Pseudophakic rhegmatogenous retinal detachment: combined pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone

Outcomes in Recurrent Rhegmatogenous Retinal Detachment Repair: Does Scleral Buckling at Primary or Secondary Surgery Impact Results?

Background/Objectives

To analyze outcomes in recurrent rhegmatogenous retinal detachment (re-RRD) repair using pars plana vitrectomy (PPV) combined with scleral buckle (SB) at the first or second surgery.

Subjects/Methods

Patients with primary uncomplicated RRD at initial presentation who were operated for re-RRD between 2014 and 2018 were included in this retrospective cohort study (n = 127). Patients were compared based on first and second surgery sequence: PPV then PPVSB (PPV-PPVSB: n = 51, 40%), or PPVSB then PPV (PPVSB-PPV: n = 76, 60%). Anatomical and functional outcomes were evaluated with second surgery success (2SS) defined as absence of reoperation after the second surgery and final pinhole visual acuity (PHVA) in logarithm of the minimum angle of resolution (logMAR), respectively.

Results

Mean age at initial presentation was 65.7 years. There were 78 (61%) men and 56 (44%) pseudophakic patients. Median [Q1, Q3] baseline PHVA in logMAR was 0.70 [0.18, 2.30]. SB at first or second surgery did not significantly alter 2SS (PPV-PPVSB: 38, 75% vs PPVSB-PPV: 57, 75%; p = 1.00) or silicone oil use at second surgery (PPV-PPVSB: 18, 35% vs PPVSB-PPV: 36, 47%; p = 0.40). At final follow-up, PHVA did not significantly differ by sequence (p = 0.16).

Conclusion

In re-RRD repair, SB at first or second surgery did not alter 2SS and final PHVA.

Primary Rhegmatogenous Retinal Detachment Repair by Pars Plana Vitrectomy with and without Scleral Buckling: A Propensity Score Analysis

Purpose

To evaluate the anatomical and visual outcomes of patients with rhegmatogenous retinal detachment (RRD) who received primary repair by combined pars plana vitrectomy with scleral buckling (PPV/SB) or pars plana vitrectomy (PPV) alone by using a propensity analysis.

Patients and Methods

This study was a single center retrospective observational study. Medical records of patients who underwent surgical interventions between January 2013 and December 2019 were retrospectively reviewed. The single surgery anatomic success (SSAS) and final anatomic success were the primary outcomes, whereas the final visual acuity changes was the secondary outcome.

Results

This study included a total of 683 patients (683 eyes), with a median (interquartile range, IQR) follow-up duration of 13 (5.5 to 28.8) months. Of them, 211 patients (30.9%) underwent PPV/SB, while 472 patients (69.1%) underwent PPV as their primary procedure. The two treatment groups did not significantly differ in the risk of achieving SSAS (weighted risk difference: 0.012, 95% confidence interval (CI): -0.067 to 0.092, p value = 0.776) or achieving final retinal anatomic attachment (weighted risk difference: -0.038, 95% CI: -0.106 to 0.030, p value = 0.272). The occurrence of proliferative vitreoretinopathy was identical between the two treatment groups (56 patients (26.5%) for the PPV/SB group and 104 patients (22.0%) for the PPV group), p = 0.199. Nonetheless, the patients who received PPV alone showed a significantly greater mean improvement in VA (weighted mean difference; 0.295, 95% CI; 0.150, 0.440, p <0.001).

Conclusion

This work supports the findings that adding SB to PPV had little impact on anatomical results (either a single surgical success rate or the overall final success rate) for RRD repair. Although PPV alone is shown to improve vision, confirmation of these associations requires further prospective studies using standardized surgical techniques.

Pars Plana Vitrectomy with and without Supplemental Scleral Buckle for the Repair of Rhegmatogenous Retinal Detachment: A Meta-analysis

TOPIC

It is unclear whether there are differences in safety and efficacy between pars plana vitrectomy (PPV) alone and PPV with a supplemental scleral buckle (SB; PPV-SB) for the treatment of rhegmatogenous retinal detachment.

CLINICAL RELEVANCE

This meta-analysis aimed to compare the safety and efficacy of these surgical procedures.

