Hassan Mortada (Cairo, Egypt)


Giant retinal tear retinal detachment entails many controversial issues including: whether or not to use scleral buckle, management of the crystalline lens, choice of internal tamponade and methods to prevent posterior slippage of posterior retinal flap. The technique used in this study includes: no scleral buckle, removal of the crystalline lens using phacoemulsification and PCIOL, radical vitrectomy (using 23 G system with valves), meticulous excision of the basal vitreous gel, including excision of the anterior flap, unfolding of inverted, rolled or scrolled posterior retinal flap using unimanual or bimanual approach, removal of epiretinal pigment clumps and membranes (including looking for adherent cortical vitreous especially in young patients), stabilization of the posterior retina with 2 cc of PFCL, excision of contracted edge of posterior flap, complete retinal reattachment by injecting more PFCL passing the edge of the posterior flap, endolaser for 360 degrees, direct silicone oil/PFCL exchange. Methods: 55 eyes with giant retinal tears RD, with or without PVR, were operated upon using the above-mentioned technique between 2007 and 2010. Removal of the crystalline lens is crucial to achieve complete shaving of the basal vitreous gel. The use of the rubber valves on the 23g cannula allows maintaining the IOP, decreases or even eliminates turbulence of PFCL and escape into subretinal space. The technique insure complete relieve of traction. Direct PFCL/Silicone oil tamponade rather than PFCL/air exchange first eliminates posterior slippage of posterior flap. The elimination of scleral buckle prevents ocular distortion and helps to prevent posterior slippage.

Effectiveness / Safety:

Using the above-mentioned technique, successful intraoperative retinal reattachment, without posterior slippage, could be achieved in all eyes. Postoperative recurrence of proliferation under silicone oil (usually within the 1st postoperative month) with recurrence of inferior RD was encountered in 8/55, all have preoperative signs of PVR. Reoperation was successful in achieving retinal reattachment in 7/8 eyes. The remaining eye developed severe hypotony and recurrence of proliferation and detachment. Functional improvement occurred in all eyes with stable attached retina.

Take home message:

The above-mentioned technique is effective in achieving intraoperative successful reattachment in all eyes. It is also successful in achieving stable attached retina in the majority of cases following silicone oil removal.