Retrospective comparison of 25-gauge transconjunctival sutureless vitrectomy to 20-gauge vitrectomy for the repair of pseudophakic primary inferior rhegmatogenous retinal detachment

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.

Stratifying the risk of re-detachment: variables associated with outcome of vitrectomy for rhegmatogenous retinal detachment in a large UK cohort study

INTRODUCTION

To identify variables associated with primary anatomical outcome following vitrectomy and internal tamponade for rhegmatogenous retinal detachment (RD).

METHODS

A retrospective analysis of prospectively collected data, using a database of RD treated with vitrectomy and internal tamponade. Collected data complied with the RCOphth Retinal Detachment Dataset. The main outcome measure was anatomical failure within six months of surgery.

RESULTS

There were 6377 vitrectomies. 869 eyes were excluded, either because no outcome was recorded, or inadequate follow up, leaving 5508 operations for analysis. 63.9% of patients were male, and the median age was 62. Primary anatomical failure occurred in 13.9%. On multivariate analysis, the following were associated with increased risk of failure: age <45, or >79, inferior retinal breaks, total detachment, one quadrant or greater inferior detachment, low density silicone oil, and presence of proliferative vitreoretinopathy. C2F6 tamponade, cryotherapy, and 25 G vitrectomy, were associated with reduced risk of failure. The area under the receiver operator curve was 71.7%. According to this model, 54.3% of RD are at low risk (<10%), 35.6% are at moderate risk (10-25%), and 10.1% are at high risk (>25%) of failure.

CONCLUSIONS

Previous attempts to identify high risk RD have been limited by small numbers, the inclusion of both scleral buckling and vitrectomy, or by excluding some types of RD. This study examined outcomes in unselected RD, treated by vitrectomy. Identification of the variables associated with anatomical outcome after RD surgery enables accurate risk stratification, which is valuable for patient counselling and selection, and for future clinical trials.

Air Tamponade for Rhegmatogenous Retinal Detachment With Inferior Breaks After 25-Gauge Pars Plana Vitrectomy: Technique and Outcome

To evaluate the outcomes of 25-guage (G) pars plana vitrectomy (PPV) with air tamponade for rhegmatogenous retinal detachment (RRD) with inferior breaks. This retrospective consecutive case series included fifty-two eyes of fifty-two RRD patients with inferior breaks who underwent 25-G PPV with air tamponade. These patients were followed up for at least 6 months following surgery. Primary and final anatomical success rates and postoperative complications were the main outcome measures. The mean age of the patients (39 men and 13 women) was 51.8 ± 11.8 years. There were 49 primary RRDs (94.2%) and three recurrent RRDs (5.8%). The mean follow-up period was 8.2 ± 1.6 months (range: 6–13 months). Sixteen eyes (30.8%) presented with high myopia, and six eyes (11.5%) were pseudophakic. Proliferative vitreous retinopathy grade was C1 in four eyes (7.7%). Of the 52 eyes, two (3.8%) were complicated with choroidal detachment, and forty (76.9%) had the macula detached. The single- and final-operation success rates were 96.2% and 100%, respectively. During follow-up, secondary cataract surgery was performed in eight eyes (17.4%) of the 46 phakic eyes. 25-G PPV with air tamponade is effective in treating selected RRD patients with inferior breaks. Patients can benefit from early visual recovery and less complications.

Supplemental Scleral Buckle for the Management of Rhegmatogenous Retinal Detachment by Pars Plana Vitrectomy: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

The present review aimed to synthesize evidence from randomized controlled trials (RCTs) that compared outcomes of pars plana vitrectomy (PPV) with and without a supplementary scleral buckle (SB) for management of rhegmatogenous retinal detachment (RRD).

METHODS

The authors searched MEDLINE, Embase, and CENTRAL to identify RCTs in English that compared PPV with and without supplemental SB. Risk of bias was assessed according to the Cochrane Risk of Bias 2 tool. We present risk ratios (RRs), mean differences (MDs), and 95% confidence intervals (CIs) estimated using random-effects meta-analyses.

RESULTS

We identified 6 RCTs involving 705 eyes. Primary reattachment (6 studies, 345 eyes PPV, 324 eyes PPV + SB; RR 0.99, 95% CI 0.93-1.06, I2 = 0%, p = 0.78) and final anatomic success rates (4 studies, 272 eyes PPV, 267 eyes PPV + SB; RR 1.00, 95% CI 0.98-1.02, I2 = 0%, p = 0.89) were similar between the 2 groups. Postoperative visual acuity improvement (5 studies, 244 eyes PPV, 222 eyes PPV + SB; MD 6.09 letters, 95% CI -0.47-12.64, I2 = 69%, p = 0.07) and frequency of adverse events (6 studies, 1,294 observations PPV, 1,221 observations PPV + SB; RR 0.76, 95% CI 0.57-1.01, I2 = 25%, p = 0.06) likewise did not differ significantly between the treatment groups.

