Retinal detachment, membrane, tear and vitrectomy

Macula still on: an emergency, aim for surgery in hours to a day. Macula already off: still operate promptly. Literature more often supports surgery within a few days of losing central vision (especially the first three days); outcomes are usually better than with further delay. This is not “wait a week”, and it is not “each extra day always costs one more line”. A curtain, a large field cut or a sudden vision drop: go to A&E now. New flashes or a clear increase in floaters without a curtain, sudden blindness or severe pain: dilated fundus exam the same day if possible.

A tear that has not detached, and that a doctor has selected, may be discussed as outpatient barrier laser: see The day of argon retinal barrier laser. A curtain or a sudden vision drop already present: go to A&E now. Do not go home and wait for laser.

Epiretinal membrane: peel if folds affect vision — not automatic at diagnosis. Macular hole: a doctor may discuss vitrectomy with ILM work and gas; whether it closes varies with duration and the individual case — still not a guarantee; shorter duration is usually more favourable.

Two operations a doctor may discuss for a rhegmatogenous detachment

Pars plana vitrectomy, scleral buckle, or both, depend on tear location, whether a PVD is already present, PVR, lens status and the doctor's judgement. This page is not comparing clinic “success rates”. Primary anatomic reattachment rates vary with the tear, PVR, lens status and technique; complex eyes are usually lower. This page does not summarise all rhegmatogenous-detachment success rates from a single paper.

Pars plana vitrectomy — outline

1. Local or general anaesthesia
2. Usually three micro-trocars (23 / 25 / 27 gauge) 3.5–4 mm behind the limbus (a little further if the natural lens is present)
3. Infusion; core vitrectomy; induce or complete a PVD
4. Find every tear; dyes may help. Drain subretinal fluid through a tear or a temporary posterior retinotomy
5. Laser or cryotherapy around tears
6. Tamponade: expanding gas (SF6 or C3F8) or silicone oil. Gas absorbs; oil needs a second operation
7. Some macular holes or inferior tears need face-down or side posture so the bubble covers the tear

While gas is in the eye

• No flying and no nitrous-oxide anaesthetic until the bubble is gone: SF6 often 2–4 weeks; C3F8 often 6–10 weeks or more — the doctor confirms
• Vision is expected to be poor while the bubble is large — not instant failure
• High-altitude road travel can expand a bubble; ask before you go

Scleral buckle — outline

1. Open the conjunctiva; localise the tear on the sclera (often with indirect ophthalmoscopy)
2. Cryotherapy (or occasionally external laser) at the tear
3. Suture a silicone / sponge explant — segmental or encircling — so the wall indents the tear
4. Some cases drain subretinal fluid through the sclera
5. Usually no intraocular gas, so no multi-week flying ban unless gas is also used

Vitrectomy — published complications

Scleral buckle — published complications

• Diplopia: more common early; most ease as swelling settles; a few need prism or further surgery
• More myopia or astigmatism after an encircling band — glasses may change
• Lid swelling and redness for weeks is common
• Extrusion or infection needing explant: can occur
• Anterior-segment ischaemia: rare with a high tight encircling band
• Choroidal effusion or haemorrhage; very rare intrusion of the buckle