Short-term external buckling with pneumatic retinopexy for retinal detachment with inferior retinal breaks

ADDITIONAL PNEUMATIC RETINOPEXY IN PATIENTS WITH PERSISTENT RETINAL DETACHMENT AFTER SCLERAL BUCKLING

PURPOSE

To investigate the efficacy, safety, and indications for additional pneumatic retinopexy (PR) in patients with persistent retinal detachment after scleral buckling.

METHODS

This retrospective study included patients who underwent additional PR after scleral buckling for primary rhegmatogenous retinal detachment (n = 78). We defined "inadequate buckle" as retinal detachment persistence because of low buckle height despite accurate buckle placement and "buckle misplacement" as an uncovered tear because of incorrect buckle placement.

RESULTS

The anatomical success rate after additional PR was 52.6%. Development of proliferative vitreoretinopathy Grade B (hazard ratio, 5.73; P < 0.001) and inferior retinal tears (hazard ratio, 2.12; P = 0.040) were significant risk factors for anatomical failure. The most common cause of anatomical failure was proliferative vitreoretinopathy (19 of 37; 51.4%), and epiretinal membrane formation was a common complication after additional PR (22 of 78; 28.2%). The anatomical success rate with additional PR was significantly higher in the inadequate buckle group than in the misplacement group (8 of 9 [88.9%] vs. 1228 [42.9%]; P = 0.023).

CONCLUSION

Development of proliferative vitreoretinopathy Grade B and inferior retinal tears were significantly associated with anatomical failure after additional PR. Additional PR may benefit patients with superior retinal tears or low buckle height and those without proliferative vitreoretinopathy.

Scleral buckling with adjuvant pneumatic retinopexy versus scleral buckling alone for rhegmatogenous retinal detachment

To compare the efficacy of scleral buckling with adjuvant pneumatic retinopexy (SB with PR) and scleral buckling (SB) alone for primary rhegmatogenous retinal detachment (RRD). This retrospective and comparative study included patients who underwent SB with PR (n = 88) or SB alone (n = 161) for primary RRD. The primary anatomical success rate for SB with PR was 81.8%, whereas that for SB alone was 80.7% (P = 0.836). Among patients who achieved primary anatomical success, those in the SB with PR group showed postoperative epiretinal membrane (ERM) formation more frequently than those in the SB alone group (11 of 72 [15.3%] vs. 6 of 130 [4.6%]) (P = 0.009). The mean time to subretinal fluid absorption was not significantly different between the SB with PR and SB alone groups (11.2 ± 6.2 vs. 11.4 ± 5.8 months, P = 0.881). In the SB with PR group, retinal detachment involving ≥ three quadrants was a significant risk factor for surgical failure (hazard ratio, 3.04; P = 0.041). Adjuvant pneumatic retinopexy does not provide additional benefit in improving the surgical outcomes of SB for primary RRD repair.

Pneumatic Retinopexy Versus Pars Plana Vitrectomy for the Management of Retinal Detachment: A Systematic Review and Meta-Analysis

INTRODUCTION

Pneumatic retinopexy (PnR) was proposed as an alternative to pars plana vitrectomy (PPV) in certain circumstances. PnR is an outpatient procedure and more cost-effective. However, its benefits should be judged alongside its success rate and adverse events. Herein, we compare the efficacy and safety of PnR and PPV for rhegmatogenous retinal detachment (RRD) repair.

METHODS

We searched the PubMed, Scopus, EMBASE, Web of Science, Cochrane, and Google Scholar databases. Observational and interventional studies comparing the efficacy and safety of PnR and PPV were included. The outcomes were the success rate of the treatment, improvement in visual acuity, and adverse event rates. Subgroup analysis was performed based on the lens and macula status. Eleven articles were eligible to enter our study; these consisted of 11,346 patients with a mean age of 74.1.

RESULTS

PnR was superior to PPV in terms of retinal displacement, photoreceptor integrity, visual function, and vertical metamorphopsia scores. In the meta-analysis, PPV showed higher a reattachment rate than PnR (OR = 3.39, 95% CI 2.25-5.11). Subgroup analysis showed that the advantage of PPV over PnR was more pronounced in studies with fewer phakic eyes, more macula-on patients, and in cases with primary PnR failure. While PnR patients had better pre-op (SMD = - 0.58, 95% CI = - 1.16 to 0.00) and post-op (SMD = - 0.45, 95% CI = - 0.60 to - 0.30) LogMAR, the improvement in visual acuity after surgery was higher in PPV patients (SMD = 0.49, 95% CI = - 0.15 to 1.13).

CONCLUSION

The success rate of PnR was higher in studies published after 2015 compared to previous studies (82% vs. 59%). Cataract formation and surgery were significantly higher in the PPV arm, while the occurrence of new retinal tears was more frequent in the PnR group. PnR can be used as the primary procedure for RRD repair in selected cases. However, we propose some modifications to the PIVOT criteria, e.g., the exclusion of cases presenting with several risk factors of poor outcomes.

A Comparative Study of Traditional Scleral Buckling to a New Technique: Guarded Light Pipe with Heads-Up Three-Dimensional Visualization

Purpose

The guarded light pipe is a recently described alternative endoillumination technique to chandelier illumination. We sought to compare the outcomes of scleral buckling (SB) under indirect ophthalmoscopy (ID) to heads-up three-dimensional visualization with a guarded light pipe (3DGLP).

Methods

A retrospective comparative study was performed, including 47 eyes that underwent SB for rhegmatogenous retinal detachment (RRD) repair with either traditional ID (n = 31) or 3DGLP (n = 16).

