clot was moved to the retinec-
tomy edge sweeping it smoothly with a silicone
tip cannula and extracted with the vitreous cut-
Snellen best-corrected visual acuity (VA) was ter. Subretinal membranes at the retinectomy
light perception (LP) without projection. edge were removed directly with forceps.
Slit-lamp examination revealed anterior cham- Finally, the vitreous cavity was filled with
ber cells ++ and posterior-superior synechia with PFCL to reattach the retina, and laser photoco-
pigment on intraocular lens (IOL) and inferior agulation was applied to the retinectomy border.
iridectomy. 5000cs SO was left as tamponade using a PFCL-
IOP was 4 mmHg. Air exchange (FAX) followed by an Air-Silicone
Fundus examination showed RD with epireti- oil exchange (ASX).
nal membranes (ERMs) on the macula and tempo-
ral quadrant with severe inferior retinal stiffness.
The left eye was amaurotic because of a RD 38.4.3 Follow-Up (Fig. 38.8)
40 years ago.
38.4.2 Surgery Description
A 23G PPV with an accessory light infusion was

conducted under general anesthesia.
First, SO was removed and macular ERMs
were peeled bimanually with two forceps. One
forceps was used to grasp the ERM and the
other one to dissect it bluntly from the
underlying retina. ERMs with extreme retinal
adherence were segmented using forceps and
scissors.
Posterior hyaloid (PH) remnants were found
on the upper retina, and they were detached up to
the posterior vitreous base (VB) by pulling with Fig. 38.8 Postoperative retinal attachment under silicone oil
38 Video Cases 391
The patient was instructed to stay on prone posi- She attended her first and second postopera-
tion during the day and on left lateral decubitus at tive follow-up visits and was awaiting her final
night, for a week. follow-up at about 4 months. The retina was
After a 4-month follow-up, the retina was attached and her visual acuity was 6/9. She pre-
attached under SO. sented to Eye Casualty at about 8 weeks postop-
Best-corrected VA was counting fingers (CF) eratively complaining of blurred and distorted
due to macular atrophy, but the patient was able vision in the left eye. The visual acuity (VA) was
to recognize colors and orient herself in an 6/12, and OCT showed that she had early signs
unknown room without help. of an epiretinal membrane (ERM). She was
listed to have PPV and peeling of ERM in
6–8 weeks.
38.5 acular PVR Membranes
M Almost 2 weeks later, she returned to Eye
Developing Acutely After Casualty with macula-off recurrent RD, and
Macula-On Retinal her VA had gone down to hand movements.
Detachment Surgery She was taken straight for surgery on the same
day (Video 38.5).
A Caucasian female patient in her late 60s pre- 38.5.2 Surgery Description
sented with a macula-on retinal detachment (Fig. 38.10)
(RD) in her left eye. During the surgery she was
found to have multiple U-shaped tears along the During surgery, it was found that she had devel-
attachment of the posterior hyaloid (PH) to the oped a significant macular PVR membrane,
posterior vitreous base (VB). She was highly which had centrifugally contracted and opened
myopic (nearly 9) and also had RD in the right up the treated breaks and caused recurrence of
eye treated with vitrectomy, cryotherapy, and the RD.
SF6 gas tamponade.
Pars plana vitrectomy (PPV) proceeded as nor-
mal. I checked complete posterior vitreous detach-
ment (PVD), and I treated the tears with cryotherapy
and performed Fluid-Air exchange (FAX) followed
by Air-Gas SF6 tamponade (AGX).
Fig. 38.9 Epiretinal membrane Fig. 38.10 RD with PVR

I used trypan blue to improve visualization of force to the fovea. Once the membrane was
the ERM and internal limiting membrane (ILM) clear of the macula and close to the arcade, I
and a contact lens to improve my stereopsis. I then used the wide-field (128D) lens to com-
started the peeling posteriorly, between the disc plete the peeling. I then performed FAX until
and fovea, proceeding first toward the fovea until the retina was attached removing the subretinal
the thick band of the membrane was off the fovea fluid (SRF) remnants with heavy liquid (PFCL)
and then proceeded away from the fovea. I felt and applied laser to the edges of the opened
that there were some remnants of the PH that breaks. I carried out AGX and used C3F8
probably had not detached fully during the first tamponade.
surgery and that this was the predisposing factor
for the development of the PVR membrane and
led to opening of the breaks and therefore recur- 38.5.3 Follow-Up (Fig. 38.11)
rence of the RD.
Further peeling was performed along the Postoperatively, VA improved to 6/12 as the cata-
axes that were not directly transferring the ract developed. After cataract surgery VA was 6/9.
Fig. 38.11 Postoperative

OCT and fundus picture
38 Video Cases 393
38.6 Long-Standing Retinal removal; it was segmented and removed with

Detachment with the vitreous cutter. The last scarred PH rem-
PVR CP12 + CA12 nants at VB insertion were gently removed
and Hypotony bimanually with forceps and scissors. PH dis-
section and PFCL injection opened the retinal
38.6.1 Case Description (Fig. 38.12) funnel, but a thickened posterior retina was
now observed.
This pseudophakic patient suffered a previous Posterior ERMs and ILM were stained with
ocular trauma and uveitis. He presented a com- Brilliant Blue and removed with forceps. However,
plete closed funnel retinal detachment (RD), stiff after ERM and ILM peeling, the posterior retina
and thickened retina, and choroidal thickening.
The eye was hypotonic (IOP = 1 mmHg), and
visual acuity (VA) was light perception (LP).
Surgery was delayed twice due to skin rash and
conjunctivitis (Video 38.6).

(Fig. 38.13)
A 23G pars plana vitrectomy (PPV) and 360°

retinectomy without buckling were indicated.
A scarred posterior hyaloid (PH) attached
at posterior vitreous base (VB) edge was
found during surgery. This PH plaque induced
massive circumferential traction and hindered
posterior epiretinal membrane (ERM) Fig. 38.13 360 retinectomy
Fig. 38.12 Preoperative ultrasound. Closed funnel RD

still looked wrinkled because of intraretinal PVR

precluding retinal reattachment.
A 360° retinectomy was performed to relieve
anterior-posterior traction due to retinal shorten-
ing and allow retinal reattachment. First, heavy
liquid (PFCL) was used to stabilize the macular
area and avoid retinal rotation. Afterward, dia-
thermy all around the cutting area was per-
formed to avoid subretinal bleeding. Then
retinectomy was performed at posterior VB edge
where many retinal tears were found. The retina
was cut with the vitreous cutter, but four retinal
bridges were left uncut to avoid retinal displace-
ment or rotation. Finally PFCL was injected
again up to the retinectomy edge, and the retinal
bridges were eventually cut. The posterior reti-
nal folded back due to intrinsic contraction, it Fig. 38.14 Peripheral RD
looked thickened and cystic, but no subretinal
membranes were found. Choroidal thickening
was also observed.
The retina was attached with PFCL. However,
the posterior retina still looked wrinkled, and it
did not stretch despite retinal massage with a soft
tip cannula and ERM remnant removal.
Photocoagulation of the retinectomy edge was
performed with three laser rows, and a PFCL/
BSS-Air exchange (FAX) was used to reattach
the retina, drying carefully the retinectomy edge
to avoid retinal slippage. Once the retinal edge
was flat and dry, the rest of PFCL was removed at
optic nerve and an Air-5000cs silicone oil (SO)
exchange (ASX) was performed. Fig. 38.15 Retinal attachment under silicone oil
because of posterior PVR. Best-corrected visual

38.6.3 Follow-Up acuity (VA) was 0.4.
Despite macula attachment peripheral RD was
The retina remained attached under oil but IOP was due to immature epiretinal membranes (ERMs)
low and best-corrected VA was hand motion (HM). covering the whole retinal surface (Video 38.7).
38.7 eripheral RD with Initial

P 38.7.2 Surgery Description
Immature Membranes over (Fig. 38.15)
360° Peripheral Retina
A 23G pars plana vitrectomy (PPV) was con-
38.7.1 Case Description (Fig. 38.14) ducted under local anesthesia plus s edation.
Initially a little vitrectomy was performed
A 52-year-old man previously operated (three because the patient had been previously vitrecto-
times) of RD who presented with a new complete mized, and there were almost no peripheral vitre-
peripheral macula-on retinal detachment (RD) ous remnants. Then heavy liquid (PFCL)
38 Video Cases 395
(perfluorooctane) was used to preserve macular 38.8 ocalized Inferior Retinal

