Surgical Management of Pseudophakic Retinal Detachments

Guidelines and treatment patterns for primary rhegmatogenous retinal detachments: Expert consensus and survey in Taiwan Retina Society

Rhegmatogenous retinal detachment (RRD) is a significant cause of vision loss and requires appropriate surgical intervention. There are several approaches available, including observation, laser demarcation, pneumatic retinopexy, scleral buckling, and pars plana vitrectomy, which are chosen based on patient condition, surgeon experience, and national health insurance policies. Despite the various options, there is still no consensus on the optimal intervention. To address this, the Taiwan Retina Society assembled an expert committee with 11 experienced retina specialists to review the current evidence and develop a guideline with seven recommendations for managing RRD patients. Additionally, a survey was conducted with six questions to assess treatment patterns in Taiwan, which included input from the expert committee and an open poll at the 2023 Congress of the Taiwan Retina Society. This report provides a comprehensive summary of the current knowledge and expert consensus on the treatment of RRD, discussing the characteristics of current approaches and providing an overview of current treatment patterns in Taiwan. These findings aim to provide ophthalmologists with the best possible treatment for RRD.

Postoperative Results in the Treatment of Retinal Detachment with Scleral Buckling Surgery

BACKGROUND

The course after scleral buckling surgery is investigated in patients with rhegmatogenous retinal detachment.

PATIENTS AND METHODS

The Ethics Committee of Eastern Switzerland approved the retrospective single-center study (EKOS19/152, Project ID: 2019-02034). The primary endpoint is the anatomical reattachment of the retina 3 months after surgery. Secondary endpoints are visual acuity and the occurrence of intra- and postoperative complications. The patient files of all patients treated for rhegmatogenous retinal detachment with scleral buckling surgery between January 2005 and December 2014 at the Cantonal Hospital of St. Gallen were included.

RESULTS

In 165 of 184 patients (89.7%), reattachment of the retina 3 months postoperatively was achieved by single scleral buckling surgery. Treatment of rhegmatogenous retinal detachment improved patients' visual acuity by an average of 4.8 ETDRS letters. Intraoperatively, subretinal hemorrhage occurred in one patient. Postoperatively, interfering buckling material was removed in 24 patients (13.1%). A pars plana vitrectomy was performed in six patients (3.2%) due to epiretinal membrane, in two patients (1.1%) due to a macular hole, and in three patients (1.6%) due to disturbing vitreous opacities.

CONCLUSIONS

Scleral buckling surgery is an effective and relatively low complication method for the treatment of selected patients with rhegmatogenous retinal detachment.

Novel classification system for management of rhegmatogenous retinal detachment with minimally invasive detachment surgery: a network meta-analysis of randomized trials focused on patient-centred outcomes

OBJECTIVE

To describe a novel classification system for primary rhegmatogenous retinal detachment (RRD) based on level 1 evidence assessing the functional outcomes of repair techniques with the goal of using a minimally invasive detachment surgery.

METHODS

A systematic review and network meta-analysis of randomized, controlled trials comparing pneumatic retinopexy (PnR), scleral buckle (SB), or pars plana vitrectomy (PPV) for RRD was conducted. Primary outcomes were best-corrected visual acuity (BCVA), metamorphopsia, and operative complications. A meta-analysis was performed with a random effects maximum likelihood model, with outcomes of standardized mean difference (SMD) or risk ratio (RR) and 95% confidence interval. Inclusion and exclusion criteria were assessed to inform a classification system.

RESULTS

Fourteen trials were included. RRDs were classified from categories 1-3 based on configuration (simple to complex). There was no significant difference in final BCVA between PnR and PPV (categories 1 and 2; SMD = -0.10, 95% CI -0.24 to 0.04), nor was a final BVCA difference found between SB and PPV (SMD = 0.01, 95% CI -0.05 to 0.08), combined SB + PPV and PPV (SMD = 0.02, 95% CI -0.08 to 0.12), or combined SB + PPV and SB (SMD = 0.01, 95% CI -0.11 to 0.12). SB had an elevated risk of choroidal detachment (RR = 5.17, 95% CI 1.68-15.97), hypotony (RR = 12.26, 95% CI 1.63-92.04), and strabismus or diplopia (RR = 5.86, 95% CI 1.04-32.91) compared with PPV but a lower risk of iatrogenic breaks (RR = 0.08, 95% CI 0.02-0.43). Vertical metamorphopsia scores were superior for PnR over PPV at 12 months (Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial, p = 0.026).

CONCLUSION

This novel classification system may be useful for future trials assessing morphologic categories of RRD in a systematic manner. Minimally invasive detachment surgery may allow for trials to focus on maximizing functional outcomes while minimizing morbidity.

Comparison of treatment outcomes of 360° intraoperative laser retinopexy and focal laser retinopexy with pars plans vitrectomy in patients with primary rhegmatogenous retinal detachment

BACKGROUND

This study was to compare the outcomes of 360° intra-operative laser retinopexy (ILR) and focal laser retinopexy in treating patients with pars plans vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD). To identify other potential risk factors for retinal re-detachment after primary PPV.

METHODS

This was a retrospective cohort study. Three hundred and forty-four consecutive cases of primary rhegmatogenous retinal detachment treated with PPV were included between July 2013 and July 2018. Clinical characteristics and surgical outcomes were compared between focal laser retinopexy and additional 360° intra-operative laser retinopexy groups. Both univariate and multiple variable analysis were used to identify potential risk factors for retinal re-detachment.

RESULTS

Median follow-up was 6.2 months (Q1, Q3:2.0, 17.2). As estimated with survival analysis, the 360º ILR group had the incidence of 9.74% and focal laser 19.54% at 6 months postoperatively. At 12 months postoperatively the difference was 10.78% vs. 25.21%. The difference in survival rates was significant (p = 0.0021). In multivariate Cox regression, the risk factors for retinal re-detachment were without additional 360° ILR, diabetes and macula off before the primary surgery (relatively OR = 0.456, 95%-CI [0.245-0.848], p < 0.05; OR = 2.301, 95% CI [1.130-4.687], p < 0.05; OR = 2.243, 95% CI [1.212-4.149], p < 0.05).

CONCLUSION

Additional 360° ILR group had a significantly lower rate of retinal re-detachment when compared with focal laser retinopexy group. Our study also elucidated that diabetes and macular off before the primary surgery might also be the potential risk factors for higher rate of retinal re-detachment outcome.

TRIAL REGISTRATION

This was a retrospective cohort study.

Reoperation Rates of Patients Undergoing Primary Noncomplex Retinal Detachment Surgery in a Cohort of the IRIS Registry

PURPOSE

To present the reoperation rates of patients who underwent a primary noncomplex RD repair in a cohort of the American Academy of Ophthalmology IRIS Registry.

DESIGN

Retrospective, nonrandomized comparative clinical study.

METHODS

This was a retrospective, nonrandomized cohort study of patients who underwent a primary noncomplex RD repair with either a scleral buckle (SB) or vitrectomy with or without scleral buckle (PPV±SB) between 2013 and 2016. The primary outcome was the odds of reoperation within 12 months.

