RETINAL DETACHMENT

Dr Laltanpuia Chhangte
PG 3
GMC, Haldwani
“Retinal detachment (RD) is a separation of the
neurosensory retina from the retinal pigment
epithelium with the accumulation of fluid in the
potential space between them”.
 TYPES OF RD
 RHEGMATOGENOUS
- associated with break(s).
 TRACTIONAL
- associated with traction,
without breaks
 EXUDATIVE
- due to fluid exudation which
may resolve spontaneously
 RD HISTORY
 Beer – 1817 first to detect RD clinically.
 Von Helmholtz – 1851 invented the
ophthalmoscope.
 Coccius – 1853 first to find retinal breaks (r.b.).
 De Wecker – 1870 first suggested that r.b. were
the causes of  RD.
RD History: cont.
 Leber – 1882 found r.b. in 70% of RD, vit.
deg. And collapse  traction  r.b.  RD.
Changed to pre-retinal memb.  r.b. (in
PVR).
 Jules Gonin – 1919 Father of RD surgery.
Performed the first RD operation to close
r.b. – Ignipuncture of Thermocautery.
RD EPIDEMIOLOGY
o Incidence 1: 10,000 / year, eventually BE
in 10%
o In aphakics: 1– 3%.
o In the second eye (-): 5%.
o In the second eye (+): 10%.
o 99% of untreated symptomatic RE 
blindness.
o 5 – 15% of population with retinal break(s)
 7% of these develop new break(s).
Normal anatomical landmarks
Normal variants of ora serrata
 Anatomy of vitreous base

• 3-4 mm wide zone straddling ora serrata

• Strong adhesion of cortical vitreous
• Anterior limit of posterior vitreous detachment
APPLIED PHYSIOLOGY
Retina stays attached because:-
 Acid mucopolysaccharide (GAG) b/w RPE and the sensory
retina acts as a ‘ biological glue’.
 RPE cell sheaths mechanically hold the sensory retina
 RPE pump and hydrostatic pressure – the SRF is pumped out
by the RPE ATP-ase dependent pump, which lowers the
hydrostatic pressure and the vitreous pressure flattens the
retina.
 Vitreous tamponade – cortical vitreous impedes movement
of liquid through breaks.
Mechanics of RD formation
 Vitreous liquefaction
 Partial/complete posterior vitreous detachment, VR traction
 Retinal breaks – tear
hole
dialysis
 Eye movements (Edie’s current)
 PVD
 Due to loss of hyaluronic acid  collapse of
vit. collagen with liquifaction.
 Rare before 30 yrs.
 Increases with age (63% in > 70 yrs.)
 15% of acute PVD have a retinal tear.
 Increases significantly after cataract
extraction: pathologic vs physiologic PVD.
 RD
 PVD
 13-19% of PVD have vit. Hem.

 PVD + hem.  70% with tears.

 PVD + no hem.  2-4% with tears.

 Acute PVD:-

 Examine periphery.

 + vit. Hem.

- rest, patching  examine.

 U/S.
 RRD Risk factors
 Myopia  Retinal pigment epithelial
clumps
 Aphakia
 Glaucoma
 Trauma
 Proliferative retinopathies
 Lattice degeneration - Diabetes
 Snail track degeneration - BRVO
 Zonular retinal traction tufts - Sickle cell, ROP
 Degenerative retinoschisis  Infections
 Retinal pits and rarefaction  RD in fellow eye or F/H of
RD
ERD Risk factors
Idiopathic – Coats disease, ICSC, Uveal effusion syndrome

Congenital – Dominant familial exudative vitreoretinopathy

Post Surgical – PRP, RD sx

Inflammatory – Scleritis (posterior), orbital cellulitis

Autoimmune –VKH, sympathetic ophthalmia

Vascular – PIH, Hypertensive retinopathy

Neoplastic – Retinoblastoma, choroidal malignant melanoma,

chooroidal metastatsis, chroidal haemangioma
TRD Risk factors

Proliferative Retinopathy of Penetrating

Diabetic prematurity posterior segment
retinopathy(PDR) (ROP) trauma
Proliferative
retinopathies like
CRVO /BRVO
and vasculitis in
their late stages
1. Myopia and RD
 Myopia constitute 10% of the general population and over
40% of RD occur in myopic eyes.
 High myopia >6D
60 year myope risk of RD is 2.5% whereas normal risk
is 0.06%
2. Lattice and other peripheral deg.
 Present in 8% of the population.
In SA – 9.1%
 As a cause of RD in 20-30%.
 In RDs with L.D.:-
30-45%  Atrophic holes.
55-70%  A tear at edge of L.D.
Predisposing peripheral degenerations
 Innocuous peripheral retinal degenerations

