Pars plana vitrectomy, scleral buckle, and pneumatic retinopexy for the management of rhegmatogenous retinal detachment: a meta-analysis

SURGICAL DRAINAGE METHODS DURING PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Systematic Review and Meta-Analysis

PURPOSE

To assess efficacy and safety outcomes of subretinal fluid drainage methods during pars plana vitrectomy for rhegmatogenous retinal detachment.

METHODS

A systematic search strategy was conducted for studies published between January 2000 and October 2022. Included studies reported on either the safety or efficacy of two or more drainage methods during pars plana vitrectomy for patients with rhegmatogenous retinal detachment.

RESULTS

Two randomized and five observational studies consisting of 1,524 eyes were included. Best-corrected visual acuity at the last study observation and primary reattachment rates were similar across groups. A significantly lower risk of epiretinal membrane formation was associated with draining subretinal fluid through preexisting retinal breaks (risk ratio = 0.70, 95% confidence interval = [0.60, 0.83], P = <0.01, I 2 = 0%) or with perfluorocarbon liquid (risk ratios = 0.70, 95% confidence interval = [0.59, 0.83], P = <0.01, I 2 = 0%) compared with posterior retinotomy. The risk of an abnormal foveal contour was significantly greater in perfluorocarbon liquid-treated eyes relative to posterior retinotomy (risk ratios = 1.56, 95% confidence interval = [1.13, 2.17], P = <0.01, I 2 = 0%).

CONCLUSION

No significant differences were observed in the final best-corrected visual acuity at the last study observation and primary reattachment rates across different drainage methods. There remains limited information on the topic, so future research is warranted.

Optimizing Surgical Management for Rhegmatogenous Retinal Detachment in Eyes with Active Retinoblastoma: A Safety-Driven Approach

Introduction: Intraocular surgeries are conventionally contraindicated for patients with active retinoblastoma (Rb) due to the potential risk of tumor dissemination. However, surgery is occasionally necessary to preserve vision in patients with a single eye when the eye is complicated by rhegmatogenous retinal detachment (RRD). Objective: This study aims to evaluate the outcomes of surgical repair for RRD in pediatric patients with active Rb utilizing a non-drainage scleral buckling approach. Results: This cohort included six eyes from six patients who harbored active Rb and presented with RRD; one had a concurrent tractional component. All eyes (100%) had active intraocular Rb and were undergoing active therapy (systemic chemotherapy, cryotherapy, and thermal laser therapy) when RRD developed. RRD consistently manifested at the site of recent cryotherapy in all cases. RRD repair in the affected eyes was performed by scleral buckling without subretinal fluid drainage. Five of the six eyes (83%) achieved complete retinal reattachment. One eye (17%) with a tractional component exhibited partial reattachment and was eventually enucleated due to persistent active disease. At a median follow-up of 15 months (range 12-180 months) after scleral buckling, all five eyes had persistent retinal attachment, and no case developed orbital or distant metastasis. Conclusions: Our study demonstrates that nondrainage scleral buckling is an effective and safe method for the surgical repair of RRD in eyes harboring active Rb, as most cases achieved persistent complete retinal reattachment without the risk of tumor spread.

Quantitative Microvascular Change Analysis Using a Semi-Automated Algorithm in Macula-on Rhegmatogenous Retinal Detachment Assessed by Swept-Source Optical Coherence Tomography Angiography

PURPOSE

The purpose of this study was to objectively evaluate the longitudinal changes observed in the retinal capillaries in eyes with macula-on rhegmatogenous retinal detachment (RRD), assessed with optical coherence tomography angiography (OCTA), and to assess the role of these microvascular measures as potential biomarkers of postoperative visual outcomes.

METHODS

This was a prospective, longitudinal study conducted on consecutive patients who underwent 25 G pars plana vitrectomy for primary RRD. The vessel area density (VAD), vessel skeleton density (VSD), and vessel diameter index (VDI) were assessed in the superficial (SCP) and deep (DCP) capillary plexuses.

RESULTS

Twenty-three eyes with macula-on RRD were included in the study. The mean preoperative VDI, VAD, and VSD of the RRD eye were 18.6 ± 1.1, 0.43 ± 0.02, and 0.17 ± 0.01 in the SCP; and 18.6 ± 0.6, 0.38 ± 0.03, and 0.15 ± 0.01 in the DCP, respectively. At month 6, eight (34.8%) eyes achieved a best-corrected visual acuity (BCVA) gain ≥ 0.1 LogMAR. A preoperative VDI > 17.80, VSD > 0.170, and VDI-change > -0.395 in the SCP; and VDI > 18.11 and VDI change > -0.039 in the DCP were predictors of achieving a BCVA-gain ≥ 0.1 LogMAR.

CONCLUSIONS

The preoperative VDI in SCP and DCP, the preoperative VSD in SCP, and their changes from preoperative values were predictors of visual outcomes. A quantitative OCTA analysis of capillary density and morphology may represent a potential predictive tool for surgical outcomes in RRD. The results reported in this study suggest that OCTA is a useful ancillary test for clinical disease management.