RESULTS

Of 24,068 patients, 2,937 patients (12.2%) underwent an SB and 21,131 patients (87.8%) a PPV ± SB. The overall reoperation rate was 12.2% for SB and 11.6% for PPV ± SB. After multivariate adjustment for age and initial RD diagnosis, the PPV ± SB group exhibited a lower odds of reoperation within 12 months compared with SB only (OR 0.84, 95% CI 0.75-0.96, P = .007). However, there was an age interaction. Patients ≤50 years old with PPV ± SB exhibited a higher odds of reoperation (OR 1.46, 95% CI 1.14-1.88, P = .003) compared to SB only. Patients >50 years with PPV ± SB had a lower odds of reoperation (OR 0.73, 95% CI 0.63-0.84, P < .0001).

CONCLUSION

The odds of reoperation of PPV ± SB compared with SB only varies depending on the patient's age. Further subset analyses are required to determine if there are clinically relevant differences with respect to RD configuration or other RD repair types (PPV only vs PPV with SB).

Functional and Structural Outcomes at the Foveal Avascular Zone with Optical Coherence Tomography Following Macula off Retinal Detachment Repair

Background

Visual recovery following macula involving rhegmatogenous retinal detachment remains poorly understood. The aim of this work is to correlate the functional and the anatomical changes in retinal vasculature in the foveal avascular zone using optical coherence tomography angiography (OCTA) after successful retinal reattachment repair and correlate this data with retinal thickness and post-operative visual recovery.

Methods

A prospective, comparative observational study of 28 eyes of 14 patients with 14 eyes undergoing macula off retinal detachment repair with pars plana vitrectomy, endo-laser and silicone oil-based tamponade compared with 14 fellow healthy eyes at 1, 6 and 12 weeks post-operative period. The study was conducted at the Research Institute of Ophthalmology, Giza, Egypt between February 2018 and August 2018.

Results

The foveal avascular zone (FAZ) area in the patients group was not significantly different compared to the control group and was found to be negatively correlated with the central retinal thickness in both the study and control group. The superficial capillary plexus (SCP) area at the FAZ was significantly larger than the deep capillary plexus (DCP) area at the FAZ in both the study and control group over the follow-up period. The DCP area at the FAZ was significantly larger at the 3rd follow-up than the 1st follow-up. The SCP FAZ area was significantly larger than the DCP FAZ area in both the study and control group over the follow-up period. BCVA was found to be negatively correlated to the retinal thickness of the temporal 3 mm paracentral quadrant with no correlation with central foveal thickness (CFT) and the FAZ area.

Conclusion

Optical coherence tomography (OCT) and OCTA are valuable noninvasive imaging tools to monitor and predict the structural changes at the foveal avascular zone during the recovery phase after successful retinal reattachment involving macula.

Pars plana vitrectomy plus scleral buckle versus pars plana vitrec-tomy in pseudophakic retinal detachment

INTRODUCTION

Cataract surgery increases the risk for rhegmatogenous retinal detachment. Pars plana vitrectomy and scleral buckling are two surgical procedures used for its repair. The combination of both techniques had been proposed for rhegmatogenous retinal detachment in patients with previous cataract surgery (pseudophakic or aphakic), but its effectiveness remains unclear.

METHODS

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews with eight studies overall, one of them was a randomized trial. With this data, we conclud-ed that pars plana vitrectomy plus scleral buckle may make little or no difference in primary or final retinal reattachment rate nor in final visual acuity, but the certainty of the evidence is low. In terms of surgery complications, we are uncertain if vitrecto-my plus scleral buckle increases the risk of proliferative vitreoretinopathy or reduces the risk of glaucoma because the certainty of the evidence is very low.

Macular microstructure and visual acuity after macula-off retinal detachment repair by 23-gauge vitrectomy plus silicone endotamponade

Objectives

To study the macular microstructural changes and their relationship to visual acuity (VA) following primary vitrectomy and silicone tamponade for retinal detachment.

Patients and methods

A total of 40 cases with macula-off rhegmatogenous retinal detachment underwent 23-gauge vitrectomy with silicone oil tamponade. Cases with open globe injury and other ocular pathology were excluded. Optical coherence tomography (OCT) imaging of the macula was done about 3 and 6 months postoperatively. OCT macular microstructural changes were recorded and correlated to VA.

Results

A total of 36 eyes were evaluated by statistical analysis. The best-corrected VA (BCVA) improved in 35 patients (97.2%) and remained unchanged in one patient (2.8%). Patients were divided into two groups based on 6-month postoperative BCVA: group I with 6-month postoperative BCVA of <1 LogMAR and group II with 6-month postoperative BCVA of ≥1 LogMAR. No disruption of retinal microstructure occurred in 70% of cases in group I. Mild disruption was found in 30% of group I and 25% of group II, whereas severe disruption was found in 75% of group II cases. Epiretinal membrane formed early in three eyes in group II and late in two eyes in group I.

Conclusion

Macular microstructural changes detected by OCT is directly correlated to visual outcomes of retinal detachment repair.

Scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives

Although the technique of pars plana vitrectomy (PPV) develops rapidly, scleral buckling (SB) has several advantages over PPV for rhegmatogenous retinal detachment (RRD), including early visual rehabilitation and prevention of cataract progression. It is recommended to select the primary procedure for RRD by considering the advantages and disadvantages of each procedure based on the patient status. The vitreous body status affects the features of RRD. Vitreous liquefaction is an age-dependent process, resulting in the development of posterior vitreous detachment (PVD). RRD is usually associated with PVD, typically presenting with a retinal tear, strong vitreoretinal traction, and bullous detachment. In contrast, RRD may develop without PVD, and typically presents with a small atrophic hole, shallow detachment, and slow progression. RRD with less liquefied vitreous and no PVD can be managed successfully with SB alone even in the presence of subretinal strand as less liquefied vitreous acts as bio-tamponade blocking fluid passage. The strong traction induced by PVD and bullous detachment in an eye with extensively liquefied vitreous reduces the success rate of SB. PPV is gaining popularity as the primary procedure for RRD, especially in eyes with retinal tears, PVD, or pseudophakia. Nevertheless, SB remains the preferred procedure in young phakic patients without PVD.

Pars plana vitrectomy with or without intraoperative 360° peripheral endolaser for rhegmatogenous retinal detachment treatment

PURPOSE

The aim of this study was to investigate whether intraoperative 360° prophylactic endolaser photocoagulation is necessary for the treatment of uncomplicated retinal detachment.

METHODS

This prospective, randomized, comparative and interventional study includes 50 consecutive patients with primary rhegmatogenous retinal detachment (RRD) who were treated by pars plana vitrectomy. The patients were divided into two groups: in Group A endolaser applied to all existing breaks as well as a 360° laser retinopexy, while Group B received endolaser only to the retinal breaks. Primary anatomical success rate, a final best-corrected visual acuity (BCVA) and postoperative complications were analyzed and compared between the groups at 1 and 3 months.