L
attachment during surgery. Redetachment Due to PVR
ERMs were stained with two-dye mixture CA4 with Macular ERM
(Brilliant Blue G plus trypan blue used for cataract
surgery) after Fluid-Air exchange (FAX). Dye was 38.8.1 Case Description (Fig. 38.16)
left in the eye for 2 min to get complete peripheral
retina proliferation staining. During the staining A 52-year-old man who came to the clinic as a
time smooth eye movements were done so that dye follow-up of a macula-on rhegmatogenous reti-
reached the whole peripheral retina, obtaining a nal detachment (RD) surgery (23 G vitrec-
nice visualization of all immature membranes. tomy + cryotherapy + endolaser + SF6 26%)
Air-Fluid exchange (AFX) was performed and performed 2.5 months ago in the right eye
the dye was washed up. (RE). He had a couple of episodes of inflamma-
Then, ERM peeling was carefully performed tory flare-up during this time as he was taper-
under fluid. During the peeling the light probe was ing his steroid drops, and these were treated by
moved to illuminate tangentially on the retinal increasing the frequency of instillation of the
surface and facilitate the visualization of immature drops. He complained of recent appearance of
membranes. PFCL was injected twice to stabilize distortion and decreased visual acuity (VA) of
the retina and peel from posterior to anterior trying his RE over the previous 2 weeks.
to eliminate the PVR membranes as much as Snellen best-corrected visual acuity (BCVA)
possible. of the RE was 0.1 (1 month prior it had been of
Finally FAX was performed to reattach the ret- 0.7) and 1.00 in the left eye (LE). Slit-lamp exam-
ina and remove subretinal fluid (SRF) completely. ination revealed a clear cornea, deep anterior
Panretinal photocoagulation was applied, and Air- chamber, no anterior chamber cells, and a mild-
Silicone oil exchange (ASX) was performed leav- moderate nuclear opacity of lens. Intraocular
ing heavy silicone oil (Densiron) as tamponade. pressure (IOP) was 10 mmHg in RE and 12 mmHg
in LE. RE fundus examination showed a thick
epiretinal membrane (ERM) on the superior half
38.7.3 Follow-Up of the macula with significant traction and epireti-
nal pigment (macular PVR). Optical coherence
Densiron was removed 4 weeks later without tomography (OCT) confirmed the ERM. The ret-
complications. BCVA was 0.4, and the retina ina looked mostly attached with cryo and laser
remained attached. scars, but there was a fibrotic vitreous skirt and
Fig. 38.16 Preoperative OCT of RE. BCVA was 0.1, and it showed a thick ERM affecting the superior half of the
macula
vitreous base (VB) on the nasal periphery (from 1 so 23 GA end-gripping forceps (Storz) were used
to 7 h) that was lifting the retina infero-nasally to start an en bloc peel of ILM and ERM. The
(localized RD) with no break seen. ILM was restained and the peel was completed.
Surgical treatment was indicated, with com- Vitrectomy was enhanced with the help of the
bined 360° buckle + vitrectomy + ERM/ILM indent created by the buckle. The indentation
peel + C3F8 in RE. Cataract surgery was left for a seemed a bit low, so the band was tightened.
future surgery once the final axial length was Triamcinolone was injected intravitreally to
determined. highlight any vitreous remnants. A peripheral
retinotomy was performed with the cutter, on the
apex of the indent in the supero-nasal quadrant,
38.8.2 Surgery (Video 38.8) to drain the subretinal fluid (SRF) since no break
had been identified.
Surgery was conducted under general anesthesia. A 360° scleral depressed search was done and
A 360° conjunctival peritomy was performed, cryotherapy was given to any suspicious areas.
creating radial relaxing incisions at 3 and 9 Fluid-Air exchange (FAX) was performed with
o’clock to prevent tearing of the conjunctiva. The internal drainage of SRF through the peripheral
rectus muscles were slung with 2/0 black silk retinotomy. Complete attachment of the retina was
sutures. An encircling band (model 240) was observed under air. 360° laser was applied and
passed under the rectus muscles, and it was fixed cryotherapy of the retinotomy was performed. The
with a sleeve in the supero-temporal quadrant. supero-temporal sclerotomy was sutured with 8/0
5/0 nylon sutures were passed in each quadrant to Vicryl, and an Air-Gas C3F8 14% exchange (AGX)
fix the band approximately around the equator of was done. The other sclerotomies and conjunctiva
the eye (12 mm posterior to the limbus). were closed with 8/0 Vicryl. Finally, subconjuncti-
Three ports for 23G pars plana vitrectomy val antibiotics and steroids were given.
(PPV) were used. Staining of the ERM and ILM
(ILM-Blue, DORC) was done directly since it
was a vitrectomized eye. A flat disposable macula 38.8.3 Follow-Up (Fig. 38.17)
lens was placed (1284 DD, DORC), and 23 GA
asymmetric peeling forceps (Storz) were used to The patient was instructed to posture face down
start the peel of the ERM. At a certain point, the during the day and to sleep on his right side for
traction exerted while peeling seemed excessive the initial 7 days after surgery. After this, posture
Fig. 38.17 OCT RE. Ten weeks post-operation. BCVA was 0.3. No signs of ERM and partial recovery of the normal
foveal contour were noted
38 Video Cases 397
was free during the day and limited to the night- Vitreous base (VB) contraction and anterior
time when he had to keep on sleeping on his right retinal pulling due to anterior PVR in nasal
side for another 2 weeks. quadrants with several retinal holes were
After 10 weeks, complete reattachment of the observed; there were also peripapillary subreti-
retina was achieved in the absence of intraocular nal membranes in a napkin ring configuration
gas. Snellen BCVA of the RE was 0.3. Slit-lamp and a subretinal clot in the superior quadrant.
examination revealed a clear cornea, deep ante- Her visual acuity (VA) was counting fingers at
rior chamber, anterior chamber cells +/−, poste- 50 cm in LE and 0.7 in RE. Slit-lamp examina-
rior synechiae at 3 and 12 h, and a moderate tion revealed corneal clouding, a posterior
nuclear opacity with moderate subcapsular scle- chamber intraocular lens (IOL) and posterior
rosis of lens. IOP was 10 mmHg in RE. RE fun- capsule fibrosis, and opacification with atrophic
dus examination showed no gas, good indentation iris (Video 38.9).
of buckle 360°, laser scars on the buckle 360°,
complete reattachment of the retina, and macula
with good appearance. 38.9.2 Surgery Description
Optical coherence tomography revealed no (Figs. 38.18, 38.19, and 38.20)
ERM and no macular edema.
Surgery was conducted under retrobulbar anes-
thesia and sedation. A 23G transconjunctival pars
38.9 VR RD with Napkin Ring,
P plana vitrectomy (PPV) with an accessory chan-
Subretinal Membranes, delier light was performed using a contact wide-
and Subretinal Clot field viewing system (Landers wide-field
vitrectomy contact lens).
38.9.1 Case Description (Fig. 38.18) At the beginning, corneal epithelium, IOL,
and fibrotic capsular bag were removed because
A 65-year-old woman was referred from another they precluded a correct retinal visualization.
hospital with a history of three failed retinal Initially, heavy liquid (PFCL) was carefully
detachment (RD) surgeries in her left eye. She injected to stabilize and fixate posterior retina
was previously treated with scleral buckle and and assess equatorial retina behavior. The retina
vitrectomy + gas tamponade, but she developed at VB had a moth-eaten aspect, and the anterior
RD with proliferative vitreoretinopathy (PVR). retinal tissue looked fibrotic at nasal and superior
Fig. 38.19 Image of the fundus with subretinal clot in

Fig. 38.18 Anterior segment with cloudy cornea and the superior arcade, subretinal membranes, moth-eaten
posterior chamber IOL with capsular fibrosis and aspect of peripheral retina, and anterior PVR at the nasal
opacification quadrant
infusion line was disconnected, and PFCL was

injected until it passed through the disconnected
infusion line. At this moment, silicone oil was
injected through the temporal-superior microcan-
nula, and PFCL aspirated with a soft-tipped can-
nula through the other superior microcannula. At
the end, the soft tip cannula was placed over the
optic nerve or far away from the macula to
remove all the PFCL.
38.9.3 Follow-Up
Fig. 38.20 Final result with complete retinal attachment
Patient was instructed to avoid face up position
for the initial 10 days after surgery.
retinal quadrants; thus a circumferential relaxing/ Complete attachment of the retina was
access retinotomy, posterior to the scarred retinal achieved, but visual acuity improvement was
tissue, was performed. Prior to performing the very poor due to corneal clouding and chronic
retinotomy, PFCL was aspirated to avoid PFCL macular edema. The patient refused further surgi-
bubble migration into the subretinal space and cal interventions.
diathermy was done, and then the retina was cut
with the vitreous cutter. The retinotomy was large
enough to allow adequate access to subretinal 38.10 Retinal Detachment
membranes. in Perforating Ocular Trauma
The best way to remove subretinal membranes
is bimanually. Forceps are used to grasp the 38.10.1 Case Description
membrane and gently pull it to determine whether
it will strip free. A cannula, vitreous cutter, Perforating ocular trauma caused by a fire
endolight, or other forceps can be used to support weapon (slug shotgun) in a 62-year-old male
the membrane tangentially and avoid traction on patient without any personal or ocular history of
the retina. interest. The entrance wound was in the superior
Once the subretinal membranes were extracted, pars plana, and the exit wound was suspected to
the subretinal clot was lifted grasping it with forceps. be temporal and retroequatorial.
The subretinal clot was attached strongly to the ante- Best-corrected visual acuity (BCVA) was light
rior retina, and two forceps were needed to pull it out perception and projection. No intraocular struc-
gently from the retina, and then it was removed with tures were observed due to dense vitreous hemor-
the vitreous cutter. rhage. Intraocular pressure (IOP) was 4 mmHg.
After all membranes were removed, the retina CT scanner showed a foreign body allocated
was reattached with PFCL, injecting it over the in the retroequatorial extraocular inferior-
retinal edge, and 360° three-row laser photoco- temporal orbit (Video 38.10).
agulation was performed at the retinal edge under
PFCL.
After the retina was reattached, silicone oil 38.10.2 Surgical Procedure
was chosen as a tamponade in this case with an (Fig. 38.21)
almost 360° retinotomy. A direct PFCL-Silicone
oil exchange was performed to prevent retinal Exploration surgery was conducted under gen-
slippage. Direct PFCL-Silicone oil exchange eral anesthesia. After conjunctival peritomy, a
(PSX) was set in the vitrectomy console. First, 3 mm superior pars plana wound was observed
38 Video Cases 399
Fig. 38.22 Retina attached under SO
Fig. 38.21 Perforating ocular trauma with RD and exit

