Presentations from retinal detachment masters at APAO/AIOC 2025 teemed with practical surgical pearls for pediatric patients, complex retinal detachments and more.
Retinal detachments can be a minefield of vision-threatening complications for posterior segment surgeons—but a panel of experts on the final day of the 40th Asia-Pacific Academy of Ophthalmology Congress, held in conjunction with the 83rd Annual Conference of the All India Ophthalmological Society (APAO/AIOC 2025), had the tools to help navigate them.
The surgical masterclass session featured eight renowned surgeons from around the world as they presented cutting-edge techniques and valuable pearls for improving retinal detachment surgical outcomes, particularly in challenging cases that have traditionally had lower success rates.
Preoperative anti-VEGF regimens, new advancements in silicone oils, and managing high myopes were just a few items on the docket, so let’s dive right in.
Decoding anatomical differences in pediatric retinal detachment
Dr. Pramod Bhende (India) addressed the unique challenges of pediatric retinal detachment surgery in his talk, placing importance on the underlying structural differences between children and adults.
“It’s important to understand pediatric anatomy,” he explained. “These eyes have narrow palpebral fissures, reduced axial length, and extremely thin sclera. The lens is softer but more spherical, creating a high risk of lens stretch.”
When selecting a surgical approach, Dr. Bhende favors scleral buckling for clear media localized detachments, single or multiple small peripheral atrophic breaks, and strong vitreous adhesions with no or focal area of PVD.
For vitrectomy cases, Dr. Bhende stressed the unique nature of the pediatric vitreous. “It’s like a gel, more dense, and very sticky,” he said, advising surgeons to spend considerable time and exercise patience during these procedures.
Methotrexate: A game-changer for complex cases?
Dr. Philip Ferrone (USA) continued with the pediatric theme by arguing for the use of intravitreal methotrexate in complicated pediatric retinal detachments—and particularly those with proliferative vitreoretinopathy (PVR).
“Though we’re familiar with methotrexate as a chemotherapeutic agent and immunosuppressive agent for uveitis, it also has dramatic anti-proliferative abilities,” Dr. Ferrone said. “It interferes with the S phase of the cell proliferation cycle and has significant anti-inflammatory characteristics.”
In his research, patients received approximately 10 methotrexate injections with impressive results: 80% of retinas remained attached following a single operation. Dr. Ferrone shared a particularly striking case of a 9-year-old with a ruptured globe who, after methotrexate treatment, had no membranes, no proliferate and no reproliferation in vision 9.5 months post-surgery.
As for Dr. Ferrone’s takeaway? “Repeated intravitreal methotrexate injections appear to facilitate persistent retinal reattachment in children with complicated retinal detachments who otherwise would not likely remain attached after complex vitreous retinal surgery,” he said.
Retinal detachments and the rise of high myopia
Myopia’s relentless march worldwide is on, and Dr. Sanyam Bajimaya (Nepal) addressed the increasing prevalence of myopia-related retinal detachments, particularly in the Asia-Pacific region.
Dr. Bajimaya listed the primary surgical challenges in high myopes: thin sclerae, long axial length, difficulty reaching the posterior pole, thin retinas with multiple retinal breaks, visualization issues during surgery, break localization, giant retinal tears (GRT), PVR, post-op hypotony and secondary glaucoma.
After playing several surgical videos demonstrating techniques for dealing with high myopia and pathologic myopia, he made his conclusion.
“Surgeons must choose their technique based on vitreoretinal relationships,” he said. “This includes the number of breaks and quadrants of detachment, the extent of chorioretinal atrophic areas, the presence of posterior staphyloma, and the status of the fellow eye.”
Strategies for complex detachments with PVR
Dr. Muhammad Amer Awan’s (Pakistan) session focused on managing complicated retinal detachments—and especially on those with PVR.
When approaching these cases, Dr. Awan believes in the importance of proper surgical planning and technique selection. “For non-posterior vitreous detachments with peripheral retinal breaks and grade C PVR, scleral buckling can be the first option, especially in young patients,” he said.
READ MORE: Novel In-Office Procedure for Retinal Detachment Shows Promise
“However, in patients with retinal detachment with coloboma detachment or large or giant retinal tears, vitrectomy is the better procedure.”
Before ending his talk, Dr. Awan also echoed Dr. Ferrone in acknowledging the emergence of postoperative intravitreal methotrexate.