CONCLUSION

Low-certainty evidence from RCTs did not demonstrate a benefit in placement of a supplemental SB during vitrectomy for management of RRD in the current analysis. Additional high-quality trials are needed to provide more precise estimates of the effect.

PATCHING RETINAL BREAKS WITH HEALAFLOW IN 27-GAUGE VITRECTOMY FOR THE TREATMENT OF RHEGMATOGENOUS RETINAL DETACHMENT

Supplemental Digital Content is Available in the Text.

This study evaluates the effectiveness of Healaflow as a retinal patch in primary rhegmatogenous retinal detachment repaired by 27-G pars plana vitrectomy combined with air tamponade. This protocol results in a high reattachment rate in the treatment of rhegmatogenous retinal detachment.

Purpose:

To report the surgical outcomes of primary rhegmatogenous retinal detachment (RRD) repaired by 27-gauge pars plana vitrectomy combined with Healaflow patch and air tamponade.

Methods:

In an initial vitro experiment, we observed and compared the dissolution and displacement of the dispersion spots of 0.05-mL Healaflow and sodium hyaluronate. We then performed a prospective, interventional cohort study on 38 eyes in 37 consecutive patients with primary rhegmatogenous retinal detachment. All eyes underwent pars plana vitrectomy combined with Healaflow patch and air tamponade; the postoperative period did not involve prone positioning. The primary and final anatomical attachment rate, best-corrected visual acuity, and intraoperative and postoperative complications were evaluated.

Results:

In the in vitro experiment, the viscoelastic Healaflow remained adherent with no change in the size of the area; however, the control dissolved completely in the balance solution. The patient study included 16 women (43.2%) and 21 men (56.8%) (mean age, 59.5 ± 9.5 years; mean follow-up period, 8.9 ± 3.8 months). A single break was present in 21 (55.3%) and 2 to 5 breaks in 17 cases (44.8%). The macula was involved in 25 (65.8%) and attached in 13 cases (34.2%) intraoperatively. Initial reattachment was achieved in 37 (97.4%) and final reattachment in 38 cases (100%). In one case (2.6%), the macula redetached because of failure of the chorioretinal scar to develop around the treated break. Mean preoperative and postoperative best-corrected visual acuities were 1.02 ± 0.82 logarithm of the minimum angle of resolution (median Snellen acuity: 20/125, range: 20/20,000–20/20) and 0.23 ± 0.17 logarithm of the minimum angle of resolution (median Snellen acuity: 20/32, range: 20/100–20/20), respectively (P < 0.001). Intraocular pressure was elevated transiently in 28 eyes (73.7%). There were no other intraoperative complications or postoperative scleral incision leakage.

Conclusion:

A 27-gauge pars plana vitrectomy combined with Healaflow patch, and air tamponade results in a high reattachment rate in the treatment of rhegmatogenous retinal detachment. Thus, patients can benefit from early visual recovery and less complications.

Vitrectomy without encircling band for rhegmatogenous retinal detachment with inferior break utilizing 3D heads up viewing system

Purpose:

This study aimed to determine the anatomical and functional outcomes of pars plana vitrectomy without encircling band for primary rhegmatogenous retinal detachments with inferior breaks utilizing 3D heads up viewing system.

Method:

This prospective, single-center study included 22 consecutive eyes with primary rhegmatogenous retinal detachments with only inferior breaks with proliferative vitreoretinopathy (PVR) CP2 or less, who underwent pars plana vitrectomy without encircling band, with silicon oil as tamponade. All surgeries were performed by a single surgeon. The single operation success rate was recorded after silicon oil removal.

Results:

The patient population consisted of 08 women (36%) and 14 men (64%) with a mean age of 56.6 +/− 14.7 years. The mean follow-up period was 8 months. A single break was present in 13 cases (59%), and 2–4 breaks were present in 9 cases (40.9%). The mean time for the surgical procedure was 35 min (range: 25–50). The macula was found to be detached in 19 cases (86.36%) and attached in 3 cases (13.6%). Single operation success rate (SOSR) of vitrectomy, after silicon oil removal without encircling band, for primary rhegmatogenous retinal detachment (RRD) with inferior breaks was 95.4%. One case redetached due to PVR changes and underwent re-surgery. Final reattachment was achieved in all 22 cases (100%). Mean best-corrected visual acuity (BCVA) significantly improved from 1.43 ± 0.59 logarithm of the minimum angle of resolution (logMAR) to postoperative BCVA was 0.48 ± 0.34 logMAR (P = 0.001).

Conclusion:

Pars plana vitrectomy without encircling band, utilizing 3D heads up the system in RRDs with inferior breaks in eyes with PVR grade C2 or less, provides good outcome.

