Primary retinal reattachment surgery: anatomical and functional outcome in phakic and pseudophakic eyes

Are all primary retinal detachments the same? Anatomic and functional differences between phakic and pseudophakic patients

BACKGROUND

Given differences in the pathogenic mechanisms underlying primary retinal detachment (RD) as a function of the status of the lens, the objective was to explore differences between pseudophakic and phakic patients with primary RD.

METHODS

A retrospective study including 821 patients who underwent surgery for RD [491 cases of phakic and 330 of pseudophakic RD (pRD and psRD, respectively)] in our hospital between 2012 and 2020.

RESULTS

The mean age was 58.24 ± 12.76 years in the pRD group and 66.87 ± 11.18 years in the psRD group (p = 0.001). There were more men in both groups (70% and 64.23% of pseudophakic and phakic patients, respectively; p = 0.07). The most common location for the RD was superior in both groups (43.94% and 51.93% of pseudophakic and phakic patients, respectively), rates of inferior and total RD were somewhat higher in the psRD group (31.82% and 13.33% in pseudophakic vs 25.25% and 11.0% in phakic patients, p = 0.001). In pseudophakic and phakic patients respectively, macular involvement in 69.09% and 62.73% of cases (p = 0.067). Proliferative vitreoretinopathy was significantly more common in the psRD group (7.88% vs 3.6% in phakic patients, p = 0.01).The rate of final anatomic reattachment differed markedly between groups, with a higher rate in phakic (94.03%) than pseudophakic (87.27%) patients (p = 0.001).

CONCLUSIONS

The specific pathogenic mechanism involved in psRD seems to be responsible for worse evolution characteristics which are associated with poorer final anatomic and functional outcomes in pseudophakic patients.

Pneumatic retinopexy versus scleral buckling for the management of primary rhegmatogenous retinal detachment

BACKGROUND AND OBJECTIVE

To compare pneumatic retinopexy (PnR) and scleral buckling (SB) for repair of primary rhegmatogenous retinal detachment.

MATERIALS AND METHODS

Single-centre retrospective analysis of patients undergoing PnR and SB. Inclusion criteria comprehend phakic patients with a single retinal break or a group of breaks in detached retina in the same quadrant above the 8- and 4-o'clock meridians. A total of 184 patients were included, respectively 106 underwent PnR and 78 SB. Follow-up time was 6 months.

RESULTS

Final visual outcome did not differ significantly between the two procedures (P  =  0.12). Single-procedure reattachment rate was significantly higher in SB (94%) than in PnR (68%) (P < 0001). Anatomical success rate was not influenced by macular involving. Reattachment rate in repeated PnR was 95% and in these patients visual outcome did not statistically differ compared to those reattached with first attempt (P  =  0.196). Total reattachment rate including repeated procedures was 87% in PnR group and 94% in SB group, the difference was not significant (P  =  0.06).

CONCLUSION

SB has a higher single reattachment rate than PnR. However, final visual outcomes of both procedures are comparable. In selected cases, PnR can be repeated with a high successful rate.

Predictors of Vision Loss after Surgery for Macula-Sparing Rhegmatogenous Retinal Detachment

PURPOSE

To determine factors associated with loss of good vision (defined as Snellen visual acuity [VA] < 20/40) after surgery among eyes presenting with macula-on primary rhegmatogenous retinal detachment (RRD) with initial VA ≥20/40.

MATERIALS AND METHODS

Multicenter, retrospective, cohort study of eyes undergoing scleral buckle (SB), pars plana vitrectomy (PPV), or combined pars plana vitrectomy/scleral buckle (PPV/SB) for non-complex macula-on RRD with initial VA ≥20/40.

RESULTS

Among 646 eyes with macula-on RRDs with initial VA ≥20/40, 106 (16.4%) had VA <20/40 (i.e. lost good vision) at final follow-up. Eyes losing good vision had slightly worse pre-operative logMAR VA (mean 0.15 ± 0.10 [20/28]) compared to eyes that preserved good vision (mean 0.11 ± 0.10 [20/26]) (p = 0.004). RRDs extending greater than 6 clock-hours were more likely to lose good vision than smaller detachments (multivariate OR 4.57 [95% CI 1.44-14.51]; p = 0.0099). Compared to eyes repaired with SB alone, eyes undergoing PPV (multivariate OR 7.22 [95% CI 2.10-24.90]; p = 0.0017) or PPV/SB (multivariate OR 10.74 [95% CI 3.20-36.11]; p = 0.0001) were each more likely to lose good vision. Eyes requiring further RRD-related (multivariate OR 8.64 [95% CI 1.47-50.66]; p < 0.017) and non-RRD related vitreoretinal surgery (multivariate OR 14.35 [95% CI 5.39-38.21]; p <0.0001) were more likely to lose good vision.