METHODS

In this meta-analysis, Ovid MEDLINE, Embase, and Cochrane Library were systematically searched (January 2000-June 2021). The primary outcome was the final best corrected visual acuity (BCVA), whereas the secondary outcomes were reattachment rates and complications. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized controlled trials (RCTs) and the risk of bias in nonrandomized studies of interventions tool for nonrandomized studies.

RESULTS

This study included 15 661 eyes from 38 studies (32 observational studies and 6 RCTs). The median follow-up duration was 6 months. The final BCVA was similar between PPV and PPV-SB (weighted mean difference [WMD], -0.03 logarithm of the minimum angle of resolution [-0.14 to 0.07]; P = 0.55). There was a significant difference in the single-operation success rate (SOSR) (88.2% versus 86.3%; relative risk [RR], 0.97 [0.95-1.00]; P = 0.03), favoring PPV-SB; however, there was no significant difference in the final reattachment rate (RR, 1.00 [0.99-1.01]; P = 0.56). Pars plana vitrectomy required a significantly higher number of operations to achieve final anatomical reattachment (WMD, 0.13 [0.02-0.24]; P = 0.02). In terms of complications, PPV was significantly less likely to be associated with macular edema (RR, 0.47 [0.25-0.88]; P = 0.02) and epiretinal membrane formation (RR, 0.70 [0.52-0.94]; P = 0.02), but these differences were no longer significant in studies published after 2010 or in RCTs. Significant proliferative vitreoretinopathy, lens status, and macular attachment status did not mediate differences in these effects.

CONCLUSIONS

There were no significant differences in the final visual acuity outcomes between PPV and PPV-SB. Pars plana vitrectomy with supplemental SB was associated with a greater SOSR than standalone PPV, although the magnitude of the effect was small, with a high number needed to treat. The final reattachment rate was similar. In recent studies and in RCTs, the risk of complications was similar between the procedures.

Outcomes in primary uncomplicated rhegmatogenous retinal detachment repair using pars plana vitrectomy with or without scleral buckle

PURPOSE

To compare outcomes following primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB).

METHODS

This is a retrospective cohort study with propensity score analysis in a single tertiary care center between 2014 and 2018 comparing patients with primary uncomplicated RRD repaired using PPV only or PPV-SB (full cohort: n=1516, propensity-matched cohort: n=908). The primary outcome was single surgery anatomic success (SSAS), while secondary outcomes were 3-month and final pinhole visual acuity (PHVA) in logarithm of the minimum angle of resolution (logMAR) and final retina status.

RESULTS

In the full cohort, SSAS was achieved in 745 (91%) of PPV patients vs. 623 (89%) of PPV-SB patients (p=0.13). This was 390 (92%) vs. 314 (88%) in phakic patients (p=0.06) compared to 353 (91%) vs. 301 (90%) in pseudophakic patients (p=0.79), respectively. After matching, SSAS was achieved in 424 (93%) of PPV patients vs. 412 (91%) of PPV-SB patients (p=0.14). Median PHVA after PPV was better at 3 months (PPV: 20/40 vs. PPV-SB: 20/50; both cohorts: p<0.001) and final follow-up (PPV: 20/29 vs. PPV-SB: 20/38; full cohort: p<0.001 and PPV: 20/29 vs. PPV-SB: 20/36; matched cohort: p<0.001).

CONCLUSION

Addition of SB does not significantly change the rate of SSAS compared to PPV only in primary uncomplicated RRD. It is also associated with worse PHVA at follow-up.

Clinical Outcomes in Sequential, Bilateral Rhegmatogenous Retinal Detachment: A Multicenter, Paired-Eye Analysis

PURPOSE

To assess the clinical outcomes in patients with sequential, bilateral rhegmatogenous retinal detachment (RRD) by using a paired-eye comparison.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Patients with sequential, bilateral RRD treated with pars plana vitrectomy (PPV), scleral buckle (SB), or PPV plus SB over an 11-year period (October 2008-April 2019) from 4 vitreoretinal practices were included.

METHODS

Data were collected on patient demographics, anatomic characteristics of the RRD, surgical procedures, and best-corrected visual acuity (VA). These variables, along with single-operation anatomic success (SOAS) and type and number of surgical procedures, were assessed with a paired-eye comparison.

MAIN OUTCOME MEASURES

Single-operation anatomic success between the initial-eye and subsequent-eye RRD.

