Surgical repair of primary non-complex rhegmatogenous retinal detachment in the modern era of small-gauge vitrectomy

The effect of axial length on pseudophakic retinal detachment

PURPOSE

The purpose of the study was to analyse the surgical management and outcome regarding axial length in the population affected by pseudophakic retinal detachment (PRD) 2015-2020.

METHOD

The patients included were from an observational cohort study of patients undergoing cataract surgery in the region of Skåne during 2015-2017. Data were retrieved from the Swedish National Cataract Register and cross-referenced with cases of PRD in the same region from 2015 to 2020. The surgical method used and findings at follow-up were recorded. The patients were stratified according to axial length (AL) to <25 mm, 25 ≤ n < 26.5 mm and ≥26.5 mm. The main outcome was primary success with one surgery apart from silicone oil removal. The secondary outcome was postoperative visual acuity.

RESULTS

In the whole study group of 58 624 cases, complete follow-up data were available for 288 eyes. The median follow-up time was 324 days, and primary operation was successful in 82.9% of these cases. The median visual acuity was 0.31 (LogMAR). In the stratification those with AL < 25 mm had a primary success of 75.8%, AL 25 ≤ n < 26.5 mm of 87.9% and ≥26.5 mm of 95.8%.

CONCLUSIONS

The primary anatomical success was 82.9% in the whole group of PRD but with stratification they had an increasing number of primary success with longer AL.

Comparing the Randomized Trial Outcomes of 3D Low-Light Intensity-Assisted and Traditional Eyepiece-Assisted Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment

INTRODUCTION

Pars plana vitrectomy (PPV) is a primary surgical method for rhegmatogenous retinal detachment (RRD). The introduction of the 3D head-up system has provided ophthalmologists with a new surgical experience. This study aimed to compare the surgical outcomes between 3D low-light intensity-assisted and traditional eyepiece-assisted PPV for RRD.

METHODS

A prospective randomized controlled design was employed to compare the surgical outcomes of 3D low-light intensity-assisted and traditional eyepiece-assisted PPV for RRD. The optical intensity parameters of optical fibers and chandeliers were set according to the minimum lighting standard for 25-G PPV. Surgery duration and intraoperative conditions were documented. Post-surgery, the light intensity of the optical fiber and chandeliers during surgery was measured using a photometer. Patients were followed up for six months to assess their postoperative recovery. Statistical analysis was performed using SPSS 26.0 software, with p < 0.05 indicating statistically significant differences.

RESULTS

There was no statistically significant difference between the two groups in baseline data (p > 0.05). PPV was completed in all patients, and there was no statistically significant difference in surgery time between the two groups (p > 0.05). The optical fiber and chandelier light intensity in the 3D group were significantly lower than those in the eyepiece group and the difference being statistically significant (p < 0.001). Six months after surgery, the retinal attachment rate was 100%. Post-surgery, both best corrected visual acuity (BCVA) and intraocular pressure (IOP) were significantly higher than presurgery levels. There were no significant differences between the two groups in terms of retinal attachment rate, BCVA, IOP, and flash electroretinogram (p > 0.05).

CONCLUSION

Compared to the traditional eyepiece, the 3D head-up system can effectively complete surgery under lower illumination intensity. The anatomical restoration and functional success of the retina after surgery are equivalent.

Characteristics of pseudophakic retinal detachment and risk factors of recurrence

BACKGROUND

The present study was designed to gain knowledge about the prognostic factors and evolution of pseudophakic retinal detachment (PRD) and to analyse the main characteristics of PRD, such as the mean time to retinal detachment following cataract surgery, as well as the clinical factors associated with the risk of recurrence and worse anatomical and functional outcomes.

METHODS

This was a retrospective monocentric study of 330 patients with PRD who underwent surgery between 2012 and 2020. All patients were pseudophakic and were referred for retinal detachment surgery at Donostia University Hospital (Terciary Hospital, Spain).