CONCLUSION

Among macula-on RRDs, loss of good vision was associated with worse vision on presentation, vitrectomy-based procedures, greater extent of detachment, and lack of single surgery success. Understanding predictors of visual outcome in macula-on RRD repair may guide pre-operative counseling regarding visual prognosis.

Scleral Buckling Alone or in Combination with Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment Repair: A Meta-Analysis of 7212 Eyes

PURPOSE

The efficacy and safety of scleral buckling (SB) versus combination SB and pars plana vitrectomy (SB+PPV) for rhegmatogenous retinal detachment (RRD) repair remains unclear.

METHODS

A systematic review and meta-analysis was conducted to identify comparative studies published from Jan 2000-Jun 2021 that reported on the efficacy and/or safety following SB and SB+PPV for RRD repair. Final best-corrected visual acuity (BCVA) represented the primary endpoint, while reattachment rates and ocular adverse events were secondary endpoints. A random-effects meta-analysis was performed, and 95% confidence intervals were calculated.

RESULTS

Across 18 studies, 3912 SB and 3300 SB+PPV eyes were included. Final BCVA was non-significantly different between SB and SB+PPV (20/38 vs. 20/66 Snellen; WMD=-0.11 LogMAR; 95%CI [-0.29,0.07]; P=0.23). Primary reattachment rate was similar between procedures (P=0.74); however, SB alone achieved a significantly higher final reattachment rate (97.40% vs. 93.86%; RR=1.03; 95%CI [1.00,1.06]; P=0.04). Compared to SB+PPV, SB alone had a significantly lower risk of postoperative macular edema (RR=0.69; 95%CI [0.47,1.00]; P=0.05) and cataract formation (RR=0.34; 95%CI [0.12,0.96]; P=0.04). The incidence of macular hole, epiretinal membrane, residual subretinal fluid, proliferative vitreoretinopathy, elevated intraocular pressure, and extraocular muscle dysfunction were similar between SB and SB+PPV.

CONCLUSIONS

There was no significant difference in final BCVA between SB+PPV and SB alone in RRD. SB alone offers a slightly higher final reattachment rate along with a reduced risk of macular edema and cataract. Primary reattachment rate and the incidence of other complications were similar between the two procedures.

Scleral Buckling: A Review of Clinical Aspects and Current Concepts

Scleral buckling represents a valuable treatment option for rhegmatogenous retinal detachment repair. The surgery is based on two main principles: the closure of retinal breaks and the creation of a long-lasting chorioretinal adhesion. Buckles are placed onto the sclera with the purpose of sealing retinal breaks. Cryopexy is usually performed to ensure a long-lasting chorioretinal adhesion. Clinical outcomes of scleral buckling have been shown to be more favorable in phakic eyes with uncomplicated or medium complexity retinal detachment, yielding better anatomical and functional results compared with vitrectomy. Several complications have been described following scleral buckling surgery, some of which are sight-threatening. Expertise in indirect ophthalmoscopy is required to perform this type of surgery. A great experience is necessary to prevent complications and to deal with them. The use of scleral buckling surgery has declined over the years due to increasing interest in vitrectomy. Lack of confidence in indirect ophthalmoscopy and difficulties in teaching this surgery have contributed to limiting its diffusion among young ophthalmologists. The aim of this review is to provide a comprehensive guide on technical and clinical aspects of scleral buckling, focusing also on complications and their management.

Vitrectomy vs. Combined Vitrectomy and Scleral Buckle for Repair of Primary Rhegmatogenous Retinal Detachment with Vitreous Hemorrhage

OBJECTIVE

To compare pars plana vitrectomy (PPV) to PPV with scleral buckle (PPV/SB) for repair of primary rhegmatogenous retinal detachment (RRD) with associated vitreous hemorrhage (VH).

