Scientiﬁ c Journal of MEDICAL & VISION RESEARCH … · 2019-03-25 · Bikramjit P Pal and Kumar Saurabh Tips & Tricks: Managing retinal detachment: tips for the beginners 7 Lingam

July 2017 Volume XXXV No 2

Scientifi c Journal of

MEDICAL & VISION RESEARCH FOUNDATIONS

insight

www.sankaranethralaya.org Editor: Parthopratim Dutta Majumder

Sankara Nethralaya – The Temple of the Eye.

It was in 1976 when addressing a group of doctors, His Holiness Sri Jayendra Saraswathi, the Sankaracharya of the Kanchi Kamakoti Peetam spoke of the need to create a hospital with a missionary spirit. His words marked the beginning of a long journey to do God’s own work. On the command of His Holiness, Dr. Sengamedu Srinivasa Badrinath, along with a group of philanthropists founded a charitable not-for-profi t eye hospital.

Sankara Nethralaya today has grown into a super specialty institution for ophthalmic care and receives patients from all over the country and abroad. It has gained international excellence and is acclaimed for its quality care and compassion. The Sankara Nethralaya family today has over 1400 individuals with one vision – to propagate the Nethralaya philosophy; the place of our work is an Alaya and Work will be our worship, which we shall do with sincerity, dedication and utmost love with a missionary spirit.

insight

Scientifi c Journal of Medical & Vision Research Foundations

Year: 2017

Issue: Vol. XXXV | No. 2 | July 2017 | Pages 1–55

Typeset at: Nova Techset (P) Ltd., Chennai, India

Printed at: Gnanodaya Press, Chennai, India

©Medical and Vision Research Foundations

ContentsGuest Editorial: Retinal detachment—evolution and changing trends in management 1Pramod Bhende

Major Review: Evolution of retinal detachment surgery down the ages 3Bikramjit P Pal and Kumar Saurabh

Tips & Tricks: Managing retinal detachment: tips for the beginners 7Lingam Gopal

Major Review: Scleral buckling versus vitrectomy for primary rhegmatogenous retinal detachment 10Aditya Maitray, V Jaya Prakash and Dhanashree Ratra

Literature Search: Rhegmatogenous retinal detachment: Contribution of Sankara Nethralaya to literature 20Rupak Roy and Rajiv Raman

Major Review: Surgical implications in exudative retinal detachment 29Suganeswari Ganesan and Ekta Rishi

Case Report: Managing a case of buckle intrusion with recurrent vitreous haemorrhage: a case report 37Sharan Shetty and Muna Bhende

Case Report: Scleral buckle infection presenting as subretinal inflammatory mass lesion 41Kalpita Das, Gaurav Mathur and Muna Bhende

Case Report: Macular buckle for myopic retinal detachment 44Anmol Naik and Pradeep Susvar

Case Report: Retinal vein occlusion following vitrectomy for rhegmatogenous retinal detachment: a case report 48Eesh Nigam and Debmalya Das

Case Report: Some holes need no peeling: a case report of spontaneous closure of macular hole in a case of treated rhegmatogenous retinal detachment 51Debmalya Das and Eesh Nigam

Current Practice Pattern: Practice pattern for managing retinal detachment: a narrative of three generations of vitreoretinal surgeons 53Chetan Rao and Girish Rao

Inquiries or comments may be mailed to the editor at [email protected]

Retinal detachment—evolution and changing trendsin management

Pramod Bhende

Since the first successful reportby Gonin, retinal detachment(RD) surgery has come a longway and over the last 70–80years, the anatomical successrate has increased to over 90%.

The evolution of RD surgeryis both exciting and fascinat-ing. RD, from being an inoper-

able problem to one where surgery has an over90% success rate, is probably one of the greatestsuccess stories in the world of medicine. AlthoughWare gave the first description of RD in 1805, anaccurate clinical diagnosis of RD was possibleonly after Helmholz invented the ophthalmoscope(1850). With further modification over time, anindirect ophthalmoscope, introduced by Schepens,became the main diagnostic tool for retinal disor-ders even today.

Many procedures were proposed to reattach theretina but with hardly any success until Goninproposed that a retinal break was responsible forthe detachment. He reported successful reattach-ment of the retina by sealing the retinal break(1920) using a cautery (Ignipuncture). With thistechnique, Gonin could achieve a success rate ofmore than 50%. Subsequently, many researcherscontributed to the advancement and success ofretinal surgery by trying various innovative tech-niques and surgical methods. Modern establishedsurgical techniques for RD repair, such as, retino-pexy, scleral buckle, vitrectomy and internal tam-ponade, have evolved over a period of time butrevolve around the basic principle of ‘closure ofretinal break and relieving vitreous traction’.

Kasner proposed and proved that the eye cantolerate removal of vitreous and was the first toadvocate open sky vitrectomy. Although Dodo(1955) and Haruta (1959) from Japan publishedtheir vitrectomy techniques years earlier, RobertMachemer, considered as the ‘Father of modernVR surgery’, reported his first pars plana vitrec-tomy in 1970 for non-resolving vitreous haemor-rhage and went on to propose newer instruments,techniques and indications for vitrectomy.Miniaturization of instruments and the develop-ment of operating microscope contributed toestablish current standard three-port vitrectomytechniques.

Scleral buckle, vitrectomy or any other proced-ure? Despite significant improvement in techni-ques, instrumentation and better understanding of

patho-anatomy leading to dramatic success in RDmanagement, reasonable disagreement exists as towhich approach is best as far as surgical interven-tion is concerned. In the past, scleral buckling wasconsidered as the ‘Gold standard’ and pars planavitrectomy was used either in recurrent RD follow-ing scleral buckling or primarily in complicateddetachments. In 1985, Escoffery published his firstreport of virectomy without scleral buckling forthe management of RD. Since then we know thatthe process of vitrectomy which includes nearcomplete removal of vitreous traction, ability toclear media opacities leads to better visualizationand identification and hence better treatment ofretinal break/s and further improvement in surgi-cal outcomes.

With the availability of smaller gauge instru-ment (MIVS) with better fluidics, wide angle visu-alization and brighter illumination, there is anincreased safety margin leading to reduced intrao-perative complication rate, reduced overall surgicaltime and reduced post-surgery morbidity with afinal better reattachment rate. There is an increas-ing trend to use vitrectomy as the primary optionfor retinal reattachment surgery, although there isno clear evidence of superiority of one procedureover the other. The combined surgical approach ofvitrectomy with scleral buckle has also been anarea of debate and multiple studies have shownconflicting results. There is a general consensusthat primary vitrectomy is better for RD in pseu-dophakic/aphakic eyes and SB yields a bettersingle-surgery success rate in phakic eyes. Theavailable set-up, training and competence andtechnical familiarity of the operating surgeon alsoinfluence the selection of surgical procedure, andwe may need ‘expertise-based’ trials to eliminate asurgeon factor while performing newer trials forbetter interpretation of the results.

The introduction of MIVS has made a paradigmshift in the way we approach our cases. The speed,efficiency, early rehabilitation and most import-antly ‘no suture technique’ are appealing for bothsurgeons and the patients. There are furtherattempts to go for thinner, smaller instrumentswith higher cut rates. Do we really need these?What is an ideal gauge for microsurgery? Are theyreally superior for patient care? What about surgi-cal efficiency and safety? Should we go for it justbecause they are available, or due to peerpressure? We do not have answer to all thesequestions at present.

Correspondence:Pramod Bhende, DirectorShri Bhagwan MahavirVitreoretinal Services,Medical Research Foundation,Sankara Nethralaya,Chennai, India.Email: [email protected]

Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | 1

Guest Editorial

With increasing options in the VR surgeons’armamentarium, it is becoming more and moredifficult for us to choose the appropriate techniquein a given case and it is here that experience andfamiliarity with various techniques matters. Whiletraining our young retina surgeons to adopt thesenewer exciting technology and techniques, it isequally important to ensure that they learn theirbasics right.

Sankara Nethralaya is organizing the ‘RetinaSummit 2017’, our second theme based annualretina meeting, in July 2017. The focus of thisyear’s meeting is ‘Retinal detachment’. Eminentand experience faculty from India and across theglobe will be discussing various managementoptions for simple and complex RDs includingcontroversies in management and associated

complications. I hope the meeting will be a greatlearning experience for both practicing surgeonsand retina surgeons in training.

This issue of ‘Insight’ is rolling out at the timeof the ‘Retina Summit 2017’ and is dedicated tothe management of RD, the very focus of thismeeting. This issue covers diverse topics related toevolution of RD surgery, tips for beginners,current trends and controversies in the manage-ment of retinal reattachment surgery, surgery forexudative RD and case reports of management ofunusual complications of surgery. As SankaraNethralaya is known for its expertise in VRsurgery, we would also highlight SN’s contributionin establishing VR surgery as a specialty in Indiansubcontinent and it’s contribution to the existingpublished literature on RD.

How to cite this article Bhende P. Retinal detachment—evolution and changing trendsin management, Sci J Med & Vis Res Foun 2017;XXXV:1–2.

2 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 |

Guest Editorial

Evolution of retinal detachment surgery down the ages

Bikramjit P Pal1 and Kumar Saurabh2

“Treatment of retinal detachment associated withretinal holes should not be urged except in onlyeyes as a last clutch at a straw of hope”. Theselines by Lister from 1927 and the famous surveyby Vail a decade prior (1912),1 which found asuccess rate of retinal detachment (RD) as 1 in1000 speaks for themselves, suggest a grave prog-nosis for RD. Although the current success rate inmanaging uncomplicated RDs is greater than 90%,the journey has been the most intriguing with theemergence of many heroes. One such hero whostands apart is Jules Gonin, whose patience andperseverance have led to the current understand-ing and treatment of RD as we know it. The evolu-tion of RD surgery has always been divided into‘Pre-Gonin’ and the ‘Post-Gonin’ phases. With nointent to change the same, we hereby brieflydescribe the evolution of RD surgery as itunfolded.

Pre-Gonin era (before 1920)Although retinal break was known to be asso-ciated with RD, the focus was solely on RD withno attention to the causative break. Various the-ories were put forward and treatment was direc-ted towards them. The first theory talked aboutRD as being spontaneous with the main culpritbeing abnormal leakage from choroid. Breaks inretina were thought as a result of increased pres-sure from fluid generated behind the retina. Thisled to treatments in the form of scleral andretinal puncture to relieve the pressure. Varioustreatments were directed towards draining thesubretinal fluid (SRF) only to meet with obviousfailure. A combination of SRF drainage alongwith the idea to induce retinopexy was probablyintroduced for the first time by Fano in 1866.1

He induced chemical retinopexy in the form ofinjection of iodine solution into the subretinalspace to achieve a chemical reaction. Apartfrom chemical retinopexy, other modalitiesemployed were galvanocautery, pioneered byDeutschmann.1

The second theory prevalence in this era saw arole of hypotony and associated circulatory altera-tions as the cause of RD. Various treatments wereput forward to counter the same. Injection ofmaterials like rabbit vitreous and gelatin toincrease the intraocular pressure were attempted.Lagrange introduced a procedure known as ‘col-matage’ whereby intraocular pressure wasincreased by applying three rows of scleral cauteryin a circumferential manner in order to increasehydrostatic pressure in the retina.1 Various

osmotic agents were also injected into the subcon-junctival space in the hope of reduction of SRF.These included saline, gelatin, cane sugar, glycer-ine and mercury salts.

A ray of hope appeared when Leber andNordenson2 put forward their theory of vitreoustraction in the genesis of RD. They postulated thatthe alterations in vitreous generated secondarytraction on the equatorial retina forming retinaltears with RD. This concept was of paramountimportance as we know today but alas it met withsevere resistance and criticism. Treatment aimingto relieve vitreous traction was introduced by likesof Deutschmann (who did the same by using VonGraefe knife).

Various non-surgical manoeuvres were alsoemployed. Samelsohn1 insisted on bilateral com-pression bandages with bed rest with idea ofincreasing intraocular pressure. Dietary modifica-tions with salt restriction were another treatmenton offer.

Jules Gonin and methods of retinopexyJules Gonin (1870–1935) legacy in history of RDdares to show how ones persistence and persever-ance can change an idea. Taking Leber andNordenson’s idea ahead with two decades ofexperimentation and self-belief, Gonin proved therole of retinal break in the pathogenesis of RD. Heintroduced a procedure called as ‘Ignipuncture’whereby retinal breaks were painstakingly loca-lized pre- and intraoperatively (not an easy taskin those days). Under local anaesthesia, subretinalspace was entered after making a radial scleralincision near the causative break and SRF wasdrained. Thermocautery was then introduced tocreate a retinopexy. In 1931, Gonin published hisseries of 221 patients who underwent ignipunc-ture with a success rate of 63%.3 Gonin’s theoryof primarily treating the break was cementedwhen his disciples namely Amslers, Weve andArruga4 reported similar success in theiroperations.

In the coming decades, various modificationsof retinopexy were developed to treat the retinasurrounding the causative break. The use of chem-ical cauterization for retinopexy in the form ofpotassium hydroxide after creating holes in sclera(trephining) was introduced by Guist and Lindner1

in 1931. Diathermy was introduced by Larsson,Weve and Safar. It was used either on the baresclera (surface diathermy) or after trephiningthe sclera (penetrating diathermy). Drainage ofSRF was performed along with diathermy. This

1,2Associate consultant,Consultant,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India

Correspondence:Bikramjit P Pal,KamalNayan Bajaj SankaraNethralaya,NewTown, Rajarahat,Kolkata, India.Email: [email protected]


Major Review

procedure was commonly employed for aroundtwo decades. Complications of diathermy in theform of thinning and perforation led to search ofother modalities for retinopexy. Electrolysis wasreintroduced by Imre in 1932, but was seen to beless effective when compared with diathermy;hence never became popular. Although cryother-apy was introduced by Deutschmann and Bietti,the credit for its current use goes to HarveyLincoff and Amoils who made its use easy by cre-ating a specially designed cryo-probe with use ofliquid nitrogen. The use of light for retinopexywas also being studied with the first human useby Moran-Sales, although their results were pub-lished after Meyer Schwickerath. Dr Schwickerathinitially used sunlight, then carbon arc and finallykrypton for retinopexy. Ruby laser and then argonlaser became available with first report of its usein 1969 by L’Esperance.

Evolution of the indirect ophthalmoscope1

The introduction of ophthalmoscope by Helmontzin 1850 was the stepping stone to the currentindirect ophthalmoscope of the modern era. Ruetewas the first to introduce indirect viewing ofretina with his monocular indirect ophthalmo-scope. The first binocular indirect ophthalmoscopewas devised by Giraud Teulon, which was a hand-held model developed in the nineteenth century.Charles Schepens devised the first clinical headmounted an indirect ophthalmoscope in 1947.Four years later, a modified version was intro-duced by Schepens who incorporated the lightsource and viewing system on the headband as weknow it today. He also described the use of scleraldepression which historically was first describedby Trantas in 1900, although he used his thumb-nails for doing so.

Localization of retinal breaks as put forwardby Gonin was tiresome and needed hours oftraining and patience. Various methods weredescribed for localization of breaks, most ofwhich relied on major anatomical landmarks andtheir distances from the break. Amsler andDubois were first to devise a fundus chart formapping extent of RD and its causative break in1928. A combination of ophthalmoscopy andperimetry was also used for the same firstdescribed by Lindner.

Evolution of scleral bucklingShortening of globe by scleral resection was thefirst step towards scleral buckling although theinitial idea was globe shortening and not support-ing the break. Creating an inward ridge for sup-porting break was initially achieved either by fullor partial thickness scleral resection with SRFdrainage and putting mattress sutures acrossthe defect. The techniques were laborious anddangerous with high complication rates. In view

of the same, scleral surgeries without tissue exci-sion were attempted. Weve’s reefing procedure byplacing lamellar suture bites, scleral outfoldingand infolding techniques was some of these.

The first ‘accidental’ temporary scleral indenda-tion during scleral buckle was done by Jess in19371 where a cotton swab was used for thepurpose to counteract hypotony secondary to SRFdrainage. The first scleral buckling procedureusing an episcleral exoplant was performed byErnst Custodis in 1949.1 He used a material madeof polyviol and postulated a non-drainage surgeryand advised reoperation if SRF failed to clear in 4days. Charles Schepens5 gets the credit for doingthe first scleral buckling surgery in the USA in1951. He popularized segmental and encirclingbands made of polyethylene tubes and used thesame after making lamellar scleral flaps.Complications secondary to polyethylene tubes ledSchepens to introduce the silicone rubber implantsin 1960. It was Brockhurst in 1965 who intro-duced the scleral buckle procedure done world-wide for decades. His technique included lamellarscleral dissection, diathermy to the scleral bed fol-lowed by implant placement. The first use of non-absorbable sutures for scleral buckling wasdevised by Arruga in 1958.

It was Harvey Lincoff in 1965 who modifiedthe original procedure by Custodis.1 The changesincluded use of silicone sponge, use of improvedscleral needles and use of cryotherapy instead ofdiathermy for retinopexy. Silicone sponges wereused in a radial or circumferential fashion depend-ing on the clinical scenario.

Evolution of vitrectomy and associatedproceduresOcular sustenance without vitreous was deemedimpossible and its removal a crime. David Kashnerwith help of cellulose sponge and scissors per-formed the first vitrectomy (open sky) in a childwith trauma on 28 July 19616 and proved how aneye could survive without vitreous. Subsequently,he operated two cases with vitreous amylodosis in1967–1968 which cemented his theory. His pupil,Robert Machemer, performed the first pars planavitrectomy in a patient of vitreous haemorrhageon 20 April 1970. He performed the same withhelp of VISC (vitrectomy, infusion, suction andcutter) developed by Jean Marie Parel. It wasConnor O’ Malley and Ralph Heinz7 who intro-duced a divided 20-G vitrectomy system calledOcutome 800 working on principle of pneumaticcutting. Gholam Peyman introduced the electricsolenoid-driven guillotine cutter.

Steve Charles7 led the way in developing thevitrectomy machines. He was instrumental indeveloping the linear or proportional mode forthe first commercial vitrectomy machine: Ocutome800. Further on, he designed the ocular


Major Review

connection machine (OCM), the forerunner forvarious vitrectomy machines like Accurus andConstellation. Dr Charles is also credited for devel-oping fluid air exchange, flute needle, internaldrainage of SRF and endophotocoagulation tech-niques. He was also instrumental in developingvarious scissor segmentation and delaminationtechniques. As success for treating simple rhegma-togenous RDs evolved, so did various instrumentsfor complex RDs. Machemer with his bent needletechnique and O’Malley with his pic forcepsmade peeling of membranes easier. End-graspingforceps by Steve Charles and diamond dustedmembrane scrapper by Yasuo Tano were otherinnovative instruments which are still widely usedtoday.

It was Ohm who gets credit for the first use oftamponade: although air in conjunction with RDsurgery in 1911. This was then routinely adoptedby Arruga8 and then Rosengren who was aleading figure in propagating the pneumoretino-pexy. The use of sulphur hexafluoride (SF6) as atamponade agent was devised by Edward W.DNorton.1,4 Perfluorocarbon gas and its use in RDwere introduced by Vygantas and Lincoff. Giantretinal tears and its complex treatment withnothing short of gymnastics being performed bythe surgeon were eliminated with the introductionof perfluorocarbon liquids (PFCL). It was Haidtwho first introduced PFCL in 1982 althoughStanley Chang gets credit for making its usepopular in treating complex RDs. Paul Cibis9

trained by Schepens himself was first to use sili-cone oil in RD surgery. However, he did not use itas a tamponade but as a tool to dissect preretinalmembranes in cases with proliferative vitreoreti-nopathy. Interestingly, Paul Cibis was part ofoperation ‘paper clip’, a secret program offered bythe government of USA to employ scientist anddoctors from Germany after the World War II. Itwas Zivojnovic who pioneered the use of siliconeoil and its use as a tamponade.

Early 21st century saw the introduction of the25 gauge by Eugene Dejuan and then the23-gauge system by Klaus Eckardt, making RDsurgery less cumbersome and much faster withexcellent results. The introduction of 27-gaugevitrectomy by Oshima has further made patientrehabilitation faster.7,10

Viewing systems used during vitrectomy havealso seen their share of evolution. From theinitial days of Goldmann planoconcave lens andLanders lens system where peripheral vitreouswas mostly untouched, various contact andnon-contact wide-angled viewing systems haverevolutionized the way we see and operate retina.The introduction of binocular indirect ophthal-momicroscope (BIOM) by Manfred Spitznas andits variants have greatly eased performing an RDsurgery.

RD surgery in IndiaLooking into the evolution of RD surgery in Indiahas proved to be more laborious than operating acomplex RD. The following paragraph was formu-lated based on the inputs from eminent indivi-duals in the field of vitreoretinal surgery in Indiaas well as with help of old issues of IndianJournal of Ophthalmology.

Probably, the first person to start vitreoretinalservices was Dr JM Pahwa from AIl India Instituteof Medical Sciences (AIIMS), New Delhi (personalcommunication). However, literature search hasnot provided any concrete evidence of same. Thesame search showed Dr Bijayananda Patnaik fromMaulana Azad Medical College publishing hisresults of scleral buckling in 100 cases in the year1974.11 Dr PK Khosla from AIIMS published theirresults of scleral buckling in 1977 followed byanother one in 1981.12 Another legend Dr DNGangwar from Postgraduate Institute of MedicalEducation and Research, Chandigarh, publishedtheir results of scleral buckle in 1983.13

The first vitrectomy in India was done byDr Gholam Peyman in a case of vitreoushaemorrhage during a workshop in MaduraiMedical College in 1974 (personal communica-tion). Those attending this workshop wereDr. SS Badrinath of Sankara Nethralaya andDr. P Namperumalsamy of Arvind Eye CareSystem; who later became the doyens in develop-ing vitreoretinal surgery and trained many morewho themselves became authorities.

It is ironic to say the least that we know solittle of our past. We hope this rich history of oursgets unfolded too. RD surgery is still evolving andits history is a candid example of how persistenceand perseverance of human endeavours can shapean idea. We conclude with following lines by DrCharles Schepens.

“Never stop dreaming; what seemed impossibleyesterday can become a reality tomorrow”

Acknowledgements We thank Dr Lingam Gopaland Dr Muna Bhende: Sankara Nethralaya,Chennai, Dr P Namperumalsamy: Aravind EyeCare System and Dr Pradeep Venkatesh: AIIMS forproviding inputs in preparing the manuscript. Wealso thank Dr Abhinav Dhami: Senior Resident,Department of Vitreoretina, Sankara Nethralaya inproviding materials for the above review.

