Tailored vitrectomy and laser photocoagulation without scleral buckling for all primary rhegmatogenous retinal detachments

Impact of drainage retinotomy on surgical outcomes of retinal detachment: insights from the Japan-Retinal Detachment Registry

We investigated the impact of drainage retinotomy on the outcome of pars plana vitrectomy for repair of rhegmatogenous retinal detachment (RRD). This study was a retrospective observational multicenter study. All patients were registered with the Japan-Retinal Detachment Registry. We analyzed 1887 eyes with RRD that had undergone vitrectomy and were observed for 6 months between February 2016 and March 2017. We compared the baseline characteristics and postoperative outcomes between eyes with and without drainage retinectomy. We then performed propensity score matching using preoperative findings as covariates to adjust for relevant confounders. Of 3446 eyes, 1887 met the inclusion criteria. Among them, 559 eyes underwent vitrectomy with drainage retinotomy, and 1328 eyes underwent vitrectomy without drainage retinotomy. After propensity score matching, each group comprised 544 eyes. There was no significant difference between the two groups in BCVA at 6 months after vitrectomy (0.181 vs. 0.166, P = 0.23), the primary anatomical success rate (6.3% vs. 4.4%, P = 0.22), or the rate of secondary surgery for ERM within 6 months (1.5% vs. 1.3%, P = 1.0). Drainage retinectomy does not increase the risk of decreased postoperative BCVA, surgical failure, or secondary surgery for ERM within six months outcomes.

Sutureless scleral buckle in the management of rhegmatogenous retinal detachment

Purpose:

To evaluate the anatomical and functional outcomes of sutureless scleral buckling for the repair of rhegmatogenous retinal detachment (RD).

Design:

Retrospective interventional case series.

Materials and Methods:

Retrospective analysis of 50 eyes of 49 patients with rhegmatogenous RD, who underwent sutureless scleral buckling from January 2009 to March 2013.

Results:

Primary retinal re-attachment rate of 86% was achieved with single surgery, but final anatomical success was 94% with additional interventions in the form of intravitreal gas, buckle revision, and/or pars plana vitrectomy. Best corrected logarithm of minimum angle of resolution visual acuity improved from 1.44 ± 1.01 preoperatively to 0.50 ± 0.40 at a mean follow-up of 6.7 months.

Conclusion:

Sutureless scleral buckling achieves excellent anatomical and functional success in majority of the patients with rhegmatogenous RD.

Dealings between Cataract and Retinal Reattachment Surgery in PVR

Introduction. To evaluate the impact of the eye lens status and oil side effects on the outcome of vitreoretinal surgery in retinal detachment with proliferative vitreoretinopathy (PVR) and a temporary silicone oil tamponade (SOT). Methods. 101 eyes were analyzed retrospectively and 103 eyes prospectively in regard to their retinal reattachment success rate and key factors for the outcome. Subgroup analysis of 27 eyes with Scheimpflug lens photography (SLP) before and after retinal reattachment service with SOT was performed. For SLP (65% phakic eyes) a Pentacam densitometry reference body with 3 mm diameter was chosen and 3 segments (anterior/mid/posterior) were evaluated separately after a quality check. Results. The retinal reattachment rate was highest in the prospective pseudophakic group (p = 0.039). Lens transparency loss occurred earlier in middle aged patients than in younger patients. Besides the nucleus, layers posterior and anterior to it showed specific transparency changes. The emulsification rate was higher when eyes had been operated on in the anterior chamber before retinal reattachment service. Conclusions. Retinal reattachment surgery seems to benefit from preoperative cataract removal. We found significant lens changes in the nucleus as well as in the layers anterior and posterior to it. This corresponds to the histology of the lens epithelium published before.

Epiretinal membrane and cystoid macular edema after retinal detachment repair with small-gauge pars plana vitrectomy

PURPOSE

To evaluate the incidence rates of cystoid macular edema (CME) and epiretinal membrane (ERM) formation after uncomplicated primary 23-G and 25-G retinal detachment (RD) repair and to identify risk factors associated with postoperative CME and ERM formation.