DESIGN

Retrospective, observational study.

SUBJECTS

Patients with RRD and associated VH who underwent PPV or PPV/SB from January 1, 2010 through August 31, 2020 were analyzed.

METHODS, INTERVENTION, OR TESTING

We performed a single-institution, retrospective, observational study of 224 eyes with RRD and VH at the time of detachment. We excluded eyes with less than 6 months of follow up, prior history of retinal detachment repair with vitrectomy or scleral buckle, VH that resolved before surgical intervention, tractional or combined tractional and rhegmatogenous detachment.

MAIN OUTCOME MEASURES

Single surgery anatomic success (SSAS) at 6 months, defined as no recurrent retinal detachment requiring surgical intervention.

RESULTS

PPV and PPV/SB were performed on 138 eyes (62%) and 85 eyes (38%), respectively. The mean age was 61.9 years in PPV patients and 60.2 years in PPV/SB patients. Single-surgery anatomic success was achieved in 107 of 138 (77.5%) eyes that underwent PPV and in 78 of 85 (91.7%) eyes that underwent PPV/SB. The difference in SSAS between types of treatment was significant (p = 0.006). Mean visual acuity improvement in the PPV/SB group was 0.54 logMAR units greater than the PPV group (p = 0.126). The incidence of postoperative PVR in the PPV/SB group (11.7%) was lower than in the PPV group (19.5%) (p = 0.128). The rate of repeat PPV for non-RD reasons was similar for both groups (p = 0.437). Final reattachment status was achieved in 137 of 138 and 84 of 85 eyes in the PPV and PPV/SB groups, respectively. Final visual acuity improvement was significantly better in eyes with PPV/SB compared to PPV alone (logMAR 2.12 vs 1.26; p=0.011).

CONCLUSIONS

In RRD with VH patients, SSAS was superior in patients treated with PPV/SB compared with PPV alone. Although not significantly different, the PPV/SB group had better visual outcomes and a lower postoperative PVR rate.

A comparison of using digitally assisted vitreoretinal surgery during repair of rhegmatogenous retinal detachments to the conventional analog microscope: A prospective interventional study

BACKGROUND

To compare outcomes and complications of pars plana vitrectomy (PPV) using a three-dimensional heads-up visualisation system (digitally assisted vitreoretinal system, DAVS) versus conventional analog microscope (CAM) in primary rhegmatogenous retinal detachment (RRD).

METHODS

This prospective interventional institutional study evaluated 60 eyes of 60 subjects with primary RRD undergoing PPV between September 2017 and February 2018. Subjects were randomly put into DAVS and CAM group and pre-operative ocular characteristics and final outcomes recorded at each visit. All subjects were followed up for a duration of 6 months. Main outcome measures recorded were post-operative retinal status, visual acuity (VA), intraocular pressure (IOP) and surgical complications.

RESULTS

Overall final retinal attachment at 6 months was 91.7% (90% in DAVS eyes and 93.3% in CAM eyes; p = 0.999). Final VA improved significantly from baseline in both groups (p < 0.001). Overall, VA improved to >  = 20/40 in 18.3% eyes (6 DAVS, 5 CAM). Median duration of silicone oil endotamponade was 3.5 months (3.5 months in DAVS, 3 months in CAM). Redetachment rate in the series was 25% (20% in DAVS, 30% in CAM). Post-operative proliferative vitreoretinopathy grade C and more was present in 15% of eyes (10% in DAVS, 20% in CAM). Average duration of surgery was 37 ± 6.2 min in DAVS group and 39.8 ± 6.6 min in CAM group (p = 0.09). All steps of vitrectomy could be performed with relative ease and comfort with the DAVS platform.

CONCLUSION

Anatomical and functional outcomes of RRD were favourable with DAVS and comparable to that with conventional microscope surgery.

Predictive Factors for Long-Term Postoperative Visual Outcome in Patients with Macula-Off Rhegmatogenous Retinal Detachment Treated with Vitrectomy

PURPOSE

The purpose of this prospective study was to evaluate potential predictive factors of long-term postoperative outcomes in patients with macula-off rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV).