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.

SEQUENTIAL PNEUMATIC RETINOPEXIES FOR THE TREATMENT OF PRIMARY INFERIOR RHEGMATOGENOUS RETINAL DETACHMENTS WITH INFERIOR BREAKS: The Double-Bubble Approach

PURPOSE

To evaluate a new approach of sequential pneumatic retinopexies for the management of inferior rhegmatogenous retinal detachments (RD) with inferior breaks.

METHODS

Multicenter retrospective consecutive case series of inferior RDs caused by retinal breaks located within the inferior 4 clock hours treated with sequential pneumatic retinopexies, 24 to 48 hours apart. A total of 26 patients with inferior RDs secondary to one or more breaks between the 4 o'clock and 8 o'clock meridians were included from September 2007 to February 2012.

RESULTS

The mean follow-up duration was 35.3 weeks. Anatomical success at 8 weeks was achieved in 65.4% of all patients (including those with giant retinal tear and patients with previous RD in the study eye). When excluding patients with giant retinal tear and previous RD in the study eye, the anatomical success rate increased to 70%. Overall, the mean visual acuity improved from 1.00 logMAR (Snellen equivalent 20/200) at baseline to 0.38 logMAR (Snellen equivalent 20/50) at last follow-up.

CONCLUSION

Sequential pneumatic retinopexy offers a new viable surgical option for the treatment of RDs secondary to inferior breaks.

Clinical outcomes of endoscope-assisted vitrectomy for treatment of rhegmatogenous retinal detachment

Summary

We evaluated the clinical outcomes for ophthalmic endoscope-assisted vitrectomy in consecutive patients with uncomplicated rhegmatogenous retinal detachment (RRD). The primary success rate was 98.4% (125/127) without performing a posterior drainage retinotomy or using perfluorocarbon liquids (PFCL) for subretinal fluid drainage.

Purpose

To investigate the clinical outcomes of endoscope-assisted vitrectomy in patients with uncomplicated RRD.

Methods

We examined 127 eyes from consecutive patients who underwent repair of RRD by 23- or 25-gauge endoscope-assisted vitrectomy, with a minimum follow-up of 3 months. Eyes with the following criteria were excluded: Giant retinal tears, grade C proliferative vitreoretinopathy, dense vitreous hemorrhage, retinal detachment secondary to other ocular diseases, and prior retinal or vitreous surgery. All cases underwent subretinal fluid drainage, endolaser photocoagulation and fundus inspection were performed under ophthalmic endoscopic observation. Success rate, visual acuity, surgery time and complications were evaluated.

Results

Primary and final success rate was 98.4% (125/127) and 100% (127/127), respectively, Surgery time was 59.6±26.3 minutes. The best-corrected visual acuity significantly improved from 20/100 to 20/20 (P<0.0001). There were 2 cases (1.6%) of creation of a peripheral drainage retinotomy and 4 cases (3.1%) of using PFCL to suppress movement of the detached retina, but there were no cases of creation of a posterior drainage retinotomy or using PFCL for subretinal fluid drainage. There was 1 case of presumed endophthalmitis after surgery. There were 12 hypotonous cases at postoperative day 1 and one of them needed additional scleral sutures at postoperative day 4 for prolonged hypotony.

Conclusion

The present study demonstrated the efficacy of endoscope-assisted vitrectomy for patients with uncomplicated RRD. To perform endoscope-assisted vitrectomy safely, sufficient closure of sclerotomies is necessary at the end of surgery.

Pseudophakic retinal detachment in young-aged patients

Objective

To investigate the incidence and risk factors for retinal detachment (RD) after cataract surgery or refractive lens exchange (RLE) in patients aged below 61 years.

Methods

Retrospective medical chart review of 7,886 patients (13,925 eyes) who underwent cataract surgery or RLE. Patients aged below 61 years were selected. Age, gender, axial length, follow-up times, and the occurrence of RD were recorded. Additional characteristics documented for RD cases were: history of RD, preexisting retinal findings, laser capsulotomy, status of macula at RD, date and details of RD.

Results

From a total of 421 patients (677 eyes) aged below 61 years 24 cases of RD were identified, resulting in an overall cumulative incidence per eyes of 3.55%. The mean follow-up time was 45 ± 32.8 months. Ninety-two % of all RDs occurred within 3.6 years from surgery. Axial length had a significant effect on the risk of RD after cataract/ RLE surgery (HR = 1.42, P = 0.0001, 95% CI 1.19–1.69). The highest incidence of RD occurred in the subgroup of 25 to 28.9 mm axial length (10.2%). With an increase in age of ten years, the hazard of postoperative RD was not significantly increased by a factor of 1.50 (P = 0.286, 95% CI 0.71–3.15). The highest incidence of RD occurred in patients aged 50–54 years (5.39%). Compared to females, males had an almost twofold not significant risk of postoperative RD (HR = 1.96, P = 0.123, 95% CI 0.83–4.63). None of the RD cases had a history of RD.