RESULTS

The mean age of the patients at the time of phacoemulsification was 63.06 ± 10.8 years, and 49.09% of them had moderate myopia [axial length (AL) (23.5-26.5 mm)]. In our series, macular detachment was evident in 69.09% (n = 228) of the patients. The mean time that elapsed between phacoemulsification and PRD surgery was 4.04 ± 4.17 years, which was reduced by half in the event of surgical complications (2.24 ± 2.65). The rate of PRD was 28.79%. The anatomical results in terms of retinal reapplication were better with the combination of vitrectomy and scleral buckling (83.1% vs. 70.5%) (p = 0,127) compared with vitrectomy. The variables associated with a higher risk of recurrence were male sex (hazard ratio (HR) = 1.75), macular detachment (HR = 2.00) and the presence of proliferative vitreoretinopathy (PVR) (HR = 3.21).

CONCLUSIONS

PRD usually occurs within 4 years of phacoemulsification, although it may occur significantly earlier in the event of surgical complications. Macular involvement, PVR, and male sex are all associated with a higher risk of PRD recurrence.

Evaluation of Pars Plana Vitrectomy With and Without Supplemental Scleral Buckle for the Repair of Rhegmatogenous Detachment Due to Inferior Retinal Breaks: A Systematic Review

In this systematic review, the efficacy of scleral buckle (SB) with pars plana vitrectomy (PPV) was compared to PPV alone in eyes with rhegmatogenous retinal detachment (RRD) due to inferior retinal breaks (IRB). Measured outcomes included final best-corrected visual acuity (BCVA), anatomic success, and complication rates in randomized controlled trials and observational studies from 2000 to 2022. Among four studies (696 eyes), three studies demonstrated no significant difference between PPV and PPV/SB for final BCVA, whereas one study reported better BCVA with added SB. PPV/SB yielded comparable single-surgery anatomical success (SSAS) and final anatomical success (FAS) in three studies relative to PPV alone (P < 0.05); however, one study reported better SSAS with added SB. Stratifying by lens status revealed a SSAS benefit with PPV/SB in phakic eyes (P = 0.046). No significant difference was seen in complication rates. In conclusion, PPV and PPV/SB were associated with similar functional outcomes and risk profile, whereas SSAS may be improved with PPV/SB in phakic eyes with RRD due to IRB. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Outcomes of Primary Vitrectomy for Rhegmatogenous Retinal Detachment With No Postoperative Positioning

Purpose: To evaluate the anatomic and visual outcomes of primary vitrectomy for rhegmatogenous retinal detachment (RRD) repair using no amount of postoperative prone positioning to clarify the role of face-down posturing for RRD reattachment. Methods: This retrospective consecutive interventional case series comprised patients who had primary vitrectomy for RRD repair. The surgical outcomes, single-surgery anatomic success rate, and postoperative best-corrected visual acuity (BCVA) were assessed. The primary objective was to evaluate the anatomic and visual outcomes of vitrectomy RRD reattachment using no postoperative prone positioning. Results: This study comprised 116 eyes of 116 patients. Single-surgery anatomic success was achieved in 112 (96.5%) of 116 eyes. The single-surgery anatomic success rate was 100% in phakic patients (n = 56) and 93% in pseudophakic patients (n = 60), with both groups having an improvement in the mean BCVA. Conclusions: Primary vitrectomy with no postoperative prone positioning is a successful surgical intervention for RRD repair. The anatomic closure rate in this study is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and a significant improvement in BCVA, primarily using 14% perfluoropropane for gas tamponade.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

In-Office Suprachoroidal Viscopexy for Rhegmatogenous Retinal Detachment Repair

Importance

In-office suprachoroidal viscopexy (SCVEXY) is a minimally invasive technique for rhegmatogenous retinal detachment (RRD) repair that can be performed with no incision, no tamponade agent, and no positioning requirements. This technique has the potential to be a step forward in the armamentarium to treat RRDs.

Objective

To describe in-office SCVEXY for RRD repair.