Pavingstone
degeneration
Microcystoid
degeneration

Honeycomb Peripheral drusen

(reticular)
degeneration
3. CATARACT Surgery
 Increases PVD: Does it convert physiological
PVD to a pathological one?
 1.3% RD in aphakes.
 ICCE > ECCE.
 Risk of RD increased with:-
- P.C. otomy: 1.3%.
- Vit. loss.
 50% of RDs in 1st year.
4. Glaucoma

 In general population – 1% COAG.

 In RD patients – 4-7% COAG.
 > in pigment dispersion synd.
? myopia.
 Miotics & RD.
5. Hereditary factors
 The most common hereditary conditions associated with RD
are axial myopia and lattice degeneration.
6. TRAUMA
Trauma

Surgical trauma
- Cataract extraction Non-surgical trauma
- PK - Blunt
- Perforating
- PPV
- Scleral perforation
- Cryotherapy, laser
photocoagulation
7. Intraocular inflammations
Intraocular
inflammations

Toxoplasmosis
Pars planitis
Toxocara
Infectious retinitis – CMV/ARN
ROP
Miotic therapy
CLINICAL EVALUATION

SIGNS AND SYMPTOMS

 Sudden increase in Floaters
 Photopsia
 VISUAL FIELD DEFECT
 Metamorphopsia and sudden DOV
 Sudden VA
 ASSOCIATED CONDITIONS
 Drugs use; Glaucoma ; Past strabismus surgery ;
Post cataract surgery

SYSTEMIC HISTORY
 CVS, RS, anticoagulants intake, DM

FAMILY HISTORY
 RD – myopia, lattice degeneration, familial VR
degenerations
 Genetic diseases – marfan, homocystinuria,
sticklers syndrome
EXAMINATION
 VA  Pupils
 VF  SCLERA
 AMSLER grid  Anterior segment
 Refractive error  IOP
 Ext. Ocular examination –  Lens
 Post segment : blood, pigment
(shafer’s sign) in the vitreous
 Careful Binocular IO with
scleral indentation
Examination techniques
 Indirect ophthalmoscopy
 Scleral indentation
 Fundus drawing
 Slit lamp biomicroscopy
 Ultrasonography – B scan
 DETERMINE FRESH & OLD RD
RD

FRESH RD
- Convex configuration with mild
opaque and corrugatedd appearance
- Undulates freely with ocular
movements
- Loss of underlying choroidal
pattern, darker apperance of retinal
blood vessels with lesser contrast
b/w venules and arterioles
Subretinal fluid may extend till the
ora serrata
OLD RD
- Retinal thinning due to
atrophy
- Intraretinal cysts
- Subretinal demarcation lines
(high water marks) due to
proliferated RPE cells at the
junction of the attached and
detached retina
U-tear in superior bullous
detached retina retinal detachmen

shallow
tempora
l retinal
detachm
en
 Proliferative vitreoretinopathy

Retina society grading of proliferative vitreoretinopathy

Assessment of Breaks
 Finding the 1 °break  Symptoms
 Traction  Size of detachment
 Type of break  Vitreous status
 Age of break  Aphakia
 Size of break  Family history of detachm
 Number of breaks  Other disease states
 Location of break
Lincoff ’s RULE
Saleh Al Amro, MD, FRCS, FCOPHTH
Criteria For Seriousness Of Breaks
 Differences between RRD, TRD and ERD
Rhegmatogenous Tractional Exudative

Symptom Floaters and flashes Absent Absent

VF defect Develops fast Develops slowly may Develops fast

remain statis for months
Laterality U/L other eye may be U/L other eye may be Involves both eyes
involved later involved later simultaneously
PVD Usually follows PVD Not associated with PVD, Not associated with PVD
which is complete which is incomplete
Break Always present Absent Absent