Quality of Life after Pars Plana Vitrectomy, Scleral Buckle, or Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment: A Meta-Analysis

PURPOSE

Comparisons of the surgical and anatomic results of rhegmatogenous retinal detachment surgery have been investigated previously. A systematic evaluation of the available evidence comparing quality of life outcomes of either pars plana vitrectomy, scleral buckling, or pneumatic retinopexy has not been evaluated to date. This article analyzes whether pars plana vitrectomy, scleral buckling, or pneumatic retinopexy for the treatment of rhegmatogenous retinal detachment results in differing quality of life outcomes.

METHODS

In February of 2022, a comprehensive search of MEDLINE, EMBASE, CINHAL, and Cochrane Library was conducted for studies on patients treated surgically for rhegmatogenous retinal detachment and included follow-up measurements of quality of life outcomes. Meta-analysis was completed using STATA v. 14.0. The main outcomes of interest were the mean vision-related quality of life score (VRQOL) and SD of VRQOL of each type of surgical procedure.

RESULTS

In this systematic review of 13 distinct trials including follow-up of patient quality of life after rhegmatogenous retinal detachment surgery (n = 1063), a better correlation was found between higher quality of life outcomes with scleral buckling than with pars plana vitrectomy (SMD = 0.62, CI: [0.31, 0.93]). There was also no signficant difference in quality of life outcomes between pneumatic retinopexy and pars plana vitrectomy (SMD = 0.08, CI: [-0.07, 0.22]).

CONCLUSIONS

Scleral buckling results in better quality of life outcomes for patients when compared to pars plana vitrectomy. Pneumatic retinopexy did not show a difference in quality of life outcomes compared to pars plana vitrectomy.

Evaluation of the Effect of Scleral Buckling on Anterior Segment and Refractive Changes Using Anterior Segment Optical Coherence Tomography

PURPOSE

To evaluate the changes of anterior segment and refractive parameters after scleral buckling (SB) surgery for uncomplicated rhegmatogenous retinal detachment (RRD) using anterior segment optical coherence tomography (AS-OCT).

METHODS

Thirty-six RRD eyes were consecutively enrolled. Analysis concerned the central corneal thickness (CCT), anterior chamber depth (ACD), anterior chamber volume (ACV), iris-trabecular contact (ITC), angel opening distance (AOD), angle recess area (ARA), trabecular-iris space area (TISA)，trabecular iris angle (TIA) and refractive parameters, including average keratometry (AvgK), cylindrical power (CYL), regular astigmatism, asymmetry and high order irregularity (HOI) at baseline and 1 day, 1 month, 2 months, 6 months and 12 months postoperatively. AS-OCT was performed at RRD diagnosis and day 1, week 1, month 1 and month 6 after SB to evaluate the scleral buckling.

RESULTS

A statistically significant postoperative CCT increase, ACD and ACV decrease were observed at 1 day and 1 month postoperatively. ITC analysis showed that the angle of the entire circumference narrowed at 1 month postoperatively. There was a significant decrease in all the angle parameters (AOD500/750, ARA500/750, TISA500/750, and ARA500/750) at 1 day and 1 month after SB surgery. However, all of the above parameters returned to the preoperative level at 12 months. Refractive parameters including AvgK, regular astigmatism, CYL, asymmetry, and HOI of anterior corneal surface and total corneal increased on the 1 day and 1 month after SB surgery and persisted even after 12 months follow-up. However, there was no significant difference in refractive parameters of posterior corneal surface during follow-up.

CONCLUSION

The changes in the structure of anterior segments after SB surgery were almost returned to the preoperative levels at 12 months postoperatively. However, SB surgery has a long-term effect on refractive parameters throughout a 12-month follow-up.

REtinal Detachment Outcomes Study (REDOS): study protocol for a factorial, randomized controlled trial

BACKGROUND

Few large randomized controlled trials provide strong evidence to guide surgical repair of primary rhegmatogenous retinal detachment (RRD) repair. The purpose of this factorial, single-blind, randomized controlled trial is to analyze and compare the surgical outcomes, functional visual outcomes, complications, and quality of life associated with RRD repair using (A) pars plana vitrectomy only (PPV) or PPV with scleral buckle (PPV-SB) and (B) sulfur hexafluoride gas (SF6) or perfluoropropane gas (C3F8) tamponade.

METHODS

Eligible patients with moderately complex RRD will be randomized 1:1 to PPV or PPV-SB and 1:1 to SF6 or C3F8 gas tamponade. Approximately 560 patients will be recruited to be able to detect a difference of around 10% in SSAS rate between the groups. Patients will be followed using multimodal imaging and quality of life questionnaires after the surgical repair until 1 year postoperative. The primary outcome will be a single-surgery anatomic success (SSAS), defined as the absence of reoperation for recurrent RRD in the operating room. Secondary outcomes will be pinhole visual acuity (PHVA) at 8-10 weeks and 6 months, final best-corrected visual acuity (BCVA), final retina status (i.e., attached or detached), time to onset of RRD recurrence, severity and number of complications, and questionnaire results.