RESULTS

After the primary procedure, the retina was reattached in 96% (24 of 25) of patients in Group A and in 88% (22 of 25) of patients in Group B at 1 and 3 months. The mean final BCVA (logarithm of the minimum angle of resolution) improved from 1.26 to 0.52 in Group A with 17 cases (68%) macula-off and 1.19 to 0.77 in Group B with 18 cases (72%) macula-off at preoperative and final follow-up visit. Epiretinal membranes were seen in four cases in Group A and four cases in Group B at 3 months. No statistically significant difference in the anatomical, functional and complication outcomes between the two groups was recorded.

CONCLUSIONS

Pars plana vitrectomy without the 360° peripheral endolaser can provide successful anatomic outcomes and functional improvement in uncomplicated primary RRDs.

Prognostic Factors after Primary Vitrectomy and Perfluorocarbon Liquids for Bullous Rhegmatogenous Retinal Detachment

Purpose

To identify prognostic factors for visual acuity and anatomic outcomes associated with bullous rhegmatogenous retinal detachment (RRD) management using primary pars plana vitrectomy, intraoperative perfluorocarbon liquids (PFCLs), and internal gas tamponade.

Methods

The authors studied a consecutive series of 115 eyes (115 patients) with a bullous RRD not complicated by proliferative vitreoretinopathy (PVR) associated with large, multiple, and/or posterior breaks in 58 (50.4%) eyes. All eyes underwent vitrectomy, injection of PFCL, and gas tamponade as the primary procedure. Encircling scleral bands were placed in all cases. The follow-up period ranged from 3 to 60 months (mean 16.6±14.1 months).

Results

Retinal reattachment was achieved in 92.2% of eyes (106/115) with one operation and in all eyes after a second procedure. PVR was observed in 1 (0.87%) eye and pre-retinal membranes in 3 (2.6%) eyes. Progression of pre-existing cataract and development of new cataract occurred in 45 (58.4%) of the 77 phakic eyes. The presence of inferior retinal breaks was significantly associated with redetachment after the first procedure (p=0.0156). On univariate analysis, better preoperative visual acuity (p<0.001), macular sparing retinal detachment (p<0.001), and fewer quadrants involved by the detachment (p=0.0015) were significant positive prognostic factors for final visual acuity. Logistic regression analysis highlighted that macular sparing retinal detachment and absence of trauma were associated with better final visual acuity.

Conclusions

Redetachment was associated with the presence of inferior retinal breaks. Visual recovery was dependent on preoperative visual acuity, macular involvement, extent of retinal detachment, and trauma.

VITREORETINAL SURGERY WITH SILICONE OIL TAMPONADE IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT: Clinical Outcomes and Complications

BACKGROUND

To determine the anatomical and functional outcomes and possible complications after pars plana vitrectomy (PPV) with silicone oil (SO) tamponade in primary uncomplicated rhegmatogenous retinal detachments.

METHODS

This is a prospective observational study. Overall, 62 consecutive patients who underwent surgical repair by PPV and SO injection for primary uncomplicated rhegmatogenous retinal detachment between January 01, 2006 and April 30, 2012 were followed. In general, PPV was chosen over scleral buckling when a significant cataract or a vitreous hemorrhage prevented adequate fundus visualization. Silicone oil was chosen over gas tamponade in patients living at 1,000 meters above the sea level, where SF6 or C3F8 tamponade could not be performed because of the risk of acute increase of intraocular pressure (IOP). One thousand centistokes SO was used in all eyes. At all visits, patients had a detailed ocular history and thorough bilateral evaluation, including best-corrected visual acuity, anterior segment examination, and IOP measurements by aplanation and fundus examination. Outcomes were assessed at 1 day, 1 week, 1 month, 3 months, 6 months, and every 6 months thereafter. Increased IOP was defined as an IOP of more than 21 mmHg.

RESULTS

Anatomical success rate, final best-corrected visual acuity, IOP elevation, cataract formation, and other complications were the main outcome measures. This study included 62 eyes of 62 patients (41 men and 21 women) that underwent retinal detachment repair by PPV and SO injection. The age at the time of intervention was 57.6 ± 10.5 years (mean ± standard deviation; range, 34-79 years). All patients were whites. Mean follow-up was 24.5 ± 17.3 months (range, 6-70 months). Anatomical success rate defined as retinal reattachment 6 months after SO removal was 93.5%. Final BCVA was improved in 55 eyes (88.7%), with a mean of 4 Snellen lines, unchanged in 5 (8.1%), and worse in 2 eyes (3.2%), with a mean of 3 Snellen lines. Mean duration of SO tamponade was 5.12 ± 2.37 months (range, 2-12 months). From the 30 eyes that were still phakic after vitrectomy, 24 eyes (80.0%) underwent cataract surgery within a period of 7.37 ± 3.00 months (range, 2-13 months). Thirty-five eyes (56.5%) had an increase in IOP during the follow-up period. Thirty-one patients had transient ocular hypertension requiring topical treatment during the immediate postoperative period (one month). Only 1 eye (2.9%) required filtrating drainage surgery for IOP control. No eyes developed optic neuropathy secondary to IOP elevation.

CONCLUSION

Pars plana vitrectomy with SO injection seems to be a safe and efficient surgical approach in the treatment of primary uncomplicated rhegmatogenous retinal detachment in patients living in high altitude (>1,000 m). Also, PPV and SO injection are associated with good anatomical and functional outcomes in our series. Reattachment rates are high, and rates of proliferative vitreoretinopathy are low. Cataract formation and elevated IOP represent frequent but successfully controlled complications.

Anatomical and functional outcomes of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment

Retinal detachment is the separation of the sensory retina from the retinal pigment epithelium by subretinal fluid. There are several types of retinal re-attachment surgery, including scleral buckling (SB), pneumatic retinopexy, and vitrectomy (with or without SB). The objective of this study was to compare anatomical and visual outcomes between patients with pseudophakic rhegmatogenous retinal detachment (RRD) who underwent pars plana vitrectomy (PPV) with silicone oil (SO) or perfluoropropane (C3F8) gas tamponade and pseudophakic RRD patients who underwent SB surgery. We evaluated retrospectively 101 pseudophakic RRD patients from a single center. The patients were classified into three groups according to the surgical procedure performed: PPV + Silicone - patients who underwent PPV with SO tamponade; PPV + Gas - patients who underwent PPV with perfluoropropane gas tamponade; and SB group - patients who underwent SB surgery. The groups were compared with regard to primary and final anatomical and visual outcomes. The number of patients in PPV + Silicone, PPV + Gas, and SB group was 39 (38.6%), 32 (31.7%), and 30 (29.7%), respectively. The mean follow-up period in PPV + Silicone, PPV + Gas, and SB group was 33.95 ± 23.58, 32.62 ± 10.95, and 33.76 ± 16.62 months, respectively. No significant difference was observed between the groups neither with regard to primary and final anatomical and visual success rates nor in relation to the recurrence rate of retinal detachment. According to our anatomical and visual outcome results, either of the three methods (i.e., PPV + Silicone, PPV + Gas, or SB) can be used in the treatment of pseudophakic retinal detachment.

