Question

Explain clearly why you would recommend your chosen surgical option and outline the surgical steps.

Hint:

Scleral buckling is an effective and minimally invasive method for reattaching the retina in cases of anterior breaks and no PVR. Proper postoperative positioning is crucial for success.

Answer 1

Recommended Surgical Option: Scleral Buckling In this case, scleral buckling is the preferred surgical option due to the following reasons:
1. Myopic Eyes:
- Myopic eyes are at higher risk for retinal detachment, and they often have anterior retinal breaks. Scleral buckling is particularly effective for anterior breaks, such as the one described at 11 o'clock, as it provides long-term support to the retina.
2. Single Break and No PVR:
- The patient has a single break without proliferative vitreoretinopathy (PVR), which makes the detachment more likely to be successfully repaired with scleral buckling. Scleral buckling offers a reliable approach in these cases, providing a tamponade effect on the retina and inducing the reattachment of the retina.
3. Younger Patient:
- In a young patient like this, scleral buckling can be a less invasive and more effective option, with better long-term outcomes in preventing recurrence. It's also less likely to cause complications like cataract formation or secondary glaucoma compared to other techniques like vitrectomy.
Surgical Steps for Scleral Buckling:
1. Preoperative Preparation:
- The patient is positioned under local or general anesthesia.
- Pupil dilation is achieved using tropicamide and phenylephrine drops to facilitate visualization.
2. Exposing the Retina:
- A conjunctival incision is made at the site of the break, and the conjunctiva and tenon’s capsule are carefully dissected.
- The rectus muscles are carefully retracted to allow access to the sclera.
3. Placement of the Scleral Buckle:
- A silicone buckle (usually a sponge or ban is selected based on the size of the detachment and is sutured around the equator of the eye.
- The buckle is placed strategically to indent the sclera and push the retina against the retinal pigment epithelium (RPE), thereby sealing the break and supporting the reattachment.
4. Drainage of Subretinal Fluid:
- Subretinal fluid is drained if necessary by creating a small retinal puncture at the site of the break to allow the fluid to drain into the vitreous cavity.
5. Closing the Incision:
- The conjunctiva is closed with absorbable sutures.
- The eye is typically left with a gas bubble or, in some cases, a silicone oil tamponade if there is concern about maintaining retinal attachment.
6. Postoperative Care:
- The patient is monitored for complications such as intraocular infection or increased intraocular pressure.
- Positioning: The patient is often advised to maintain a specific head position to keep the gas bubble in place.
- Follow-up: Regular follow-up visits are scheduled to monitor for recurrence of the detachment and assess for complications.