RESULTS

Five hundred four eyes of 252 patients were included. The mean interval between RRD in either eye was 13.6 ± 13.4 months. Single-operation anatomic success in the initial eye was 82.5% with a mean of 1.2 surgeries (range, 1-4 surgeries). Single-operation anatomic success in the subsequent eye was 83.7% (P = 0.80) with a mean of 1.2 surgeries (range, 1-4 surgeries; P = 0.68). Visual acuity was better in the subsequent eye at presentation (mean, 20/62 vs. 20/149; P < 0.001) and postoperative month 6 (mean, 20/41 vs. 20/49; P = 0.03), but final VA was similar (20/36 vs. 20/37; P = 0.68). Macular detachment was less prevalent (34.1% vs. 56.0%; P < 0.001) with fewer quadrants detached (mean, 1.9 quadrants vs. 2.0 quadrants; P = 0.010) in the subsequent eye. Mean duration of symptoms was shorter in the subsequent eye (mean, 5.9 days vs. 7.5 days; P = 0.008). In patients who underwent a different surgical technique in each eye, PPV plus SB yielded a higher SOAS of 89.7% compared with 69.0% for PPV alone in 116 eyes (P = 0.010).

CONCLUSIONS

In this study of sequential, bilateral RRD, the SOAS was similar for each eye. The second eye was more likely to be treated earlier and to have less macular involvement, but the final VA outcomes were similar. Pars plana vitrectomy plus SB yielded a significantly higher SOAS than PPV or SB alone.

Outcomes of primary rhegmatogenous retinal detachment repair with extensive scleral-depressed vitreous removal and dynamic examination

There are multiple surgical approaches to the repair of rhegmatogenous retinal detachment (RRD). Here, we evaluated the outcomes of small-gauge pars plana vitrectomy (PPV), alone or in combination with scleral buckle (SB-PPV), for RRD repair using a standardized technique by 3 vitreoretinal surgeons: “extensive” removal of the vitreous with scleral depression and dynamic examination of the peripheral retina. One hundred eighty seven eyes of 180 consecutive patients treated for primary RRD by three vitreoretinal surgeons at a tertiary academic medical center from September 2015 to March 2018 were analyzed. Most RRDs occurred in males (134 [71.3%] eyes), affected the left eye (102 [54.3%]), and were phakic (119 [63.3%]). PPV alone was performed in 159 eyes (84.6%), with a combined SB-PPV used in the remaining 29 eyes (15.4%); focal endolaser was used in all (100%) cases. The single surgery anatomic success rate was 186 eyes (99.5%) at 3 months, and 187 (100%) at last follow up. Overall best-corrected visual acuity (BCVA) had significantly improved at 3 months ([Snellen 20/47] P<0.00005) and last follow up ([Snellen 20/31] P<0.00005), as compared to day of presentation ([Snellen 20/234]). Our findings suggest that “extensive” removal of the vitreous and dynamic peripheral examination with scleral depression may lead to high single surgery success in primary uncomplicated RRD repair.

Scleral buckling versus vitrectomy for young japanese patients with rhegmatogenous retinal detachment in the era of microincision surgery: real-world evidence from a multicentre study in Japan

PURPOSE

To evaluate real-world evidence for young Japanese patients with rhegmatogenous retinal detachment (RRD) by retrospectively examining surgical procedures and clinical outcomes in the Japan Clinical Retina Study group.

METHODS

This was a multicentre retrospective study of the medical records of 562 young patients (384 males and 178 females; mean age: 33.0 ± 11.8 years) who had been diagnosed with RRD and who underwent surgical procedures in participating centres during the period between April 2013 and August 2016.

RESULTS

The selected surgeries were scleral buckling (SB) for 295 eyes (49.7%) and pars plana vitrectomy (PPV) for 262 eyes (44.1%). Between the two surgical procedures, there was no significant difference in the primary anatomical reattachment rate (PARR, SB = 92.2%, PPV = 93.9%); improvements in vision were noted in both groups. The incidences of proliferative vitreoretinopathy and cataract formation within 1 year of PPV were 2.3% (p = 0.0047) and 6.5% (p = 0.0005), whereas they were 0% and 1.0% in the SB group, respectively.

CONCLUSION

Scleral buckling (SB) and PPV were chosen with almost equal frequency for young patients with RRD. Clinical outcomes for SB and PPV exhibited a similar PARR. The incidence of cataract formation after PPV may constitute an important limitation of the procedure.