METHODS

This was a consecutive interventional case series of 587 eyes that underwent one RD repair with 23-G or 25-G pars plana vitrectomy (PPV) with scleral buckling. Epiretinal membrane and CME were confirmed by optical coherence tomography (OCT) and fluorescein angiography (FA).

RESULTS

A total of 587 eyes with a mean follow-up of 404 days had incidence rates of 35.1% for ERM and 15.2% for CME. The incidence of ERM after combined PPV and scleral buckling (48.4%) (n = 61) was greater (p<0.0001) compared to that after PPV alone (31.2%) (n = 144).

CONCLUSIONS

Epiretinal membrane and CME develop frequently after small-gauge RD repair. Pars plana vitrectomy combined with scleral buckling is associated with a higher incidence of ERM. Patients might benefit from increased use of OCT and FA to help rule out CME/ERM.

Clinical variables associated with failure of retinal detachment repair: the European vitreo-retinal society retinal detachment study report number 4

OBJECTIVE

To identify risk factors associated with failure of anatomic reattachment in primary rhegmatogenous retinal detachment repair.

DESIGN

Nonrandomized, multicenter, collaborative study.

PARTICIPANTS

Primary procedures for 7678 rhegmatogenous retinal detachments reported by 176 surgeons from 48 countries.

METHODS

We recorded specific preoperative clinical findings, repair method, and outcome after intervention. We performed univariate, bivariate, and multivariate analyses to identify variables associated with surgical failure.

MAIN OUTCOME MEASURES

Final failure of retinal detachment repair (level 1), remaining silicone oil at study conclusion (level 2), and need for additional procedures to repair the detachment (level 3).

RESULTS

We analyzed 7678 cases of rhegmatogenous retinal detachment repair. Presence of choroidal detachment or significant hypotony was associated with significantly higher level 1 failure rates when grade 0 or B proliferative vitreoretinopathy (PVR) was present and higher level 2 failure rates, regardless of PVR status (P<0.05). Excluding cases with choroidal detachment or hypotony, increasing PVR was associated with increasing level 1 failure rates. The difference between grade B and C-1 PVR was significant (P = 2 × 10(-6)). No difference was observed in level 1 failure rates when operated eyes were phakic versus pseudophakic. Level 1 failure was significantly higher when all 4 quadrants of retina (4.4%) were detached than when only 1 quadrant (0.8%) had subretinal fluid. With grade B or C-1 PVR, cases with large or giant tears had significantly higher level 1 failure rates. No association was observed between number of retinal breaks and failure rates. Multivariate analysis showed grade C-1 PVR, 4 detached quadrants, and presence of choroidal detachment or significant hypotony were independently linked with a greater level 1 failure rate; the presence of a smaller retinal break was associated with a lesser level 1 failure rate.

CONCLUSIONS

Choroidal detachment, significant hypotony, grade C-1 PVR, 4 detached quadrants, and large or giant retinal breaks were independent explanatory variables of retinal detachment repair failure. In contrast to earlier studies, the significance of phakic versus pseudophakic status was not confirmed.

Scleral buckling and pars plana vitrectomy for rhegmatogenous retinal detachment: an analysis of 542 eyes

PURPOSE

To investigate the anatomical success rates of scleral buckling (SB) and pars plana vitrectomy (PPV) performed for rhegmatogenous retinal detachment (RRD) in a large case series and to identify prognostic factors for the primary anatomical success rates of surgical techniques.

METHODS

We reviewed 542 consecutive eyes for primary RRD in this retrospective study. Follow-ups were performed for at least six months. In each of the two groups, 271 eyes were examined. The main outcome measure was the primary anatomical success rate. Multivariate analysis was also performed to determine whether independent risk factors of the preoperative parameters for redetachment exist.

RESULTS

The primary anatomical success rates were 93.7% and 96.3% in the SB and PPV groups; and the final anatomical success rates were 100% in both groups (each with 271 eyes). In the SB group, eyes with macula-off had significantly lower primary anatomical success rates than those with macula-on (p = 0.002). Preoperative break location or lens status had no significant effect on primary anatomical success rates in either group. Multivariate logistic regression analysis using four variables, namely, sex, posterior vitreous detachment, macular status and preoperative visual acuity, showed that the macular status was an independent risk factor for redetachment in the SB group (p = 0.039, odds ratio 3.7). The six-month follow-up visual acuity was significantly better than the preoperative visual acuity in both groups (p ≤ 0.001).