DISCUSSION

This will be the first 2 × 2 factorial RCT examining repair techniques in primary RRD. It will also be the first RCT to compare gas tamponade between the two most common agents. Notably, it will be adequately powered to detect a clinically significant effect size. The use of multimodal imaging will also be a novel aspect of this study, allowing us to compare head-to-head the impact of adding an SB to the retina's recovery after RRD repair and of differing gas tamponades. Until now, the treatment of RRD has been largely guided by pragmatic retrospective cohort studies. There is a lack of strong evidence guiding therapeutic decisions and this trial will address (1) whether supplemental SB is justified and (2) whether longer duration gas tamponade with C3F8 is necessary.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05863312. Registered on 18 May 2023.

Forward Light Scattering of First to Third Generation Vitreous Body Replacement Hydrogels after Surgical Application Compared to Conventional Silicone Oils and Vitreous Body

To treat certain vitreoretinal diseases, the vitreous body, a hydrogel composed of mostly collagen and hyaluronic acid, must be removed. After vitrectomy surgery, the vitreous cavity is filled with an endotamponade. Previously, pre-clinical hydrogel-based vitreous body substitutes either made from uncrosslinked monomers (1st generation), preformed crosslinked polymers (2nd generation), or in situ gelating polymers (3rd generation) have been developed. Forward light scattering is a measure of Stray light induced by optical media, when increased, causing visual disturbance and glare. During pinhole surgery, the hydrogels are injected into the vitreous cavity through a small 23G-cannula. The aim of this study was to assess if and to what extent forward light scattering is induced by vitreous body replacement hydrogels and if Stray light differs between different generations of vitreous body hydrogel replacements due to the different gelation mechanisms and fragmentation during injection. A modified C-Quant setup was used to objectively determine forward light scattering. In this study, we found that the 1st and 3rd generation vitreous body replacements show very low stray light levels even after injection (2.8 +/- 0.4 deg2/sr and 0.2 +/- 0.2 deg2/sr, respectively) as gel fragmentation and generation of interfaces is circumvented. The 2nd generation preformed hydrogels showed a permanent increase in stray light after injection that will most likely lead to symptoms such as glare when used in patients (11.9 +/- 0.9 deg2/sr). Stray light of the 2nd generation hydrogels was 3- and 2-fold increased compared to juvenile and aged vitreous bodies, respectively. In conclusion, this significant downside in the forward light scattering of the 2nd generation hydrogels should be kept in mind when developing vitreous body replacement strategies, as any source of stray light should be minimized in patients with retinal comorbidities.

Bilateral sequential and simultaneous rhegmatogenous retinal detachments: anatomic and functional outcomes

OBJECTIVE

To assess the anatomic and functional outcomes in sequential and simultaneous bilateral rhegmatogenous retinal detachment (BRRD) repair.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 218 eyes in 109 patients.

METHODS

Patients diagnosed with BRRD between 2014 and 2020 at the University Centre of Ophthalmology-CHU de Québec-Laval University were reviewed. Main outcomes were single-surgery anatomic success (SSAS) and final pinhole visual acuity (PHVA) in logMARs.

RESULTS

Of the 109 patients, 86 (79%) were male, and median (Q1, Q3) age at presentation for the first eye was 60 years (range, 54-66 years). Of these patients, 92% (n = 100) had sequential BRRD and 8% (n = 9) simultaneous BRRD. Median (Q1, Q3) duration of symptoms was shorter for second eyes (first, 7 days [range, 3-15 days] vs second, 4 days [range, 2-10 days]; p = 0.028). Second eyes also had less retinal tears (first, 2.94 ± 2.76 tears vs second, 2.38 ± 1.79 tears; p = 0.031) and better median preoperative PHVA (first, 0.46 logMAR [range, 0.14-2.30 logMAR] vs second, 0.24 logMAR [range, 0.06-0.95 logMAR]; p = 0.012). SSAS was achieved in 100 (92%) and 101 (93%) of first and second eyes, respectively (p = 1.00). Final PHVA was better for the first eye (first, 0.14 logMAR [range, 0.04-0.30 logMAR] vs second, 0.20 logMAR [range, 0.04-0.43 logMAR]; p = 0.010) but comparable at 3 months (first, 0.30 logMAR [range, 0.14-0.48 logMAR] vs second, 0.34 logMAR [range, 0.13-0.70 logMAR]; p = 0.36).

CONCLUSIONS

SSAS was similar for both eyes. The subsequent eye was more likely to be treated earlier with less advanced presentations, but at 3 months, PHVA was not significantly different between eyes. Difference in final PHVA may be attributable to longer follow-up in first eyes.

COVID-19 reduced scleral buckling training in fellows and shifted young ophthalmologists' preference toward vitrectomy: An Asia-Pacific survey

BACKGROUND

To assess rhegmatogenous retinal detachment (RRD) surgery trends and training among young ophthalmologists (YOs, vitreoretinal fellows or attendings/consultants with ≤10 years of independent practice) and the impact of the COVID-19 pandemic.

METHODS

An anonymous online survey was completed by 117 YOs in the Asia-Pacific regarding their RRD surgery experiences in 2021-2022.

