View 2: the case for primary vitrectomy

Enhancing Scleral Buckling Surgery Using an Illuminated Scleral Depressor

PURPOSE

To report a technique for scleral buckling surgery under the operating microscope with wide-field viewing.

METHODS

The identification and reliable marking of retinal breaks is one of the key steps for successful surgery in scleral buckling. For sufficient visualization of retinal breaks, some kind of indentation and illumination is necessary. In this technique, one instrument (Visible Periphery illuminated scleral indentor; Oertli Instrumente AG, Switzerland) combines scleral depression, illumination, and color marking (using a surgical marking pen) of the corresponding sclera above the retinal break.

RESULTS

The illuminated scleral depressor enables the surgeon to safely and precisely mark the retinal break while stabilizing and rotating the eye with the other hand. This technique simplifies scleral buckling surgery by improving the handling and visualization of marking retinal breaks at the corresponding scleral. Neither intraoperative indirect ophthalmoscopy nor sclerotomies for chandelier light systems or any intraocular instrument are necessary.

CONCLUSION

The illuminated scleral depressor facilitates scleral buckling surgery in a convenient way for easy and precise scleral marking of the retinal breaks even in challenging situations and positions of retinal breaks under the operating microscope with wide-field viewing. Indirect ophthalmology or other illumination sources are no longer needed.

Absorbable suture for band tightening of scleral buckling in pseudophakic rhegmatogenous retinal detachment: a modified surgical technique and a 6-month follow-up

Background

Rhegmatogenous retinal detachment (RRD) is a separation of the neurosensory retina from the retinal pigment epithelium as a result of liquid vitreous passing through a retinal break. Scleral buckling surgery (SB) is a conventional treatment for RRD. In SB, a silicon explant is used to indent the sclera, reduce vitreous traction, and close the retinal break, and an encircling band is used circumferentially, leading to myopia. This study aimed to evaluate the functional and biometric outcomes after SB with absorbable band-tightening sutures in patients with pseudophakic RRD.

Methods

In this prospective interventional study, we included pseudophakic eyes with RRD treated surgically with SB and a temporary encircling band using a 6-0 absorbable Vicryl suture to tighten the band, instead of conventional permanent suture tightening. Anterior chamber depth (ACD), axial length (AL), intraocular pressure (IOP), spherical equivalent refractive error (SER), and best-corrected distance visual acuity (BCDVA) were measured preoperatively and at 1 day, 2 weeks, 3 months, and 6 months postoperatively.

Results

We included 30 eyes of 30 patients with a mean (standard deviation [SD]) age of 66.1 (10.5) years who underwent SB with an absorbable band-tightening suture for pseudophakic RRD. Significant increases in AL and ACD were observed at 2 weeks after surgery, with a significant decline in values thereafter; however, at the 6-month follow-up, the values were significantly higher than those at baseline (all P < 0.05). Based on the Vicryl tension and its hydrolysis, mean (SD) SER at 2 weeks postoperatively was significantly more myopic than at baseline (-5.8 [1.6] D versus +1.3 [1.8] D). However, the mean (SD) SER decreased significantly throughout the 6-month follow-up (all P < 0.05), and it reached -1.8 (0.9) D, which was comparable with the mean baseline SER (P = 0.140). The participants experienced significant improvement in BCDVA throughout the follow-up period (all P < 0.05).

Conclusions

Using an absorbable suture to tighten the encircling band in patients with pseudophakic RRD can reduce postoperative myopia without adversely affecting the anatomical or functional outcomes. Future comparative studies with larger sample sizes and longer postoperative follow-up are needed to verify these findings.

COMPARISON BETWEEN RELEASABLE SCLERAL BUCKLING AND VITRECTOMY IN PATIENTS WITH PHAKIC PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT

By comparing releasable scleral buckling and pars plana vitrectomy in the treatment of phakic patients with primary rhegmatogenous retinal detachment, we found that releasable scleral buckling and pars plana vitrectomy procedures have the same effects on the functional and anatomical success for patients with phakic primary rhegmatogenous retinal detachment, but releasable scleral buckling was associated with fewer complications.

To compare the efficiency of releasable scleral buckling (RSB) and pars plana vitrectomy (PPV) in the treatment of phakic patients with primary rhegmatogenous retinal detachment.

Vascular changes after vitrectomy for rhegmatogenous retinal detachment: optical coherence tomography angiography study

PURPOSE

To analyse the postoperative foveal avascular zone (FAZ) area, superficial vessel density (SVD) and deep vessel density (DVD) and their correlation with functional (best-corrected visual acuity, BCVA) and anatomical outcomes (foveal macular thickness, FMT) after surgery for rhegmatogenous retinal detachment (RRD) repair.

METHOD

Patients with RRD eyes, successfully treated with a single pars plana vitrectomy (PPV) with gas tamponade and a minimum 12 months follow-up, were re-examined. Foveal avascular zone (FAZ) area, SVD, DVD and FMT were evaluated by using optical coherence tomography angiography (OCTA) and compared to fellow eye.

RESULTS

Fifty-six patients with macula-on and 37 with macula-off RRD were included in the study. In both groups, no difference in FMT and FAZ area was found compared to fellow eyes. In macula-on RRD eyes, a lower parafoveal DVD (p = 0.001) was detected; FAZ area was related to FMT (p = 0.025), and the postoperative BCVA was correlated with parafoveal DVD (p = 0.010) and FAZ area (p = 0.003). In macula-off RRD eyes, lower parafoveal SDV (p = 0.012), and foveal and parafoveal DVD (p = 0.012 and p < 0.001, respectively) were observed. BCVA was related to FAZ area (p = 0.012), foveal SVD (p = 0.005) and parafoveal DVD (p = 0.010).

