Retinal Detachment Surgery

 

This is my latest recording of surgery for a retinal detachment.

This is the second of (what I hope) to be a series of “videos” on the surgical aspects of retinal eye disease.  This is a recording of two procedures often combined to repair, or fix, a retinal detachment.

Anesthesia

Now, this video is quite graphic.  Believe it or not, however, the patient is completely comfortable…as it does not hurt.  I generally favor this procedure be done with a retrobulbar block (this is an injection behind they eye that “blocks” all pain conduction) in addition to very light sedation for this eye surgery.

On occasion general anesthesia is preferred.

The Scleral Buckle

The scleral buckle is passed around the outside of the eye and underneath each of the 4 four rectus muscles.  I sew the buckle to the eye using some thin suture material.  In the video, the suture is white in color.

There are various techniques to pass the buckle around the eye and innumerable varieties of buckles from which to choose.  I have used the same, small thin buckle almost exclusively for the last 10 years.  I do not think the size or thickness of the buckle, nor its material, is important.

I prefer to always go completely around the eye.  Some choose to place the buckles in different orientations and configurations.  Again, I don’t think this is important.

Efficiency of Surgery

By repeating the same techniques over and over, my surgical team can easily anticipate my each and every move.  They can be sure to accurately predict the correct instruments and materials I’ll need for each part of the case.

In this way, we have developed a very efficient surgical model for our patients.  From the technical aspect, we are quite competent having done this time and time again.  From the patients perspective, there is less surgical trauma and reduced time under anesthesia.

I believe that the more efficient a team, the less likely complications may occur due to reduced operating time and increased experience of the team.

Vitrectomy for Retinal Detachment

After the scleral buckle is placed, I then go inside the eye and repair the retinal detachment from the inside by performing a vitrectomy.  This “3 port” system is not unlike arthroscopic surgery or laparoscopic surgery…all “closed” systems.

The goal of the vitrectomy is to remove the stressers on the retina by removing the vitreous.  I can also remove the fluid from within the vitreous cavity (where fluid is normally located) and underneath the retina (abnormally located fluid.)

Intraocular gas used to temporally keep the retina reattached while appropriate scarring takes place.  The scarring is induced usually by use of the laser.  The goal of the laser is to “spot weld” around each and every tear and hole in the retina.

What Does This Mean?

The scleral buckle has been around for generations.  It remains a mainstay of treatment due to its success in repairing retinal detachments.

The modern day vitrectomy has been around for only 30 years, while the present 25 gauge systems have been around less than 10.

My estimation is that a scleral buckle alone or vitrectomy surgery alone is about 90% successful in reattaching the retina.  Used in combination, I believe that “success” is somewhere around 95%.

This has now become a highly effective surgery combining both “old” and “new” techniques.  Both can usually be performed in an outpatient setting under similar settings.  As these techniques become more common place, they are therefore more available to everyone.

 



Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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***This post is for information purposes only. This posting does not offer legal or medical advice, so nothing in it should be construed as legal or medical advice. The information on this blog/post is only offered for informational purposes. You shouldn’t act or rely on anything in this blog or posting or use it as a substitute for legal/medical advice from a licensed professional. The content of this posting may quickly become outdated, especially due to the nature of the topics covered, which are constantly evolving. The materials and information on this posting/blog are not guaranteed to be correct, complete, or timely. Nothing in this posting/blog and nothing you or I do creates a doctor-patient relationship between you and the blog; between you and me; or between you and Randall Wong, M.D. or RetinaEyeDoctor.com. Even if you try to contact me through the blog or post a comment on the blog you are still not creating a doctor-patient relationship. Although, I am a doctor, I’m not YOUR doctor until and unless there is a written agreement specifically providing for a doctor-patient relationship.***

Comments

  1. Elizabeth says:

    This amazing and so are you.

  2. floateredeyes says:

    Dear Dr. Wong,
    Would you be kind enough to also post a video of a PPV done on one of your floater patients? It will be a nice learning tool for all of us, even though it wont be much different from vitrectomies done for other indications. Maybe watching how you induce PVD would be nice. Moreover, if the video was of surgery done on patient with lattice, that would be even more educational for all of us out there.