RPE PUMP Intact Not affected Occurs d/t RPE failure

Configuration Convex, bullous, Concave Convex but surface is

corrugated folds smooth, no folds
Mobility of retina Mobile in fresh case, Restricted Mobile
restricted in old case
Extent Extends to ora Seldom extends Extends to ora

PVR Present in due course Absent Absent

of time
SRF SHIFT No shitt Shallous and no shit Shift with posture

Treatment Surgical Surgical No surgery, treat

underlying cause
Differences between RRD and CD
RRD CD
Symptoms Flashes and floaters positive Absent
Visual field defect Develops fast Absent unless it is very
extensive i.e., kissing
choroidals
AC and IOP Normal AC, IOP is low Shallow AC, IOP is very low
Break Present Absent
Configuration Greyish white, corrugated, Convex, dome shaped
retinal fold, mostly mobile brownish, smooth and not
mobile
Extent From disc to ora Mostly anterior to equator, it
usually extends beyond ora
Treatment Surgical Mostly there is spontaneous
resolution
RETINAL DETACHMENT TREATMENT
PRINCIPLES OF SURGERY
 Emergency.
 Localization of break(s).
 Creation of C-R adhestion around the
break(s).
 Closure of break(s).
 Relief of V-R traction.
Creation of C-R adhesion
It can be achieved by –
 Cryotherapy
 Diathermy
 Photocoagulation
 1. CRYOTHERAPY
Advantages Disadvatages
1. Full thickness buckle can be applied to full 1. Difficult to see reaction in deep SRF
thickness sclera, which is not damaged

2. No thermal damage to vitreous or sclera – easy 2. Excessive cryo release of RPE cells into the
reoperations vitreous cavity. This has been linked to PVR.
3. Can be applied transconjunctivally or directly to Thus direct freezing over the breaks has been
sclera discouraged recently

4. No damage to large vessels, vortex veins or

ciliary vessels – lesser risk of ant. Seg ischaemia
5. Can be safely over staphylomatous areas taking
care to allow complete thawing before removing the
probe
6. By forcing fluid during indentation, it may allow
for buckcle placement without drainage
7. Applicable to wet sclera as may occur following
premature release of SRF
8. Lower incidence of macular pucker
2. DIATHERMY
3. Photocoagulation
 Laser delivery systems coupled with indirect ophthalmoscope
 Great precision in intensity and location
 Causes less breakdown of blood ocular barrier.
 The thermal effect is confined to retina and RPE sparing
choroid and sclera
 Induces adhesive reaction within 24 hours
 However an attached retina is prerequisite and hence SRF
needs to be drained before laser retinopexy.
 Select a spot size of 200 µm and set the duration to 0.1 or
0.2 seconds
 Surround the lesion with two rows of confluent burns of
moderate intensity
 RD TREATMENT CONTD/
 LA/GA
Surgical techniques:-
 Scleral buckle.
 Orbital balloon.
 Pneumatic retinopexy.
 Primary vitrectomy + GFX, Long-term
tamponade.
By Earnst custodis
1. ENCIRCLAGE BUCKLES
 360 deg buckling effect that relieves the vitreoretinal traciton
 Support the suspected but non visualized pathology b/w the
ora and equator
 Achieve buckling effect with band only
 Occupy volume replacing the drained fluid
 Support a contracted retina in early PVR
 FALSE ORA created – prevents further hole formation and
detachment; this in practice needs for deep indent and is not
recommended
 Undetected holes are sealed – when no breaks were found
2. RADIAL BUCKLES
 Used in
 Wide horse shoe tears – b/c they cause lesser fish mouthing
of the posterior edge
 Very posterior breaks – easier to place sutures as well as
reach posteriorly
3. CIRCUMFERENTIAL BUCKLES
 Used in
 Dialysis
 Multiple tears
 Uncertain about breaks – SRF not located, failed RD, aphakia
 GRT
 Thin sclera
 Statis vitreoretinal traction
Factors promoting attachment
 Physiologic adhesion of retina and RPE
 Thermal chorioretinal adhesions
 Scleral buckling promotes retinochoroidal
approximation
 Traction on retinal surface
reduced/eliminated
 Buckles may favourably influence fluid flux
Factors favouring detachment
 Vitreous traction
 Fluid movements and retinal breaks
 Epiretinal membranes
Promoting attachment of retina to the
eyewall
 SRF drainage
 Intravitreal bubble of gas or air
 Reducing vitreretinal traction
By Hilton and Grizzard
 Physical characteristics of gases
Gases Purity Expansion Longetivity Non expansile
conc.