METHODS

Participants in this study were 86 patients diagnosed with macula-off RRD, who underwent PPV. Demographic characteristics and preoperative characteristics of RRD were recorded, while best corrected visual acuity (BCVA) was measured preoperatively and at specific postoperative time points (6 weeks and 6, 12, and 24 months). In addition, spectral domain-optical coherence tomography (SD-OCT) characteristics at postoperative week 6 were assessed as potential factors affecting the long-term postoperative visual outcome 24 months after PPV for RRD.

RESULTS

Increasing age, duration of RD of more than 1 week, presence of proliferative vitreoretinopathy, increasing central retinal thickness, ellipsoid zone disruption, and external limiting membrane disruption were significantly associated with a worse BVCA. BCVA was not associated with gender, lens status, the location of breaks, the gas tamponade agent used in PPV, the presence of subretinal fluid, and intraretinal fluid.

CONCLUSIONS

It is important to determine predictive factors for visual outcomes in order to inform patients about their prognosis and help in the decision-making process for patient management.

[Proliferative vitreoretinopathy (PVR) minimal: same, same but different. Characteristics and surgical treatment of PVR-associated macular pucker]

BACKGROUND

Epiretinal membrane formation resulting in a macular pucker is among the typical complications associated with proliferative vitreoretinopathy (PVR) in retinal detachment and has a major impact on the functional outcome after surgical treatment.

METHODS

A literature search was carried out in PubMed.

RESULTS

Approaches to the surgical treatment of PVR-associated macular pucker include complete membrane removal within the vascular arcades aimed at relieving retinal traction at the posterior pole and peeling of the internal limiting membrane (ILM). As a further option it has been suggested that primary ILM peeling in rhegmatogenous retinal detachment repair may reduce or even prevent postoperative epiretinal membrane formation. In addition, correct timing of surgery is a factor that may contribute to successful treatment.

DISCUSSION

Due to the particularly strong adhesion and the frequent occurrence of concurrent retinal detachment, the surgical approach to PVR-associated macular pucker is particularly challenging. As with idiopathic epiretinal membranes, surgical removal has the potential to improve functional outcomes; however, visual improvement depends largely on whether the macula was involved in the original retinal detachment.

Preoperative Electrophysiological Characterization of Patients with Primary Macula-involving Rhegmatogenous Retinal Detachment

Purpose:

To determine 1) which components of retinal function are impaired after rhegmatogenous retinal detachment, 2) which outer retinal pathways (rod- or cone-driven) are more severely affected, and 3) whether there is concomitant inner retinal dysfunction.

Methods:

We conducted a prospective observational study in a large academic institution. We performed preoperative electroretinography on eight patients to assess outer and inner retinal function. In all cases, a comparison between the eye with the detached retina and the control fellow eye was made.

Results:

Eyes with a detached retina had significantly lower a-wave and b-wave amplitudes with respect to both rod- and cone-dominated testing parameters (P < 0.05) and reduced 30 Hz flicker responses compared to fellow eyes (P < 0.05); the effect size was similar for all significantly reduced parameters (r~0.6). There were no significant differences between eyes with detached retinas and control fellow eyes with respect to b/a-wave ratios, a-wave latencies, or b-wave latencies.

Conclusion:

Patients with rhegmatogenous retinal detachment have preoperative outer retinal dysfunction equally affecting both rod- and cone-driven pathways, and they have minimal inner retinal dysfunction.

Effect of symptom duration on outcomes following vitrectomy repair of primary macula-off retinal detachments

PURPOSE

To examine the effect of symptom duration on visual and anatomical outcomes following pars plana vitrectomy repair of primary macula-off rhegmatogenous retinal detachments.

METHODS

This is a retrospective, consecutive, interventional case series. All eyes underwent repair of macula-off rhegmatogenous retinal detachment with a 20-gauge, 23-gauge, or 25-gauge standard 3-port pars plana vitrectomy. Eyes with previous retinal surgery, giant retinal tear, Grade C or higher proliferative vitreoretinopathy, or less than 6 months of follow-up were excluded from the study. The main outcome measure studied was final best-corrected visual acuity (BCVA) as dependent on the duration of macular detachment symptoms. The secondary outcomes studied were single surgery anatomical success and complication rates. Visual acuity analysis was performed on all eyes that were pseudophakic by the final follow-up visit.