RESULTS

To achieve a 90% probability of surgical competency, 91 vitrectomy and 34 scleral buckling (SB) completions during fellowship were needed. In total, 49 (41.9%) YOs had fellowship affected by COVID-19. In the COVID versus pre-COVID era, however, the volume of SB completions per fellowship year decreased significantly (median [IQR] 3.3 [1.5, 9] vs. 13 [6.5, 23]; p < 0.001) and was lower than the required volume to achieve competency. YOs were less confident in conducting SB versus vitrectomy (3.5 ± 1.1 vs. 4.2 ± 0.8, p < 0.001), and they reported a decrease in the proportion of SB (-3.1%, p = 0.047) and an increase in the proportion of vitrectomy (+4.8%, p < 0.001) after the pandemic outbreak. Apart from RRD clinical characteristics, surgical confidence is among the main factors that affect surgical method decisions. During the pandemic, more YOs may have avoided SB due to the need for general anaesthesia, leading to longer surgical time and risk of viral transmission during intubation/extubation.

CONCLUSIONS

SB surgical exposure is suboptimal in most fellowship programs in the 11 Asia-Pacific countries/regions we surveyed and further declined during the COVID-19 pandemic. YOs are less confident in performing SB, leading to a trend toward primary vitrectomy since the COVID-19 outbreak.

Incidence of early complications requiring treatment plan changes after vitreoretinal surgery: a single-center study in South Korea

BACKGROUND

Information regarding incidence of treatment plan changes may be useful when discussing postoperative treatment plans for patients. Moreover, it may help establish a standardized postoperative treatment plan. This study aimed to evaluate the incidence of early complications requiring treatment plan changes in patients following vitreoretinal surgery and investigate its risk factors.

METHODS

This single-center retrospective study included 465 patients who had undergone vitreoretinal surgery. The reasons, incidence, and timing of treatment plan changes within 14 days of surgery were identified. Potential factors associated with the changes, such as patient demographics, surgeon's experience, diagnoses, and type of surgery were also analyzed.

RESULTS

The treatment plan was changed in 76 patients (16.3%) at a mean of 4.0 ± 3.2 days after vitreoretinal surgery. The reasons for the plan changes were increased intraocular pressure (IIOP) in 66(86.8%), intraocular inflammation in 2(2.6%), corneal edema in 3(3.9%), leakage from the sclerotomy wound in 3(3.9%) patients, and combined IIOP and intraocular inflammation in 2(2.6%). The date of discharge was postponed because of treatment plan changes in 17 patients (22.4%). The incidence of plan changes was higher in patients who underwent gas or oil tamponade (P < 0.001) and those who underwent surgery performed by less experienced surgeons (P = 0.034).

CONCLUSIONS

Treatment plan was changed in 16.3% of patients after vitreoretinal surgery. The risk of treatment plan changes was associated with the surgeon's experience in vitreoretinal surgery and the type of surgery. These results should be considered when establishing standardized care plans for patients who require vitreoretinal surgery.

A Prediction Nomogram for Recurrent Retinal Detachment

Purpose

Recurrent retinal detachment (re-RD) is one of the complications in rhegmatogenous retinal detachment patients who underwent surgical treatment. We investigated the risk factors for re-RD and developed a nomogram for estimating clinical risk.

Methods

Univariate and multivariable logistic regression models were performed to determine the association between variables and re-RD, and a nomogram was then developed for re-RD. The nomogram performance was assessed based on its discrimination, calibration, and clinical usefulness.

Results

This study analyzed 15 potential variables of re-RD in 403 rhegmatogenous retinal detachment patients who underwent initial surgical treatment. Axial length, inferior breaks, retinal break diameter, and surgical methods were independent risk factors for re-RD. A clinical nomogram incorporating these four independent risk factors was constructed. The diagnostic performance of the nomogram was excellent (area under the curve = 0.892, 95% CI: 0.831-0.953). Our study further validated this nomogram by bootstrapping for 500 repetitions. The area under the curve of the bootstrap model was 0.797 (95% CI: 0.712-0.881). This model showed good calibration curve fitting and a positive net benefit in decision curve analysis.

Conclusion

Axial length, inferior breaks, retinal break diameter, and surgical methods could be risk factors for re-RD. We have developed a prediction nomogram of re-RD for rhegmatogenous retinal detachment following initial surgical treatment.

Efficacy of Perioperative Intravenous Dexamethasone on Postoperative Analgesia in Scleral Buckle Surgery: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

Postoperative pain is frequently reported following scleral buckle (SB) surgery. This study assessed the efficacy of perioperative dexamethasone on postoperative pain and opioid use following SB.

MATERIALS AND METHODS

Forty-five patients with rhegmatogenous retinal detachments undergoing SB or SB and pars plana vitrectomy were randomly assigned to either standard care of postoperative oral acetaminophen and oxycodone/acetaminophen as needed or standard care plus 8 mg single-dose peri-operative intravenous dexamethasone. A questionnaire was administered on postoperative days 0, 1, and 7 to determine visual analog scale 0 to 10 pain score and number of opioid tablets consumed.