CONCLUSION

Rhegmatogenous retinal detachment eyes successfully treated with PPV had lower vessel density in the superficial and deep retinal plexus compared to fellow healthy eyes; BCVA was related to FAZ area and vessel density.

Outcomes of Rhegmatogenous Retinal Detachment Repair With Nonrestricted Postoperative Positioning

Purpose:

To investigate the anatomical success rate associated with rhegmatogenous retinal detachment (RRD) repair without postoperative head positioning.

Methods:

Data on 182 individuals undergoing pars plana vitrectomy (PPV) with or without phacoemulsification or scleral buckle for primary RRD with intraocular tamponade were retrospectively reviewed. The primary outcome was the initial anatomical success rate. Secondary outcome measures were the change in best-corrected visual acuity and the final reattachment rate.

Results:

A total of 122 eyes from 122 patients who underwent RRD repair without postoperative positioning were included in this study. PPV alone was performed in 39% of cases, whereas the remaining patients had PPV combined with phacoemulsification (35%), with scleral buckle (19%), or both (7%). Inferior breaks between the 4 o’clock and 8 o’clock positions were present in 47% of cases. Primary and final anatomical success was achieved in 86% and 98% of cases, respectively. The most common cause for redetachment was proliferative vitreoretinopathy. Age and combined inferior retinal and superior breaks were predictive of recurrence in the logistic regression model. The mean baseline best-corrected visual acuity improved from 1.2 (Snellen equivalent, 20/320) to 0.76 (Snellen, 20/125) logarithm of the minimum angle of resolution after retinal reattachment ( P < .001).

Conclusions:

PPV combined with or without phacoemulsification or scleral buckle for primary RRD in pseudophakic eyes or those rendered pseudophakic is associated with good anatomical outcomes without restricted postoperative head positioning. Retinal detachment in eyes with combined retinal inferior and superior breaks may have a lower success rate, and whether this is due to lack of postoperative positioning needs further evaluation in prospective, controlled studies.

Scleral buckling-a brief historical overview and current indications

The key to successful management of rhegmatogenous retinal detachment (RRD) is to find and seal all of the retinal breaks, and the two main surgical techniques used to achieve this are scleral bucking (SB) or pars plana vitrectomy (PPV). Techniques for SB have remained mostly unchanged for the last 60 years, whilst PPV techniques and instruments have developed substantially over that time and have greatly contributed to increased success rate for types and configurations of retinal detachments unsuitable or difficult to manage with buckling alone. However, there is a growing dependency to rely on PPV as the sole and only approach for repair of all types of retinal detachment, such that some centres are no longer offering training in scleral buckling. There are also many studies comparing SB with PPV, but many of these lack information on the type, technique or rationale for deployment of the buckle. Many studies deploy the same scleral buckle technique without customising it to the type, position or number of tears being treated. Scleral buckling is not a one-size-fits-all technique. It requires careful patient selection and careful buckle selection and orientation tailored to the tear(s) to ensure success. When used appropriately, it is a simple and highly effective technique, particularly for retinal dialyses, round retinal hole detachments and selected cases of retinal detachment associated with horseshoe retinal tears. There is no doubt that for some more complex cases, such as multiple large breaks, giant retinal tears, bullous detachments and cases complicated by proliferative retinopathy, PPV offers a safer and more effective management. However, SB remains an important and relevant surgical technique, and for the right cases, the results can be superior to PPV with reduced comorbidity.

Fortified Barrier Laser On The Vitreous Base In Vitrectomy For Rhegmatogenous Retinal Detachment

Purpose

To investigate the efficacy of fortified barrier laser (FBL) on the vitreous base in vitrectomy for rhegmatogenous retinal detachment (RRD).

Patients and methods

This was a retrospective study of patients who underwent vitrectomy for RRD without proliferative vitreoretinopathy. Barrier laser was applied as 3-4 rows surrounding the break at the end of fluid-air exchange. For the FBL, 3-4 rows of laser burn were additionally made about 0.5 clock-hour long adjacent to the break along the posterior border of the vitreous base. The primary outcome was single surgery success rate (SSSR) between two groups: FBL and conventional barrier laser (CBL) groups.

Results

Overall, 118 eyes were included; 50 eyes in the FBL group and 68 eyes in the CBL group. SSSR was 100% (50/50) in the FBL group and 91.2% (62/68) in the CBL group with a significant difference (p=0.038). Four eyes of the recurrent cases in the CBL group were related to reopening of the break. All eyes achieved reattachment, and no differences were found in postoperative visual acuity at 6 months.

Conclusion

FBL on the vitreous base was efficacious in improving the anatomical success rate of vitrectomy.

Surgical outcomes of Pars Plana Vitrectomy for recurrent retinal detachment in eyes previously treated with Pars Plana Vitrectomy or Scleral Buckling

PURPOSE

To report anatomical and functional outcomes of pars plana vitrectomy (PPV) for recurrent retinal detachment (RD) after failed scleral buckling (SB) or primary PPV.

METHODS

Retrospective analysis of 59 eyes with recurrent RD treated previously with SB or PPV was performed. All eyes underwent 23 gauge PPV. The primary outcome was single surgery success rate (SSSR) for retinal reattachment at the final visit. Secondary outcomes were visual acuity change and number of reoperations.

RESULTS

SSSR was 77.4 % in the SB group and 67.9 % in the PPV group (P=0.41). The mean change in visual acuity was not significantly different between the two groups (P=0.35). The mean number of reoperations was 1.2±0.5 and 1.4±0.6 in the SB and PPV groups, respectively (P=0.38).