RESULTS

Overall, 81 eyes of 81 patients met inclusion criteria, with a mean follow-up length of 55 months (range, 6-171 months) and mean duration of macular detachment symptom of 12 days (range, 1-64 days). The mean final BCVA was 20/40 (range, 20/20 to hand motion), with 70% (n = 57) of all patients obtaining 20/40 or better final BCVA. Patients with symptom duration of 6 days or less achieved better final BCVA (mean 20/25, n = 34) than patients with longer symptom duration (mean 20/50, n = 47) (t-test, P = 0.0030; α = 0.005). After 7 days of macular detachment, no significant difference was seen in final BCVA (t-test, P > 0.05). The overall single surgery anatomical success rate was 88% (71 of 81 eyes). There was no correlation between the single surgery anatomical success rate and duration of macular detachment symptom (Fisher's exact test, P > 0.10).

CONCLUSION

Primary pars plana vitrectomy repair results in good final visual outcome for patients with primary macula-off rhegmatogenous retinal detachments. Surgical repair within 6 days of the symptom onset yielded better visual outcomes. After 7 days, visual outcome was not affected by the timing of the surgical repair. Anatomical outcome following pars plana vitrectomy repair is not affected by symptom duration.

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.

Scleral buckling dislocation mimicking glaucoma progression

PURPOSE. To report a case of scleral dislocation mimicking glaucoma progression.

METHODS

Interventional case report.

RESULTS

A 71-year-old man was referred for glaucoma surgery in his right eye because of perimetry defect progression and uncontrolled intraocular pressure despite maximal medical therapy. A scleral buckling procedure in his right eye was previously performed for rhegmatogenous retinal detachment. At the time of presentation, a visible protruded sponge buckle element was noted at ocular inspection, without any sign of infection. The buckle element was posteriorly in contact with the optic nerve and anteriorly protruding under intact conjunctiva. We eventually managed for its removal via upper eyelid orbitotomy. Visual field lesions were unchanged on every follow-up visit.

CONCLUSIONS

This case report describes severe permanent optic nerve damage due to previous misdiagnosis of a rare complication of scleral buckling surgery. Our surgical solution appears to be a safe and successful approach for this ocular disorder, also able to stabilize visual function and interrupt disease progression.

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.

Anatomic and visual outcomes in early versus late macula-on primary retinal detachment repair

PURPOSE

The purpose of this study was to describe the single surgery anatomic success rates and visual outcomes of primary macula-on retinal detachment repaired within 24 hours compared with later than 24 hours.

METHODS

This is a retrospective, comparative, interventional, consecutive case series. All eyes underwent primary surgical repair of the macula-on retinal detachment with a scleral buckle, pars plana vitrectomy, or combination of both procedures. The duration from the initial examination to the time of surgical repair was categorized as early (<24 hours) versus late (>24 hours).

RESULTS

Sixty-six eyes, 42 phakic and 24 preoperative pseudophakic, had retinal detachment repair with a median time to surgery of 1.0 ± 2.1 days (0.8 ± 0.4 days in early group versus 3.7 ± 2.2 days in late group, P < 0.005). The overall single surgery anatomic success rate was 59 of 66 eyes (89%). The single surgery anatomic success rate between the early (32 of 37 [87%]) versus late (27 of 39 [93%]) repair groups showed no statistical difference (P = 0.45). The mean time of follow-up was 13.1 months (range 0.9-39.2 months) with the mean final logarithm of the minimum angle of resolution best-corrected visual acuity showing no statistical difference between the 2 groups (early [0.10 ± 0.02] versus late [0.12 ± 0.03], t-test; P = 0.52). The rates of postoperative glaucoma (P = 0.5) and hemorrhage (P = 0.19) did not differ significantly between the 2 groups.

CONCLUSION

Delaying the repair of primary macula-on retinal detachment by more than 24 hours does not appear to cause worse visual or anatomic outcomes compared with early (<24 hours) surgical intervention. There was no significant difference in the complication rates between the two groups.

The scleral buckling of primary rhegmatogenous retinal detachment under the surgical microscope

BACKGROUND AND OBJECTIVE

To analyze the feasibility of performing scleral buckle under the surgical microscope without using the indirect ophthalmoscope.

