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| EDITORIAL |
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| Year : 2001 | Volume
: 49
| Issue : 3 | Page : 149-150 |
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Locating the retinal break(s) in rhegmatogenous retinal detachment: The first step in successful management
Lingam Gopal
Sankara Nethralaya, Vision Research Foundation, 18 College Road, Chennai - 600 006, India
Correspondence Address:
Lingam Gopal
Sankara Nethralaya, Vision Research Foundation, 18 College Road, Chennai - 600 006, India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 15887721 
How to cite this article:
Gopal L. Locating the retinal break(s) in rhegmatogenous retinal detachment: The first step in successful management. Indian J Ophthalmol 2001;49:149-50 |
The practice article in this issue is by Drs. Sandeep Saxena and Harvey Lincoff[1] on a subject that is crucial to the success of surgery for retinal detachment. Historically, the treatment of retinal detachment was put on a firm scientific footing only after the identification of its primary cause the 'Rhegma' by Gonin.[2] Hence, identification of the retinal breaks in a case of rhegmatogenous retinal detachment is perhaps the single most important step that dictates the success of the surgery. The authors have emphasised some simple well-known rules that permit concentration of the efforts to a small area of the periphery to identify the break. One must understand that more than one break is present in as many as 50% of eyes.[3] Hence, there is a need to inspect the rest of the fundus including areas of attached retina for additional breaks. Similar guidelines have been described by Hilton and associates.[4]
One must realise that all retinal breaks are not obvious. In addition to the visualisation difficulties caused by lens opacities, capsular remnants, intraocular lens deposits, non-dilating pupil, etc., one has to contend with the fact that some breaks may not be obvious despite good visualisation of retina. The important causes include very tiny breaks, breaks located within areas of chorioretinal atrophy, breaks within a staphyloma, breaks covered by flimsy membranes or vitreous condensation, and breaks in pars plana epithelium, seen especially in cases of post-traumatic retinal detachments.
In the evaluation, one needs to stress the importance of good binocular indirect ophthalmoscopy with scleral depression. Slitlamp biomicroscopy can help clear the doubt in case of suspicious lesions.
Vitrectomy can be indicated in certain cases of failure to detect retinal breaks. If the retinal detachment is restricted posterior to the buckle and if even scleral depression fails to show any fluid on the buckle, it is most likely that there is a break posterior to the buckle only. Such a "difficult-to-see break" is best identified during vitrectomy. A prospective examination can direct our suspicion to some areas but definitive identification may not be possible. The high magnification of the operating microscope coupled with improved viusalisation caused by removal of opacities and membrane helps locate the break with ease and the phenomenon of 'Schleiren' can confirm the same.
Is diligent preoperative detection of retinal breaks necessary if primary vitrectomy is planned? If primary vitreous surgery is being planned, there could be complacency in identifying preoperatively all retinal breaks in the belief that the breaks can be identified during vitrectomy. It is important to realise that treatment of all the retinal breaks is a must for the success of the surgery irrespective of whether it is a primary buckling or primary vitreous surgery is performed. Additional breaks can form due to traction on the vitreous base and ora serrata. Locating the breaks in the periphery can still be difficult intraoperatively. Very often, intraoperatively indirect ophthalmoscopy helps identify peripheral breaks, better even than a wide-angle viewing system, especially in the presence of crystalline lens. It is obvious that a diligent preoperative examination and identification of these breaks will make the job easier during surgery.
It is of course a different matter if extensive proliferative vitreoretinal is present. In these circumstances, the surgery would involve thorough cleaning of the entire retina. Peripheral iatrogenic breaks (accidental and deliberate) are fairly common during vitreous base excision. Hence it may not be vital to identify all the breaks preoperatively. Having said that, one should still eschew cursory preoperative evaluation, which is akin to a 'General going to a war without adequate knowledge of the enemy'.
| References | |  |
| 1. | Saxena S, Lincoff H. Finding the retinal break in Rhegmatogenous retinal detachment. Indian J Opthalmol 2001;49:199-202.  [ PUBMED] [ FULLTEXT] |
| 2. | Gonin J. Treatment of detached retina by searing retinal tears. Arch Ophthalmol 1930;4:621-25. |
| 3. | Kreissg I. A Practical Guide to Minimal Surgery for Retinal Detachment. Vol.1, Stuttgart; Thieme, 2000. P 25. |
| 4. | Hilton GF, Mc Lean JB, Brinton DA. Retinal Detachment-Principles and Practice. San Francisco, American Academy of Ophthalmology. 1989. P 65-67. |
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