Long-term follow-up of vitrectomy, with or without 360° encircling buckle, for rhegmatogenous retinal detachment due to inferior retinal breaks

Objective

The aim of this study was to report and compare the anatomic and functional results of primary vitrectomy with and without 360° encircling scleral buckle (SB) for the treatment of rhegmatogenous retinal detachment (RRD) due to inferior retinal break(s).

Background

A variety of options, including SB, pars plana vitrectomy (PPV) with or without SB, and pneumatic retinopexy have been described as methods to repair RRDs. The use of additional SB with vitrectomy for RRD associated with inferior breaks has been a recent controversy after the introduction of transconjunctival cannula systems.

Patients and methods

A retrospective, interventional, comparative case study was performed. In this study, we reviewed 105 consecutive patients who underwent vitrectomy for primary RRD with inferior retinal break(s) at the vitreoretinal center, performed by a single surgeon. Ninety four patients (94 eyes) were followed up for at least 4 months after silicon oil removal (SOR), and were analyzed. They were divided into two groups: group I included 50 patients who underwent PPV alone + silicon oil (SO); and group II included 44 patients who underwent PPV with 360° SB + SO. The essential parameters were single-operation success rate (SOSR) before SOR, incidence of retinal redetachment after SOR, and final visual acuity.

Results

SOSR was obtained in 89 eyes (47 [94%] in group I and 42 [95.5%] in group II). From overall 59 phakic retinal detachments (RDs), SOSR was obtained in 56 eyes (30 in group I [93.8%] and 26 in group II [96.3%]) while from overall 35 aphakic or pseudophakic RDs, SOSR was obtained in 33 eyes (17 in group I [94.4%] and 16 in group II [94.1%]). Retinal redetachments after SOR occurred in three patients in group I and two patients in group II. Visual acuity improvement was greater in group I than in group II before SOR.

Conclusion

Both surgical procedures had similar reattachment rates. The addition of 360° SB to PPV + SO might not have additional benefits in patients with RD due to inferior retinal break.

Scleral Buckling for Rhegmatogenous Retinal Detachment Associated with Pars Planitis

Purpose. To evaluate the surgical outcome of scleral buckling (SB) in rhegmatogenous retinal detachment (RRD) patients associated with pars planitis. Methods. Retrospective review of RRD patients (32 eyes of pars planitis RRD and 180 eyes of primary RRD) who underwent SB. We compared primary and final anatomical success rates and visual outcomes between two groups. Results. Primary and final anatomical success were achieved in 25 (78.1%) and 31 (96.8%) eyes in the pars planitis RRD group and in 167 eyes (92.7%) and 176 eyes (97.7%) in primary RRD group, respectively. Both groups showed significant visual improvement (p < 0.001) and there were no significant differences in final visual acuity. Pars planitis RRD group was associated with higher rate of postoperative proliferative vitreoretinopathy (PVR) development (12.5% versus 2.8%, p = 0.031). Pars planitis and high myopia were significant preoperative risk factors and pseudophakia was borderline risk for primary anatomical failure after adjusting for various clinical factors. Conclusions. Pars planitis associated RRD showed inferior primary anatomical outcome after SB due to postoperative PVR development. However, final anatomical and visual outcomes were favorable. RRD cases associated with pars planitis, high myopia, and pseudophakia might benefit from different surgical approaches, such as combined vitrectomy and SB.

A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment

PURPOSE

To compare face-down positioning and adjustable positioning after pars plana vitrectomy for the repair of rhegmatogenous retinal detachment.

METHODS

Sixty-eight eyes from 68 patients with rhegmatogenous retinal detachment were included in this study. All patients received pars plana vitrectomy with long-acting gas for tamponade and then subdivided into 2 groups: 29 were included in a face-down group and 39 were included in the adjustable positioning group. Patients were followed up for 3 months. The main outcome was the rate of anatomical retinal reattachment. Secondary outcome measures were best-corrected visual acuity and postoperative complications.

RESULTS

Most of the preoperative baseline characteristics between the two groups were not significantly different. The anatomical success rates after primary surgery were 89.7% and 92.3% for the face-down group and the adjustable positioning group, respectively (P = 1.00). Best-corrected visual acuity at the 3-month postoperative visit was 0.74 ± 0.25 for the face-down group and 0.77 ± 0.36 for the adjustable positioning group, respectively (P = 0.41). The rates of complications were not statistically different in the two groups.

CONCLUSION

Adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment repair is effective and safe. Face-down positioning seems not to be necessary for all patients with rhegmatogenous retinal detachment.

Comparison of scleral buckling and vitrectomy using wide angle viewing system for rhegmatogenous retinal detachment in patients older than 35 years

Background

To compare scleral buckling (SB) and pars plana vitrectomy (PPV) using a wide angle viewing system (WAVS) for uncomplicated phakic rhegmatogenous retinal detachment (RRD).

Methods

The medical records of patients with uncomplicated phakic RRD were retrospectively reviewed. Eyes with pseudophakic or attached fovea were excluded. Patients treated with SB were classified as group B, and PPV using WAVS as group V. Primary success rate, visual acuity (VA), macular complications, and sustained subretinal fluid (SRF) were compared between groups.

Results

Seventy-two eyes were included in group B and 57 eyes in group V. Group B had better preoperative VA (1.38 ± 0.87 vs 1.84 ± 0.97 in LogMAR, P = 0.010), but worse final VA (0.51 ± 0.48 vs 0.30 ± 0.23, P = 0.012) than group V. The primary success rate of 94.7 % in group V was higher than 77.8 % in group B (P = 0.010). Final success rate was 100 % in both groups. There was no significant difference in macular complications between groups (P = 0.087). Sustained SRF was found in 22 eyes in group B (38.6 %), while only two eyes in group V exhibited sustained SRF (2.8 %, P < 0.001).

Conclusions

Pars plana vitrectomy using WAVS was more efficacious than SB for treating uncomplicated phakic RRD.

Combined pars plana vitrectomy-scleral buckle versus pars plana vitrectomy for proliferative vitreoretinopathy

The purpose of the study is to evaluate the surgical outcomes of combined pars plana vitrectomy-scleral buckle (PPV-SB) versus pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment complicated with proliferative vitreoretinopathy (PVR). One thousand one hundred and seventy four patients with rhegmatogenous retinal detachment surgery between January 2002 and December 2013 were retrospectively reviewed. Patients with grade C PVR treated with either combined PPV-SB or PPV alone were included in the study. Study outcomes included single surgery anatomic success rate and postoperative visual outcome at 12 months postoperatively. Seventy-seven patients with grade C PVR were identified for analysis. At the end of 12-month follow-up, 80.5 % eyes (33/41) in the PPV-SB group and 58.3 % eyes (21/36) in the PPV group achieved single surgery anatomical success. In a multiple logistic regression model, none of the baseline variables (age, gender, macula status, grade of PVR, extent of detachment, presence of vitreous hemorrhage, lens status, status of high myopia) nor types of retinal detachment surgery (use of scleral buckle, barrier endolaser, 360 degree endolaser, cryopexy, retinectomy, tamponade agent, phacoemulsification) had significant effect on single surgery anatomical success. The post-treatment mean logMAR visual acuity of the PPV-SB group was 1.58 ± 0.58 and the PPV group was 1.57 ± 0.61. There was no significant difference in the postoperative visual acuity between the two groups (P = 0.849). For patients with grade C PVR, PPV-SB did not demonstrate a superiority over PPV alone in achieving single surgery anatomical success.