CONCLUSION

PPV was found to be an effective technique for the management of recurrent RD after SB and PPV surgeries. However, the small sample size and the retrospective design prevent any claims of advantages or disadvantages of one surgical technique over the other.

Reviving the lost art of scleral buckling surgery for rhegmatogenous retinal detachment: evaluation of risk factors of detachments, poor physiological outcomes, and perspective from a developing country

PURPOSE

To evaluate the primary anatomic and physiological success of scleral buckling surgery for rhegmatogenous retinal detachment and factors influencing its outcomes.

METHODS

This is a prospective analytical study of 92 eyes that underwent scleral buckling at the Lumbini Eye Institute and Research Center, in Lumbini, Nepal. Parameters evaluated which could influence the outcome of the surgery included the lens status, duration of symptoms, locations of breaks, the extent of retinal detachment, and preoperative proliferative vitreoretinopathy.

RESULTS

A total of 92 eyes from 88 patients with rhegmatogenous retinal detachment were evaluated; 68 (74%) eyes were of male and 24 (26%) were of female. The mean time of presentation was 4.71 ± 8.45 months. The overall primary anatomical and physiological success was achieved in 79 (84.9%) and 68 (73.9%) of the cases at 6 months. Sixteen cases developed re-detachment (mean duration of 2.8 ± 1.8 months). Eleven of the cases had a successful anatomical outcome and five of the patients had persistent detachment despite second surgery. In phakic patients, the primary success rate was 92.7% whereas in pseudophakic it was 71.4%. Proliferative vitreoretinopathy 10 (63%) was the most common cause of surgical failure. Bilateral buckling at the same setting was done to two patients-both achieving primary success.

CONCLUSION

Scleral buckling is a very good surgical option for rhegmatogenous retinal detachment and represents a surgical technique worth being trained, performed, practiced, and continued despite advancements in modern vitreoretinal surgical devices and preference for vitrectomy and tamponade agents. It may also be successfully tried in cases of bilateral rhegmatogenous retinal detachment if a doubt regarding compliance for follow-up and surgery for the fellow eye exists.

Modified Vitrectomy Technique for Phakic Rhegmatogenous Retinal Detachment with Intermediate Break

Purpose

To evaluate the effects of a modification of the traditional 25-gauge pars plana vitrectomy technique in the treatment of uncomplicated macula-on rhegmatogenous retinal detachment (RRD) with intermediate retinal break(s) and marked vitreous traction in the phakic eye.

Methods

Prospective, noncomparative, and interventional case series. All consecutive phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, with at least 1 year of postoperative follow-up, were enrolled. In all eyes, "localized 25-gauge vitrectomy" under air infusion with localized removal of the vitreous surrounding the retinal break(s), in association with laser photocoagulation and air tamponade, was performed. The primary end point was the rate of primary retinal attachment. Secondary end points were cataract progression and assessed by digital Scheimpflug lens photography (mean change of nuclear density units) and the rate of complications.

Results

Thirty-two phakic eyes were included in the final analysis. At 12 months, the primary outcome of anatomical success was achieved in 94% of eyes. The mean nuclear density units did not change significantly at any time point during the follow-up. After localized vitrectomy, one eye developed an epiretinal membrane, and one eye developed cystoid macular edema; no other significant complications were reported.

Conclusions

"Localized vitrectomy" has a high anatomical success rate in phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, without causing progression of cataract.

Pars plana vitrectomy with or without intraoperative 360° peripheral endolaser for rhegmatogenous retinal detachment treatment

PURPOSE

The aim of this study was to investigate whether intraoperative 360° prophylactic endolaser photocoagulation is necessary for the treatment of uncomplicated retinal detachment.

METHODS

This prospective, randomized, comparative and interventional study includes 50 consecutive patients with primary rhegmatogenous retinal detachment (RRD) who were treated by pars plana vitrectomy. The patients were divided into two groups: in Group A endolaser applied to all existing breaks as well as a 360° laser retinopexy, while Group B received endolaser only to the retinal breaks. Primary anatomical success rate, a final best-corrected visual acuity (BCVA) and postoperative complications were analyzed and compared between the groups at 1 and 3 months.

RESULTS

After the primary procedure, the retina was reattached in 96% (24 of 25) of patients in Group A and in 88% (22 of 25) of patients in Group B at 1 and 3 months. The mean final BCVA (logarithm of the minimum angle of resolution) improved from 1.26 to 0.52 in Group A with 17 cases (68%) macula-off and 1.19 to 0.77 in Group B with 18 cases (72%) macula-off at preoperative and final follow-up visit. Epiretinal membranes were seen in four cases in Group A and four cases in Group B at 3 months. No statistically significant difference in the anatomical, functional and complication outcomes between the two groups was recorded.

CONCLUSIONS

Pars plana vitrectomy without the 360° peripheral endolaser can provide successful anatomic outcomes and functional improvement in uncomplicated primary RRDs.

Prognostic Factors after Primary Vitrectomy and Perfluorocarbon Liquids for Bullous Rhegmatogenous Retinal Detachment

Purpose

To identify prognostic factors for visual acuity and anatomic outcomes associated with bullous rhegmatogenous retinal detachment (RRD) management using primary pars plana vitrectomy, intraoperative perfluorocarbon liquids (PFCLs), and internal gas tamponade.

