The Future retinal detachment surgery

Philadelphia-The treatment of retinal detachments has advanced markedly in recent years-and continues to evolve. However, the goal remains simple and constant: locate, treat, and close the hole.

Alexander J. Brucker, MD, explained how the surgical approach to retinal detachments is changing.

"Clearly, retinal detachment surgeries maintain the principles of find the hole, treat the hole, and close the hole," said Dr. Brucker, professor, Scheie Eye Institute, University of Pennsylvania, Philadelphia. "Our means of finding the hole in the past have been by using direct and indirect ophthalmoscopy with scleral depression."

"Once the holes closed, subretinal fluid was drained in some cases to make sure that the retina was flat against the buckle," Dr. Brucker said.

"Nondrainage procedures were also successful in some cases," he continued.

There have been many advances in treatment of retinal detachments. Laser surgery with indirect ophthalmoscopy, endophotocoagulation, and gas pneumatic retinopexy have all been developed over the last 20 years, as were the perfluorocarbon liquids. The introduction of wide-field viewing has made an enormous difference in surgery, according to Dr. Brucker.

"These advances have made a tremendous contribution to the way we approach retinal detachments," Dr. Brucker said. "To find the holes, we now use heavy liquids and vitrectomy instrumentation. Wide-field view allows identification of the retinal breaks.

"The holes are now closed internally instead of externally with the heavy fluids and fluid-air exchange, and we maintain the retina in a flat position using gas, air, or oils such as silicone oil," Dr. Brucker added.

Breaks also are treated differently now. Diathermy and cryotherapy are used less than before to avoid the release of pigment into the vitreous. Laser surgery, instead, has been adopted to reduce the pigment dispersed into the vitreous and thus, perhaps, reduce the risk of proliferative vitreoretinopathy. Retinal breaks now are flattened under gas or oil, which allows laser surgery using direct endolaser or the indirect laser ophthalmoscope, he said.

"The big change today is that there is a great decrease in the number of scleral buckling procedures being performed," Dr. Brucker said. "We have more retinal detachment surgeons than ever before. Gas pneumatic retinopexy is often the first stage in retinal detachment repair.

"Less experience with scleral buckling procedures is the result, and many of the retinal surgeons being trained today are more comfortable performing a vitrectomy than a scleral buckling procedure," he said.

The use of vitrectomy to treat primary retinal detachment is now favored. According to Dr. Brucker, vitrectomies can be used effectively even when location of a retinal break is not identified. Laser surgery can be performed 360°-so identifying breaks is not as important.

The pitfalls associated with primary vitrectomy for primary retinal detachments are the loss of skills with the indirect ophthalmoscopy and the surgical risks of vitrectomy, cataract formation, and iatrogenic breaks, he added.

There is controversy over which of the procedures are shorter, he said. However, additional surgery with removal of silicone oil adds to the problems associated with retinal detachment surgery.

In commenting on the advances in retinal detachment procedures, Dr. Brucker said that there are no clear benefits of one procedure over another, and studies are usually not randomized and are retrospective in nature. A present ongoing study by German surgeons may resolve the debate, he said.

In the offing In the next 20 years, Dr. Brucker predicts that pharmacologic vitrectomy and enzymatic membrane dissection will be the waves of the future.

"Someday, we hope to be able to inject a drug into the eye that will liquefy the vitreous and improve our retinal detachment repair rates," he said.

"Our new approaches haven't really changed," he continued. "We still find the hole, using new techniques; we still treat the hole, using new techniques; and we still close the hole, using new techniques.