References1. Wilkinson CP, Rice TA. (1997) Michels retinal detachment, 2nd

edn. Mosby, St Louis, MO, pp. 241–333.2. Gloor BP, Marmor MF. Controversy over the etiology and

therapy of retinal detachment: the struggles of Jules Gonin.Surv Ophthalmol. 2013;58(2):184–95.

3. Wolfensberger TJ, Gonin Jules. Pioneer of retinal detachmentsurgery. Indian J Ophthalmol. 2003;51(4):303–8.


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4. Rezaei KA, Abrams GW. (2005) Chapter 1: the history of retinaldetachment surgery: primary retinal detachment: options forrepair., 1st edn. Springer, pp. 1–25.

5. McPherson A. Charles Schepens 1912–2006. Retina. 2006;26(6):597–98.

6. Blodi CF, Kasner David, MD, and the road to pars planavitrectomy. Ophthalmol Eye Dis. 2016;8(Suppl 1):1–4.

7. Charles S. The history of vitrectomy: innovation and evolution.Retina Today. 2008:27–29.

8. Ascaso FJ, Grzybowski A. Hermenegildo Arruga (1886–1972): aversatile ophthalmologist who simplified cerclage to retinalsurgery. Acta Ophthalmol. 2014;92(8):814–7.

9. Feibel RM, Blodi CF, Cibis Paul A., MD: a pioneer of modernvitreoretinal surgery. JAMA Ophthalmol. 2013;131(8):1077–82.

10. Nagpal M, Verma A, Goswami S. Micro-incision vitrectomysurgery past, present and future. Eur Ophthal Rev. 2015;9(1):64–8.

11. Patnaik B, Kalsi R. Retinal detachment (operative experience inhundred consecutive cases). Indian J Ophthalmol. 1974;22(1):25–9.

12. Khosla PK, Tewari HK, Garg SP. Aphakic retinal detachment.Indian J Ophthalmol. 1981;29(4):369–76.

13. Gangwar DN, Grewal SP, Jain IS. Retinal detachment surgerysine retinopexy. Indian J Ophthalmol. 1983;31(3):197–8.

How to cite this article Pal B.P. and Saurabh K. Evolution of retinal detachment surgery down the ages, Sci J Med &Vis Res Foun 2017;XXXV:3–6.

Evolution of retinal detachment surgery:The ‘Firsts’Albrecht von Grafe: first to notice and docu-ment a retinal tearHerman von Helmontz: first to introduceophthalmoscopeJames Ware: first attempt in treating retinaldetachment in 1805Jules Gonin: first to give retinal tear its dueimportance and attempts to treat the sameGiraud Teulon: first to introduce binocular indir-ect ophthalmoscope (hand-held) in nineteenthcentauryCharles Schepens: first to introduce headmounted indirect ophthalmoscope in 1947, firstto introduce encircling silicone bandsLarsson, Weve and Safar: first to introducediathermyErnst Custodis: first to use exoplant for scleralbuckle in 1949Deutschmann: first to introduce cryotherapy in1933Harvey Lincoff: first to introduce the moderncryounit for trans-scleral useMoran Sales: first to use photocoagulation as atherapeutic modality in humansGerd Meyer Schwickerath: first to publish tech-nique in use of therapeutic photocoagulation in1949

L’Esperance: first to use argon laser as retino-pexy in 1969David Kashner: first to perform ‘open skyvitrectomy’Robert Machemer: first to perform pars planavitrectomy on 20 April 1970 in a patient withvitreous haemorrhageAnton Banko: first to develop vitrectomy probehaving infusion and aspiration, although nevercommercialized itJean Marie Parel (along with Machemer): first tocommercialize vitrectomy probe called as VISC(vitrectomy, infusion, suction and cutter), first tointroduce operating microscope with X–YmovementJean Haut: first to use silicone oil in combin-ation with pars plana vitrectomy in 1978Conor O’ Malley: first to introduce three-port20-g pars plana vitrectomyGholam Peyman: first to introduce a separateendoillumination probeSteve Charles: first to start internal drainage ofsubretinal fluid, fluid gas exchange, air-siliconeoil exchangeOHM: first use of intravitreal gas (air) in 1911Edward Norton: first to use iso-expansile gas(SF6) with retinal detachment surgeryHaidt: first to introduce perfluorocarbon liquidsas vitreous substitute in 1982


Major Review

Managing retinal detachment: tips for the beginners

Lingam Gopal

IntroductionIn the portfolio of a vitreo-retinal surgical prac-tice, management of retinal detachments occupiesthe premium position. The following serves as anintroduction with a philosophical slant rather thanas a detailed listing of the dos and don’ts.

Is it retinal detachment?While most often the diagnosis of retinal detach-ment is straightforward, there could be confusionon occasions. Conditions that can be confusedwith retinal detachment are retinal oedema (as inBerlin’s oedema), retinoschisis, choroidal detach-ment, thick vitreous membranes (as in Uveitis),altered blood, etc.1 Evaluation should includecareful slit lamp biomicroscopy, indirect ophthal-moscopy and where needed ultrasonography (evenwhen there is view of some fundus details).

Is it rhegmatogenous retinal detachment?In most cases, the rhegmatogenous nature ofretinal detachment is obvious from the appearanceof the retinal detachment as well as the presenceof retinal break. There are, however, situationswhen this may not be that obvious. Chronicretinal detachments can, on occasion, have sometendency towards shifting fluid and can be con-fused with secondary retinal detachments. Retinaldetachments in the milieu of uveitis can some-times cause confusion since a retinal break canoccur due to the traction caused by the vitreousmembranes (due to uveitis) and can actually berhegmatogenous in nature. If the break is notobvious, it may be wrongly treated with steroidsand immunosuppression. Indicators as to the truenature of the problem are relatively quiet eye,undulations in retinal surface, extent of retinaldetachment following Lincoff’s rules, pigment invitreous cavity, etc.

There are several instances of retinal detach-ments secondary to tumours such as melanomahaving been subjected to scleral buckling. Thiserror in judgment can occur especially, when thesurgeon did not evaluate the eye in detail beforesurgery and relied upon the input from lessexperienced personnel. This is one instance whereultrasonography is valuable in the presence ofclear media.

Discussion with patient/relativesIn the discussion with the patient, it is importantone is able to indicate broadly the approach tosurgery, the expected success in terms of reattach-ment of retina, the expected recovery of vision if

surgery is successful, any limitations in travel, risksof surgery including risk of loss of existing vision,need for multiple surgeries (if anticipated), etc. Thepatients often misinterpret expression of percentageof success as the expected visual improvement.This can become very important while operatingon eyes with chronic retinal detachments.

Planning the approachThere is no confusion in case of obviously compli-cated cases where in vitreo retinal surgery wouldbe the only approach possible such as in cases ofgross proliferative vitreo retinopathy, giant retinaltears, posterior retinal tears, macular holes withretinal detachment, colobomas with retinaldetachment, vitreous haemorrhage with retinaldetachment, etc.

In case of simple retinal detachments, theoptions one faces are between pneumatic retino-pexy, scleral buckling and pars plana surgicalapproach. A lot would depend on one’s trainingand individual discretion. The following guidelinesmay be helpful if one has an open mind to choosebetween the three options:

a If choosing pneumatic retinopexy, note thatthe entire retina can be evaluated well withbinocular indirect ophthalmoscope and scleralindentation to exclude additional retinalbreaks, especially inferiorly. Even minimal vit-reous haemorrhage or peripheral cortical cata-ract can interfere with proper visualization allround. Just because there is an obvious horse-shoe tear superiorly, does not mean there areno other less obvious breaks elsewhere. Failureto identify the additional breaks is the mostcommon cause for failure of pneumatic retino-pexy, unfairly blamed on new breaks/prolifera-tive vitreoretinopathy (PVR), etc.

b Avoid pneumatic retinopexy in relatively largebreaks. Chances of sub-retinal migration of thebubbles are high.

c Retinal detachments due to retinal dialysis aremostly managed with scleral buckling. Thereare several advantages to managing them withscleral buckling instead of performingvitreo-retinal surgery.

d Retinal detachments clearly related to latticedegeneration with atrophic holes are again bestmanaged with scleral buckling. Even eyes withsome amount of intra-retinal and sub-retinalgliosis can do well with scleral buckle in thesecircumstances.

Consultant Emeritus,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

Correspondence:Lingam Gopal,Consultant Emeritus,Sri Bhagwan MahavirVitreoretinal Services,Medical Research Foundation,Chennai, India


Tips & Tricks

e Pseudophakic eyes with retinal detachmentcaused by retinal tears (not atrophic holes) arebest managed by pars plana route. The add-ition of encirclage is optional but avoided ifpossible.

f The addition of encirclage to pars planasurgery would be preferred in eyes where vitre-ous cannot be closely shaved (as in phakiceyes), and inferior retinal breaks that couldpotentially lift up because of contracture ofresidual vitreous.

g Choice of gas tamponade after vitrectomy:simple rhegmatogenous retinal detachmentswith superior breaks distributed in not morethan one quadrant can be managed with shortacting gases such as SF6. Eyes with wider dis-tribution of breaks or relatively inferior breaksare best managed with longer acting gasessuch as C2F6 or C3F8.

Importance of preoperative detailedevaluationOne cannot over emphasize the need for detailedpreoperative evaluation. A detailed retinal drawingis optional but valuable, especially when scleralbuckling is performed. The conditions during thesurgery may not be as good as in the clinic fromthe perspective of indirect ophthalmoscopic visu-alization. In addition to the physical impedimentscaused by the operation theatre set up, trolleysand sterile draping, the cornea can becomeoedematous and the pupil may constrict causingsub-optimal visualization. The presence of adetailed drawing can function as an excellentroad map to help localize the lesions under thesecircumstances. In addition, the act of performing adetailed retinal drawing forces the novice surgeonto become familiar with the retinal condition sowell that surgical time can actually be shortened.

Issues that could potentially compromisethe final outcome

1 Decision to do scleral buckling when the visu-alization is inadequate.

2 Attracted by one obvious large tear andmissing the other tiny tears along the vitreousbase.

3 DACE technique (Drain–Air injection–Cryo-Exoplant) that has gone awry: too manybubbles of air that interfere with proper local-ization of break as well as appropriateness ofthe buckle location.

4 Not evaluating the location of the break vs.buckle relationship at conclusion (after drain-age) and performing corrective measures ifneeded. In some cases, the break may fall just

at the edge of buckle and may not beadequately supported. If identified duringsurgery, what is needed is a small additionalstep of shifting the buckle posteriorly to avoidrecurrences.

5 Not placing an adequately wide buckle: thereis a general tendency to choose the buckleswith narrow width (#276/277) since it makesit easier to place the mattress sutures.However, this choice should not be at theexpense of inadequate coverage of the break.One should not hesitate to place a broaderbuckle such as #279 if needed.

6 Sub-retinal bleed at conclusion of SRF drain-age: this is not an often-predictable problem.Contrary to intuitive thinking, significantbleeds can occur at conclusion of drainageeven in younger age groups and in non-myopiceyes. Cauterization of the knuckle of choroiddoes not always prevent the bleed. Most signifi-cant bleeds occur at conclusion of drainagewhen the pressure is released suddenly, evenbefore the sutures can be tightened. One wayout can be to do controlled drainage. Drainagesome amount—inject BSS—drain more and thentighten the buckle sutures. If despite the pre-cautions bleed occurs and has migrated intosub-retinal space, one can inject a bubble ofC3F8 and place patient prone to permit theblood to shift away from macula.

7 Inadequate cryo-induced chorio-retinal adhe-sion around the retinal break: this situationcan arise when the retina in the area ofbreak is highly elevated and the ice ballformed by the cryoprobe is not reaching theretina. Theoretically freezing the choroid—RPEcomplex should be enough to cause adequatechorio-retinal adhesion once the retina is reat-tached; however, due to the high degree ofparallax, the freezing may not be under theedge of break—as desired.

One can supplement with postoperativelaser as long as there is no fluid around thebreak.

8 Fish mouthing: this is not an uncommon com-plication after placing circumferential bucklesfor large horseshoe tears. Injecting a bubble ofgas and positioning the patient can easilyremedy this complication.

The use and misuse of silicone oilIn addition to more common indications such assevere PVR, coloboma-related retinal detachments,large giant retinal tears (180° and more), etc., onemay have to use silicone oil in patients whocannot posture themselves, patients who need to


Tips & Tricks

fly immediately after surgery, one eyed patients(for early visual rehabilitation), etc.

One should not take usage of silicone oil lightly.Once injected, we have committed the patient for atleast one more surgery. The worry of facing arecurrent total retinal detachment after gas tam-ponade should not push novice surgeons to overuse silicone oil. With use of silicone oil, we post-pone the issues but do not get rid of them.Long-term complications are well known.2 Shallowinferior retinal detachments may go unnoticed.

There is a tendency to postpone removal of sili-cone oil even when retina is well attached—forfear of facing possible recurrence after removal ofsilicone oil. Some surgeons keep convincingthemselves that it is OK to leave the oil in till itcauses complications. Some surgeons place sili-cone oil for inferior breaks, where gas tamponadewith additional encirclage would have sufficed—just to avoid converting so-called suture lessvitrectomy to a sutured one.

Adopting new techniquesChange is a constant phenomenon and thisapplies to the field of vitreo-retinal surgery as

well. Adopting a new technique does not meanone should forget an old technique, especially oneas robust as scleral buckling. It is accepted thatscleral buckling is less forgiving but the tendencyto manage all cases of retinal detachment with thepars plana approach should be abhorred.

The new technique of using a 25-G chandelierlight along with the wide-angle visualizationsystem (BIOM) and performing scleral bucklinghas certain advantages.3 Unlike with indirect oph-thalmoscopy, the image of the retina can be mag-nified making it easier to localize smaller lesions.The use of this hybrid technique may be the bestway of bringing some of the young surgeons backto scleral buckling.

References1. Bhomaj S, Khare C. Retinal detachment — in postgraduate

ophthalmology. In Chaudhari Z., Vanathi M. (Eds). Chapter 12.11.Jaypee Highlights, New Delhi. p. 1255.

2. Federman JL, Schubert HD. Complications associated with theuse of silicone oil in 150 eyes after retina-vitreous surgery.Ophthalmology 1988;95(7):870–6.

3. Temkar S, Takkar B, Azad SV, et al. Endoillumination(chandelier) assisted scleral buckling for a complex case of retinaldetachment. Ind J Ophthalmol. 2016;64:845–6.

How to cite this article Gopal L. Managing retinal detachment: tips for the beginners, Sci J Med & Vis Res Foun2017;XXXV:7–9.


Tips & Tricks

Scleral buckling versus vitrectomy for primaryrhegmatogenous retinal detachment

Aditya Maitray1, V Jaya Prakash2 and Dhanashree Ratra3

IntroductionRetinal detachment (RD) surgery is the mostcommon retinal surgery performed. RD can berepaired either by scleral buckling (SB) or parsplana vitrectomy (PPV). Pneumoretinopexy, laserdelimitation or observation can be done inselected cases. The decision to perform SB orvitrectomy depends on various factors, includingage of the patient, duration and extent of RD,presence of proliferative vitreoretinopathy (PVR)changes, the number, location and size of retinalbreaks and the lens status. Other factors whichinfluence the decision are availability of operatingroom equipment or staff, various patient factors(especially expected compliance with positioningafter surgery) and surgeon preference.1 Untilabout a decade ago, SB was the preferred proced-ure, but there is a general trend towards vitrec-tomy with the development of newer technology.There are several retrospective and prospectivestudies which compare SB and vitrectomy forprimary RD. The anatomical and visual outcomesfollowing retinal reattachment surgeries reportedin the recent peer-reviewed literature will be dis-cussed in this article.

Scleral bucklingSB provides target-oriented retinal attachment. Itis ideally suited for detachments with anteriorretinal breaks and dialysis. It is also a veryrewarding surgery for suitable paediatric RDswherein PVD induction during PPV is a challenge.It is efficacious for both superior and inferiorbreaks, does not cause cataract, does not requirepostoperative positioning, unless gas or air isinjected, and has a high single-surgery successrate (SSSR). Success rate can be further improvedby meticulous preoperative and intraoperativesearch for breaks. Chandelier-assisted SB has alsobeen described that can allow direct intraoperativevisualization of peripheral retina under magnifica-tion.2 On the other hand, patients with giantretinal breaks (GRTs), posterior breaks, PVR worsethan grade B, thin sclera, glaucoma drainagedevice, previous strabismus surgeries and mediahaze (e.g. vitreous haemorrhage) precluding visu-alization of peripheral retina are not ideally suitedfor scleral bucking procedures and respond morefavourably to PPV. The main reasons for failedbuckle surgery are missed breaks, fishmouthing,inadequate buckling effect, development of newretinal breaks and PVR. The drawbacks with SB

include increased postoperative morbidity likepain and periorbital oedema, drainage-relatedcomplications like vitreoretinal incarceration, sub-retinal haemorrhage and choroidal detachment,diplopia due to muscle restriction, chorioretinalcirculatory disturbances, refractive changes (typic-ally axial myopia), epiretinal membrane forma-tion, buckle intrusion, extrusion and infection.Subretinal fluid may take time to absorb in caseof non-drainage procedure delaying anatomicalrecovery and resulting in poorer final visualoutcomes.

Pars plana vitrectomyThe major advantage of PPV over SB is theimproved internal search for breaks with micro-scopic visualization of peripheral fundus by scleralindentation and internal illumination. Other majoradvantage usually cited is the direct eliminationof vitreous traction and removal of the vitreousleading to elimination of PVR-stimulatingenvironment.3

It can help to clear media opacity, can addressvery posterior breaks and giant retinal tears andallow use of PFCL, internal drainage of subretinalfluid and intraoperative retinal attachment.With the development of improved visualizationsystems and smaller gauge surgical techniques,the success rate of vitrectomy has improved con-siderably. The potential problems with vitrectomyare the increased rate of cataract formation, iatro-genic breaks, requirement for postoperative posi-tioning and higher cost.

Table 1 summarizes the basic differencesbetween the two techniques. Based on the abovedifferences between SB and vitrectomy, it isobvious that a few cases like localized detachmentwith single or neighbouring breaks are ideal forSB and complicated cases like PVR grade C or D,giant retinal tears, very posterior breaks andmacular holes are better treated with vitrectomy.However, for a vast majority of cases that lie inbetween these two extreme scenarios, there existssome confusion regarding which surgical modalitywould give the best outcome. This group com-prised about 30% of all primary rhegmatogenousRDs in the SPR recruitment study.4 Certainambiguous cases which include patients with mul-tiple breaks in different quadrants, bullous rheg-matogenous RDs, breaks extending central to theequator, breaks with marked vitreous traction andrhegmatogenous RDs with unclear hole situations

1Fellow,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

2Associate consultant,Consultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

3Senior Consultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

Correspondence:Dhanashree Ratra,Senior Consultant,Shri Bhagwan MahavirVitreoretinal Services,Medical Research Foundation,Sankara Nethralaya,Chennai, India.Email: [email protected]


Major Review

(no break or not all breaks could be identified onexamination before surgery) require a lot ofdebate.

We searched PUBMED for the following terms:‘retinal detachment’, ‘scleral buckle’ & ‘vitrectomy’and finally analyzed recent relevant studies (pub-lished after year 2000) comparing SB and vitrec-tomy with minimum of 6 months mean follow-upand a minimum sample size of 30 eyes.

OutcomesThe most commonly reported anatomical out-comes in these comparative trials between SB andPPV for primary rhegmatogenous RDs includesingle-surgery success rate (SSSR: defined by moststudies as an attached retina at final follow-upafter a single surgery) and final anatomicalsuccess rate (defined as an attached retina at finalfollow-up after ≥1 surgical interventions). Thefunctional outcomes studied include change inbest-corrected visual acuity (BCVA, in terms oflogarithm of the minimum angle of resolution[LogMAR] or Snellen’s acuity expressed as theproportion of study eyes achieving final visionbetter than 6/60 −6/18, depending on the studycriteria). Apart from the surgical technique used,the visual acuity results may also be affected byseveral other factors like the presence or absence

of macular detachment, height and duration ofmacular detachment (DMD) and amount of pre-existing cataract. The other reported outcomeswere the number of retinal procedures/reopera-tions, the redetachment rate and complicationslike postoperative PVR rate, raised intraocularpressure, epiretinal membrane and cataract devel-opment (in phakic patients).

Retrospective studiesTable 2 summarizes the recent retrospective com-parative studies between SB and PPV for rhegma-togenous RD.

Most of the retrospective studies showed nodifference in anatomical and functional outcomesbetween SB and PPV groups (table 2).5–13

However, Park et al. have reported that PPV mightshow better visual outcomes compared with SB inolder phakic patients, the final anatomical out-comes still remaining comparable. This may bedue to the presence of PVD and performing com-bined cataract surgery along with PPV wheneverrequired.12

In pseudophakic eyes with uncomplicated RDs,initial and final anatomical outcomes have beenreported to be better with PPV alone/PPV com-bined with SB compared with SB as per ameta-analysis of comparative retrospective studies

Table 1: SB versus PPV: comparison

Scleral buckle PPV

Mechanism of vitreous tractionrelief

Indirect/passive Direct

Internal tamponade Nil Silicone oil/gas

Efficacy for superior/inferiorbreaks

Equal Better for superior breaks

Efficacy in the presence ofPVR > grade B

Less Better

Postoperative morbidity* More Less

Postoperative positioning Not required Required

SSSR 90–95% 85–90%

Other advantages Can support missed breaksAllows air travelEffective for retinal dialysisNo cataract formation

Clears media opacitiesEffective for giant retinal tears, posteriorbreaks

Potential complications Refractive changesOcular motility disturbanceVitreoretinal incarcerationSubretinal/suprachoroidalhaemorrhageMigration/exposure of buckleelementsMacular pucker

Cataract progressionRaised intraocular pressureIatrogenic breaks

Miscellaneous disadvantages Moisture condensation on silicone IOLsduring fluid–air exchangeRestricted air travel in immediatepostoperative period if gas tamponade usedExpensive

*Pain and periorbital oedema in immediate postoperative period.