Methods

The authors studied a consecutive series of 115 eyes (115 patients) with a bullous RRD not complicated by proliferative vitreoretinopathy (PVR) associated with large, multiple, and/or posterior breaks in 58 (50.4%) eyes. All eyes underwent vitrectomy, injection of PFCL, and gas tamponade as the primary procedure. Encircling scleral bands were placed in all cases. The follow-up period ranged from 3 to 60 months (mean 16.6±14.1 months).

Results

Retinal reattachment was achieved in 92.2% of eyes (106/115) with one operation and in all eyes after a second procedure. PVR was observed in 1 (0.87%) eye and pre-retinal membranes in 3 (2.6%) eyes. Progression of pre-existing cataract and development of new cataract occurred in 45 (58.4%) of the 77 phakic eyes. The presence of inferior retinal breaks was significantly associated with redetachment after the first procedure (p=0.0156). On univariate analysis, better preoperative visual acuity (p<0.001), macular sparing retinal detachment (p<0.001), and fewer quadrants involved by the detachment (p=0.0015) were significant positive prognostic factors for final visual acuity. Logistic regression analysis highlighted that macular sparing retinal detachment and absence of trauma were associated with better final visual acuity.

Conclusions

Redetachment was associated with the presence of inferior retinal breaks. Visual recovery was dependent on preoperative visual acuity, macular involvement, extent of retinal detachment, and trauma.

SCLERAL BUCKLE SURGERY FOR PRIMARY RETINAL DETACHMENT WITHOUT POSTERIOR VITREOUS DETACHMENT

PURPOSE

To present and analyze the anatomical and functional outcomes for scleral buckling (SB) in a group of patients with rhegmatogenous retinal detachment without posterior vitreous detachment.

METHODS

A total of 244 patients underwent SB from 2005 through 2014 by a single surgeon (A.W.E.). Forty patients (45 eyes) were identified as fulfilling the criteria of presenting with a rhegmatogenous retinal detachment without posterior vitreous detachment. Visual outcomes, preoperative retinal findings, and the SB technique were analyzed. The main outcome measure was the primary reattachment rate at 6 months after single surgery.

RESULTS

The mean age was 29 years (range 11-51 years). The mean follow-up period was 20 months. The mean refractive error was -5.16 diopters. Subretinal fluid drainage was performed in 17 eyes (37.8%). The anatomical success rate after single SB surgery at 6 months was 91.1%. The only factor that had statistically significant correlation with primary anatomical failure was development of subretinal hemorrhage during the drainage procedure (P = 0.03).

CONCLUSION

Despite an increasing trend toward primary vitrectomy for rhegmatogenous retinal detachment, an indication for SB is in younger patients without a preexisting posterior vitreous detachment. We showed a 91.1% success rate with a primary SB and 100% with a second surgery.

Scleral depressed vitreous shaving, 360 laser, and perfluoropropane (C3 F8) for retinal detachment

Purpose:

To review the characteristics and outcomes of patients who underwent pars plana vitrectomy (PPV) with scleral depressed vitreous shaving, 360 degree peripheral endolaser, and 14% C3F8 gas for rhegmatogenous retinal detachment (RRD).

Materials and Methods:

A retrospective review of a consecutive series of patients who underwent primary repair of RRD by PPV with scleral depressed vitreous shaving, 360 degree peripheral endolaser, and 14% perfluoropropane (C₃F₈) was conducted. Patients with less than 3 months follow-up, previous retinal surgery, and higher than grade B proliferative vitreoretinopathy were excluded.

Results:

Ninety-one eyes were included in the study. The mean age was 60.1 years. The mean follow-up was 13.7 months. The macula was detached in 63% (58/91) of the eyes. The reattachment rate after one surgical procedure was 95% (86/91) while overall reattachment rate was 100%. There was no statistically significant difference between reattachment rates of superior, nasal/temporal, or inferior RRDs. The mean final best corrected visual acuity (BCVA) was 20/40. Of all the patients, 66% of patients with macula-off RRDs had a final BCVA of 20/40 or better.

Conclusions:

PPV with scleral depressed vitreous shaving, 360 degree peripheral endolaser, and 14% C₃F₈ leads to successful anatomical reattachment with visual improvement in patients with primary RRD.

Pars plana vitrectomy with silicone oil tamponade in failed scleral buckle surgery

OBJECTIVE

This study aimed to evaluate the anatomical and functional outcomes of secondary pars plana vitrectomy (PPV) after failed scleral buckling (SB) surgery and to compare it with primary PPV for rhegmatogenous retinal detachment (RRD), including complicated proliferative vitreoretinopathy cases.

DESIGN

Retrospective series in a tertiary care centre.

PARTICIPANTS

One hundred and twenty consecutive patients.

METHODS

The medical records of patients who underwent PPV with silicone oil tamponade for RRD were reviewed. Forty-four eyes were operated on for primary RRD (primary PPV group), and 76 eyes were operated on for failed SB surgery (secondary PPV group). The single-operation anatomical success rate, final anatomical success rate, and best-corrected visual acuity preoperatively, at 6 months, at 1 year, and at final follow-up were analyzed.

RESULTS

The single-operation anatomical success rate was 74.2% in the primary PPV group and 77% in the secondary PPV group (p = 0.48). The final anatomical success rate was 90.3% in the primary PPV group and 91.8% in the secondary PPV group (p = 0.55). The number of cases with visual acuities of 3 visual categories (20/50 or better, 20/200 to 20/50, less than 20/200) was not statistically different at each time point.

CONCLUSIONS

Consequent PPV with silicone oil tamponade for failed SB surgery seems not to have inferior anatomical and functional outcomes when compared with primary PPV for RRD.