CONCLUSIONS

Both SB and PPV gave excellent primary and final anatomical success rates. The macula-off status was associated with a lower success rate in the SB group, although break location and lens status had no significant effect on success rates in either group.

A comparison of the anatomic successes of primary vitrectomy for rhegmatogenous retinal detachment with superior and inferior breaks

PURPOSE

To compare the anatomic success between repair of rhegmatogenous retinal detachment (RRD) with superior breaks and repair of RRD with inferior breaks, by performing primary vitrectomy and using similar techniques and the same gas.

METHODS

Eighty-two consecutive eyes of 80 patients with RRD were included in this retrospective comparative study. The eyes were divided into two groups according to the location of the breaks: superior (n = 62) and inferior (n = 20). All the patients underwent a standard, 3-port, 20-gauge pars plana vitrectomy with 20% sulphur hexafluoride gas tamponade performed by the same surgeon. The main outcome measured was the primary anatomic reattachment at 3 months after surgery.

RESULTS

The primary anatomic success rate in the inferior group was significantly lower than that in the superior group (80% versus 98%, p = 0.012). In the inferior group, the primary anatomic success rate in patients whose symptoms lasted for more than 2 weeks was significantly lower than that in others (5/9 versus 11/11, p = 0.026). Multivariate logistic regression analysis identified inferior break as the only independent risk factor for redetachment (odds ratio, 11.88; p = 0.034).

CONCLUSION

The anatomic success of primary vitrectomy for RRD with inferior breaks is lower than that for RRD with superior breaks. In particular, the duration of symptoms longer than 2 weeks is associated with a worse outcome in patients who had RRD with inferior breaks.

Non-buckled vitrectomy for retinal detachment with inferior breaks and proliferative vitreoretinophathy

AIM

To investigate the efficacy of non-buckled vitrectomy with classical endotamponade agents in the treatment of primary retinal detachment (RD) complicated by inferior breaks and proliferative vitreoretinophathy (PVR).

METHODS

A retrospective, consecutive and case series study of 40 patients with inferior break RD and PVR ≥C1 was conducted. All patients underwent a standard 3-port 20-gauge pars plana vitrectomy (PPV) with gas or silicone oil tamponade without supplementary scleral buckling. The vitreous and all proliferative membrane were completely removed, and retinectomy was performed when necessary. The mean follow-up was 12.5 months. The primary and final anatomic success rate, visual acuity and complications were recorded and analyzed.

RESULTS

Primary anatomic success rate was achieved in 35 of 40 eyes (87.5%) and the final anatomic success rate was 100%. The most common cause of redetachment was recurrent PVR. The best-corrected visual acuity (BCVA) at final follow-up was improved in 34 eyes (85%), remained stable in 1 eye (2.5%), and worsened in 5 eyes (12.5%). The mean visual acuity at final follow-up was improved significantly (P=0.000).

CONCLUSION

This retrospective study provides evidence that vitrectomy without scleral buckling seemed to be an effective treatment for inferior break RD with PVR. With complete removal of vitreous and proliferative membranes and timing of retinectomy, the inferior breaks which complicated with PVR could be closed successfully without additional scleral buckling.

Outcome of surgery after macula-off retinal detachment - results from MUSTARD, one of the largest databases on buckling surgery in Europe

PURPOSE

To evaluate the anatomical success rate of scleral buckling surgery in the treatment of rhegmatogenous retinal detachment and to evaluate the differences in outcome between patients suffering macula-off retinal detachment and those without a macular involvement.

METHODS

As a retrospective interventional case series, Munster Study on Therapy Achievements in Retinal Detachment (MUSTARD) is one of the largest ever established of retinal detachment patients and their outcome after buckling surgery, with 4325 patients who underwent surgery between 1980 and 2001. In 53.94% (n = 2134) of 3956 patients with nontraumatic retinal detachment, the macula was involved. The main outcome measure was the achievement of dry anatomical attachment of the retina.

