Impact of Age on Scleral Buckling Surgery for Rhegmatogenous Retinal Detachment

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.

Evaluation of the Effect of Scleral Buckling on Anterior Segment and Refractive Changes Using Anterior Segment Optical Coherence Tomography

PURPOSE

To evaluate the changes of anterior segment and refractive parameters after scleral buckling (SB) surgery for uncomplicated rhegmatogenous retinal detachment (RRD) using anterior segment optical coherence tomography (AS-OCT).

METHODS

Thirty-six RRD eyes were consecutively enrolled. Analysis concerned the central corneal thickness (CCT), anterior chamber depth (ACD), anterior chamber volume (ACV), iris-trabecular contact (ITC), angel opening distance (AOD), angle recess area (ARA), trabecular-iris space area (TISA)，trabecular iris angle (TIA) and refractive parameters, including average keratometry (AvgK), cylindrical power (CYL), regular astigmatism, asymmetry and high order irregularity (HOI) at baseline and 1 day, 1 month, 2 months, 6 months and 12 months postoperatively. AS-OCT was performed at RRD diagnosis and day 1, week 1, month 1 and month 6 after SB to evaluate the scleral buckling.

RESULTS

A statistically significant postoperative CCT increase, ACD and ACV decrease were observed at 1 day and 1 month postoperatively. ITC analysis showed that the angle of the entire circumference narrowed at 1 month postoperatively. There was a significant decrease in all the angle parameters (AOD500/750, ARA500/750, TISA500/750, and ARA500/750) at 1 day and 1 month after SB surgery. However, all of the above parameters returned to the preoperative level at 12 months. Refractive parameters including AvgK, regular astigmatism, CYL, asymmetry, and HOI of anterior corneal surface and total corneal increased on the 1 day and 1 month after SB surgery and persisted even after 12 months follow-up. However, there was no significant difference in refractive parameters of posterior corneal surface during follow-up.

CONCLUSION

The changes in the structure of anterior segments after SB surgery were almost returned to the preoperative levels at 12 months postoperatively. However, SB surgery has a long-term effect on refractive parameters throughout a 12-month follow-up.

Effect of external subretinal fluid drainage on persistent subretinal fluid after scleral buckle surgery in macula-involving rhegmatogenous retinal detachment

This study aimed to analyze the duration and causes of persistent subretinal fluid (PSF) after scleral buckle (SB) surgery in patients with macula-involving rhegmatogenous retinal detachment (RRD). Sixty-one eyes of 61 patients with macula-involving RRD who underwent SB surgery between 2016 and 2022 were reviewed retrospectively. PSF was confirmed on optical coherence tomography. The PSF duration after surgery and the analysis of relevant ocular and systemic factors were conducted according to the PSF duration. The mean duration of PSF was 5.9 ± 4.6 months in all eyes and 8.1 ± 5.0 months in eyes not treated with external subretinal fluid (SRF) drainage, which was significantly longer than 4.5 ± 3.7 months in those subjected to external SRF drainage. The mean best-corrected visual acuity improved significantly 3 months after surgery. There were significant visual improvements in the external SRF drainage group compared to the non-drainage group during all follow-up periods. Longstanding shallow RRD was significantly associated with longer PSF duration after SB surgery. External SRF drainage during SB surgery can effectively reduce SRF, shorten the duration of PSF, and accelerate visual improvement.

Features of a well-timed macular hole closure related retinal regmatogenous detachment complicated by macular hole

The literature review deals with the analysis of the timing and surgical techniques of macular hole closure in patients with retinal detachment complicated by macular hole. Modern concepts of treatment tactics for this disease, its efficacy are analyzed. Benefits and drawbacks of each of the discussed surgical treatment methods are specified.

Retinal surgery quality indicators for uncomplicated primary rhegmatogenous retinal detachment without a national registry

PURPOSE

The objective of this study was to evaluate the possibility of analysing quality indicators for uncomplicated primary rhegmatogenous retinal detachment in a hospital department of ophthalmology without the support of a national registry or need to collect data from referring ophthalmological centres.

METHODS

In 2014, we operated 231 consecutive eyes with uncomplicated retinal detachment. Our quality indicators were primary anatomical success, final anatomical success and postoperative endophthalmitis. We reviewed medical records in our university surgical department retrospectively and compared them with medical records from the regional hospitals that had referred most of the operated patients and done their own postoperative examination. Our hypothesis was that any retinal re-detachment and/or serious postoperative complication would be reported back.

RESULTS

The medical records at the surgical department revealed primary anatomic success for 91.3% of eyes and final anatomical success of 99.6%. The data from the regional hospitals confirmed that our hypothesis was correct. All patients with adverse outcomes were referred back for reoperation. Patients who were not referred again had an attached retina and showed no signs of endophthalmitis.