Small-Gauge Pars Plana Vitrectomy With SF6 Gas for the Repair of Primary Rhegmatogenous Retinal Detachment With Multiple Breaks

BACKGROUND AND OBJECTIVE

To compare outcomes of 25-gauge pars plana vitrectomy (PPV) and sulfur hexafluoride (SF6) gas for primary rhegmatogenous retinal detachment (RRD) associated with multiple-quadrant versus single-quadrant breaks.

PATIENTS AND METHODS

A retrospective study of patients with RRD who underwent 25-gauge PPV with breaks involving multiple quadrants (Group A) or versus a single quadrant (Group B).

RESULTS

One hundred eighteen eyes of 118 patients with a mean age of 60.4 years ± 11.8 years were reviewed, 27 with multiple-quadrant breaks and 91 with single-quadrant breaks. Single surgery anatomical success was achieved in 92.6% of Group A versus 93.4% of Group B patients (P = .88). The location and number of quadrants did not account for the variation in single surgery success or visual outcome.

CONCLUSIONS

RRD with multiple-quadrant breaks is not associated with worst outcomes than single-quadrant breaks when treated with 25-gauge PPV and SF6 gas. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:820-827.].

Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review

Floaters are a common ocular condition which form as a consequence of aging changes in the vitreous. Although in most patients the symptoms are minimal, they can cause significant impairment in vision-related quality of life in a small population of patients. Recently there has been an increase in awareness of the visual disability caused by floaters, and the evidence-base for treatment of this condition using small-gauge vitrectomy has increased. In this review, we define the term 'floaters' as symptomatic vitreous opacities (SVO). We suggest a classification dependent on the presence or absence of posterior vitreous detachment and discuss their pathogenesis and natural history. We review their impact on patients' quality of life related to visual function. We review the psychological factors that may have a role in some patients who appear to be affected by SVO to the extent that they pursue all options including surgery with all its attendant risks. We summarise the available evidence-base of treatment options available for SVO with special emphasis on the safety and efficacy of vitrectomy for this condition.

Scleral buckling surgery using multiple radial buckles: A valid option?

PURPOSE

To determine whether radial buckling surgery using two or more radial buckles with or without circumferential silicone tires is still a treatment option for rhegmatogenous retinal detachment (RRD) in the current scenario.

METHODS

Retrospective chart review. Patients with RRD with two or more horse-shoe tears with/without proliferative vitreoretinopathy up to grade C1 who underwent buckling surgery using at least two radial buckle segments without encircling bands or drainage and with at least a 3 year follow up were included in the study. Data collected included demographics, corrected distance visual acuity (CDVA) at baseline and final follow up, details of the examination, surgical procedure(s) and complications noted, if any. Appropriate statistical analysis was done. Statistical significance was set at p < 0.05.

OUTCOME MEASURES

Proportion of patients who had an attached retina at final follow up, improvement in CDVA and complications.

RESULTS

25 patients (25 eyes; 12 males and 13 females; 9 pseudophakic) were included.

MEDIAN AGE

35.15 ± 8.32 years. Median baseline CDVA: 1.97 ± 1.12 log MAR. Median final CDVA: 0.65 ± 0.37 log MAR (significant improvement). Most common presenting complaint was decreased vision (87.5%). Number of radial buckle segments placed varied between 2 and 4 per eye. One patient required vitrectomy for persistent retinal detachment. One required buckle removal for infection 5 years after the primary procedure. One patient required strabismus surgery.

MEDIAN FOLLOW UP

12.25 years ± 2.14 years. None of the other patients had any complications.

CONCLUSION

Radial buckling surgery (two or more segments) is a reasonably safe and valid alternative to vitrectomy for RDs with multiple breaks in different planes.

23-Gauge Pars Plana Vitrectomy Versus Scleral Buckling Versus Combined Pars Plana Vitrectomy-Scleral Buckling for Medium-Complexity Retinal Detachment Repair

PURPOSE

To compare the anatomic and visual outcomes of 23-gauge pars plana vitrectomy (PPV), scleral buckling (SB), and combined 23-gauge PPV/SB in the treatment of primary medium-complexity rhegmatogenous retinal detachment (RRD).

DESIGN

A retrospective, consecutive case series.

METHODS

A consecutive chart review of patients with medium-complexity RRD treated with PPV, SB, and combined PPV/SB was conducted. The primary outcome measure was retinal reattachment at 6 months' follow-up. The secondary outcome measure was Snellen best-corrected visual acuity (BCVA) of 20/40 or better at 6 months' follow-up.

RESULTS

Five hundred sixty-five cases met inclusion criteria. The overall primary anatomic success rate was 83.6% (95% confidence interval, 80.3%-86.5%). Logistic regression analysis did not demonstrate a significant difference between the 3 techniques in terms of likelihood of anatomic success or likelihood of achieving a Snellen BCVA of 20/40 or better. Patients with multiple breaks in 2 or more quadrants or inferior breaks were more likely to undergo SB/PPV, whereas patients with phakic lens status with breaks confined to 1 quadrant were more likely to undergo SB. Patients with macula-off detachments and those with postoperative proliferative vitreoretinopathy were less likely to achieve a Snellen BCVA of 20/40 or better.

CONCLUSIONS

Although there was not a statistically significant difference in the anatomic and visual outcomes between the repair techniques analyzed, SB/PPV was performed on the more complicated spectrum of medium-complexity RRDs with the overall highest anatomic success rate and therefore may be the most effective repair technique for this patient population.

Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for secondary repair of retinal detachment

BACKGROUND AND OBJECTIVE

To investigate the optimal technique for repairing recurrent rhegmatogenous retinal detachments.

