Improving the Outcome of Rhegmatogenous Retinal Detachment Repair by Adding Pieces to the Puzzle

Abstract

Thanks to the consecutive introduction of penetrating thermocautery, buckling surgery and pars plana vitrectomy, the anatomical success rate of rhegmatogenous retinal detachment (RRD) repair improved dramatically, from 1/1000 about a hundred years ago, to about 90% by the late 20th century.

In the past 30 years, the basic approach is shifting towards vitrectomy and (in phakic eyes) primary lens extraction, as standard care for all cases of RRD. This more aggressive surgical approach has many potential complications and does not yield better results. We have therefore attempted to modify our surgical approach to better address the critical causes of failure, while eliminating certain elements that can adversely affect the outcome. Blood-ocular barrier (B-O B) breakdown is an important event in RRD and extensive surgical manipulation seems to increase the B-O B breakdown. We have demonstrated that both pre-treatment with subconjunctival dexamethasone and omitting intra-operative retinopexy, can reduce B-O B breakdown.

Functional recovery can be effected by post-operative persistence of subretinal fluid under the fovea. A modified surgical drainage technique (“subretinal fluid lavage”) was designed to prevent fluid persistence. To improve the efficacy and reproducibility of membrane peeling during PVR surgery, we reported the use of trypan blue dye to enhance the visibility of membranes on the retinal surface.

To limit the surgical trauma of a retinotomy to treat recurrent PVR related detachments, we have eliminated intra-operative retinopexy. This modification may allow the ongoing contraction to shorten the retina without promoting re-detachment as long as the oil tamponade is in place. Laser retinopexy to secure the central retinotomy edge can be applied before oil removal.

The treatment of RRD has come a long way in the past century. In order to tackle the remaining obstacles we should aim to re-define minimally invasive surgery and target the key aspects of the disease without creating additional iatrogenic pathology. The future of RRD therapy looks bright, let’s keep our eye on the target.