RESULTS

The success rate in patients with macula-off retinal detachment is 80.46% and thus 7.78% lower (p < 0.01) than that in those patients with their macula intact whose success rate amounted to 88.24%. The overall success rate of all 4325 MUSTARD patients was 83.98%.

CONCLUSIONS

Scleral buckling is an established and mostly successful method for the treatment of retinal detachment. As our case series has demonstrated, even eyes with macula-off can be treated successfully by this procedure, thereby avoiding the complications of primary vitrectomy.

Neuronal and glial alterations in complex long-term rhegmatogenous retinal detachment

PURPOSE

To explore neuronal and glial alterations in eyes with complex long-term rhegmatogenous retinal detachment (RRD).

METHODS

Morphological analysis was performed on eight retinal specimens derived from patients treated with peripheral retinectomy for RRD complicated by retinal shortening or retinal thinning. All eyes had undergone previous surgeries including silicone oil tamponade, and had a median total detachment time of 2.5 months (range 2-12). Specimens were examined with hematoxylin and eosin staining and immunohistochemistry directed against activated Müller cells, ganglion cells, rod bipolar cells, and photoreceptors.

RESULTS

Retinal specimens displayed severe loss of photoreceptor and rod bipolar cells. Remaining neuronal cells exhibited disorganized perikarya and neurites with disruption of the normal retinal lamination. Müller cell activation was evident in all specimens with subretinal and epiretinal hypertrophy present in tissue derived from shortened retinal detachments.

CONCLUSION

Long-term RRD leads to retinal remodeling characterized by loss of first and second order retinal neurons, disruption of the entire retinal lamination and gliosis. The severity of histopathological changes indicates that anatomical as well as functional recovery of the involved retina is precarious. The findings may be important when devising surgical strategies to avoid permanent retinal detachment.

Pars plana vitrectomy without adjuvant procedures for repair of primary rhegmatogenous retinal detachment

PURPOSE

To evaluate the anatomical and functional outcomes of pars plana vitrectomy without adjuvant scleral buckling, prophylactic 360° endolaser photocoagulation, or perfluorocarbon liquid use for the treatment of primary uncomplicated rhegmatogenous retinal detachment.

METHODS

Retrospective interventional case series of consecutive patients undergoing vitrectomy for noncomplex rhegmatogenous retinal detachment over a 10-year period. Main outcome measures included primary anatomical success rate, defined as retinal reattachment at final follow-up after a single operation, proportion of eyes achieving a final best-corrected visual acuity ≤ logarithm of the minimum angle of resolution 0.3 (≥ Snellen 20/40), and postoperative complications.

RESULTS

With a mean follow-up of 31 months, primary anatomical success was achieved in 95.7% (89 of 93) of eyes. Final anatomical success, defined as retinal attachment at final follow-up without regard to additional procedures, was achieved in 98.9% (92 of 93). Final best-corrected visual acuity of ≤ logarithm of the minimum angle of resolution 0.3 (≥ Snellen 20/40) was achieved in 77.4% of eyes in the cohort. Postoperative proliferative vitreoretinopathy developed in 3.2% of eyes. No new retinal breaks developed postoperatively in the absence of clinically evident proliferative vitreoretinopathy.

CONCLUSION

Thorough pars plana vitrectomy alone, without adjuvant scleral buckling, 360° endolaser photocoagulation, or routine perfluorocarbon liquid use, yields high anatomical and functional success rates and low complication rates in the treatment of primary uncomplicated rhegmatogenous retinal detachment. In the absence of observable proliferative vitreoretinopathy, postoperative vitreous base contraction does not appear to be a clinically relevant phenomenon.

