SUPRACHOROIDAL BUCKLING FOR THE MANAGEMENT OF RHEGMATOGENOUS RETINAL DETACHMENTS SECONDARY TO PERIPHERAL RETINAL BREAKS

Modification of the Suprachoroidal Buckling Technique for the Treatment of Rhegmatogenous Retinal Detachment

PURPOSE

To describe modification of the suprachoroidal buckling technique for the treatment of rhegmatogenous retinal detachment (RRD), which may improve the safety profile.

METHODS

A single-surgeon foot-pedal-controlled automated suprachoroidal injection (SCI) of sodium hyaluronate 1%, namely ProVisc (Alcon Laboratories, Fort Worth, TX) was used for the treatment of RRD. MicroDose Injection Kit (MedOne Surgical, Sarasota, FL) including a connector and a 1-mL syringe, designed for subretinal injection, was used to adapt Constellation Vision System (Alcon Laboratories) console for SCI of ProVisc from the 1-mL syringe.

RESULTS

This approach enables better surgeon control during SCI. Three highly myopic eyes of three patients with primary macula-on RRD and single superior peripheral retinal break were treated. Complete retinal reattachment was achieved in all eyes without complications.

CONCLUSION

Injecting ProVisc under foot-pedal control provides a more precise and potentially safer suprachoroidal buckling technique compared with the manual technique with more variable injection speed and pressure.

A PILOT CLINICAL STUDY OF TREATING RHEGMATOGENOUS RETINAL DETACHMENT BY SILICONE RUBBER BALLOON SCLERAL BUCKLING

PURPOSE

To evaluate the efficacy and primary safety of treating rhegmatogenous retinal detachment (RRD) using foldable capsular vitreous body scleral buckling.

METHODS

Five patients with simple RRD were treated with foldable capsular vitreous body scleral buckling. B-ultrasound and fundus photography examining of retina reattachment were used to evaluate the postsurgery efficacy. The safety of the treatment was evaluated based on the occurrence of infection, eye pain, diplopia, elevated intraocular pressure, and other serious postoperative complications after surgery. The observation time after the operation was at least 12 weeks.

RESULTS

The simple RRD of all five patients was successfully reattached before being evaluating by B-ultrasound and fundus photography after surgery. Visual acuity was enhanced in two patients who were macularly affected. One patient had temporary diplopia and eye movement limitation after surgery. No other complications were recorded.

CONCLUSION

This pilot study determined that foldable capsular vitreous body scleral buckling can be efficacious and safe for simple RRD. The results indicate that this surgery may be a novel alternative to the current extraocular procedures for simple RRD.

Vortex Vein Imaging: What Can It Tell Us?

This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.

Hemorrhagic complications associated with suprachoroidal buckling

Background

Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve.

Methods

A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts.

Results

Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement.

Conclusion

SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.

Medical and Surgical Applications for the Suprachoroidal Space

In recent years, advances in ocular imaging, drug delivery, and ophthalmic surgery have allowed for better visualization and access to the suprachoroidal space. Although previously considered as only a potential space, the suprachoroidal space may serve as a route for drug delivery to the posterior pole, an egress for glaucoma drainage devices, a location for temporary buckling, and a site for prosthesis implantation. Drugs delivered to the suprachoroidal space may achieve higher concentrations in the retina while minimizing exposure to anterior segment tissues, potentially reducing risks of glaucoma or cataracts. Finally, advanced multimodal imaging now allows not only a better understanding of the physiology of the suprachoroid, but also in vivo monitoring of pathologies and drug delivery to the suprachoroidal space. Here, we discuss the newest developments in the medical and surgical applications of this space with potential.

The suprachoroidal space as a route of administration to the posterior segment of the eye

The suprachoroidal space (SCS) is a potential space between the sclera and choroid that traverses the circumference of the posterior segment of the eye. The SCS is an attractive site for drug delivery because it targets the choroid, retinal pigment epithelium, and retina with high bioavailability, while maintaining low levels elsewhere in the eye. Indeed, phase III clinical trials are investigating the safety and efficacy of SCS drug delivery. Here, we review the anatomy and physiology of the SCS; methods to access the SCS; kinetics of SCS drug delivery; strategies to target within the SCS; current and potential clinical indications; and the safety and efficacy of this approach in preclinical animal studies and clinical trials.

A Review of Innovations in Rhegmatogenous Retinal Detachment Surgical Techniques

Rhegmatogenous retinal detachment (RRD) requires surgical intervention for its repair. There are variable techniques used for this purpose, and they are all being continuously refined. In this review, we detail the recent innovations in surgical management of RRD and proliferative vitreoretinopathy (PVR).