Conclusions

Axial length is a significant risk factor for pseudophakic RD. The need for cataract surgery or RLE should be carefully considered in patients with axial lengths between 25 and 29 mm, aged 50–54 years, in males, and in case of preexisting retinal findings.

Ultra-widefield fundus imaging in gas-filled eyes after vitrectomy

Background

To evaluate the quality of the images obtained by an ultra-widefield device in gas-filled eyes after vitrectomy for a retinal detachment.

Methods

Retrospective case series. The ultra-widefield scanning laser ophthalmoscopic images (Optos 200Tx imaging system) of 40 eyes that were gas-filled with 40 to 90% of the vitreous cavity after vitrectomy for a rhegmatogenous retinal detachment were studied. The rates of detecting the rates of reattachments and the causative retinal tears that were treated and were in the superior or inferior areas in eyes with intravitreal gas of ≥60% were compared to that to eyes with intravitreal gas of <60% of the vitreous cavity. The widefield images recorded with 532 nm (green) or 633 nm (red) wavelength laser lights were compared to determine which wavelength had clearer images in 20 eyes of retinal detachment with superior retinal tears and were more than 50% gas-filled.

Results

The ultra-widefield images showed a retinal reattachment in all eyes on postoperative days 1 to 40 (mean; 8.7 ± 7.5 days). A superior retinal break was not visible in 5 of 26 eyes due to a reflection from the intravitreal gas bubbles when the gas was <60%. However, the superior retinal breaks were visible when the patients were requested to gaze downward to reduce the reflection of the gas bubble. The retinal breaks treated with laser burns and the retinal vasculature were imaged better with green laser than red laser light, and the choroidal vasculature was seen better with red laser light.

Conclusions

Ultra-widefield fundus images can be used to evaluate and document the retinal breaks and retinal reattachments in gas-filled eyes. The green and red laser lights can image different depths of the retina and choroid in gas-filled eyes.

Anatomical and Functional Results Following 23-Gauge Primary Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: Superior versus Inferior Breaks

PURPOSE

In this retrospective study, we evaluated the anatomical and functional outcomes of patients with rhegmatogenous retinal detachment primarily treated with pars plana vitrectomy in regard to the location of the breaks. Methods. 160 eyes were enrolled in this study, divided into two groups based on break location: the superior break group (115 eyes) and the inferior break group (45 eyes). The main endpoint of our study was the anatomical success at 3 months following surgery.

RESULTS

Primary retinal reattachment was achieved in 96.5% of patients in group A and in 93.3% in group B (no statistically significant difference, OR 1.98, 95% CI: 0.4, 7.7). Mean BCVA change and intraoperative complication rate were also not statistically significantly different between the two groups (p > 0.05, OR: 1.0, 95% CI: 0.9, 1.01, resp.). Statistical analyses showed that macula status, age, and preoperative BCVA had a significant effect on mean BCVA change (p = 0.0001, p = 0.005, and p = 0.001, resp.).

CONCLUSION

This study supports that acceptable reattachment rates can be achieved using PPV for uncomplicated RRD irrespective of the breaks location and inferior breaks do not constitute an independent risk factor for worse anatomical or functional outcome.

Comparison of outcomes: scleral buckling and pars plana vitrectomy versus vitrectomy alone for primary repair of rhegmatogenous retinal detachment

Objective

To assess the combination of scleral buckling (SB) and pars plana vitrectomy (PPV) versus PPV alone in the primary repair of rhegmatogenous retinal detachments (RRDs).

Methods

The current study was a retrospective, comparative, interventional, consecutive case series of 179 eyes of 174 patients who underwent primary RRD repair by five surgeons between January 1, 2008 and December 31, 2010, utilizing SB with PPV or PPV. Univariate and multivariate analyses were used to compare the efficacy of the two surgical strategies and assess for risk factors of proliferative vitreoretinopathy (PVR).

Results

Single surgery anatomic success (SSAS) was similar (P=0.76) between the PPV group (112 of 132 eyes, 85%) and SB with PPV group (39 of 47 eyes, 83%). Final anatomic success was 100% in each group. There was no difference in rates of PVR formation (PPV 16% vs SB with PPV 19%, P=0.70). Final logarithm of the minimum angle of resolution acuity was 0.33 (20/43) in the PPV group and 0.37 (20/47) in the SB with PPV group (P=0.62). Postoperative anterior chamber fibrin was highly correlated with PVR formation (PVR 13% vs no PVR 0.7%, P=0.003; odds ratio =68.37, P=0.007). Separate analysis of medium- to high-complexity cases showed similar SSAS (PPV 86% vs SB with PPV 83%, P=0.45).