Air - 0 5- 7 days 0%

SF6 99.9 2x 10- 14 days 18%

C3F8 99.7 4x 30-35 days 14%

Xe 99.995 0 1 -
Contraindications to pneumatic retinopexy
a. Breaks larger than one clock hour or
multiple breaks over more than one clock
hour
b. Breaks in inferior four clock hours
c. Proliferative vitreoretinopathy grade C or D
d. Physical disability or mental incompetence
preventing maintainance of head positioning
4. Severe uncontroled glaucoma/recent Catract
surgery
5. Cloudy media preventing adequate assessment of
the retina
 Complications of pneumatic retinopexy
Intraoperative complications Postoperative complications

Elevated iop New retinal breaks

Vitreous haemorrhage Infective endophthalmitis

Vitreous incarceration Cataract

Subconjunctival gas Intravitreal proliferation

Extension of detachment Low anatomic success rate

Multiple gas bubbles

Subretinal gas

Enlargement of tears
By Robert Machemer
OTHER MODALITIES
1. Lincoff balloon (Orbital/Episcleral)
2. Absorbable scleral buckles – fascia lata or
Gelatin
3. Suprachoroidal hyaluronic acid
4. Subretinal fluid drainage and intraocular
gas injection
5. Primary vitrectomy without buckling
6. Nd:Yag laser vitreolysis
7. Combination of techniques
1. LINCOFF BALLOON (orbital /episcleral)
 Used to create a temporary scleral buckling
 A deflated balloon with catheter is inserted into
the tenon space via a conjunctival incision, which
is then inflated by fluid to cause scleral
indentation
 Cryotherapy before or photocoagulation after
insertion to create C-R adhesion
 Monitor IOP and CRA perfusion
 Complication – Shift in position
 Success rate – 64 – 96%
2. Absorbable scleral buckles
 Fascia lata - it has excellent strength and mild elasticity
with easy manipulation and no immunogenic reactivity
 It eventually gets bonded to the episclera
 It has low rate of extrusion and reinforces thin sclera
 It can also be layered or coiled to achieve great thickness and
width
 Other materials used – preserved sclera, plantaris tendon,
Achilles tendon, Cartilage, tarsus, perichondrial tissue, dura
matter, embryonic bone and human skin
 2. Absorbable scleral buckles cont/
 Gelatin : available as thin dehydrated sheets, which are then
hydrated and cut to required sizes
 May produce severe allergic reactions
 Usually used with scleral dissection and embedded in the scleral bed
 Can be used in non – drainage surgery since its buckle height
increases on absorbing fluid
 Slowly absorbed in 2-24 months and then its effect disappears
 Can be used beneath the silicone buckle
 Other absorbable materials : collagen, catgut and fibrin (not
commercially available)
 3. Suprachoroidal hyaluronic acid
 By injecting materials like hyaluronic acid
into the suprachoroidal space, the choroid
and the RPE are pushed against the retina and
apposed.
4. SRF drainage and intraocular gas
injection
 Scleral buckling is not done
 Drainage is f/b subsequent intraocular gas
injection
 Combines the advantages of pneumatic
retinopexy with that of conventional RD surgery
 CANDIDATE – small or medium sized breaks in
the superior quadrants without significant
vitreoretinal traction
5. Primary vitrectomy without buckling
 Usually reserved for complicated detachments
wherein it decreases the risk and difficulties
associated with scleral buckling
 Helps to relieve the traction and assists in
introducing a sizeable amount of intravitreal gas
6. Nd: Yag laser vitreolysis
 Nd:Yag is used to cut the flap of hourshoe shaped retinal
tears
 Traction is understood to be relieved when the flap becomes
a free operculum and is pulled centrally into the vitreous
7. Combination of techniques
 The most commonly used methods are scleral
buckling and intraocular gas tamponade
 Other alternatives : combining pneumatic
retinopexy with orbital balloon or aspiration of
liquid vitreous or absorble scleral buckling
materials
PROPHYLAXIS OF RD
 CANDIDATES

1. Symptomatic holes
2. Aphakic holes
3. Fellow eye with detachment and breaks
4. Asymptomatic holes in dialysis, GRT
5. Snail tract degeneration with holes
6. Lattice degeneration in fellow eyes,
aphakia and myopia
Fellow eye of atraumatic GRT
Complication of RD surgery
Complication of RD surgery contd/
COMPLICATIONS OF RD SX contd/
 late glaucoma
Pupillary block
glaucoma

cataract in an eye
with (inverted
‘pseudo-
hypopyon

band keratopathy
LATE REDETACHMENT
 RD prognosis & VA:
 90-95% - Approx. success.

