Retinal detachment, specifically rhegmatogenous retinal detachment (RRD), significantly impacts the skills required by a retina specialist. We do not intend to overwhelm you with information readily available in significant reference texts, nor do we aim to replace important bibliographic sources crucial for your education. Instead, we wish to share a balanced perspective based on published literature, clinical practice, and experiential recommendations for managing these cases. Let's begin.

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Rhegmatogenous retinal detachments occur in approximately 1 in 10,000 individuals¹. As the name suggests, they result from a tear or "regma" that allows fluid migration beneath the neurosensory retina, leading to retinal detachment.

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Early diagnosis and treatment significantly improve each patient's prognosis. First and foremost, establishing causality by identifying the retinal tear or hole is crucial. While the appearance often suggests a rhegmatogenous detachment, distinguishing it from serous detachments is essential, as their management differs significantly.

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Secondly, assessing the extent of retinal detachment, particularly its involvement in the macula, is crucial. Patients with no macular involvement typically have a better visual recovery and prognosis. Additionally, consider the location of the detachment: superior bullous detachments that do not involve the macula necessitate more rapid management. Positioning such patients supine at 180 degrees helps prevent inferior fluid migration toward the macula. Conversely, inferior detachments without macular involvement benefit from elevated head positioning.

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The optimal timeframe for intervention in RRD cases hinges on whether the macula is involved. Generally, all retinal detachments, except those with minimal corrected visual acuity (perception of light or worse), require attention as soon as possible. For detachments not involving the macula or with the macula on, surgery within 24 to 48 hours is ideal. For detachments involving the macula or macula off, intervention within the first 3 days post-diagnosis is recommended to optimize visual prognosis¹.

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Furthermore, it is essential to consider the location of the causative hole or tear when planning treatment. For instance, many retina specialists opt for a combined approach involving vitrectomy and scleral buckling when dealing with tears in the inferior periphery. Conversely, when addressing tears in the upper peripheral quadrants, some prefer to perform vitrectomy alone or, if it matches, a pneumatic retinopexy. The choice largely depends on the underlying pathogenic cause of the tear. While rhegmatogenous retinal detachment stems from a hole, not all holes result from vitreoretinal traction. With current vitrectomy technology and increasingly advanced visualization systems, vitrectomy alone can suffice for most cases of RRD. Supplementing with scleral buckling should not be the default approach, especially when the primary component is predominantly tractional. This article does not delve into treatment options for these detachments; however, exploring this aspect in depth in another context would be good. Here, we will focus on the step-by-step process of vitrectomy in these cases.

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The first step in every vitrectomy is the core vitrectomy or central vitrectomy. Generally, starting away from the area where the retina is most elevated is recommended, especially in cases with bullous detachments and extensive retinal detachment. It is advisable to directly approach the tear, which should be identified before surgery, and use the vitrector to aspirate subretinal fluid. This helps flatten the retina and provides excellent stability. Dealing with a floppy retina during vitrectomy can lead to more tears and complications.

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After core vitrectomy, it's crucial to apply triamcinolone to confirm there's no residual posterior hyaloid and, if there is, perform a posterior vitreous detachment (PVD). Often, suspicion of PVD arises because it can cause retinal tears and detachment. Nevertheless, a double-check is never redundant.

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Next, performing thorough shaving of the vitreous base and periphery is important. Retinal detachment often occurs due to vitreous adhesion and pulling, so releasing this traction is beneficial. The less vitreous left behind, the lower the risk of peripheral retinal contraction, reducing pigment and inflammatory debris that could lead to proliferative vitreoretinopathy (PVR) and the need for reoperation due to redetachment. Some studies suggest that performing vitreous shaving without indentation may be sufficient². However, given the limitations of these reports, particularly retrospective nature, I believe it is prudent not to take risks and strive for the best possible outcome in these cases. The last thing you want is to operate on an eye twice for retinal detachment.

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Before flattening the retina, marking tears and holes with diathermy is essential, especially for small ones that might be lost once the retina is flat. Depending on the case, heavy liquid can flatten the retina and aid in draining subretinal fluid. Laser application around tears and holes can follow under heavy liquid, but applying a laser to the entire retinal periphery is not always advisable as it can cause microholes and increase the risk of redetachment.

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Some surgeons opt for an air-fluid exchange instead of heavy liquid, which helps drain subretinal fluid and flatten the retina. However, visibility may be compromised. Regardless of the approach, applying laser around tears and holes is crucial once the retina is flat under heavy liquid or air.

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Many surgeons perform a posterior retinotomy, typically nasally and posteriorly, before air exchange or heavy liquid application, although it is not always necessary. This helps facilitate the last drainage of subretinal fluid. In cases where tears are very peripheral and complex to visualize distinctly, a retinotomy provides an additional window for drainage. It is also helpful in multiple tears where simultaneous drainage is not feasible³.

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Emerging evidence suggests that effective drainage of subretinal fluid may prevent retinal translocation⁴,⁵. However, further studies are needed to refine approaches. During air-fluid exchange, it is important to aspirate fluid above the heavy liquid bubble (if used) or as much fluid as possible anterior to tears or holes to remove pigment and inflammatory particles that could complicate the case and lead to redetachment due to PVR.

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While performing an air-fluid exchange, position the extrusion tip at tear level, maintaining it until fluid surpasses the tear, then direct it nasally, sometimes aiming towards the optic nerve (without touching it). Finally, residual subretinal fluid can be absorbed and removed through an accessory retinotomy if performed. Additional laser can be applied around tears to verify proper adhesion. The next step is to introduce intraocular gas to complete the procedure.

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You can review our video demonstrating a technique for repairing a RRD. Not all retinal detachments are the same, but these steps ensure a mindset. In future discussions, we will delve deeper into other treatment modalities. I hope this aids your learning; remember, your interest makes us better.

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EyeQpoints: 

1. Precision in Tear Localization: Accurate identification and direct approach to retinal tears during vitrectomy ensure adequate fluid drainage and stabilize the retina for optimal surgical outcomes.

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2. Role of Core Vitrectomy: Initiating with core vitrectomy away from elevated retinal areas reduces the risk of iatrogenic tears and enhances maneuverability in complex detachment cases.

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3. Importance of Posterior Hyaloid Removal and vitreous base shaving: Thorough removal of posterior hyaloid and peripheral vitreous using techniques like triamcinolone staining and posterior vitreous detachment (PVD) prevents tractional forces that could lead to redetachment.

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4. Strategic Use of Heavy Liquid and Air-Fluid Exchange: Utilizing heavy liquid or performing air-fluid exchange aids in flattening the retina facilitating precise laser application around tears and holes to promote adhesion.

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5. Laser application: Applying the laser to the retinal holes or tears alone could be more beneficial than applying it in all retinal periphery; remember that sometimes, we can create micro-holes with the laser, which could lead to a secondary retinal detachment.

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6. Consideration for accessory draining Retinotomy: Consideration of posterior retinotomy facilitates targeted drainage of subretinal fluid, enhancing good retinal flattening and adhesion.