One such strategy is to suture the perforation site and then raise the intraocular pressure to stem the hemorrhage.
Alternatively, if a subretinal hemorrhage has occurred in the context of a macula-off detachment, then further action must be taken to prevent irreversible damage to the vision from submacular blood. If retinal damage has occurred, then further retinopexy followed by extending the buckle to cover this area may be all that is required. A white choroidal fleck may be the only trace of scleral perforation however, it is important to exclude a retinal perforation or a subretinal hemorrhage (Figure 4). Although inadvertent drainage and subsequent suturing of a soft eye are relatively minor consequences, it is important to stop and inspect the retina when this occurs. Inadvertent scleral perforation could potentially cause a number of consequences, some of which could be catastrophic to vision. Most retina surgeons agree that one of the most intimidating steps of extraocular detachment surgery is the passing of scleral sutures.
In contrast, overzealous cryopexy with refreezing of previously treated areas can cause retinal necrosis, creating redetachments from the leaky edges of cryotherapy scars. Thorough postoperative examinations, with top-up argon laser retinopexy where necessary, could prevent this complication (Figure 3). Segmental buckles fade over time, and after 6 months, if there has been inadequate retinopexy, the retina will redetach. It is vital at this stage, however, to check that adequate retinopexy has been applied. If all has gone well, the day after surgery, the retina may be flat. Not only does this ensure a high indent, but it also reduces the force required to tie the knot and prevents the suture from being torn out of the sclera, particularly in patients with high myopia. The best way of achieving this is to perform a paracentesis prior to tying each knot. Once the sutures have been correctly sited, it is important to create a sufficiently high indent to allow the subretinal fluid to resorb and the break to settle on the buckle. 6 This gives the added advantage of supporting the vitreous base and preventing the formation of an anterior gutter detachment. To avoid this potential pitfall, radial explants can be used, or a circumferential buckle that extends from the posterior edge of the break right up to the ora, known as a break-ora-occlusive-buckle (Figure 2D). These folds tend to pass through the break, holding them open. Fishmouthing can also occur secondary to redundancy folds created by large segmental buckles, which shorten the circumference of the globe. Once the retina flattens, therefore, the buckle is found to be too posterior, and the anterior edge of the break may be unsupported, known as fishmouthing (Figure 2C). Parallax errors give the impression that the break is more posterior than it actually is when the retina is detached. This can be fraught with difficulty, especially in bullous detachments, as it requires you to be aware of the potential for anterior-posterior localization errors due to parallax (Figures 2A and 2B). One of the most important steps is to accurately mark the break on the sclera. The accurate placement of a scleral buckle requires experience and a degree of perfectionism if it is to succeed. 4,5 Having an accurate drawing of the retinal detachment, breaks and associated landmarks visible during the operation itself will not only save time but also reduce the chances of missing a break. Lincoff's rules are invaluable in this regard (Figure 1). Preoperatively one must be completely satisfied that the breaks fully explain the subretinal fluid distribution. With scleral buckling in particular, as opposed to vitrectomy, the importance of meticulous preoperative examination cannot be overemphasized. This is either because of missed breaks, inadequate or misplaced buckles, or inadequate retinopexy. 3 The vast majority of redetachments occur ultimately because breaks are unsupported.
#WEBMD DETACHED RETINA SYMPTOMS HOW TO#
In this article we discuss some of the possible complications of scleral buckling and how to avoid them.īy far the most common complication of scleral buckling surgery is retinal redetachment, which may be as high as 47% in the first year. 3 Although this figure is impressive, it gives no indication of the complication rates of surgery. This is because repeatedly, in large prospective multicenter studies, both buckling and vitrectomy have approximately a 95% final anatomical success rate. 1 Despite stiff competition from pars plana vitrectomy, which has been used for 39 years, 2 scleral buckles are not about to retire. Scleral buckles have been successfully used to repair rhegmatogenous retinal detachments for the past 60 years.
0 kommentar(er)