wound sive PVR; initial scarred PH membranes at VB
were removed with vitreous cutter and forceps.
and sutured, but no exit wound was found. The exit wound was already separated from the
Then, according to CT scan images, lateral rec- retina and supported by the buckle; thus no reti-
tus muscle was deinserted to access retroequa- nectomy or chorioretinectomy was performed
torial sclera where the exit wound was found because there was no retinal traction from the
and sutured. wound.
Once the ocular globe was closed, a 23G pars
plana vitrectomy (PPV) was performed. The lens
was removed preserving lens capsule due to the 38.10.3 Follow-Up (Fig. 38.22)
complexity of the case to improve visualization.
A retinal detachment (RD) with subretinal bleed- The evolution was favorable getting a complete
ing and a temporal exit wound were observed. retinal reapplication. A secondary intraocular
Vitreous shaving, lifting posterior hyaloid (PH) lens (IOL) implantation surgery in sulcus was
as much as possible up to vitreous base (VB), performed, achieving 20/60 BCVA.
was performed. Then, the retina was attached We would like to highlight in these cases that
with heavy liquid (PFCL), and the exit wound early intervention, with vitrectomy lifting PH to
treated with laser. Finally silicone oil (SO) was VB, improves considerably the prognosis of
left as tamponade performing Fluid/PFCL-Air these cases.
exchange (FAX) followed by Air-Silicone oil
exchange (ASX).
No retinectomy/chorioretinectomy was per- 38.11 I nferior Retinal Detachment
formed due to bad visualization to reduce iatrog- with Subretinal Strands
eny leaving it for a second procedure if
necessary despite a likely redetachment due to 38.11.1 Case Description
PVR. (Fig. 38.23)
The postoperative evolution was satisfactory
achieving a retinal reattachment; however, 2 This 22-year-old military man came back from
weeks later an expected redetachment was war with a head blunt trauma associated with a
observed in the temporal area. A second surgery full right eye retinal detachment (RD) since more
under local anesthesia was performed. than 2 weeks. Multiple strands of subretinal PVR
First, a 2.5 mm encircling band was sutured at were observed in the fundus (including under the
equator to relax a likely scarred VB. Then 23G macular area) and associated with a series of
PPV was performed lifting PH thoroughly up to inferior retinal breaks extending from 3 to 7
VB in order to avoid redetachment and aggres- o’clock in the periphery.
injected again in the vitreous cavity to perform a

laser treatment of the periphery as well as on
every posterior access retinotomy. And a direct
PFCL-Heavy silicone oil (SO) (Densiron)
exchange (PSX) was performed to allow a com-
plete vitreous filling.
38.11.3 Follow-Up (Fig. 38.25)
In this young patient, heavy SO removal was per-

formed 6 weeks after surgery, and retina is still
attached 18 months after surgery with a best-
corrected visual acuity (BCVA) of 20/100, even
following this submacular cord removal.
In conclusion, the use of a 23G ILM pick sub-
retinally frequently allows weakening the sub-
Fig. 38.23 RD with subretinal strands
retinal strands prior to removing them from the
subretinal space with conventional forceps. This
38.11.2 Surgical Procedure action is more respectable of the subretinal anat-
(Fig. 38.24) (Video 38.11) omy by pulling in a counter direction, opposite to
the site of attachment of the residual PVR cord.
Viewing modes: Slit lamp from Zeiss. Sometime, multiple subretinal openings are
Noticeable instruments: 23G vertical scissors required to weaken the cord at different places
from Eyetech, 23G ILM pick from Synergetics, prior to its removal.
and 23G ILM forceps from DORC.
A two-port 23G pars plana vitrectomy (PPV)
was thus performed, and posterior vitreous detach- 38.12 R
etinal Detachment Under
ment (PVD) was obtained using the vitreous probe. Silicone Oil with PVR CA3
A heavy liquid (PFCL) bubble was then injected to
secure the retina during peripheral vitrectomy. As 38.12.1 Case Description (Fig. 38.26)
observed in the video, a cautious vitrectomy was
performed using the DORC peristaltic pump to This is the case of a 49-year-old man who pre-
avoid grasping the retina while shaving the vitre- sented 5 months ago with a history of ocular
ous, even using a cut-by-cut method. Peripheral trauma and a decreased visual acuity (VA) since
retinal breaks were then enlarged inferiorly to help 10 days. Examination showed a full retinal
remove subretinal fluid (SRF) and tobacco dust. detachment (RD) of the left eye due to a giant
PFCL was then removed to work on the subretinal retinal tear (GRT) extending from 7 to 11 o’clock
PVR. As shown in one example of subretinal band associated with multiple risk factors of PVR
removal, the retina is dissected using a vertical (massive vitreous bleeding, hypotony, choroidal
scissor parallel to the subretinal strand, and a 23G detachment, and tobacco dust). The patient was
ILM pick is then inserted subretinally to allow a operated with a 23G pars plana vitrectomy (PPV),
lateral mobilization of the strand prior to pulling it. a laser treatment around the GRT, and silicone oil
Normally, the weaker part of the subretinal cord (SO) injection at the end of surgery to reposition
will release first, and a 23G forceps would then the retina.
allow grasping efficiently the residual cord to pull Even with an appropriate tamponade using
on it in a contralateral direction. SO, the patient developed 1 month after his first
After removing the different subretinal PVR surgery a massive inferior PVR CA3, contract-
cords using the same method, a PFCL bubble is ing the retina from 4 to 7 o’clock and opening
38 Video Cases 401
Fig. 38.24 Subretinal

strand removal
Fig. 38.25 Postoperative retinal reattachment Fig. 38.26 RD with inferior PVR
again the initial tear at 7 o’clock. He was thus

immediately reoperated to stabilize the
situation.
38.12.2 Surgical Procedure

(Fig. 38.27) (Video 38.12)
–– Viewing modes: Slit lamp and Resight from

Zeiss.
–– Noticeable instruments: 23G diamond duster,
23G ILM pick from Synergetics, and 23G
Fig. 38.27 Anterior PVR dissection
ILM forceps from DORC.
The procedure started with a SO removal

through a two-port 23G PPV and an active extru-
sion. A wide-angle viewing system allowed to
visualize the PVR areas contracting the retina
inferiorly, as confirmed by a trypan blue
staining.
Complete vitreous shaving was checked
using a vitrectomy probe, and a diamond duster
and 23G forceps were then used to try to detach
anterior epiretinal membranes (ERMs).
However, ERM attachment was too strong, and
these attempts were inefficient using these con-
ventional methods. As a contrary, the use of an
ILM pick allowed a smooth dissection and
detachment of this ERM until being peeled
using forceps.
A second set of ERM dissections was then
Fig. 38.28 Postoperative retinal reattachment
performed to show how this pick can be helpful
to weaken and dissect the anterior PVR prior to
removing it from the retina using forceps.
As observed at the end of surgery, the inferior 38.13 C
hronic Retinal Detachment
retina was mobile again, and laser was applied with PVR CA1
inferiorly from 3 to 8 o’clock under heavy liquid
(PFCL) to secure the retina prior to performing a 38.13.1 Case Description (Fig. 38.29)
direct PFCL-Heavy SO (Densiron) exchange
(PSX). A 68-year-old male affected by a chronic pseudo-
phakic retinal detachment (RD) of 6 months of
evolution, vitreous haze, and localized upper
38.12.3 Follow-Up (Fig. 38.28) anterior PVR CA1.
Eight weeks later, a new surgery was performed

to remove Densiron and the retina remained 38.13.2 Surgical Procedure (Video 38.13)
attached. Another 2 months after surgery, the
patient is recovering with a flat retina and a best- Surgery started by placing a 2.5 mm scleral band
corrected VA (BCVA) of 20/200. 12 mm from the limbus. The band was fixed with
In conclusion, in some tricky situations, ILM scleral tunnels, avoiding the need for sutures and
pick is becoming a powerful instrument to achieving a better integration with ocular
weaken and dissect the PVR from the retina and surface.
then detach it with forceps. By slightly moving it Afterward, 23G pars plana vitrectomy (PPV)
laterally, this instrument achieves to weaken the was performed although vitreous turbidity hin-
PVR. However, in some situations, PVR cannot dered detached retina visualization. Once central
be dissected even using this method, and a vitreous was removed, superior vitreous base
peripheral retinectomy is preferred, particularly (VB) scarring and a retinal tear at 5 hours were
in cases where retinal breaks occur while peeling observed. Posterior hyaloid (PH) remained
the PVR. adherent to the upper peripheral retina. Vitreous
38 Video Cases 403
Fig. 38.29 RD with PVR CA1