CONCLUSION

Our hypothesis that data in the surgical department's medical records would closely reflect those in referring hospitals was borne out. This supports, under current conditions, an effective strategy for analysing chosen quality indicators without relying on a national registry or reviewing records from regional hospitals.

Effect of surgical modality on visual outcomes for young patients with primary rhegmatogenous retinal detachments: a retrospective cohort study

Objective

To examine outcomes of different surgical modalities for correcting primary rhegmatogenous retinal detachments in patients younger than 50 years of age.

Methods and analysis

A single-centre, retrospective, cohort study of 754 patients who underwent retinal surgery at the University of Virginia Hospital between 1 July 2012 and 1 July 2020 was conducted. Exclusion criteria were patients less than 18 or over 50 years of age, repeat detachments, second eyes of patients with bilateral detachments and follow-up less than 3 months. A multivariate regression model was used to compare overall outcomes in patients.

Results

86 patients met inclusion criteria and of those, 38 (44%) underwent vitrectomy, 22 (26%) underwent scleral buckling, 13 (15%) underwent pneumatic retinopexy and 13 (15%) underwent combined scleral buckle and vitrectomy repair. Comparison of eye-level parameters among the procedure groups shows difference with respect to macular involvement (p<0.05) but not regarding clock hour involvement or giant tear status (p>0.05). Preoperative visual acuity was superior in the scleral buckle group compared with vitrectomy (p<0.001). Mean postoperative visual acuity improved with all procedures and all repair procedures had comparable rates of complication. The mean overall anatomical success rate was 73% (n=63) and comparable among all modalities.

Conclusions

Vitrectomy, scleral buckle, pneumatic retinopexy or combined procedures are viable repair options for rhegmatogenous retinal detachments in patients younger than 50 years of age. Selection of the repair modality should be guided on baseline clinical features of the patient and detachment.

RELATIONSHIP BETWEEN PREOPERATIVE FOVEAL MICROSTRUCTURE AND VISUAL ACUITY IN MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENT: Imaging Analysis by Swept Source Optical Coherence Tomography

PURPOSE

To visualize foveal microstructures in macula-off rhegmatogenous retinal detachment using swept source optical coherence tomography preoperatively and postoperatively and to investigate the relationship between foveal microstructures and postoperative visual acuity.

METHODS

We retrospectively analyzed 42 eyes of 42 consecutive patients diagnosed with macula-off rhegmatogenous retinal detachment who underwent anatomically successful repair surgery and were followed up for 6 months. We used swept source optical coherence tomography to investigate the relationship between preoperative and postoperative continuity of both the external limiting membrane (ELM) and ellipsoid zone (Ez) and preoperative and postoperative best-corrected visual acuity.

RESULTS

Both preoperative ELM and Ez were continuous in 9 eyes (21%; ELM+/Ez+ eyes), only the ELM was continuous in 25 eyes (60%; ELM+/Ez- eyes), and neither was continuous in 8 eyes (19%; ELM-/Ez- eyes). Postoperative best-corrected visual acuity in ELM+/Ez+ eyes (-0.05 ± 0.04 logarithm of the minimum angle of resolution units, Snellen equivalent 20/18) was significantly better than that in both ELM+/Ez- (0.16 ± 0.16, 20/29; P = 0.03) and ELM-/Ez- (0.86 ± 0.37, 20/145; P < 0.001) eyes. Postoperative best-corrected visual acuity was significantly better in ELM+/Ez- than in ELM-/Ez- eyes (P < 0.001).

CONCLUSION

In macula-off rhegmatogenous retinal detachment, preoperative continuity of the ELM and Ez may be a predictor of postoperative best-corrected visual acuity.

Multifactor analysis of delayed absorption of subretinal fluid after scleral buckling surgery

Background

The purpose of this study is to assess the absorption of subretinal fluid (SRF) after scleral buckling (SB) surgery for the treatment of rhegmatogenous retinal detachment (RRD). We also examined related factors that may affect the delayed absorption of SRF.

Methods

This retrospective study included patients who underwent successful SB surgery for the treatment of macula-off RRD and in which the retina was reattached after the surgery. The patients were categorized according to gender, duration, age, the number, and location of retinal breaks. Subfoveal choroidal thickness (SFCT), height of subretinal fluid (SRFH), and the choriocapillaris flow density (CCFD) within 3 × 3 mm macular fovea were included. Delayed absorption was determined by the SRF that remained unabsorbed for 3 months after the procedure. The endpoint was determined when the SRF could no longer be observed.