Vitrectomy combined with endolaser or an encircling scleral buckle in primary retinal detachment surgery: a pilot study

PURPOSE

To compare pars plana vitrectomy and 360° endolaser therapy with pars plana vitrectomy and an encircling scleral buckle for the treatment of primary rhegmatogenous retinal detachments in a randomized pilot study including 60 patients.

METHODS

Main outcome measures were single-surgery anatomic success rate and final best-corrected visual acuity at 6 months follow-up. Cofactors analysed were complication rates, patients' comfort, refractive outcome and macula status assessed using a spectral-domain optical coherence tomography.

RESULTS

With differences between both treatment groups regarding type of the retinal detachment, localization of retinal tears (p = 0.0085) and the choice of the intraocular tamponade (p < 0.0202), there were no significant differences between the single-surgery anatomic success rate (93.33% both groups, p = 1.0) and the visual acuity at final follow-up (≤0.3 logMAR [logarithm of minimum angle of resolution] in 66.67% in the endolaser group versus 40.0% in the scleral buckle group, p = 0.0514). Questionnaire responses showed lower levels of patients' discomfort in the endolaser group. A significant difference between both groups was found in the refractive error change after surgery (-0.20 ± 0.51 dioptres in the endolaser group versus -0.88 ± 0.88 dioptres in the scleral buckle group, p = 0.0003).

CONCLUSION

Primary vitrectomy combined with 360° endolaser therapy seems to be as effective as vitrectomy combined with an encircling scleral buckle in patients with rhegmatogenous retinal detachment, with possible benefits of an improved patients' comfort and a more stable refractive status after surgery.

Surgical complications of primary rhegmatogenous retinal detachment: a meta-analysis

BACKGROUND

To investigate the surgical complications of scleral buckling (SB) and pars plana vitrectomy (PPV) performed on primary rhegmatogenous retinal detachment (RRD) and to discover which surgical procedures bring fewer complications.

METHODS

An electronic literature search using the PubMed database, ISI Web of Knowledge and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and observational studies comparing SB with PPV on primary RRD. Outcome measures included intra-operative complications and early and late post-operative complications.

RESULTS

During the operation, significantly less subretinal hemorrhage occurred in the PPV group than in the SB group (OR = 4.71; 95%CI, 1.33-16.64; p = 0.02) and the hypotony incidence was significantly higher in the SB group (OR = 18.24; 95%CI, 2.37-140.44; p = 0.005); however, the occurrence of iatrogenic breaks was significantly lower in the SB group (OR = 0.05; 95%CI, 0.01-0.21; p<0.0001). In the early stage of post-operation, significantly higher incidence of choroidal detachment was identified in the SB group than in the PPV group (OR = 10.19; 95%CI, 2.36-44.09; p = 0.002); patients undergoing SB had significantly higher odds of residual subretinal fluid (OR = 14.71; 95%CI, 1.84-117.32; p = 0.01); the occurrence of high intraocular pressure was significantly lower in the SB group (OR = 0.46; 95%CI, 0.23-0.89; p = 0.02); and no significant difference was shown in the incidence of epithelia defect (p = 0.37) between the two groups. In the late stage of post-operation, the incidence of diplopia/extraocular muscle dysfunction was significantly higher in the SB group (OR = 4.04; 95%CI, 1.30-12.52; p = 0.02); and significantly less cataract was observed in the SB group (OR = 0.20; 95%CI, 0.14-0.30; p<0.00001); no significant difference was found in the incidences of cystoid macular edema (p = 0.65), macular pucker (p = 0.52), post-operative proliferative vitreoretinopathy (p = 0.73) and epiretinal membrane (p = 0.47) in other late post-operative complications.

CONCLUSIONS

This meta-analysis suggests that PPV could be considered as potential surgical management on primary RRD.

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center

PURPOSE

To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center.

METHODS

Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed.

RESULTS

There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes.

CONCLUSION

There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

Cost-effectiveness of retinal detachment repair

OBJECTIVE

To evaluate costs and treatment benefits of rhegmatogenous retinal detachment (RD) repair.

DESIGN

A Markov model of cost-effectiveness and utility.

PARTICIPANTS

There were no participants.

METHODS

Published clinical trials (index studies) of pneumatic retinopexy (PR), scleral buckling (SB), pars plana vitrectomy (PPV), and laser prophylaxis were used to quantitate surgical management and visual benefits. Markov analysis, with data from the Center of Medicare and Medicaid Services, was used to calculate the adjusted costs of primary repair by each modality in a hospital-based and ambulatory surgery center (ASC) setting.

MAIN OUTCOME MEASURES

Lines of visual acuity (VA) saved, cost of therapy, adjusted cost of therapy, cost per line saved, cost per line-year saved, and cost per quality-adjusted life years (QALY) saved.

RESULTS

In the facility, hospital surgery setting, weighted cost for PR ranged from $3726 to $5901 depending on estimated success rate of primary repair. Weighted cost was $6770 for SB, $7940 for PPV, and $1955 for laser prophylaxis. The dollars per line saved ranged from $217 to $1346 depending on the procedure. Dollars per line-year saved ranged from $11 to $67. Dollars per QALY saved ranged from $362 to $2243. In the nonfacility, ASC surgery setting, weighted cost for PR ranged from $1961 to $3565 depending on the success rate of primary repair. The weighted costs for SB, PPV, and laser prophylaxis were $4873, $5793, and $1255, respectively. Dollars per line saved ranged from $139 to $982. The dollars per line-year saved ranged from $7 to $49, and the dollars per QALY saved ranged from $232 to $1637.

CONCLUSIONS

Treatment and prevention of RD are extremely cost-effective when compared with other treatment of other retinal diseases regardless of treatment modality. Retinal detachment treatment costs did not vary widely, suggesting that providers can tailor patient treatments solely on the basis of optimizing anticipated results because there were no overriding differences in financial impact.

Rhegmatogenous retinal detachment--an ophthalmologic emergency

BACKGROUND

Rhegmatogenous retinal detachment is the most common retinological emergency threatening vision, with an incidence of 1 in 10 000 persons per year, corresponding to about 8000 new cases in Germany annually. Without treatment, blindness in the affected eye may result.

METHOD

Selective review of the literature.