Major Review

Table 2: SB versus PPV: retrospective studies

Study Type ofsurgery

No. of eyes(follow-up)

SSSR (p*) Visual outcome (p*) Complications (p*) Comments

Oshima et al. (2000)8,Primary uncomplicatedmacula off RD

SB 55(24 months)

91%(finalreattachment rate100%)

0.42 LogMAR Iatrogenic breaks 4%Subretinal/vitreous bleeding 5%Cataract progression 12%ERM formation 7%PVR 3.8%Ocular hypertension 0

Preoperative VA, IOP and DMD best predictors ofpostoperative visual recovery in both groups

PPV group had better visual recovery in patientswith preoperative visual acuity <0.1, DMD >7 daysand preoperative IOP <7 mmHg

PPV 47 (24 months) 91% (finalreattachment rate100%)

0.45 LogMAR at 24months (p=0.85)

Iatrogenic breaks 4% (p=0.24)Subretinal/vitreous bleeding 2% (p=0.62)Cataract progression 64% (p<0.001)ERM formation 2% (p=0.37)PVR 4% (p>0.99)Ocular hypertension 2% (p>0.99)

Miki et al. (2001)9,Uncomplicated RD fromflap tears in superiorquadrant

SB 138 (6 months) 92% (final 100%) Initial failure in 11 eyes due to malpositioned buckle(seven eyes multiple tears and four posterior largeflap tears)Subretinal haemorrhage 4.3%Penetrating suture 2.6%Ocular motility defect 5.1%ERM 2.2%PVR 0Postoperative cataract 0

Eyes undergoing PPV+encircling band achieved100% SSSR compared with eyes treated with PPValone (86.3%).

Vitrectomy appeared to have a better success rate96.6% in case of multiple superior breakscompared with SB (69.9%) but not statisticallysignificant

PPV 87 (6 months) 92% (final 100%) - Initial anatomical failure in seven eyes (new tearsfive eyes, reopening of old tears in two)Subretinal haemorrhage 0Penetrating suture 0ERM 2.3%PVR 3.4%Lens trauma (6.9%)Iatrogenic breaks (9.2%)Postoperative cataract 20.7% (p<0.05)

Huang et al. (2013)10,Macula off RDs

SB 32 (8 weeks) Mean change inLogMAR 0.4± 0.8

ERM on SDOCT in 15.6% Residual SRF at macula on SDOCT in 81.3% in SBgroup versus 19.2% in the PPV group at 8 weeks(p<0.05)

PPV 26 (8 weeks) Mean change inLogMAR 0.7± 0.8(p<0.05)

ERM on SDOCT in 19.2% (1.0) PPV faster for macular recovery in macula off RDsNo difference in structural changes at macula onSDOCT between two groups

SB 0.29–0.13 (p=0.001)

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Kobashi et al. (2014)11,Uncomplicated RD

271 (6 months)260 phakic, 11pseudophakic

93.7% (finalsuccess rate100%)

Needle perforation 0.4%Reopening of original break 3%New break causing redetachment 3.8%PVR 0.4%Macular pucker 0.4%CME 0.7%Choroidal detachment 0.7%Transient diplopia 0.7%

In the SB group, eyes with macula-off statusassociated with a lower success rate (p=0.002).Although break location and lens status had nosignificant effect on success rates in either group.

All phakic eyes in the PPV group underwentcombined cataract surgery

PPV 271 (6 months)228 phakic and 42pseudophakic

96.3% (finalsuccess rate100%)

0.68–0.14 (p<0.001) Iatrogenic breaks 7.7%Reopening of original break 2.2%New break causing redetachment 1.1%PVR 0.4%Macular pucker 0.7%CME 0.4%Pupillary block 1.1%

Erakgun et al. (2014)12,Uncomplicated RDwith mild vitreoushaemorrhage

SB 38 (6 months) 79% 0.55 Subretinal haemorrhage (5.2%)Macular pucker(7.8%)Cataract progression (13%)PVR grade B or worse (10.5%)Subsequent cataract sx (5.2%)Ocular hypertension 0

Phakic eyes with mild rhegma- related vitreoushaemorrhage with visible peripheral fundusselected.SSSR better in the PPV group, final anatomicalsuccess 100% in both groups

BCVA at 3 months better in the PPV group butsimilar in two groups at 6 monthsPPV 40 (6 months) 95% (p=0.03) 0.6 (p=0.9) Iatrogenic breaks (10%)

Macular pucker 5% (0.6)Cataract progression 35% (0.02)Lens damage (5%)PVR grade B or worse 5% (0.4)Cataract sx 20%Ocular hypertension 2.5%

Rush et al. (2014)13,Medium complexity RD

SB 121 eyes (6 months) 87.6% 65.12% ≥20/40 No difference in overall outcomes between differenttechniques.

PPV 444eyesC3F8/SF6 tamponade(6 months)

81% for PPV(p=0.2)89.7% for PPV+SB combined

54.4% in PPV and48.2% in PPV/SB≥20/40(p 0.21)

No difference in anatomical (p 0.11, 0.78) or visualoutcomes (0.63, 0.55) with the three techniquesbetween phakic andpseuodphakic lens status

Stamenkovic et al.(2014)14,Uncomplicated RD

SB 68 eyes (6 months) 76.5% From 1.89±1.04 to0.98±0.70 LogMAR(p 0.04)

Better anatomical outcomes in the PPV group.

PPV 30 eyes (6 months) 100% (<0.05) From 2.56±0.67 to1.31±0.74 LogMAR (p0.001)

Both groups showed significant visual improvement

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Table 2: Continued

Study Type ofsurgery

No. of eyes(follow-up)


Park et al. (2015)15,Phakic uncomplicatedRD, age >35 years

SB 72 eyes (6.9 months) 77.8% 1.38±0.87 to 0.51±0.48

Sustained submacular fluid in 38.6% Final BCVA worse in the SB group (p 0.01)Primary success rate better in PPV.

PPV 57 eyes(6 months)

94.7% (p=0.01) 1.84±0.97preoperatively to 0.30±0.23 postoperatively

Sustained submacular fluid in 2.8% eyes(p <0.001)

Final success rate 100% in both groups

Cankurtaran et al.(2017)16,Pseudophakic RDs

SB 30 eyes (34 months) 73.3% 63.3% ≥ 2 lineincrease in BCVA

No difference between groups in primary or finalanatomical or visual outcomes

PPV 39 PPV+siliconepseudophakic RDs(32.6 months)

77% 69.2% ≥ 2 lineincrease in BCVA

32 PPV+C3F8pseudophakic (33.7months) RDs

81.2% (p 0.76) 87.5% ≥ 2 lineincrease in BCVA (p0.4)

*p-value for difference in parameter in the PPV versus SB group.Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane; BCVA: best-correctedvisual acuity; IOP: intraocular pressure.

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Table 3: SB versus PPV: prospective studies

Study Type of surgery No. of eyes(follow-up)

SSSR (p*) Visual outcome(p*)

Complications (p*) Comments

Ahmadieh et al.(2005)17,(pseudophakic andaphakic RDs)

SB 126 (6 months) 68.2% 0.96±0.68Mean LogMar at6 months

Macular pucker (22%)CME (6.3%)IOP rise early postoperativeperiod (24.6%)EOM dysfunction 4%

Baseline features matched.20G PPV, 20% SF6 tamponade in the PPV group

Trauma, glaucoma, uveitis, AMD, DR, macular hole,GRT, PVR worse that grade B excludedNo significant difference in anatomical and visualoutcomes and complication ratesFinal attachment rate 85% in the SB group and92% in the PPV group

PPV 99 (6 months) 62.6% 0.96±0.62Mean LogMar at6 months

Macular pucker (22.2%)CME (6.1%)IOP rise early postoperativeperiod (26.3%)

Sharma et al. (2005)18,Pseudophakic primaryrhegmatogenous RDs

SB 25 eyes (6 months) 76% 0.19±0.15decimal acuity

IntraoperativeNeedle perforation 4%Retinal haemorrhage 8%EarlyRaised IOP 4%Choroidal detachment 8%LateERM 16%CME 4%Buckle infection 4%Diplopia 4%PVR causing failure 20%

Final anatomical reattachment 100% in bothgroups.Better long-term visual and anatomical outcomesin PPV in pseuophakic RDs

PPV 25 eyes (6 months) 84%(p 0.48)

0.28±0.12(p 0.03)Decimal acuity

IntraoperativeIatrogenic breaks24%Retinal haemorrhage 4%EarlyRaised IOP 32%LateERM 12%CME 4%PVR causing failure 4%

Brazitikos et al.(2005)19,RCT

SB 75 eyes (1 year) 83% 0.4 LogMAR Mean change in axial length at 1year 0.95 mmMean operating time 65.8 min(p=0.004)

PPV has less operative time, more accuratediagnosis of breaks and higher single-surgeryreattachment rate with less postoperative axiallength changes.

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Table 3: Continued


SSSR (p*) Visual outcome(p*)

Complications (p*) Comments

Primary pseudophakicRRD, PVR ≤grade B

Undiagnosed breaks aftersurgery 7New intraoperatively diagnosedbreaks 8

But similar final attachment rate with multiplesurgeries: 96% in the SB group and 98.6% in thePPV group (p=0.37)

PPV 75 eyes primarypseudophakic RRD, PVR≤grade B20% SF6 forendotamponade(1 year)

94%(p=0.03)

0.33 LogMAR(p=0.26)

Mean change in axial length at 1year 0.33 mm (p=0.0001)Lower mean operating time54.6 min (p=0.004)Undiagnosed breaks after surgery0 (p=0.01)New intraoperatively diagnosedbreaks 22 (p=0.004)

Azad et al. (2007)20,Phakic eyesuncomplicated RD

SB 31 eyes (6 months) 80.6% From 1.48(median) to 0.6LogMAR

SB and PPV comparable in outcomes

PPV 30 eyes (6 months) 80% From 1.78(median) to 0.6LogMAR

Cataract in 5 (17%)

Heimann et al. (2007)21,‘SPR study’,RCT

Phakic eyes SB 209 eyes (12 months) 63.6% 0.33 Cataract progression 45.8%PVR grade B or C 12.4%

Final anatomical success 96.7% and 96.6% in SBand PPV groups, respectively.

PPV 207 eyesSF6 in primary Sx(12 months)

63.8%(0.97)

0.48 (0.005) Cataract progression 77.3%(<0.0005)PVR B or C 16.4% (0.08)

Silicone oil used in revision surgeries in 9.1% inthe SB group and 17.9% in the PPV groupBenefit of SB with respect to BCVA improvement inphakic eyes

Pseudophakiceyes

SB 133 eyes (12 months) 53.4% 0.46 PVR 22.6% Final anatomical success 93.2% and 95.5% in SBand PPV groups, respectively (comparable).

PPV 132 eyes SF6 in primarySx(12 months)

72%(0.002)

0.38 (0.1) PVR 15.2% (0.1) Silicone oil used in revision surgeries in 21.8% inthe SB group and 11.3% in the PPV groupBetter anatomical outcomes of PPV group inpseudophakic/aphakic groups

*P-value for difference in parameter in the PPV versus SB group.Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane; RCT:randomized control trial; IOP: intraocular pressure.

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Table 4: SB versus PPV: meta-analysis studies



Arya et al. (2006)14,Uncomplicatedpseuophakic RDs

SB 1579 Lower initialreattachmentrates

Lower probability of finalvisual improvement comparedwith PPV/PPV+SB

Initial and final anatomical outcomes betterwith PPV/PPV+SB compared with SB.Final visual success highest with PPV+SB,followed by PPV alone, compared with SBUndetected breaks, loss of capsular supportand macular detachment found to be significantnegative predictors of primary success rate.

‘Meta-analysis’ PPV 457 OR 1.69[95% CI 1.07–2.68]

Higher probability of visualimprovement than SB[OR 2.34; 95% CI, 1.58–3.46]

Sun et al. (2012)22, Phakic SB 76% 88.6% final visual success PVR 10.3%Postoperativecataract 40%

Final anatomical success 97.3% both groups.SB is superior in terms of final VA andoccurrence of postoperative cataract inuncomplicated phakic RRDs.Meta-analysis of

RCTsPPV 76.9% (0.8) 79.6% final visual success

(0.005)PVR 15% (0.1)Postoperativecataract 69.6%(0.00001)

Pseudophakic SB 68.8% 86.7% final visual success PVR 21.2% Final anatomical success 91.1% in the SB groupversus 95.5% in the PPV group (p 0.04)

PPV 78.2% (0.16) 90.5% final visual success(0.19)

PVR 17.8% (0.4) PPV is more likely to achieve a favourable finalreattachment in pseudophakic/aphakic RRDs.

*P-value for difference in parameter in the PPV versus SB group.Abbreviations: SSSR: single-surgery success rate; SB: scleral buckle; PPV: pars plana vitrectomy; RD: retinal detachment; PVR: proliferative vitreoretinopathy; ERM: epiretinal membrane;RRD: rhegmatogenous retinal detachment.

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by Arya et al.5 (table 4). Final visual success washighest when PPV was combined with SB, fol-lowed by PPV alone, compared with SB.Undetected breaks, loss of capsular support andmacular detachment found to be significant nega-tive predictors of primary success rate in thesepsedophakic RDs.

Even in eyes with mild vitreous haemorrhage(where peripheral fundus can be adequately visua-lized), Erakgun et al.found that though the initialvisual outcome was better in the PPV group, thefinal visual and anatomical outcomes (at 6months) were comparable in both groups.

Various retrospective studies have also com-pared PPV alone and PPV with additional SB.Anatomical and functional success rates werebetter with the use of a scleral explant duringPPV for uncomplicated forms of phakic rhegmato-genous RDs with inferior breaks.,6. However, theyseem to have similar efficacy in the repair of amatched group of patients with primary non-complex pseudophakic RD.7

Common complications in SB according tomost studies were subretinal haemorrhage due toperforation, epiretinal membrane formation anddelayed absorption of submacular fluid (in non-drainage procedures). In the PPV group, the inci-dence of cataract progression and lens damage,occurrence of iatrogenic breaks was significantlymore common when compared with the SBprocedure.

Retrospective studies suffer from the fact theremay be severe selection bias as the decision to optfor a particular surgery is influenced by variousother factors like preoperative findings, patientcharacteristics, available tools for surgery, andexperience, ability and preference of the operatingsurgeon.

Prospective studiesThere are relatively limited number of prospectivestudies that compare outcomes of SB and PPV(Table 3).

In phakic eyes, most prospective studies havefound better visual outcomes with SB when com-pared with PPV for uncomplicated RDs, althoughthe final anatomical outcomes may be similar inboth groups.20,21 This can be explained by thehigher incidence of cataract progression and diffi-culty in adequate vitreous base excision duringvitrectomy.

In pseudophakic eyes on the other hand, PPVis more likely to achieve a favourable anatomicaloutcome, though there was not much difference infinal visual outcomes.17-19,21The main issue inpseudophakic/aphakic eyes is the difficulty in pre-operative visualization as the breaks are usuallysmall and multiple, anterior and posterior capsularhaze, cortical remnants, suboptimal dilatation andoptical aberrations due to the IOL. Most studies

have attributed the lower anatomical success inthe SB group to missed small breaks possibly dueto poor visualization of periphery. SB has alsobeen shown to be associated with a significantincrease in axial length postoperatively comparedwith PPV.16

The SPR studyThe Scleral Buckling versus Primary Vitrectomy inRhegmatogenous Retinal Detachment Study (SPRStudy)21 was the first large-scale, open-label pro-spective randomized multicentre clinical trialwhich compared SB surgery and primary PPV inrhegmatogenousretinal detachments of mediumcomplexity with 1-year follow-up. It separatedphakic and pseudophakic patients (parallel groupdesign). Forty-five surgeons (who had to have per-formed atleast 100 SB procedures and 100 PPVsas primary surgeons) from 25 centres in fiveEuropean countries recruited 416 phakic and 265pseudophakic patients. In the phakic arm, themean BCVA change was significantly (p=0.0005)greater in the SB group (SB, −0.71 logMAR,standard deviation [SD] 0.68; PPV, −0.56logMAR, SD 0.76). In the pseudophakic arm,changes in BCVA showed a non-significant differ-ence of 0.09 logMAR. In phakic patients, cataractprogression was greater in the PPV group(p<0.00005). In the pseudophakic group, theprimary anatomical success rate (SB, 71/133[53.4%]; PPV, 95/132 [72.0%]) was significantlybetter (p=0.0020), and the mean number ofretina-affecting secondary surgeries (SB, 0.77, SD1.08; PPV, 0.43, SD 0.85) was lower (p=0.0032) inthe PPV group. Re-detachment rates were 26.3%(SB, 55/209) and 25.1% (PPV, 52/207) in thephakic trial and 39.8% (SB, 53/133) and 20.4%(PPV, 27/132) in the pseudophakic trial. The studyshowed a benefit of SB in phakic eyes with respectto BCVA improvement. No difference in BCVA wasdemonstrated in the pseudophakic trial; based ona better anatomical outcome, PPV was recom-mended in these patients.

Meta-analysisTable 4 summarizes the results of two largemeta-analyses of studies comparing SB with PPV.

The results of different studies cannot be com-pared together as the surgical techniques may bedifferent, for example combining cataract surgerywith vitrectomy in phakic patients might improvethe visual acuity results, use of additional SB/encirclage, use of 360° endolaser and the use ofgas or oil for tamponade in vitrectomy may changethe rate of re-detachment and anatomical progno-sis. The decision to drain or not in SB may alsoaffect the complication rates and final outcomes.

It is also important to note that most prospect-ive and retrospective studies comparing PPV withSB have employed gas as primary tamponade


Major Review

(SF6/C3F8) for PPV. Silicone oil was used only incases of recurrent detachments. In clinical prac-tice, it is not uncommon to use silicone oil as theprimary tamponading agent during PPV for rheg-matogenous RDs. Silicone oil and its associatedcomplications can also have an impact on finalvisual and anatomical outcomes of PPV.

Furthermore, most of these studies have usedtraditional 20G systems for PPV. In the currentscenario, small gauge vitrectomy and microinci-sion vitrectomy systems (MIVS) have become thenorm, with improved outcomes and reduced com-plication profiles which should be taken into con-sideration during these comparisons.

ConclusionsThe controversy still continues and debate can goon regarding the efficacy of both these surgicalprocedures as a primary form of repair for RD.Many retrospective and prospective studies haveshown nearly equal SSRs, anatomical successrates and functional outcomes in SB as well asPPV. In general, SB remains the method of choicein uncomplicated retinal situations, i.e., singlebreaks and/or a limited RD. In contrast, PPV isindicated in complicated situations. However, thedecision to choose one particular type of surgeryhas to be individualized to that particular casescenario. It would also depend on the surgeon’spreference and comfort with a particular tech-nique. SB, although an old technique still holdsgood and can give excellent results if performedwell. It would be advisable for the young retinasurgeons to acquire this skill set.

References1. Schwartz SG, Mieler WF. Management of primary

rhegmatogenous retinal detachment. Comp Ophthalmol Update2004; 5:285–94.

2. Nam KY, Kim WJ, Jo YJ, et al. Scleral buckling technique usinga 25-gauge chandelier endoilluminator. Retina 2013;33(4):880–2.

3. SPR Study Group. View 2: the case for primary vitrectomy. Br JOphthalmol. 2003;87:784 –7; McLeod D. Is it time to call timeon the scleral buckle? Br J Ophthalmol. 2004;88:1357–9.

4. Feltgen N, Weiss C, Wolf S, et al. Scleral buckling versusprimary vitrectomy in rhegmatogenous retinal detachment study(SPR Study): recruitment list evaluation. Study report no. 2.Graefes Arch Clin Exp Ophthalmol. 2007;245:803–9.

5. Arya AV, Emerson JW, Engelbert M, et al. Surgicalmanagement of pseudophakic retinal detachments: ameta-analysis. Ophthalmology 2006;113(10):1724–33.

6. Chanana B, Azad R. Pars plana vitrectomy versus combinedscleral buckling—pars plana vitrectomy for phakicrhegmatogenous retinal detachment with inferior breaks. Open JOphthalmol. 2016;6:129–35.

7. Weichel ED, Martidis A, Fineman MS, et al. Pars planavitrectomy versus combined pars plana vitrectomy–scleral

buckle for primary repair of pseudophakic retinal detachment.Ophthalmology 2006;113:2033–40.

8. Oshima Y, Yamanishi S, Sawa M, et al. Two-year follow-upstudy comparing primary vitrectomy with scleral buckling formacula-off rhegmatogenous retinal detachment. Jpn JOphthalmol. 2000;44(5):538–49.

9. Miki D, Hida T, Hotta K, et al. Comparison of scleral bucklingand vitrectomy for retinal detachment resulting from flap tearsin superior quadrants. Jpn J Ophthalmol. 2001;45(2):187–91.

10. Huang C, Fu T, Zhang T, et al. Scleral buckling versusvitrectomy for macula-off rhegmatogenous retinal detachmentas accessed with spectral-domain optical coherencetomography: a retrospective observational case series. BMCOphthalmol. 2013;13:12 doi: .

11. Kobashi H, Takano M, Yanagita T, et al. Scleral bucklingand pars plana vitrectomy for rhegmatogenous retinaldetachment: an analysis of 542 eyes. Curr Eye Res. 2014;39(2):204–11.

12. Erakgun Tansu, et al. Scleral buckling versus primaryvitrectomy in the management of retinal detachment associatedwith mild vitreous hemorrhage. Turk Oftalmoloji Dergisi.2014;44(2):92–7. 6p

13. Rush R, Simunovic MP, Sheth S, et al. 23-Gauge pars planavitrectomy versus scleral buckling versus combined parsplana vitrectomy-scleral buckling for medium-complexityretinal detachment repair. Asia Pac J Ophthalmol. 2014;3(4):215–9.

14. Stamenkovic M, Stefanovic I, Sencanic I, et al. Morphologicaland functional outcome of scleral buckling surgery compared toprimary vitrectomy in patients with retinal detachment.Vojnosanit Pregl. 2014;71(10):920–4.

15. Park SW, Kwon HJ, Kim HY, et al. Comparison of scleralbuckling and vitrectomy using wide angle viewing system forrhegmatogenous retinal detachment in patients older than 35years. BMC Ophthalmol. 2015;15:121.

16. Cankurtaran V, Citirik M, Simsek M, et al. Anatomical andfunctional outcomes of scleral buckling versus primaryvitrectomy in pseudophakic retinal detachment. Bosn J BasicMed Sci. 2017;17(1):74–80.

17. Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic andvisual outcomes of scleral buckling versus primary vitrectomyin pseudophakic and aphakic retinal detachment: six-monthfollow-up results of a single operation—report no. 1.Ophthalmology 2005;112(8):1421–9.

18. Sharma YR, Karunanithi S, Azad RV, et al. Functional andanatomic outcome of scleral buckling versus primary vitrectomyin pseudophakic retinal detachment. Acta Ophthalmol Scand.2005;83(3):293–7.

19. Brazitikos PD, Androudi S, Christen WG, et al. Primary parsplana vitrectomy versus scleral buckle surgery for the treatmentof pseudophakic retinal detachment: a randomized clinical trial.Retina 2005;25(8):957–64.

20. Azad RV, Chanana B, Sharma YR, et al. Primary vitrectomyversus conventional retinal detachment surgery in phakicrhegmatogenous retinal detachment. Acta Ophthalmol Scand.2007;85(5):540–5.

21. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleralbuckling versus primary vitrectomy in rhegmatogenous retinaldetachment: a prospective randomized multicenter clinicalstudy. Ophthalmology 2007;114:2142–54.