Pars plana vitrectomy for primary rhegmatogenous retinal detachment

Pars plana vitrectomy (PPV) is growing in popularity for the treatment of primary rhegmatogenous retinal detachment (RD). PPV achieves favorable anatomic and visual outcomes in a wide variety of patients, especially in pseudophakic RD. A growing number of clinical series, both retrospective and prospective, have demonstrated generally comparable outcomes comparing PPV and scleral buckling (SB) under a variety of circumstances. The Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study is a multicenter, randomized, prospective, controlled clinical trial comparing SB versus PPV. This study should provide useful guidelines in the future. At this time, the choice of SB versus PPV should be based on the characteristics of the RD, the patient as a whole, and the experience and preference of the individual retinal surgeon.

Evaluation of viscoelastic poly(ethylene glycol) sols as vitreous substitutes in an experimental vitrectomy model in rabbits

The aim of this study was to employ an experimental protocol for in vivo evaluation of sols of 5 wt.% poly(ethylene glycol) (PEG) in phosphate-buffered saline as artificial vitreous substitutes. A 20 gauge pars plana vitrectomy and posterior vitreous detachment were performed in the right eye of eight pigmented rabbits. Approximately 1 ml of the viscoelastic PEG sols was then injected into the vitreous space of six eyes. PEG with an average molecular weight of 300,000 and 400,000 g mol(-1) was used in two and four eyes, respectively. Two eyes received balanced salt solution and served as controls. Full-field electroretinography was carried out and intra-ocular pressure (IOP, palpation) measured pre- and post-operatively at regular intervals up to 41 days. The rabbits were killed and the eyes examined by retinal photography, gross macroscopic examination and histology. The viscoelastic sols were successfully injected and remained translucent throughout the post-operative period, with some inferior formation of precipitates. None of the eyes displayed IOP elevation post-operatively, but in three of the PEG sol injected eyes transient hypotony was noted. One eye sustained retinal detachment during surgery and another two in the post-operative period. ERG recordings confirmed preservation of retinal function in three out of four eyes injected with 400,000 g mol(-1) PEG. Histological examination revealed up-regulation of glial acidic fibrillary protein in Müller cells in PEG sol injected eyes, but normal overall morphology in eyes with attached retinas. The viscosity of the sol was not retained throughout the post-operative period, indicating the demand for polymer cross-linking to increase residence time. The results provide promising preliminary results on the use of PEG hydrogels as a vitreous substitute.

LASER demarcation photocoagulation for rhegmatogenous retinal detachments

PURPOSE

to evaluate demarcation laser photocoagulation (DLP) for macula-sparing rhegmatogenous retinal detachments (RRD) with and without symptoms of posterior vitreous separation or progressive visual field defect.

METHODS

retrospective, interventional, single surgeon case series of consecutive patients with RRD treated with demarcation laser photocoagulation between March 1999 and February 2008 at an academic center. The null hypothesis was that there exists no difference in the rate of progression for retinal detachment irrespective of the presence ('symptomatic') or absence ('asymptomatic') of symptoms of posterior vitreous separation or visual field defect at presentation.

RESULTS

a total of 27 eyes of 26 patients were included in the study. In all, 22 of the 27 eyes (81.4%) did not require additional treatment and remained attached during mean follow-up of 38.4 months. None of the 14 asymptomatic patients required surgery (0%) whereas 5 out of the 13 patients (38.5%) who were symptomatic at presentation required further intervention (p=0.016): one patient required additional laser only and four patients required scleral buckling or vitrectomy. Pre- and post- DLP logMAR visual acuity was 0.15 and 0.14, respectively.

CONCLUSION

demarcation laser photocoagulation is an effective alternative to scleral buckling or vitrectomy for treating asymptomatic RRDs. It has a high failure rate among eyes with symptomatic RRD.

Primary repair of retinal detachment with 25-gauge pars plana vitrectomy

PURPOSE

To evaluate 25-gauge pars plana vitrectomy (PPV) for primary repair of rhegmatogenous retinal detachment (RRD).

STUDY DESIGN AND PARTICIPANTS

This retrospective, consecutive case series included 42 eyes of 41 patients who underwent primary repair of RRD utilizing transconjunctival 25-gauge PPV without scleral buckling at the Cincinnati Eye Institute from July 2004 through January 2007.