PATIENTS AND METHODS

A 2-year retrospective review of recurrent rhegmatogenous retinal detachments by 23-gauge pars plana vitrectomy (PPV) or combined 23-gauge PPV with encircling scleral buckling was performed. The primary outcome was anatomical success. The secondary outcome was the likelihood of achieving a final best corrected visual acuity of 6/12 or better at 6-month follow-up.

RESULTS

Anatomical success was achieved in 65.2% (95% CI, 53.4% to 75.4%) of the PPV group versus 74.3% (95% CI, 57.9% to 85.8%) of the PPV-scleral buckling group with one additional procedure (not statistically significant). There was no significant difference in the likelihood of achieving a final acuity of at least 6/12 between groups at 6-month follow-up.

CONCLUSION

The results of our study do not demonstrate a superiority of method of primary repair, or of one method of secondary repair, over another.

Scleral buckling versus vitrectomy for macula-off rhegmatogenous retinal detachment as accessed with spectral-domain optical coherence tomography: a retrospective observational case series

BACKGROUND

Scleral buckling surgery and pars plana vitrectomy are competing methods in the treatment of retinal detachment. The recent development of spectral-domain optical coherence tomography (SD-OCT) has dramatically improved the visualization of the photoreceptor layer relative to conventional OCT, and offers new opportunities to investigate the discordances between anatomic and functional outcomes after retinal detachment surgery. Hence, the study aim was to use SD-OCT to compare the postoperative macular recovery between scleral buckling and vitrectomy for macular-off rhegmatogenous retinal detachment.

METHODS

In this retrospective observational case series, we observed 32 patients who underwent scleral buckling surgery (group 1) and 26 patients who underwent pars plana vitrectomy (group 2) as the primary surgery for macula-off rhegmatogenous retinal detachment. OCT was used to examine microstructural changes in the macular area.

RESULTS

The mean visual acuity improvement was 0.4 ± 0.8 logMAR in group 1 and 0.7 ± 0.9 logMAR in group 2. As detected by SD-OCT, subretinal fluid was present in 26 of the group 1 eyes (81.3%) and 5 of the group 2 eyes (19.2%) at 8 weeks postoperatively.This difference was statistically significant (Fisher's exact test, P < 0.05). Moreover, detection by SD-OCT revealed epiretinal membranes in 5 of the group 1 eyes (15.6%) and 11 of the group 2 eyes (42.3%), a difference that was statistically significant (Fisher's exact test, P < 0.05).

CONCLUSIONS

Macular recovery and the mean visual acuity differed between the 2 groups of patients. With the help of SD-OCT, we observed that subretinal fluids could persist for a relatively longer period after scleral buckling. Based on our results, we conclude that primary vitrectomy surgery is a better choice for macular recovery of the macula-off rhegmatogenous retinal detachment.

Iatrogenic retinal breaks in 20-G versus 23-G pars plana vitrectomy

BACKGROUND

The purpose of this study was to compare the incidence of iatrogenic anterior retinal breaks in 20-G vitrectomy (PPV) with transconjunctival 23-G PPV.

METHODS

Retrospective, observational review study involving consecutive patients undergoing PPV in a single center in the UK during a 2-year period.

RESULTS

Sclerotomy-related entry-site breaks (ESB) were found in 50/628 (7.9 %) 20-G PPV cases and 5/296 (1.7 %) 23-G PPV eyes (p<0.0001*). Anterior non-sclerotomy iatrogenic breaks (ANSB) were present in 55/628 (8.7 %) 20-G PPV cases and 18/296 (6.1 %) 23-G PPV eyes (p=0.19). The incidence of total anterior iatrogenic breaks (ANSB + ESB) was 105/628 (16.7 %) for 20-G PPV and 23/296 (7.8 %) for 23-G PPV (p=0.002*). Univariate analysis showed that posterior vitreous detachment induction was the only risk factor significantly associated with the development of anterior retinal breaks for both 20-G and 23-G PPV. Multivariate logistic model of risk factors for development of iatrogenic retinal breaks demonstrated that 23-G PPV was the most important factor reducing the risk of anterior breaks (p<0.0001*).

CONCLUSIONS

We report the largest series of patients undergoing 20-G and 23-G vitrectomy, where 23-G vitrectomy was associated with a significantly lower incidence of anterior iatrogenic retinal breaks.

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.

Does surgical experience have an effect on the success of retinal detachment surgery?

PURPOSE

To examine the relationship between surgeon experience and success rates in retinal detachment surgery.

METHODS

Success rates during a follow-up of 11 months of 8 surgeons who performed in total 375 retinal detachment procedures ranging from 14 to 115 cases between December 1997 and January 2002 were correlated to the total number of vitreoretinal procedures ranging between 176 and 2,587. All patients received either scleral buckling or vitrectomy, and complicated cases were excluded.

RESULTS

Mean primary anatomical success rates were 0.69 ± 0.14 for scleral buckling and 0.9 ± 0.05 for primary vitrectomy (P < 0.05). The primary anatomical success rates did not correlate to the number of vitreoretinal procedures. Seven of the eight surgeons showed an intraindividual learning effect with better success rates in the second versus the first half of the observed procedures. The learning effect was correlated to the total number of procedures with a higher effect in inexperienced surgeons.

CONCLUSION

An intraindividual learning effect that was higher in inexperienced surgeons could be demonstrated. The learning effect was reduced by half after 500 vitreoretinal procedures while the primary anatomical success rates were not correlated to the number of vitreoretinal procedures.

Trends in primary retinal detachment surgery: results of a Bicenter study

PURPOSE

To assess trends and outcomes in retinal detachment (RD) surgery based on a retrospective, interventional, bicenter study.

