What is RD

• Rhegmatogenous RD: Separation of neurosensory retina from the RPE due to a full-thickness retinal break that allows liquefied vitreous to enter the subretinal space.
  • Risk factors: lattice degeneration, PVD with traction, high myopia, prior surgery/trauma, aphakia/pseudophakia.
• Exudative RD: Subretinal fluid from choroidal/retinal vascular leakage (e.g., inflammatory, neoplastic). No break.
• Tractional RD: Retinal elevation from fibrovascular membranes exerting traction (e.g., PDR, ROP).

Treatment Goal: close all retinal breaks and achieve chorioretinal adhesion (laser/cryotherapy) while neutralizing vitreoretinal traction.

Core Surgical Options

• Pneumatic Retinopexy (PR): In-office gas bubble + retinopexy (cryotherapy/laser).
  • Best for one or few superior breaks in mobile retina, cooperative patient, no significant PVR.
• Scleral Buckle (SB): External indentation using silicone elements to support breaks and reduce vitreoretinal traction
  • Ideal for young phakic, anterior/inferior pathology, small atrophic holes, round holes, and no PVD.
• Pars Plana Vitrectomy (PPV): 23/25/27-gauge microincisional vitrectomy to remove traction, identify/laser all breaks, and provide
  internal tamponade (gas or oil).
  • Often combined with SB for PVR, inferior breaks, dialysis, or giant retinal tears (GRT).

Key Steps in PPV for Rhegmatogenous RD

1. Mark sclerotomy sites (3.5–4.0 mm posterior to limbus depending on lens status).
2. Core vitrectomy → induce/complete PVD.
3. Shave vitreous base with scleral depression.
4. Identify and treat all breaks (endolaser/cryotherapy).
5. Drain SRF via break or posterior retinotomy (assisted by perfluorocarbon liquid if needed).
6. Fluid–air exchange.
7. Internal tamponade selection (SF6/C3F8/C2F6 or silicone oil).
8. Sclerotomy closure as needed.

When to Add a Buckle to PPV?

• Inferior pathology
• Extensive lattice with multiple small holes;
• Young phakic eye with strong vitreous base traction
• Dialysis
• GRT edge support
• Early PVR

Postoperative Positioning (General Principles)

Position such that the tamponade bubble contacts the break(s).

• Superior breaks: head upright or slight face-down
• Macula-off with posterior breaks: strict face-down early
• inferior breaks: face-down or specific side-tilt
• Silicone oil less position-sensitive but still advisable initially.

Complications

CME, ERM, recurrent RD (missed break/PVR), choroidal detachment/effusion, hypotony, IOP spikes, endophthalmitis, cataract progression (in phakic eyes), diplopia with SB, myopic shift from SB