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Subspecialties Retina

PR – 10 Steps to Success

1. Pick the right patient
  • With PR, the patient is your cosurgeon, and you need to make sure they have the physical and mental capacity to perform postop positioning.
2. Pick the right eye
  • Make every effort to assess the vitreoretinal interface, find all the breaks and regions of subretinal fluid accumulation (a three mirror lens may help), note lens status and chamber depth.
  • Multiple breaks or extensive lattice degeneration suggest an abnormal vitreoretinal interface. If the fellow eye has a giant tear, PR might not be a good idea.
  • Ideally, the break should not extend below the horizontal.
3. Pre-op prep and anesthesia
  • Subconjunctival anesthesia is usually adequate, and I do all the procedures in my office.
4. Immediate cryo vs. deferred laser
  • Avoid excessive cryotherapy.
  • If the break is highly elevated, inject the gas, position the patient, and apply laser the next day.
5. Paracentesis
  • Perform a paracentesis prior to gas injection, with a 30 G needle on a plungerless syringe. This helps avoid issues like hard eye, pain, iris incarceration, arterial occlusion and displacement of the bubble into the anterior chamber.
6. Gas selection
  • Use a half cc of 100% SF6, but consider C3F8 if the eye is large, the break is posterior, or if multiple breaks are present.
7. Injection technique
  • I inject using a one cc syringe with a 32 G needle, with the exact amount of gas I plan to inject preloaded in the barrel of the syringe.
  • With the patient supine, I inject the gas into the superior temporal quadrant, away from large breaks. 
  • The injection is made perpendicular to the eye wall, and the needle is inserted about 4 mm into the eye. 
  • To avoid subretinal gas, never inject inferiorly. 
8. Steamroller
  • The streamroller maneuver is used to debulk subretinal fluid, by rolling the bubble towards the break, pushing subretinal fluid back into the vitreous cavity. 
  • It is performed to prevent displacement of subretinal fluid into the detached macula, or into flat inferior breaks.
9. Positioning
  • Proper patient positioning is crucial to success.
  • I use the Tornambe Pneumo Level (Escalon) on the patch to aid positioning.
  • Some patients don’t listen, so in these cases make sure a family member knows how to position the patient.
10. Postop care
  • I prescribe a steroid-antibiotic combination for five days, and I position as much as the patient can tolerate for the first 24 hours – and I always see the patient the next day.
  • Inferior subretinal fluid not involving the macula may be managed conservatively, because in some cases it may take weeks to resolve.
  • If the macula is still detached after a few days, the break is open or there is an unrecognized break, I usually go directly to vitrectomy – do not delay the rescue operation.
  • In my experience if minimal cryo is used and the patient is reoperated upon promptly, failed cases do well.
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About the Author
Mark Hillen

I spent seven years as a medical writer, writing primary and review manuscripts, congress presentations and marketing materials for numerous – and mostly German – pharmaceutical companies. Prior to my adventures in medical communications, I was a Wellcome Trust PhD student at the University of Edinburgh.

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