In traumatic retinal detachments, it is important to assess pupillary dilation, baseline inflammation, and lens status. Traumatic events can lead to sequelae of intraocular inflammation (corneal edema, posterior synechiae) and lens opacification. These changes can limit direct visualization of the posterior segment.

The retinal exam always starts with the slit lamp. Also, it is essential to perform a dilated examination of the contralateral eye to assess for asymptomatic pathology, such as lattice degeneration. It can be challenging to assess optic nerve health without direct visualization. I use the indirect ophthalmoscope’s blue and green lights, as well as a loose red lens, to assess the patient’s ability to discriminate color. This can provide valuable prognostic information. I always discuss the role of scleral buckle placement, potential intraocular perfluorocarbon use, and silicone oil tamponade.

SCLERAL BUCKLING WITH BELT LOOPS

This is a wonderful technique for anyone wanting to place a scleral buckle to support the vitreous base. Some training programs have limited scleral buckling experience, but I encourage young colleagues to learn this invaluable technique.

When performing the conjunctival peritomy, I like to keep some distance from the edge of the limbus, thereby limiting limbal stem cell damage and subsequent postoperative ocular surface disease. Efficiency can be achieved when each step is performed correctly upon first attempt.

Completely dissect Tenon’s capsule to ensure optimal scleral visualization. Inspection of the sclera is important, as belt loops shouldn't be placed in quadrants with scleral thinning. To limit postoperative pain and diplopia, hook the entire recti muscle by sweeping between scleral quadrants without elevating the muscle hook end. Only strip Tenon’s capsule adjacent to the recti muscles, and never over the muscles. This will limit myositis and post-op pain. Remember, scleral buckles can be performed without causing excessive discomfort.

Understanding the surgical technique requires respect for retinal anatomy. The purpose of encircling scleral buckles, within the context of concomitant vitrectomy, is to support the vitreous base—a structure that straddles the ora serrata. The four recti muscles insert at the level of the ora serrata, and the equator is about 5 mm posterior to the ora serrata. I like to use the crescent blade (2.5 mm width) as a reference guide when marking the distance from the muscle insertions and equator. Once created, I pass the sharply angled silicone bands under the recti muscles and through the belt loops. I close the silicone band with a sleeve in the superonasal quadrant.

In order to limit postoperative discomfort, I always close the conjunctiva in a buried fashion with episcleral anchoring and trim all knots. A little sub-Tenons’ lidocaine/bupivacaine and IV dexamethasone can greatly assist with postoperative analgesia. There are many variations to this technique, feel free to modify and teach others.

OUTCOMES

All surgical procedures have risks and side effects. Vitrectomy leads to cataract progression and may cause ocular hypertension. Chronic silicone oil tamponade can result in silicone oil migration into the anterior chamber with emulsification (reverse hypopyon). Perfluorocarbon should never purposefully be kept within the vitreous cavity, as this can result in inflammation. Other complications include secondary epiretinal membrane, optic neuropathy, and recurrent retinal detachment.

It is also important to appreciate the emotional aspects of vision loss. Their funnel retinal detachments may have an unfavorable configuration, and may be inoperable. Surgical intervention has the risk of leading to worsening vision. Always consider the psychological aspects of going from light perception (LP) to no light perception (NLP). NRP

Dr. Pandya is a vitreoretinal surgeon with Dallas Retina Center in Dallas, TX, and president of the American Retina Forum. He has no disclosures to report. Contact him at DrPandya@dallasretina.com.