Conclusion

SB with PPV versus PPV alone were similarly efficacious for repair of primary RRDs of varying complexity. SSAS rates, PVR incidence, and final visual acuities were not significantly different.

Primary vitrectomy for rhegmatogenous retinal detachment in pseudophakic eyes: 20-gauge versus 25-gauge vitrectomy

PURPOSE

To report anatomical and functional outcome of 20-gauge versus 25-gauge primary pars plana vitrectomy for management of complex rhegmatogenous retinal detachment in pseudophakic eyes.

METHODS

Prospective single-centre randomized comparative pilot trial. Fifty patients with retinal detachment (RD) not complicated by proliferative vitreoretinopathy grade B or C, who cannot be treated with a single meridional sponge, were randomized (1:1) from November 2006 to January 2010 to either 20-gauge or 25-gauge vitrectomy as first surgical intervention and followed up over a 12-month period, evaluating change in best-corrected visual acuity, anatomical success and intraocular pressure dysregulation.

RESULTS

Mean visual acuity improved by 0.88 (SD 0.67) from 1.22 logMAR (SD 0.63) to 0.34 logMAR (SD 0.31) in the 20-gauge group and by 0.53 (SD 0.91) from 0.86 logMAR (SD 0.73) to 0.34 logMAR (SD 0.46) in the 25-gauge group. Final anatomical success rate was 100% and primary success rate was 69% at 6 months of follow-up. In the 20-gauge group, the retina was attached after one single procedure in 18 eyes (72%) and in 21 eyes (84%) of the 25-gauge group. Two patients in the 25-gauge group had hypotony at the first postoperative day which normalized within 6 weeks.

CONCLUSION

In our series, transconjunctival sutureless 25-gauge and 20-gauge vitrectomy showed comparable results in pseudophakic RD not suitable for single sponge surgery with respect to visual outcome and retinal reattachment. Postoperative hypotony does not seem to be a significant problem of transconjunctival sutureless vitrectomy.

Vitrectomy with and without encircling band for pseudophakic retinal detachment: VIPER Study Report No 2-main results

Background

It is unclear whether or not an additional encircling band improves outcome in vitrectomy for pseudophakic retinal detachment (PRD). Also unclear is whether small gauge transconjunctival trocar-guided vitrectomy is as successful as conventional 20 gauge (G) vitrectomy.

Methods

257 adult patients with uncomplicated PRD were enrolled in 14 vitreoretinal centres across Germany. Contingent on availability of qualified surgeons, eligible patients were randomly assigned either (i) with ratio 1:1 to 20 G vitrectomy plus encircling band (group E1) or 20 G vitrectomy without any buckle (group C) or (ii) with ratios 1:1:1 to group E1, C or 23/25 G vitrectomy without any buckle (group E2). Treatment success was defined as no indication for any retina reattaching procedure during the follow-up of 6 months.

Results

Success was reached in 79.0% (=79/100, group E1) versus 73.5% (=72/98, group C) (p=0.558, OR 1.32, 95% CI 0.65 to 2.65. In group E2 87.7% (=50/57) of patients reached success compared with 78.7% (=48/61) in group C, demonstrating non-inferiority of E2 to C regarding the prespecified margin of 0.8 (OR scale; p=0.05, OR 2.17, 95% CI 0.80 to 5.89). Best corrected visual acuity significantly increased after surgery independent of technique, that is, on average −0.7 (from 1.0 to 0.3) logMAR. Patients suffered from a shift in spherical refraction of −1.0 D in group E1 compared with −0.1 D in group C. Similarly, intraoperative complications (15.2% vs 8.8% of patients) and serious adverse events (30.3% vs 22.5% of patients) were more frequent in group E1.

Conclusions

Vitrectomy with gas is an efficient and safe treatment for uncomplicated PRD. An additional encircling band does not significantly reduce the risk for any second procedure necessary to reattach the retina in 20 G vitrectomy. Small gauge transconjunctival vitrectomy is not inferior to the conventional 20 G technique.

Trial registration number

DKRS 00003158, Results.

Pars Plana Vitrectomy Alone for the Management of Pseudophakic Rhegmatogenous Retinal Detachment with Only Inferior Breaks

PURPOSE

To report the surgical results of primary pseudophakic rhegmatogenous retinal detachment (RRD) with only inferior retinal breaks (IRBs) repaired by pars plana vitrectomy (PPV) alone and complete drainage of subretinal fluid.

DESIGN

Prospective, interventional cohort study.

PARTICIPANTS

A total of 147 consecutive pseudophakic eyes of 147 patients with primary RRD with causative inferior breaks.