    I have asked for a lot, but hopefully you will think about it and see some value in my requests (and hopefully of many others out there).
    Regards,

  3. Thanks.

    Glad you liked.

    See you guys soon.

    r

  4. Dear Floateredeyes,

    Yes. Forthcoming. I have one ready, but not with lattice. Also, I don’t favor inducing a PVD. Keep on the alert!

    Randy

  5. VERY COOL. Great information and demonstration!

  6. Thanks. Appreciate the comments.

    r

  7. It is really great educational website.
    I am a patient who is suggested to have combination of scleral bucle and vitrectomy surgery next week.
    Your information that the combination of the surgery is higher (95%) than each surgery (90%)
    convince me. God bless you doc…

  8. Best of luck!

    Let us know how you do.

    Randy

  9. Dear Dr. Wong,
    I was diagnosed by my ophthalmologist as having a hole in my retina. I have a central area in my left eye that is dim. I have uvitus and have had surgery on my right eye. I’m told that I need surgery ASAP, so what’s the latest method of repairing the retina? I know the viterus fluid has to be removed, but would the retina repair surgery be done with a laser or a scapel? Thanks!

  10. Dear Fred,

    I am wondering if you have macular edema from uveitis. This can lead to a macular hole.

    There are other macular holes, they look identical, not related to macular edema.

    In either case, surgery is indicated. This would be manual, not laser.

    Good luck,

    r

  11. Dr. Wong,

    I had scleral buckle surgery with a gas bubble on Feb. 22. My Doctor says everything is healing great and that I may resume physical activities. I was wondering would playing basketball again this soon after surgery be okay from your professional opinion? I will probably wait another couple of weeks unitl my vision is better anyway. I’m a little scared to get back out there because I don’t want to have to go through this again.

    Thanks,
    Chris

  12. Dear Dr. Wong,
    I would like your thoughts on using the scleral buckle as a preventative measure.

    A little history. I am 38 years old. I had a successful retinal detachment surgery via buckle, vitrectomy, and gas last August for my left eye. Now, my doctor is recommending that I have buckle with cryo surgery to repair a retinal hole in my right eye. The tear has been there for sometime as it has been walled off naturally. I am just not looking forward to another trip to the OR. Thoughts?

  13. Dear Joel,

    The literature recommends prophylactic scleral buckle and laser for a condition call “Giant Retinal Tear.”

    This does not seem to be your exact case, but the risk of retinal detachment in the right eye is higher due to the retinal hole. I think it’s a good idea to move forward with the cryo.

    I don’t know if a buckle and/or vitrectomy needs to be considered.

    Randy

  14. Dear Chris,

    Not sure basketball had anything to do with the detachment. Why are you concerned?

    Randy

  15. Dear Doctor Randy, In your opinion should silicone oil be used on a patient that has had a previous cataract surgeryI and had a silicone lens placed? I know the oil will attatch to the lens and could cause the lens to have to be taken out.

  16. I had this done and now have very poor vision in that eye. There are probrably 40-50 different size bubbles in my vison and vision is very blurry. The doctor was aware of the cataract implant but didn’t ask what type of lens until after the surgery oil attatclhed to the lens and behind lens. He tried to remove oil with surgery but was unable to get all of the oil out.. The doctor said I can have another surgery if it bothers me. At this ;point and time the bubbles make me dizzy when I am ambulating. My vision is terrible. I have to wear a patch at all times to just be able to see.

  17. cheri lemay says:

    I love this site. It has helped me so very much. I have had a total of approx. 10 surgeries of which 2 were for catarcts in 2003. The rest have been for retinal detatchments and complications I had after surgery that brought on more surgeries. I had very little knowledge of the retina and had no idea so many people had this problem. It somehow makes me feel better to know that I am not the lone ranger to this horrific problem. Thank you so very much for sharing your knowledge. I am truly considering making an appointment to see you for a problem with right eye that has not been resolved. I live in ohio but it would be worth the trip to get some peace of mind. Thank you again for sharing.

