TWENTY-FIVE-GAUGE PARS PLANA VITRECTOMY IN COMPLEX RETINAL DETACHMENTS ASSOCIATED WITH GIANT RETINAL TEAR

Management, risk factors and treatment outcomes of rhegmatogenous retinal detachment associated with giant retinal tears: scoping review

BACKGROUND

Rhegmatogenous retinal detachment (RRD) is a serious condition that occurs when the retina detaches from its underlying retinal pigment epithelium. RRDs associated with giant retinal tears (GRTs) are caused by retinal tears at least 90° or one-quarter of the circumferential extent. This scoping review systematically identifies and summarizes clinical studies evaluating surgical techniques for the management of GRT-related RRDs, discusses functional and visual outcomes and the risk factors affecting treatment outcomes.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Google Scholar, and Springer Link databases were searched for relevant papers (from January 2001 to March 2023). Studies that were published in the English language and reported the risk factors, management, and treatment outcomes of GRT-related RRDs were included in the review. The outcome measures included anatomic success rates, changes in BCVA (logMAR) from baseline to the final follow-up, and adverse events.

RESULTS

A total of 11,982 articles were identified. After the title and abstract review, 71 studies were deemed eligible for full-text review. Thirty-six studies that met the eligibility criteria were included in the final review. Four surgical techniques were identified: pars plana vitrectomy (PPV), combined PPV and scleral buckling, scleral buckling alone, and pneumatic retinopexy. Various types of tamponades, including gas, silicone oil, and air, have been used. PPV was the most commonly used surgical technique in 33.1-100% of patients. Among the 20 studies that used PPV alone, 17 were associated with preoperative PVR. In addition, scleral buckling alone or in combination with PPV was reported as a treatment option in 10 studies, with 2-100% of patients experiencing scleral buckling alone and 13.6-100% experiencing combined PPV and complementary scleral buckling. Primary anatomic success (PAS) was achieved with retinal reattachment via a single operation with no residual tamponade, whereas final anatomic success (FAS) was achieved via more than one operation with no residual tamponade. Reported single surgery anatomic success (SSAS) rates range from 65.51 to 100%. The preoperative best-corrected visual acuity (BCVA) ranged from 0.067 to 2.47 logMAR, whereas the postoperative BCVA ranged from 0.08 to 2.3 logMAR. An improvement in visual acuity was observed in 29 studies. Cataracts (3.9-28.3%) were the most common postoperative complication, followed by high IOP (0.01-51.2%) and PVR (0.8-31.57%).

CONCLUSION

PPV is the most common surgical technique, and currently microincision vitrectomy surgery (MIVS) systems are commonly employed. Silicone oil is the most frequently used tamponade in RRD repair. Risk factors for GRT-related RRD include age, sex, lens status, high myopia status, proliferative vitreoretinopathy (PVR), presenting visual acuity, the extent of the GRT and retinal detachment, and macular involvement. Future research areas include guidelines to reduce variability in the reporting of surgical methodology, choice of tamponades, and reporting of functional and visual outcomes to inform the best therapeutic interventions in GRT-related RRD.

Vitrectomy versus Vitrectomy with Scleral Buckling in the Treatment of Giant Retinal Tear Related Retinal Detachments: An International Multicenter Study

PURPOSE

To determine the practice pattern for treating giant retinal tear (GRT) related detachments, and their anatomic and visual outcomes with pars plana vitrectomy (PPV) with or without scleral buckling (SB).

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes with GRT detachments repaired from 2008-2020 with at least 6 months of follow-up from seven institutions in North and South America, Europe, and Asia.

METHODS

Eyes repaired using PPV versus PPV/SB were compared.

MAIN OUTCOME MEASURES

Anatomic and functional outcomes.