METHODS

All eyes underwent PPV alone and complete drainage of subretinal fluid, with air, 20% sulfur hexafluoride (SF6), or 12% perfluoropropane (C3F8) as tamponade and with no face-down position in the postoperative period.

MAIN OUTCOME MEASURES

Postoperative primary and final anatomic outcome, visual acuity, and complications.

RESULTS

The patient population consisted of 44 women (30%) and 103 men (70%) with a mean age of 60.8±12.9 years. The mean follow-up period was 24.9±19.4 months. The mean number of quadrants affected was 2.4 (range, 1-4). A single break was present in 90 cases (61.2%), and 2 to 4 breaks were present in 57 cases (38.8%). The macula was found to be detached in 118 cases (80.3%) and attached in 29 cases (19.7%) intraoperatively. Of 152 breaks located between 5 and 7 clock-hours, 124 breaks (81.6%) were located outside the limits of the gas bubble on the first or third day postoperatively. Initial reattachment was achieved in 139 cases (94.5%; 95% confidence interval, 89.5-97.6). Final reattachment was achieved in 147 cases (100%). Two cases (1.3%) redetached because of new or missed retinal breaks. Six cases (4.1%) redetached because of incomplete retinal adhesion of the treated break(s). Mean preoperative best-corrected visual acuity (BCVA) was 1.11±0.59 logarithm of the minimum angle of resolution (logMAR). The mean final postoperative BCVA was 0.42±0.33 logMAR.

CONCLUSIONS

Pars plana vitrectomy alone with complete drainage of subretinal fluid achieves a high reattachment rate in the management of primary pseudophakic RRD due to IRBs.

Influence of silicone oil tamponade on self-sealing sclerotomy using 25-gauge transconjunctival sutureless vitrectomy: a retrospective comparative study

Background

Characteristic complications have been reported for transconjunctival sutureless vitrectomy, such as postoperative sclerotomy leakage and postoperative hypotony. Particular attention to sclerotomy closure is required in cases of silicone oil tamponade, because postoperative supplementation of silicone oil implies reoperation, whereas postoperative supplement of gas is comparatively easy. This study investigated sclerotomy closure in cases of silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy.

Methods

We enrolled 19 consecutive eyes with silicone oil injection (Group A, self-sealing sclerotomies, n = 10) (Group B, sutured sclerotomies, n = 9) and 10 eyes with silicone oil removal (Group C, self-sealing sclerotomies) using 25-gauge TSV. Postoperative intraocular pressure was compared between Groups A and B, and between Groups A and C using repeated-measures analysis of variance (ANOVA), one-way factorial ANOVA, and the Tukey-Kramer test.

Results

No significant differences in age or axial length were seen among groups, but surgical time differed significantly between Group C and the other groups. Mean duration of silicone oil tamponade was 3.2 ± 1.4 months in Group C, and no sclerotomies in Group A or C required suture placement. Postoperative silicone oil leakage to the subconjunctival space was not encountered in Group A. No cases showed postoperative hypotony (defined as intraocular pressure <5 mmHg). Significant differences in intraocular pressure within the same postoperative period were not identified between Groups A and B. Conversely, significant differences in intraocular pressure within the same postoperative period were identified at postoperative days 1 and 2, although not at postoperative week 1 or postoperative month 1 between Groups A and C.

Conclusions

The procedure for sclerotomy closure seems to have little influence on postoperative intraocular pressure in eyes with silicone oil tamponade using 25-gauge transconjunctival sutureless vitrectomy, because silicone oil tamponade may avoid postoperative hypotony by decreasing sclerotomy leakage in the early postoperative period.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-015-0159-z) contains supplementary material, which is available to authorized users.

Sutureless 25-Gauge Vitrectomy for Rhegmatogenous Retinal Detachment Caused by Superior Breaks Using Air Tamponade

PURPOSE

This study was aimed to evaluate the efficacy and safety of 25-gauge sutureless vitrectomy in repairing primary rhegmatogenous retinal detachment (RRD) with air tamponade.

DESIGN

This is a prospective, clinic-based, case series.

METHODS

Twenty consecutive eyes of 20 patients with primary RRD caused by superior breaks of less than a month underwent transconjunctival sutureless 25-gauge vitrectomy with intraocular air tamponade. Patients who had a follow-up of less than 6 months were excluded. Outcome measures included best corrected visual acuity (BCVA), reattachment rate by a single procedure, final reattachment rate by additional procedures, and complications.

RESULTS

The mean follow-up was 10 months (range, 6-15 months). The proportion of eyes with BCVA of between 20/200 and 20/70 increased significantly from 15% at baseline to 65% on day 14 (P = 0.024). At final follow-up, 15%, 60%, and 25% had BCVA worse than 20/200, between 20/200 and 20/70, and better than 20/70, respectively. The mean BCVA was significantly better than baseline (logMAR, 1.4) by day 14 (logMAR, 0.87). The reattachment rate by a single procedure was 70%, and the final success rate was 100% after 1 additional procedure. The primary success rate increased to 77.8% after excluding 2 eyes with proliferative vitreoretinopathy grade C1. High myopia and large retinal break were 2 other conditions associated with failed primary reattachment. No postoperative complication was observed.

