Type of Tamponade Agent for Inferior Breaks

The ability of tamponade agents to avoid seepage of fluid through the retinal breaks depends on the interaction of three factors: the aqueous phase, the tamponade agent and the retina [5, 23]. The rationale for using a long-term tamponade for managing inferior breaks in PPV is based on the theory that the intraocular gas bubble will prevent intravitreal fluid from entering the break and accumulating in the subretinal space. However, as was mentioned above, the critical step is the development of a sealed chorioretinal adhesion

During the last 5 years there has been a change in the surgical management of retinal detachment with inferior breaks by PPV (Table 10.1). This section centers on two schools of thought in this respect. The first advocates the use of scleral buckling combined with PPV. Initially, a case series reported promising results with PPV alone [19] and the initial reattachment rate was 89%. However, this pilot study included only 9 cases, 4 pseudophakic and 5 phakic. Moreover,

Fig. 10.2 a Second postoperative day. Confluent diode laser spots around the borders of the retinal break and retinal edema are evident. The retina is completely attached. b Tenth postoperative day. Retinal edema decreases. Note the change in color of the laser spots. c One month postoperatively. A chorioretinal scar has developed around the borders of the retinal break

Table 10.1 Rhegmatogenous retinal detachments with inferior breaks managed with pars plana vitrectomy alone

Reference

Year

Number

Inferior breaks

Primary success (%)

Final success (%)

(%)

VA (%)

Tamponade

Postoperative positioning

Study design

[4]

1985

29

2

79

93

7

81 >20/50

Air

Yes

Retrospective

[21]

1987

60

3

86

92

0

76>20/50

sf6

Yes

Retrospective

[10]

1995

32

Not available

78

94

19

41 >20/50

sf6

Yes

Retrospective

[9]

1996

53

6

64

92

6

41 >20/50

SP«

Yes

Retrospective

[2]

1999

275

Not available

88

96

6

61 >20/40

Air, C,F8,

sf6

Yes

Prospective

[17]

2000

78

29

94

96

5

Not available

SFfo C3F8,

Yes

Retrospective

[19]

2001

9

9

89

100

0

66.6 >20/40

SF6 ,C3F8j

SO

Yes

Prospective

[16]

2004

48

48

81.3

95.8

NA

Not available

SF6 jCjI'S,

SO

Yes

Prospective

[22]

2004

41

41

89

95

5

Not available

sf6 ,c,f8

Yes

Retrospective

[11]

2004

27

5

89

100

96 >20/50

Air

Yes

Prospective

[18]

2004

45

Not available

97.78

100

2.2

Not available

sf6

Yes

Prospective

[15]

2005

15

15

93.3

100

0

Mean: 20/30

Air

No

Prospective

[14]

2005

40

40

90

100

2.5

Mean: 20/33

Air

No

Prospective

three types of tamponade agents were used, SF6, C3F8, and silicone oil. All the patients underwent postoperative positioning for 10 days. Two recent clinical studies [16, 22] comparing PPV alone versus PPV combined with scleral buckling have shown that anatomic and functional results do not differ between the two groups. Phakic and pseudophakic patients without clinical proliferative vitreoretinopathy were included in these studies, gas tamponade (SF<¡ or C3F8) was used, and patients were positioned postoperatively.

The second approach refers to the management of inferior breaks with PPV alone and no postoperative positioning [14, 15]. It is important to highlight that only pseudophakic patients without signs of proliferative vitreoretinopathy were included in these studies in order to achieve complete vitreous dissection around the causative retinal breaks located inferiorly. These pilot studies have provided evidence that face-down posture after PPV is not necessary to achieve retinal reattachment in pseudophakic RRD with inferior breaks. Although this issue was not specifically addressed, other authors have reported favorable results with pars plana vitrectomy alone for the management of pseudophakic and aphakic retinal detachment including superior and inferior breaks [2, 18].

As previously discussed, patients with primary pseudophakic and aphakic retinal detachment are the best candidates for this surgical technique. Asymptomatic inferior RRDs, retinoschisis, pediatric inferior retinal detachments, retinal dialysis, giant tears, and retinal detachments with proliferative vitreoretinopathy should be excluded. The intraoperative number of retinal breaks is an important factor to consider when air is used as a tamponade agent.

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