22. Sun Q, Sun T, Xu Y, et al. Primary vitrectomy versus scleralbuckling for the treatment of rhegmatogenous retinaldetachment: a meta-analysis of randomized controlled clinicaltrials. Curr Eye Res. 2012;37(6):492–9.

How to cite this article Maitray A., Jaya Prakash V. and Ratra D. Scleral buckling versus vitrectomy for primaryrhegmatogenous retinal detachment, Sci J Med & Vis Res Foun 2017;XXXV:10–19.


Major Review

Rhegmatogenous retinal detachment: contribution ofSankara Nethralaya to literature

Rupak Roy1 and Rajiv Raman2

The management of acute retinal detachmenthas improved over the past two decades withpatients experiencing better outcomes from surgi-cal intervention for this potentially blinding oph-thalmic emergency. The vitreoretinal (VR) team atSankara Nethralaya, for last nearly four decades,has been involved in managing these challengingclinical situations. Owing to the large patientdataset, over the years, the group has publishedmany peer-reviewed articles in scientific journals.

• This India-centric research could highlightpatient–clinical characteristics related to simpleand complex rhegmatogenous retinal detach-ment in Indian subcontinent.

• The evidences generated from these studies arenow the preferred practice pattern in the man-agement of these cases.

• The success and failure rates have helped us tocounsel the patient, preoperatively.

• The understanding of reasons for success andfailure of procedures have helped in choosingappropriate management for different clinicalsituation.

This article compiles these evidences and thetake home messages from these studies whichwould help the clinicians in managing the patientsin the best way ‘Evidence-based medicine’.

Evidences regarding scleral buckleA. Drainage of SRF during scleral buckleWe reported the complications of SRF drainage in506 eyes which underwent scleral buckle andcompared the complications in 49 eyes which hadnon-drainage.

Take home messages:

• Major and minor complications occurred in31% of the wherein the subretinal fluid wasdrained and 4.0% in eyes wherein the fluidwas not drained.

• The incidence of complications between thediathermy and cryotherapy groups was similar.

• The location of drainage site close to or awayfrom the retinal break did not make a signifi-cant difference in the incidence of complica-tion. Similarly, the drainage in the bed oroutside the bed did not have any significance.Drainage was attempted in almost all

meridians though more often closer to hori-zontal meridian. There was no statistically sig-nificant difference in the incidence ofcomplication in the upper half clock meridianscompared with the lower half clock meridians.

• The aphakic patients were more vulnerable tocomplications during the release of subretinalfluid. There was no significant higher inci-dence of complications in myopes.

• When perforation was done, the complicationsoccurred in 22% of eyes. The incidenceincreased with an increasing number ofattempts at drainage of subretinal fluid reach-ing 90% in cases with more than four perfora-tions, most of them were major complications.

• The retina was successfully reattached in 81%of the eyes operated. Inspite of the develop-ment of drainage site complications, the retinawas successfully reattached in 79% cases. Thevision improved in 68%, maintained in 3%and deteriorated in 29% eyes.

• The failure to reattach retina occurred in 24.5%of the cases in which drainage site complica-tions occurred compared with 18.5% in theuncomplicated cases.

• If buckle is placed properly even in caseswhere subretinal fluid is present at the conclu-sion of surgery, it tends to get absorbed andresults in a higher success rate of anatomicalreattachment. Whereas, even if the fluid isdrained till dry if the surgical procedure isfaulty, it does lead to failure of surgery.

B. Scleral buckle for RD: predictors for anatomicalfailureWe reported the anatomical results and predictorsof anatomical failure in consecutive 601 eyeswhich underwent scleral buckle by a singlesurgeon.

Take home messages:

• Retinal reattachment rates after single surgerywas 86% which increased to 90% after secondsurgery (revision buckle and pneumaticretinopexy).

• Preoperative factors which were significantlyassociated with anatomical failure included thepresence of choroidal detachment, the presence

1Consultant,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India

2Senior Consultant,Vitreoretinal Services,Sankara Nethralaya,Chennai, India

Correspondence:Rajiv Raman, MS, DNB,Senior Consultant,Vitreoretinal Services,Sankara Nethralaya,Chennai, India


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of significant vitreous opacification (due tovitreous haze and haemorrhage) and the pres-ence of multiple lattices at varying distancesfrom ora.

• Intraoperative risk factors for anatomicalfailure included buckle extent of >2 quadrants,and intravitreal injection of air or fluid.

• Postoperative factors associated with anatom-ical failure included the presence of sterilevitritis.

• There was no correlation between intraopera-tive complications and anatomical failure.

• Proliferative vitreoretinopathy was the mostcommon reason for anatomical failure.

C. Scleral buckle: explant vs. implantWe report the comparison of patients undergoingprimary scleral buckling who were randomized tothe explant or implant technique.

Take home messages:

• No significant difference was found betweenthe two groups for total duration of thesurgery, complications, anatomical results,visual outcome and buckle height.

• For the one- to two-quadrant buckles, durationof the surgery up to the initiation of subretinalfluid drainage was found to be significantlyshorter for the explant group.

• Serial ultrasonography showed significantreduction in buckle height over 6 months inboth groups to an equal degree.

D. Locating the breaksTake home messages

• Identification of the retinal breaks in a case ofrhegmatogenous retinal detachment is perhapsthe single most important step that dictates thesuccess of the surgery.

• One must understand that more than one breakis present in as many as 50% of eyes.

• One must realize that all retinal breaks are notobvious. In addition to the visualization diffi-culties caused by lens opacities, capsular rem-nants, intraocular lens deposits, non-dilatingpupil, etc., one has to contend with the factthat some breaks may not be obvious despitegood visualization of retina. The importantcauses include very tiny breaks, breaks locatedwithin areas of chorioretinal atrophy, breakswithin a staphyloma, breaks covered by flimsymembranes or vitreous condensation andbreaks in pars plana epithelium, seen espe-cially in cases of post-traumatic retinaldetachments.

• In the evaluation, one needs to stress theimportance of good binocular indirect ophthal-moscopy with scleral depression. Slit-lampbiomicroscopy can help clear the doubt in caseof suspicious lesions.

• Vitrectomy can be indicated in certain cases offailure to detect retinal breaks. If the retinaldetachment is restricted posterior to the buckleand if even scleral depression fails to show anyfluid on the buckle, it is most likely that thereis a break posterior to the buckle only. Such a‘difficult-to-see break’ is best identified duringvitrectomy. A prospective examination candirect our suspicion to some areas, but defini-tive identification may not be possible. Thehigh magnification of the operating micro-scope coupled with improved visualizationcaused by removal of opacities and membranehelps locate the break with ease and the phe-nomenon of ‘Schleiren’ can confirm the same.

• If primary vitreous surgery is being planned,there could be complacency in identifying pre-operatively all retinal breaks in the belief thatthe breaks can be identified during vitrectomy.It is important to realize that treatment of allthe retinal breaks is a must for the success ofthe surgery irrespective of whether it is aprimary buckling or primary vitreous surgeryis performed. Additional breaks can form dueto traction on the vitreous base and oraserrata. Locating the breaks in the peripherycan still be difficult intraoperatively. Veryoften, intraoperatively indirect ophthalmos-copy helps identify peripheral breaks, bettereven than a wide-angle viewing system, espe-cially in the presence of crystalline lens. It isobvious that a diligent preoperative examin-ation and identification of these breaks willmake the job easier during surgery.

• It is of course a different matter if extensiveproliferative VR is present. In these circum-stances, the surgery would involve thoroughcleaning of the entire retina. Peripheral iatro-genic breaks (accidental and deliberate) arefairly common during vitreous base excision.

• Hence, it may not be vital to identify all thebreaks preoperatively. Having said that, oneshould still eschew cursory preoperative evalu-ation, which is akin to a ‘General going to awar without adequate knowledge of theenemy’.

E. Massive submacular haemorrhage during scleralbuckleWe reported a case who underwent scleral bucklefor partial rhegmatogenous retinal detachmentwith a small dialysis at 3.30 meridian. While


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passing the mattress suture, accidental globe per-foration occurred. Fundus evaluation revealed alarge amount of subretinal haemorrhage in themacular area. Pars plana three-port vitrectomywas done, a retinotomy was done to remove thesubretinal blood and retina was attached usingtamponade. At 6 months after oil removal, patienthad a good functional recovery and attachedretina.

Take home messages:

• Massive submacular haemorrhage as a compli-cation of simple scleral buckling can be anindication of immediate vitrectomy andinternal drainage of subretinal blood at thesame sitting.

• This procedure greatly improves the post-operative visual recovery.

E. Clinical profile of patients undergoing scleralbuckle removal surgeryWe reported the clinical and microbiologicalprofile of 101 patients undergoing scleral buckleremoval(SBR) surgery.

Take home messages:

• Buckle exposure with clinical infection(79.41%) was the most common indication.

• Of the eyes which underwent surgery, 88.2%eyes were positive culture, 83.3% revealed singleand 16.6% revealed multiple microorganisms.

• Staphylococcus epidermidis (41.2%) was themost common isolate. Fungus was isolated in2.94% eyes.

• Globe perforation (13.7%) and recurrentretinal detachment (6.9%) were the common-est complications. Time gap between SBRand recurrent retinal detachment rangedfrom 15 days to 50 months (mean 12.2 ±18.3 months).

• Most of the exposed scleral buckles developedclinical infection few months to years aftersurgery, ultimately requiring SBR. Recurrentretinal detachment after SBR may appear fromfew days to years later warranting a long-termfollow-up.

Evidences regarding pneumatic retinopexyA. Recurrent retinal detachment treated withpneumatic retinopexyWe reported 36 eyes with recurrent retinal detach-ment after failed scleral buckle who underwentpneumatic retinopexy.

Take home messages:

• Retinal reattachment was obtained in 69.4%after pneumatic retinopexy

• We identified two factors for failure: locationof retinal break on the posterior slope or pos-terior to buckle and the extent of retinaldetachment—more than two quadrants.

• Pneumatic retinopexy is an effective alterna-tive to revision buckle or vitreous surgery,especially if the leaking breaks are located onthe buckle.

B. Reporting a posterior extension of retinal breakafter pneumatic retinopexyTake home messages:

• A patient underwent pneumatic retinopexy forpartial rhegmatogenous retinal detachmentsparing the macula.

• After reattachment of the retina, a radial, pos-terior extension of the retinal break developed,causing recurrent retinal detachment.

• Later, the patient underwent pars plana vitrec-tomy twice and attained reattachment of theretina. At the last follow-up, his visual acuitywas 20/30.

• This report highlights the importance of pre-operative assessment of the VR relationship ineyes undergoing pneumatic retinopexy.

Evidences regarding vitrectomy in managingrhegmatogenous retinal detachmentA. Pars plana vitrectomy and buckling in managementof complex rhegmatogenous retinal detachment.We reported the importance of vitreous surgery in65 cases of complex rhegmatogenous retinaldetachment.

Take home messages:

• In cases with massive peri-retinal retraction,successful retinal reattachment was achieved ina third of cases. The location and type of thebreaks and subsequent problems that occur aredirectly related to the type of perforation.About 60% of them had prior surgery for RD.

• Cases with vitreous haemorrhage and RD hadbetter visual prognosis.

B. Histopathological study in silicone filled eyesWe reported the histopathological review of eightsilicone oil filled enucleated eyes using lightmicroscopy.

Take home messages:

• In all cases, silicone oil vacuoles, both free andincorporated within macrophages, were seen inall the retinal layers.

• Silicone oil vacuoles were seen in the opticnerve, choroid, retinal pigment epithelium,corneal stroma, iris and ciliary body stroma,


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preretinal and subretinal membranes and retro-corneal membranes.

• Silicone oil migration could be seen in intrao-cular tissues as early as 2 months post-surgery.

• There was no definite histopathological correl-ation between the duration of tamponade andthe distribution of silicone oil vacuoles.

• Silicone oil vacuoles were seen in the opticnerve in eyes with neovascular glaucoma.Chronic inflammatory reaction was observedin the retinal tissue in the vicinity of siliconeoil vacuoles.

C. Reporting a rare occurence of suprachoroidalcollection of internal tamponade agents through achoroidal hole

• We reported two cases of significantly largechoroidal holes following penetrating traumathat led to suprachoroidal migration of internaltamponading agents during repair of retinaldetachments with proliferative vitreoretinopa-thy secondary to penetrating trauma.

• In the first case, choroidal hole was a directresult of the injury and was identified immedi-ately after VR surgery which was done fortraumatic retinal detachment with haemor-rhagic choroidal detachment.

• In the second case, the hole occurred over aperiod of several months after the repair oftraumatic retinal detachment with silicone oiltamponade. This was attributed to progressivefibrosis exerting traction on the bare choroid/retinal pigment epithelium.

• Choroidal hole significant enough to causesuprachoroidal migration of internal tampo-nading agents is a very rare complication seenin eyes with post-traumatic retinal detachmentwith proliferative vitreoretinopathy.

D. Retinal detachment secondary to ocular perforationduring retrobulbar anaesthesiaWe reported clinical characteristics and retinalbreaks associated with rhegmatogenous retinaldetachment secondary to accidental globe perfor-ation during local infiltration anaesthesia in fivehighly myopic eyes.

Take home messages

• The location and type of the breaks and subse-quent problems that occur are directly relatedto the type of perforation and whether or notthe intraocular Injection was given.

• In most cases, the accidental perforation wouldhave occurred in large myopic eyes with orwithout equatorial staphyloma.

• Although the general direction of the path ofthe needle was considered correct. In suchcases, the needle is likely to be parallel to theglobe wall and cause multiple sewing machinetype of breaks that are close to each other.

• These breaks are relatively large and oblong inshape In contrast needle that has been intro-duced in a wrong direction is likely to strike ata more acute angle and exit posteriorlycausing two widely separated breaks of ovalshape.

• Depending on the direction, the posterior breakcan be present anywhere around the posteriorpole or upper nasal quadrant.

• In accidental perforation during local anaes-thesia, the scleral perforation is likely to be ofa larger size compared with accidental perfora-tions caused during subconjunctival or subte-non injection wherein 26-gauge or smallerneedles are used.

• Hence, most of these cases are recognizedimmediately because of the sudden softeningof the eye. If recognized the surgeon shouldabort the intended surgery and seek the helpof a VR surgeon for management.

• With rest, the vitreous haemorrhage may settledown permitting laser photocoagulation of thebreaks. In the event of non-resolution of vitre-ous haemorrhage within 7–10 days, vitrectomycombined with intraoperative treatment ofbreaks is advocated. This approach is quiteeffective in the prevention of retinaldetachment.

E. Anterior chamber collapse after VR surgery withgas tamponade in aphakic eyesWe reported the risk factors associated with theoccurrence of anterior chamber collapse inaphakic eyes that underwent vitrectomy with gastamponade. A total of 314 eyes of 314 patientswho underwent vitrectomy with gas tamponadeand who were aphakic or were made aphakicintraoperatively were studied prospectively

Take home messages

• Anterior chamber collapse occurred in 3.14%eyes.

• The presence of preoperative shallow anteriorchamber, removal of intraocular lens as a partof the procedure, occurrence of intraoperativeanterior chamber collapse and use of sulfurhexafluoride (SF6) were associated with ahigher risk of anterior chamber collapsepostoperatively.

• The identification of potential risk factors in agiven eye can alert the surgeon to the


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possibility of the development of anteriorchamber collapse postoperatively.

F. Primary vitrectomy for rhegmatogenous retinaldetachment associated with choroidal detachmentWe reported the success rate of primary vitrec-tomy, scleral buckling and oral steroids in eyeswith combined rhegmatogenous retinal detach-ment (RRD) and choroidal detachment (CD) andcompared these results with those reported in theliterature for similar cases managed by scleralbuckling alone.

Take home messages

• At mean follow-up of 11.4 months, retinalreattachment was attained in 90.5% eyes com-pared with less than 53% reported in the litera-ture for scleral buckling alone.

• With preoperative oral steroids, choroidaldetachment regressed completely in 61.9%eyes. In the remaining eyes with persistentchoroidal detachment, suprachoroidal fluid wasdrained during vitrectomy.

• Aggressive treatment with oral steroids fol-lowed by pars plana vitrectomy and scleralbuckling or encircling is recommended insteadof scleral buckling alone in the managementof combined primary rhegmatogenous retinaldetachment and choroidal detachment.

G. Primary vitrectomy for combined rhegmatogenousretinal detachment with choroidal detachment with orwithout oral corticosteroidsThe occurrence of CD in eyes with primary RRD isrelatively uncommon (2–4.5%). Reports suggestthat primary vitrectomy yields better anatomicalsuccess than scleral buckling. However, for theseinflamed eyes with low intraocular pressure, theinfluence of preoperative oral steroids on reattach-ment rates had not been elucidated. We did a pro-spective study was undertaken to elucidate theexact role of preoperative oral steroids in anatom-ical and functional outcomes for eyes with com-bined CD and RRD

Take home messages

• Preoperative clinical data such as mean age, lensstatus, Snellen visual acuity, duration of maculardetachment, CD (size and extent) and retinaldetachment characteristics (e.g., extent, numberof retinal breaks, atrophic or tractional retinalbreak, size of retinal break and location of retinalbreak) were similarly distributed in both groups.

• Single-operation anatomical success rate was81.8% among those patients who received pre-operative oral steroids and was 66.7% amongthose who did not receive preoperative oralsteroids.

• After reoperation, anatomical success rate was100% in both groups. The mean follow-up was20.1 months.

H. Sympathetic ophthalmitis following vitrectomyWe reported the differences in the presentationand outcomes of sympathetic ophthalmitis (SO) ineyes with or without a history of antecedent pene-trating trauma; SO being diagnosed after VRsurgery. All Group I patients had received systemicsteroids prior to presentation.

Take home messages

• Differences were observed between Group Iand Group II mainly with regard to time inter-val between VR surgery and diagnosis of SO(1.5 vs. 8 months), the presence of neurosen-sory detachments (100 vs. 30%) and the incit-ing eye vision at presentation (nil lightperception in 28.5 vs. 80%).

• Other differences observed though not statistic-ally significant were optic disc and retinalvessel involvement (42 vs. 70%), Dalen–Fuchsnodules (localized vs. diffuse) and leaks onfundus fluorescein angiography (pin–head vs.pin–point leak).

• SO in patients with antecedent penetratingocular trauma present early with the centralserous chorioretinopathy-like picture. Prior useof systemic steroids might have a bearing onthe differences in presentation and the visualacuities between the two groups.

Evidences regarding managing complex RRDA. Clinical characteristics of retinal detachments inpatients with Marfan syndrome and the surgicaloutcome of VR surgeryWe described the clinical characteristics of retinaldetachments in patients with Marfan syndromeand reported the surgical outcome of VR surgery.

Take home messages

• Characteristic findings included total retinaldetachment in 75.5% eyes, atrophic holes in45.3% eyes, more than four retinal breaks in39.6%, pre-equatorial and post-equatorialbreaks in 37.7% eyes, giant retinal tears in11.3% eyes and proliferative vitreoretinopathy(posterior, anterior or both) in 17% eyes.

• In 56.6% eyes, retinal breaks were located onlyin the temporal half of the retina. Of the eyeswith myopia, 54.2% had a myopic correctiongreater than 7 diopters.

• At the median follow-up of 10.7 months,complete retinal reattachment was obtained in87.6% and 86.2% of patients undergoing scleralbuckling (including additional procedures


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such as vitrectomy) and vitrectomy surgery,respectively.

• In eyes with reattached retinas, a final visualacuity of 20/200 or better was obtained in81% of the patients after scleral buckling andin 56% of the patients after vitrectomysurgery.

• Retinal detachment in Marfan syndrome iscomplete in 75% of the eyes. More than half(56%) the eyes had a retinal break only in thetemporal half of the retina, and 83% had atleast a break in the temporal half of the retina.Currently available VR surgical techniquesresult in successful reattachment of the retinain approximately 86% of the eyes.

B. Use of silicone oil in the management of complexretinal detachment—an Indian experienceThis study reported the results and complicationsof temporary silicone oil tamponade that was usedto treat complicated RD in 4488 eyes associatedwith multiple aetiologies. An eye was consideredan anatomical success if there was a completeretinal reattachment or macular attachment.Functional success was defined as attainment ofvisual acuity of 5/200 or better.

Take home messages

• Overall, anatomical success was achieved in73% of the eyes, and functional success, in47%. After removal of silicone oil, recurrenceof retinal detachment was observed in 9% ofthe eyes; a high percentage (70%) of eyesattained functional success. Postoperative cata-ract was observed in 65.3%, abnormal corneasin 21.3%, hypotony in 16.9% and glaucoma in16.4% of the eyes.

• The overall anatomical success rate in eyeswith primary or recurrent retinal detachmentwith PVR was 72 and 70%, respectively.

• In traumatic RD with or without PVR, anatom-ical success rate was achieved in 73–75% ofeyes and functional success, in 43–50%.

• In GRT with or without PVR, after silicone oiltamponade, the retina was reattached in 75–79% of eyes and functional success wasattained in 65–69% of eyes.

• In choroidal coloboma with RD, the overall,anatomical success rate was 82% and func-tional success, 66%.

• Despite the onset of complications related tosilicone oil usage, a high rate of reattachmentof the retina was observed following vitrec-tomy and silicone oil tamponade in the man-agement of complex RD associated withmultiple aetiologies.

C. Management options and outcomes afterreoperations for recurrent retinal detachment insilicone oil-filled eyesOne hundred eighteen silicone oil-filled eyes withrecurrent retinal detachment were managed withrevision of vitrectomy with membrane surgerywith or without silicone oil removal, just scleralbuckling or both. Anatomical success rate wasdefined as complete reattachment of the retina,and functional success was defined as recovery ofambulatory visual acuity of 5/200 at the lastfollow-up (mean follow-up, 29.7 months).

Take home messages

• In 82.2% of the cases, proliferative vitreoreti-nopathy was responsible for recurrent retinaldetachment in silicone oil-filled eyes.

• Reoperations without removal of the silicone oilwere performed in 65.3% of the cases.Anatomical success occurred in 62.7% of theeyes, and functional success occurred in 52.5%.

• Silicone oil was removed in 59.5% of the eyeswith retinal reattachment; the retina remainedattached in 90.9% of the eyes.

• Predictors of poor anatomical success were thepresence of posterior diffuse proliferativevitreoretinopathy and combined posterior andanterior proliferative vitreoretinopathy.

• Reoperations for recurrent retinal detachmentin silicone oil-filled eyes were successful innearly two-thirds of the cases, and over onehalf of the eyes recovered an ambulatoryvision.