CONCLUSIONS

Selected eyes with primary RRD may gain the benefit of early visual recovery when treated with 25-gauge vitrectomy and air tamponade.

Examination of Self-Sealing Sclerotomy for Vitrectomized Eye under Gas Tamponade in 23-Gauge Transconjunctival Sutureless Vitrectomy

INTRODUCTION

To investigate whether a previous history of vitrectomy affects sclerotomy self-sealing under gas tamponade in 23-gauge transconjunctival sutureless vitrectomy.

MATERIALS AND METHODS

This study retrospectively reviewed two groups, a vitrectomized group (seven consecutive cases) and an initial vitrectomy group (82 consecutive cases), who underwent 23-gauge transconjunctival sutureless vitrectomy at Jikei University School of Medicine Daisan Hospital in Tokyo. Factors affecting sclerotomy self-sealing were examined using multiple regression analysis. The criterion variable was massage time, and independent variables were age, surgical time, axial length, vitreous incarceration, history of vitrectomy, preoperative intraocular pressure (IOP), and postoperative IOP.

RESULTS

Age (F = 10.4) was the only significant factor. History of vitrectomy was not a significant factor (F = 0.06).

CONCLUSIONS

Previous history of vitrectomy does not affect sclerotomy self-sealing under gas tamponade in 23-gauge transconjunctival sutureless vitrectomy.

Factors predicting duration of intraocular gas presence after 23-gauge transconjunctival sutureless vitrectomy for rhegmatogenous retinal detachment

BACKGROUND AND OBJECTIVE

To investigate factors predicting duration of intraocular gas presence in 23-gauge transconjunctival sutureless vitrectomy.

PATIENTS AND METHODS

Retrospective review of 130 eyes that underwent 23-gauge transconjunctival sutureless vitrectomy. At the end of surgery, gas exchange and sclerotomy massage to promote self-sealing were performed. If sclerotomy leakage was suspected despite sclerotomy massage, a suture was placed. Factors predicting duration of intraocular gas presence in 23-gauge transconjunctival sutureless vitrectomy were examined using multiple regression analysis. An F value greater than 2 and P value less than 0.05 were considered statistically significant.

RESULTS

Significant factors were axial length (F = 7.08; P < .05) and IOP on postoperative day 1 (F = 4.35; P < .05). Age, operation time, preoperative IOP, and number of sutured sclerotomies were not statistically significant.

CONCLUSION

Factors predicting duration of intraocular gas presence in 23-gauge transconjunctival sutureless vitrectomy were axial length and postoperative IOP on day 1.

Supplemental scleral buckling for inferior retinal detachment in silicone oil-filled eyes

PURPOSE

To evaluate the efficiency of treating selected cases of inferior retinal detachment in silicone oil-filled eyes using a supplemental scleral buckling with external drainage of subretinal fluid, versus performing a second vitreoretinal surgery and silicone oil endotamponade.

METHODS

A prospective interventional pilot study that was performed on silicone oil-filled eyes with inferior retinal detachment. Twenty-three eyes of 23 consecutive patients were alternatively distributed between 2 groups: Group A included 12 eyes treated with supplemental scleral buckling with drainage of subretinal fluid and without the removal of silicone oil, and Group B included 11 eyes treated with silicone oil removal, vitreoretinal surgery, and reinjection of silicone oil. The preoperative data included indications and details of primary vitreoretinal surgery, cause of retinal redetachment, subretinal fluid, grade of proliferative vitreoretinopathy, lens status, and the duration between primary vitreoretinal surgery and reoperation. The postoperative examination included the best-corrected visual acuity, retina status, proliferative vitreoretinopathy, silicone oil, and any reported complication. Follow-up examinations were scheduled at Day 1, weekly for 1 month, and monthly thereafter till the end of the follow-up period which extended for at least 2 months after silicone oil removal.