Results

The single surgery anatomic success rate was 87.0% in the ID group and 87.5% in the 3DGLP group. The final anatomic success rate was 100% in both groups. The median (interquartile range) post-operative logMAR was 0.10 (0.0–0.20) in the ID group and 0.08 (0.02–0.69) in the 3DGLP group (p = 0.51). The median operative time was 107 (94–123) minutes in the ID group and 100 (90–111) minutes in the 3DGLP group (p = 0.25). Among eyes that underwent subretinal fluid drainage, the operative time was significantly longer in the ID group compared to the 3DGLP group, 113 (100–135) minutes vs 93 (85–111) minutes (p = 0.035). There were no post-operative complications in the ID group and one complication of self-resolving vitreous hemorrhage associated with a malfunctioning cryoprobe in the 3DGLP group (p = 0.34). There were no cases of post-operative cataract progression in either group.

Conclusion

Compared to traditional SB, 3DGLP improves ergonomics and educational value with similar anatomical, visual, intra and post-operative outcomes and may result in shorter operative time in cases requiring subretinal fluid drainage.

Pneumatic retinopexy: A critical reappraisal

Pneumatic retinopexy (PR) has been widely advocated for treatment of selected rhegmatogenous retinal detachments: those with small, anterior, superior, retinal breaks and little or no proliferative vitreoretinopathy. It has been suggested that PR is underused and is advantageous because it is an outpatient clinic or office procedure, short in duration, nonincisional, and cost saving - with reduced perioperative morbidity, faster postoperative recovery, better and faster visual recovery, a low rate of complications and a high rate of overall success compared with scleral buckling or pars plana vitrectomy. We reevaluated these advantages to substantiate the effectiveness and efficiency of PR and critically define its role in the treatment of rhegmatogenous retinal detachment. We found that PR has a much higher rate of subsequent reoperation and proliferative vitreoretinopathy than scleral buckling or pars plana vitrectomy for simple, good prognosis rhegmatogenous retinal detachments. PR often involves multiple procedures that largely negates its potential cost savings and subjects the patient to prolonged stress and disability. Scleral buckling rather than PR is ideally suited for simple, good prognosis rhegmatogenous retinal detachments for surgeons who feel comfortable with the technique; alternatively, pars plana vitrectomy is indicated.

Pneumatic retinopexy: patient selection and specific factors

Pneumatic retinopexy is a minimally invasive, non-incisional procedure for repairing retinal detachment. This procedure is associated with reduced morbidity, reduced cost and faster postoperative recovery compared to pars plana vitrectomy and scleral buckling. Superior visual acuity outcomes have also been reported. Intraoperative complications are primarily related to the intraocular pressure rise caused by gas injection, or the misdirection of the gas. There is a low rate of postoperative complications. Anatomic success rates of over 90% can be achieved when strict selection criteria are applied. However, a number of studies have revealed good outcomes in cases with expanded clinical indications. Pneumatic retinopexy is currently underutilized. With appropriate patient selection, a high success rate can be achieved, and therefore, this procedure has an important role in the armamentarium of the vitreoretinal surgeon.

Pneumatic retinopexy combined with scleral buckling in the management of relatively complicated cases of rhegmatogenous retinal detachment: A multicenter, retrospective, observational consecutive case series. J Int Med Res 2017;46:316-325. [PMID: 28840752 PMCID: PMC6011313 DOI: 10.1177/0300060517724931]

Objective

To evaluate the efficacy of maximal pneumatic retinopexy (PR) and subretinal fluid (SRF) drainage combined with scleral buckling (SB) in the treatment of complicated rhegmatogenous retinal detachment (RRD).

Methods

Patients with RRD who underwent maximal PR and SRF drainage combined with SB from June 2007 to June 2012 were included in this multicenter retrospective study. The outcome measures were the primary and final operation success rates and best-corrected visual acuity (BCVA).

Results

In total, 159 consecutive patients were included. The mean follow-up period was 13.76 ± 1.97 months. Primary operation success was achieved in 146/159 (91.82%) eyes. After salvage management, the final reattachment rate increased to 98.11%. All eyes had improved BCVA, with 62/159 (38.99%) attaining BCVA of ≥20/40.

Conclusions

Maximal PR and SRF drainage combined with SB achieved satisfactory anatomical and visual recovery in relatively complicated cases of RRD. The decreased need for vitrectomy makes this surgical approach more widely available.

[Scleral buckling for inferior rhegmatogenous retinal detachments]

PURPOSE

To investigate the epidemiological, clinical, therapeutic and prognostic factors in cases of inferior rhegmatogenous retinal detachments (RD) treated by scleral buckling surgery.

PATIENTS AND METHODS

A retrospective chart review was performed on 45 patients (45 eyes) with inferior RD with only inferior tears (4:00-8:00), who had been treated by scleral buckling surgery over a 6-year period from 2006 to 2011. The parameters studied included patient demographics, refractive status, time until consultation, clinical exam data, treatment modalities and functional and anatomic results.

RESULTS

Forty-five cases were included in this study (45 eyes), with an average patient age of 44.5 years (14 to 75 years) and a slight male predominance (56%). Myopia was observed in 60%. Mean time until consultation was 3.5 months. Visual acuity on admission was less than 1/10 in 53.33%. Macular detachment was found in 80%. Causative lesions were holes in 26 eyes. Proliferative vitreoretinopathy was essentially stage B in 48.9%. Scleral buckling surgery was performed in all patients, with drainage of subretinal fluid in 37.8%. Retinal reattachment was obtained in 36 eyes (80%) with a final visual acuity greater than or equal to 1/10 in 71.11%. The mean follow-up in our study was 6.62 months.

CONCLUSION

Inferior retinal detachment has a predilection for young myopes. The time until consultation is often long, and extraocular surgery, although difficult, exhibits documented efficacy.