Surgery: Scleral Buckle with Double Segmental Elements and Vitrectomy Under Air to Fix a PVR-related RD

Dr. John W. Kitchens: This is a patient that had a failed primary vitrectomy and had a horseshoe tear that was the cause of the primary failure, inferotemporally with some early PVR. I find if you fail a primary vitrectomy, you most certainly need a scleral buckle to help support the peripheral vitreous.

Now in this case, this tear was fairly ragged, had an early proliferation, and was fairly posterior, along with being inferely. So I encircled the eye with a 41 band using scleral tunnels. And I placed a 106 element. I really like this 106 element as a segmental element where I can lock it in place, as shown here, and trim it. You don’t need any sutures, typically. And it will hold in place and give you just really nice imbrication. But when I went back in the eye, I found that the traction wasn’t adequately supported in that area, so I placed a second 106. I debated taking out my scleral belt loop. But I left it in place and it actually worked out really nicely.

So here we are trimming off the anterior edge of that 106. And now as I go back inside the eye, and go to an air fluid exchange, I actually have really good support on the anterior aspect of the tear itself. And it’s really critical to get support on that anterior aspect because that’s really where the vitreous is going to contract and pull up from.

Posteriorly, there shouldn’t be any vitreous traction and so you can let that fall on the downslope or off of your buckle, in fact. We’re able to drain through the break really nicely. And then I do vitrectomy under air. And I do this whenever I have anomalous vitreous insertion or just a lot of vitreous left inside the eye. And I use the shadows of the vitrector, as well as the reflection when the vitrector touches the vitreous to know when I’m actually removing it.

I go back and redrain more fluid through the break, this time with the soft tip. I get it flat, so I can actually laser around the tear here, and on the buckle anteriorly. And I do do 360 degrees of laser, in this case, for fear of small breaks that might be missed. And then close with 6-O plain sutures, anchoring the conjunctiva to the sclera. Thanks for watching.