Vitrectomy with scleral buckling versus with inferior retinectomy in treating primary rhegmatogenous retinal detachment with PVR and inferior breaks

Can wall shear-stress topology predict proliferative vitreoretinopathy localization following pars plana vitrectomy?

We numerically study the fluid dynamics of oil tamponade in models of vitrectomized eyes prompted by a subset of daily activities corresponding to movements on the horizontal plane with the patient in a standing position. Bulk flow features are related to near-wall flow topology and transport at the retinal surface through a wall shear-stress-based analysis. Proliferative VitreoRetinopathy (PVR) is the leading cause of retinal re-detachment occurring in about 20% of all cases due to the accumulation of inflammatory cells in discrete retinal regions. Signalling soluble mediators stimulate inflammatory cells' chemotaxis and studying their distribution across the retinal surface may acquire clinical relevance. In all the investigated cases, persistent and elongated regions along the retina, potentially prone to accumulate chemo-attractants and cells are observed. Gradients of soluble inflammation mediators present in the aqueous are known responsible for the so-called epithelial-mesenchymal transition that initiates PVR and favours recurrent retinal detachment prompting the proliferation of inflammatory cells with collagen matrix deposition and its contraction. The surgical apposition of encircling scleral buckling elements, known for over a century to influence PVR formation and localization, modifies the attracting regions, possibly causing an accumulation of molecules and cells along approximately vertical lines that follow the rising menisci due to the cerclage indentation. The resulting spatial pattern is compatible with clinical observations. This study may open toward rational analyses of near-wall transport to predict PVR pathogenesis by relating biochemical accumulation in certain areas of the retina to clinical conditions.

Scleral Buckle, Vitrectomy, or Combined Surgery for Inferior Break Retinal Detachment: Systematic Review and Meta-Analysis

TOPIC

To compare outcomes of scleral buckle (SB), pars plana vitrectomy (PPV), and combined PPV-SB to treat rhegmatogenous retinal detachments (RRDs) with inferior retinal breaks (IRBs).

CLINICAL RELEVANCE

Rhegmatogenous retinal detachments with IRBs are not uncommon; their management is challenging with higher risk of failure. There is no consensus about their treatment, specifically whether SB, PPV, or PPV-SB should be performed.

METHODS

Systematic review and meta-analysis. Randomized controlled trials, case-control, and prospective/retrospective series (if n > 50) in English were eligible. Medline, Embase, and Cochrane databases were searched up to January 23, 2023. Standard systematic review methods were followed. The following outcomes at 3 (± 1) and 12 (± 3) months were evaluated: number of eyes with retinal reattachment after ≥ 1 surgeries, change in best-corrected visual acuity from preoperative to postoperative levels, and number of eyes with improvement of > 10 and > 15 ETDRS letters after surgery. Authors of eligible studies were asked for individual participant data (IPD) and IPD meta-analysis was undertaken. Risk of bias was assessed using National Institutes of Health study quality assessment tools. This study was registered prospectively in PROSPERO (CRD42019145626).

RESULTS

A total of 542 studies were identified: 15 were eligible and included and 60% were retrospective. Individual participant data was obtained from 8 studies (1017 eyes). Given that only 26 patients had received SB alone, these data were not considered in the analysis. There was no evidence for differences between treatment groups (PPV versus PPV-SB) in the probability of having a flat retina at 3 or 12 months postoperatively after 1 (P = 0.067; odds ratio [OR], 0.47; P = 0.408; OR 2.55; respectively) or > 1 (OR, 0.54; P = 0.21; OR, 0.89; P = 0.926; respectively) surgery. Pars plana vitrectomy-SB showed less improvement in vision postoperatively at 3 months (estimate, 0.18; 95% confidence interval, 0.01-0.35; P = 0.044), but this difference was no longer observed at 12 months (estimate, -0.07; 95% confidence interval, -0.27, 0.13; P = 0.479).

CONCLUSION

Available evidence suggests a lack of benefit of adding SB to PPV to treat RRDs with IRBs. Evidence, however, comes mainly from retrospective series and, thus, despite the large number of eyes included, should be interpreted with caution. Further research is needed.

FINANCIAL DISCLOSURE(S)

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

Use of Heavy Silicon Oil as Intraocular Tamponade for Inferior Retinal Detachment Complicated by Proliferative Vitreoretinopathy: A Multicentric Experience

INTRODUCTION

This is a multicentric study on the use of heavy silicon oil (HSO) as an intraocular tamponade for inferior retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR).