Results

A total of 62 patients (63 eyes) were enrolled. In 35 eyes (56.45%) SRF was completely absorbed and in 28 (43.55%) eyes delayed absorption of SRF in macular areas was observed at 3 months after surgery. A young age (< 35 years), inferior retinal breaks were associated with good outcomes by applying multivariable analysis on the rate of SRF absorption after SB instead of gender, the number of breaks, and duration (p < 0.05). CCFD was significantly different between the SRF group and the non-SRF group after SB (0.66 ± 0.04% vs 0.63 ± 0.05%, P < 0.05). SRFH showed a moderate positive correlation with SFCT (r_s = 0.462, p = 0.000), however, using binary logistic regression analysis it was determined that SFCT was not related to the absorption of the SRF.

Conclusions

The absorption of SRF after SB may be correlated with choriocapillaris flow density. Age and location of breaks are significant factors affecting the absorption of SRF. The duration of disease is an uncertain factor due to several subjective reasons.

Predictive Factors for Long-Term Postoperative Visual Outcome in Patients with Macula-Off Rhegmatogenous Retinal Detachment Treated with Vitrectomy

PURPOSE

The purpose of this prospective study was to evaluate potential predictive factors of long-term postoperative outcomes in patients with macula-off rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV).

METHODS

Participants in this study were 86 patients diagnosed with macula-off RRD, who underwent PPV. Demographic characteristics and preoperative characteristics of RRD were recorded, while best corrected visual acuity (BCVA) was measured preoperatively and at specific postoperative time points (6 weeks and 6, 12, and 24 months). In addition, spectral domain-optical coherence tomography (SD-OCT) characteristics at postoperative week 6 were assessed as potential factors affecting the long-term postoperative visual outcome 24 months after PPV for RRD.

RESULTS

Increasing age, duration of RD of more than 1 week, presence of proliferative vitreoretinopathy, increasing central retinal thickness, ellipsoid zone disruption, and external limiting membrane disruption were significantly associated with a worse BVCA. BCVA was not associated with gender, lens status, the location of breaks, the gas tamponade agent used in PPV, the presence of subretinal fluid, and intraretinal fluid.

CONCLUSIONS

It is important to determine predictive factors for visual outcomes in order to inform patients about their prognosis and help in the decision-making process for patient management.

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.

Scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives

Although the technique of pars plana vitrectomy (PPV) develops rapidly, scleral buckling (SB) has several advantages over PPV for rhegmatogenous retinal detachment (RRD), including early visual rehabilitation and prevention of cataract progression. It is recommended to select the primary procedure for RRD by considering the advantages and disadvantages of each procedure based on the patient status. The vitreous body status affects the features of RRD. Vitreous liquefaction is an age-dependent process, resulting in the development of posterior vitreous detachment (PVD). RRD is usually associated with PVD, typically presenting with a retinal tear, strong vitreoretinal traction, and bullous detachment. In contrast, RRD may develop without PVD, and typically presents with a small atrophic hole, shallow detachment, and slow progression. RRD with less liquefied vitreous and no PVD can be managed successfully with SB alone even in the presence of subretinal strand as less liquefied vitreous acts as bio-tamponade blocking fluid passage. The strong traction induced by PVD and bullous detachment in an eye with extensively liquefied vitreous reduces the success rate of SB. PPV is gaining popularity as the primary procedure for RRD, especially in eyes with retinal tears, PVD, or pseudophakia. Nevertheless, SB remains the preferred procedure in young phakic patients without PVD.

Novel techniques in scleral buckling

Scleral buckling is a surgical technique that is employed successfully to treat rhegmatogenous retinal detachments (RRD) for more than 60 years. With the introduction of pars plana vitrectomy (PPV), there is a growing trend towards the use of PPV for treatment of retinal detachment. There is a reluctance to perform scleral buckling (SB) in RRD due to the perceived steep learning curve, declining mastery over indirect ophthalmoscopy, and poor ergonomics associated with SB. In this article, we discuss the surgical challenges and tips to overcome these in four headings: localization of the break, retinopexy, SB, and subretinal fluid (SRF) drainage. Localization of the break can be performed by the use of forceps or illuminated scleral depressor. It can be facilitated by prior drainage of SRF in cases with bullous RRD. Chandelier with wide-angle viewing system can be used for easier localization of break and cryopexy. Sutureless buckling and suprachoroidal buckling are easier and faster alternatives to the conventional technique. Reshaping the silicone segment helps in accommodating the wider circumferential band. Modified needle drainage, laser choroidotomy, and infusion-assisted drainage can make SRF drainage easier and safer. The above techniques and other practical tips have been explained in detail with the illustrations to make the process of learning the art of SB easier.