Chapter 111 - Vitreoretinal surgery

Summary

Vitreoretinal surgical techniques are used to approach disorders of the posterior segment of the eye. Over the past 30 years, great strides have been made in the ability to safely and effectively operate in this segment. The spectrum of disorders menable to operative intervention has broadened significantly with the evolution of advanced, smaller-gauge microsurgical instruments, computer-controlled infusion and aspiration systems, endolaser probes, perfluorocarbon heavy liquid for manipulation of detached retinal tissue, implantable slow-release pharmacological devices, wide-angle optical viewing systems, and long-acting gases and silicone oil for intraocular tamponade. The treatment of intraocular tumors with radioactive episcleral plaques has also become well-characterized and “evidence-based” through large-scale, prospective, randomized clinical trial data. The advent and sophistication of the pars plana approach with microsurgical vitrectomy instrumentation has allowed for the repair of most simple and complex primary and recurrent retinal detachments. The pars plana is the section of the eye located approximately at the junction of the iris and the sclera and is a safe place to insert intraocular instruments without damage to internal structures. However, in certain cases of primary retinal detachment, the most appropriate treatment remains scleral buckling surgery, as has been performed for over 60 years.

Scleral buckling surgery involves the placement of a strip of silicone around the outside of the globe to cause a slight indentation or buckle of the eye wall and support the intraocular retinal breaks and vitreous base. The procedure is effective because the external support helps close the causative retinal tear inside the eye. The retinal tear is repaired by a combination of support from the buckle and the formation of a chorioretinal scar induced by a thermal modality such as cryotherapy (freezing) or laser (heating). The usual procedure for addressing complex retinal detachments with very large or posteriorly located retinal tears, significant retinal scarring, vitreous hemorrhage, or severe cataract formation is to combine scleral buckle surgery with the more advanced intraocular vitrectomy techniques.