RESULTS

Mean visual analog scale score and opioid use were significantly lower in the dexamethasone group on postoperative day 0 compared with control (2.76 ± 1.96 vs 5.64 ± 3.40, P = .002; 0.41 ± 0.92 vs 1.34 ± 1.43, P = .016). The dexamethasone group also demonstrated significantly lower total opioid use (0.97 ± 1.88 vs 3.69 ± 5.32, P = .047). No significant differences in pain score or opioid use were observed on days 1 or 7 (P = .078; P = .311; P = .326; P = .334).

CONCLUSION

Single-dose intravenous dexamethasone following SB can significantly reduce postoperative pain and opioid use. [Ophthalmic Surg Lasers Imaging Retina 2023;54(x):X-X.].

Pneumatic Retinopexy Involving the Use of Intravitreal Air Injection and Laser Photocoagulation for Rhegmatogenous Retinal Detachment in Phakic Eyes

The clinical efficacy of pneumatic retinopexy (PR) using intravitreal pure air injection and laser photocoagulation for rhegmatogenous retinal detachment (RRD) remains unknown. Thirty-nine consecutive patients with RRD (39 eyes) were included in this prospective case series. All patients underwent two-step PR surgery containing pure air intravitreal injection and laser photocoagulation retinopexy during hospitalization. The main outcomes were best-corrected visual acuity (BCVA) and primary anatomic success rates after PR treatment. The mean follow-up was 18.3 ± 9.7 months, ranging from 6 to 37 months. The primary anatomic success rate was 89.7% (35/39) after PR treatment. Final reattachment of the retina was achieved in 100% of cases. Macular epiretinal membrane was developed in two patients (5.7%) among successful PR cases during the follow-up. The mean logMAR BCVA value was significantly improved from 0.94 ± 0.69 before surgery to 0.39 ± 0.41 after surgery. The average central retinal thickness was significantly thinner in the RRD eyes of macula-off patients (206.8 ± 56.13 μm) when compared with the fellow eyes (234.6 ± 48.4 μm) at the last follow-up (p = 0.005). This study concluded that an inpatient PR procedure with pure air injection and laser photocoagulation is a safe and effective approach to treating patients with RRD, who may achieve a high single-operation success rate and good visual acuity recovery.

Visual outcomes and complications of combined vs sequential cataract surgery and pars plana vitrectomy: multicenter database study

PURPOSE

To compare the visual outcomes and rates of intraoperative complications in eyes that underwent combined cataract extraction (CE) and pars plana vitrectomy (combined group) with those that underwent sequential surgery (sequential group).

SETTING

Multicenter study.

DESIGN

Retrospective chart review.

METHODS

CE data set pooled from 8 UK sites between 2000 and 2015. The main outcome measures were the mean postoperative visual acuity (VA) and the rate of intraoperative complications in both groups.

RESULTS

2236 eyes in the combined group and 2270 eyes in the sequential group were included in this study. Mean preoperative VA was 1.0 logMAR in both groups. The mean logMAR postoperative VA was worse in the combined group than in the sequential group ( P < .0001) at all timepoints, however, the differences in visual improvement between both groups decreased with longer follow-up time: 1.0 ± 0.7 vs 0.6 ± 0.6, 0.7 ± 0.6 vs 0.4 ± 0.5, and 0.7 ± 0.6 vs 0.5 ± 0.5 at 0 to 4 weeks, 4 to 12 weeks, and 12 to 24 weeks, respectively. Proportions of eyes that gained >3 logMAR units were 49% in the combined group and 66.2% in the sequential group ( P < .0001). Logistic regression analysis showed that sequential surgery (odds ratio, 2.1) was a predictor for reaching 20/40 vision by 6 months. In the combined group, there was a statistically significantly higher rate of posterior capsular rupture.

CONCLUSIONS

Postoperative visual gain was less in the combined group with a higher rate of posterior capsular rupture as compared with sequential phacovitrectomy. However, small differences in visual improvements between both groups by 6 months were observed.

Assessment of the Effectiveness of Glaucoma Treatment Using MicroPulse Transscleral Cyclophotocoagulation in Patients with Glaucoma Who Have Previously Undergone Vitreoretinal Surgery

INTRODUCTION

This retrospective study aimed to assess the effectiveness of using MicroPulse transscleral cyclophotocoagulation (µP-TSCPC) in patients who had previously undergone pars plana vitrectomy (PPV), depending on the endotamponade used.

METHODS

For the study, a total of 60 patients were enrolled who underwent PPV followed by tμP-TSCPC as a result of an increase in intraocular pressure (IOP) over the norm of 21 mmHg. In this group of patients, 20 received silicone oil endotamponade during PPV, 20 received sulfur hexafluoride gas SF6, and in another 20 a differentiated balanced salt solution (BSS) was used.

RESULTS

The main indications for conducting PPV were (1) retinal detachment (silicone oil endotamponade was used; n = 12); (2) dislocation/subluxation of the patient's own or artificial intraocular lens (balanced salt solution (BSS) endotamponade was used; n = 11); (3) the presence of an epiretinal membrane and/or a macular hole (BSS endotamponade was used; n = 9, or SF6; n = 20); and (4) hemorrhage into the vitreous chamber (silicone oil endotamponade was used; n = 8).

