Retinal Detachment Surgery

Retinal detachment surgery is an ophthalmological emergency: without prompt treatment, vision can be permanently lost. Retinal detachment surgery primarily relies on two techniques: cryopexy with scleral buckling and vitrectomy. Julien Gozlan, M.D., ophthalmic surgeon in Paris 16, explains the differences between these procedures, their indications, and postoperative course.

What is a retinal detachment?

The retina is a thin membrane lining the back of the eye, responsible for converting light into nerve signals. In the case of retinal detachment, this membrane lifts away from its underlying support, much like wallpaper peeling off a wall. Most often, it all begins with a retinal tear through which fluid passes and lifts the retina.

The classic warning signs are:

• the sudden appearance of a large number of floaters;
• flashes of light (photopsia);
• the sensation of a dark curtain or shadow in the visual field;
• a sometimes significant decrease in vision.

If you experience these symptoms, seek emergency care: only retinal detachment surgery can reattach the retina and offer hope of recovering vision.

Key principles of retinal detachment surgery

Regardless of the type of procedure, the objectives are the same:

• seal the causative tear or tears;
• reattach the retina against its underlying support;
• stabilize the situation while healing takes place.

To achieve this, the surgeon can act either from outside the eye with cryopexy and scleral buckling, or from inside with a vitrectomy, or sometimes by combining both techniques.

Preoperative assessment: factors that guide the choice of technique

Before choosing the strategy, the examination determines several decisive factors:

• whether the detachment is macula-on (macula still attached) or macula-off (macula detached);
• the number and location of tears;
• the extent of the detachment and how long-standing it is;
• the presence of traction or proliferative vitreoretinopathy (PVR);
• lens status: phakic (natural crystalline lens) or pseudophakic (intraocular lens implant after cataract surgery);
• the clinical context (high myopia, trauma, prior surgical history).

These criteria explain why no single technique is "better" in absolute terms: the best surgery is the one most suited to the specific configuration of the retinal detachment.

Cryopexy with scleral buckling: acting from the outside

Cryopexy with scleral buckling is a classic technique in retinal detachment surgery. The goal is to push the wall of the eye toward the retina to "plug" the tear from the outside and reduce traction.

In practice, the surgeon:

• locates the retinal tear;
• applies cryotherapy (intense cold) to this area to create a strong adhesion;
• places a silicone band on the sclera (the white outer shell of the eye) that creates an inward indentation.

This approach is often indicated in young, phakic patients with a limited retinal detachment and tears accessible in the periphery. The advantage is that it preserves the vitreous and avoids entering the inside of the eye.

Vitrectomy: treating retinal detachment from the inside

Vitrectomy involves removing the vitreous, the transparent gel that fills the inside of the eye, and then directly treating the tears from within. It is currently the most widely used technique for retinal detachment, particularly in older patients or those who have already undergone cataract surgery.

During the procedure, the surgeon:

• makes micro-incisions in the sclera;
• removes the vitreous and eliminates the traction pulling on the retina;
• treats the tears with laser or cryotherapy;
• fills the eye with a gas or sometimes silicone oil to hold the retina flat against the wall.

Vitrectomy is preferred in cases of complex retinal detachment, extensive forms, recurrences, and cases with PVR or when the patient is pseudophakic.

Gas or silicone oil: why use a tamponade?

In vitrectomy, the surgeon often uses an internal tamponade to hold the retina in place while the treated areas around the tears heal:

• Intraocular gas: it resorbs spontaneously over several weeks. Vision is very blurry at first and gradually improves as the gas diminishes.
• Silicone oil: reserved for certain more complex cases (PVR, recurrence, inability to maintain positioning, etc.). It often requires a second procedure for removal.

When gas is present, air travel and altitude are contraindicated until the gas has completely resorbed, as the bubble can expand and dangerously increase intraocular pressure.

Proliferative vitreoretinopathy (PVR): why it is a risk factor for recurrence

Proliferative vitreoretinopathy (PVR) is one of the main causes of failure or recurrence of retinal detachment. It involves an excessive scarring reaction: cells proliferate and form membranes on the surface of the retina or beneath it, capable of pulling on the tissue.

In practice, PVR can:

• create new traction and reopen a fragile area;
• cause a "rigid" detachment that is more difficult to reattach;
• require more complex procedures (membrane peeling, retinectomy in severe cases);
• increase the need for long-term tamponade, sometimes with silicone oil.

PVR is more common in certain situations: long-standing or very extensive detachment, intravitreal hemorrhage, trauma, recurrences, or inflammation. This explains why some detachments require multiple surgical stages and prolonged follow-up.

Cryopexy with scleral buckling or vitrectomy: how to choose?

The choice of technique depends on the characteristics of the retinal detachment and the patient:

• age and lens status (phakic or pseudophakic);
• number, size, and location of tears;
• extent and duration of the detachment;
• presence or absence of tractional membranes or PVR;
• risk of recurrence and associated factors (high myopia, trauma, prior history).

In a young patient with a limited detachment and a peripheral tear, cryopexy with scleral buckling can be an excellent option. Conversely, for an extensive, long-standing, pseudophakic, or complicated detachment, a vitrectomy often provides better control of traction and recurrence. In some cases, both techniques may be combined.

Postoperative course and recovery

After retinal detachment surgery, the eye may be red, sensitive, and vision very blurry at first, especially with gas tamponade. A specific head position may be required for several hours a day over several days (depending on the location of the tears).

Return to activities is gradual: driving, sports, and strenuous exertion are generally postponed. With intraocular gas, air travel and stays at altitude are contraindicated until complete resorption. Close follow-up ensures the retina remains properly reattached.

Visual prognosis: what determines recovery?

The prognosis depends mainly on two factors:

• the status of the macula (macula-on versus macula-off);
• the time to treatment and the complexity of the detachment (PVR, recurrence, extent).

When the macula is still attached (macula-on) and surgery is performed promptly, visual recovery can be excellent. In cases where the macula is detached, vision often improves after reattachment, but recovery may be partial and slower, over several weeks to several months.

Julien Gozlan, M.D., ophthalmologist in Paris 16, evaluates on a case-by-case basis the best strategy for retinal detachment surgery: cryopexy with scleral buckling, vitrectomy, or a combined approach, in order to maximize the chances of success while taking into account your personal situation.

Further reading

• Retinal detachment: symptoms, emergency care, and treatments.
• Vitrectomy: principles of vitreoretinal surgery.
• Macular OCT: the key examination for analyzing the retina.
• Amsler grid: a simple self-monitoring tool for central vision.