The Clinical Analysis Of Reoperation Of Rhegmatogenous Retinal Detachment

Rhegmatogenous retinal detachment is one of the ocularfundus diseases which destroy visual acuity seriously.Nowthe episcleral surgery is the main treatment to cureit.With the developments and improvements of ocularexamination, surgery's methods , and using the transplantwhich low in bio-react,90% patients'eyes can be cured byepiscleral buckling surgery.The successful rate ofreattachment can reach 85%-90% after the first surgery.Butthere are some retina which can't be reattached orredetached after surgery.With the appearence of vitrectomy and more knowledgeabout vitreoretinopathy, We have learned a lot ofpathogenesis of disease and reasons of recurrence aboutrhegmatogenous retinal detachment.Basically,in anatomyif the reattached retina postoperation preserve more than6 months after surgery,we say the surgery succeeds.If theretina can't be reattached within 6 months ,it fails.Ifthe reattached retina appears to be redetachedpostoperation more than 6 months,we say it recurrents.Robert found that the causes of recurrent retinal detachemtmore than 1 year after reattachment are different from thatwithin 1 year.So we classify recurrent retinal detachmentto early recurrent retinal detachment and late recurrentretinal detachment.If reattached retina happened toredetach postoperation 6 months to 1 year,we say it earlyrecurrent retinal detachment.If it happened to redetachpostoperation more than 1 year,we say it late recurrentretinal detachment.Nowadays,there are many studies aboutthe reoperation of rhegmatogenous retinal detachment.Butmajority of them confused the failure and recurrence(earlyrecurrence and late recurrence)postoperation.We willexplore the causes,methods selection and effects ofreoperation about failure and recurrent retinal detachmentpostoperation.What caused reoperation of rhegmatogenous retinaldetachment ?We found that they are attributed to Progre-ssive vitreoretinal traction with PVR,formation of newretinal breaks, reopening of original breaks and et al.PVRis the principal reason which causes the failure andrecurrence.It's also the critical complication oforiginal retinal detachment. The retina is so thin andmetamorphic that will be pulled to form new breaks byPVR.As the same time,PVR can pull posterior edge of retinaltear and prevent it from closing.All these lead to therecurrent retinal detachment.New retinal breaks and thereopening of original breaks can aggravate the process ofPVR.So we think that PVR affects recurrent retinaldetachment each other.The longer of duration of recurrentretinal detachment,the more aggravating of the grade ofPVR.In our study,there are eight eyes with severe grade PVRwhich happened to late recurrent retinal detachment afterreattachment.In five eyes,PVR was first observed when thelate recurrent retinal detachment was diagnosed.It isuncertain whether PVR occurred before or after therecurrent of retinal detachment in all cases.It is probablythat vitreous base traction opened new or oldbreaks,leading to late recurrent retinal detachment,andthat the PVR was the secondary phenomenon and not acausative factor in most cases of late recurrent retinaldetachment.New retinal breaks also lead to the failure ofsurgery.What causes retina to produce new breakspostoperation?The reasons are maybe following.(1)Meta-morphic retina can be caused to produce new retinal breaksafter infilling expansile gas.(2)Peripheral retina arepulled by anterior PVR to bring new breaks. (3)If detachedduration is long and detached area is great,choroidalvessels will become ischemic.Choroids and retina becomedystrophic,metamorphic,even atrophic.They are apt toproduce new breaks.(4)The figures of eye ball are changedafter scleral buckling surgery. New retinal breaks whicharound the crest of the buckle will come into being becausethe alterative traction direction of PVR.(5)Iatrogenicretinal breaks.(6)Excessive cryocoagulation destroychoroids seriously and even produce choroids scar.There isapt to bring new breaks under the traction by contractionof epiretinal membranes.Basically,a majority of new breaksproduced by excessive cryocoagulation are small andmultiple breaks.So,we should charge the cryocoagulationintensity well intraoperation in order to avoid new retinalbreaks.The operation should be done under binocularindirect binophthalmoscope.The reopening of original breaks is another matterwhich lead to failure of operation.What causes reopeningof old breaks?(1)The location of buckle is too anterior toseal of posterior edge of tears.(2)The multiple and smallbreaks is fore-and-aft.It's different to seal all tearswith one buckle.(3)The tear's diameter is too long to sealthe top of it.(4)Intraoperation of ora serrata rupture,wewould leave out the breaks within pars plana corporisciliary When we condensed.(5)The retina around breaks areaggraviated by PVR.Traction between vitreous body andretina will prevent original rentinal breaks fromclosing.(6)The operation methods were selected wrongly.Weshould select encircle scleral buckling surgery but onlysegmental scleral buckling surgery,vitrectomy butbuckling surgery.Both of two operations don't release thetraction between vitreous body and retina.(7)The bucklewas shifted because sutures on the scleral loosen.(8)Undetected original retinal breaks.Our study is aretrospective analysis.We can hardly found the data aboutundetected original retinal breaks.But undetectedoroginal retinal break is also a matter that causeoperative failure.Especially,the patients with cataractwho would be left out original retinal breaks easily infirst operation.Our study indicate that,scleral buckling surgery isalso the main method in reoperation.Majority of retina canbe reattached through reoperation.But we shouldn't chooseaccommodation of vitrectomy strictly.We should think aboutthe relationship between PVR and recurrent retinaldetachment.We should cure recurrent retinal detachmentthrough vitrectomy in these cases.(1)Failure cases ofgiant retinal detachment after scleral buckling surgery.(2)Failure cases after infilling gas in vitreous bodycavity.(3)Retinal detachment accompanied with opacities.(4)Retinal redetachment accompanied with C3 grade oranterior PVR.(5)Retinal redetachment accompanied withretinal impaction.(6)Cases ,which sclera injury ,can'tbe treated by scleral buckling.During surgery,we shouldclear out vitreous body drastically,release tractionbetween vitreous body and retina and infill expansile gasor silicon oil in vitreous cavity.Only this can we succeedand improve visual acuity.In conclusion,the key to operative success is to searchocular fundus carefully before operation and to buckle allof retinal breaks during it.We should use silt-lampbiomicroscope,full retinal lens,three-mirror contact lensand binocular indirect ophthalmoscope to examine ocularfundus carefully.The patients should be bandged up in botheyes and confined to bed without pillow before operationin order to reduce subretinal liquid.During operation weshould make tears anterior slope of buckle.If we didn'tbuckle all of them,the operation failed.As the sametime,doctors should master the intensity of Cryocoagu-lation well during operation.Excessive cryocoagulationwill destroy sclera seriously.But inefficient cryoco-agulation can't build up concrescece between retina andchoriod.It would cause operative failure.So,patients should be reoperated earlier afterrecurrent retinal detachment to reduce formation ofPVR.Doctors should examine ocular fundus carefullypreoperation,select proper operative method and seal allof retinal breaks correctly during operation.Only this canwe decrease the ratio of reoperation of retinal detachment.