Managing Giant Retinal Tears with PFCL
GRTs can cause giant problems, and Dr. Tariq Ali (Bangladesh) shared his tips for managing them.
One key advancement in GRT management has been the introduction of perfluorocarbon liquid (PFCL), which has drastically increased primary attachment rates since its introduction by Stanley Chang in 1987.
Dr. Ali offered precise technical guidance on using PFCL in GRTs. “Inject PFCL very slowly with a double-bore cannula, and PFCL should be given as a single bubble to prevent fish eggs,” he said.
Besides PFCL, Dr. Ali mentioned other tools and techniques in the modern vitrectomy landscape, including wide-angle viewing systems and chandelier illumination. But despite these advancements, there is one critical, time-tested tip that doesn’t require the latest tech. “GRTs, above all else, need early treatment in addition to these modern vitrectomy tools and techniques,” he concluded.
The times with silicone oil in retinal detachments, they are a-changin’
Dr. Ling Kiet Phang’s (Malaysia) presentation revolved around the evolving role of silicone oil in retinal detachments as he addressed the present landscape and future prospects for the material.
One major talking point was the differences between standard and heavy silicone oils like Densiron Xtra (Geuder GmbH; Heidelberg, Germany, and Fluoron; Ulm, Germany).
“Theoretically, 5,000-centistoke silicone oil is more resistant to emulsification over time,” Dr. Phang noted, making it preferable when longer-term tamponade is needed. For inferior breaks, heavier oils are also a good choice. “Heavy silicone oil offers better and higher primary success rates for inferior pathology and reduces the rate of retinectomy intraoperatively,” he said.
While Dr. Phang believes that silicone oil is still viable in modern retinal detachment surgeries in the near term, he also shouted out up-and-comers like foldable capsular vitreous bodies1, hydrogel-based tamponades2, and medium-chain triglycerides3 as being on the long-term horizon.
Success Factors in Scleral Buckling
Scleral buckling isn’t going out of style in retinal detachments, and Dr. Salvin Karahin Arachchige (Sri Lanka) discussed predictive factors for successful scleral buckling procedures.
He first noted the procedure’s advantages in the modern vitreoretinal surgery landscape. “Scleral buckling preserves the vitreous and reduces the risk of cataract and glaucoma, with no need for tamponade or positioning, and is cost-effective,” he said.
Patient selection is crucial, with age being a key, independent factor for predicting the success of scleral buckling. “Younger patients without PVD have more success with scleral buckling alone,” he said.
He also pointed to the extent of the detachment, lens status, ocular and systemic conditions, the presence of myopia, and PVR as important predictive factors to examine when deciding for or against the procedure.
Diabetic Tractional Retinal Detachments
Dr. Carlo Nasol (Philippines) rounded out the session with updates on managing diabetic tractional retinal detachments.
The anti-VEGF age is here, and it’s not just for disease management. Dr. Nasol praised the benefits of preoperative anti-VEGF therapy, pointing to its ability to shrink neovascular complexes and reduce bleeding.
Dr. Nasol also advocated for small-gauge vitrectomy, noting that with the new 20k cut rate available on some devices, surgeons can operate safely with less traction.
After a series of carefully explained surgical videos detailing various procedures he uses in management of diabetic tractional retinal detachments, he touted modern advancements like bimanual procedures, the aforementioned utility of anti-VEGF therapies, and intraoperative optical coherence tomography, and intravitreal dexamethasone.
References:
- Lin, X., Wang, Z., Jiang, Z., et al. (2021). Preliminary efficacy and safety of a silicone oil-filled foldable capsular vitreous body in the treatment of severe retinal detachment. Annals of Palliative Medicine, 10(10), 10922–10929. https://doi.org/10.21037/apm-21-2554
- Spang, M. T., & Christman, K. L. (2018). Extracellular matrix hydrogel therapies: In situ tissue engineering and regenerative medicine approaches. Biomaterials, 164, 66–81. https://doi.org/10.1016/j.biomaterials.2018.02.024
- Traul, K. A., Driedger, A., Ingle, D. L., & Nakhasi, D. (2000). Review of the toxicologic properties of medium-chain triglycerides. Food and Chemical Toxicology, 38(1), 79–98. https://doi.org/10.1016/S0278-6915(99)00137-5