Contrary to popular dogma, the most important element in the pathogenesis of a rhegmatogenous retinal detachment (RRD) is not the break but the vitreoretinal traction that causes the break (i.e., the RRD is a vitreogenic pathology). In the presence of vitreous degeneration (syneresis) such dynamic traction is inevitable if the eyeball and/or the head moves: this hypothesis is supported by the clinical observation that a RRD spontaneously resolves if the patient is bilaterally patched).

Whether in an eye with a syneretic vitreous (an admixture of gel vitreous and free fluid are present in the vitreous cavity) a retinal break develops is determined by the outcome of a battle between the traction force and the resistance of the retina itself; whether, once a retinal break formed, RRD also develops is determined by the outcome of a battle between the tractional element and the forces holding the retina in place (mainly, the suction exerted by the retinal pigment epithelium and the glue of the interphotoreceptor matrix).

Treatment, then, is aimed at countering the traction force. While scleral buckling is an effective method of reducing the traction force by approximating its endpoints, vitrectomy is a more rational approach by eliminating the traction itself. Vitrectomy, however, must be complete, removing the vitreous both anterior and posterior to the tear to not only negating the traction but also countering the intraocular currents, which would have a shearing effect on the retina. The treatment must also take aim at future traction development: hence the need to remove the anterior hyaloid face. If a meticulous job is done, the results of vitrectomy should be superior to those achieved by scleral buckling: the sole cause of a redetachment is the development of proliferative vitreoretinopathy.

This talk summarizes the rationale and technique, and analyzes the outcomes of various surgical approaches to RRD. It is also emphasized that the choice of treatment is up to the individual surgeon: as long as surgery is effective, each surgeon should be content about his/her choice.

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Ferenc Kuhn