D. Surgical outcomes of patients of HIV on HAART whounderwent surgery for CMV retinitis-related retinaldetachmentWe reported surgical outcomes in 40 eyes of 35consecutive HIV-positive patients who underwentsurgical repair for CMV retinitis-associated rheg-matogenous retinal detachment.

Retinal detachment surgery was performedonce active retinitis subsided (average of 4–6weeks). Total retinal detachment was observedin 45%, while 55% had subtotal retinal detach-ment. Macular detachment was seen in 87.5%eyes. Proliferative vitreoretinopathy was presentin 37.5% eyes and epiretinal membrane wasseen in 2.5% eyes. None of the eyes hadreceived preoperative laser prophylaxis. All 40eyes underwent vitrectomy with silicone oilinjection (1500 mL).

Take home messages

• Redetachments on follow-up were seen in 30%eyes that were surgically managed, with 10%eyes having a persistent retinal detachment atfinal follow-up.


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• Favourable anatomical outcome was achievedin 80% eyes with attached retina, clear mediaand controlled intraocular pressure.

• Of these, 37.5% eyes had silicone oil removalwith no detachments on follow-up. The rest ofthe 42.5% eyes had silicone oil in situ.

• Favourable functional outcome (vision >3/60)was achieved in 57.5% eyes. The causes forpoor vision in the rest were pale disc in 22.5%eyes, phthisis in 12.5% eyes and persistingretinal detachments in 10% eyes.

• Though anatomical outcomes have notchanged from the pre-HAART era, but therehas been an increase in favourable functionaloutcomes possibly due to effects of antiretro-viral therapy.

E. Patterns of breaks and detachments in eyes withchoroidal colobomaWe described the type of breaks in the diaphanoustissue that can lead to coloboma-related retinaldetachments.

Take home messages

• In an eye with coloboma with RD, the colo-boma may or may not be causative ofdetachment. On examination of fundus, withspecial attention to the margin of the colo-boma, one can definitely segregate a groupof eyes wherein the detachment does notextend at all inside the margin. The manage-ment does not differ from RDs in eyeswithout coloboma.

• Retinal detachments that extend into the colo-bomatous area always are associated withbreaks in the diaphanous tissue.

• Three distinct types of breaks were identifiedwithin the coloboma. A. Breaks at the edge ofthe detachment inside the coloboma. B. Ovalatrophic breaks and C. breaks in anatomicalmacula that was involved in the coloboma.

• Multiple breaks were common.

F. Management of retinal detachment with choroidalcolobomaStudy 1: 17 eyes with retinal detachment second-ary to retinal breaks in the colobomatous areawere managed by vitrectomy procedures.Endodrainage was done through the break in thecolobomatous area, with simultaneous fluid-airexchange. Endolaser photocoagulation was per-formed along the colobomatous margin poster-iorly, while the anterior portion was treated bytransscleral cryopexy. Silicone oil was thenexchanged with air.

Take home messages

• In nine cases, the silicone oil had to beremoved for complications such as emulsifica-tion, glaucoma and keratopathy; in three ofthese eyes, oil removal resulted in recurrentretinal detachment.

• At the 2-month follow-up visit, there was100% anatomical success, and 12 eyes (70.6%)recovered visual acuity of 10/200 or better.

• Of the 11 eyes with follow-up of more than 6months, in 9 (81.8%), the retina remained reat-tached at last-follow up, and in 6 eyes (54.5%),a visual acuity of 10/200 or better wasobtained.

Study 2: 85 eyes of 81 patients with retinaldetachments related to coloboma of the choroidunderwent pars plana vitrectomy with internaltamponade using silicone oil (80 eyes) or perfluro-propane gas (5 eyes). Behaviour of the retina onfluid-air exchange was used to guide the furthersteps of surgery. Endolaser was performed alongthe coloboma border. Silicone oil was removed in80% of eyes.

Take home messages

• When there was no identifiable break in theintercalary membrane, fluid-air exchange wasused as a guide to further management.

• If a communication existed between the sub-retinal space and the subintercalary membranespace and onward into the vitreous cavity (byway of breaks in the intercalary membrane),then injection of air into the vitreous cavity,aided by mere suction of fluid from the ectaticcolobomatous area, flattened the retina.

• If no such communication existed, the retinawas seen to balloon around the coloboma. Ifthe ballooned retina stopped short of the colo-bomatous border, it was inferred that theretinal detachment was not related to the colo-boma and its management was directedaccordingly to the peripheral break alone.

• If, however, the ballooned retina extended intothe coloboma, then the coloboma could becontributing to the occurrence of the retinaldetachment in addition to the peripheral break.

• Recurrent retinal detachment occurred in16.3% of silicone oil-filled eyes and 60% ofgas-filled eyes.

• After silicone oil removal, 15.6% of eyes hadrecurrent retinal detachment. After a meanfollow-up of 13.4 months, 81.2% of eyes hadattached retina and 69.4% recovered equal toor better than 10/200 visual acuity.


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• Retinal detachment secondary to coloboma ofchoroid is treated best by pars plana vitrectomyalong with silicone oil tamponade. Gas tam-ponade has limited indications. Clinical evalu-ation of the extent of retinal detachmentwithin the colobomatous area and the behav-iour of the retina on fluid-air exchange helpsto understand the pathogenesis of the retinaldetachment and plan a rational therapy.

G. A clinical and optical coherence tomography studyof the margins of choroidal colobomasTake home messages

We described the features at the margin of thechoroidal colobomas as evaluated clinically andby optical coherence tomography (OCT).

• Histologically, there is no normal choroid,retinal pigment epithelium or retina overlyingchoroidal colobomas; rather, the overlyingtissue is an extension of the retina called theintercalary membrane (ICM).

• In these patients, OCT showed that transitionfrom normal retina to the ICM could be cate-gorized as abrupt or gradual and also showedthat the inner neurosensory retinal layers con-tinued as the ICM, whereas the outer layerscould not be traced beyond a point.

• In some cases with apparently attached retina,subclinical retinal detachments were identifiedalong the margin of the coloboma.

• In cases with retinal detachment, OCT allowedfor identification of the precise site of commu-nication between the sub-ICM space and sub-retinal space at the locus minoris resistentiae.

• The margin of the choroidal coloboma, in somecases, showed the appearance of a hump owingto inward turning of the retinochoroidal layerswith thickening of the layers at the margin.

• In small colobomas, OCT revealed the ICMthickness comparable to normal retina butshowed structural alterations.

• Fundus lesions that were clinically labelledforme fruste of choroidal coloboma seemed tohave normal retinal thickness and layering onOCT. In one patient, a temporal optic pit wasassociated with the forme fruste choroidalcoloboma in one eye; the fellow eye had atypical choroidal coloboma.

• Optical coherence tomographic evaluation ofthe margins of choroidal colobomas helps inunderstanding the transition from retina toICM, detects subclinical retinal detachmentsand aids in identifying the site of communica-tion between the sub-ICM space and the sub-retinal space in eyes with retinal detachment.

H. Pneumatic retinopexy in a case of shallowdetachment with choroidal colobomaWe reported the surgical outcome of pneumaticretinopexy in a patient with retinal detachmentfrom a single break in the intercalary membraneof an eye with macula-sparing retinochoroidalcoloboma. Pneumatic retinopexy with laserbarrage to coloboma margin can achieve andmaintain retinal reattachment in eyes withmacula-sparing retinochoroidal coloboma withshallow SRF.

I. Rhegmatogenous retinal detachment followingtreatment for retinoblastomaWe reported the characteristics of rhegmatogenousretinal detachment that developed in nine childrenwho underwent treatment for retinoblastoma andanalyzed the outcome following VR surgery insuch clinical settings.

Take home messages

• At the time of diagnosis of rhegmatogenousretinal detachment, retinoblastoma wasregressed in 67% eyes. The retinal detachmentinvolved less than two quadrants in 78% eyesand was caused by an atrophic break in seveneyes.

• Seven eyes underwent a non-drainage scleralbuckling procedure. Three eyes underwent vit-reous surgery; in two of these eyes, tumourexcision along with retinectomy using melpha-lan infusion was performed and eventuallysilicone oil tamponade was used.

• Retinal reattachment was achieved in all eyeswith eventual tumour control in seven eyes.

• Rhegmatogenous retinal detachment in treatedeyes with retinoblastoma is usually caused byan atrophic retinal break. Retinal detachmentcan be repaired successfully in most eyes.

ConclusionVitreoretina is a unique specialty in which amixture of both medical and surgical interven-tions are routinely performed. It is well knownthat randomized controlled trials (RCTs) aregenerally harder to conduct for surgical treat-ments and previous studies have shown that theproportion of evidence from RCTs was lower insurgical studies compared with studies ininternal medicine. The India-centric evidencesfrom the large dataset from South-India hasprovided evidence for managing rhegmatogen-ous retinal detachment.

References1. Shah SJ, Badrinath SS. Release of subretinal fluid in retinal

detachment surgery. Indian J Ophthalmol. 1979;27(4):79.


Literature Search

2. Sharma T, Challa JK, Ravishankar KV, Murugesan R. Scleralbuckling for retinal detachment: predictors for anatomic failure.Retina 1994;14(4):338–43.

3. Gopal L, D’souza CM, Bhende M, Fogla S, Ratra D, Shetty NS,Sharma T, Shanmugam MP, Bhende P, Bhattu RR, Badrinath SS.Scleral buckling: implant versus explant. Retina 2003;23(5):636–40.

4. Gopal L. Locating the retinal break(s) in rhegmatogenous retinaldetachment: the first step in successful management. Indian JOphthalmol. 2001;49(3):149.

5. Gopal L, Badrinath SS. Massive submacular haemorrhageduring scleral buckling—an indication for vitrectomy.Asia-Pacific J. Ophthalmol. 1994;6:18–20.

6. Kazi MS, Sharma VR, Kumar S, Bhende P. Indications andoutcomes of scleral buckle removal in a tertiary eye care centerin South India. Oman J. Ophthalmol. 2015;8(3):171.

7. Sharma T, Badrinath SS, Mukesh BN, Gopal L, Shanmugam MP,Bhende P, Bhende M, Shetty NS, Agrawal R. A multivariateanalysis of anatomic success of recurrent retinal detachmenttreated with pneumatic retinopexy. Ophthalmology1997;104(12):2014–7.

8. Sharma T. Posterior extension of retinal break followingpneumatic retinopexy. Ann Ophthalmol. 2002;34(1):47–8.

9. Doshi H, Badhinath SS. Pars plana vitrectomy and buckling inmanagement of complex rhegmatogenous retinal detachment.Indian J Ophthalmol. 1983;31(7):872.

10. Biswas J, Verma A, Davda MD, Ahuja S, Pushparaj V.Intraocular tissue migration of silicone oil after silicone oiltamponade: a histopathological study of enucleated siliconeoil-filled eyes. Indian J Ophthalmol. 2008;56(5):425.

11. Gopal L, Mittal N, Verma A. Suprachoroidal collection ofinternal tamponading agents through a choroidal hole. Indian JOphthalmol. 2008;56(2):149.

12. Gopal L, Badrinath SS, Parikh S, Chawla G. Retinal detachmentsecondary to ocular perforation during retrobulbar anaesthesia.Indian J Ophthalmol. 1995;43(1):13.

13. Gopal L, Nagpal A, Kabra S, Roy J. Anterior chamber collapsefollowing vitreoretinal surgery with gas tamponade in aphakiceyes: incidence and risk factors. Retina 2006;26(9):1014–20.

14. Sharma T, Gopal L, Badrinath SS. Primary vitrectomy forrhegmatogenous retinal detachment associated with choroidaldetachment. Ophthalmology 1998; 105(12):2282–5.

15. Sharma T, Gopal L, Reddy RK, Kasinathan N, Shah NA,Sulochana KN, Miriam KC, Arvind K, Ramakrishnan S,

Sukumar B. Primary vitrectomy for combined rhegmatogenousretinal detachment and choroidal detachment with or withoutoral corticosteroids: a pilot study. Retina 2005;25(2):152–7.

16. Rishi E, Rishi P, Appukuttan B, Walinjkar J, Biswas J, Sharma T.Sympathetic ophthalmitis following vitreoretinal surgery: doesantecedent trauma make a difference? Indian J Ophthalmol.2015;63(9):692.

17. Sharma T, Gopal L, Shanmugam MP, Bhende PS, Agrawal R,Shetty NS, Gopalakrishna M, Rao MK, Balusamy SU. Retinaldetachment in Marfan syndrome: clinical characteristics andsurgical outcome. Retina 2002;22(4):423–8.

18. Silicone Oil Study Group of Sankara Nethralaya. Use ofsilicone oil in the management of complex retinal detachment—an Indian experience. Int Ophthalmol. 2004;25(3):129–42.

19. Sharma T, Gopal L, Shanmugam MP, Bhende PS, Agrawal R,Badrinath SS, Samanta TK. Management of recurrent retinaldetachment in silicone oil-filled eyes. Retina 2002;22(2):153–7.

20. Mathur G, Ratra D, Bhuibhar SS, Roy R. Clinical outcomes ofretinal detachment surgery following cytomegalovirus retinitisin patients on highly active anti-retroviral therapy for acquiredimmune deficiency syndrome. Ocular Immunol Inflamm.2015;23(5):400–4.

21. Gopal L, Badrinath SS, Sharma T, Parikh SN, Biswas J. Patternof retinal breaks and retinal detachments in eyes with choroidalcoloboma. Ophthalmology 1995;102(8):1212–7.

22. Gopal L, Kini MM, Badrinath SS, Sharma T. Management ofretinal detachment with choroidal coloboma. Ophthalmology1991;98(11):1622–7.

23. Gopal L, Badrinath SS, Sharma T, Parikh SN, Shanmugam MS,Bhende PS, Agrawal R, Deshpande DA. Surgical management ofretinal detachments related to coloboma of the choroid.Ophthalmology 1998;105(5):804–9.

24. Gopal L, Khan B, Jain S, Prakash VS. A clinical and opticalcoherence tomography study of the margins of choroidalcolobomas. Ophthalmology 2007;114(3):571–80.

25. Rishi E, Rishi P, Govindarajan MV. Pneumatic retinopexy forthe treatment of shallow retinal detachment caused by a retinalbreak in the intercalary membrane of macula sparingretinochoroidal coloboma. Retinal Cases Brief Rep. 2016;10(2):187–90.

26. Pal SS, Gopal L, Khetan V, Nagpal A, Sharma T.Rhegmatogenous retinal detachment following treatment forretinoblastoma. J Pediatr Ophthalmol Strabismus. 2010;47(6):349–55.

How to cite this article Roy R. and Raman R. Rhegmatogenous retinal detachment: contribution of SankaraNethralaya to literature, Sci J Med & Vis Res Foun 2017;XXXV:20–28.


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Surgical implications in exudative retinal detachment

Suganeswari Ganesan1 and Ekta Rishi2

BackgroundSurgeries for retinal reattachment form themain stay of treatment for rhegmatogenous,tractional and combined retinal detachment.However, they do not form the first line ofmanagement in exudative retinal detachment.Massive exudative retinal detachment notresponding to the conventional line of treatmentor not permitting the performance of conven-tional line of treatment is chosen for surgicalintervention. It is a mandatory prerequisite toidentify the pre-existing factor that has beeninstrumental in the initiation of exudativeretinal detachment (ERD).

ERD occurs due to breakdown of the complexinteractions of forces that maintain the normalapposition of the retina, RPE, Bruch’s membraneand choroid (Table 1). Failure of these forces, dueto various causes enlisted below, potentially couldlead to formation of fluid under the neurosensoryretina. Central serous chorioretinopathy (CSCR)known to be a very common cause for localizedERD either in stressed males or patients who areon steroid medication for various ailments arepotentially at risk for CSCR. This variety of CSCRis described as typical and is treated with lifestylemodification, avoiding steroids in all forms; focallaser photocoagulation is done to leak identifiedon fundus fluorescein angiogram for extrafovealleaks and photodynamic therapy (PDT)/micropulsediode laser for subfoveal leak.

When the fluid is non-resolving and retinaldetachment is chronic and bullous, permanentdamage to retinal pigment epithelium as well asouter retinal structures occurs and persistence ofsubretinal fibrin may lead to subretinal fibrotic scarformation. To avoid these complications, surgicalintervention is planned after failure of conventionaltreatment. However, surgical treatment is never thefirst line of management in these conditions.

Surgical optionsDrainage of subretinal fluid (SRF)

– External approach

– Internal approach

External approachMethods of external drainage of SRF

1 Scleral cut down and choroidotomyNeedle opening of choroidLaser opening of choroid

2 Needle aspiration

3 26-G trocar and cannula drainage byretraction

Steve Charles technique1 of needle drainage is arelatively safer procedure can be combined withChandelier illumination offers the comfort of usingBIOM with the hands free for drainage of SRFunder direct visualization and also allows surgeonto withdraw needle as the retina flattens avoidingcomplications like retinal incarceration, subretinalhaemorrhage and vitreous loss. Continuous moni-toring2 with indirect ophthalmoscopy during the

Table 1: Causes of exudative retinal detachment

Choroidal causes:

a Idiopathic choroidal vascular hyperpermeabilityCSCR

b Localized choroidal vascular hyperpermeabilityChoroidal haemangioma

c Tumours of choroidChoroidal melanoma

d Impaired outflow through scleraUveal effusion syndrome

e Inflammatory conditions of choroid and scleraVKH syndrome

Sympathetic ophthalmitis

Posterior scleritis

f Ischaemia and altered choroidal hyprpermeabilityPreeclampsia, malignant hypertension,disseminated intravascular coagulation,idiopathic polypoidal choroidal vasculopathy

Retinal causes:

a Retinal angiomatosis

b Coats’ disease

c Retinal venous occlusive disease

d Retinal artery macroaneurysm

e Idiopathic frosted branch angiitis

Miscellaneous causes:

a Post-retinal reattachment surgery

b Post-laser therapy

c Post-cryotherapy

1Consultant, Sri BhagwanMahavir Vitreoretinal Services,Sankara Nethralaya, Chennai,India

2Senior Consultant, Sri BhagwanMahavir Vitreoretinal Services,Sankara Nethralaya, Chennai,India

Correspondence:Suganeswari Ganesan,Consultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India.Email: [email protected]


Major Review

drainage has also been reported to be free fromcomplications.

Subretinal aspiration and injection device(SA-AID) introduced by Kang et al.3 to facilitatecontrolled external drainage of SRF. This device pro-vides a safe approach to the subretinal space becauseit penetrates the eye wall obliquely and allows achangeable, predetermined length of the needle tip.The surgeon can also directly observe the retina withan indirect ophthalmoscope during the drainage.

Internal approach

– Pars plana vitrectomy with endodrainagethrough a drainage retinotomy, endolaser/cryo-pexy and tamponade with gas /silicon oil.

– Pars plana vitrectomy with liquid perfluoro-carbon assisted external drainage.

– Pars plana approach endolaser withoutvitrectomy.

Pearls for external drainage

• External drainage done for bullous RD inperiphery

• If using needle, bevel down will avoid retinalaspiration.

• Choroidotomy opening and needle can getoccluded by sub retinal fibrin/cholesterol.

• AC maintainer may help for near completedrainage in selected situations.

Central serous chorioretinopathyLongstanding CSCR can cause severe vision lossdue to significant photoreceptor damage and lateron may lead to subretinal fibrotic scar formationand foveal scarring (Figure 1).

Various authors have claimed to have goodresults via both external and internal drainageapproaches of SRF in non-responding chronicCSCR.

Bondalapati et al.4 had reported external drain-age of SRF in six male patients with ERD follow-ing chronic CSCR with no recurrences. Externaldrainage was performed with 26-G needle (SteveCharles technique). Chandelier-assisted externaldrainage gives the advantage of keeping the sur-geon’s hands free to perform drainage. An exter-nal approach has been modified by variousauthors. Figueroa et al.5 performed suturelesssclerotomies beyond equator one in each inferiorquadrant without SRF drainage followed by erectpositioning. Retinal reattachment occurred within24 h of surgery allowing focal laser photocoagula-tion to the leaking lesions on FFA. Good visualgain was recorded noted by the authors postopera-tively with the interesting fact of nil surgical com-plications that were recorded.

Reasonable success rates were also claimed byauthors6 who had done an internal approach byparsplana vitrectomy (PPV) with scleral buckle.Chen et al.7 suggested the use of liquid perfluoro-carbon in a procedure which combined both PPV


Major Review

and external drainage when SRF was present pos-teriorly. Liquid perflurocarbon was used to attachthe posterior retina while the SRF was drained viathe external drainage and then applied diode laserto the area of leak. However, the visual outcomewas poor which they attributed to long durationof macular detachment and subsequent subretinalfibrosis adjacent to the central retina. A similarobservation was also made by Kang et al.8 whoconcluded that surgical treatment would be bene-ficial if performed early to prevent subretinal pro-liferation, which usually tends to have a negativeinfluence on the final visual prognosis.

CSCR

• CSCR usually is treated well with photo-dynamic therapy/laser/ micro pulse diode laser.

• Exudative detachment usually occurs due to aRPE rip which may heal in few months.

• All precipitating factors should be treatedbefore resorting to surgical treatment

Diffuse choroidal haemangiomaDiffuse choroidal haemangioma is a benign vas-cular tumour associated with cutaneous, ocular orcentral nervous system findings and may also beassociated with Sturge-Weber syndrome. Diffusered-orange thickening of the posterior choroidthat has poorly defined borders and extends overa broad area.

Ultrasonography shows a diffusely thickenedchoroid on B scan, while A scan shows moderateto high internal reflectivity with an overlying SRF.Magnetic resonance imaging in T1-weightedimages are hyperintense while it is isointense tothe vitreous in T2-weighted images. Conventionaltherapy includes photodynamic therapy, externalbeam radiation therapy and oral propranolol.Shanmugam et al.9 in their unpublished data havetreated a patient with diffuse choroidal haemangi-oma with bullous RD, resistant to conventionaltherapy with external drainage of SRF along withintraoperative transpupillary thermotherapy withgood control of tumour and resolution of SRF.

Uveal effusion syndromeUveal effusion syndrome (UES) may be idiopathicor associated with abnormalities of choroid orsclera. It is basically a diagnosis of exclusionwhen all other causes are ruled out. Histologicalstudies have demonstrated disruption of collagenfibers and filling of the interfibrillary spaces withamorphous glycosaminoglycan-like materialobtained from the excised scleral tissue.

Gass10 hypothesized that abnormal thicknessof the sclera could possibly compromise the chor-oidal vascularization, favouring the accumulationof extravascular proteins in the choroid and the

ciliary body and thereby increasing fluid migra-tion into the suprachoroidal space producing aciliochoroidal detachment with secondary move-ment of water and proteins into the subretinalspace. Eye being devoid of lymphatics intraocularextravascular proteins are removed via Schlemm’scanal and aqueous veins anteriorly while poster-iorly by trans-scleral diffusion and through theemissary canals into the orbital tissues. Sinceincreased thickness of the sclera was preventingthe trans-scleral diffusion, partial thickness scler-otomies would help in successful reabsorption ofsubretinal fluid.

