Department of Ophthalmology, Dunedin Public Hospital, Dunedin, New Zealand.
Department of Ophthalmology, Norfolk and Norwich University Hospitals, Norwich, UK.
Surv Ophthalmol. 2018 Jul-Aug;63(4):579-588. doi: 10.1016/j.survophthal.2017.08.002. Epub 2017 Aug 12.
The successful detection of retinal breaks is a critical step in rhegmatogenous retinal detachment surgery in order to prevent persistent/recurrent retinal detachments. Not all retinal breaks causing retinal detachments are obvious. Retinal breaks may be obscured by opacities that are either anterior segment related, lens related, or posterior segment related. Rules to identify breaks based on subretinal fluid configuration are more difficult to apply in pseudophakic, aphakic, and scleral buckle encircled eyes-and in eyes with repeat detachments and those with proliferative vitreoretinopathy. Exudative detachments exhibit characteristic features and must be ruled out. A thorough clinical examination preoperatively is important even if a vitrectomy is planned. We review the incidence and causes of undetected breaks, along with preoperative/clinical issues that may hinder break detection. We review the literature with respect to investigative approaches and techniques that are available to the vitreoretinal surgeon when primary breaks remain clinically undetected during the preoperative examination. We broadly divide the surgical approaches into ones where the surgeon utilizes techniques to pursue actively a search for breaks versus adopting a purely speculative approach. Advantages and disadvantages of various techniques are appraised. Intuitively one might argue that an encircling scleral buckle combined with vitrectomy would give higher single operation success than pars plana vitrectomy alone because "undetected" retinal breaks would be addressed by a 360° plombage. We could not confirm this concept. Newer techniques, such as pars plana vitrectomy augmented with dye extrusion or endoscopic-assisted pars plana vitrectomy, show encouraging results. Technological advances such as intraoperative optical coherence tomography will also help to broaden the vitreoretinal surgeon's armamentarium. At this time, there is no gold standard in terms of the recommended approach, and this is reflected in the many options that are available for management. The surgeon must consider the benefits versus the risk of their preferred approach.
视网膜裂孔的成功检测是孔源性视网膜脱离手术中的关键步骤，目的是防止视网膜脱离的持续/复发。并非所有导致视网膜脱离的视网膜裂孔都很明显。视网膜裂孔可能会被前节相关、晶状体相关或后节相关的混浊所掩盖。基于视网膜下液形态识别裂孔的规则在无晶状体眼、人工晶状体眼和巩膜扣带环绕眼中以及在重复脱离眼和增殖性玻璃体视网膜病变眼中更难应用。渗出性脱离具有特征性表现，必须排除在外。即使计划进行玻璃体切除术，术前进行彻底的临床检查也很重要。我们回顾了未检测到裂孔的发生率和原因，以及可能阻碍裂孔检测的术前/临床问题。我们回顾了文献中玻璃体视网膜外科医生在术前检查中临床仍未发现原发性裂孔时可使用的各种检查方法和技术。我们将手术方法大致分为两种，一种是外科医生积极寻找裂孔的方法，另一种是纯粹推测性的方法。评估了各种技术的优缺点。直观地说，有人可能会认为环形巩膜扣带联合玻璃体切除术比单纯的扁平部玻璃体切除术有更高的单次手术成功率，因为“未检测到”的视网膜裂孔将通过 360°的填压来解决。但我们无法证实这一概念。新的技术，如染料挤出增强的扁平部玻璃体切除术或内镜辅助的扁平部玻璃体切除术，显示出令人鼓舞的结果。术中光学相干断层扫描等技术进步也将有助于拓宽玻璃体视网膜外科医生的治疗手段。目前，在推荐的方法方面尚无金标准，这反映在可用于治疗的多种选择中。外科医生必须考虑其首选方法的利弊。