METHODS

139 eyes treated for RD with PVR were included in the study. 10 (7.2%) were affected by primary RD with inferior PVR, while 129 (92.8%) were affected by recurrent RD with inferior PVR. 102 eyes (73.9%) had received a silicon oil (SO) tamponade in a previous intervention prior to receiving HSO. Mean follow-up was 36.5 (standard deviation = 32.3) months.

RESULTS

The median interval between HSO injection and removal was 4 months (interquartile range: 3). At the time of HSO removal, the retina was attached in 120 eyes (87.6%), whereas in 17 eyes (12.4%), it had re-detached while the HSO was in situ. 32 eyes (23.2%) showed recurrent RD. A subsequent RD relapse was observed in 14.2% of cases with no RD at the time of HSO removal, and in 88.2% if an RD was present at the time of HSO removal. Advancing age showed a positive association with retinal attachment at the end of follow-up, while the risk of RD relapse at the end of the follow-up showed a significant negative association with HSO tamponade duration and with the use of SO rather than air or gas as post-HSO tamponade materials. Mean best corrected visual acuity was 1.1 logarithm of minimum angle of resolution at all follow-up time points. 56 cases (40.3%) needed treatment for elevated intraocular pressure (IOP), with which no clinically relevant variables were associated during follow-up.

CONCLUSION

HSO represents a safe and effective tamponade in cases of inferior RD with PVR. The presence of RD at the time of HSO removal is a negative prognostic factor for the development of a subsequent RD relapse. According to our findings, in cases of RD at the time of HSO removal, a short-term tamponade should definitely be avoided, in favor of SO. Special attention must be paid to the risk of IOP elevation, and patients should be closely monitored.

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.

Silicone Oil Tamponade-Retina Contact in Highly Myopic Eyes With and Without Encircling Bands: A Computational Fluid Dynamics Study

Purpose

To investigate the behavior of silicone oil (SiO) at a steady equilibrium and during saccades in pseudophakic highly myopic eyes with posterior staphyloma with and without an encircling band and compare it to behavior in emmetropic eyes. The SiO–retina contact area and shear stress were calculated by computational fluid dynamics.

Methods

A numerical model of an emmetropic eye and a myopic eye with and without scleral band underwent a saccade of 50°/0.137 s. The vitreous chamber surface was divided into superior and inferior 180° sectors: lens, pre-equator, post-equator, and macula. SiO–retina contact was evaluated as a function of fill percentages between 80% and 90% for standing, 45° upward tilt, and supine patients. Maximum and average shear stress were calculated.

Results

Overall, SiO–retina contact ranged between 40% and 83%; fill percentage varied between 80% and 95%. Neither the encircling scleral band nor the staphyloma significantly affected the SiO–retina contact area, although the presence of a scleral band proved disadvantageous when gazing 45° upward. The inferior retina–SiO contact remained below 40% despite 95% SiO fill. The SS significantly increased at the scleral band indentation and decreased elsewhere. The staphyloma greatly reduced shear stress at the macula.

Conclusions

The presence of a myopic staphyloma reduces shear stress at the macula but does not alter SiO–retina contact significantly. The apposition of a 360° scleral band may reduce SiO–retina contact at least in some postures and increases the SS at the indentation.

Translational Relevance

Assessing SiO–retina contact when vitreous chamber geometry changes according to pathologic or iatrogenic modifications allows accurate prediction of real-life tamponade behavior and helps explain surgical outcomes.

Retinotomy and retinectomy for anterior inferior proliferative vitreoretinopathy: Can visual outcome be improved?

PURPOSE

To describe the treatment outcomes and prognostic factors of retinotomy/retinectomy for rhegmatogenous retinal detachment (RD) complicated anterior inferior proliferative vitreoretinopathy (PVR).

METHODS

Retrospective, nonrandomized, single-center case series. The outcomes of 126 cases of retinotomy/retinectomy for RD complicated by advanced (Grade C) anterior inferior PVR managed consistently by one surgeon during a 15-year period were evaluated.