Fig. 38.30 Retina attached under air
cutter without cutting was used to detach PH

using anterior-posterior movements parallel to Fluid/PFCL-Air exchange (FAX) was per-
the retina. This maneuver should always be performed followed by 360° laser cerclage. C3F8
formed stabilizing detached retina with external 12% was left as tamponade.
scleral indentation. Indentation can be performed
by an experienced assistant or preferably by the
surgeon (using an auxiliary chandelier light). 38.13.3 Follow-Up (Fig. 38.30)
Once PH was lifted, the vitreous cutter was
used to segment scarred PH at VB. When the vit- The retina was completely attached without
reous cutter could not dissect PH anymore, 23G tamponade.
ILM forceps were used instead. Anterior mem-
branes and scarred PH at VB were completely
dissected and removed bimanually with forceps 38.14 Complete Retinal
and vitreous cutter. Forceps were used to lift the Detachment with PVR CP1
membranes and vitreous cutter to dissect them and Retinal New Vessels
bluntly by back pressure movements. When a Secondary to Branch Retinal
cleavage plane was obtained, PH traction was cut Vein Occlusion
with the vitrectomy probe.
After dealing with localized anterior PVR, 38.14.1 Case Description (Fig. 38.31)
heavy liquid (PFCL) was injected to perform the
reattachment test and remove thick subretinal A 79-year-old man who reported to the clinic
fluid (SRF) through a pre-existing retinal tear. A because of decreased visual acuity of his right
pocket of persistent SRF in the nasal retina was eye over the previous 2 weeks. Snellen best-
removed with gentle massage toward the retinal corrected visual acuity (BCVA) of the right eye
tear by scleral indentation. Then, complete was counting fingers at 30 cm and 1.00 in the left
peripheral vitrectomy with indentation was eye. Slit-lamp examination revealed anterior
performed. chamber (AC) cells ++ and posterior synechia in
Finally, the eye was filled with PFCL, and 360° that were partially released after topical
laser photocoagulation was done on rheg- atropine administration. Nuclear opacity of lens
matogenous retinal lesions, especially on the and anterior capsule pseudoexfoliation were
retinal area where proliferations were removed. present. Right eye fundus examination showed
supero-temporal quadrant where an epiretinal

membrane (ERM) and fixed retinal starfolds
were present in the context of PVR. PH was also
attached at different foci of retinal NV. PVD and
partial ERM peeling at site of PVR were done
after staining with brilliant peel and trypan blue
(MembraneBlue-Dual, DORC). Special care
was taken during peeling in order to avoid iatro-
genic retinal tears in an ischemic and very friable
retina. Perfluorocarbon liquid (PFCL) was also
used to exert counterpressure during peeling.
Bimanual maneuvers to detach PH were done
with the help of an ILM forceps and a diamond-
dusted scraper. These permitted the creation of a
dissection plane that allowed to perform seg-
mentation of the PVR membranes and attached
Fig. 38.31 Right eye. Retinal detachment case
PH using the vitreous cutter. Dissection and
endodiathermy to retinal NV adjacent to the reti-
nal tear were done. Peripheral vitrectomy was
asteroid hyalosis, complete rhegmatogenous reti- performed under indentation with the light pipe.
nal detachment (RD) with proliferative vitreoret- Because of the posterior location of the retinal
inopathy (PVR), and the presence of different tear and presence of subretinal fluid (SRF) ante-
foci of retinal new vessels (NV) at the supero- rior to this lesion, the following maneuvers were
temporal quadrant secondary to ischemic branch performed before doing endolaser. First, vitre-
retinal vein occlusion (BRVO). Surgical treat- ous cavity was filled with PFCL up to the level of
ment was indicated, with combined phacoemul- retinal break. Then, a Fluid-Air exchange (FAX)
sification, intraocular lens (IOL) implantation, was performed with internal drainage of SRF
and pars plana vitrectomy (PPV). Measurement through the tear. Finally, additional PFCL was
of IOL was based on the keratometry of the right injected reaching an anterior plane of the tear,
eye and axial length of the left eye after discard- while residual air was replaced by fluid. Thus,
ing previous anisometropia. endolaser to the tear and sectorial laser to the
ischemic retina were done in complete absence
of SRF. After laser, Fluid/PFCL-Air (FAX) and
38.14.2 Surgery (Video 38.14) Air-Gas (C3F8 14%) exchange (AGX) were per-
formed. Complete attachment of the retina was
Surgery was conducted under retrobulbar anes- observed under PFCL, either under air.
thesia and sedation. Release of posterior syn-
echia, clear cornea phacoemulsification, and
in-the-bag implantation of IOL were initially 38.14.3 Follow-Up (Fig. 38.32)
performed. Three ports for transconjunctival
23-gauge PPV and an accessory chandelier light Patient was instructed to posture sitting up,
were used. At the beginning, exploration of com- avoiding faceup position for the initial 10 days
plete RD confirmed the presence of a single reti- after surgery. After 9 weeks, complete reat-
nal tear adjacent to retinal NV in between tachment of the retina was achieved in the
temporal vascular arcades. During initial central absence of intraocular gas. Optical coherence
vitrectomy, the absence of complete posterior tomography revealed no macular edema. Right
vitreous detachment (PVD) was observed. eye BCVA was 0.4 with impaired central
Posterior hyaloid (PH) was still attached at the fixation.
38 Video Cases 405
Fig. 38.33 Initial RD due to GRT with PVR CP1

Fig. 38.32 Right eye. Nine weeks after surgery with
complete retinal reattachment, sectorial endolaser scars at
the supero-temporal quadrant and the presence of hyalin-
ized retinal vessels secondary to BRVO. Arrow showing
remnants of dissected PVR membrane
38.15 Pediatric Retinal

Detachment with PVR
and Closed Funnel Retinal
Configuration
A 3-year-old highly myopic patient (−12D)

with a total retinal detachment (RD) due to Fig. 38.34 RD PVR CP12 + CA12 in closed funnel reti-
giant retinal tear (GRT). RD showed initial nal configuration
PVR with epiretinal membranes (ERM) at
macular area and rolled retinal edges. Best- 38.15.2 Surgery Description
corrected visual acuity (BCVA) was hand (Fig. 38.34) (Video 38.15)
movements.
A four-port 23G phaco-vitrectomy was car- A four-port 23G pars plana vitrectomy (PPV)
ried out, macular ERM and ILM were peeled, was performed to deal with RD with PVR
and careful bimanual posterior hyaloid (PH) CP12 + CA12 in a closed funnel retinal
detachment up to vitreous base (VB) was com- configuration.
pleted with two forceps. The retina was reat- First SO was removed, and the closed retinal
tached with heavy liquid (PFCL), and endolaser funnel was opened with viscodissection in order
was applied to the GRT edge. PFCL-Air to be able to reach the posterior pole. Then, pos-
exchange (FAX) followed by Air-Silicone terior ERMs were removed bimanually with two
exchange (ASX) was performed leaving forceps, and the macular area was stabilized with
5000cs silicone oil (SO) as tamponade. Despite PFCL. The peripheral retina was extremely stiff
meticulous initial surgery with preventive ILM due to intraretinal PVR, and a relaxing 360° reti-
peeling and PH detachment up to VB insertion, nectomy was done to relax anterior-posterior
PVR evolved inducing a complete RD under traction. The posterior retinal remnant was
silicone oil. attached with PFCL, but it was still contracted, so
Fig. 38.35 Retina attached under PFCL Fig. 38.36 RD with PVR CA6 and intraretinal PVR
retinal massage with a silicone tip cannula and complications. Eye fundus examination showed a
retinal stretching with two forceps were fulfilled complete rhegmatogenous retinal detachment
to relax circumferential retinal traction. (RD) with anterior PVR and the edge of the retina
Finally a complete retinal attachment under attached but a microbreak at posterior pole, which
PFCL was achieved and 360° endolaser at the enlarged during the bimanual surgery and multi-
retinectomy edge applied. FAX followed by ASX ple breaks in the second surgery. A dexametha-
was performed leaving 5000cs SO as tamponade sone implant was still inside the eye (in aphakia
(Fig. 38.35). cases, I currently suture it at one sclerotomy).
38.15.3 Follow-Up 38.16.2 Surgery Description