CONCLUSION

The choice of endotamponade used during PPV was not found to determine the effectiveness of µP-TSCPC treatment. The effectiveness of µP-TSCPC in patients after PPV depended, above all, on the etiology of the disease, for which PPV was previously performed. The lowest effectiveness of µP-TSCPC was noted in cases where the reason for conducting PPV was hemorrhage into the vitreous chamber and silicone oil endotamponade was used, while the highest effectiveness was noted in cases where PPV was conducted owing to the presence of an epiretinal membrane and/or a macular hole and SF6 endotamponade was used.

Comparison of Surgical Outcomes for Uncomplicated Primary Retinal Detachment Repair

Purpose

To compare the outcomes of primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV), scleral buckling (SB), or combined scleral buckling with vitrectomy (SB/PPV).

Patients and Methods

Single-institution, retrospective, observational study of 179 patients with primary RRD managed at a large academic hospital system. We excluded patients with less than 6 months of follow-up, previous vitrectomy or buckle, giant retinal tears, aphakia, recurrent forms of RRD, or extensive proliferative vitreoretinopathy (Grade C or worse) documented on exam or requiring membrane peel. Outcome measures included primary anatomical success at 6 months, functional success defined as BCVA ≥ 20/200, and best corrected visual acuity (BCVA) using logMAR scoring. Subgroup analysis was performed in the following patient groups: phakic, pseudophakic, inferior detachments, and prior pneumatic retinopexy.

Results

Primary anatomical success was achieved in 145 of 179 eyes (81.0%), with SB/PPV showing a significantly greater success rate (p = 0.046) when compared to SB and PPV. Functional success was achieved in 137 of the 145 anatomically successful eyes (94.5%), with values ranging between 92% and 97% amongst the interventions (p = 0.552). No difference was found in final BCVA (p = 0.367). Patients with inferior detachment had an odds ratio of 2.15 for primary anatomic failure. Prior pneumatic retinopexy did not significantly affect any of the primary outcomes.

Conclusion

SB/PPV yielded a significantly better primary anatomical success rate when compared to SB and PPV. Functional success and final BCVA was similar amongst the interventions. Inferior detachments were associated with worse primary anatomic outcomes. Prior pneumatic retinopexy did not significantly affect surgical outcomes.

Vitreous humor proteome: unraveling the molecular mechanisms underlying proliferative and neovascular vitreoretinal diseases

Proliferative diabetic retinopathy (PDR), proliferative vitreoretinopathy (PVR), and neovascular age-related macular degeneration (nAMD) are among the leading causes of blindness. Due to the multifactorial nature of these vitreoretinal diseases, omics approaches are essential for a deeper understanding of the pathophysiologic processes underlying the evolution to a proliferative or neovascular etiology, in which patients suffer from an abrupt loss of vision. For many years, it was thought that the function of the vitreous was merely structural, supporting and protecting the surrounding ocular tissues. Proteomics studies proved that vitreous is more complex and biologically active than initially thought, and its changes reflect the physiological and pathological state of the eye. The vitreous is the scenario of a complex interplay between inflammation, fibrosis, oxidative stress, neurodegeneration, and extracellular matrix remodeling. Vitreous proteome not only reflects the pathological events that occur in the retina, but the changes in the vitreous itself play a central role in the onset and progression of vitreoretinal diseases. Therefore, this review offers an overview of the studies on the vitreous proteome that could help to elucidate some of the pathological mechanisms underlying proliferative and/or neovascular vitreoretinal diseases and to find new potential pharmaceutical targets.

Advances in biomaterials as a retinal patch for the repair of rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment (RRD) is the most common retinological emergency that can cause blindness without surgical treatment. RRD occurs when liquefied vitreous accumulates between the neurosensory retina and the retinal pigment epithelium via retinal breaks, which are caused by the separation of the vitreous from the retina with aging. Currently, the main treatment option is pars plana vitrectomy, which involves surgical removal of the vitreous and laser photocoagulation around retinal breaks to generate firm chorioretinal adhesion, as well as subsequent filling of the vitreous cavity with long-lasting substitutes (expansile gas or silocone oil) to prevent the connection between the subretinal space and the vitreous cavity via the breaks before the chorioretinal adhesion firm enough. However, the postoperative face-down position and the not very satisfactory first retinal reattachment rate place a heavy burden on patients. With the development of technology and materials engineering, researchers have developed biomaterials that can be used as a retinal patch to seal retinal breaks and prevent the connection of subretinal space and vitreous cavity via breaks, thus replacing the long-lasting vitreous substitutes and eliminating the postoperative face-down position. Preclinical studies have demonstrated that biomaterial sealants have enough biocompatibility and efficacy in the in vitro and in vivo experiments. Some sealants have been used in clinical trials on a small scale, and the results indicate promising application prospects of the biomaterial sealants as retinal patches in the repair of RRD. Herein, we review the recent advances in biomaterials as retinal patches for the repair of RRD, focusing on the biomaterial categories, methods, and procedures for sealing retinal breaks, as well as their biocompatibility and efficacy, current limitations, and development perspectives.

