Some Basics of Surgical Technique

This surgery, performed under local anesthesia, is suitable for primary retinal detachments caused by one or several breaks. It consists of cryosurgery under ophthalmoscopic control and a sponge, preferably radially oriented, to the break. Consequently, the size of the buckle is determined only by the size of the break(s) and not by the extent of the detachment. The treatment of the two detachments, presented in Fig. 6.1, is the same and consists of a sponge buckle of equal size. After an analysis of 1,000 detachments, we found that there is one break in 50% of detachments, two breaks in 30%, and three or more breaks in 20%. Thus, after a meticulous preoperative and intraoperative search for the break, in about 50%, not more than one break has to be buckled. In addition, in general, multiple breaks are not distributed over the entire retinal circumference of the eye, but tend to be located within the quadrant of the primary break.

Optimum segmental buckling aims to fit the various sizes and configurations of retinal breaks. There can be three or four segmental buckles to circumvent a cerclage. The complications of a cerclage tend to be: anterior segment ischemia, hypertension or hypotension, uveitis, decreased retinal and choroidal blood flow and eventual unilateral pigmentary dystrophy, constricted visual field, reduction in two-point discrimination, and diminished retinal activity or a reduced amplitude of the electroretinogram [27-32].

Detachments with multiple breaks and even with proliferative vitreoretinopathy (PVR) grade C1-C2 can be treated with segmental buckling and without drainage (Figs. 6.4-6.8). The segmental buckles may consist of radials, short circumferentials, or a combination of both, but without a cerclage.

Cerklage Retina

Fig. 6.4. Total detachment in pseudophakic eye. a There is a horseshoe tear at 11:00, a round hole at 12:00, and traction lines (insertion of the vitreous base) in the entire periphery. b After buckling of the two breaks by a short circumferential sponge buckle, the retina had attached without drainage the next morning. After 1 week, the cryopexy lesions had pigmented and subsequently the so-called traction lines disappeared. The retina remained attached during the next 15 years

Fig. 6.4. Total detachment in pseudophakic eye. a There is a horseshoe tear at 11:00, a round hole at 12:00, and traction lines (insertion of the vitreous base) in the entire periphery. b After buckling of the two breaks by a short circumferential sponge buckle, the retina had attached without drainage the next morning. After 1 week, the cryopexy lesions had pigmented and subsequently the so-called traction lines disappeared. The retina remained attached during the next 15 years

Fig. 6.5. Multiple breaks in 11/2-quadrant detachment. a In this detachment, there are three horseshoe tears and a round hole at the same latitude. The "round hole" in lattice degeneration at 10:00 is a pseudohole. b After the breaks had been tamponaded with a short circumferential sponge buckle (4 mm in diameter) and with precise localization of each break, the retina attached without drainage. Pigmentation around the breaks was completed after 1 week (the lattice degeneration was not treated)

Fig. 6.5. Multiple breaks in 11/2-quadrant detachment. a In this detachment, there are three horseshoe tears and a round hole at the same latitude. The "round hole" in lattice degeneration at 10:00 is a pseudohole. b After the breaks had been tamponaded with a short circumferential sponge buckle (4 mm in diameter) and with precise localization of each break, the retina attached without drainage. Pigmentation around the breaks was completed after 1 week (the lattice degeneration was not treated)

Retinal Break Without Detachment

Fig. 6.6. Multiple breaks of various sizes in 1V2-quadrant detachment. a The breaks from 8:15 to 9:30 are at the same latitude, and the "hole"within the lattice is a pseudohole. However, the horseshoe tear at 10:45 extends more posteriorly than the other breaks. b The breaks at the same latitude were supported by a circumferential 4-mm sponge cylinder, and the horseshoe tear at 10:45 was supported by a radial 5-mm sponge cylinder without drainage. The retina attached, and the cryopexy lesions had pigmented after 1 week. The lattice with the pseudohole was not coagulated

Fig. 6.6. Multiple breaks of various sizes in 1V2-quadrant detachment. a The breaks from 8:15 to 9:30 are at the same latitude, and the "hole"within the lattice is a pseudohole. However, the horseshoe tear at 10:45 extends more posteriorly than the other breaks. b The breaks at the same latitude were supported by a circumferential 4-mm sponge cylinder, and the horseshoe tear at 10:45 was supported by a radial 5-mm sponge cylinder without drainage. The retina attached, and the cryopexy lesions had pigmented after 1 week. The lattice with the pseudohole was not coagulated

Fig. 6.7. Three breaks in three-quadrant detachment. a In this detachment, the three breaks are 272 to 3 clock hours apart. b The three breaks were treated with cryopexy and tamponaded by three radial sponge cylinders without drainage. The retina attached. The retina remained attached during a 14-year follow-up period. (Four radial sponges may imply the limits of radial buckles; instead, a segmental circumferential or a combination of both be preferred)

Fig. 6.7. Three breaks in three-quadrant detachment. a In this detachment, the three breaks are 272 to 3 clock hours apart. b The three breaks were treated with cryopexy and tamponaded by three radial sponge cylinders without drainage. The retina attached. The retina remained attached during a 14-year follow-up period. (Four radial sponges may imply the limits of radial buckles; instead, a segmental circumferential or a combination of both be preferred)

Fig. 6.8. Group of breaks in 3-quadrant PVR-C1 detachment. a The breaks, between 1:00 and 2:00, are with adjoining starfolds from 2:30 to 6:00 posterior to equator. No additional break was found between 10:00 over 12:00 to 1:00. b After buckling of breaks with 7-mm radial sponge without drainage, the retina and macula attached, except for a residual tractional detachment located at starfolds still present 2 months postoperatively; it disappeared over time. The retina remained attached during follow-up period of 17 years

Fig. 6.8. Group of breaks in 3-quadrant PVR-C1 detachment. a The breaks, between 1:00 and 2:00, are with adjoining starfolds from 2:30 to 6:00 posterior to equator. No additional break was found between 10:00 over 12:00 to 1:00. b After buckling of breaks with 7-mm radial sponge without drainage, the retina and macula attached, except for a residual tractional detachment located at starfolds still present 2 months postoperatively; it disappeared over time. The retina remained attached during follow-up period of 17 years

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