Posterior microphthalmos (PM) is an entity thathas been very newly introduced to differentiatefrom nanophthalmos. Both have short axiallength, except the fact that PM has normal cornealdiameter while nanophthalmos has reducedcorneal diameter. Clinical features reported in PMare reduced axial length with a normal-sizedcornea and normal anterior segment and a dispro-portionately small size of the posterior segment.Other features reported are high hyperopia, uvealeffusion, elevated papillomacular retinal fold, fineretinal striae, tapetoretinal degenerations similar tofundus flavimaculatus and fundus albipunctatus,retinoschisis, reduced foveal avascular zone, pseu-dopapilledema and macular holes.11–15

Drainage of SRF is never successful as an inde-pendent procedure as it leads to higher chances ofrecurrences. The most common treatment per-formed is full-thickness sclerectomies to providean exit for choroidal fluid, and this has been wellsupported in the literature by a large case series11

which showed anatomical improvement in singleprocedure amounting to 83% and visual recoveryof two or more lines in 56% of eyes.

Faulborn et al.16 described regression of SRFand resolution of choroidal detachment followingpars plana full-thickness unsutured sclerotomieswithout sclerectomy in their series of five eyes offour patients with UES due to nanophthalmos.

Coats’ diseaseThe most popular and widely used classificationfor Coats’ disease is by Shields et al.17

Stage 1: TelangiectasiaStage 2: Telangiectasia and exudation (2A

extrafoveal exudation, 2B foveal exudation)Stage 3: ERD (3A subtotal and 3B total)Stage 4: Total retinal detachment and second-

ary glaucomaStage 5: Advanced end-stage diseaseMultiple modalities have been employed to

treat including diathermy, laser photocoagulation,cryotherapy, SRF drainage, scleral bucklingsurgery, pars plana vitrectomy and intravitrealanti-vascular endothelial growth factor (VEGF)therapy. Treatment is aimed at destroying abnor-mal vasculature and aneurysmal dilations.


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The surgical approach is contemplated at stages3 and 4 as serous bullous retinal detachment thatdoes not permit regular laser ablation or transcon-junctival cryopexy of retinal vessel telangiectasias(Figure 2).

Interventional case series of 13 patients byDaniela et al.18 presented a modified surgical

technique in the treatment of retinal detachmentsecondary to advanced Coats’ disease in childrenand reported on long-term anatomical and func-tional outcome. Their patients underwent PPVincluding exocryotherapy applied after fluid-airexchange in order to achieve complete treatment ofthe vascular changes, to reduce associated side-

Figure 2: Colour funds montage of successfully drained ERD following Coats’ disease.

Figure 1: CSCR with subretinal fibrosis.


Major Review

effects and to avoid retinectomy and silicone oiltamponade. They described nil further therapy in31%, additional therapy in 69% and revisionalsurgery with silicone oil tamponade in 46% ofpatients as well as visual improvement (27%), visualstability (36%) and visual deterioration (36%).

Cai et al.19 have described the effectiveness ofendolaser photocoagulation by a two-port parsplana nonvitrectomy approach for treating Coats’disease with shallow ERD treatment. In their studyof 25 eyes with treatment sessions varying from oneto five, the retina reattachment rate was 96% andretinal redetachment rate was 4%. The proposedtechnique involves laser application directly to tel-angiectasia within the retina without targeting theRPE to create thermal injury in a non-vitrectomizedeye with good peripheral retinal examination.Injection of viscoelastic was performed to minimizevitreous traction at the side ports.

Risk of vitreoretinal traction20 on usage of bev-acizumab for Coats’ disease with ERD was alertedby Ramasubramanian et al. in their analysis ofeight patients with Coats’ disease manifestingtotal or partial ERD where the retinal telangiecta-sia was treated with standard laser photocoagula-tion and/or cryotherapy plus additionalintravitreal bevacizumab (1.25 mg/0.05 ml).Authors reported resolution of retinopathy (100%),SRF (100%), retinal exudation (75%) and vitreousfibrosis developed (50%).

Use of intravitreal bevacizumab is controver-sial. Victor et al.21 in their study of 24 patientsused intravitreal bevacizumab followed by laser

vascular ablation in the management ofadvanced Coats’ disease presenting with ERD.None of the patients in their series developedvitreous fibrosis.

Rishi et al.22 have described treatment andoutcome patterns in 307 Indian eyes with Coats’disease. Subretinal drainage was done in 21(6.8%) cases and an attached retina was found in12 and detached retina in 9 cases. Vitrectomy wasdone in 8(4.2%) cases and an attached retina wasfound in 7 and detached retina in a single case.

Coats disease

• Laser is the main stay of treatment in Coatsdisease

• SRF drainage attempted in combinationwith cryotherapy for bullous peripheraldetachments.

• The aim of SRF drainage is to prevent phthisisor painful blind eye and not visual gain.

• Retinotomy should be avoided and endodrai-nage should be performed in cases of combinedretinal detachment with signs of chronicity.

• Retinoblastoma should be excluded in all chil-dren with bullous detachment and leukocoria.

Vogt–Koyanagi–Harada syndromeThe Vogt–Koyanagi–Harada syndrome (VKH) is anautoimmune-mediated genetically influencedbilateral, diffuse granulomatous uveitis associated

Figure 3: Polypoidal choroidal vasculopathy with ERD.


Major Review

with poliosis, vitiligo, alopecia and centralnervous system and auditory signs.

Tyrosinase or tyrosinase-related proteins havebeen proposed to be possible target antigens.23 Tilldate, there is no single diagnostic test which canpinpoint the diagnosis of VKH. We do not haveany evidence in the literature regarding the occur-ence of sensitization to melanocytic antigens.VKH disease diagnosis is purely based on exclu-sion of other diseases. Ultrasonography is manda-tory to demonstrate diffuse choroidal thickening,without a positive ‘T’ sign. FFA should show thepresence of pinpoint areas of choroidal leakage.

The conventional treatment includes control ofinflammation by regional, oral and intravenouscorticosteroids, cyclosporine, antimetabolites andalkylating agents.

A successful surgical treatment (vitrectomy)for bilateral bullous retinal detachment in apatient with VKH disease is reported. Gaunet al.24 has described parsplana lensectomy andvitrectomy being done on a 78-year-old femalewith severe reduction of visual acuity in botheyes because of an extremely bullous non-rhegmatogenous retinal detachment accompaniedby VKH disease. They had also supplementedwith systemic and topical corticosteroid therapy.They reported no recurrence of retinal detach-ment even after tapering the dose of corticoster-oid. They had concluded that vitrectomy may bean effective therapeutic option in the treatmentfor severe bullous retinal detachment associatedwith VKH disease.

Vogt-Koyanagi-Harada syndrome

• Chronic VKH can be differentiated from CSCRby a course of steroids and improvement withno worsening.

• Control of inflammation is the mainstay oftreatment.

• SRF drainage is attempted in chronic, nonresponsive bullous retinal detachments like inCoats disease.

• Recurrences are common.

Von Hippel–Lindau diseaseVon Hippel–Lindau disease (VHL) is a multisystemfamilial tumour syndrome with autosomal domin-ant inheritance with high penetrance. Ocularlesions are characterized by retinal capillaryhaemangioma which is the most common presen-tation of VHL disease. Extraocular lesions includecentral nervous system haemangioma, endolym-phatic sac tumour of the inner ear, pancreaticcysts, pancreatic adenoma, pancreatic islet celltumours, pheochromocytoma, renal cyst, renalcarcinoma, cystadenoma of the epididymis and

the broad ligament. VHL gene is a tumour sup-pressor gene and is mapped to the short arm ofchromosome 3p25. Genetic testing can be donewith greater precision. Use of surveillance proto-cols is recommended for improving survival ratethrough early detection.

Conventional therapy to retinal capillary haem-angioma is based on size of lesion, amount ofexudation and the coexisting clinical condition.Treatment modalities are observation, laser photo-coagulation, transpupillary thermotherapy, cryo-therapy, photodynamic therapy, plaqueradiotherapy and proton therapy. ERD in VHL canoccur due to retinal capillary haemangioma itselfor secondary to treatment of retinal capillaryhaemangioma.

Fang-Yi et al.25 have reported a rare case ofVHL disease with multiple peripheral retinal capil-lary haemangioma (RCHs) treated by PDT com-bined with intravitreal bevacizumab injection,which showed significant tumour regression butwith persistent exudative RD that required surgicalintervention. The massive exudation which devel-oped during the second day was probably due tothe summation reaction of three large RCHs toPDT. The authors further recommended that frac-tionated PDT may be used in cases with multipleRCHs where one tumour is treated at a time toreduce the post-treatment reaction.

Kim et al.26 indicated that treatments for largeRCHs in patients with VHL disease must be basedon careful selection. Although PDT is consideredone of the useful treatment options for RCH, PDTcombined with an intravitreal injection of bevaci-zumab can lead to permanent and severe deterior-ation of vision because of massive ERD.27–30

Therefore, frequent fundus examinations shouldbe performed after PDT. They could successfullyreattach the retina with PPV, internal SRF drain-age retinotomy, endodiathermy, cryotherapy andendolaser therapy on the RCH, and injection ofsilicone oil and bevacizumab.

The two theories explain the increased exud-ation from retinal haemangioma following PDT.First, it could be increased leakage from the vas-cular lesion, a response known to occur with laserphotocoagulation and cryotherapy. Alternatively,PDT can affect the choroidal vasculature, causingischaemia and even shutdown of the choriocapil-laris or retinal capillaries with breakdown of thevascular barrier and significant SRF exudation, aresponse seen in PDT treatment of choroidalneovascularization.31

Von Hippel-Lindau disease

• Peripheral tractional detachment can occur fol-lowing laser/ cryotherapy and can be treatedwith scleral buckling.


Major Review

• Occurrence of iatrogenic retinal breaks shouldbe prevented while performing vitrectomy inbullous retinal detachments.

• Absence of posterior vitreous detachments andpresence of thick fibrous sheets is challenging.

• Bleeding can be uncontrollable.

• Endocryotherapy can be used to treat vascularlesions

ERD in retinopathy of prematurityIttiara et al.32 had reported the rare complicationof bilateral ERDs in a preterm infant (25 weeks ofgestational age) treated with only intravitreal bev-acizumab for ROP. The bilateral ERDs developedafter 1 year. The right eye was treated with intra-vitreal bevacizumab, laser ablation and scleralbuckling, resulting in resolution of the exudationand detachment. The left eye was treated withvitrectomy and lensectomy, but persistent exud-ation and detachment remained. This case studydemonstrates the need for frequent and longerfollow-up after bevacizumab injection for retinop-athy of prematurity until the completion of retinalvascularization or until the completion of periph-eral ablation with laser photocoagulation.

Other conditions with ERD

– Exudative detachments can occur with poster-ior scleritis which can be managed with anti-inflammatory agents or anti-infective therapybased on proper diagnosis.

– Exudative detachments can occur afterendophthalmitis or choroidal abscess andcontrol of infection is the mainstay of treatment.Therapeutic and diagnostic vitrectomies may berequired for proper medical management.

– Exudative detachments can occur followingidiopathic polypoidal choroidovasculopathy(Figure 3) and anti-VEGFs are the mainstay oftreatment. Vitrectomy may be required to treatbreakthrough vitreous haemorrhage in conjunc-tion with anti-VEGF to settle the exudativeelement. Gas tamponade helps in displacementof subretinal bleeds in these patients with orwithout the use of tissue plasminogen activator.

– Exudative detachments can present with chor-oidal detachments following sudden decompres-sion of globe in glaucoma filtration surgeriesand can be managed medically similar toexudative RD following laser or cryotherapy.

– Masquerade syndrome can present withexudative detachments of retina, and choroidand malignancy (primary or secondary) shouldbe excluded before resorting to any surgery.

ConclusionExudative detachments may show typical shiftingfluid and the ethology should be ascertained. Theprimary cause should be treated and exudativedetachments may resolve. Surgery is reserved forlimited patients which do not respond to conven-tional therapy. Recurrences are common evenafter surgery and visual results may not beencouraging. Patients may require long-termfollow-up to achieve a complete remission.

References1. Charles ST. Controlled drainage of subretinal and choroidal

fluid. Retina 1985;5:233–4.2. David F, Patterson BS, Ryan EH Jr. Controlled drainage of

subretinal fluid using continuous monitoring with indirectophthalmoscopy. JAMA Ophthalmol. 2013;131(2):228–313.

3. Kang JE, Kim HJ, Boo HD, et al. Surgical management ofbilateral exudative retinal detachment associated with centralserous chorioretinopathy. Korean J Ophthalmol. 2006;20:131–8.

4. Pathengay A S, Chhablani J. External drainage for exudativeretinal detachment secondary to central serouschorioretinopathy. Eye Sci. 2015;30(4):204–8.

5. Figueroa MS, Arruabarrena C, Sales-Sanz M, et al. Inferiorsclerotomies without subretinal fluid drainage for exudativeretinal detachment in diffuse retinal pigment epitheliopathy. EurJ Ophthalmol. 2008;18(6):965–71

6. John VJ, Mandelcorn ED, Albini TA. Internal drainage forchronic macula-involving serous retinal detachment inidiopathic central serous chorioretinopathy. Int Ophthalmol.2014;34(1):91–5.

7. Chen HC, Ho JD, Chen SN. Perfluorocarbon liquid-assistedexternal drainage in the management of central serouschorioretinopathy with bullous serous retinal detachment.Chang Gung Med J. 2003;26:777–81.

8. Kang JE, Kim HJ, Boo HD, et al. Surgical management ofbilateral exudative retinal detachment associated with centralserous chorioretinopathy. Korean J Ophthalmol. 2006;20(2):131–8.

9. Shanmugam PM, Ramanjulu R. Vascular tumors of the choroidand retina. Indian J Ophthalmol. 2015;63(2):133–140.

10. Gass JD. Uveal effusion syndrome: a new hypothesisconcerning pathogenesis and technique of surgical treatment.Trans Am Ophthalmol Soc. 1983;81:246–60.

11. Elagouz M, Stanescu-Segall D, Jackson TL. Uveal effusionsyndrome. Surv Ophthalmol. 2010;55(2):134–45.

12. Boynton JR, Purnell EW. Bilateral microphthalmos withoutmicrocornea associated with unusual papillomacular retinalfolds and high hyperopia. Am J Ophthalmol. 1975;79(5):820–6.

13. Lee S, Ai E, Lowe M, et al. Bilateral macular holes in sporadicposterior microphthalmos. Retina 1990;10(3):185–8.

14. Spitznas M, Gerke E, Bateman JB. Hereditary posteriormicrophthalmos with papillomacular fold and high hyperopia.Arch Ophthalmol. 1983;101(3):413–7.

15. Ryckewaert M, Zanlonghi X, Bertrand-Cuignet H, et al. Highhyperopia with papillomacular fold. Ophthalmologica 1992;204(1):49–53.

16. Faulborn J, Kölli H. Sclerotomy in uveal effusion syndrome.Retina 1999;19(6):504–7.

17. Shields JA, Shields CL, Honavar SG, et al. Classification andmanagement of Coats’ disease: the 2000 Proctor Lecture. Am JOphthalmol. 2001;131(5):572–83. doi:

18. Cai X, Zhao P, Zhang Q, Jin H. Treatment of stage 3 Coats’disease by endolaser photocoagulation via a two-port parsplana nonvitrectomy approach. Graefes Arch Clin ExpOphthalmol. 2015;253(7):999–1004.


Major Review

19. Ramasubramanian A, Shields CL. Bevacizumab for Coats’disease with exudative retinal detachment and risk ofvitreoretinal traction. Br J Ophthalmol. 2012;96(3):356–9.

20. Villegas VM, Gold AS, Berrocal AM, et al. Advanced Coats’disease treated with intravitreal bevacizumab combined withlaser vascular ablation. Clin Ophthalmol. 2014;8:973–6.

21. Suesskind D, Altpeter E, Schrader M, et al. Pars planavitrectomy for treatment of advanced Coats’ disease—presentation of a modified surgical technique and long-termfollow-up. Graefes Arch Clin Exp Ophthalmol 2014;252(6):873–9.

22. Rishi P, Rishi E, Uparkar M, et al. Coats’ disease: an Indianperspective. Indian J Ophthalmol. 2010;58(2):119–24.

23. Kondo I, Yamagata K, Yamaki K, et al. Analysis of thecandidate antigen for Harada’s disease. Nippon Ganka GakkaiZasshi. 1994;98(6):596–603.

24. Gaun S, Kurimoto Y, Komurasaki Y, et al. Vitreous surgery forbilateral bullous retinal detachment in Vogt–Koyanagi–Haradasyndrome. Ophthalmic Surg Lasers 2002;33(6):508–10.

25. Gaudric A, Krivosic V, Duguid G, et al. Vitreoretinal surgery forsevere retinal capillary hemangiomas in Von Hippel–Lindaudisease. Ophthalmology 2011;118(1):142–9.

26. Tsai FY, Lau LI, Chen SJ, et al. Persistent exudative retinaldetachment after photodynamic therapy and intravitrealbevacizumab injection for multiple retinal capillary

hemangiomas in a patient with Von Hippel–Lindau disease. JChin Med Assoc. 77(1):52–6.

27. Kim HM, Park KH, Woo SJ. Massive exudative retinaldetachment following photodynamic therapy and intravitrealbevacizumab injection in retinal capillary hemangioma. KoreanJ Ophthalmol. 2015;29(2):143–5.

28. YM , Jalil A, Mathews J, et al. Exudative retinal detachmentfollowing photodynamic therapy for retinal capillaryhemangioma. Can J Ophthalmol. 2010;45:299–300.

29. Goto S, Oshima Y, Tsujikawa M, et al. Massive exudativeretinal detachment after photodynamic therapy for peripheralretinal capillary hemangioma. Retin Cases Brief Rep.2013;7:86–8.

30. Chen Y, Liu H, Zhang K, et al. Massive exudative retinaldetachment following photodynamic therapy for retinalhemangioma in Von Hippel–Lindau Syndrome. PhotodiagnPhotodyn Ther. 2014;11:250–3.

31. Arnold JJ, Blinder KJ, Bressler NM, et al. Acute severe visualacuity decrease after photodynamic therapy with verteporfin:case reports from randomized clinical trials — TAP and VIPreport no. 3. Am J Ophthalmol. 2004;137:683–96.

32. Ittiara S, Blair MP, Shapiro MJ, et al. Exudative retinopathyand detachment: a late reactivation of retinopathy ofprematurity after intravitreal bevacizumab. J AAPOS 2013;17(3):323–5.

How to cite this article Ganesan S. and Rishi E. Surgical implications in exudative retinal detachment, Sci J Med &Vis Res Foun 2017;XXXV:29–36.


Major Review

Managing a case of buckle intrusion with recurrent vitreoushaemorrhage: a case report

Sharan Shetty1 and Muna Bhende2

IntroductionScleral buckling (SB) with silicone implants is aneffective method to reattach the retina. Siliconeimplants used for SB in retinal detachmentsurgery have been associated with various compli-cations which include buckle infection, granulomaformation, extrusion of the implant through theconjunctiva, double vision and restriction ofocular motility. Intrusion of the implant throughthe sclera may develop due to progressive scleralthinning.1

Intrusion is defined as erosion, followed byprotrusion of the scleral implant into the vitreouscavity. The intruding material may either be thematerial implanted on the sclera or the sutures.Intrusion of the buckle through the sclera into thesubretinal space is particularly difficult to manageand can result in severe vision loss, recurrentretinal detachment and subretinal or vitreoushemorrhage.2 We report a case of a patient suffer-ing from recurrent vitreous haemorrhages follow-ing scleral buckle intrusion 14 years after surgery,managed by buckle removal without removing theencirclage band.

Case reportA 31-year-old male presented to us with historyof recurrent floaters in the left eye since 3months. He had undergone SB 14 years back forrhegmatogenous retinal detachment following ablunt trauma. Patient had good vision followingthe surgery and was on regular follow-up. Hedeveloped recurrent retinal detachment for whichhe underwent pars plana vitrectomy, 3 monthsago. On examination, his best-corrected visualacuity (BCVA) was 20/40 with intraocular pres-sure of 30 mmHg. Slit-lamp examination waswithin normal limits. Fundus examinationrevealed an attached retina with high buckleindentation and buckle intrusion in the inferiorhalf (Figure 1) along with neovascularization andhaemorrhage over the area of intrusion(Figure 2). Patient was started on topical 0.5%timolol maleate twice a day. On follow-up visitafter a month, he gave a history of one moreepisode of vitreous haemorrhage. On examin-ation, subconjunctival haemorrhage was notedover the superior bulbar conjunctiva with anter-ior migration of the buckle element. Patient wasput on a full course of oral antibiotic along withtopical antibiotics and was advised removal ofthe segmental buckle. General anaesthesia was

preferred in view of high chance of intraoperativeglobe rupture. However, patient did not undergothe surgery and reported back to us after 3months. Anterior migration of the scleral bucklewas noted this visit. Patient was taken up forscleral buckle removal along with trimming theencirclage over the segmental buckle element.

An external approach was planned for buckleremoval. A standby scleral graft was madeavailable to patch any visible scleral defect. Theconjunctiva and the tenons were dissected ofthe scleral buckle in the supero-temporal quad-rant. The two anchor sutures were cut andremoved. The buckle element was cut at thecentre and gentle expressed out. The encirclageover the buckle was trimmed and edges wererepositioned into the sub-tenons space. Thetenons and the conjunctiva were sutured inlayers (Figure 3).

Postoperatively, the retina remained attachedwith a BCVA of 20/30. Two months later, patienthad maintained a vision of 20/30 with reductionin the buckle indent with no further episodes ofvitreous haemorrhage with persisting NVE at thearea of buckle intrusion (Figure 4).

DiscussionSB with exogenous material is an effectivemethod to reattach the retina. Retrospective serieshave reported complications of SB, most com-monly extrusion and infection, in 1.3–24.4% ofeyes. Intrusion and erosion are rarely reportedcomplications of SB, noted to occur in approxi-mately 4 of 4400 cases.3 It has been associatedwith myopia because of the related scleral thin-ning and altered scleral strength.4 SB erosion andintrusion may cause visual symptoms and resultin retinal detachment, vitreous haemorrhage andendophthalmitis. An intruding or eroding SB maybe left untouched unless there is any complica-tions, or is a significant danger to the integrity ofthe ocular structures.5

The decision to remove an SB can be puzzling,as each case is unique. SB removal can be consid-ered necessary if signs and symptoms are progres-sive or additional complications occur (e.g.,endophthalmitis and scleral necrosis). If signs andsymptoms are chronic and stable (e.g., extrusion),SB removal is elective. The most dreaded conse-quence of SB removal is recurrent detachment.6

The cause of retinal detachment after buckleremoval can be proliferative vitreoretinopathy or a

1Fellow,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

2Senior Consultant & DeputyDirector,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

Correspondence:Muna Bhende,Deputy Director and SeniorConsultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India.Email: [email protected]


Case Report

new retinal break.7 Patients with areas of tractionor high-risk lesions should have laser prophylaxisbefore SB removal.

