Functional and anatomical outcomes after successful repair of macula-off retinal detachment: a 12-month follow-up of the DOREFA study

THE LONG-TERM RECOVERY OF VISION IN PSEUDOPHAKIC MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENTS

PURPOSE

To assess the long-term visual recovery in uncomplicated macula-off pseudophakic rhegmatogenous retinal detachment treated with pars plana vitrectomy and gas tamponade in the absence of other visual comorbidities.

METHODS

Single-center retrospective longitudinal study on eyes with macula-off pseudophakic rhegmatogenous retinal detachment successfully treated with pars plana vitrectomy between 2011 and 2020 and with at least 2 follow-ups (FU), first gas-free FU (first-FU) and a final-FU, were included. Patients with subsequent ocular surgery or comorbidities affecting best-corrected visual acuity were excluded. The duration between operation date and final-FU was calculated (total days FU) and split into total days quintiles-1: ≤57, 2: >57 and ≤77, 3: >77 and ≤152, 4: >152 and ≤508, and 5: >508 days. Multivariable regression was performed with logMAR gain between the first and the final-FU as the dependent variable.

RESULTS

In 209 eyes, the authors report association with increase of logMAR gain between the first and the final-FU, with reducing clock hours of pseudophakic rhegmatogenous retinal detachment ( P = 0.041) and relative to the total days Quintile 1. Mean (SD) logMAR gain between the first and the final-FU was 0.02 (0.07) in the first quintile, increasing to 0.14 (0.13) ( P < 0.001) by the fifth quintile on multivariable regression. For patients not achieving 0.30 logMAR at the first-FU, this was attained at the final-FU with a sensitivity of 51.9% and specificity of 95.5% at a cut off ≤0.58 logMAR at the first-FU (area under the curve 0.756 [95% confidence interval 0.664-0.848], P < 0.001).

CONCLUSION

The authors report a significant time-dependent visual improvement after uncomplicated pars plana vitrectomy with gas tamponade for macula-off pseudophakic rhegmatogenous retinal detachment without visual confounders and provide important quantitative data for counselling patients with macula-off repair.

Recurrences and Macular Complications after Perfluorocarbon-Liquid-Free Vitrectomy for Primary Rhegmatogenous Retinal Detachment

INTRODUCTION

This study investigates factors associated with recurrent rhegmatogenous retinal detachment (RRD), macular complications, and visual outcomes after pars plana vitrectomy (PPV) without perfluorocarbon liquids (PFCLs) for primary RRD.

METHODS

A longitudinal cohort study included consecutive patients with RRD who underwent PFCL-free PPV. Postoperative visual acuity and spectral-domain optical coherence tomography findings [cystoid macular edema (CME), epiretinal membrane (ERM), ellipsoid zone/interdigitation zone (EZ/IZ) damage] were collected. Logistic regression and linear mixed models analyzed rates and risk factors for RRD recurrence, CME, ERM, EZ/IZ damage, and visual acuity at 12 months.

RESULTS

346 eyes with RRD were studied. Single-operation success rates were 96% and 93% for uncomplicated (n = 274 eyes) and complicated (n = 72 eyes) RRD, respectively. Factors associated with RRD recurrence were posterior retinal breaks [odds ratio (OR) = 10.7 compared to peripheral retinal breaks, p = 0.008], silicone oil tamponade (OR = 5.66 compared to gas, p = 0.01), and sectorial laser retinopexy (OR = 4.34 compared to 360° laser retinopexy, p = 0.007). The prevalence of CME, ERM, and EZ/IZ damage at 12 months was 10%, 9%, and 6%, respectively. Eyes with EZ/IZ defects had worse postoperative visual acuity in both uncomplicated and complicated RRD. Proliferative vitreoretinopathy (OR = 2.95, p = 0.03) and silicone oil tamponade (OR = 3.70 compared to gas, p = 0.05) were associated with EZ/IZ damage.

CONCLUSIONS

PFCL-free PPV demonstrated satisfactory single-operation success rates for uncomplicated and complicated RRD, with a low prevalence of macular complications. Analyzing factors associated with RRD recurrence can provide provisional recommendations for PFCL-free approaches in the absence of randomized trials.