Design, Setting, and Participant

In this single-case report with short follow-up, a man in his 50s with pseudophakia and recent visual loss presented to St Michael's Hospital, Unity Health Toronto, with a fovea-off RRD in the right eye, extending from 6 to 10 o'clock, with no visible causative retinal break.

Exposure

Injection of suprachoroidal sodium hyaluronate, 1%, in the region of the suspected break, using a 30-gauge needle with a custom-made guard that exposed only 1 mm of the needle.

Main Outcome and Measures

Ability to perform in-office SCVEXY and to obtain a visible choroidal indentation.

Results

After the procedure, a dome-shaped choroidal convexity was present in the superior temporal area. The patient achieved macular reattachment in less than 24 hours with no postoperative abnormalities, such as outer retinal folds, residual subfoveal fluid, or retinal displacement, with rapid recovery of the outer retinal bands on optical coherence tomography. The optical coherence tomography scans acquired in the area of the choroidal convexity demonstrated the location of the viscoelastic material in the suprachoroidal space. Laser retinopexy was applied in the suspected region of the retinal tear, and the patient was able to resume normal activity immediately after the procedure with no restrictions.

Conclusions and Relevance

Suprachoroidal viscopexy is feasible as an in-office technique to create a temporary choroidal buckle for RRD repair. It is a minimally invasive procedure with the potential to maximize anatomical outcomes of integrity and postoperative functional outcomes in RRD because its mechanism of action does not require drainage of subretinal fluid or intraocular gas tamponade. Nevertheless, this was a single-case report with short follow-up, which limits the ability to determine the procedure's benefits, potential adverse events, failure rates, and best-case selection. Further work is required to refine the procedure and assess its efficacy and safety.

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.

Analysis of vitreoretinal surgery activity in metropolitan France in 2016: impact on training capacities

PURPOSE

The purpose of the study was to describe vitreoretinal surgery activity and vitreoretinal surgeons in private or public practice in metropolitan France over the year 2016 to anticipate surgical training needs.

METHODS

Patients aged ≥20 years who had undergone vitreoretinal surgery, alone or combined with cataract surgery were included using the French National Healthcare system database. For surgery performed by ophthalmologists carrying out ≥50 procedures during the year, the incidence per 100 000 of population ≥ 20 years of age, the number and mean age of surgeons and the number of surgeons aged >55 years were calculated.

RESULTS

Overall, 57 947 posterior segment surgical procedures were included, 40% in the public sector and 49% in the private sector for private surgeons and/or public centres performing ≥50 procedures/year. The remaining 11% of procedures were from private surgeons and/or public centres performing <50 procedures/year. The analysis included 356 surgeons with a mean age of 41 ± 10 years (39% female) in the public sector and 47 ± 10 years (14% female) in the private sector. The majority of urgent surgery was for retinal detachment (n = 30 290 [52% of total surgical procedures]). Scheduled surgery involved surgery for macular holes and epiretinal membranes (n = 16 454 [28% of total surgical procedures]). Combined vitrectomy-phacoemulsification surgery (n = 10 120) represented 17% of all vitreoretinal surgery. University regions with the fewest surgeons and regions with surgeons >55 years of age were identified, to anticipate the training need for new surgeons.

CONCLUSION

This study demonstrated disparities in the geographic distribution of vitreoretinal surgery in France and identified regions that need increased training capacities to ensure a sufficient number of surgeons.

Pars Plana Vitrectomy versus Scleral Buckle: A Comprehensive Meta-Analysis of 15,947 Eyes