SB removal is performed in the operating roomwith topical, local or general anaesthesia. A localanaesthetic injection should be performed with

Figure 1: Fundus photo montage of the left eye showing attached retina with buckle intrusion in theinfero-nasal quadrant.

Figure 2: Neovascularization and haemorrhage over the area of buckle intrusion.


Case Report

Figure 3: (A) Intraoperative photo showing buckle element in situ with the encirclage band cut overit. (B) The buckle element is cut at the centre. (C) The buckle element is expressed out. (D) Theencirclage band is trimmed and repositioned in the sub-tenons space.

Figure 4: Postoperative fundus photo showing reduction in buckle indent height with resolution ofhaemorrhage.


Case Report

caution as many eyes are myopic with a distortedglobe after buckle surgery. General anaesthesiashould be opted for in cases where scleral necrosis,erosion and intrusion are suspected as chances ofglobe perforation are high.

Often the SB can be removed with opening onequadrant of conjunctiva or using a pre-existingexposure site. Information of which elements wereused and where their ends lie is vital, as dissectingwithout a clear plan is difficult. When this infor-mation is unavailable, SB details can sometimesbe gathered by examining the conjunctiva andlooking at the buckle indentation on fundusexamination. The route of removal of buckleelement depends on the degree of intrusion. Forexample, if the segment is intravitreal then it canbe removed via the pars plana.

Depending on the indication, SB-related com-plications can be managed by 1) cutting theencircling band, 2) removing the exposed segmen-tal buckle element with the other elements left inplace and 3) most often, all elements removedalong with sutures.8 Sutures can be removed orleft in place, depending on if they are causing pro-blems and their accessibility. Irrigation with anti-biotics should be considered after the procedure,particularly with an infected SB. If scleral necrosisor erosion and intrusion are suspected, patchmaterials and sutures should be kept available.

Removed SB and sutures should be sent for micro-biological examination.

In this case, a conservative approach ofremoval of the just the buckle element withoutremoval of the encirclage was followed as therewas anterior migration of the scleral buckleelement along with the intrusion of the encirclagein the opposite quadrant.

References1. Kokame GT, Germar GG. Successful management of intruded

hydrogel buckle with buckle removal, scleral patch graft, andvitrectomy. Retina 2003;23(4):536–8.

2. Shami MJ, Abdul-Rahim AS. Intrusion of a scleral buckle: a latecomplication of retinal reattachment surgery. Retina 2001;21(2):195–7.

3. Deutsch J, Aggarwal RK, Eagling EM. Removal of scleral explantelements: a 10-year retrospective study. Eye 1992;6(6):570–3.

4. Nguyen QD, Lashkari K, Hirose T, et al. Erosion and intrusion ofsilicone rubber scleral buckle: presentation and management.Retina 2001;21(3):214–20.

5. Kitagaki T, Morishita S, Kohmoto R, et al. A case of intraocularerosion and intrusion by an arruga suture. Case Rep Ophthalmol.2016;7(1):174–8.

6. Deokule S, Reginald A, Callear A. Scleral explant removal: thelast decade. Eye 2003;17(6):697–700.

7. Goezinne F, La Heij EC, Berendschot TT, et al. Incidence ofredetachment 6 months after scleral buckling surgery.Actaophthalmologica 2010;88(2):199–206.

8. Tsui I. Scleral buckle removal: indications and outcomes. SurveyOphthalmol. 2012;57(3):253–63.

How to cite this article Shetty S. and Bhende M. Managing a case of buckle intrusion with recurrent vitreoushaemorrhage: a case report, Sci J Med & Vis Res Foun 2017;XXXV:37–40.


Scleral buckle infection presenting as subretinalinflammatory mass lesion

Kalpita Das1, Gaurav Mathur2 and Muna Bhende3

IntroductionScleral buckling (SB) is an important and effectivesurgical technique for the management of rheg-matogenous retinal detachment.1,2 Scleral buckleexposure with or without infection remains mostcommon complication of the surgery requiringremoval of the explant or implant.3–5 Intraocularinfection following SB surgery is extremely rare,6

the procedure being mostly extraocular. We reporta case of subretinal inflammatory mass lesion fol-lowing scleral buckle infection and its successfulmanagement.

Case reportA 40-year-old female underwent uncomplicatedretinal detachment surgery in the form of inferiorscleral buckle (276 segmental silicone sleeve from3–80o clock hours with 240 circumferential band),cryopexy with no subretinal fluid drainage for apost-traumatic subtotal macula involving retinaldetachment of the left eye. She recovered goodvision postoperatively and was lost to follow-up.She came to us again after 10 years with com-plaints of mild pain and discharge. Her vision inthe right eye was 6/6, N6 and left eye 6/45, N36.The anterior segment in the right eye was withinnormal limits. The left eye showed an exposedscleral buckle in the inferior fornix. There wasno conjunctival congestion or associated scleralthinning. Intraocular pressure in both eyes was16 mmHg. Fundus examination of the right eyewas normal and left eye showed an attachedretina with good buckle effect inferiorly. Patientwas advised buckle removal but did not report forthe same. She was also diagnosed as a case ofmicrocytic hypochromic anaemia for which shewas started on medical therapy.

Patient came again after 4 years of last pres-entation with complaints of sudden diminutionof vision, pain, redness in the left eye of 1 monthduration. Her vision dropped to counting fingerone meter, <N36 in the left eye and anteriorsegment showed hyperemic conjunctiva, exposedbuckle inferiorly with surrounding discharge.Cornea was clear and anterior segment showedgrade 1 cells. Dilated fundus examination showedvitreous haze with a diffuse elevated subretinallesion and surrounding subretinal fluid in thetemporal quadrant (around 30o clock) suggestiveof a subretinal inflammatory lesion. Rest of theretina was flat with good buckle effect seeninferiorly. Ultrasound of the left eye showed aretinochoroidal elevation with high surfacereflectivity and heterogenous internal reflectivityover the buckle. CT scan of the orbit showed ill-defined soft tissue thickening of the temporalperiocular area continuous with the lateralrectus insertion. Scleral buckle was removedunder general anaesthesia, and the buckle andsutures were sent for microbiological investiga-tions. Surgery was uneventful, and the bucklewas noted to have blackish deposits on thesurface. There was no scleral perforation,abscess or granuloma noted intraoperatively.Microbiological studies from the buckle revealedmethicillin-sensitive Staphylococcus aureus andAspergillus terrus. Patient was treated postopera-tively with oral Ciprofloxacin 500 mg twice dailyfor 5 days and oral Fluconazole 200 mg twicedaily for 3 weeks, fortified Gentamicin eye dropsevery 1 hourly with weekly tapering schedule for1 month. Postoperatively on the third day,fundus examination showed clearer media with adecrease in size of the retinochoroidal lesion. On

Figure (A–C) External photograph and fundus pictures of a patient with exposed scleral buckle andpainful drop in vision 14 years after surgery. Note the blackish material at the junction of theexposed and unexposed buckle (arrow). (B and C) The vitreous haze with exudation temporally(arrow) and a mass-like lesion anterior to it (arrow in C).

1,2Fellow, Sri Bhagwan MahavirVitreoretinal Services, SankaraNethralaya, Chennai, India

3Senior Consultant & DeputyDirector, Sri Bhagwan MahavirVitreoretinal Services, SankaraNethralaya, Chennai, India

Correspondence:Muna Bhende,Deputy Director and SeniorConsultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India.Email: [email protected]


Case Report

follow-up at 3 months, vision improved to 6/36,N36 and fundus examination showed clearmedia, attached retina with good buckle effectwith a flat plaque of subretinal hard exudates.There was no subretinal fluid or mass visiblethough residual buckle effect was noted. Ocularmovements were full range and painless. Patientwas advised a regular follow-up after 6 monthshenceforth.

DiscussionSB is an extraocular procedure with an associatedrisk of intraocular infection being only 0.19%.7

Intraocular infection is mainly associated withprocedures like subretinal fluid drainage, gasinjections or accidental needle perforation duringsuturing.6 The most common causative organismin buckle infections includes Staphylococcusaureus, Staphylococcus epidermidis, Proteus and

Figure (D–F) B scan images of the same eye showing vitreous echoes suggestive of inflammation(arrow in D). (E) A temporal mass-like lesion of variable reflectivity and an area of echolucencysuggestive of the solid silicone buckle element (arrow). (F) The appearance of the exposed buckle—seen as an echolucent structure with no evidence of inflammation or damage to the surroundingareas.

Figure (G) CT scan shows a soft tissue mass around the scleral buckle continuous with the lateralrectus insertion.


Case Report

Pseudomonas.5,8–10 Fungal infections causingbuckle infections are rare as the severity of infec-tion is related to host immune defences and envir-onmental conditions.11 Severe anaemia couldprobably be one of the risk factors for infectionwith Aspergillus in our patient. A case report ofscleral buckle infection with subretinal abscesshas been reported; however, the infection site waslikely to be the drainage retinotomy in it.10

Without any scleral perforation, intrusion of thebuckle or a drainage retinotomy, it is unlikely foran organism to invade and cause endophthalmitis.Some of the highly virulent organisms have beenfound to invade the intact sclera,11 but in our caseon removal of the buckle the sclera was foundintact with no evidence of scleral abscess or thin-ning or perforation.

In this patient, we did not consider the sub-retinal inflammatory lesion as a sign of intraocu-lar infection and did not treat it with intravitrealantibiotics because of the following reasons. It israre for any bacteria or fungus to penetratethrough intact sclera when there has been nodrainage done, it is the toxin-mediated severeinflammatory response leading to sterile vitritisand the subretinal lesion. The patient improvedsignificantly after removal of the buckle withoutthe use of steroids or intravitreal antibiotics, indi-cating that the changes were secondary to theexposed, infected buckle. It is interesting to notethat the area of the exposed buckle did not showany abscess, but it was the segment that wascovered by conjunctiva that had the subretinallesion beneath it.

This is a unique case where an inflammatoryretinal lesion simulated an endophthalmitis-likepicture but resolved after scleral buckle removaland conservative management with systemic andtopical antibiotics.

References1. Schwartz SG, Flynn HW. Primary retinal detachment: scleral

buckle or pars plana vitrectomy. Curr Opin Ophthalmol.2006;17:245–50.

2. Falkner-Radler CI, Myung JS, Moussa S, et al Trends inprimary retinal detachment surgery: results of a Bicenter study.Retina 2011;31:928–36.

3. Tsui I. Scleral buckle removal: indications and outcomes. SurvOphthalmol. 2012;57:253–63.

4. Han DP, Covert DJ, Wirostko WJ, et al. Scleral buckle removalin the vitrectomy era: a 20-year clinical experience. Retina2013;33:387–91.

5. Kazi MS, Sharma VR, Kumar S, et al. Indications and outcomesof scleral buckle removal in a tertiary eye care center in SouthIndia. Oman J Ophthalmol. 2015;8:171–4.

6. Ho PC, McMeel JW. Bacterial endophthalmitis after retinalsurgery. Retina 1983;3:99–102.

7. Oz O, Lee DH, Smetana SM, et al. A case of infected sclerabuckle with Mycobacterium chelonae associated with chronicintraocular inflammation. Ocul Immunol Inflamm. 2004;12:65–7.

8. Pathengay A, Karosekar S, Raju B, et al. Microbiologicspectrum and susceptibility of isolates in scleral buckle infectionin India. Am J Ophthalmol. 2004;138:663–4.

9. Smiddy WE, Miller D, Flynn HW Jr. Scleral buckle removalfollowing retinal reattachment surgery: clinical andmicrobiological aspects. Ophthalmic Surg. 1993;24:440–5.

10. Tay E, Bainbridge J, da Cruz L. Subretinal abscess after scleralbuckling surgery: a rare risk of retinal surgery. Can JOphthalmol. 2007;42:141–2.

11. Chhablani J, Nayak S, Jindal A, et al. SB infections:microbiological spectrum and antimicrobial susceptibility.J Ophthalmic Inflamm Infect. 2013;3:67.

How to cite this article Das K., Mathur G. and Bhende M. Scleral buckle infection presenting as subretinalinflammatory mass lesion, Sci J Med & Vis Res Foun 2017;XXXV:41–43.

Figure (H and I) The same patient after removal of the buckle and treatment with topical andsystemic antifungals (the culture of the buckle element and discharge showed Aspergillus). The eyeis quiet. The fundus montage shows that the media is clear, retina attached with few residual hardexudates (arrow). The persistence of buckle effect is seen anterior to the exudates (thin arrow)


Macular buckle for myopic retinal detachment

Anmol Naik1 and Pradeep Susvar2

Macular holes are more frequently accompaniedby retinal detachment in highly myopic eyes thanin those with lesser or no myopia, and the inci-dence of retinal detachment increases with thepresence and the degree of posterior staphyloma.1

The main cause of visual impairment in patho-logical myopia is myopic traction maculopathy(MTM). It comprises of myopic foveoschisis (MS),lamellar or full thickness macular hole and poster-ior pole retinal detachment (with or withoutmacular hole). Posterior staphyloma, being a com-ponent of progressive myopia, predisposes to for-mation of these tractional maculopathies. In somecases, macular retinal detachment developing atthe posterior pole exhibits a shortening of theretina in relation to the steep bowing of the scleraat the staphyloma area. This mismatch usuallytends to be the cause of failure of retinalre-attachment in conventional vitrectomies withan internal limiting membrane (ILM) peeling pro-cedure. It is in this scenario where macular buck-ling helps to support the posterior globe tocounteract the sclero-retinal mismatch present atthe staphyloma. We present a case of highmyopia-related posterior pole detachment andmacular hole treated successfully with a macularbuckling procedure combined with conventionalvitrectomy.

Case reportA 56-year-old high myopic lady presented to uswith complaint of painless progressively decreas-ing vision in her right eye since 15 days. On

examination, her best-corrected visual acuity(BCVA) was counting fingers at 1 meter, <N36 inthe right eye (OD) with −20 DS and that in theleft eye (OS) was 6/18, N6 with −16 DS, −3DC at150°. The anterior segment examination, pupillaryreaction, intraocular pressure and extraocularmovements were within normal limits. The fundusimages of both eyes are shown in Figure 1. Botheyes revealed a myopic tessellated fundus. ODshowed a circumscribed area of myopic maculardegeneration with localized retinal detachment(denoted by black arrow) along with a pocket ofsub-retinal fluid inferior to the degenerated area.OS showed extensive myopic chorio-retinalatrophy at the macula with pigmentary changes.

A swept source optical coherence tomography(SSOCT) of OD (Figure 2) revealed a full thicknessmacular hole (thick arrow) and a lamellar holeeccentric to the fovea (thin arrow) with a chronicschitic retina. SSOCT in these cases also helps tolook at the severity of the staphyloma at its edgesin relation to the retinal layer. Based on thehistory, clinical findings and investigations, acombined vitrectomy, ILM peeling and macularbuckling procedure was planned.

TechniqueMorin–Devin wedge, also called as T-shapedmacular buckle (France Chirurgie Instrumentation—FCI, France), was used for buckling the macula.The solid silicone [Morin wedge (Figure 3a)]macular plate was threaded onto the 4-mm solidsilicone band [Devin band (Figure 3b)]. After a

Figure 1: Colour fundus images of the right and left eye (black arrow denotes the area oflocalized RD).

1Fellow, Sri Bhagwan MahavirVitreoretinal Services, SankaraNethralaya, Chennai, India

2Senior Consultant, Sri BhagwanMahavir Vitreoretinal Services,Sankara Nethralaya, Chennai,India

Correspondence to:Pradeep Susvar,Senior Consultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, IndiaEmail: [email protected]


Case Report

360° limbal peritomy and tagging of four rectimuscles, one end of this 4-mm band was firstpassed under the lateral rectus muscle, then pos-teriorly under the inferior oblique muscle andbrought to nasal side of the inferior rectus. Otherfree end was passed superiorly under superiorrectus and oblique to be brought to the nasal sideof superior rectus insertion. Both the ends of theDevin band were then temporarily sutured to thesclera at their respective locations between thevertical and medial rectii. Macular plate wasslowly manoeuvred posteriorly under the lateralrectus towards the posterior globe. The anteriorend of the macular plate was temporarily securedto the sclera by a 5-0 Mersilene suture. A23-gauge, three-port complete pars plana vitrec-tomy (PPV) was carried out. The posterior inden-tation of the macular plate was titrated andoptimized by pulling the nasal side band ends.Conventional staining and ILM peeling were per-formed followed by fluid-gas exchange and

silicone oil tamponade. Buckle securing sutureswere finalized followed by complete conjunctivalclosure.

Follow-up changesClinical findings and SSOCT showed a closedmacular hole with good apposition of the retinaindented by the convex buckle contour as early asthird postoperative day (Figure 4). Six-weekfollow-up had retinal attachment maintained withclosed macular hole appreciated both on slit-lampbiomicroscopic examination and on SSOCT(Figure 5).

BCVA improved to 3/60, N36 at 7 weeks post-operatively and the myopic refractive errorreduced to −10 DS from −20 DS due to the inden-tation at the staphyloma. The anatomical retinalattachment (Figure 6) and vision were maintainedmonths post-silicone oil removal (at 19 months)with moderate cataract changes at the lastfollow-up 2 years post primary surgery.

Figure 2: Preoperative SSOCT of the right eye demonstrating schitic retina (thicker arrow denotesfull thickness macular hole and thinner arrow denotes lamellar hole eccentric to fovea).

Figure 3: (a) Morin macular wedge. (b) Devin band threaded into the plate of the wedge.


Case Report

DiscussionRD in pathological myopia typically develops atthe posterior pole in cases of MTM. The under-lying patho-mechanisms that interplay at the pos-terior pole are rigidity of ILM relative to theretina, stretching of the retinal layers and progres-sion of staphyloma. The entire process leads to thedevelopment of schisis followed by lamellar or fullthickness hole at the macula leading to posteriorpole detachments. RD due to traction

maculopathies can be surgically treated by con-ventional vitrectomy with ILM peeling in mostcases, thereby taking care of both anteroposteriorand tangential traction at the surface of the innerretina. Macular buckle procedure is effective incases of maculopathy where there is a gross mis-match between the retinal layers and depth of thescleral out-pouch at the staphyloma. Macularbuckle can be performed either as a primary pro-cedure or combined with vitrectomy.

Figure 4: SSOCT right eye—third postoperative day. Note the closure of macular hole with retinalapposition due to the macular buckle effect.

Figure 5: SSOCT right eye—sixth postoperative week.

Figure 6: SSOCT right eye—19 months postoperatively. The closure of macular hole and retinalattachment is well maintained.


Case Report

Various types of macular buckle are available,namely Ando plombe, T-shaped buckle, AJLmacular buckle, L-shaped macular buckle, adjust-able macular buckle and the traditionalwire-strengthened sponge exoplant,2 each withtheir own merits and demerits. The success rates ofretinal attachment after macular buckle with/without vitrectomy have been quite promising.Ando et al.3 reported permanent retinal reattach-ment in 93.3% of the eyes after the macular buck-ling procedure with no remarkable intraocularcomplications, compared with 50% attachmentrate with PPV alone. Theodossiadis andTheodossiadis4 in their 15-year follow-up foundthe rate of reattachment to be 88% after macularbuckle surgery. Ma et al.5 recently published theresults of a randomized study with 24-monthfollow-up, comparing 23G PPV with ILM peelingto 23G PPV, ILM peeling with macular buckleunder direct vision. The initial retinal reattachmentrate was significantly higher in the second group(93.48%) compared with the first group (76.92%).Xiong et al.6 reported resolution of MS in all theirpatients following the combined procedure ofmacular buckling, vitrectomy and ILM peeling.

Thus, macular buckling with vitrectomy andILM peeling seems to more effective than PPV and

ILM peeling alone in myopic retinal detachmentwith macular hole with posterior staphyloma andfailed or recurrent cases of retinal detachmentwith/without macular hole.2

References1. Akiba J, Konno S, Yoshida A. Retinal detachment associated

with a macular hole in severely myopic eyes. Am J Ophthalmol.1999;128(5):654–5.

2. Pradeep S, Vinay Kumar S. Macular buckle in myopia. Sci J MedVis Res Foun. 2015;XXXIII:71–4.

3. Ando F, Ohba F, Touura K, et al Anatomical and visual outcomesafter episcleral macular buckling compared with those after parsplana vitrectomy for retinal detachment caused by macularholein highly myopic eyes. Retina 2003;27(1):37–44.

4. Theodossiadis GP, Theodossiadis PG. The macular bucklingprocedure in the treatment of retinal detachment in highlymyopic eyes with macular hole and posterior staphyloma. Meanfollow-up of 15 years. Retina 2005;25(3):285–9.

5. Ma J, Li H, Ding X, et al Effectiveness of combined macularbuckle under direct vision and vitrectomy with ILM peeling inrefractory macular hole retinal detachment with extreme highaxial myopia: a 24-month comparative study. Br J Ophthalmol.2017;1–9. doi:.

6. Xiong SQ, Jiang HB, Li FL, et al. Treatment of myopicfoveoschisis via macular buckling and vitrectomy. Int JOpthalmol. 2017;10(5):815–8.

How to cite this article Naik A. and Susvar P. Macular buckle for myopic retinal detachment, Sci J Med & Vis ResFoun 2017;XXXV:44–47.


Case Report

Retinal vein occlusion following vitrectomy forrhegmatogenous retinal detachment: a case report

Eesh Nigam1 and Debmalya Das2

IntroductionOcular vascular occlusions after intraocularsurgery are rare complications. The causativefactors are difficult to identify specially aftervitreoretinal procedures. Vascular occlusions aremore frequent when a cardivascular disease coex-ists. We present a case where a person presentedwith branch retinal vein occlusion (BRVO) andcystoid macular oedema (CME) after vitrectomyfor rhegmatogenous retinal detachment (RRD)without any systemic predisposing factors.