Impact of COVID-19 lockdown on surgical procedures for retinal detachment in France: a national database study

BACKGROUND/AIMS

The COVID-19 crisis and the decisions made regarding population lockdown may have changed patient care. We aimed to investigate the incidence rate of rhegmatogenous retinal detachment (RRD) cases during the COVID-19 lockdown period.

METHODS

In this nationwide database study, we identified hospital and clinic admissions of French residents for a first episode of RRD in France from 2017 to the lockdown period in 2020. The monthly hospital incidence rates of RRD procedures per 100 000 inhabitants before, during and after lockdown were computed for the whole country. Finally, we assessed the influence of viral incidence on the RRD incidence rate, comparing two regions with highly contrasting viral penetration.

RESULTS

From January to July, the average monthly national hospital incidence rate of RRD decreased from a mean of 2.59/100 000 inhabitants during 2017-2019 to 1.57/100 000 inhabitants in 2020. Compared with 2019, during the 8-week lockdown period in 2020, a 41.6% decrease in the number of RRD procedures was observed (p<0.001) with the weekly incidence of RRD decreasing from 0.63/100 000 inhabitants in 2019 to 0.36/100 000 inhabitants. During the 4-month post-lockdown period, no increased activity related to postponed procedures was observed. No difference was found in the rate of RRD surgery when comparing two regions with highly contrasting viral incidence.

CONCLUSION

Containment may have been responsible for a decrease in the number of surgical procedures for RRD, without any compensating post-lockdown activity in France. These results might help increase awareness of the management of RRD emergencies.

Primary ILM peeling during retinal detachment repair: a systematic review and meta-analysis

Epiretinal membrane (ERM) formation is a known postoperative complication following retinal detachment (RD) repair surgery. Prophylactic peeling of the internal limiting membrane (ILM) during surgery has been shown to reduce the risk of developing postoperative ERM formation. Some baseline characteristics and degrees of surgical complexity may act as risk factors for ERM development. In this review we aimed to investigate the benefit of ILM peeling in patients without significant proliferative vitreoretinopathy (PVR) who underwent pars plana vitrectomy for RD repair. A literature search using PubMed and various keywords retrieved relevant papers from which data were extracted and analyzed. Finally, the results of 12 observational studies (3420 eyes) were summarized. ILM peeling significantly reduced the risk of postoperative ERM formation (RR = 0.12, 95% CI 0.05-0.28). The groups did not differ in final visual acuity (SMD 0.14 logMAR (95% CI - 0.03-0.31)). The risk of RD recurrence (RR = 0.51, 95% CI 0.28-0.94) and the need for secondary ERM surgery (RR = 0.05, 95% CI 0.02-0.17) were also higher in the non-ILM peeling groups. In summary, although prophylactic ILM peeling appears to reduce the rate of postoperative ERM, this benefit does not translate into consistent visual recovery across studies and potential complications must be considered.

How should we report the foveal status in eyes with "macula-off" retinal detachment?

Whilst pre- and postoperative multimodal imaging technologies including optical coherence tomography (OCT) have investigated the morphological correlates of worsened visual outcomes in rhegmatogenous retinal detachment (RRD) with foveal involvement, the nomenclature has adhered to the traditional ophthalmoscopy-based and rather vague term "macula-off". This article appraises the current literature with regard to the preoperative assessment and nomenclature of the foveal status in macula involving retinal detachment (MIRD). A literature review of recent publications assessing functional or morphological outcomes in MIRD was conducted, using the search terms "fovea-off" or "macula-off". The search date was April 28^th, 2021. Original studies in English language were included. Case reports, review articles or letters were excluded. Forty relevant articles (range of publication dates: July 29^th, 2020 - April 18^th, 2021) were reviewed to assess the diagnostic modalities used, morphological parameters assessed, and any specific nomenclature introduced to specify the extent of macular detachment. The results suggest widespread variability and inconsistencies with regard to the preoperative assessment, diagnostic modalities and nomenclature used to describe the foveal status in eyes with RRD termed "macula-off". The extent of macular detachment may be classified by a wide range of morphological parameters, including the height of foveal detachment and the ETDRS grid as overlay tool in OCT devices. There is a scientific and clinical need for an updated nomenclature for eyes with "macula-off" RRD. Preoperative OCT findings should be reported on a regular and standardized basis in order to establish a consensus how to report the foveal status in eyes with MIRD.