RESULTS

A comparable number of eyes underwent PPV (n=101) and PPV/SB (n=99). Except for prior intraocular surgery and lens status, no differences in baseline demographics, ocular characteristics, or intraoperative surgical adjuncts were observed. Overall single surgery anatomic success (SSAS) at 6 months and 1 year was similar between the groups (82.2% and 77.2% of PPV, and 87.9% and 85.7% of PPV/SB). However, when stratified by age, the 1-year SSAS rate was higher for PPV/SB (88.5%) than PPV (56.3%) (p=0.03) for children < 18 years. For both children and adults, mean best corrected visual acuity (BCVA) at baseline did not differ between the PPV and PPV/SB groups. However, for children, mean BCVA at 1 year was better in the PPV/SB than PPV groups (p=0.001) while for adults, no difference was found between the two groups. The mean time to first redetachment was 7.9 months in the PPV group and 5.5 months in the PPV/SB group (p=0.8). PVR was the most common cause for redetachment (70.4% of PPV and 93.8% of PPV/SB in redetached eyes; p=0.1). Postoperative complications were also similar between the two groups including ocular hypertension, epiretinal membrane, and cataract.

CONCLUSIONS

PPV and PPV/SB are equally popular among surgeons globally for managing GRT detachments and have comparable anatomic and visual outcomes in adults. In children, PPV/SB is superior to PPV for anatomic and functional success at one year. In adults, the relief of traction by the GRT may reduce peripheral traction and obviate the need for a SB. However, in children, a supplemental SB can be beneficial as complete vitreous shaving and posterior hyaloid detachment, and postoperative positioning are difficult in this group.

Outcomes of 25-gauge pars plana vitrectomy for cytomegalovirus retinitis-related retinal detachment

Purpose:

The purpose of this study is to evaluate the anatomical and functional outcomes of 25-gauge (G) pars plana vitrectomy (PPV) in patients with cytomegalovirus retinitis (CMVR)-related rhegmatogenous retinal detachment (RRD).

Methods:

Single-center retrospective consecutive case series of patients who underwent 25-G PPV for CMVR-related RRD repair with a minimum follow-up of 3 months. Complete anatomic success was defined as the complete attachment of retina including the periphery. Best-corrected visual acuity (BCVA) of ≥20/400 was defined as functional success.

Results:

Sixteen eyes of 15 patients were included in the study. Eleven patients were human immunodeficiency virus positive, three patients had hematological malignancies, and one patient suffered from dyskeratosis congenita. The mean follow-up was 20.5 ± 17.4 months (range 3–60 months). Complete anatomical success was seen in 15 eyes (93.75%). One eye had a residual inferior detachment with attached macula. Silicone oil was used as tamponade in 15 eyes and C₃F₈ gas in one eye. The mean change in BCVA was statistically significant, preoperative LogMAR BCVA was 2.05 ± 0.94 while the final follow-up postoperative LogMAR BCVA was 1.03 ± 0.61 (P < 0.001). Thirteen eyes (81.25%) had final BCVA ≥20/400.

Conclusion:

Microincision vitrectomy surgery can achieve excellent retinal reattachment rates in post-CMVR RRDs without significant intraoperative and postoperative complications. The visual outcome varies depending on the status of the optic disc and macula. Majority of the patients maintained functional vision.

Demography, clinical profile and surgical outcomes of paediatric giant retinal tear related retinal detachments

OBJECTIVE

To determine the demographic profile, clinical features and surgical outcomes of giant retinal tear (GRT) related retinal detachments (RD) in children.

METHODS

In this retrospective study, medical records of children aged 14 years and below, who underwent surgery for RD at our centre in the last 5 years were reviewed. Among these, we selected medical records of children with RDs with GRT, and examined the coloured retinal drawings, ultrawidefield photographs and/or surgical videos.

RESULTS

Out of 1536 medical records, 91 eyes of 87 children (5.6% of all RDs) were included. Mean age was 10.21 ± 3.08 years with male:female ratio of 8.6:1. The most common aetiologies for GRTs were high myopia (28 cases-32.18%) and trauma (25 cases-28.73%). Bilateral RD were possibly present in 29/87 (33.3%) cases. Six months follow up data was available for 82/91 eyes. Overall retinal re-attachment was achieved in 52/82 (63.41%) eyes; in 33/82 (40.24%) eyes retinal attachment could be achieved by a single surgery. Absence of proliferative vitreoretinopathy (PVR) (OR: 2.44, p-value:0.03, 95%CI: 1.21-5.08) or PVR-A (OR: 3.62, p-value: 0.03, 95%CI: 1.52-12.26) and presence of preexisting posterior vitreous detachment (OR: 7.14, p-value: 0.02, 95%CI: 1.31-38.73) were associated with successful retinal re-attachment after single surgery. Median time to presentation of cases succeeding after 1 surgery was 10 days. Ambulatory vision (1/60 and better) at final followup could be achieved in 45/82 (54.88%) eyes.