(Fig. 38.37) (Video 38.16)
The patient was operated to remove SO 8 months
after surgery, the retina remained attached with- First surgery: PPV + peeling and delamination of
out tamponade, BCVA was 20/200, and IOP was epiretinal membranes + retinectomy <180° + tan-
8 mmHg. gential retinotomy due to the intrinsic rigid-
ity + endolaser 360° + silicone oil 5000cs. An
encircling band was already placed.
38.16 R
etinal Redetachment PVR A three-port 23G transconjunctival PPV was
CA6 and Intraretinal PVR conducted under general anesthesia; using con-
with Posterior Pole Breaks tact wide-angle viewing system, anterior PVR at
the edge of the previous treated breaks of the
38.16.1 Case Description (Fig. 38.36) anterior failed PPV was observed.
First internal limiting membrane (ILM) and
A mentally challenged 7-year-old boy who epiretinal membrane (ERM) peeling (stained
underwent a pars plana vitrectomy (PPV) on his with Membrane Blue-Dual) were carried out
left eye 1 month ago. Snellen best-corrected under heavy liquid (PFCL) to avoid posterior
visual acuity (BCVA) of the right eye was 20/20 PVR. It would have been better to peel ILM
and left eye: hand moving. widely (I currently peel the ILM of the nasal area
Left eye slit-lamp examination revealed apha- to decrease the risk of funnel-shaped retinal
kia and + cells in anterior chamber with no other redetachment).
38 Video Cases 407
Fig. 38.37 Retina reattached under air

Fig. 38.38 Retinal redetachment due to intraretinal PVR
In the previous surgery, posterior hyaloid (PH)
was detached up to equator (due to posterior vit- 38.16.3 Follow-Up
reous base insertion (VB)) in order not to induce
iatrogenic breaks. So, the remaining membranes Prognosis is grim in children for this kind of
and scarred PH at VB insertion were peeled off surgery. Vitreous is so attached and posterior
bimanually with forceps and a diamond-dusted in children that incomplete detachment of PH
silicone tip or scissors. can induce complications. Bimanual surgery
Then, the remaining contracted and devitalized is necessary to remove all ERMs. ILM peeling
retina anterior to the retinotomy was excised with prevents further tractions at the posterior pole
the vitreous cutter. The edge of the retinotomy was with secondary breaks that can detach the ret-
treated with several rows of laser, and BSS/PFCL- ina again. Wide ILM peeling, extending it even
Air exchange (FAX) followed by Air-Silicone oil in the nasal area, is a good maneuver to avoid
(SO) exchange (ASX) was performed leaving postoperative retinal funnels avoiding a new
5000cs SO as a tamponade. In order to avoid reti- redetachment.
nal slippage during FAX, a soft silicone tip needle
should be placed underneath the anterior edge of
the retinotomy until it is completely dried. 38.17 Long-Standing Retinal
After 1 month and a half, the retina detached Detachment with PVR CP6
again due to some breaks at the posterior pole
due to the rigidity of the retina. 38.17.1 Case Description (Fig. 38.39)
Second surgery: PPV + peeling and delamina-
tion of ERMs + 360° retinectomy + endolaser A 70-year-old phakic woman complained of
360°+ SO 5000cs. floaters and poor visual acuity (VA) (hand
A 360° retinotomy had to be performed to motion) for 3 months in her left eye. A long-
reattach the retina. Retinal suspenders were standing retinal detachment (RD) with PVR CP6
maintained during retinectomy to avoid retinal was found. RD showed full thickness retinal con-
folding. Endodiathermy was applied on the ves- traction at the posterior pole, retinal starfolds
sels, but it was a quite posterior retinectomy, and close to the inferior vitreous base (VB), and mild
bleeding from vessel trunks was harder to stop VB contraction. The lens was clear with no sig-
(Fig. 38.38). nificant cataract.
cleavage plane was found sliding an illuminated

pick through the retinal valleys, and then ERMs
were delaminated up to VB grasping ERMs with
ILM forceps and dissecting them from the under-
lying retina with the blunt illuminated pick
(Alcon Grieshaber).
An inferior starfold due to immature ERM
was impossible to grasp directly or lift from a
cleavage plane. To deal with it, a homemade
sharp membrane pick was made by bending the
tip of a 25G retrobulbar Atkinson needle. The
sharp pick was moved anteriorly on the retinal
surface until a cleavage plane was created.
Fig. 38.39 RD with PVR CP6 Afterward, ERM delamination was performed
the same way as mature membranes, but com-
plete ERM removal was impossible. Thus, ERM
38.17.2 Surgery Description edges were grasped with two forceps
(Fig. 38.40) (Video 38.17) (ILM + Serrated) and pulled apart to strip the
ERM without tearing the retina, relaxing tangen-
A 23G phaco-vitrectomy was indicated to get a tial traction completely. Then, ERM remnants
complete vitrectomy and silicone oil (SO) tam- were dissected up to VB using the blunt illumi-
ponade. First, phacoemulsification and intraocu- nated pick again.
lar lens (IOL) implantation were carried out Afterward, vitreous shaving with self-indentation
through a 2.75 mm corneal incision, with 5.5 mm was performed, cutting PH at VB insertion as short
CCC and anterior capsule polishing to avoid as possible and debulking vitreous at VB (23G vit-
anterior capsular phimosis and opacification. reous cutter was set to perform shaving = 300 mmHg
Then, 23G four-port pars plana vitrectomy (PPV) max vacuum/7500 cpm/50/50 duty cycle).
with chandelier light at 12 h (to allow direct illu- A complete vitrectomy was achieved dis-
mination by the assistant) was performed. secting anterior hyaloid (AH) at Salzmann’s
Posterior hyaloid (PH) was detached and con- hiatus (SH) 360° and then shaving AH anteri-
tracted forming an anterior fibrous plaque at the orly to ciliary body and posteriorly to VB. The
posterior border of the VB. PH was lifted up to AH dissection (AHD) maneuver is of para-
VB in every quadrant and removed together with mount importance to avoid anterior PVR and
the attached anterior retinal flaps. The retinal hypotony because it removes any traction from
tears were marked with diathermy trying to cau- ciliary body to VB. AHD is done cutting AH at
terize the everted retinal edges. SH just over the VB anterior border (23G vit-
Internal limiting membrane (ILM) and epireti- reous cutter was set to perform trench-
nal membranes (ERMs) were stained with ing = 400 mmHg max vacuum/500–1000 cpm/
MembraneBlue-Dual and peeled under heavy core duty cycle).
liquid (PFCL) to hold the macular area and avoid The retina looked completely relaxed after
shearing forces at optic nerve. First centripetal complete vitrectomy and ERM peeling. The reti-
peeling movements were applied until the fovea nal tear everted edges were removed with a
was clean of ERM (not to induce a macular hole), microretinectomy, and the anterior chamber
and then taut ILM/ERM were peeled centrifu- (AC) depth was adjusted with BSS injection
gally, as far as possible, using direct visualization prior to performing BSS/PFCL-Air exchange
with contact macular lens or BIOM. (FAX) with a sandwich technique to remove all
Next, mature starfolds were addressed remov- subretinal fluid (SRF). After FAX, BSS was
ing ERMs from posterior to anterior. First a dripped over the macular area to get rid of any
38 Video Cases 409
PFCL remnant, and a superior sclerotomy (the 38.18 Retinal Detachment

one whose microcannula was to be removed last) with PVR CP6 + CA9
was presutured. Then Air-Silicone oil exchange and Traumatic Cataract
(ASX) was performed keeping air pressure at
30 mmHg until SO reached the infusion cannula. 38.18.1 Case Description
At that time, air infusion was stopped to avoid
air bubbles, and SO was injected until there were A 35-year-old phakic patient was operated else-
no air remnants behind the lens. Finally, all where of retinal detachment (RD) due to superior
microcannulae and sclerotomies, but the last giant retinal tear (GRT) with 23G pars plana vit-
one, were removed and sutured, lid speculum rectomy (PPV) and 2.5 mm encircling band. He
was loosened to avoid unintentional eye pres- was referred due to redetachment observed with
sure, IOP was adjusted to 15–21 mmHg by ultrasound. His visual acuity (VA) was light per-
injecting SO and checking IOP with a Terry- ception (LP). Intraocular pressure (IOP) was
Barraquer tonometer (Ocular Instruments), and 3 mmHg.
the last microcannula was removed, while the Slit-lamp examination showed an intumescent
presutured sclerotomy was tied so that no SO cataract with an iatrogenic posterior circular tear
leaked. at posterior lens capsule. A retinal detachment
Complete SO filling is mandatory to get a (RD) with stiff retina could be observed by ultra-
good tamponade effect and avoid fluid compart- sound examination.
ments where PVR develops. To get a perfect SO
filling, the AC must keep its normal depth, vitre-
ous has to be removed completely, no SRF must
be left, and IOP must be normal (15–21 mmHg) 38.18.2 Surgery Description
at the end of the case. (Fig. 38.41) (Video 38.18)
A four-port 23G phaco-PPV was indicated to get