PATIENTS AND METHODS

Data came from 342 eyes of 339 patients with primary rhegmatogenous retinal detachment (RRD) that were suitable for scleral buckling. All surgeries were performed under the surgical microscope including examination and localization of retinal breaks, scleral buckling, and retinal cryotherapy.

RESULTS

During intraoperative examination, additional retinal breaks were found in 39 cases. Among 36 eyes in which a retinal break was not observed pre-operatively, 23 cases had retinal breaks detected during surgery. The anatomic success rate after one operation was 88.9% and the final success rate was 98.0%.

CONCLUSION

Scleral buckling of RRD with equatorial or pre-equatorial breaks can be easily done under the surgical microscope, which has the merits that the surgeon's view is a clear upright image, manipulations are simple, and good surgical results can be obtained.

[Reasons for readmission to hospital after vitreoretinal surgery: 5-year retrospective follow-up]

INTRODUCTION

To study the etiologies and occurrence rate of readmissions after vitreoretinal surgery.

PATIENTS AND METHODS

One hundred fifty-three eyes requiring vitreoretinal surgery in 2000 at the Besançon (France) University Hospital were retrospectively studied. The occurrence rate and etiologies of these readmissions and the time between surgery and readmission were analyzed from the patient files.

RESULTS

The main indications for vitreoretinal surgery were retinal detachment, epiretinal membrane surgery, idiopathic macular holes, neovascular retrovascular membranes, and intravitreal hemorrhage. A total of 40.5% of the patients were readmitted. The major causes were redetachment and cataract for retinal detachment surgery and cataract for epiretinal membrane and macular hole surgeries.

CONCLUSION

The results highlight the possibly iatrogenic association between anterior and posterior eye segment surgeries, in agreement with the literature.

Rhegmatogenous retinal detachment

Patients often present after trauma with symptoms of vision loss or loss of a field of vision from a rhegmatogenous retinal detachment (RRD). This study aims to equip the health care provider with knowledge on the recognition, evaluation, and management of RRD to improve communication between the patient and consultant. The article highlights the symptoms, signs (including ophthalmoscopic findings), and pathogenesis of RRD. Causes and presentations of RRD are considered. Treatment paradigms are discussed and surgical options for treatment of RRDs are reviewed, including pneumatic retinopexy, pars plana vitrectomy, and scleral buckle surgery.

Repair of primary rhegmatogenous retinal detachment using 25-gauge transconjunctival sutureless vitrectomy

PURPOSE

: To evaluate the anatomical and visual outcomes of primary rhegmatogenous retinal detachment repairs performed using 25-gauge transconjunctival sutureless vitrectomy.

METHODS

: A retrospective, noncomparative interventional case series including 53 consecutive eyes of 52 patients who underwent 25-gauge transconjunctival sutureless vitrectomy to repair primary rhegmatogenous retinal detachment was performed. Variables collected for the study were patient demographics, lens status, preoperative visual acuity, and macular status. Outcome measures included single-operation anatomical success rate, final anatomical success rate, postoperative visual acuity, and surgical complications.

RESULTS

: The retina was reattached with a single operation in 39 (74%) of 53 eyes. The final anatomical success rate was 100%. The mean time to redetachment was 72 days (range, 13-334 days). Proliferative vitreoretinopathy (64%) and development of new retinal breaks (43%) were the most common reasons associated with redetachment. Mean visual acuity improved from 20/100 to 20/60 (P = 0.001); 55% of eyes had final vision of 20/40 or better. Three eyes (6%) developed postoperative choroidal hemorrhage. Three eyes (6%) developed visually significant macular pucker that required surgery. No postoperative hypotony or endophthalmitis was observed.

CONCLUSIONS

: Repair of primary rhegmatogenous retinal detachments using 25-gauge transconjunctival sutureless vitrectomy resulted in excellent final anatomical success rate and postoperative visual outcomes. However, redetachments due to new tears and/or proliferative vitreoretinopathy resulted in a lower single-operation success rate than those reported with 20-gauge systems.

