There are a host of avoidable problems that can limit the success of retinal detachment (RD) surgery. Speaking at the Retina Subspecialty Day, Steve Charles, MD, discussed various failure modes and how and why to circumvent them.
Noting that missed retinal breaks/holes/tears are a leading cause of failed RD surgery, Dr. Charles outlined strategies for improving detection. He emphasized the importance of obtaining a good history, taking advantage of core vitrectomy as a diagnostic tool, and using the right technology to optimize visualization.
As explained by Dr. Charles, a more thorough description of the patient’s evolving symptom history can provide a clue to the site of a retinal break.
“Knowing that the first symptom a patient noticed was a shadow in the upper left-hand corner of his vision will direct you to look for the initial detachment and breaks in the lower right-hand corner when you do your examination,” said Dr. Charles, founder, Charles Retina Institute, Germantown, TN.
He also encouraged surgeons not to overlook the potential to find clues to the site of a retinal break while performing core vitrectomy.
Dr. Charles explained that during peripheral vitreous removal, surgeons should watch carefully for subretinal fluid that may stream out from the break and become visible because of the Schlieren optical effect. Streaming of vitreous collagen fibers towards the tear is another phenomenon to watch for.
“Instead of thinking about core vitrectomy as a therapeutic step in the repair procedure, consider that it can be a tremendous asset for your diagnostic effort,” Dr. Charles said.
The ability to identify these clues and to otherwise find retinal breaks depends on having good visualization. Dr. Charles recommended using conventional endoilluminators that are better than chandeliers because they provide focal, specular, and retro- illumination; 3-D viewing systems that increase depth of field and enable better visualization of transparent vitreous because of software adjustable color parameters; and wide-angle visualization and/or scleral depression to ensure visualization of the peripheral retina.
What not to do
Better success with RD surgery also involves avoiding certain measures that are not helpful, but may even introduce harm. Practices that are not the answer for improving outcomes of RD surgery include using rows of 360° laser spots or scleral buckles as safeguard procedures.
Dr. Charles noted that some surgeons place row upon row of laser spots for fear they might have missed the tear.
However, this technique does not eliminate missed breaks and new breaks may develop between or posterior to the laser spots as well.
Furthermore, excessive laser treatment increases inflammation and subsequently proliferative vitreoretinopathy that is a risk factor for RD surgery failure.
Discussing scleral buckling, Dr. Charles noted that some surgeons consider it a good idea to routinely place a scleral band as a precautionary measure. However, there is no acceptable randomized clinical trial evidence that combining a buckle with vitrectomy increases success rates versus vitrectomy alone.
“New breaks and proliferative vitreoretinopathy often occur posterior to encircling elements, even broad buckles,” Dr. Charles said.
Furthermore, buckling makes future glaucoma surgery more difficult and is associated with many complications, including induced axial myopia, diplopia, pain, ocular surface disorders, ptosis, buckle extrusion or intrusion.
“Some surgeons say that in case a tear was missed, using a scleral buckle in a belt and suspenders approach lets them sleep better at night. With all of its downsides, however, it certainly doesn’t let patients sleep better,” Dr. Charles said.
He also commented that there is overemphasis on doing phacoemulsification as a combined procedure.
“Phacoemulsification causes the pupil to come down, makes the case go longer, and leads to suboptimal refractive outcomes,” he explained.
Dr. Charles is a consultant to Alcon Laboratories and receives royalties on the Constellation Vision System.