CONCLUSION

GRT relatedRDs constitute a significant proportion of paediatric RDs. Anatomical success can currently be achieved in a large number of cases. Early surgery, absence of PVR and presence of PVD are associated with higher surgical success.

Contemporary Management of Complex and Non-Complex Rhegmatogenous Retinal Detachment Due to Giant Retinal Tears

Purpose

To investigate the clinical features and surgical outcomes of rhegmatogenous retinal detachment (RRD) associated with giant retinal tears (GRTs) at a tertiary referral center.

Patients and Methods

A retrospective, non-consecutive interventional case series of GRT-associated RRDs that underwent primary surgical repair at the University of Michigan W.K. Kellogg Eye Center between January 1, 2011 and July 1, 2020. Clinical characteristics and preoperative, perioperative, and postoperative data were collected.

Results

Forty-eight eyes of 47 patients with GRT-associated RRDs met inclusion criteria, including those that were children (under 12 years, N=4, 8.3%), associated with a history of trauma (N=20, 41.7%) or with grade C proliferative vitreoretinopathy (PVR-C) (N=7, 14.6%) at baseline. Median age was 46 years (interquartile range (IQR): 29 years, range: 4 to 72 years), median follow-up was 28 months (IQR: 43 months, range: 3-124 months), and 83.3% (N=40) of subjects were male. Primary surgical repair for GRT-associated RRDs included pars plana vitrectomy (PPV) (N=40, 83.3%), scleral buckle (SB) (N=1, 2.1%), or combined PPV/SB (N=7, 14.6%). Surgical approach commonly involved the use of perfluorocarbon liquid (N=43, 90%) and gas tamponade (N=39, 81%). Single surgery anatomic success (SSAS) was 75% (95% CI: 60%, 85%) at 3 months and 65% (95 CI: 47%, 78%) at 2 years. Final anatomic success was achieved in all 48 eyes (100%). Median visual acuity improved from 20/250 preoperatively to 20/60 at final follow-up, with 44% (N=20) of eyes achieving postoperative visual acuity of 20/40 or better.

Conclusion

In this series from a tertiary referral center, both complex and non-complex GRT-associated RRDs were most commonly managed with PPV alone, perfluorocarbon liquid, and gas tamponade with favorable final anatomic and visual outcomes comparable to other modern GRT series.

Outcomes of 25-gauge pars plana vitrectomy with encircling scleral band for acute retinal necrosis-related rhegmatogenous retinal detachment

Purpose

The aim of this study was to evaluate the anatomic and functional outcomes of 25-gauge pars plana vitrectomy (25G PPV) with encircling scleral band (ESB) in patients with acute retinal necrosis (ARN)-related rhegmatogenous retinal detachment (RRD).

Methods

Single-center retrospective interventional case series of patients who underwent 25G PPV with ESB for ARN-related RRD. Complete anatomic success was defined as the complete attachment of retina after primary PPV. Functional success was measured by the final best-corrected visual acuity (BCVA) ≥20/400. Intraoperative and postoperative complications were also noted.

Results

14 eyes of 13 patients were included in the study. Six patients (46.1%) were immunocompromised. The mean follow-up was 23.64 ± 9.95 (range 6-42) months. Silicone oil was used as tamponade in 13 eyes and C3F8gas in one eye. After the primary PPV, complete anatomical success was seen in all eyes (100%), however, one eye developed phthisis bulbi after silicone oil removal (SOR). Statistically significant improvement of BCVA was seen, from LogMAR 2.03 ± 0.29 preoperatively to LogMAR 1.57 ± 0.63 postoperatively (p-value 0.014). Six eyes (42.9%) had functional success. Nine eyes (64.3%) had improvement in vision while 4 eyes (28.6%) maintained preoperative vision. 10 eyes (71.4%) underwent cataract surgery, nine eyes (64.3%) underwent SOR while 2 eyes (14.3%) had epiretinal membrane (ERM) under oil during follow-up.