Recent trends in the management of rhegmatogenous retinal detachment

It has been nearly a century since Jules Gonin performed the first intervention for rhegmatogenous retinal detachment, trans-scleral cautery, achieving successful outcomes in close to 50% of his cases. With the introduction of alternative surgical approaches in the last half-century, including Charles Schepens' scleral buckle technique and Robert Machemer's pars plana vitrectomy, the surgical success rates have risen to close to 90%. Nonetheless, despite dramatic progress in the success of reattachment surgeries, reasonable disagreement exists as to which approach (or combination of approaches) is the best form of surgical intervention for patients with rhegmatogenous retinal detachments. In this review, the authors summarize the current knowledge of retinal detachment, and examine emerging results from the first large scale, prospective, randomized, controlled clinical trials addressing the efficacy of these surgical approaches for retinal detachment, with the hope of identifying the most appropriate (evidence-based) therapeutic intervention for the treatment of rhegmatogenous retinal detachment.

Mental health measures of anxiety and depression in patients with retinal detachment

In this study, the researchers examined anxious and depressive symptoms of patients with rhegmatogenous retinal detachment (RRD) prior to and up to year after retinal detachment surgery. One hundred and thirteen (113) patients with RRD took part in this prospective longitudinal study. Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS). Visual acuity (VA) results and HADS scores of all participants were recorded prior to and 3, 6 and 12 months after retinal detachment surgery. Pearson correlation analysis showed a significant association between the patients' VA and HADS psychological scores both prior to and three months after surgery, regardless of the type of surgery performed. Psychological distress is a significant problem associated with retinal detachments that requires more attention.

Visual complications of Stickler syndrome in paediatric patients with Robin sequence

BACKGROUND

The most frequent diagnosis in patients with syndromic Pierre Robin sequence is Stickler syndrome, which may be complicated by congenital high myopia and substantial risk of retinal detachment. However, cases of Stickler syndrome with probable visual complications are rarely identified among this group of patients by members of the cleft team. This study was designed to determine the prevalence of Stickler syndrome among the author's group of patients with Robin sequence, and to investigate the visual outcome among paediatric patients with Robin sequence and Stickler syndrome.

MATERIAL AND METHODS

Eight children (six male and two female) with Stickler syndrome and Robin sequence were referred to be followed up every 6 months in the Ophthalmologic Department because of high myopia at less than 10 years of age. Three patients came from the author's study group and five were referred by other cleft surgeons. They were examined with repeat ophthalmic and indirect fundus examinations including cycloplegic refraction, and slit lamp biomicroscope examinations. Laser photocoagulation (2 cases) treatment for retinal degeneration or operation (3 cases) for retinal detachment was performed once evidence of significant ophthalmologic finding was noted.

RESULTS

Of the 91 cases of newborns with isolated cleft palate treated by the first author, eight patients had Robin sequence, and among these, three had Stickler syndrome. The prevalence of Stickler syndrome among this subgroup of patients was 37.5% (3/8). Among these three patients and the additional five referred by other cleft surgeons, the average spherical equivalents of the first cycloplegic refraction for the 16 eyes was -12.39+/-2.72 diopter (D) (range -8.75 to -18.5D). Of the eight patients, five did not need any therapy, two children had retinal degeneration in the left eye and retinal detachment in the right eye while one child had retinal detachment in the right eye only. Laser photocoagulation was performed in the two left eyes with retinal degeneration and was successful. Surgery was performed on the three eyes with retinal detachment, one was successful while two failed and the patients developed total blindness at ages four and six respectively. Out of these three children with retinal complications, only one child remained free of visual deterioration in both eyes during the follow-up period.

CONCLUSION

Early identification of Stickler syndrome in children with Robin sequence by cleft surgeons is necessary to insure early referral to an ophthalmologist for detection of myopia, monitoring for retinal detachment, and prevention of visual complications.

Surgical Management of Pseudophakic Retinal Detachments

PURPOSE

To compare the success of pars plana vitrectomy (PPV) versus scleral buckle (SB) in the management of uncomplicated pseudophakic retinal detachments (RDs).

DESIGN

Meta-analysis of published studies from 1966 to 2004 regarding surgical treatment of pseudophakic RDs.

PARTICIPANTS

Two thousand two hundred thirty eyes: 1579 operated by SB, 457 by PPV, and 194 by the combined method of PPV and SB.

