The appropriate technique for retinal detachment
This year’s Gisbert Richard Lecture Award was given to Professor Borja Corcóstegui, Institut Microcirurgia Ocular, Barcelona, Spain
This year’s Gisbert Richard Lecture Award was given to Professor Borja Corcóstegui, Institut Microcirurgia Ocular, Barcelona, Spain.
Prof Corcóstegui delivered the keynote Gisbert Richard Lecture on the topic: “Selecting the Appropriate Surgical Technique for Retinal Detachment.”
“Retinal detachment is not one, single disease and cannot be treated with one, single technique,” said Prof Corcóstegui. “A recent, rapidly progressive retinal detachment with several horseshoe tears is different from a detachment due to a giant retinal tear. These are also different from a retinal dialysis, which is in turn not the same disease as a chronic detachment with proliferative vitreoretinopathy (PVR).”
Selecting the optimal technique early on is crucial for long-term success rates. “Most ophthalmologists agree that the correct first-choice technique selection in retinal detachment marks the outcome,” he said. However, each technique has its advantages and disadvantages.
Although there are many surgical possibilities, current practice is reduced to four: scleral buckling; primary vitrectomy; pneumatic retinopexy; and combined vitrectomy and scleral buckling. Either scleral buckling or primary vitrectomy is appropriate in most cases.
“Primary vitrectomy is indicated in superior breaks, especially in pseudophakic eyes,” said Prof Corcóstegui, suggesting a rather limited range of indications. And yet, primary vitrectomy has long ago surpassed scleral buckling as the first choice for most surgeons. Why?
Prof Corcóstegui explained several reasons for this discrepancy. “Vitrectomy requires less time to examine the patient preoperatively, fellows are no longer trained to perform scleral buckling, vitrectomy is promoted as a modern and better technique and the reimbursement for vitrectomy is higher than scleral buckling in most countries.”
Disadvantages of vitrectomy include postoperative cataract formation in older patients, possible long-term increase in intraocular pressure, subretinal perfluorocarbons and an increased incidence of macular retinal folds as compared to scleral buckling.
Further, “there is probably more intraocular inflammation and epiretinal membrane formation as well as increased surgical cost”, said Prof Corcóstegui. “Of course, vitrectomy has its own advantages, including a lack of refractive eye changes, the absence of floaters, less postoperative pain and more reliable discovery of all potentially missed breaks during surgery,” he said.
For inferior breaks, especially in young, myopic, phakic patients with no posterior vitreous detachment, Prof Corcóstegui usually selects scleral buckling with subsequent retinal laser retinopexy using binocular indirect ophthalmoscopy. This also applies to young patients with retinal dialysis and in cases of what Prof Corcóstegui refers to as “easy” retinal detachments.
Most interestingly, Prof Corcóstegui reviewed several cases in which he combined scleral buckle and vitrectomy. These were beautifully photographed using wide-field photography.
“In cases of giant tears, I like to place a buckle before performing vitrectomy in order to decrease traction and thus decrease the chances of redetachment,” said Prof Corcóstegui. He prefers this combination to vitrectomy with heavy silicone oil tamponade, which he says always produces some degree of inflammation in the eye.
Regardless of the selected technique, “efficacy is always related to the surgeon’s experience”. However, scleral buckle probably remains the gold standard for certain types of detachment in trained surgeons, as it has low morbidity and is cost-effective, he concluded.