Year : 1991 | Volume
: 39 | Issue : 2 | Page : 40-
Retinal detachment surgery
CBM Opthalmic Institute, Little Flower Hospital, Angamally 683 572 Kerala, India
T P Ittyerah
CBM Opthalmic Institute, Little Flower Hospital, Angamally 683 572 Kerala
|How to cite this article:|
Ittyerah T P. Retinal detachment surgery.Indian J Ophthalmol 1991;39:40-40
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Ittyerah T P. Retinal detachment surgery. Indian J Ophthalmol [serial online] 1991 [cited 2020 Feb 20 ];39:40-40
Available from: http://www.ijo.in/text.asp?1991/39/2/40/24475
The evolution of Retinal Detachment Surgery during the post Gonin era is something spectacular. The changes are so distinct that the earlier surgeries on the sclera have transformed to surgery of the vitreous and the retinal directly. Even though implant surgery and explant surgery are still widely performed, intravitreal procedures are acquiring great momentum in the efforts to reattach the retina. The controversy between implant surgery and explant surgery is still very much alive and the whole world still continues to participate in this great debates on implant versus explant surgery. The same is also true regarding the materials used as implants or explants.
While the controversy continues whether one should dissect the sclera or not, another new concept was creeping into the minds of great vitreous surgeons like Machemer and Peyman. The buckles (implants and explants) relieve traction partially and encircling relieves it permanently. Hence vitrectomy became popular as a part of retinal detachment surgery especially in complicated cases of retinal detachment with PVR. The cryo versus diathermy controversy was already very much alive when the concept of retinal glues (cyanoacrylate), endo-cryo and endo-LASER were introduced. So among the adhesive procedures at present the retinal surgeons have enough choice depending upon the type of surgery performed.
Internal tamponade with air was one of the oldest method tried in the reattachment surgery of the retina. But it was not very popular among retinal surgeons. The use of expandable gases like Sulpha Hexa Fluoride (SF6), perfluro carbons etc gave new life to the concept of internal tamponade. In spite of these tremendous developments there remained a group of retinal detachments which could not be reattached. The Vitreous Surgeons decided to cut extensively and remove the severely damaged contracted retina to get the relatively healthy retina reattached. Management of giant tears was also revolutionized to a great extent. Today the retinal surgeons "nail down" these giant breaks with retinal tacks. Besides these they may even cut the retina and create even a giant break so that a contracted short retinal can be reattached. Making a hole in the retina is a sin of the past. Today retinotomy and retinectomy are performed by retinal surgeons boldly.
The vitreous was the substance capable of increasing the pulse rate and heating up the temper of any cataract surgeon in the sixties and seventies of this century. Many eyes were lost, many assistants were scolded and many theatre instruments were thrown on the floor just because this jelly like thing peeped out of its container. Now we have tamed the vitreous and remove it liberally. We are even replacing it with many a type of material viz., AIR-SF6, perfluro carbon, silicon oil and balanced salt solution depending upon the need of the situation and of course the availability of the material.
With the use of indirect ophthalmoscope before, during, and after retinal detachment surgery the overall prognosis of retinal detachment surgery has tremendously improved. The use of microscope in retinal detachment surgery may further enhance the chances of retinal re-attachment. Microscopes gives good magnification for intravitreal procedures; membrane peeling, retinotomies and internal drainage of SRF became easier and rewarding with the use of the microscope. Pneumo-retinopexy and episcleral balloon buckles are part of an attempt to simplify retinal detachment surgery and have limited use in selected cases.
In the West multiple surgeries for retinal detachment, especially for complicated cases have become fairly common and modern retinal surgeons do not seems to give up even if he had failures three or four times. The generally accepted concept is minimum surgery for detachment without PVR and to go step by step by adding encirclage, vitrectomy, silicon oil filling, retinotomy, endo-LASER etc, if the retina did not get re-attached.
In the Indian context I feel that our aims should be to get the retina re-attached in the first surgery itself even if it means that in some of the cases excess surgery is performed. This is because re-operations are difficult to the surgeon as well as to the patient. Most of the patients do not have any insurance to cover their medical expenses. The surgeons always have a backlog of surgeries. So I personally believe that whenever there is doubt, relieve the retinal traction permanently and completely besides the adhesive procedure. Or in other words an encirclage is a must for our context and vitrectomy if there is any doubt about the ability of the buckle to relieve traction sufficiently. I believe that one should use all available modalities to make sure that the retina gets re-attached after the first surgery itself.
We have a very enthusiastic and dedicated group of eye surgeons in our country eagerly trying to eradicate the backlog of cataract surgery. In this process we should not have a big backlog of retinal surgeries. As all of you know one of the predisposing factors for retinal detachment is cataract surgery.