38.17.3 Follow-Up (Fig. 38.40) a complete vitrectomy and anterior PVR
dissection.
The patient was instructed to keep a prone posi- Phacoemulsification was carried out through a
tion for 24 h so that if a PFCL bubble migrated 2.75 mm corneal incision, with a 5.5 mm CCC to
subretinally it did not collect in the macular area.
The retina was completely attached and SO
removed in 3 months achieving 20/60 BCVA.
Fig. 38.41 RD with PVR CP6 + CA9

Fig. 38.40 Retina attached under silicone oil
put an intraocular lens (IOL) at ciliary sulcus formed, and the anterior chamber (AC) was
because posterior lens capsule was damaged. filled with dispersive viscoelastic to keep a nor-
Hydrodissection broke posterior lens capsule, mal AC depth.
and anterior lensectomy was performed with Then, a reattachment test was performed with
phacoemulsification handpiece and vitreous cut- a Fluid/PFCL-Air (FAX), but the retina was too
ter, preserving anterior capsule to implant a stiff, and retinal tears and scarred VB were pos-
three-piece IOL at sulcus with the buttonhole terior to buckle indentation precluding retinal
(BH) maneuver, luxating the IOL optic through reattachment. Therefore, an Air-Fluid exchange
the CCC and leaving haptics at ciliary sulcus. (AFX) was performed, and a relaxing retinec-
Then, a 23G four-port PPV with chandelier light tomy was indicated. Retinectomy was performed
was performed. A RD with PVR CP6 + CA9 at under PFCL-BSS to improve visualization, con-
inferior and nasal vitreous base (VB) was observed. trol bleeding vessels, and avoid subretinal blood
First, luxated lens remnants were removed collection and inadverted choroidal impacts.
with the vitreous cutter and posterior epiretinal Diathermy was applied first, and then the retina
membranes (ERMs) at posterior pole, and macu- was cut with the vitreous cutter. Retinectomy
lar ILM was stained with MembraneBlue-Dual extension was 200°, enlarging it well into
and peeled under heavy liquid (PFCL). healthy retina. The retina was cut with the vitre-
Then, anterior ERM was removed bimanually ous cutter just posterior to VB insertion to avoid
(two forceps or pick + forceps) as peripheral as reproliferation. All bleeding points were cauter-
possible up to VB. However, a few nasal imma- ized, preretinal and subretinal clots removed,
ture membranes were impossible to delaminate and the anterior retinal flap was completely
from retinal surface and were left behind. shaved up to ora serrata to avoid inflammation,
Next, anterior PVR due to VB scarring was iris rubeosis, or ciliary scar tissue from devital-
dealt with. VB membranes were removed or seg- ized peripheral retina remnants.
mented bimanually (two forceps or pick + for- Finally the retina was attached with PFCL,
ceps) trying to relax VB circumferential 360° endolaser was applied, and FAX (with care-
centripetal traction. An encircling band was ful retinal edge drying to avoid slippage) f ollowed
already in place, and it was expected to support by Air-Silicone exchange (ASX) was performed
scarred VB and allow retinal reattachment. to fill the eye completely with 1000cs SO at
Afterward, complete PPV was performed with 15–21 mmHg.
self-indentation. First vitreous shaving was car-
ried out, cutting scarred posterior hyaloid (PH) at
VB insertion as short as possible and debulking 38.18.3 Follow-Up (Fig. 38.42)
vitreous at VB (23G vitreous cutter was set to
perform shaving vitrectomy). Then, anterior hya- The retina remained attached under SO, VA
loid (AH) dissection at Salzmann’s hiatus (SH) improved to 20/60, and IOP raised to 14 mmHg.
360° was completed (23G vitreous cutter was set A new 23G PPV was performed 3 months
to perform trenching vitrectomy). later to remove SO and new ERMs.
The AH dissection (AHD) maneuver is impor- SO was removed from vitreous cavity and AC
tant to avoid anterior PVR and hypotony. AHD emulsification, cleaning cells over the IOL as well.
relaxes any traction from ciliary body to VB and Anterior and posterior new or mature ERMs were
anterior retina. AHD avoids ciliary body scarring removed bimanually with forceps and illuminated
with subsequent hypotony if retinectomy is per- pick up to retinectomy edge. A few ERMs were so
formed, by preventing detached pars plana epithe- stuck to the retinal tissue they had to be segmented
lium and anterior retinal remnant folding anteriorly and left behind. 360° endolaser was enlarged and
and being part of the ciliary scar tissue. FAX followed by Air-Gas exchange (AGX) per-
Silicone oil (SO) tamponade was planned, formed to leave SF6 20% as tamponade.
and the iris-lens diaphragm was not sure to be The retina remained attached without tampon-
competent; thus, an inferior iridotomy was per- ade, VA was 20/60, and IOP was 12 mmHg.
38 Video Cases 411
Fig. 38.42 Retina attached without tamponade
Fig. 38.43 Retinal detachment
38.19 R
etinal Detachment After
Penetrating Ocular Trauma
38.19.1 Case Description
A 46-year-old male, professional driver suffered

a scleral laceration in his right eye by a piece
of wood while chopping them. At admission the
eye was hypotonic with deep anterior chamber
(AC). Behind the transparent posteriorly dis-
located lens, there was a dense vitreous hem-
orrhage, and ultrasound examination showed
complete retinal detachment (RD). Wound
exploration revealed scleral laceration in the
upper temporal quadrant with uveal and retinal
Fig. 38.44 Retinal reattachment
prolapse. The prolapsed tissue was excised and
the wound sutured with Vicryl 7/0 interrupted
X-sutures. wound, removal of subretinal membranes and
hemorrhage, pupilloplasty, secondary retropupil-
lary iris claw intraocular lens (IOL) implantation,
38.19.2 Surgery (Figs. 38.43 and 38.44) and silicone oil (SO) tamponade.
(Video 38.19)
A week after the primary surgery, 23G pars plana 38.19.3 Follow-Up
vitrectomy (PPV) was performed. Preoperatively
posterior lens dislocation, dense vitreous hemor- Surgery was repeated two times in the following
rhage, complete retinal detachment with supero- 2 months due to reproliferation with ERM peel-
temporal and infero-nasal giant retinal tear ing and SO exchange. SO was successfully
(GRT), epiretinal (ERM), subretinal PVR, and removed 6 months later. Initial best-corrected
subretinal hemorrhage were observed. visual acuity (BCVA) was light perception only,
They were treated with 23G PPV, lensectomy, and final BCVA 3 months after silicone oil
epiretinal membrane (ERM) peeling, retinec- removal was 0.1–0.2 eccentrically. Unfortunately
tomy 360° to release posterior retina from periph- this result was not good enough for the patient to
eral vitreous base (VB) scar and sclerochoroidal keep his professional driving license.
38.20 R
etinal Detachment Under
Silicone Oil with PVR
CP2 + CA6 (Video 38.20)
A 65-year-old male underwent a combined phaco-

emulsification with posterior chamber intraocular
lens (IOL) implantation and pars plana vitrectomy
(PPV) with silicone oil (SO) tamponade for retinal
detachment (RD) in the right eye at another clinic.
He was admitted for the treatment of inferior rede-
tachment with PVR CP2 and anterior PVR CA6,
several retinal tears, and SO under the retina. He Fig. 38.46 Retinal reattachment
lost the vision in his left eye due to secondary glau-
coma after phacoemulsification with IOL implan-
tation and PPV with SO tamponade for RD as well. 38.20.3 Follow-Up
Three months after surgery, SO was successfully

38.20.2 Surgery Description (Fig. 38.46) removed. Initial best-corrected visual acuity
(BCVA) at presentation was 0.04, and final
A 23G PPV with SO removal, peeling of epiretinal BCVA 2 months after SO removal was 0.2.
membranes (ERM), scarred posterior hyaloid (PH)
dissection at vitreous base (VB), peripheral circum-
ferential 270° retinotomy, and endolaser treatment 38.21 M
yopic Retinal Detachment
were performed, and the retina was completely Without Posterior Vitreous
attached with heavy liquid (PFCL) and Detachment (Video 38.21)
Fluid/PFCL-Air (FAX) followed by Air-Silicone oil
exchange (ASX) leaving 1000cs SO as tamponade. 38.21.1 Case Description (Fig. 38.47)
A 12-year-old myopic male (−8,25 D) was admit-

ted for treatment of rhegmatogenous retinal
detachment (RD) with macular involvement in his
left eye after 2-week duration. Retinal tears were
observed at 2 and 3 h.

(Fig. 38.48)
Lens sparing 23G pars plana vitrectomy (PPV)

combined with encircling band was performed.
Induction of posterior vitreous detachment (PVD)
was made after triamcinolone staining, lifting
posterior hyaloid (PH) up to vitreous base (VB),
retina was attached with heavy liquid (PFCL) and
Fluid/PFCL-Air exchange (FAX), tears were
treated with endolaser, and Air-Gas exchange was
Fig. 38.45 Retinal detachment performed (AGX) leaving gas as tamponade.
38 Video Cases 413
ber intraocular lens (IOL) implantation for compli-

cated cataract after corneal ulceration.