Does choroidal thickness predict persistent subretinal fluid after rhegmatogenous retinal detachment repair? A retrospective study with fellow eye comparison

PURPOSE

To evaluate whether choroidal thickness (CT) is associated with persistent subretinal fluid (pSRF) after simple primary rhegmatogenous retinal detachment (RRD) repair.

METHODS

This single-centre, retrospective, observational study included patients who underwent RRD repair with at least 12-month follow-up. Preoperative and postoperative parameters were evaluated for association with pSRF. CT measurements were obtained at the central 1 mm area on enhanced depth imaging (EDI) OCT scans, using a semiautomatic method. Multiple logistic regression analyses were assessed to determine predictive factors for pSRF.

RESULTS

Overall, 100 eyes of 100 patients, mean age of 59.9 ± 12.6 years were included. pSRF was found in 21.0% of eyes and resolved over time in 85.7% of eyes at 12 months. In the pSRF group both RRD and fellow eyes showed lower mean choroidal and RPE thickness values as compared to those without pSRF (p < 0.05). A significant correlation was found between pSRF occurrence and choroidal thinning (p = 0.02). After multiple regression analyses, macula-off RRD (p = 0.005) and scleral buckling (SB) technique (p = 0.001) were retained as final predictors for pSRF. In macula-off SB eyes, detachment duration was the only factor associated with pSRF (p = 0.046). There were no significant differences in best-corrected visual acuity outcomes between the pSRF and the no-pSRF eyes.

CONCLUSIONS

Patients with pSRF showed lower choroidal and RPE thickness as compared to those without pSRF. CT did not turn out to be a final predictor for pSRF, as this was mainly associated with macular involvement, surgical technique and detachment duration.

Optical Coherence Tomography Findings in Rhegmatogenous Retinal Detachment: A Systematic Review

Rhegmatogenous retinal detachment is a sight-threatening condition that may lead to blindness if left untreated. Surgical treatments may vary and are tailored to a single patient. Anatomical and functional results may vary, due to factors that are currently under study. Optical coherence tomography (OCT) allows a detailed visualization of the retinal structure. Some studies have been performed using OCT on eyes with retinal detachment. We performed a review on the subject. Several data have been obtained using different OCT applications. Some alterations may represent potential biomarkers since they are associated with visual and anatomical prognoses. Increased knowledge on the subject may be helpful to choose among different surgical strategies and endotamponades. More research on the topic is needed.

Cystoid Macular Edema after Rhegmatogenous Retinal Detachment Repair with Pars Plana Vitrectomy: Rate, Risk Factors, and Outcomes

(1) Background: The aim was to describe the rate and outcomes of cystoid macular edema (CME) after pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD) and to identify risk factors and imaging characteristics. (2) Methods: A retrospective consecutive case study was conducted over a 5-year period among adult patients who underwent PPV for primary RRD repair. The main outcome measure was the rate of CME at 12 months following PPV. (3) Results: Overall, 493 eyes were included. The CME rate was 28% (93 patients) at 12 months. In multivariate analysis, eyes with worse presenting visual acuity (VA) (odds ratio [OR], 1.55; 95% CI, 1.07–2.25; p = 0.02) and grade C proliferative vitreoretinopathy (PVR) (OR, 2.88; 95% CI, 1.04–8.16; p = 0.04) were more at risk of developing CME 1 year after PPV. Endolaser retinopexy was associated with a greater risk of CME than cryotherapy retinopexy (OR, 3.06; 95% CI, 1.33–7.84; p = 0.01). Eyes undergoing cataract surgery within 6 months of the initial RRD repair were more likely to develop CME at 12 months (OR, 1.96; 95% CI, 1.06–3.63; p = 0.03). (4) Conclusions: CME is a common complication after PPV for primary RRD repair. Eyes with worse presenting VA, severe PVR at initial presentation, endolaser retinopexy, and cataract surgery within 6 months of initial RRD repair were risk factors for postoperative CME at 12 months.