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.

Structural and Functional Analysis of Multiple Subretinal Fluid Blebs after Successful Surgery for Rhegmatogenous Retinal Detachment

INTRODUCTION

This retrospective study investigated the clinical characteristics of multiple subretinal fluid blebs (MSFBs) after successful surgery for rhegmatogenous retinal detachment (RRD) and explored the association between MSFB with best-corrected visual acuity (BCVA) and metamorphopsia.

METHODS

The study comprised 206 patients after successful surgery for RRD, with 58 and 148 eyes undergoing, respectively, scleral buckling (SB), and pars plana vitrectomy (PPV). The clinical characteristics of MSFBs were analyzed by optical coherence tomography (OCT). The choroidal vessels in some cases were evaluated with OCT angiography. M-charts were used to determine the metamorphopsia.

RESULTS

MSFBs occurred in 17 (29.3%) and 8 (5.4%) eyes given SB and PPV, respectively. MSFBs appeared 5.6 ± 5.5 weeks after surgery and required 34.9 ± 13.8 weeks to disappear. Disrupted external limiting membrane and ellipsoid zone could still be seen in 83.3% and 66.7% of the patients 12 months after surgery; these rates were significantly higher than those of patients without MSFBs (p = 0.047, 0.022, respectively). Twelve months post-surgery, BCVA and metamorphopsia scores of the patients with MSFBs were statistically comparable to those of the controls.

CONCLUSIONS

MSFBs occur more commonly after SB than PPV. MSFBs may delay the recovery of the outer retina structure but do not affect postoperative BCVA and metamorphopsia.

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.

Visual Outcomes in Macula-Involving Retinal Detachments Based on Time to Surgical Repair

BACKGROUND AND OBJECTIVE

To examine the relationship between duration of macular detachment and postoperative visual acuity in macula-involving rhegmatogenous retinal detachments.

PATIENTS AND METHODS

Retrospective review of patients who underwent surgical repair of macula-involving rhegmatogenous retinal detachments was conducted with Institutional Review Board approval. Primary outcome measure was postoperative best-corrected visual acuity (BCVA) as dependent on duration of macular detachment.

RESULTS

In eyes with duration of macular detachment less than or equal to 7 days, postoperative BCVA increased by 0.017 logarithm of the minimum angle of resolution (logMAR) units (P = .001), and the odds of achieving logMAR 0 decreased by a factor of 0.43 (95% CI, 0.21 to 0.87; P = .02) with each additional day of detachment. Eyes repaired within 3 days of macular detachment were more likely to have postoperative BCVA of logMAR 0 than eyes repaired 4 to 7 days after macular detachment (odds ratio, 2.32; 95% CI, 1.15 to 4.70; P = .02).

CONCLUSION

Increased duration of macular detachment is associated with progressive decline in postoperative visual acuity. [Ophthalmic Surg Lasers Imaging Retina 2022;53:439-444.].

Nationwide Trends in Vitreoretinal Procedures within Australia

PURPOSE

To investigate Australian age stratified nationwide trends in vitreoretinal procedures.

METHODS

Nationwide retrospective analysis of vitreoretinal procedures in Australia over 2001-2019 using Australian National Hospital Morbidity Database for public and private hospitals. Age and gender-specific trends in selected procedures including pars plana vitrectomy for retinal detachment (PPV for RD), scleral buckle, intravitreal injections, and PPV unrelated to RD were analysed using negative binomial regression.

RESULTS

Total included procedures increased from 8102 in 2001 to 136430 in 2019. Between 2001 and 2019, the incidence per 100,000 persons of PPV for RD increased from 7.5 to 20.7, whilst scleral buckling decreased from 10.5 to 4.0. Similarly, the incidence per 100,000 persons of PPV unrelated to RD increased from 18.4 to 67.1, and intravitreal injections increased from 5.6 to 446.0. The rate of scleral buckling decreased by 6% annually (p < .001), most pronounced in those 40 years and above. In contrast, PPV for RD increased by 5% annually (p < .001), also most pronounced in those aged 40 and above. PPV unrelated to RD increased by 7% annually (p < .001), and intravitreal injections increased by 210% annually (p < .001).

CONCLUSION

Between 2001 and 2019, the rate of scleral buckling declined compared to an increase in PPV for RD. Our analysis suggests an increasing trend to PPV over scleral buckling for RD repair in Australia over the last two decades. Additionally, rates of PPV unrelated to RD and intravitreal injections increased across all age groups. Overall, these trends mirror those seen internationally and reflect changing practice patterns over time.