METHODS

Baseline demographic data, surgical procedures, and outcomes from 230 patients with a diagnosis of primary rhegmatogenous RD, who underwent surgery between January 2007 and December 2008 at the Rudolf Foundation Clinic, Vienna (Center 1) and the Weill Cornell Medical College, New York, (Center 2) were analyzed using a regression model.

RESULTS

Besides the baseline parameters, lens status (P = 0.01), refraction (P = 0.01), retinal tears (P < 0.02), proliferative vitreoretinopathy (P = 0.02), and previous treatment (P < 0.02), the primary RD procedure (P < 0.0001) was significantly different between the 2 centers. In Center 1, scleral buckling was the most common primary RD procedure (66.19%) compared with vitrectomy (82.42%) in Center 2. Primary retinal reattachment (88.49% Center 1 vs. 84.62% Center 2, P = 0.43) and best-corrected visual acuity at the final follow-up (best-corrected visual acuity ≥ 0.3 logarithm of minimum angle of resolution 48.92% Center 1 vs. 47.25% Center 2, P = 0.78) were not significantly different between the 2 centers.

CONCLUSION

Although there is a trend toward primary vitrectomy, scleral buckling was preferred in the center in Vienna and primary vitrectomy in the center in New York. Despite the different primary RD procedures, anatomical and visual outcomes were comparable.

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.

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.

Proliferative vitreoretinopathy: pathobiology and therapeutic targets

The cell biology and molecular mediators of proliferative vitreoretinopathy continue to be elucidated. The purpose of this review is to summarize contemporary findings in the visual and neurosciences relevant to the pathophysiology of proliferative vitreoretinopathy, with an emphasis on the biologic mediators that represent potential therapeutic targets.

Trends and outcomes of treatment for primary rhegmatogenous retinal detachment: a 9-year nationwide population-based study

PURPOSE

To determine the trends and outcomes for treating primary rhegmatogenous retinal detachment (RRD) in a nationwide population-based study in Taiwan.

METHODS

We collected admission data during the period of 1997-2005, from the Taiwan National Health Insurance Research Database, a source that covers over 96% of Taiwan's 23 million citizens. Totally 28 911 patients with a first-time admission diagnosis of RRD (ICD-9-CM codes 361 to 361.07) and undergoing surgical treatment (scleral buckling (SB), pars plana vitrectomy (PPV), or their combination) were identified. The utilized operation type, 180-day readmission rate for recurrent retinal detachment, length of hospital stay, and admission charge were obtained. Contingency table/chi (2) test and t-test were employed for the statistical analysis.

RESULTS

Primary PPV (with or without SB) was a primary procedure in 47.3% of cases in 1997. This rate rose significantly to 61.2% in 2005. A significant decrease in the total 180-day readmission rate occurred from 18.95% in 1997 to 13.81% in 2005. These rates also significantly decreased for each surgical modality (from 16.30 to 11.38% for SB, from 21.29 to 14.69% for PPV, and from 22.99 to 16.55% for PPV+SB). The length of hospital stay decreased for each surgical modality between 1997 and 2005.

CONCLUSIONS

There was a significant trend towards more frequently employing primary PPV (with or without SB) for the management of primary RRD. In addition, significant improvements in the primary success rates were shown for each surgical modality group and for total samples between 1997 and 2005.

Phacovitrectomy for primary retinal detachment repair in presbyopes

PURPOSE

To review the results of phacovitrectomy for primary retinal detachment repair in presbyopes.

METHODS

The outcome and complications of surgery were examined in a retrospective case series of 93 presbyopic patients who underwent phacoemulsification and vitrectomy for primary rhegmatogenous retinal detachment.

RESULTS

Eighty-two patients (88.2%) had reattachment with a single procedure. The final reattachment rate with further procedures was 97.8%. Two patients (2.2%) in whom final reattachment did not occur declined further surgery after the primary repair. All redetachments were due to proliferative vitreoretinopathy. The median Snellen converted logMAR visual acuity improved from 1.00 preoperatively to 0.30 postoperatively (P < 0.001, Wilcoxon test). Postoperative complications included transient intraocular pressure rise (29%), fibrinous uveitis (16.2%), and iris/intraocular lens capture (8.6%). One of the eight patients with iris/intraocular lens capture required surgical reintervention. All cases of fibrinous uveitis and intraocular pressure rise resolved within a few days with medical treatment. Posterior capsular opacification occurred in 23 patients (24.7%).

CONCLUSION

Combined surgery with phacoemulsification, lens extraction, and vitrectomy offers significant advantages to both patient and surgeon in the management of primary retinal detachment. We believe that it should be considered for presbyopes even in the absence of significant lens opacity. Fibrinous uveitis and intraocular pressure rise may occur in a few patients in the immediate postoperative period but are transient and resolve with medical treatment. Further prospective studies are required, in particular to examine the rate of postoperative proliferative vitreoretinopathy, which may be higher than with vitrectomy alone.

Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): recruitment list evaluation. Study report no. 2

BACKGROUND

Accompanying the patient recruitment within the "Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment multicentre trial (SPR)", all patients with primary rhegmatogenous retinal detachment (RRD) had to be documented in a detailed recruitment list. The main goal of this analysis was to estimate the prevalence of "medium-severe" RRD (SPR Study eligible) as defined by the SPR Study inclusion criteria. In addition, the detailed anatomical situation of medium-severe RRD is investigated.

