Graefe's Arch Clin Exp Ophthalmol (1997) 235:672-673 © Springer-Verlag 1997 C. Batman O. Cekic Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment Received: 25 January 1997 Dear editor: Heimann and collabora- tors [2] report performance of pri- mary vitrectomy with gas tamponade without the use of additional scleral buckling in a series of patients who had unusual, multiple or large breaks, vitreous hemorrhage, proliferative vitreoretinopathy (PVR) and bullous retinal detachment. It is known that scleral buckling might have some complications like oculomotor imbalance, altered re- fractive error, anisometropia, infec- tions due to the external implant and even macular distortion. So, it is log- ical to perform primary vitrectomy in patients with ocular media opacities due to dense vitreous hemorrhages and detachments with vitreoretinal tractions [1]. However, there are three points which merit further consider- ation in this article. First, the authors did not state the PVR grades. It is important to separate vitreous base and to remove tractions completely in the patients with PVR extending to three or more quadrants, especially if anterior PVR is present. Anterior PVR is the most common cause of ana- tomic failure after vitreoretinal sur- gery for severe PVR (4). Such severe cases require vitreoretinal surgery in addition to scleral buckling [3]. Second, it is almost impossible to remove anterior tractions without dis- turbing the lens in these cases. Even clear lens extraction is offered in such severe cases to relieve anterior trac- tions completely [3]. So, scleral buck- ling is again advantageous here over pars plana vitrectomy (PPV). Third, neovascularization as a complication is seen much more frequently after PPV than after conventional surgery. In cases like single breaks, conventional sur- gery would suffice and would be safer. Third, patient selection criteria for primary vitrectomy, especially if PVR is considered, are not clearly stated in the article. It appears to us it would be convenient to perform primary vit- rectomy in patients with poor view of the retina, breaks posterior to the equator, large breaks, and early PVR. On the other hand, cataract incidence is very high following primary vit- rectomy in this study, so it is obvious that a second surgical procedure would be needed. Thus, it is inadvis- able to perform primary vitrectomy alone in eyes where conventional surgery is also strongly indicated or would suffice by itself, as the vitrec- tomy without buckling may cause the situation to become more complicated and may increase the recurrence rate. References 1. Gartry DS, Chignell AH, Franks WA, Wong D (1993) Pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment uncomplicated by advanced proliferative vitreoretinopathy. Br J Ophthalmol 77:199-203 2. Heimann H, Bornfeld N, Helbig H, Kellner U, Foerster MH (1996) Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment. Graefe's Arch Clin Exp Ophthalmol 234:561-568 3. Lewis H (1994) Management of severe proliferative vitreoretinopathy. In: Lewis H, Ryan SJ (eds) Medical and surgical retina. Mosby Year Book, St. Louis, pp 115-145 4. Lewis H, Aaberg TM (1991) Causes of failure after repeat vitreoretinal surgery for severe proliferative vitreoretinopathy. Am J Ophthalmol 111:15-19 C. Batman • O. Cekic Vitreoretinal Surgery Division, SSK Ankara Eye Hospital, Ankara, Turkey C. Barman ( ~ ) Koroglu Caddesi, Kupe Sokak, No. 11/3, TR-06700 Gaziosmanpasa, Ankara, Turkey Tel. +90-3 12-4 25 31 32; Fax +90-3 12-4 25 34 41 H. Heimann N. Bornfeld H. Helbig U. Kellner M.H. Foerster Reply Received: 6 March 1997 Dear Editor: We would like to thank Dr. Batman and Dr. Cekic for their comments in which they underline two major unresolved issues con- cerning the use of primary pars plana vitrectomy (PPPV) in rhegmatoge- nous retinal detachment (RRD): 1. The indications for PPPV in RRD are not clearly established. Most sur- geons would agree on using scleral buckling surgery for the treatment of uncomplicated RRD with single small breaks as well as on using PPPV in cases complicated by dense vitreous haemorrhage or preoperative prolifer- ative vitreoretinopathy (PVR). How- ever, between these two extremes, a large grey zone exists (encompassing clinically problematic cases such as most of the patients of our series) in which both techniques could be used but neither has been proven advanta- geous over the other. The intention of our study was not to demonstrate that PPPV is superior to other techniques in these cases. Instead, the study was conducted to report the outcome and complications of this surgical tech- nique, particularly as the use of PPPV is currently gaining widespread pop- ularity in comparable cases. 2. The surgical technique of PPPV varies considerably from surgeon to surgeon. For example, different in- traocular tamponades are installed (air, SF6, C3F8, silicone), and the use of additional scleral buckling is a point of intense debate. To our knowledge, no scientific data exist that prove the advantages of addi- tional scleral buckling with PPPV for RRD or define its indications.