RESULTS

Forty-two eyes (33%) had primary RDs and 84 (67%) had recurrent RDs. The extent of retinotomy/retinectomy varied: 90° in 21 eyes (17%), >90° to <180° in 49 eyes (39%), and ⩾180° to ⩽240° in 56 eyes (44%). The retinotomy/retinectomy location was peripheral in 58 eyes (46%) and equatorial in 68 eyes (54%). The mean follow-up period was 43 ± 42 months. The silicone oil (SO) was removed from 98% of the eyes. The single-operation success rate after the primary retinectomy was 87%, and the final attachment rate was 94%. Visual acuity improved from 20/630 to 20/160 (p < 0.001). Vision ⩾20/200 was achieved in 101 eyes (80%). Good visual outcome was correlated positively with preoperative VA (p = 0.02), previous vitrectomy with gas tamponade (p = 0.007), and was negatively correlated with number of previous RD operations (p = 0.01), larger extent of RD (p = 0.02) and more extensive retinotomy/retinectomy (p = 0.04).

CONCLUSIONS

An appropriate and timely intervention, including vitrectomy alone, inferior relaxing retinotomy/retinectomy and standard SO tamponade provide satisfactory outcomes for RDs complicated by PVR. Lesser extension of grade C PVR at baseline, such as PVR limited to one quadrant should encourage vitreoretinal specialists to consider retinotomy/retinectomy at a milder clinical stage of PVR development.

Results of different strategies to manage complicated retinal re-detachment

PURPOSE

Complicated retinal re-detachment with inferior proliferative vitreoretinopathy (PVR) remains a challenge. This study's aim was to compare vitrectomy with conventional silicon oil (CSO) combined with an encircling band (EB) and vitrectomy with heavy silicon oil (HSO) alone to treat retinal re-detachment through inferior PVR, where standard procedures have already failed.

METHODS

A retrospective analysis was done on patients with inferior complex re-detachment with secondary PVR after primary surgery, who received pars plana vitrectomy (PPV) with CSO combined with EB (group 1) or PPV alone with HSO (group 2) between December 2006 and August 2017. The primary endpoint was retinal reattachment, and the secondary endpoint was visual acuity (VA) change and complications in both groups.

RESULTS

This study included 119 eyes. Total single surgery anatomical success (SSAS) was 64%, with 80% (52/65) achieved in group 1 and 44.5% (24/54) in group 2 (p < 0.0001). The total final anatomical success (FAS) rate was 79% (94/119). In group 1, FAS was 91% (59/65) compared with 65% (35/54) in group 2 (p = 0.003). The pretreatment VA of group 1 had a median of 1.4 logMAR (95% CI 0.3-1.8), and group 2 showed a median of 1.4 logMAR (95% CI 0.2-1.8). The post-treatment decrease in group 1 was a median equal to - 0.6 versus - 0.1 for group 2 (p = 0.0001). Serious complications were similar in both groups.

CONCLUSION

For complicated retinal re-detachment through inferior PVR, the combination of PPV with EB may lead to better anatomical (SSAS, FAS) and functional success compared with PPV alone with HSO.

Densiron® 68 Heavy Silicone Oil As A Short-Term Intraocular Tamponade For Macula-On Inferior Retinal Detachments - A Case Series

PURPOSE

To describe our experience using short term Heavy Silicone oil (Densiron® 68®) for Macula-On inferior rhegmatogenous retinal detachments (RRD) with inferior retinal breaks.

METHODS

Retrospective, consecutive, observational case series. Data was retrospectively collected from the medical records of patients who underwent pars plana vitrectomy and Densiron® 68 endotamponade for macula-on RRD repair.

RESULTS

Eight patients were included in the study. The mean patient age was 57.1 ± 12.3 (±SD) years. The mean time to Densiron® 68 removal was 57.8 ± 17.8 (±SD) days (ranging from 24 to 83 days). One patient (12.5%) detached three weeks after Densiron® 68 removal and required further surgery. All patients were attached at last follow up with a mean follow up of 192 days. The mean final BCVA was 20/40 (0.29 logMAR), similar to the 20/45 pre-operative BCVA (0.35 logMAR, p=0.501). No significant emulsification was noted before or during the removal of the Densiron® 68. Two patients developed an increase in intraocular pressure (IOP) before Densiron® 68 removal that resolved after removal. One patient developed cystoid macular edema (CME) that resolved with a short course of topical medications, and one patient had persistent CME that required an intravitreal triamcinolone acetate 1% injection.

CONCLUSION

The high anatomic success rate, good visual outcomes, and minimal complications suggest that Densiron® 68 be considered as a short-term tamponade for macula-on retinal detachments with inferior pathology.