Case reportA 26-year-old male presented with blurred visionin his left eye for 1 month. Distant best-correctedvisual acuity (BCVA) of the left eye was countingfingers at 3 m. Fundus examination revealed totalRRD in his left eye with horse shoe tears at theperiphery. The patient underwent routine work-up

before surgery excluding all possible coexistingcardivascular risk factors. Patient underwentroutine 23G vitrectomy with belt buckling andsilicone oil tamponade under peribulbar anaesthe-sia. SRF was drained through a retinotomy. Thepostoperative period was uneventful except thaton the fifth postoperative day, few retinal haemor-rhages were noted around superotemporal vessels.In his follow-up visit, after 6 weeks, BCVA in hisleft eye was 6/24 with an intraocular pressure of12 mmHg. Fundus examination of the left eyeshowed an attached retina with sclerosed vesselsin superotemporal quadrant along with retinalhaemorrhages and cystic changes at macula sug-gestive of a superotemporal BRVO with CME.No signs of inflammation were seen in either ofthe eye.

Fundus fluorescein angiography (FFA) revealeda wide area of non-perfused retina (red arrow)

Figure 1 FFA showing nonperfused retina (red arrow), retinotomy site (yellow arrow), patelloidleakage at macula (blue arrow).

1,2Associate consultant,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India

Correspondence:Eesh Nigam,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India.Email: [email protected]


Case Report

near the retinotomy site (yellow arrow) along withsclerosed vessels with a petalloid pattern dye leakpresent at fovea (blue arrow) suggestive of CME,which was confirmed by the optical coherencetomography (OCT) (Figures 1 and 2). Further sys-temic investigations failed to find a systemiccause. The patient was advised topical non-steroidal anti-inflammatory eye drop and wasasked to review after 1 month. The OCT after 2months showed non-resolution of macularoedema (Figure 3). He subsequently underwentsilicone oil removal with an intravitreal injectionof triamcinolone acetonide (2 mg) for non-resolving cystoid macular oedema.

DiscussionThe primary mechanisms for BRVO are mechan-ical compression of vein at arterio-venous cross-ing by anterior rigid artery, degenerative changes

of vessel wall and/or abnormal haematologicalfactors.1

The main cause of impaired vision in BRVO isdue to CME. CME occurs in 30% of eyes withBRVO.1 CME can be differentiated by FFA bytypical petalloid leakage pattern from cystoiddegeneration which does not show leakagein FFA.

There are reported incidents of vascular occlu-sion after retrobulbar anaesthesia. The cause ofsuch an episode attributed to reduction of retro-bulbar blood flow velocities after retrobulbaranaesthesia.4 Drug-induced vasoconstriction playsa role in the decrease in ocular blood flow afterperibulbar anaesthesia as does increase IOP whichis probably caused by the mechanical effect of theinjected volume in the orbit.4 Although the retinalvessels has a wide range of autoregulation underchange in perfusion pressure, the autoregulation

Figure 2 OCT at 6 weeks.

Figure 3 OCT at 2 months.


Case Report

gets compromised in diseased states like diabeticretinopathy and glaucoma. And, in these situa-tions, even a small reduction in ocular perfusionpressure, as induced by an increase in intraocularpressure, may reduce ocular blood flow. Similarly,high fluctuation of intraocular pressure is seenduring vitrectomies. An increase in intraocularpressure occurs during fluid gas exchange due toa forward displacement of the lens-iris diaphragmresulting in anterior chamber flattening andsecondary angle-closure glaucoma.2 Anteriorchamber flattening can also occur due to ciliarybody oedema and choroidal swelling caused byextensive laser or cryocoagulation.

A direct vascular trauma with endolaser burnor mechanical trauma could also be a possiblereason for the BRVO in our case as is evident thelocation of vein occlusion close to endolaserburns and the retinotomy site.

ConclusionSurgical manipulations causing decreased retinaland choroidal blood flow as well as pressurechanges and mechanical damage may act as

triggering mechanisms for retinal vein occlusionsin such cases.

Vascular occlusion after intraocular surgerymay occur without any associated cardiovasculardisease. Affected patients should undergo systemicevaluation to rule out possible underlyingsystemic diseases and should be treatedconventionally.

References1. Li j, Paulus YM, Shuai Y, et al. New developments in the

classification, pathogenesis, risk factors, natural history, andtreatment of branch retinal vein occlusion. J Ophthalmol.2017;2017:4936924.

2. Costarides AP, Alabata P, Bergstrom C. Elevated intraocularpressure following vitreoretinal surgery. Ophthalmol Clin NorthAm. 2004;17(4):507–12.

3. Cugati S, Wang JJ, Rochtchina E, et al. Ten-year incidence ofretinal vein occlusion in an older population: the blue mountainseye study. Arch Ophthalmol. 2006;124(5):726–32.

4. Huber KK, Remky A. Effect of retrobulbar versus subconjunctivalanaesthesia on retrobulbar haemodynamics. Br J Ophthalmol.2005;89:719–23.

5. Findl O, Dallinger S, Menapace R, et al. Effects of peribulbaranesthesia on ocular blood flow in patients undergoing cataractsurgery. Am J Ophthalmol. 1999;127:645–9.

How to cite this article Nigam E. and Das D. Retinal vein occlusion following vitrectomy for rhegmatogenous retinaldetachment: a case report, Sci J Med & Vis Res Foun 2017;XXXV:48–50.


Case Report

Some holes need no peeling: a case report ofspontaneous closure of macular hole in a case oftreated rhegmatogenous retinal detachment

Debmalya Das1 and Eesh Nigam2

IntroductionFull thickness macular hole (FTMH) formation iscaused by tangential vitreous tractions1 andanteroposterior tractional components.2,3 Surgicalintervention includes vitrectomy with or withoutpeeling of the inner limiting membrane (ILM) torelieve these tractional forces.4 Several small caseseries have described FTMH formation after vitrec-tomy for rhegmatogenous retinal detachment(RRD).5,6 In these vitrectomized eyes, the mechan-ism actually responsible for the formation ofFTMHs remains unclear. We present a case ofFTMH that developed in an eye after vitrectomyfor RRD and its spontaneous closure.

Case ReportA 56-year-old man presented with RRD in hisleft eye with a best-corrected visual acuity(BCVA) of 20/800. On examination, total RRDwith multiple horseshoe tears were seen in thetemporal and inferior quadrants. He was advisedand subsequently underwent vitrectomy withencirclage and silicone oil tamponade for thesame. Four weeks post-operation, he had anattached retina with a BCVA of 20/100. He wasscheduled for a second operation for silicone oilremoval (SOR), when he reported with a suddendrop in vision in his left eye with a BCVA of20/200. Examination revealed an attached retinawith an FTMH.

Optical coherence tomography (OCT) of the lefteye showed a small (<200 µm) FTMH (Figure 1).

SOR and ILM peeling with C3F8 tamponade wasplanned for the same. However, the patient pre-sented with an improved BCVA of 20/40 in his lefteye after a month. OCT (Figure 2) revealed a spon-taneous closure of FTMH with outer retinal defect atfovea.

DiscussionBased on clinical, histopathological and OCTstudies,2,3 it has been argued that FTMH formationis a result of tractional forces between the vitreousand retina. There are several small case seriesdescribing the development of FTMH after vitrec-tomy for RRD in the literature with a prevalencerate between 0.9 and 1.1%.7,8 In such cases, a pos-sible mechanism of action could be direct tractionon the macula during the vitrectomy for RRD.8

Further aetiologies include vitreoschisis and trac-tion caused by epiretinal membrane (ERM). In theabsence of cortical vitreous, another factor thatmay cause tangential traction leading to MH for-mation is the ILM.9 Our case had ILM striae aswas demonstrated in the OCT (Figure 2).

ILM peeling, in these cases, has become themainstay treatment for the repair of FTMHs, withbetter visual and anatomical success comparedwithout ILM peeling. Spontaneous closure ofFTMH was described previously in the presenceof ERM; however, this phenomenon is consideredto be rare.10,11 We believe that a small FTMH in avitrectomized eye, such as ours, can be observedfor some time before an intervention.

Figure 1: A small FTMH (<200 µm) (white arrow). Oil meniscus (white arrow head) can be seen.

1,2Associate Consultant,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India

Correspondence:Debmalya Das,Associate Consultant,Vitreoretinal Services,Sankara Nethralaya,Kolkata, India.Email: [email protected]


Case Report

ConclusionThis case report has its limitations. Larger cohortstudies are needed to delineate the ways in whichFTMH behaves in post vitrectomized eyes. Insummary, this report demonstrates that a smallFTMH that may develop after vitrectomy for RRDcan be observed for some time as it may closespontaneously. The pathogenesis of the formationof the holes in the absence of intact vitreous stillremains unclear.

References1. Gass JD. Reappraisal of biomicroscopic classification of stages

of development of a macular hole. Am J Ophthalmol.1995;119:752–9.

2. Smiddy WE, Flynn HW Jr. Pathogenesis of macular holes andtherapeutic implications. Am J Ophthalmol. 2004;137:525–37.

3. Gaudric A, Haouchine B, Massin P, et al Macular holeformation: new data provided by optical coherence tomography.Arch Ophthalmol. 1999;117:744–51.

4. Smiddy WE, Feuer W, Cordahi G. Internal limiting membranepeeling in macular hole surgery. Ophthalmology2001;108:1471–6; discussion 7–8.

5. Benzerroug M, Genevois O, Siahmed K, et al Results of surgeryon macular holes that develop after rhegmatogenous retinaldetachment. Br J Ophthalmol. 2008;92:217–9.

6. Rahman W, Georgalas I, da Cruz L. Macular hole formationafter vitrectomy for retinal detachment. Acta Ophthalmol.2010;88:e147–8.

7. Benzerroug M, Genevois O, Siahmed K, et al Results of surgeryon macular holes that develop after rhegmatogenous retinaldetachment. Br J Ophthalmol. 2008;92:217–9.

8. Fabian ID, Moisseiev E, Moisseiev J, et al Macular hole aftervitrectomy for primary rhegmatogenous retinal detachment.Retina 2012;32(3):511–9.

9. Gordon LW, Glaser BM, Ie D, et al Full-thickness macularhole formation in eyes with a pre-existing completeposterior vitreous detachment. Ophthalmology1995;102:1702–5.

10. Guyer DR, de Bustros S, Diener-West M, et al Observations onpatients with idiopathic macular holes and cysts. ArchOphthalmol. 1992;110:1264–8.

11. Lewis H, Cowan GM, Straatsma BR. Apparent disappearance ofa macular hole associated with development of an epiretinalmembrane. Am J Ophthalmol. 1986;102:172–5.

How to cite this article Das D. and Nigam E. Some holes need no peeling: a case report of spontaneous closure ofmacular hole in a case of treated rhegmatogenous retinal detachment, Sci J Med & Vis Res Foun 2017;XXXV:51–52.

Figure 2: Closure of FTMH with outer retinal defect (white arrow) and ILM striae (white arrow head)


Case Report

Practice pattern for managing retinal detachment: anarrative of three generations of vitreoretinal surgeons

Chetan Rao1 and Girish Rao2

The main aim of retinal detachment surgery isrelieving the vitreous traction on the retinal break,opposing the retinal break to the retinal pigmentepithelium and achieving retinopexy by laser orcryotherapy. The principles remain the same butthe surgical treatment has evolved from the timescleral buckling (SB) technique was popularizedby Charles Schepens to the introduction ofparsplana vitrectomy by Robert Machemer.Furthermore, refinement of surgical procedures,instrumentation, technological advancement invitrectomy machines, lasers, microscopes and skillenhancement of surgeon has ensured almost100% success rate of reattachment. The purpose ofthis interview was to explore how the practicepattern in vitreoretinal surgery is evolving acrossgenerations in India. We sought to know thecurrent trends in management from the experi-ences of vitreo-retina specialists of three differentgenerations in India.

Atul Kumar Ashish Vaidya Amit Jain

Atul Kumar, MD, FAMS is chief & professorof ophthalmology at Dr R.P. Centre forOphthalmic Sciences All India Institute ofMedical Sciences, New Delhi. He pursued hisvitreo-retinal fellowship at the University ofMaryland, Baltimore. He is a vitreoretinal surgeonpar excellence and has been in this field for morethan 25 years.

Ashish Vaidya MS, FRCS (Edin), FMRF hasbeen in retinal practice for the past 20 years inMumbai at Nethra Retina and Laser Centre and isattached to Lilavati Hospital. He had his trainingin vitreoretina at Sankara Nethralaya.

Amit Jain, MS, FMRF has completed fellow-ship in vitreoretina from Sri Bhagwan MahavirVitreoretinal Services, Sankara Nethralaya andrepresents the youngest generation of vitreoretinalsurgeon in this interview. He is presently workingas an associate consultant in the Department ofVitreoretinal Services at Shri Ganapati Netralaya,Jalna since 2016

What are the current treatment modalities formanaging rhegmatogenous retinaldetachment?

Amit Jain: Rhegmatogenous retinal detach-ment (RRD) treatment modalities include laserbarrage for peripheral, subclinical RD, pneumaticretinopexy, SB and primary vitrectomy withtamponade.

Ashish Vaidya: Most common in my practicewould be vitrectomy with silicone oil followed byvitrectomy with gas, scleral buckle and the leastcommon would be pneumoretinopexy.

Atul Kumar: There are three primary modal-ities for the treatment of RRD in the modern era—SB, primary vitrectomy with endotamponade andpneumatic retinopexy. A combination of SB andvitrectomy (vitrectomy–buckle) is also a popularmodality.

In brief, what are the tips to choose aparticular modality (SB/pneumaticretinopexy/primary vitrectomy) formanaging a case of RD?

Amit Jain: For any patient presenting withRRD in OPD, my first thought is ‘Is it Bucklable’.If it’s a yes, then scleral buckle (SB) is my proced-ure of choice. My criteria for SB are peripheraldepressible break/breaks, PVR (proliferativevitreo-retinopathy) not more than grade C1(ideally PVR B or less), absence of PVD in youngpatients and pediatric cases. Also in cases withextensive sub-retinal gliotic bands, where removalof bands would be difficult via vitrectomy, I preferSB, as adequate indent and treatment of breaksobviates the need for removal of these bands inmany cases. I have a very high threshold forpneumatic retinopexy which include single super-ior break in a relatively fresh RD. Primary vitrec-tomy would be used in all cases which doesn’t fitthe SB criteria.

Ashish Vaidya: In today’s era, primary vitrec-tomy would be the procedure of choice. Thefactors pushing me not to do a vitrectomy wouldbe phakic patient, young patient, absence of aposterior vitreous detachment in which case Iwould do a buckle. Pneumoretinopexy would berestricted to single superior breaks and a verycooperative patient in terms of understanding theprocedure and willing for resurgery.

Atul kumar: Vitrectomy as a primary modalityworks well in most cases, especially pseudophakic

1,2Senior ConsultantSri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India

Correspondence:Girish Rao,Medical Director,Sankara Nethralaya

Senior consultant,Sri Bhagwan MahavirVitreoretinal Services,Sankara Nethralaya,Chennai, India


Current Practice Pattern

RDs. At times, it is the only modality of use incases such as those with extensive PVR, choroidalcolobomas, choroidal detachments, giant retinaltear with rolled flap and open globe injuries, andmacular pathologies induced RDs. SB is a goodchoice in young, phakic patients who are likely tohave a tightly adherent posterior hyaloid. Thesingle operation success rate is comparable forboth modalities. Pneumatic retinopexy has anunacceptably high failure rates for use as primarymodality except in select cases where retinalbreaks are perfectly aligned to the vertical or hori-zontal meridian.

What is the role of encirclage in RD in theera of MIVS (micro-incisional vitrectomysurgery)?

Amit Jain: Complete vitrectomy is almostimpossible to achieve and for me it is here thatencirclage still holds a big role in the managementof RRD as it helps support the ora and vitreousbase thus minimizing the risk of traction andresultant break from the residual vitreous. Iusually pass encirclage in almost all my RRDcases unless it is difficult to pass the encirclagedue to extensive scarring (in previously operatedscleral tear cases) or where 360° relaxing retinot-omy is done.

Ashish Vaidya: I would still do an encirclagein inferior breaks and if the patient has PVR.

Atul Kumar: MIVS has allowed shaving vitre-ous close to the retina and a safe vitreous basedissection. This reduces the postoperative inci-dence of PVR. Nevertheless, in cases with intrin-sically contracted retina, anterior PVR failedsurgeries or in phakic patients with multiple per-ipheral breaks, an encircling element togetherwith vitrectomy will help achieve successfulretinal reattachment and avoid chances ofre-detachment secondary to PVR.

What is the most important factor inimproving the surgical outcome in a caseof RD?

Amit Jain: I would like to divide into twoparts:

Disease factor: absence of PVR.Surgeon factor: appropriate planning of tech-

nique and commitment to the approach used helpsin improving the surgical outcome.

Atul Kumar: removing all traction on thebreak is the most important factor for improvingsurgical outcome in a case of RD. ‘Do it right, thefirst time’.

What are the current indications for usingheavy density vitreous substitutes?

Amit Jain: With no personal hands on experi-ence with heavy density vitreous substitutes, I

would like to try them in cases of inferior breaksor recurrent inferior RRDs.

Ashish Vaidya: I would use them in recurrentinferior detachments.

Atul Kumar: Earlier silicone oil, which isheavier than water, was considered useful in thetreatment of complex RDs (such as those asso-ciated with extensive PVR and open globe injury)with retinal breaks and PVR primarily located inthe inferior quadrant. But, in the modern era, eventhese cases can be adequately managed with com-bined vitrectomy and encirclage along with lighterthan water silicone oil.

When would you use PFCL for managingan RD?

Amit Jain: absolute indications (almost): InGRT to flatten the posterior retina, in extensivePVR (PVR C,D) during membrane peeling, duringILM peeling in cases with macular hole. Relativeuse: PFCL is used to flatten the retina and drainsubretinal fluid through primary peripheral breakand thus avoid making an additional posteriordrainage retinotomy.

Ashish Vaidya: I primarily do a posterior reti-notomy and do a fluid-gas exchange. PFCL wouldbe used for a giant retinal tear or with otheradjunctive conditions like a nucleus or a lens dropor in management of intraocular foreign body.

Atul Kumar: PFCL is a useful adjuvant in themanagement of RD and acts as a ‘third hand’ ofthe surgeon. It is of invaluable use in the manage-ment of detachments with giant retinal tears, dis-located lens or IOL and retained intraocularforeign body. It is also useful during ILM peelingin detached retina, for placing ILM flaps overmacular holes in myopic macular hole retinaldetachments and in the management of subretinalbleeding.

What are the factors for choosing silicone oilversus gas as tamponade?

Amit Jain: Personally prefer oil in almostevery case unless it is a case of simple RRD withmacular hole as gas provides better tamponade formacular hole closure.

Ashish Vaidya: In the Indian scenario withpatients not complying for positioning and poorerfollow-ups, I would prefer silicone oil in mostpatients. It also gives them earlier visual rehabili-tation than gas. Gas would be the first choice forsuperior or posterior retinal breaks.

Atul Kumar: The choice of tamponade dependson the age of the patient, ability to maintain post-operative positioning, location and extent of thebreak, PVR at the time of surgery, presence ofchoroidal detachment, phakic status and felloweye status. (Silicon oil may be preferred in



pediatric patients, complex RDs like GRT and RDwith CD and in one-eyed patients.)

What are the major innovations in themanagement of RD in the new millennium?

Amit Jain: Use of 23–27G MIVS surgery withbetter instrumentation provides superior fluidicsand reduces surgical trauma and hastens post-operative recovery.

1 Addition of valves to the trocar system thusallowing a closed-system vitrectomy surgery.

New cutter designs with larger port areas tofasten vitrectomy, location of port closer tothe tip allowing it to be used even in mem-brane dissections along with increased stabilitywhen around mobile retina. Higher cut ratesand varying duty cycles with open or closedbias help in extensive vitreous shaving ormembrane dissection.

2 Advances in the viewing systems with newerwide-angle contact and non-contact systems.

3 Higher lumen light sources provide excellentview. Chandelier also comes with advantage ofbimanual surgery in difficult situations/exten-sive PVR.

4 Postoperatively, OCT has become an importantdiagnostic tool to look for residual subretinalfluid in chronic RD cases where functionaloutcome is not in accordance with anatomicalsuccess.

5 Macular buckle in cases of RD associated withhigh myopia and macular hole-historyrevisited.

Ashish Vaidya: MIVS with safer and fastervitrectomy and more delicate control in which onecan go close to the retina and shave the vitreousbase has tremendously changed the outcome ofthe surgeries. Also one must keep in mind thatpatient awareness is increasing and we are seeingmore patients with a recent decrease in vision.More patients are seen with pseudophakia and RD.MIVS enables us to do a better vitrectomy andalso reduces the lens-related complications likecataract or lens touch which were more commonearlier.

Atul Kumar: The development of high-speed(upto 10,000/- cuts per min) small-gauge dutycycle-controlled vitrectomy systems with betterfluidics is the only significant and path breaking

development in the last two decades in the man-agement of RD.

Innovations in buckling:

1 Chandelier-assisted buckling

2 Suprachoroidal buckling (Injecting hyaluronatein suprachoroidal space corresponding toretinal break.

Innovations in vitrectomy:

1 Macular buckle for macular hole RDs

2 Use of microscope-intergrated intraoperativeOCTs (MiOCT)

3 Ngenuity Heads-up digital-assisted vitrectomysurgery

4 High-frequency electric welding for retinopexy

What are the preoperative evaluations andchecks that are specific for managing RD inpaediatric patients?Amit Jain:

1 Age of patient as positioning won’t be possiblein very small kids.

2 Cause of RD—trauma, etc.

3 Associated syndromes—Marfan syndrome,Stickler syndrome, etc.

4 Associated ocular anomalies—microcornia,coloboma.

5 Location of breaks.

6 Presence of posterior vitreous detachment.

7 Grade of PVR

Ashish Vaidya: A complete paediatric systemicevaluation and fitness for anaesthesia would be amust for these patients including an X-ray chest.The surgery also needs to be done in a set-upwhich is geared for giving general anaesthesia tochildren and has an ICU facility at hand.

Atul Kumar: Preoperative evaluation for causeof RD and confirming existence of RRD, rule outtumour, evaluation of extent of PVR (if requiredwith the help of ultrasound biomicroscopy foridentifying anterior PVR), lens status and evalu-ation of fellow eye. Wide field imaging and angi-ography (Retcam or UltraWide field imaging) mayhelp to document and rule out secondary causes.An examination under anaesthesia may help toformulate the plan.

How to cite this article Rao C. and Rao G. Practice pattern for managing retinal detachment: a narrative of threegenerations of vitreoretinal surgeons, Sci J Med & Vis Res Foun 2017;XXXV:53–55.



Vitreoretina Services,

Sankara Nethralaya,

Kolkata, India

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Scientiﬁ c Journal of MEDICAL & VISION RESEARCH … · 2019-03-25 · Bikramjit P Pal and Kumar Saurabh Tips & Tricks: Managing retinal detachment: tips for the beginners 7 Lingam