 Overall 40-50%  20/50 or >

25%  20/60 – 20/100

25%  20/200 or <

 RD prognosis & VA: cont.
 If macula off < 1 wk – 75%  20/70 or >.

 If macula off 1-8 wk – 50%  20/70 pr >.

 If macula on 90%  Preop. VA  pucker,

CME, recurrent RD.

 RD Prognosis:
1. Excellent prognosis (nearly 100%):

 Detachments due to dialysis or to small or

round holes.
 Detachments with demarcation lines.
 Detachments with minimal subretinal fluid.
 RD Prognosis: cont.
2. Slightly poorer prognosis (95%):

 Aphakic detachments.
 Total detachments.
 Detachments with associated de-tachment of
the nonpigmented epithelium of the pars
plana.
 Detachments caused by flap tears.
 RD Prognosis: cont.
3. Poor prognosis (50 to 70%):

 Detachments with associated choroidal

detachment
 Detachments with breaks larger than 180.
 Detachments with PVR.
 Detachments in patients with stickler’s
syndrome.
 Detachments caused by acute retinal
necrosis.
 Gas Injection: PR

 Tornambe published experiences in 302 eyes, in which

he found a single injection attachment rate of 68%
and a final attachment rate after reoperations of
95%, with a minimum follow-up of 6 months.
 He found that the extent of retinal detachment, the
number of breaks and the lens status affects the rate of
attachment.
 In a subgroup where less than 25% of the retina is
detached with a single small hole and clear media and no
PVR, the reattachment rate was 98% when he used 360°
retinopexy
 Gas Injection: PR contd/

 Recently, Ellakwa evaluated long-term data after PR in a

prospective interventional case series of 40 patients and
found a stable reattachment of the retina in 60% after
a single injection
 The final anatomical success rate after additional
procedures was reported as 96.1%, additional
breaks were found in 11.7% and PVR occurred in
5.2% according to a review by Chan et al.
 Gas Injection: PR contd/

 In a recently published retrospective chart analysis of 213

patients receiving PR, Davis et al. found a single injection
success rate of 64% with a follow-up of at least 6 months. T
 They found that vitreous hemorrhage and large detachments
(>4.5 clock hours) are indicators for a high risk of failure.[
 Single injection success rates are different between phakic and
nonphakic eyes. In phakic eyes, success rates are reported to be
between 71 and 84% and in nonphakic eyes the success rates are
between 41 and 67%.

 Complications of PR were new retinal breaks (7–33%),
cystoid macular edema (0–8%), subretinal gas (0–4%), PVR
(3–13%), cataract formation (1–20%) and epiretinal
membranes (2–11%)
 Primary Pars Plana Vitrectomy
 In a retrospective comparative case series Kinori et al.
found a reattachment rate of 81.3% in patients treated
with vitrectomy alone, whereas the reattachment rate after
one surgery was 87.1% in patients where vitrectomy was
combined with an encircling band.
 The difference was not statistically significant.
 There was also no difference in final visual acuity between the two
groups.
 In that study all patients were included if they had either ppV or
ppV and SB. Patients after trauma, with PVR C or worse, giant
retinal tears, children under 16 years, patients with previous
vitreoretinal procedures and patients with proliferative retinal
diseases were excluded
Primary Pars Plana Vitrectomy contd/

 In another retrospective study by Mehta and coworkers, a

significant difference in reattachment rates occurred in
phakic patients; 83% in the vitrectomy alone group versus
97% in the vitrectomy and encircling band group. In
pseudophakic patients no difference was found
 In another study by Weichel et al., reattachment rates in
pseudophakic retinal detachments were 92.6% in the
vitrectomy alone group and 94% in the ppV and SB group,
which was not significant. Also, the rate of complications was
statistically not different in both groups in this retrospective
comparative study.
Primary Pars Plana Vitrectomy contd/
 Wickham et al. found no difference in the reattachment
rates between vitrectomy with or without a buckle in
detachments caused by inferior breaks.[
Primary Pars Plana Vitrectomy contd/