METHODS

The medical records were retrospectively reviewed, and the corresponding demographic data, preoperative ophthalmic diagnoses, surgical management, and postoperative course and treatment were recorded. Main outcome measures included single surgery anatomical success, preoperative and postoperative visual acuity, and complications.

RESULTS

Most patients had pseudophakic RRD (36 [85.7%] of 42 eyes). The crystalline lens was present in the remaining 6 eyes (14.3%). Of 42 eyes, 28 (66.7%) had macula-on RRD, while 14 (33.3%) had macula-off RRD. Four surgeons contributed to this study, and 25-gauge PPV instrumentation, a wide-angle viewing system, endolaser photocoagulation, and gas tamponade were used in each case. The single surgery anatomical success rate was 92.9% (39 of 42 eyes). For eyes with macula-on RRD, best-corrected visual acuity was 20/50 (0.43 logMAR [logarithm of the minimum angle of resolution]) preoperatively and 20/30 (0.23 logMAR) postoperatively (P = 0.24). For eyes with macula-off RRD, best-corrected visual acuity was 5/200 (1.56 logMAR) preoperatively and 20/30 (0.23 logMAR) postoperatively (P = 0.001). Three eyes required additional surgery for final reattachment. Final reattachment was achieved in 100% of patients (mean follow-up, 8 months).

CONCLUSIONS

Twenty-five-gauge PPV with laser retinopexy and gas tamponade is effective for primary repair of RRD. The single operation anatomical success rate is comparable with rates reported for primary vitrectomy with 20-gauge instrumentation, scleral buckling, and combined vitrectomy/scleral buckling.

Retinal function and PKC alpha expression after focal laser photocoagulation

PURPOSE

To examine the effects of focal laser photocoagulation on general and local retinal function and to relate electrophysiological findings with changes in protein kinase C (PKC) alpha expression.

METHODS

Twelve rabbits were treated with 70 spots of laser photocoagulation in the central cone-rich retina. The operated eyes were investigated with electroretinography (full-field ERG and multifocal electroretinography, mfERG) preoperatively and at 1, 3, and 5 weeks after surgery. The expression of PKC alpha was examined at all three time points using immunohistochemistry, and PKC alpha mRNA levels were quantified using real-time polymerase chain reaction (PCR). Immunohistochemistry for glial fibrillary acidic protein (GFAP) and hematoxylin and eosin staining was employed to monitor the extent and dynamics of the morphological response.

RESULTS

The full-field ERG revealed a significant increase in b-wave amplitudes derived from the isolated rod response (blue light) at all three time points after surgery (p < 0.05). Supernormal b-wave amplitudes were also found for the combined rod-cone response at 3 weeks (white light), and for the isolated cone response (light-adapted 30-Hz flicker) at 5 weeks after treatment. In the mfERG, amplitudes derived from the central retina did not change postoperatively, while the implicit time was significantly increased at all time points. Immunohistochemistry for PKC alpha revealed a reduced expression of the enzyme in rod bipolar cells 1 and 3 weeks after laser treatment compared with untreated controls. Five weeks postoperatively, no PKC alpha labeling in rod bipolar cells was found in any part of the retina. Real-time PCR 1 and 3 weeks after treatment displayed a decreased level of PKC alpha mRNA compared to the controls. Immunolabeled tissue sections from laser-treated eyes displayed GFAP expression in Müller cells in the treated as well as untreated retina 1 week postoperatively. At 3 and 5 weeks, GFAP labeling was less pronounced and was concentrated around the laser-treated spots.

CONCLUSIONS

Focal laser treatment in the rabbit eye induces local and wide-spread alterations in both rod- and cone-mediated retinal function in the form of supernormal b-wave amplitudes in the full-field ERG and increased latency in the mfERG. The electrophysiological abnormalities are accompanied by a progressive down-regulation of the PKC alpha isoenzyme in rod bipolar cells, reaching far beyond the treated area. PKC alpha is down-regulated directly by impaired protein synthesis, and also possibly indirectly by protein consumption related to GFAP up-regulation. The results indicate that focal laser photocoagulation interferes with PKC-alpha-mediated inhibitory regulation of inner retinal signal transmission.