Conclusion

25G PPV combines the advantages of minimally invasive vitrectomy surgery while offering improved anatomic outcomes in patients with ARN-related RRD. The functional outcome varies depending on the status of the optic disc and macula.

Successful surgical outcomes after 23-, 25- and 27-gauge vitrectomy without scleral encircling for giant retinal tear

PURPOSE

Retinal detachment due to giant retinal tears (GRTs), tears larger than 90°, is rare and difficult to treat. Here, we show and compare surgical results of 23-, 25- and 27-gauge (G) micro-incision vitrectomy surgery (MIVS) for GRT.

STUDY DESIGN

Retrospective and interventional case series.

METHODS

Retrospective review of 41 eyes of 38 patients with GRT who underwent MIVS. Surgical outcomes after MIVS, including reattachment rates and postoperative complications, were compared between instrument gauges. All patients were followed for at least 6 months postoperatively.

RESULTS

MIVS with 23G, 25G and 27G instruments was performed in 7, 19 and 15 eyes, respectively. Silicone oil (SO) was used in 34 of 41 eyes (83%) with a mean removal time of 43.8 days after first surgery. Best-corrected visual acuity (BCVA) was recovered or maintained in 39 eyes (95%). Reattachment was attained after initial surgery in 38 of 41 eyes (93%) (23G: 6/7 [86%]; 25G: 17/19 [89%]; 27G: 15/15 [100%]). Final reattachment was eventually achieved in all eyes (two eyes needed support from scleral encircling). Postoperative complications occurred in 16 eyes (39%) (23G: 3/7 [43%]; 25G: 8/19 [42%]; 27G: 5/15 [33%]), including macular pucker, cystoid macular edema, macular hole, subretinal perfluorocarbon liquid, retinal folds, vitreous hemorrhage and redetachment. There were no significant differences between the three groups in rate of high myopia, GRT size, operation time, phacovitrectomy rate, SO usage rate, initial reattachment rate, final reattachment rate, preoperative BCVA, final BCVA or rate of postoperative complications.

CONCLUSION

Despite occasional postoperative complications, primary MIVS, regardless of gauge size, appears to be a safe and feasible option for GRT surgery.

Analysis of the rates of emulsification in intraocular silicone oil tamponades of differing viscosities

AIM

To investigate the rates of emulsification in silicone oil (SO) tamponades of differing viscosities used during pars plana vitrectomy (PPV) in the treatment of complicated vitreoretinal diseases.

METHODS

This study was a prospective randomized clinical trial. Totally 290 cases with greater likelihoods of secondary detachment were included and randomly grouped into either Siluron 2000 (n=143) or Siluron 5000 (n=147) SO tamponades with 23-gauge PPV. Patient follow-ups and data analyses were conducted 1, 3, 6, and 12mo post-surgery.

RESULTS

The time of the SO emulsification ranged from 1 to 17mo, with a mean of 7.3±4.2mo. The Siluron 5000 group showed a slower emulsification rate in comparison to the Siluron 2000 group. The Siluron 2000 group took a shorter time to show signs of emulsification, necessitating earlier SO removal. However, there were no significant differences in the occurrence of complications, including secondary retinal detachment, cataract, corneal abnormality, high intraocular pressure and hypotony.

CONCLUSION

The Siluron 2000 SO tamponade shows a faster rate of emulsification than the Siluron 5000 SO, necessitating earlier removal. Both groups show similar results in terms of anatomical success and visual acuity outcome, and there is no significant difference between the SOs regarding the occurrence of complications.

Comparison Between Silicone Oil and Gas in Tamponading Giant Retinal Breaks

Purpose

The purpose of this study is to compare anatomical and visual outcomes after using silicone oil (SO) or C₃F₈ gas as tamponades after pars plana vitrectomy (PPV) for retinal detachment (RD) associated with giant retinal tears (GRTs).

Methods

A retrospective chart review was conducted for cases that underwent PPV for GRT-associated RD. We excluded eyes that had prior vitreoretinal surgery, a history of ocular trauma or worse than grade B proliferative vitreoretinopathy (PVR). Baseline demographic and ocular characteristics, surgical details and postoperative anatomical and visual outcomes were recorded and statistically analyzed.

