Retinal Detachments and Vitrectomy
Xinxin Zhang, MD
Lejla Vajzovic, MD
HISTORY
Onset—often delayed presentation as patient or caregivers may not recognize or report vision loss.1
Birth history—retinopathy of prematurity, TORCH infections (rare cause).
Medical history—Stickler (Fig. 31.1), Marfan, Wagner, Knobloch, atopic dermatitis, incontinentia pigmenti, hemoglobinopathies.
Ocular history—previous intraocular surgery, X-linked retinoschisis, choroidal coloboma, retinal vascular disease (persistent fetal vasculature, familial vitreoretinopathy, uveitis).
Family history.
Trauma (Fig. 31.2)—most frequent cause; history may be lacking.
Secondary findings—leukocoria and strabismus.
 FIGURE 31.1. A 12-year-old male with amblyopia OD and moderate myopia OU presented with new-onset floaters and decreased visual acuity in the right eye. He was found to have retinal detachment of the right eye with giant retinal tears. Initial visual acuity on presentation was LP OD and 20/20 OS. The patient underwent repair with scleral buckle, pars plana vitrectomy, and endolaser. Subsequent repair was needed for PVR and subretinal fluid involving the macula. Visual acuity on follow-up 2 years later is 20/150 OD. Genetic testing showed positive COL2A1 mutation for Stickler syndrome. |
 FIGURE 31.2. Macula-off combined tractional and rhegmatogenous retinal detachment of the left eye with grade C vitreoretinal proliferation of an 8-year-old female after BB gun injury to the left eye. The detachment was found at a follow-up appointment ˜1 month after initial injury and initial surgery for removal of the BB from the orbit with closure of a conjunctival laceration. |
EXAMINATION
Depending on the age and cooperation of the child, an examination under anesthesia may be necessary. Extra attention should be given to the following examination components:
Best corrected visual acuity.
Intraocular pressure—check for relative hypotony in the affected eye, which is present in 40% of unilateral uncomplicated retinal detachments.
Anterior segment—look for pigmented cell in the anterior vitreous as it is strongly predictive of a retinal tear or hole.
Posterior segment—perform scleral depression, which typically requires an exam under anesthesia. Note the extent of involvement, including the number of quadrants affected and the location of retinal holes, dialyses, and/or proliferative vitreoretinopathy (PVR).
In children, it is particularly important to perform a thorough evaluation of the fellow eye as they have higher incidence of bilateral pathology and bilateral presentation.
DIAGNOSTIC TESTING
Perform a B-scan ultrasonography if the view is inadequate (Fig. 31.3).
 FIGURE 31.3. B-scan ultrasonography (vertical axial view) showing a total retinal detachment in a closed funnel configuration in the right eye of a 9-year-old male. The patient presented with intermittent exotropia and light perception vision in the right eye for likely more than 1-year duration. He was found to have total retinal detachment with giant retinal tear and dense vitreous membranes in the right eye as well as lattice degeneration with atrophic holes, small horseshoe tears, and syneretic vitreous in the left eye. Patient underwent pars plana vitrectomy and lensectomy with scleral buckle, endolaser, retinectomy, PVR peeling and silicone oil fill in the right eye, and 360 prophylactic laser retinopexy in the left eye. Patient is undergoing genetic testing for suspected inherited vitreoretinopathy. |
SURGICAL CONSIDERATIONS
Manage patient and caregiver expectations regarding prognosis and possible need for further intervention. Retinal detachments in children tend to present when they are chronic and may require multiple surgeries. Perform prompt refraction and monitor for amblyopia postoperatively in order to achieve the best visual outcome.
Aphakic eyes become less hyperopic when the vitreous cavity is filled with silicone oil (eg, an aphakic eye with 10-12 diopters of hyperopia would have 4-6 diopters of hyperopia when filled with silicone oil). Phakic eyes typically develop 5-7 diopters of hyperopia when the vitreous cavity is filled with silicone oil.1
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