RESULTS

The average number of detached clock hours per eye was 2.7 in Group A and 2.4 in Group B, caused by a mean of 1.58 ± 0.80 break per eye in Group A and 1.48 ± 0.66 break per eye in Group B. The mean interval between the primary vitreoretinal surgery and the scleral buckling procedure in Group A patients was 2.83 ± 1.22 months (range, 1-5 months), while in Group B, the mean interval between the primary and the secondary vitreoretinal surgeries was 3.00 ± 1.61 months (range, 1-6 months). The mean operative time was statistically significantly (P < 0.05) shorter in Group A (38.7 ± 11.2 minutes) than in Group B (65.3 ± 15.1 minutes). The mean follow-up duration was 15.00 ± 3.22 months in Group A and 14.18 ± 2.99 months in Group B. After silicone oil removal, the retina was attached in 10 of the 12 eyes (83.3%) and redetached in 2 eyes (16.7%) in Group A, while in Group B, the retina was attached in 9 of the 11 eyes (81.8%) and redetached in 2 eyes (18.2%) after silicone oil removal. The mean logarithm of the minimum angle of resolution best-corrected visual acuity has improved from 1.82 ± 0.72 to 1.36 ± 0.52 in Group A patients (P > 0.05) and from 1.93 ± 0.74 to 1.55 ± 0.63 in Group B patients (P > 0.05) at the end of the follow-up duration.

CONCLUSION

For selected cases of inferior retinal detachment in silicone oil-filled eyes, supplemental scleral buckling could be as effective as a second vitreoretinal surgery. Scleral buckling could offer a faster, less invasive, and better economic alternative to repeated vitreoretinal surgery for treatment of such cases.

Twenty-five-gauge vitrectomy for the removal of 5000 centistokes silicone oil

PURPOSE

To compare the safety and efficacy of removing 5000 centistokes silicone oil between 20-gauge and 25-gauge vitrectomy technique.

METHODS

Prospective case series of 34 consecutive patients undergoing 5000 centistokes silicone oil removal using 20-gauge or 25-gauge cannulas. The main outcome measures were the safety and efficacy of silicone oil removal. The safety was evaluated by recording intraoperative and postoperative complication rates, including bleeding, recurrence of retinal detachment, hypotony, choroidal detachment, corneal edema, endophthalmitis, vitreous hemorrhage, conjunctival injection, and subconjunctival hemorrhage. The efficacy was judged by the ability to attain the complete removal of silicone oil and the total surgical time to complete the procedure.

RESULTS

Sixteen patients underwent 20-gauge vitrectomy for the removal of 5000 centistokes silicone oil between January 2008 and January 2010, and 18 patients underwent 25-gauge vitrectomy for the removal of 5000 centistokes silicone oil from January 2010 to August 2012. Silicone oil was successfully removed completely in all cases. Using 25-gauge vitrectomy to remove silicone oil was significantly more time efficient with the mean total surgical time of 25 ± 6 minutes compared with 42 ± 10 minutes in 20-gauge vitrectomy group (P < 0.05). There were no differences in the intraoperative or postoperative complication rates between the two groups. None of the patients developed postoperative recurrence of retinal detachment, hypotony, choroidal detachment, corneal edema, endophthalmitis, or vitreous hemorrhage.

CONCLUSION

Twenty-five-gauge silicone oil removal is safe and effective. Surgical time is significantly reduced using sutureless 25-gauge sclerotomies. This may translate to cost reduction by decreasing time spent in the operating room.

Pars plana vitrectomy for the repair of primary, inferior rhegmatogenous retinal detachment associated to inferior breaks. A comparison of a 25-gauge versus a 20-gauge system

Background

To compare anatomical, functional outcomes and complications of high-speed 25-gauge (G) pars plana vitrectomy (PPV) versus 20-G PPV for the management of primary inferior rhegmatogenous retinal detachment (RRD) associated to inferior breaks/holes.

Methods

Eighty-five eyes from 85 patients with a minimum follow-up of 3 months were retrospectively evaluated. Forty-one patients underwent 25-G and 44 patients underwent 20-G PPV. All patients underwent PPV with fluid-air exchange, sulfur hexafluoride (SF6) 20 % gas tamponade and laser or cryo retinopexy.

Results

The mean follow-up interval was 6.51(±2.32) and 6.63 (±2.58) months in the 25-G and 20-G groups respectively. Single-operation success rate was 92.7 % for the 25-G group and 81.8 % for the 20-G group (P = 0.24). Post-operative hypotony was observed in no case. Redetachment occurred in 3 eyes operated on with 25-G and in 8 eyes operated on with 20-G system. All retinas were attached at final follow-up. Logarithm of the minimum angle of resolution visual acuity significantly improved from 0.69 ± 0.76 to 0.33 ± 0.37 in the 25-G and from 0.47 ± 0.59 to 0.21 ± 0.28 in the 20-G group (P = 0.0007 and P < 0.0001 respectively).

Conclusions

High-speed PPV and SF6 gas tamponade using either 25-G or 20-G PPV system, yields similar single operation anatomical success rates for the repair of uncomplicated, primary inferior RRDs associated to inferior breaks.

Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment

PURPOSE

To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD).

DESIGN

Retrospective, nonrandomized, interventional case series.

METHODS

We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA).

RESULTS

SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29).

CONCLUSIONS

The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.