In dealing with these detachments, whether RRD, TRD, or combined detachments, a wide instrumentation is extremely helpful in facilitating repair. A standard three-port vitrectomy may be used. A thorough vitrectomy with elevation of the hyaloid and scleral depression should be performed. The hyaloid, which tends to be very adherent, should be shaved out as anteriorly as possible, paying particular attention to the margin of healthy and necrotic retina. For these complicated cases, 20-gauge vitrectomy still may be the preferred gauge due to the widest array of instrumentation for repair; however, nowadays the gauge choice may be mostly of surgeon preference, as smaller gauge (such as 23 and 25 gauge) instrumentation and variety have become more plentiful. These smaller gauges may also be better for dissection of membranes. On the other hand, smaller gauges may have higher infusion turbulence and if using perfluorocarbon (PFO) may lead to retained or subretinal PFO (Fig. 3.2).

Intraoperative complications are increased in uveitis. Careful attention is required to prevent creating retinal holes if instruments are passed through pars plana exudates and posterior breaks during peeling of densely adherent hyaloid and membranes. Attention to tangential peeling rather than anterior-posterior movements may be helpful in preventing unwanted breaks.

Removal of the tractional membranes can be time-consuming and tedious. Some surgeons find staining techniques, such as ICG and brilliant blue, helpful. Kenalog, unless in a noninfectious eye, should be avoided for visualization of the membranes. A bimanual technique may be employed with the help of chandelier lighting. Using PFO may also be useful for applying countertraction while completely the vitrectomy or peeling membranes. If traction remains, retinectomies and retinotomies may be employed. For retinectomies, an endodiathermy edge is created posterior to the traction and atrophic retina into healthy retina and cut. The retina is then treated with endophotocoagulation with several rows. Care should be taken to diathermize blood vessels to avoid excessive bleeding. Cryotherapy can exacerbate inflammation and should be avoided. Scleral buckles may be helpful for peripheral support. Silicone oil is the preferred tamponading agent and remains for at least 3–6 months and sometimes indefinitely (Fig. 3.3).

Removal of subretinal bands can also be arduous and time-consuming. Only those bands causing traction should be removed. Those that are too dangerous to remove may be relieved with the help of a scleral buckle. When they do need to be removed, subretinal bands, such as those seen in toxocariasis TRD (Fig. 3.1), can be a major obstacle. Cautery directly over the band can allow for access for subretinal removal, but the angle for removal may be awkward. Also, by dissecting the band, it may be more difficult to remove. Creating an opening adjacent to the band allows for access as well as use of the tautness of the band to facilitate removal, with or without a bimanual technique (i.e., hand-over-hand extraction). Another technique is to diathermize openings on either side of the subretinal band and using a bent pick to gain access under the band for exposure and removal. Once the band has been externalized, a gentle hand-over-hand technique with two forceps (with chandelier lighting) can be used or a forceps and lighted pick for gentle extraction of the band. Once the retina is flat, laser should be applied to the areas of the tears if possible (Fig. 3.4). If this is not possible, such as in cases with necrosis, laser is usually recommended at the posterior edge of the healthy and necrotic retina to secure the retina.