  18. Dear Cheri,

    Reading your post here and those you left on FB.

    1. “Comment Awaiting Moderation” means that the webmaster (yours truly) must approve every comment made from a new contributor. This protects the website from ridiculous comments or inappropriate material, etc. More importantly, it prevents spammers from posting non-sense comments, BUT including a link back to their spam site, aka, “Comment Spam.”)

    Basically, I have to read each post before it’s published. I try and answer on twice a week.

    2. Making an appointment is easy…just call and ask to see me.

    3. Thanks for your kind comments regarding the site. I am pretty proud of the past few years and how this has evolved!

    Look forward to meeting you.

    Randy

  19. Dear Cheri,

    I just answered this on the other post…..but the short answer is yes, I don’t think oil on the lens competes with the importance of getting the retina attached.

    Randy

  20. Dear Cheri,

    From what you say, sounds like the oil remnants are indeed problematic. I had to wear a patch for awhile and understand how “relaxing” it can be.

    We spoke about meeting in another post. I would be honored to meet you. If however, we don’t….I would suggest a second opinion from another retina specialist specifically asking that person if the oil/lens combo is indeed impacting your vision.

    Randy

  21. Dr. Wong,

    I am 10 days post op from scleral buckle surgery used as a preventative measure to prevent retina detachment. I lost vision in my right eye at a young age due to ROP and recently had a tear in my left eye that was repaired with laser, however due to my situation (high myopic and lattice in left eye), my doctor recommended the buckle. My retina doc is pleased with the outcome thus far and has stated that the vitreous is no longer pulling on my retina (no traction) as a result of the placement of the buckle. The only issue that I’m having so far is that I seem to be light sensitive and still notice light flashes on occassion, particulalrly when I’ve been in a well lit room and then walk in to a dark room or if I close my eyes sitting in a well it room. It’s different than what I saw before in terms of light flashes that were attributed to the tear diagnosis. This seems to be more like light reflection thwn just a simple “flash”. I wonder if the inflammation due to the surgery is causing this, medicine (pred forte and vigamox) or light sensitivity. I’ve been following up so far once a week and have mentioned this to my retina doctor, but he notes that all looks good in the eye. His words were “we are winning the battle”. I’m definitely encouraged by the news, but still concerned about the other factors present.

    I’ve heard some note that due to the buckle itself, flashes or light reflection is sometimes normal? Any information you can provide would be helpful. Also, how much protection does the buckle offer in terms of future eye health in my case. Thanks so much and Happy Easter!

  22. one more thing in regards to flashes, they are like the light from a copy machine and they are located where I have the most redness from surgery in lower corner of the eye near my nose. I can almost feel the sensation when they happen at times…like nerves endings. With no pulling on retina indicated by my retina doc, im just at a loss

  23. Liesel Meier says:

    On 1/3/12 I had a scleral buckle placed due to retinal detachment from 3 o’clock to 6 o”clock position. No bubble. I had lots of pain weeks after surgery and total double vision. I was referred to a muscle specialist for surgery to correct hypotropia with restriction of the left inferior rectus muscle on 2/3/12. At that surgery the inferior rectus muscle was adjusted and adhesions and scar tissue between the scleral buckle and muscle were dissected. That surgery did not have a positive outcome. To this day (4/10) the double vision is worse than before. They now want to do another muscle surgery and at the same operation remove the buckle. I have not agreed to that operation yet. I would like to go some place else for a second opinion.
    My question is: If I would just have the buckle removed, would that improve the double vision. I am worried that the muscle surgery, which I now believe was premature, will also have to be addressed. Secondly, would it be better to have each operation done separately or in one operation?
    Would you have any suggestions for me. I live in Michigan.
    Thank you for your response

  24. Dear Liesel,

    I would encourage a second opinion. I have been doing this for 20 years. There is something amiss here.

    I would recommend seeking the opinion of another pediatric ophthalmologist (they deal with adult misalignment).