RESULTS

Rhegmatogenous retinal detachment typically presents with the perception of light flashes, floaters, or a "dark curtain." In most cases, the retinal tear is a consequence of degeneration of the vitreous body. Epidemiologic studies have identified myopia and prior cataract surgery as the main risk factors. Persons in the sixth and seventh decades of life are most commonly affected. Rhegmatogenous retinal detachment is an emergency, and all patients should be seen by an ophthalmologist on the same day that symptoms arise. The treatment consists of scleral buckle, removal of the vitreous body (vitrectomy), or a combination of the two. Anatomical success rates are in the range of 85% to 90%. Vitrectomy is followed by lens opacification in more than 70% of cases. The earlier the patient is seen by an ophthalmologist, the greater the chance that the macula is still attached, so that visual acuity can be preserved.

CONCLUSION

Rhegmatogenous retinal detachment is among the main emergency indications in ophthalmology. In all such cases, an ophthalmologist must be consulted at once.

Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR study): Risk assessment of anatomical outcome. SPR study report no. 7

PURPOSE

The 'Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study' (SPR study) is a randomized multicentre trial comparing primary vitrectomy (PV) and scleral buckling surgery (SB) for rhegmatogenous retinal detachment (RRD). This subanalysis was conducted to identify risk factors associated with anatomical outcomes.

METHODS

Relating the anatomical success results at the 1-year follow-up visit to pre- and intraoperative findings using multivariate statistical methods.

RESULTS

In the phakic subtrial, anatomical success was negatively associated with the number of breaks (p < 0.0001), break extension > 1 clock hour (p = 0.0005) and intraoperative use of cryotherapy (p = 0.0484). It was positively associated with retinal breaks with irregular edges (p = 0.0353) and subretinal fluid drainage (p = 0.0155). In the pseudophakic/aphakic subtrial, anatomical success was negatively associated with the number of retinal breaks (p = 0.0004) and previous YAG capsulotomy (p = 0.0256), and the combined effect of the surgical procedure and intraoperative use of laser (p = 0.0229).

CONCLUSION

Primary anatomical success is an important result for patients undergoing RRD surgery. Our data demonstrate that the final anatomical outcome is related to a higher preoperative number of breaks and cryotherapy in phakic eyes. Additional risk factors varied between phakic and pseudophakic subgroups. Our findings may be used to facilitate the prognosis of future patients with RRD.

Timing of acute macula-on rhegmatogenous retinal detachment repair

PURPOSE

To determine if same-day or next available surgery changed the outcome of patients presenting with acute macula-on rhegmatogenous retinal detachments.

METHODS

A retrospective review of patients presenting with acute macula-on rhegmatogenous retinal detachments treated with small-gauge vitrectomy was performed. Data collection included subjects' demographics, duration of symptoms, location and extent of the retinal detachment, and timing of surgery. The primary outcome was anatomical and functional success rate for patients having same-day surgery compared with those for whom surgery was delayed.

RESULTS

One hundred and fourteen patients were included in this study. Sixty-two patients operated on day of presentation, 46 patients operated the day after presentation, and in 6 patients, surgery was delayed from 2 to 5 days. Time to surgery in hours ranged between 1 and 120 hours (mean 14.5 ± 15.05 hours). Retinal reattachment was achieved in 95.6% of patients, with 80% requiring only one procedure. Mean initial visual acuity was logarithm of the minimum angle of resolution 0.42 (SD 0.6), and mean final visual acuity was logarithm of the minimum angle of resolution 0.39 (SD 0.67) (P = 0.53). Time to surgery was not found to effect final anatomical outcome (P = 0.56). No statistically significant association was observed between change in visual acuity and time to surgery (P = 0.99).

CONCLUSION

Modest delay in timing of surgery for macula-on rhegmatogenous retinal detachment did not adversely impact on patients' outcome.

Strategy for the management of complex retinal detachments: the European vitreo-retinal society retinal detachment study report 2

OBJECTIVE

To study the outcome of the treatment of complex rhegmatogenous retinal detachments (RRDs).

DESIGN

Nonrandomized, multicenter, retrospective study.

PARTICIPANTS

One hundred seventy-six surgeons from 48 countries spanning 5 continents reported primary procedures for 7678 RRDs.

METHODS

Reported data included clinical manifestations, the method of repair, and the outcome.

MAIN OUTCOME MEASURES

Failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the study's conclusion (level 2 failure rate), and need for additional procedures to repair the detachments (level 3 failure rate).

RESULTS

The main categories of complex retinal detachments evaluated in this investigation were: (1) grade B proliferative vitreoretinopathy (PVR; n = 917), (2) grade C-1 PVR (n = 637), (3) choroidal detachment or significant hypotony (n = 578), (4) large or giant retinal tears (n = 1167), and (5) macular holes (n = 153). In grade B PVR, the level 1 failure rate was higher when treated with a scleral buckle alone versus vitrectomy (P = 0.0017). In grade C-1 PVR, there was no statistically significant difference in the level 1 failure rate between those treated with vitrectomy, with or without scleral buckle, and those treated with scleral buckle alone (P = 0.7). Vitrectomy with a supplemental buckle had an increased failure rate compared with those who did not receive a buckle (P = 0.007). There was no statistically significant difference in level 1 failure rate between tamponade with gas versus silicone oil in patients with grade B or C-1 PVR. Cases with choroidal detachment or hypotony treated with vitrectomy had a significantly lower failure rate versus treatment with scleral buckle alone (P = 0.0015). Large or giant retinal tears treated with vitrectomy also had a significantly lower failure rate versus treatment with scleral buckle (P = 7×10(-8)).

CONCLUSIONS

In patients with retinal detachment, when choroidal detachment, hypotony, a large tear, or a giant tear is present, vitrectomy is the procedure of choice. In retinal detachments with PVR, tamponade with either gas or silicone oil can be considered. If a vitrectomy is to be performed, these data suggest that a supplemental buckle may not be helpful.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials

PURPOSE

To examine possible differences in clinical outcomes between pars plana vitrectomy (PPV) and scleral buckling (SB) for uncomplicated rhegmatogenous retinal detachment (RRD).

DESIGN

Meta-analysis.

PARTICIPANTS

Adult patients with uncomplicated RRD from previously reported randomized controlled trials of PPV and SB.

METHODS

A comprehensive literature search using the Cochrane Collaboration methodology to identify randomized controlled trials comparing PPV with SB for uncomplicated RRD.

MAIN OUTCOME MEASURES

Analysis was divided into phakic and pseudophakic/aphakic patients. Primary outcome parameters included proportion of primary reattachment and difference of means of best-corrected visual acuity (BCVA) at 6 months or more between the PPV and SB groups. Secondary outcome parameters included the proportion of secondary reattachment and complications between the PPV and SB groups.