Chandelier-assisted scleral buckling using wide angle viewing contact lens for pseudophakic retinal detachment repair

AIM

To evaluate a modified technique for scleral buckling (SB) in pseudophakic retinal detachment (RD).

METHODS

A retrospective non-comparative study included 21 consecutive eyes with uncomplicated pseudophakic RD that was repaired by chandelier assisted SB using wide angle viewing (WAV) contact lens. Segmental tire alone was used in 5 eyes (23.81%), and combined with encircling band in 7 eyes (33.33%). Radial sponge alone was used in 3 eyes (14.29%) and combined with encircling band in 6 eyes (28.57%).

RESULTS

Primary success rate was (90.48%). External drainage of subretinal fluid was performed in 8 eyes (38.1%). Intraoperative complications included vitreous prolapse at chandelier sclerotomy site in 4 eyes (19.05%) and localized subretinal hemorrhage at drainage site in one eye (4.76%). No case of intraocular lens (IOL) displacement, retinal incarceration or iatrogenic retinal tear was detected. Postoperative complications included choroidal detachment in one eye (4.76%), elevated intraocular pressure in 2 eyes (9.52%), epiretinal membrane formation in one eye (4.76%) and proliferative vitreoretinopathy in 3 eyes (14.29%). Mean postoperative corrected distance visual acuity was 0.7±0.3 logMAR units.

CONCLUSION

Chandelier-assisted SB using WAV contact lens is a reliable technique for repairing selected cases of simple pseudophakic RD.

[Treatment of retinal detachment of the pseudophak: vitrectomy without episcleral indentation versus ab externo surgery]

Several factors predispose to the occurrence of rhegmatogenous retinal detachment, including cataract surgery, myopia, and degenerative lesions of the peripheral retina as well as eye trauma. This study aims to compare the anatomical and functional outcome of the two surgical techniques (AB interno vs AB externo) in our Hospital. We conducted a descriptive, retrospective study in the Department of Ophthalmology at the University Hospital Mohamed VI in Marrakech, over a period of 3 years, ranging from January 2013 to December 2015. During the study period we compared two groups of people: the first group undergoing surgery by an external approach (cryoapplication of the dehiscences with episcleral indentation) while the second undergoing surgery by endo-ocular approach. Group A or AB externo group included 26 eyes (26 patients) while Group B or vitrectomy with internal tamponade group included 22 eyes (22 patients). In the AB externo group, the average age was 54.92 years against 51.64 years in the AB interno group, with a slight predominance of males in both groups. After the first surgery, retinal reapplication was obtained in both groups with no significant difference, (about 80.76% in Group A versus 81.82% of the second group). In both groups failure was caused advanced vitreoretinal proliferation (4 cases), de novo breaks (3 cases) and breaks which had not been detected on first examinations (2 cases). All these cases underwent reoperation by AB interno approach: patients of group A underwent complete vitrectomy with revision of the indentation +/- internal limiting membrane peeling with internal gas tamponade while patients of group B underwent complementary vitrectomy with dissection of proliferative vitreoretinopathy (PVR) and an internal tamponade with silicone oil. After a mean follow-up period of 12 months, there was no significant difference in visual acuity between the 2 groups, with more than one third of the patients who had regained visual acuity between 1/10 and 5/10 (about 34,61% in AB externo group and 36,36% in AB interno group). Given the technological advances in vitrectomy, the current trend is the endo-ocular surgery however ab-externo surgery is mainly used in the treatment of retinal detachment with visible breaks which can be easily treated with indentation without advanced vitreoretineal proliferation (PVR A-B).

Modified Controlled Encircling Scleral Buckle for Retinal Detachment

During encircling scleral buckle placement, the ends of the element are tightened to achieve a shortened radius of the eye. The determining factor of the final buckle height is subjective using usually a combination of the buckle height visualized with the degree of scleral indentation and can be difficult to be taught early on to trainees. Here, we describe a case series in which a modified controlled encircling scleral buckle technique that simplifies and standardizes the achievement of reproducible buckle height of about a 1 mm is objective and easy to be taught. This novel encircling scleral buckling technique successfully achieves a good postoperative scleral buckle height in a reproducible and standardized fashion using objective measurements and it is easier to be taught to trainees.