Vitrectomy for Retinal Detachment
Steve Charles, MD, stops by The Pro Shop to dispense tips on vitrectomy surgery for retinal detachment.
For our ongoing interview series, we invited Steve Charles, MD, to discuss retinal detachment surgery. Anyone who attends retina meetings on a routine basis knows that Dr. Charles is happy to share pearls from his surgical experience with young retina doctors seeking specific or general advice. We are excited to welcome Dr. Charles, an innovator in the OR and in the laboratory, to The Pro Shop.
—Eric Nudleman, MD, PhD, and Joshua Robinson, MD
1. Do you discuss pneumatic and scleral buckling options for retinal detachment repair preoperatively? What success rates do you cite?
I never use scleral buckles. If patients ask for a success rate, I tell them pneumatic procedures have a 70% success rate, and pars plana vitrectomy (PPV) 90%.
2. Please walk us through how you perform a routine vitrectomy for rhegmatogenous retinal detachment (RRD).
How important do you consider elevation of the posterior hyaloid when performing primary vitrectomy for retinal detachment repair in younger patients?
I don’t aggressively create a posterior vitreous detachment (PVD). If an inferior retinal detachment is present, I use PPV with medium-term perfluoro-n-octane (PFO) that lasts 14 days and laser. A PVD will occur gradually and safely during the ensuing 2 weeks, and the posterior vitreous cortex can be removed during PFO removal.
How do you recommend managing retinal breaks?
I routinely amputate the flap, and I do not recommend enlarging or “anteriorizing” breaks.
What about subretinal fluid (SRF)?
I consider posterior drainage retinotomies if the preexisting break is too small to drain SRF. However, the best option is to drain SRF through preexisting retinal breaks. I reserve use of perfluorocarbon liquids for giant breaks or cases in which the patient will return within 14 days for removal.
Are there specific indications in which you consider general anesthesia in lieu of local anesthesia?
Pediatric patients and patients with severe claustrophobia are well suited for general anesthesia. Otherwise, local anesthesia usually works well.
3. What is your stance on peeling the internal limiting membrane (ILM) over the macula in the absence of visible epiretinal membranes (ERMs) during retinal detachment repair?
There is no role for peeling the ILM in the absence of ERMs.
What factors influence your decision when choosing a tamponade?
For cases involving superior retinal detachments, I use SF6. Patients presenting with inferior detachments show good results following medium-term PFO use. For proliferative vitreoretinopathy (PVR) cases, I employ silicone oil.
How often do you add an encircling band to support inferior breaks?
I never add an encircling band.
How do you manage a case involving dense cataract?
I prefer phacofragmentation rather than phacovitrectomy, and I do not recommend placing an intraocular lens if the lens is removed from a phakic patient during retinal detachment repair.
What is your typical postoperative drop regimen for uncomplicated RRD?
I prescribe tobramycin and prednisolone, and I avoid prescribing drugs that induce cycloplegia.
How do you counsel patients on head positioning?
I do not advise bed rest. Phakic patients should stay face down. I advise pseudophakic patients to sleep in the prone position, and I tell them that they should stay seated during waking hours. For patients with temporal or nasal detachments, I advise sleeping on their side.
What do you suggest to help minimize the risk of developing PVR?
Cryotherapy can lead to PVR, and I avoid it. During surgery, I avoid buckles, keep surgical time to a minimum, and perform minimal retinopexy. n
Section Editor Eric Nudleman, MD, PhD
• assistant clinical professor of ophthalmology, Shiley Eye Institute, University of California, San Diego
• e email@example.com
Section Editor Joshua Robinson, MD
• assistant professor of vitreoretinal surgery and disease, Emory Eye Center, Atlanta
Steve Charles, MD
• founder, Charles Retina Institute; clinical professor, department of ophthalmology, University of Tennessee College of Medicine, both in Memphis, Tenn.