Results

We included 88 eyes; 48 eyes had C₃F₈ gas and 40 eyes had SO as a tamponading agent. Mean age was 39 years. All eyes underwent 23G PPV with no adjuvant scleral buckling and phacovitrectomy was performed for all phakic eyes. Final retinal reattachment was achieved in 86 eyes (97.7%). One eye from each group had recurrent RD. Postoperative vision was significantly better in the gas group (p= 0.008). Prolonged increase of IOP developed in 6 eyes in the SO group and 5 eyes in the gas group. Prolonged uveitis developed in 4 eyes in the gas group and 6 eyes in the oil group (P= 0.04). Epiretinal membranes (ERM) developed in 10 eyes in the gas group and 9 eyes in the oil group. We found no significant difference between both groups regarding postoperative glaucoma or ERM formation.

Conclusion

Both agents achieved similar favorable anatomical outcomes in a series of eyes with fresh GRT-associated RD and low-grade PVR, with better visual outcome and less frequent uveitis associated with the use of gas tamponade.

Pars plana vitrectomy combined with scleral buckle versus pars plana vitrectomy for giant retinal tear

BACKGROUND

A giant retinal tear (GRT) is a full-thickness neurosensory retinal break extending for 90° or more in the presence of a posterior vitreous detachment.

OBJECTIVES

To evaluate the effectiveness and safety of pars plana vitrectomy combined with scleral buckle versus pars plana vitrectomy alone for eyes with giant retinal tear.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 8), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Literature on Health Sciences (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in our electronic search. We last searched the electronic databases on 16 August 2018.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) comparing pars plana vitrectomy combined with scleral buckle versus pars plana vitrectomy alone for giant retinal tear regardless of age, gender, lens status (e.g. phakic or pseudophakic eyes) of the affected eye(s), or etiology of GRT among participants enrolled in these trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts, then full-text articles, using Covidence. Any differences in classification between the two review authors were resolved through discussion. Two review authors independently abstracted data and assessed risk of bias of included trials.

MAIN RESULTS

We found two RCTs in abstract format (105 participants randomized). Neither RCT was published in full. Based on the data presented in the abstracts, scleral buckling might be beneficial (relative risk of re-attachement ranged from 3.0 to 4.4), but the findings are inconclusive due to a lack of peer reviewed publication and insufficient information for assessing risk of bias.

AUTHORS' CONCLUSIONS

We found no conclusive evidence from RCTs on which to base clinical recommendations for scleral buckle combined with pars plana vitrectomy for giant retinal tear. RCTs are clearly needed to address this evidence gap. Such trials should be randomized, and patients should be classified by giant retinal tear characteristics (extension (90º, 90º to 180º, > 180º), location (oral, anterior, posterior to equator)), proliferative vitreoretinopathy stage, and endotamponade. Analysis should include both short-term (three months and six months) and long-term (one year to two years) outcomes for primary retinal reattachment, mean change in best corrected visual acuity, study eyes that required second surgery for retinal reattachment, and adverse events such as elevation of intraocular pressure above 21 mmHg, choroidal detachment, cystoid macular edema, macular pucker, proliferative vitreoretinopathy, and progression of cataract in initially phakic eyes.

Sandwich Technique with Anterior Silicone Oil and Posterior Perfluorocarbon Liquid for Intraoperative Retinal Stabilization in Eyes with Large Retinal Breaks

During retinal surgeries, the presence of large retinal defects or breaks (giant retinal tears or retinotomies ≥3 clock hours) requires the use of perfluorocarbon liquid (PFCL) to stabilize the posterior retina. Thereafter, direct PFCL-oil exchange is preferred to avoid posterior slippage of the retina. However, in an eye filled with PFCL, fluid currents at the surface of the PFCL pose a few problems when laser is attempted. Multiple bubbles are formed due to fluid currents, and the fluid jet from the infusion port may continually dislodge the free end of the retina despite the presence of PFCL. This effect is accentuated when instruments are exchanged or if the active port is unoccluded. On the other hand, if laser is postponed until the eye is filled with oil, fluid accumulation may occur under the macula, as posterior tamponade is absent. We present a modified technique that entails the use of a “sandwich” of anterior SO and posterior PFCL to comfortably perform laser in a well-formed closed vitreous chamber with continuous maintenance of retinal attachment.