METHODS

We compared reattachment and functional success rates after 3 commonly practiced surgical interventions for pseudophakic RDs: PPV, SB, and the combined method. Twelve hundred thirty-two articles were retrieved from Medline and by cross-reference searches. Articles with sufficient data on preoperative evaluation, applied surgical technique, and anatomical and functional success rates were included in this analysis. Articles regarding complex pseudophakic RDs, treatment by laser or pneumatic retinopexy, studies with indistinguishable treatment outcomes from phakic and pseudophakic RDs, or reviews without original data were excluded.

MAIN OUTCOME MEASURES

Anatomical success rates after initial surgical intervention and after reoperation(s) for primary failures, and best or final visual outcome at the end of follow-up.

RESULTS

Of 1232 papers, 29 matched inclusion criteria. After controlling for variation between study characteristics, PPV and the combined method resulted in higher initial reattachment rates (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.07-2.68, and OR, 3.54; 95% CI, 1.57-7.97, respectively) as compared with SB. The differences between the procedures persisted for final reattachment outcome despite reoperation for primary failures. Final visual outcome also was found to depend on the choice of primary surgical intervention. After controlling for differences in the study characteristics, the probability of visual improvement was higher after PPV (OR, 2.34; 95% CI, 1.58-3.46) or the combined method (OR, 11.52; 95% CI, 4.42-30.04) as compared with SB.

CONCLUSIONS

A meta-analysis of published literature implies that PPV with or without SB is more likely to achieve a favorable anatomical and visual outcome than conventional SB alone in uncomplicated pseudophakic RDs. However, the inherent limitations of differing study protocols, quality of included studies, and publication bias in a pooled analysis should be recognized.

Primary retinal detachment: scleral buckle or pars plana vitrectomy?

PURPOSE OF REVIEW

There remains no consensus among vitreoretinal surgeons regarding the optimal management of primary rhegmatogenous retinal detachment. In this article, fundamental principles are discussed and applied to recent clinical reports.

RECENT FINDINGS

The consensus of the peer-reviewed literature appears to be that scleral buckling and primary pars plana vitrectomy may yield comparable single-operation success rates and visual acuity outcomes for a wide variety of rhegmatogenous retinal detachments.

SUMMARY

No definitive prospective, randomized, multicenter trial compares scleral buckling with pars plana vitrectomy. The upcoming Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment study may yield useful information in this regard. Even when this study is completed, the choice of surgical modality is complex and may be individualized for specific patients.

LXII Edward Jackson lecture: open angle glaucoma after vitrectomy

PURPOSE

To present data and an hypothesis for the late development of open angle glaucoma (OAG) after vitrectomy.

DESIGN

A retrospective observational case series.

METHODS

The records of 453 eyes that had undergone vitrectomy were reviewed for postoperative OAG. Eyes with confounding factors were excluded. Sixty-eight eyes of 65 patients that underwent routine vitrectomy were followed for a mean of 56.9 months (range, seven to 192 months). For the main outcome measures, patients were classified into three groups: patients with suspected glaucoma, patients in whom glaucoma developed after the operation, and patients with pre-existing glaucoma.

RESULTS

In glaucoma suspects, the mean intraocular pressure was significantly higher in the operated eye compared with the fellow eye (P = .0001). In eyes with new onset glaucoma, 23 of 34 eyes (67.6%) had it in the vitrectomized eye only. In phakic eyes, the time interval between vitrectomy and the development of glaucoma (mean, 45.95 months) was significantly longer than eyes that were nonphakic at the time of vitrectomy (mean, 18.39 months; P = .0115). When the interval between cataract surgery in phakic eyes to the development of glaucoma was compared with the interval from vitrectomy to glaucoma diagnosis in the nonphakic group, the difference was not statistically significant. In eyes with glaucoma before the operation, the mean number of antiglaucoma medications that were required to control the intraocular pressure was significantly higher in the vitrectomized eye, compared with the fellow eye (2.9 medications +/- 1.2 vs 2.0 medications +/- 1.4; P = .0215; n = 14).

CONCLUSION

There is an increased risk of OAG after vitrectomy. The presence of the lens may be protective. In established OAG before the operation, the number of antiglaucoma medications may increase after surgery. Oxidative stress is hypothesized to have a role in the pathogenesis.