Pars plana vitrectomy (PPV) and scleral buckling (SB) are two of the most common surgical treatments for rhegmatogenous retinal detachment (RRD). This meta-analysis compares the efficacy and safety of PPV and SB for RRD. A systematic literature review was performed using Ovid MEDLINE, EMBASE and Cochrane CENTRAL from 2000 to June 2021. Comparative studies, randomized controlled trials and observational studies investigating PPV and SB for RRD repair were included. The primary endpoint was final best- corrected visual acuity (BCVA). Secondary endpoints were reattachment rates, total operation time, and incidence of adverse events. Subgroup analyses including phakic status, presence of PVR-C or greater at baseline, and macular attachment status were conducted. Across 41 studies (8 RCTs, 33 observational studies), 5,401 SB and 10,546 PPV eyes were included. SB achieved a statistically significant, but likely not clinically significant, better final BCVA than PPV (0.38 ± 0.53 vs. 0.33 ± 0.53 logMAR (20/48 vs. 20/43 Snellen); weighted mean difference [WMD]: 0.07; 95% confidence interval: [0.02-0.11]; P=0.005). SB had a better final BCVA compared to PPV in observational studies (P=0.007) but not in RCTs (P=0.21). SB had a lower incidence of post-operative cataract formation (P<0.00001) and iatrogenic breaks (P<0.00001), but a higher incidence of choroidal hemorrhage (P=0.007), choroidal detachment (P=0.004), and residual subretinal fluid (RSRF) (P<0.00001). Primary (86.5% vs. 84.8%; P=0.13) and final (96.7% vs. 97.7%; P=0.12) reattachment rates were similar between PPV and SB. PPV had a significantly higher primary reattachment rate in RCTs (P=0.02) but not in observational studies (P=0.30). SB was associated with a better final BCVA than PPV; however, this result was primarily driven by observational studies and phakic patients who developed cataracts. Primary and final reattachment rates were similar between the comparators. SB was associated with a significantly lower incidence of iatrogenic breaks and cataracts, while PPV was associated with a reduced risk of choroidal detachment, subretinal hemorrhage, and RSRF.

Diagnosis and Management of Degenerative Retinoschisis and Related Complications

Degenerative retinoschisis is a common condition characterized by elevation of the inner layers of the peripheral retina. While uncomplicated retinoschisis (i.e. with no associated retinal layer breaks) is almost invariably a benign process, retinal detachment associated with isolated outer layer breaks (termed schisis-detachment) is fairly common. Historically, schisis-detachment has been treated with a variety of interventions ranging from retinopexy to intraocular surgery. Based on published descriptions of the natural history of the disease, these interventions are likely unnecessary in many cases and may place the patient's vision at unnecessary risk. Progressive symptomatic schisis-related retinal detachment, on the other hand, is a vision threatening condition that requires intervention. While clinical examination remains the mainstay of diagnosis, recent advances in multimodal imaging can provide supplemental information in subtle cases and may prove valuable for long-term disease monitoring. When evaluating patients with peripheral retinal elevation, it is important for ophthalmologists to make an accurate diagnosis and understand the risk-benefit ratio associated with intervention. Thus, we summarize the current literature on the natural history, clinical and imaging diagnosis, and surgical management of degenerative retinoschisis and its related complications.

Clinical Presentation and Outcomes of Rhegmatogenous Retinal Detachments During the COVID-19 Lockdown and Its Aftermath at a Tertiary Care Center in Michigan

BACKGROUND AND OBJECTIVE

To investigate the effect of the coronavirus disease 2019 (COVID-19) lockdown on the presentation and management of acute, primary rhegmatogenous retinal detachment (RRD).

PATIENTS AND METHODS

This was a single-center, consecutive case series with historic controls, examining patients during the COVID-19 "stay-at-home" order (March 24 to June 1, 2020), the subsequent reopening phase (June 1 to July 31, 2020), and corresponding preceding intervals (March 24 to July 31, 2016 to 2019).

RESULTS

Despite a significant increase in patients presenting with macula-off RRD during the COVID-19 lockdown compared to the 2016 to 2019 timeframe (P = .03), the rate of single surgery anatomical success was similar between all groups (P = .66), as was final visual acuity (P = .61). No delays between presentation and surgical intervention were observed during the lockdown (P = .49).

CONCLUSIONS

Despite the limitations of the COVID-19 lockdown, patients underwent surgery in a timely manner and achieved comparable visual outcomes to controls before COVID-19. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:593-600.].