RESULTS

Seven studies were identified and analyzed for comparing PPV (636 eyes) with SB (670 eyes) for uncomplicated RRD. In the phakic group, there were no significant differences in the proportion of primary reattachments (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.69-1.46) or secondary reattachments (OR, 0.99; 95% CI, 0.34-2.87) between the PPV and SB groups. Meta-analysis showed a statistically significant difference in the logarithm of the minimum angle of resolution (logMAR) BCVA at 6 months between the PPV-treated and SB-treated phakic eyes (mean deviation, 0.14; 95% CI, 0.06-0.21; P<0.0004). In the pseudophakic/aphakic group, there were no significant differences in the proportion of primary reattachments (OR, 1.46; 95% CI, 0.79-2.71) or logMAR BCVA at 6 months between the PPV and SB groups (mean deviation, -0.03; 95% CI, -0.10 to 0.04). A statistically significant difference was noted in the proportion of secondary reattachments (OR, 2.08; 95% CI, 1.08-4.03; P = 0.03) between the PPV and SB groups in pseudophakic/aphakic eyes. Meta-analysis showed a statistically significant rate of cataract progression in the PPV group (OR, 4.11; 95% CI, 2.70-6.25; P<0.00001).

CONCLUSIONS

There were no significant differences in the proportions of primary reattachment in the PPV and SB groups in phakic eyes. The SB-treated phakic eyes had better postoperative BCVA at 6 months or more. This is most likely related to higher rates of cataract progression in PPV-treated phakic eyes. There were no significant differences in proportions of primary reattachment and postoperative BCVA at 6 months or more in pseudophakic/aphakic eyes.

Rhegmatogenous retinal detachment treatment guidelines

This paper outlines general guidelines following the initial diagnosis of rhegmatogenous retinal detachment. These include preoperative evaluation, treatment, possible intra- and post-operative complications, retinal re-detachment, and all therapeutic options available for each case. Treatment of the traumatic retinal detachment is also described, due to its importance and peculiarities. Treatment or prophylactic guidelines are suggested for the different types of retinal detachment described. These are based on both the experience of the ophthalmologists that have participated in preparing the guidelines, and also on evidence-based grading linked to bibliographical sources. However, these guidelines should not be interpreted as being mandatory. Given that there is a wide spectrum of options for treatment of retinal detachment, the surgeons' experience with one or other surgical technique will be of utmost importance in obtaining the best surgical result. As guidelines, they are intended as an additional aid to the surgeon during the decision-making process, with the expectation that the final choice will still be left to the surgeon's judgment and past experience.

Trends in primary retinal detachment surgery: results of a Bicenter study

PURPOSE

To assess trends and outcomes in retinal detachment (RD) surgery based on a retrospective, interventional, bicenter study.

METHODS

Baseline demographic data, surgical procedures, and outcomes from 230 patients with a diagnosis of primary rhegmatogenous RD, who underwent surgery between January 2007 and December 2008 at the Rudolf Foundation Clinic, Vienna (Center 1) and the Weill Cornell Medical College, New York, (Center 2) were analyzed using a regression model.

RESULTS

Besides the baseline parameters, lens status (P = 0.01), refraction (P = 0.01), retinal tears (P < 0.02), proliferative vitreoretinopathy (P = 0.02), and previous treatment (P < 0.02), the primary RD procedure (P < 0.0001) was significantly different between the 2 centers. In Center 1, scleral buckling was the most common primary RD procedure (66.19%) compared with vitrectomy (82.42%) in Center 2. Primary retinal reattachment (88.49% Center 1 vs. 84.62% Center 2, P = 0.43) and best-corrected visual acuity at the final follow-up (best-corrected visual acuity ≥ 0.3 logarithm of minimum angle of resolution 48.92% Center 1 vs. 47.25% Center 2, P = 0.78) were not significantly different between the 2 centers.

CONCLUSION

Although there is a trend toward primary vitrectomy, scleral buckling was preferred in the center in Vienna and primary vitrectomy in the center in New York. Despite the different primary RD procedures, anatomical and visual outcomes were comparable.

Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment

PURPOSE

To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD).

DESIGN

Retrospective, nonrandomized, interventional case series.

METHODS

We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA).

RESULTS

SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29).

CONCLUSIONS

The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.

Pars plana vitrectomy for primary rhegmatogenous retinal detachment

Pars plana vitrectomy (PPV) is growing in popularity for the treatment of primary rhegmatogenous retinal detachment (RD). PPV achieves favorable anatomic and visual outcomes in a wide variety of patients, especially in pseudophakic RD. A growing number of clinical series, both retrospective and prospective, have demonstrated generally comparable outcomes comparing PPV and scleral buckling (SB) under a variety of circumstances. The Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study is a multicenter, randomized, prospective, controlled clinical trial comparing SB versus PPV. This study should provide useful guidelines in the future. At this time, the choice of SB versus PPV should be based on the characteristics of the RD, the patient as a whole, and the experience and preference of the individual retinal surgeon.

Pars plana vitrectomy versus combined pars plana vitrectomy and scleral buckle for primary repair of rhegmatogenous retinal detachment

OBJECTIVE

To compare pars plana vitrectomy (PPV) with PPV and scleral buckle (PPV/SB) for repair of rhegmatogenous retinal detachment (RRD).

DESIGN

A retrospective chart review.

PARTICIPANTS

Patients who underwent PPV or PPV/SB for RRD repair at a single institution.

METHODS

A retrospective chart review of patients in two different treatment groups and analysis of the anatomic and functional results.

RESULTS

Single-surgery anatomic success was achieved in 31 of 37 (83.8%) phakic eyes that underwent PPV and in 66 of 68 (97.1%) phakic eyes that underwent PPV/SB (p = 0.0216). Among pseudophakic eyes, 42 of 48 (87.5%) in the PPV group and 62 of 66 (93.9%) in the PPV/SB group achieved single-surgery reattachment (p = 0.3175). Visual acuity improvement was marginally greater in the PPV group among phakic (p = 0.4898) and pseudophakic (p = 0.2465) eyes.

CONCLUSIONS

PPV/SB may be associated with a decreased risk for retinal redetachment when compared to PPV for repair of phakic RRD. In pseudophakic eyes, the anatomic success rate between the two techniques appears to be similar.

Vitreoretinal fellow surgical outcome of small gauge pars plana vitrectomy for acute rhegmatogenous retinal detachment

BACKGROUND

Our purpose was to determine the anatomical outcome following small gauge vitrectomy for acute rhegmatogenous retinal detachment (RRD) operated by vitreoretinal fellows.

METHODS

We undertook a retrospective review of adult patients presenting with an acute RRD treated with small gauge vitrectomy where the operating surgeon was either a vitreoretinal fellow or consultant surgeon. The patient's demographics were recorded as well as relevant clinical findings. The end point was determined to be the anatomical outcome and number of surgeries.

RESULTS

Two hundred and twelve eyes were included in this study. The age range was 21-90 years, with approximately one third of the patients being female. The macula was attached in 53% at presentation, and 65% of the eyes were phakic. Primary re-attachment with a single operation was achieved in 75% of cases, and final re-attachment rate was 92%. Mean presenting visual acuity was LogMAR 1.07 (SD 1.09) and final visual acuity was LogMAR 0.63 (SD 0.85). We found no association between final anatomical success and experience of the surgeon (p = 0.6).