 Another debate is the use of transconjunctival techniques using 23,

25 or even 27 gauge instruments for vitrectomy.
 In a retrospective chart review, Mura et al. found a single success
rate of 92.4% after 25-gauge vitrectomy
 These very good data were confirmed by Bourla et al. with
single surgery success rates of 97.4% in a retrospective case series
with a follow-up of 3 months.
 Similar data were reported by Miller et al. (92.9%)and
Mendrinos et al. (92%).
 However, only 74% were reported by Lai and coworkers.[
 For 23 gauge vitrectomy, good single surgery success rates were
also reported. In Tsang et al.'s prospective case series, this rate was
91.7%
Primary Pars Plana Vitrectomy contd/

 In a retrospective comparison between 25- and 20-gauge

vitrectomy, von Fricken et al. reported single surgery
success rates of 90.6% for 25-gauge vitrectomy and 91.8%
for the 20-gauge group.
 Colyer and coworkers compared success rates of
transconjunctival 25-gauge vitrectomy with the standard 20-
gauge approach.
 They found a single operation success rate after 25-gauge
transconjunctival vitrectomy in 83.3% and in 89.6% after
20-gauge vitrectomy in pseudophakic eyes with inferior
breaks, indicating no difference
SB versus Primary Vitrectomy

 Schaal et al. noted reattachment rates of

86% for SB, 90% for ppV alone, 94% for
the combination of SB and ppV and 63% for
PR after 1 year.
 For pseudophakic retinal detachments Le
Rouic et al. found similar reattachment rates
for SB as well as for ppV (84% SB vs 82.5%
ppV) confirmed by Miki et al. who found
reattachment rates of 92% in both groups
SB versus Primary Vitrectomy contd/
 In SPR TRIAL,
 In phakic eyes, primary reattachment was achieved in 63.6%
with SB and in 63.8 % with vitrectomy. Final anatomical
success was also the same. However, final visual acuity was
worse in the vitrectomy group because of cataract
progression.
 In pseudophakic eyes, primary reattachment was achieved in
53.4% of eyes after SB but in 72.0% of eyes after vitrectomy.
This difference was statistically significant.
 The final anatomic success again was the same; however, in
the SB group more patients needed further intervention
SB versus Primary Vitrectomy contd/
 Azad et al. did not find a statistically significant
difference between SB and ppV with respect to
retinal reattachment rates (80.6% for SB vs 80%
for vitrectomy).
 Cataract progression in the vitrectomy group was
the major risk factor for worse visual outcome,
confirming the SPR findings
 PR versus SB
 The Retinal Detachment Study was a prospective clinical trial
where SB was compared with PR in a multicenter setting.
 A total of 198 patients were followed over 6 months.
 Patients were recruited with retinal breaks not greater than 1 o'clock
diameter and located in the superior two-third of the fundus.
Significant PVR was excluded.
 The single operation reattachment rate was 82% for SB and
74% for PR.
 Final success rates were 98 and 99%, respectively.
 The occurrence of PVR was not significantly different between the
groups but the morbidity was less in the PR group and the visual
acuity was better in the PR group.
 Therefore, PR was recommended for those types of retinal
detachments meeting the admission criteria
 PR versus SB contd/

 Mulvihill et al. conducted a small prospective clinical

trial comparing ten patients with PR and ten patients with
SB.
 They reported a final success rate of 90% in the PR
group and 100% in the SB group after one or more
procedures
 PR versus SB contd/

 In the comparative case series of Han et al., single

procedure success rates were reported for PR as 62% and
for SB as 84%.
 In this series, 50 eyes in each group were followed for a
minimum postoperative period of 6 months.
 However, the final reattachment rate was 98% in both
groups.
 For phakic eyes the visual outcome was comparable in both
groups
RECOMMENDATIONS FOR VR SX
 Simple detachment (phakic eye, one break less
than 1 o'clock size, shallow detachment, no PVR, no
visible traction, and good visibility): SB or PR (if the
resources for SB are not given);
 Complex detachment (pseudophakic eye or bad
visibility, PVR, large breaks, multiple breaks, irregular
breaks, central breaks or other complicating factors):
primary vitrectomy or primary vitrectomy plus SB