    All the best.

    Randy

  25. I had a detached retina in my right eye on 10/14/10 at age 46. It was repaired by gas bubble, vitrectomy, and lots and lots of lasering (over 4,500 shots). My MDs feel a buckle is necessary only AFTER these measures fail. Thank goodness, knock on wood, the eye was saved. It led to a cataract (of course) and on 1/11/12 I had cataract surgery. I see 20/25 in that eye without any correction. Images are bigger (beats smaller) but I do have slight distortion. Only noticeable on straight lines. I also had battled floaters, severe ones my whole life. After my PVD the floaters were insanely bad, disabling. I don’t buy the “it will settle down” crap cuz they never did. But the vitrectomy cured that too. At a -14 I was pretty myopic, with lattice and cobbling. Also it runs in my family. Sister had macula off retinal detachment, gas bubble and laser repaired hers, again no buckle. That was 9 years ago for her, no problems since. Sees 20/20 with slight distortion. Dad had it at age 48, they repaired it years ago with cryo, still holding strong when he passed at 83 in 2011. No buckle. Both eyes have had preventitive 360 degree lasering as well. I respect your stats doctor, but for me, the extra 5% with statistical error, isn’t worth the buckle, I would much prefer laser only.

  26. Wanted to add that for those people worried about future detachments, check into laser cerclage, its the 360 degree preventative that is being done. This surgery isn’t your father’s cerclage, improvements have been made and this a great option. Google it.

    One cool thing I had which a lot of people will not experience, is that my cataract lense has a 0.00 power. In other words, based on the length of my eye 30 mm (which is llloooonnnnggggg), cornea shape etc., for me to see 20/20, the doctor only had to remove my cataract lense. They measured me 3 times and on the operating table. My MD was Dr. Douglas Koch, one of the best in the country (I live in Houston). So right now, my left eye has a contact, right eye sees 20/25 and almost 20/20 without anything. And my retina surgeon held up his hands and made a big fat zero and said, “this is how much retinal problems you will have after your cataract surgery.” Dr Eric Holz, considered a superdoc, he saved my sight.

    Also, for those of you who don’t know, after you laser your retina in place, your retina is “stronger than the day you were born.” Retina docs words. Googled it and boy he’s right. They did some rabbit retina studies at Stanford which I read, puts healed lasered retina’s strength to be 3 times normal by 2 weeks.

    Anyway, do your research before you buy!

  27. Ok, last post. Sorry, just want to help those who have had RDs. No MD ever told me this but my retina doctor. Only after he was asked…

    For those of you who have very thin retinas cuz you are highly myopic, with lattice and cobbling, ask the MD how your MACULA looks. At the end of the day, that’s your central vision. I was told my macula was perfectly normal and healthy. Nice to hear after being beaten up my whole life about how thin and fragile my retina was….

  28. Dear RobK,

    Congrats to you. You have a true appreciation of how lucky you are! Thanks for sharing.

    r

  29. RobK,

    Agreed, but not just for highly myopic. Macular function is what gives everyone 20/20 and best color perception.

    Thanks again.

    r

  30. Liesel Meier says:

    Dear Doctor Randy,
    Thank you so much for you response. I made an appointment with a pediatric ophthalmologist for the end of next month.
    I do have an additional question for you. Is it common to remove a buckle. Also, how dangerous would that be re. Retina detachment. According to the surgeon who put the buckle in, it was a small tear on left lower side. He stated, that he has no problem with the buckle being removed, but never suggested that he would do it….

  31. Cesar Samaniego says:

    Dear Dr Wong

    I want to thank you and your team as well as the staff of the Hospital for their excellent service and treatment I received during my surgery. We will recommend widely, waiting to continue helping people for a long time.

    Thank you Cesar S.S.

  32. Jake Rashid says:

    I am grgeryoing to have caatarac surgery on an eye that has a psuedo hole in the retina
    Is it okay to have catarac surgery?
    Thank You
    Jake

  33. Hi I m 26 and have had the buckle and was wondering i work