CONCLUSION

We found that acute RRD treated by vitreoretinal fellows using small gauge vitrectomy did not place the patient at any discernable disadvantage.

Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): predictive factors for functional outcome. Study report no. 6

PURPOSE

To identify risk factors associated with best-corrected visual acuity (BCVA) 1 year after initial surgery following primary vitrectomy (PV) and scleral buckling surgery (SB) for rhegmatogenous retinal detachment (RRD).

METHODS

Relating the final BCVA at the 1-year follow-up visit to pre- and intraoperative findings in the "randomized, prospective, multicenter clinical trial comparing scleral buckling versus primary vitrectomy for repair of rhegmatogenous retinal detachment" (SPR Study) using multivariate statistical methods.

RESULTS

In the phakic subtrial, final BCVA is associated with the number of breaks (p = 0.0259), duration of symptoms (p = 0.0476), baseline BCVA (p = 0.0002), retinal detachment central to major vessels arcades (p = 0.0088), total detachment (p = 0.0027), and chain formation of breaks (p = 0.0129). In the pseudophakic/aphakic subtrial, final BCVA is related to the number of retinal breaks (p = 0.0010), secondary cataract or central capsular fibrosis (p = 0.0141), intraoperative laser photocoagulation (p = 0.0373), and inferior detachment with breaks below the 4 and 8 o'clock positions (p = 0.0173).

CONCLUSION

Final BCVA is the most important outcome for patients undergoing RRD surgery. Our results demonstrate that the final BCVA is related to a higher preoperative number of breaks in both subtrials. Additional risk factors varied between phakic and pseudophakic subgroups.

One-year outcomes after retinal detachment surgery among medicare beneficiaries

PURPOSE

To determine longitudinal rates of second retinal detachment operation and postoperative adverse outcomes after retinal detachment surgery in a nationally representative sample of older Americans.

DESIGN

Retrospective, longitudinal cohort analysis.

METHODS

A total of 9216 Medicare beneficiaries were identified from the Medicare 5% sample who were diagnosed with rhegmatogenous retinal detachment and underwent primary pars plana vitrectomy (PPV), scleral buckle, pneumatic retinopexy, or laser photocoagulation or cryotherapy alone. Rhegmatogenous retinal detachment, PPV, scleral buckle, pneumatic retinopexy, or laser photocoagulation/cryotherapy was ascertained from International Classification of Diseases and Current Procedural Terminology procedure codes. Rates of second retinal detachment operation and postoperative adverse outcomes were analyzed by cumulative incidence and logistic regression to control for prior adverse outcome measures and demographic factors.

RESULTS

At 1-year follow-up, the rate of receipt of a second retinal detachment operation for beneficiaries who had undergone primary pneumatic retinopexy was much higher (40.6%, P < .0001) relative to the scleral buckle (19.2%) group. After controlling for demographic variables and ocular comorbidities, pneumatic retinopexy individuals were nearly 3 times more likely to receive a second retinal detachment surgery than scleral buckle individuals. No significant differences exist in risk of second retinal detachment surgery for the PPV compared to the scleral buckle group. Individuals receiving PPV were 2 times more likely to suffer adverse outcomes than were those undergoing scleral buckle. Results were robust in sensitivity analysis.

CONCLUSIONS

Rates of second operation were much higher after pneumatic retinopexy than PPV or scleral buckle, and rates of adverse outcomes were higher in PPV, even after controlling for risk factors and demographic variables.

Incidence of redetachment 6 months after scleral buckling surgery

PURPOSE

The preoperative and intraoperative clinical variables associated with redetachment and/or a poor visual outcome following scleral buckling (SB) surgery for rhegmatogenous retinal detachment (RRD) have mainly been studied after a short follow-up. This study aimed to analyse long-term effects by following patients for at least 6 months.

METHODS

In a retrospective survey we evaluated the data of 436 eyes that underwent SB surgery. Postoperative data were collected at 3-month intervals.

RESULTS

After a mean follow-up period of 51 months, anatomic reattachment was achieved in 76% after one SB procedure, with a final reattachment rate of 97% after additional vitreoretinal procedures. In total, 104 eyes developed redetachment during follow-up. After more than 6 and 12 months of follow-up, 32 eyes (7%) and 20 eyes (5%), respectively, developed redetachment. Multivariate regression analysis showed that recurrent redetachment and more than 7 days of visual field loss were significant predictors for a poor postoperative visual outcome at 12 months. A cumulative size of the tear of more than three disc diameters was a significant predictor of recurrent RRD.

CONCLUSION

Conventional SB surgery is a reliable procedure in a selected group of eyes with primary RRD. However, in eyes with a retinal tear with a cumulative size of more than three disc diameters, a primary vitrectomy should be considered. Taking into account that 7% of eyes developed redetachment after 6 months, a longer follow-up period seems necessary to evaluate the anatomical and visual outcomes after SB surgery.

Primary 360° Broad Buckling in Retinal Detachment

BACKGROUND

Chronic rhegmatogenous retinal detachment behaves like proliferative vitreo-retinopathy (PVR) even without evidence of the same. Surgery could be done either with conventional buckling procedures where the extent of buckling is determined by the number and location of the breaks or by primary vitreous surgery. In this study these cases were managed with primary 360°encircling broad buckle without a vitreous procedure.

METHODS

210 eyes, with rhegmatogenous retinal detachment of more than six months duration and with PVR up to C3 (CP3 focal) were subjected to buckling surgery. Trans-scleral cryopexy of the breaks, 360°encircling buckle with a 276 - 279 tire and subretinal fluid drainage was performed.

RESULT

Most (85.74%) of the eyes showed anatomical retinal re-attachment.

CONCLUSION

Primary broad encircling buckling can be conducted successfully in cases of long standing retinal detachment.

Visual and anatomic outcomes of vitreoretinal surgery: results at the Boston VA and a review of the literature

Introduction

The veteran population presents unique challenges in the management of vitreoretinal disorders. We compiled the surgical outcomes for the most common visually significant vitreoretinal diagnoses. Those results were then compared to visual and anatomic outcomes established in the literature.

Materials and Methods

Medical records over a three-year time period, from January 2005 through December 2007, were reviewed for 208 persons who underwent vitreoretinal surgery for vitreous hemorrhage, retained lens fragment, rhegmatogenous and tractional retinal detachment, macular hole, and macular pucker at the Jamaica Plain Campus of the Veterans Affairs Boston Healthcare System in Boston, MA. A comprehensive search of the literature was conducted on Medline. Data from several large case series and meta-analyses were compared to results obtained at the VA Boston.

Results

A total of 208 veterans underwent vitreoretinal surgery from January 2005 to December 2007. After excluding those with rare diagnoses and lack of adequate follow-up data, the outcomes of 181 vitreoretinal procedures were included in this study.

Discussion

Overall, veterans at a regional referral center in Boston demonstrate postoperative visual and anatomic outcomes comparable to outcomes reported in the ophthalmic literature.