[Surgical treatment of complicated retinal detachment]

Treatment of retinal detachment advanced markedly during the 20th century. The surgical approach to rhegmatogenous retinal detachment was first established by Joules Gonin, and treatment of traction retinal detachment by vitrectomy was developed by Robert Machemer. Although favorable outcomes are obtained in most cases of retinal detachment using current vitreoretinal surgical techniques, several special types of complicated retinal detachment can be refractory to treatment. The biologic mechanism and the strategy for treatment of a complicated retinal detachment will be discussed in this lecture. A discrepancy in the length between the retina and the outer shell, specifically in the extension of the sclera or shortening of the retina, is commonly seen in refractory cases. To correct this, shortening of the sclera should be the primary treatment approach. Relaxing retinotomy should not be a primary procedure in most cases, since retinotomy encourages further shortening of the retina. Equal extension of the scleral wall is frequently seen in eyes with Marfan's syndrome, buphthalmos, and blue sclera, and the discrepancy is corrected by equal shortening of the sclera by encircling and not by focal shortening of the sclera. Unequal extension of the sclera occurs in posterior staphyloma in highly myopic eyes, morning glory syndrome, and posterior coloboma of the choroid. Focal expansion of the posterior sclera should be corrected by placement of a posterior buckle or circumferential lamellar scleral resection and shortening in the same quadrant. Circumferential surgical shortening of the sclera is also indicated in extreme shortening of the retina in congenital retinal folds with persistent fetal vasculature. In cases with associated retinal detachment with retinal folds, radial surgical shortening of the sclera or radial buckling of the sclera corresponding to the retinal fold is indicated, and retinotomy must be avoided. In comparison, in the presence of the retinal shortening and folding that develops postnatally in retinopathy of prematurity, familial exudative vitreoretinopathy, and incontinentia pigment, spontaneous release of the shortening can be expected following surgical removal of the preretinal fibrous tissue, and associated encircling procedures can be effective in selected cases. Inadequate surgical procedures such as creation of multiple iatrogenic retinal breaks to remove extensive subretinal tissue, excessive photocoagulation for retinal angiomatous lesions, and inadequate indications for vitrectomy to treat a special form of rhegmatogenous retinal detachment frequently result in the most complicated form of traction retinal detachment. A large circumferential retinotomy is beneficial rather than multiple small breaks. Penetrating diathermy through a lamellar scleral flap and encircling carries less risk of inducing traction retinal detachment compared with excessive photocoagulation. For oral breaks or ciliary epithelial breaks commonly seen with blunt ocular trauma or atopic dermatitis, a scleral implant more anterior to the extraocular muscle insertion combined with separate encircling is safer and more effective than primary vitrectomy.