(Fig. 38.50)
A 23G pars plana vitrectomy (PPV) and peeling of

epiretinal membranes (ERMs) and two subretinal
strands were performed. Anterior epiretinal mem-
branes, actually scarred posterior hyaloid (PH) at
vitreous base insertion (VB), were removed biman-
ually with forceps and scissors. Subretinal mem-
branes at VB were removed bimanually with two
Fig. 38.47 Retinal detachment
forceps through two access retinotomies. Peripheral
tears were observed at 5, 7, and 8 h and were treated
with endolaser after retinal attachment with heavy
liquid (PFCL) and Fluid/PFCL-Air exchange
Fig. 38.48 Retinal reattachment
38.21.3 Follow-Up Fig. 38.49 Retinal detachment
Initial best-corrected visual acuity (BCVA) was 0.3,

and final BCVA 3 months after surgery was 0.5.
38.22 Retinal Detachment

with PVR CA4 and Subretinal
Strands (Video 38.22)
A 60-year-old male was admitted for the treatment of

tractional rhegmatogenous retinal detachment (RD)
with PVR CA4 of 3-month duration. He underwent
previously phacoemulsification with posterior cham- Fig. 38.50 Retinal reattachment
(FAX) removing subretinal fluid (SRF) completely. 38.23.2 Surgery Description

Finally 1000cs silicone oil (SO) was injected with (Fig. 38.52)
Air-Silicone oil exchange (ASX).
A combined phacoemulsification and intraocular
lens implantation (IOL) with 23G pars plana vit-
38.22.3 Follow-Up rectomy (PPV) was performed. Intraoperatively
after removal of vitreous hemorrhage, a traction
Three months later, SO was successfully retinal detachment with retinal incarceration at
removed. Initial best-corrected visual acuity laceration site and ora dialysis at opposite side
(BCVA) was hand motions (HM), and final (temporally) was observed.
BCVA 2 months after SO removal was 0.1. A peripheral circumferential retinectomy 360°
released the retina from the sclerochoroidal wound.
Then the retina was unfolded, relocated, and reat-
38.23 Traumatic Retinal tached with heavy liquid (PFCL). Endolaser 360°
Detachment with Retinal was done under PFCL. Finally a Fluid/PFCL-Air
Incarceration and Ora exchange (FAX) was performed followed by
Dialysis (Video 38.23) Air-Silicone oil exchange (ASX) leaving 1000cs
silicone oil (SO) as tamponade. At the end of the
38.23.1 Case Description (Fig. 38.51) surgery, the retina was completely attached.
A 30-year-old female was admitted for the treat-

ment of traumatic retinal detachment (RD) in 38.23.3 Follow-Up
her right eye with vitreous hemorrhage and
advanced PVR, 12 days after suturing of scleral Three months later, surgery was repeated due to
laceration and removal of intraocular foreign development of subretinal PVR. After removal of
body (IOFB) (glass) that was performed at subretinal strands, SO 5700cs was injected and
another clinic. no additional surgery was planned. Initial best-
Fig. 38.51 Retinal detachment Fig. 38.52 Retinal reattachment

38 Video Cases 415
corrected visual acuity (BCVA) was light percep- scarred posterior hyaloid (PH) were removed up to
tion (LP), and final BCVA 2 months after vitreous base (VB). However, the retina remained
injection of dense silicone oil was 0.1. contracted and shortened, and a primary inferior
circumferential retinectomy was performed. After
it was done, all visible subretinal strands were
38.24 Traumatic Retinal removed, and the retina was attached completely
Detachment CP12 + CA12 with heavy liquid (PFCL) injection. Three rows of
with Closed Funnel Shape continuous endolaser were placed at the retinec-
tomy edge, and Fluid/PFCL-Air (FAX) followed
38.24.1 Case Description (Fig. 38.53) by Air-Silicone oil (ASX) exchange was performed
to leave 1000cs silicone oil (SO) as tamponade.
A 42-year-old male was hit by a piece of wood in
his left eye. He didn’t see more than light percep-
tion (LP) for the last 6 months and decided to ask 38.24.3 Follow-Up
for help by the beginning of the next year.
Examination revealed mature traumatic cataract The retina was attached with a single surgery, and
and funnel-shaped retinal detachment (RD) 4 months later, silicone oil (SO) was successfully
shown by ultrasound. Patient was informed about removed. Initial VA improved from LP to 0.05
limited expectations and probable need for sev- 2 months after SO removal.
eral surgeries.
38.25 Retinal Redetachment

38.24.2 Surgery Description with PVR CP12
(Fig. 38.54) (Video 38.24)
Combined phacoemulsification with intraocular
lens (IOL) implantation and 23G pars plana vitrec- A 55-year-old male presented with an aggres-
tomy (PPV) were performed in peribulbar anesthe- sive looking total retinal detachment (RD) with
sia. Preoperatively, a closed funnel RD with PVR PVR in four quadrants 6 weeks post pseudopha-
CP12 + CA12 and subretinal strands was observed. kic macula-on RD treated with pars plana vit-
All visible epiretinal membranes (ERM) and rectomy (PPV) and air. There were starfolds in
Fig. 38.53 Retinal detachment Fig. 38.54 Retinal reattachment

branes (rather Muller cell-based) dictates

surgical strategy [1, 2].
Caveat: be patient, don’t look at the clock, just
think this is your only case for today and you
have the day off tomorrow!!
Basic surgical setup: 23G four-port (chande-
lier) PPV. End-gripping forceps, vertical scissors
(very versatile: spatula, pick, scissors), soft-tipped
active backflush, and MembraneBlue-Dual (try-
pan blue + Brilliant Blue). If this would have been
a primary surgery with fresh PVR, an encircling
buckle could have been an additional tool to try
and avoid retinotomy in the acute phase.
38.25.3 Surgical Procedure

Fig. 38.55 Intraoperative picture
First, posterior ERMs were removed bimanually
without retinal breaks. Fresh PVR membranes
two circumferential zones: first between poste- tend to stain poorly: repeat if necessary, prefer-
rior pole and equator and second anterior to ably under air (despite high viscosity and density
equator near vitreous base (VB). There were no of the dye, in contracted retina with breaks, the
anterior PVR complications because ciliary dye tends to move subretinally: this can be toxic
body was free (complete vitrectomy was done and it also reduces the contrast because every-
during primary PPV). thing tends to have a bluish hue afterward).
Caution: do not restain after extensive peel-
ing; trypan blue will stain tissue damage that you
38.25.2 Surgical Strategy (Video 38.25) have caused inadvertently, making further peel-
ing of the stained tissue rather perilous.
Peeling should start centrally, since posterior mem- As ERMs reach the VB, they seem to be inte-
branes are most often purely epiretinal (ERMs) so grated intraretinally: you have reached the border
they can be peeled/freed completely from the between purely epiretinal and intraretinal
underlying retina. As your peeling extends toward PVR. Intraretinal PVR cannot be peeled without
VB, be careful because the membranes tend to have making breaks. Consequently the anterior trac-
deeper intraretinal extensions anteriorly. Complete tion can only be counteracted by broad indenta-
removal without additional breaks may be impossi- tion with an encircling buckle or with retinotomy
ble: the zone where epiretinal becomes intraretinal [3].
will be the retinotomy site. So the goal is to free as Then, heavy liquid (PFCL) was injected (pref-
large an area of central retina as possible from erably perfluorooctane, as it is less heavy than
ERMs. A retinotomy (as last resort) releases/res- decalin). It facilitated ERM engaging for addi-
cues the “conquered” and “healthy” central area tional peeling as the membrane is less “squashed.”
from the anterior retina that is beyond repair due to Thus, using directional endolight and PFCL, pos-
intraretinal PVR. terior ERMs were removed easier (better visual-
Understanding this fundamental difference ization than chandelier). It also makes anterior
between posterior ERMs (most likely originat- ERM peeling easier, because PFCL functions as
ing from RPE seeding) and anterior (VB) mem- thirdhand stabilizing central retina, while ante-
38 Video Cases 417
rior ERMs are removed with one hand indenting 38.26 Retinal Detachment
and the other using forceps. with Epiretinal
Afterward, a relaxing retinectomy was per- and Subretinal PVR
formed to remove anterior ERMs and anterior- Removal
posterior traction due to retinal stiffness.
Diathermy on large vessels was used at the bor- 38.26.1 Case Description (Fig. 38.56)
der of the retinectomy (between peeled central
retina and the redundant periphery). Retinectomy This is a case of redetachment following a failed
extension was calculated according to residual primary repair with pars plana vitrectomy (PPV),
stiffness of the retina. Anterior retinal remnants laser retinopexy, and heavy silicone oil for a sub-
were completely removed to prevent anterior total retinal detachment (RD) with multiple tem-
retinal loop with hypotony or ischemia with poral and inferior breaks. Now the retina is
rubeosis. detached nasally and inferiorly under heavy oil
Finally the retina was attached. Rather than due to an epiretinal proliferative vitreoretinopa-
laser under heavy liquid and performing direct thy (PVR) and two subretinal PVR bands (a large
PFCL-Silicone oil exchange (PSX), a Fluid-Air nasal band and a small temporal band).
exchange (FAX) was performed first because the
retina would settle in a more relaxed central posi-
tion. This is a fundamental difference with large
retinotomy (as in full macular translocation (FMT)
or giant tear (GRT) cases) without PVR; in these
cases retinal slippage has to be avoided with direct
PSX. Very limited laser was done, just to the reti-
notomy border, or even no laser at all is a correct
option because extensive laser at this point is not
going to prevent recurrent PVR and is sacrificing
healthier retina [4].
38.25.4 Follow-Up
Retina remained attached without silicone oil.