Biocompatibility and Efficacy of a Linearly Cross-Linked Sodium Hyaluronic Acid Hydrogel as a Retinal Patch in Rhegmatogenous Retinal Detachment Repairment

To prevent the migration of retinal pigment epithelium (RPE) cells into the vitreous cavity through retinal breaks after the pars plana vitrectomy for the repair of rhegmatogenous retinal detachment (RRD), sealing retinal breaks with an appropriate material appears to be a logical approach. According to a review of ocular experiments or clinical trials, the procedure for covering retinal breaks with adhesives is complex. A commercially available cross-linked sodium hyaluronic acid (HA) hydrogel (Healaflow®) with the injectable property was demonstrated to be a perfect retinal patch in RRD clinical trials by our team. Based on the properties of Healaflow®, a linearly cross-linked sodium HA hydrogel (HA-engineered hydrogel) (Qisheng Biological Preparation Co. Ltd. Shanghai, China) with the injectable property was designed, whose cross-linker and cross-linking method was improved. The purpose of this study is to report the characteristics of an HA-engineered hydrogel using Healaflow® as a reference, and the biocompatibility and efficacy of the HA-engineered hydrogel as a retinal patch in the rabbit RRD model. The HA-engineered hydrogel exhibited similar dynamic viscosity and cohesiveness and G′ compared with Healaflow®. The G′ of the HA-engineered hydrogel varied from 80 to 160 Pa at 2% strain under 25°C, and remained constantly higher than G″ over the range of frequency from 0.1 to 10 Hz. In the animal experiment, clinical examinations, electroretinograms, and histology suggested no adverse effects of the HA-engineered hydrogel on retinal function and morphology, confirming its favorable biocompatibility. Simultaneously, our results demonstrated the efficacy of the HA-engineered hydrogel as a retinal patch in the RRD model of rabbit eyes, which can aid in the complete reattachment of the retina without the need for expansile gas or silicone oil endotamponade. The HA-engineered hydrogel could play the role of an ophthalmologic sealant due to its high viscosity and cohesiveness. This pilot study of a small series of RRD models with a short-term follow-up provides preliminary evidence to support the favorable biocompatibility and efficacy of the HA-engineered hydrogel as a promising retinal patch for sealing retinal breaks in retinal detachment repair. More cases and longer follow-up studies are needed to assess its safety and long-term effects.

Scleral Buckling: A Look at the Past, Present and Future in View of Recent Findings on the Importance of Photoreceptor Re-Alignment Following Retinal Re-Attachment

Scleral buckling (SB) remains an important technique to master for those interested in treating rhegmatogenous retinal detachment (RRD). Several ways to repair RRD include pneumatic retinopexy (PR), pars plana vitrectomy (PPV), SB or a combination of these. There is a growing worldwide trend that favors PPV as the preferred method for retinal reattachment of primary uncomplicated RRD. Reimbursement issues, operating room access, and technological advances in PPV that improve retinal visualization and less exposure to SB during fellowship training may explain this trend. As the number of SB cases decreases over time, there is a risk that SB becomes a dying art and surgeons in training may not be trained in SB. SB is preferred in eyes with no posterior vitreous detachment and retinal dialysis. SB with minimal gas vitrectomy may be indicated for eyes with inferior pathology. Non-contact wide-angled visualization with chandelier assisted SB may be well suited for teaching new generations of aspiring vitreoretinal surgeons. Its functional and anatomic results compare favorably with conventional SB for primary uncomplicated primary RRD. The main advantage of this technique is the improved visualization even through small pupils. Better visualization ensures treatment of all breaks while avoiding complications during drainage of subretinal fluid and a safer placement of intrascleral sutures for scleral fixation of the buckling element. Recordings of the procedure are easily performed, allowing the surgeons involved to review the case and learn from it. The main disadvantage is the cost involved with the chandelier and the need to have a microscope or a 3D system with a wide angle viewing system. Photoreceptor re-alignment following retinal re-attachment is an important determinant of the post-operative functional outcomes. Different methods of retinal re-attachment apparently result in different degrees of photoreceptor re-alignment. SB may hold an advantage over PPV in this regard.

Six-Year Outcomes of 25-Gauge Chandelier Illumination-Assisted Scleral Buckling

Objectives

To report the long-term results of scleral buckling using 25-gauge chandelier illumination.

Methods

The medical records of all patients presenting to Shanghai Tenth People's Hospital with simple rhegmatogenous retinal detachment (RRD) from June 2013 to Oct 2015 were retrospectively reviewed in this consecutive case series. All patients underwent preoperative and postoperative best corrected visual acuity (BCVA), B-ultrasound, fundus photography, and optical coherence tomography examination. Ultrasound biomicroscopy (UBM) was obtained postoperatively.

Results

Ten patients (10 eyes) were included in the final analysis. Of 10 patients, the average age was 49.3 ± 18.9 years old, the average duration of RRD was 30.9 ± 53.3 days, and the mean follow-up period was 6.2 ± 0.9 years. There were nine eyes with myopia and four eyes with macular detachment. The primary anatomical success rate was 90%. Five eyes underwent 360-degree band with element surgery, and five eyes underwent element surgery alone. The average length of encircling band and element was 68.2 ± 1.3 mm and 10.5 ± 2.5 mm, respectively. There were no intraoperative or postoperative complications that occurred. The final BCVA was greater than or equal to 20/40 in nine eyes, of which four eyes achieved 20/20. UBM examination of the 25-gauge chandelier insertion site revealed no tissue proliferation.

Conclusions

For simple rhegmatogenous retinal detachment treatment, 25-gauge chandelier illumination-assisted scleral buckling is a kind of effective and safe method.

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.