Vitrectomy with silicone oil tamponade for retinal detachment associated with giant retinal tears: Favourable outcomes without adjuvant scleral buckling

PURPOSE

To evaluate the outcomes of pars plana vitrectomy with silicone oil tamponade in the management of retinal detachment associated with giant retinal tears.

METHODS

We reviewed 45 eyes of 42 patients with primary retinal detachment associated with giant retinal tears over 10 years at a tertiary referral centre. Patients underwent 23-gauge vitrectomy without adjuvant scleral buckling by a single surgeon and had follow-up at least 6 months after silicone oil removal.

RESULTS

Mean follow-up was 37 ± 35 months. Seven eyes (16%) had grade C proliferative vitreoretinopathy, and 16 (36%) had a giant retinal tear ≥180° at baseline. The primary reattachment rate was 84%, and the overall final anatomical success rate was 98%. The mean Snellen visual acuity equivalent at the final visit was 20/58. Final visual acuity ≥20/40 was achieved in 64%. The mean duration of silicone oil tamponade was 10.5 ± 4 weeks. By the final visit, silicone oil had been removed from 44 eyes (98%).

CONCLUSION

The high rates of anatomical and functional success support management of giant retinal tears-associated retinal detachment with vitrectomy without adjuvant scleral buckling. Removal of silicone oil at the earliest possible time helps to avoid complications such as keratopathy, glaucoma and visual loss without apparent reason.

Bimanual 25-gauge chandelier technique for direct perfluorocarbon liquid-silicone oil exchange in retinal detachments associated with giant retinal tear

Direct perfluorocarbon liquid (PFCL)-silicone oil exchange presents its own set of challenges in the micro incision vitreous surgery era. We propose a simple bimanual technique to circumvent this problem. Thirteen eyes of patients with retinal detachment associated with giant retinal tears underwent vitrectomy followed by self-retaining endo illuminator (Chandelier) assisted direct PFCL-silicone exchange. No intra or postoperative complications related to the surgical technique were noted. All patients had attached retinas and satisfactory visual recovery at 6 months. Direct bimanual PFCL silicone oil exchange using a Chandelier seems to be a safe and effective technique.

Giant retinal tears: clinical features and outcomes of vitreoretinal surgery at a university teaching hospital (2011-2017)

Purpose

The purpose of this study was to report clinical features and outcomes in patients with giant retinal tears (GRTs) undergoing vitreoretinal surgery and to compare data from this contemporary series to a previous study from the same institution.

Materials and methods

A retrospective, interventional, consecutive case series was conducted for all patients diagnosed with GRTs who underwent vitreoretinal surgery between January 2011 and August 2017. Intraoperative data including the use of scleral buckling, perfluorocarbon liquid, and intraocular tamponade were collected and compared according to GRT size. These parameters, along with postoperative anatomic success and best-corrected visual acuity (BCVA), were compared with the previous series.

Results

The study included 80 eyes of 79 patients with a presentation of retinal detachment with a GRT. Management approach for repair of GRT-associated retinal detachments included scleral buckle (SB) alone (three eyes, 4%), pars plana vitrectomy (PPV) (16 eyes, 20%), and combined SB/PPV (61 eyes, 76%). Perfluorocarbon liquids were used in 60/77 eyes (78%) undergoing PPV, and silicone oil was used in 54/77 eyes (70%). Single surgery success rate was in 69/80 eyes (86%). Eyes managed with SB (including SB alone and SB/PPV) or PPV without SB had similar rates of recurrent retinal detachment (16% vs 6%; P=0.33). Anatomic success was achieved in 76/80 eyes (95%) with one or more surgical procedures, and 54/80 eyes (68%) achieved postoperative BCVA of ≥20/400.

Conclusions

In the current series, repairs of retinal detachment due to GRTs were most commonly managed with combined PPV/SB and perfluorocarbon liquid, resulting in reasonably generally favorable anatomic and visual outcomes.