METHODS

SPR Study recruitment was evaluated via a standardised questionnaire, which contained a coloured fundus drawing and information regarding possible reasons for exclusion from the SPR Study in each case. A team of three experienced vitreoretinal surgeons evaluated all fundus drawings from a 1-year period. The review led to a decision on SPR Study eligibility on the pure basis of anatomical assessment. The main outcome measures were assessment of feasible inclusion into the SPR Study by the evaluation team based on the fundus drawing and anatomical details.

RESULTS

A total of 1,115 patients with RRD from 13 European centres were prospectively enrolled in the year 2000. The quality of the drawings sufficed for assessment in 1,107 cases (99.3%). Three hundred and twelve fundus drawings (28.2%) met the anatomic inclusion criteria of the SPR Study. RRD of medium severity is characterised by an average number of 2.6 (SD 2.4) retinal breaks, 5.8 (SD 2.8) clock hours of detached retina, unclear hole situation in 15.1% of cases (n=47), attached macula in 42.9% (n=134), bullous detachment in 15.1% (n=47) and vitreous haemorrhage/opacity in 7.7% (n=24).

CONCLUSIONS

In the recruitment lists of the SPR Study of the year 2000, RRD of medium severity was present in nearly one third of the patients with primary RRD. These findings emphasise the clinical relevance of the SPR Study.

Primary retinal detachment: scleral buckle or pars plana vitrectomy?

PURPOSE OF REVIEW

There remains no consensus among vitreoretinal surgeons regarding the optimal management of primary rhegmatogenous retinal detachment. In this article, fundamental principles are discussed and applied to recent clinical reports.

RECENT FINDINGS

The consensus of the peer-reviewed literature appears to be that scleral buckling and primary pars plana vitrectomy may yield comparable single-operation success rates and visual acuity outcomes for a wide variety of rhegmatogenous retinal detachments.

SUMMARY

No definitive prospective, randomized, multicenter trial compares scleral buckling with pars plana vitrectomy. The upcoming Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment study may yield useful information in this regard. Even when this study is completed, the choice of surgical modality is complex and may be individualized for specific patients.

Scleral Buckling Procedures for Longstanding or Chronic Rhegmatogenous Retinal Detachment with Subretinal Proliferation

OBJECTIVE

To investigate longstanding or chronic retinal detachments (RDs) with subretinal strands and their clinical features and therapeutic effects using conventional retinal surgery.

DESIGN

Retrospective, consecutive, noncomparative case series.

PARTICIPANTS

Cases of 36 patients (40 eyes) with longstanding RD and subretinal proliferation who had undergone scleral buckling or encircling procedures between January 1, 1995 and October 31, 2003 at one institution were reviewed.

METHODS

A retrospective analysis of the patient data was conducted from the medical records.

MAIN OUTCOME MEASURES

Visual acuity (VA) and postoperative anatomic retinal reattachment at the final follow-up visit between 3 and 24 months (mean, 6.9).

RESULTS

Forty eyes with an RD (mean duration, 13.8 months) treated with scleral encircling and buckling had a 90% cure rate after one surgery. The VA levels increased in 77.5% of eyes to over 5/100 at the final follow-up visit. Longstanding or chronic RD with subretinal proliferation had subretinal proliferative strands (i.e., a shallow RD) and a smooth atrophic detached retina, not a thickened retina.

CONCLUSIONS

Our results suggest that scleral encircling and buckling can be used in most patients with a longstanding RD. The chronic pathologic course of longstanding rhegmatogenous RD should be considered before treatment.

Primary vitrectomy for rhegmatogenous retinal detachment: an analysis of 512 cases

BACKGROUND

Primary pars plana vitrectomy (PPPV) has gained widespread popularity in the treatment of rhegmatogenous retinal detachments (RRD). However, the surgical procedure is still flawed by a significant rate of anatomical and functional failures. The study was conducted to analyse the risk factors for a dissatisfying postoperative outcome.

METHODS

We carried out a retrospective study of 512 cases of PPPV with a minimum follow-up of 3 months from one institution over a 9-year period. Preoperatively, 24.8% of patients (127 out of 512) were pseudophakic, 16.4% (84 out of 512) highly myopic, 19.9% (102 out of 512) had preoperative proliferative vitreoretinopathy (PVR) and 14.6% (75 out of 512) had vitreous haemorrhage.

RESULTS

The follow-up period ranged from 3 to 108 months (median 14.8). Retinal reattachment was achieved with one operation in 70.7% (362 out of 512) and after one or more operations in 97.5% of cases (499 out of 512). The major reasons for redetachments were new retinal breaks, followed by a combination of new breaks and PVR, and PVR without apparent breaks. Postoperative visual acuities of > or =0.1 and > or =0.4 were achieved in 82.8% (424 out of 512) and 48.2% (247 out of 512) respectively. Out of 376 phakic patients at study entry, 66.4% (250 out of 376) underwent cataract surgery either in combination with PPPV or during the postoperative course. Factors that were significantly associated with either anatomical or functional failure included duration of symptoms, low preoperative visual acuity, myopia, amblyopia, hypotony, macular detachment, preoperative PVR, extent of detachment, involvement of inferior quadrants, no detectable breaks, large breaks, breaks posterior to the equator, surgeon, level of surgical training, endocryotherapy, and combined scleral buckling surgery.

CONCLUSION

Primary pars plana vitrectomy is still flawed by a relatively high primary redetachment rate following the initial procedure. The advantages of the technique are a high final reattachment rate and relatively good functional results in a subset of patients with more complicated types of RRD. The risk factors for postoperative failures following PPPV for RRD match to a large extent those following scleral buckling surgery (SBS). Future improvements of the technique will have to focus on modifiable risk factors, such as details of the surgical procedures, surgical training and case selection, to distinguish it from SBS.