Fig. 38.57 Subretinal strand removal
PREOP
Epiretinal PVR
Subretinal PVR
x
Optic Nerve Head
Fovea
Detached retina
Fig. 38.56 Attached retina

Preoperative RD
Fig. 38.58 Postoperative

retinal attachment POSTOP
Retinotomy
Laser retinopexy
Optic Nerve Head
Fovea
Detached retina
Attached retina
38.26.2 Surgical Procedure silicone oil was performed and the surgery was
(Fig. 38.57) (Video 38.26) completed.
As first step, the heavy oil was removed with the

viscous fluid removal set using a 23G pack. Then, 38.26.3 Follow-Up (Fig. 38.58)
trypan blue was employed to stain the epiretinal
membrane (ERM) that was peeled with an end- The retina was completely attached under heavy
grasping forceps using a small heavy liquid oil and after its removal.
(PFCL) bubble to counterpressure the traction
exerted with the forceps during the peel. Once
this step has been completed, the supero-temporal References
sclerotomy was enlarged to a 20G port, a retinot-
omy was performed with endodiathermy and a 1. Lewis GP, Charteris DG, Sethi CS, Fisher SK. Animal
models of retinal detachment and reattachment: iden-
passive-aspiration backflush cannula flute, and a tifying cellular events that may affect visual recovery.
20G angled forceps was employed to remove the Eye. 2002;16:375–87.
circumferential subretinal band of PVR nasally. 2. Charteris DG, Downie J, Aylward GW, Sethi C,
A second retinotomy was performed with the Luthert P. Intraretinal and periretinal pathology in
anterior proliferative vitreoretinopathy. Graefes Arch
same approach (endodiathermy + backflush can- Clin Exp Ophthalmol. 2007;245:93–100.
nula flute) to complete the band removal, and 3. Veckeneer MAH. Improving the outcome of rheg-
once the nasal band had been completely matogenous retinal detachment repair by adding
removed, a temporal retinotomy was also per- pieces to the puzzle. Rotterdam: Erasmus University;
2015. Chapter 3. . ISBN 978-94-6228-695-5
formed and the small temporal subretinal band 4. Veckeneer M, Maaijwee K, Charteris DG, van Meurs
was removed too. A superior iridotomy was per- JC. Deferred laser photocoagulation of relaxing
formed with the vitreous cutter through a tempo- retinotomies under silicone oil tamponade to reduce
ral side port. The vitreous cavity was completely recurrent macular detachment in severe proliferative
vitreoretinopathy. Graefes Arch Clin Exp Ophthalmol.
filled with PFCL, and laser retinopexy was 2014;252:1539–44.
applied to all retinal breaks. Direct PFCL-Heavy

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Retinal Detachment

Surgery and Proliferative

From Scleral Buckling to Small

ISBN 978-3-319-78445-8 ISBN 978-3-319-78446-5 (eBook)

Library of Congress Control Number: 2018947569

© Springer International Publishing AG, part of Springer Nature 2018

Dr. Živojnović (Photo courtesy DORC)

1. Practical knowledge of many different surgical techniques (binocular

Retinal detachment surgery requires theoretical and practical knowledge.

Uppsala, Sweden Ulrich Spandau

I want to thank my wife, Katrin, for her non-ending patience regarding

Part I Proliferative Vitreoretinopathy (PVR). Introduction

1 Surgery of Vitreoretinal Disorders:

Part II Before Surgery

5 Assessment of a Retinal Detachment�������������������������������������������� 45

8 Surgical Techniques ���������������������������������������������������������������������� 79

11 Episcleral Buckling for Detachment Surgery

Part IV Special and Advanced Cases

16 Total and Chronic Retinal Detachment �������������������������������������� 159

Part V After Surgery

24 After Surgery and Complications������������������������������������������������ 215

Part VI Proliferative Vitreoretinopathy (PVR).

26 Vitreoretinal Surgeons Assess Surgical Cases:

Part VII Surgical Trends and Case Reports

35 PVR Detachment Questionnaire: Part 1�������������������������������������� 325

38 Video Cases������������������������������������������������������������������������������������ 385

Pasha Anvari Eye Department, Eye Research Center, Rassoul Akram

Shunji Kusaka Department of Ophthalmology, Kindai University Faculty

J. Marticorena Salinero Department of Ophthalmology, Complejo

Collaborators for Video Cases

B. Fernandez Arevalo Guadalajara Universitary Hospital, Guadalajara,

M.I. Relimpio-Lopez Virgen Macarena Hospital/Santa Angela de la Cruz,

Video 13.11 PVR peeling short

Video 29.1 FEVR Kusaka (Japan)

Pre-Gonin era: Retinal detachment has always 1.1  he Beginning of Retinal

© Springer International Publishing AG, part of Springer Nature 2018 3

In the 1970s, Lincoff, following Bietti’s (Rome,

Fig. 1.3 Scissors and forceps

Fig. 1.2 The surgical microscope is an essential part of

I also abandoned combined vitrectomy with

2.1 PVR Anyway, initial mechanisms implicated in PVR

© Springer International Publishing AG, part of Springer Nature 2018 11

Retina Society Terminology Committee classification

B (moderate) Surface retinal wrinkling, rolled edges of the retinal,

The Retina Society updated classification

Grade and type Clinical signs

B Wrinkling of inner retinal surface, retinal stiffness, vessel tortuosity, rolled

CP (posterior) Full-thickness retinal folds or subretinal strands posterior to equator

CA (anterior) Full-thickness retinal folds or subretinal strands anterior to equator

Fig. 2.4 Human retina

Fig. 2.5 Human retina

Fig. 2.6 Human retina

2.1.3 The Problem Classification was then updated in 1991 [40]

tify preoperatively, but their presence may be References

Pasha Anvari and Khalil Ghasemi Falavarjani

3.1 Introduction cellular components involved in the pathophysiol-

© Springer International Publishing AG, part of Springer Nature 2018 25

Fig. 3.1 Proposed Scar formation and

3.3.6 Anti-vascular Endothelial Matrix metalloproteinases (MMPs) are zinc-­

Resveratrol (trans-3,4′,5-trihydroxystilbene) is a thy. In: Sebag J, editor. Vitreous. New York:

Uppsala, Sweden Ulrich Spandau

Part I Proliferative Vitreoretinopathy (PVR). Introduction

1 Surgery of Vitreoretinal Disorders:

Part II Before Surgery

5 Assessment of a Retinal Detachment�� 45

8 Surgical Techniques �� 79

11 Episcleral Buckling for Detachment Surgery

Part IV Special and Advanced Cases

16 Total and Chronic Retinal Detachment �� 159

Part V After Surgery

24 After Surgery and Complications�� 215

Part VI Proliferative Vitreoretinopathy (PVR).

26 Vitreoretinal Surgeons Assess Surgical Cases:

Part VII Surgical Trends and Case Reports

35 PVR Detachment Questionnaire: Part 1�� 325

38 Video Cases�� 385

Pre-Gonin era: Retinal detachment has always 1.1 he Beginning of Retinal

2.1 PVR Anyway, initial mechanisms implicated in PVR

2.1.3 The Problem Classification was then updated in 1991 [40]

3.1 Introduction cellular components involved in the pathophysiol-

3.3.6 Anti-vascular Endothelial Matrix metalloproteinases (MMPs) are zinc-

• The change of surgical technique from epi- 4.1 Review of International

4.2 Retinal Reattachment 4.3 Gases

5.2 he Next Most Important

5.3 t the University of Uppsala,

5.4.2.1 Buckle vs. Vitrectomy

The highly bullous inferior detachment 5.4.2.3 Ora Dialysis

5.4.2.6 R etinal Breaks in Two

5.4.2.13 PVR Stage D

6.2 riday 4 o’Clock Detachment

7.1 Chandelier Light Fibre

7.3 Instruments for Removal

7.4 Instruments for Subretinal

7.5 Instruments for Retinotomy

7.5.1 Flattening of Retinotomy

7.5.2 Dyes sponge. Indication: Ora dialysis, all breaks

8.1.2 Episcleral Buckling bullous inferior detachment with a small hole at