COMPARISON BETWEEN SCLERAL BUCKLING AND VITRECTOMY IN THE ONSET OF CYSTOID MACULAR EDEMA AND EPIRETINAL MEMBRANE AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To investigate the incidence and risk factors for the main complications in patients with rhegmatogenous retinal detachment treated with scleral buckling (SB) or pars plana vitrectomy (PPV).

METHODS

A retrospective, comparative, observational study was conducted. The medical records of 107 patients with primary rhegmatogenous retinal detachment who were managed with SB (n = 57) or PPV (n = 50) were reviewed. Scleral buckling was performed using scleral encircling solid silicone band and circumferential solid silicone exoplant to support the break. Pars plana vitrectomy was combined with phacoemulsification in phakic eyes and with scleral encircling in inferior detachments. Follow-ups, including spectral-domain optical coherence tomography examination, were scheduled at 1, 3, and 12 months after surgery. Propensity score matching was used to adjust for potential preoperative selection bias.

RESULTS

The overall incidence of postoperative cystoid macular edema (CME) and epiretinal membrane was 14.95% and 30.84%, respectively. Compared with SB, CME was more frequent in the PPV (P = 0.021) and in the PPV pseudophakic eyes (P = 0.027). Postoperative CME was an early, predominantly transient complication and regressed in 67% of SB and in 77% of PPV eyes within 12 months after surgery. No differences were observed regarding epiretinal membrane development. Except for the surgical technique, no preoperative factors associated with CME were identified. A correlation between epiretinal membrane and patients' age was found (P = 0.028).

CONCLUSION

The incidence of CME after rhegmatogenous retinal detachment repair was higher in patients who underwent PPV, either alone or combined with phacoemulsification, than in those treated with SB. Epiretinal membrane development was correlated to older age, regardless of the surgical procedure.

Association of microvasculature changes with visual outcomes after successful retinal detachment surgery

PURPOSE

To evaluate macular microvascular changes and their correlation with visual outcomes after rhegmatogenous retinal detachment (RRD) surgery.

DESIGN

Retrospective case series PARTICIPANTS: Seventy-four eyes successfully operated for RRD were included in the study.

METHODS

The area of the foveal avascular zone in the superficial capillary plexus, the vessel density in the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillary plexus (CCP) were evaluated using optical coherence tomography angiography (OCTA) at 1 and 6 months postoperatively. The fellow eyes were used as controls for comparison.

MAIN OUTCOME MEASURES

The correlation between OCTA parameters and postoperative best-corrected visual acuity (BCVA) was assessed using a hybrid linear mixed model. We also analyzed the relationship between OCTA parameters and the integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) of photoreceptors.

RESULTS

The median vessel density in the DCP was significantly decreased in RRD eyes at 1 month (p=0.019), but gradually improved over time to reach the value of the fellow eyes at 6 months (p=1). There was no significant difference between the 2 groups in median foveal avascular zone area, vessel density in the SCP and in the CCP (p=0.579, p=0.618, p=0.068 and p=0.819, p=1 and p=1, respectively) at both 1 and 6 months postoperatively. Postoperative BCVA was positively correlated with the vessel density in the DCP (p=0.009) in multivariate analysis. Eyes with low 1-month vessel density in the DCP tended to have worse final BCVA (p=0.067). There was no correlation between the vessel density in the DCP and ELM and/or EZ integrity at both 1 (p=0.156) and 6 months postoperatively (p=0.161). Eyes with intact ELM and EZ at 6 months, however, had significantly higher 1-month vessel density in the DCP than those with disrupted ELM and/or EZ (p=0.027).

CONCLUSION

The vessel density in the DCP was affected in RRD eyes as well as associated with postoperative BCVA and the restoration of photoreceptor layers. It might thus serve as a predictor for visual recovery following successful RRD surgery.